Virginia DSS · Assisted Living Facility

Golden Years Assisted Living Facility, Inc.

📍 40 Hunt Club Boulevard, Hampton, VA, 23666

ID 42432One Year licenseActive
30
Inspections
On record
23
With violations
Visits that cited something
7
Clean visits
Nothing cited
147
Violations cited
Individual findings
71
Standards cited
Distinct rules
18
Complaint visits
Prompted by a complaint

Golden Years Assisted Living Facility, Inc. was inspected 30 times between September 22, 2020 and December 18, 2025 by the Virginia Department of Social Services. 23 of those visits ended with violations cited and 7 with none. Across that history VDSS cited 147 violations under 71 distinct standards. 18 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. 27 of these 30 are still on the state's site; the other 3 have since dropped off it and are reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type
Assisted Living Facility
License type
One Year
License expires
11/28/2025
Administrator
Jonathan Aldridge
Licensing inspector
Alyshia Walker
Inspector phone
(757) 670-0504
Approved for
Assisted Living

Inspection History

30

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

December 18, 2025Complaint survey0 violations
Inspection dates
12/18/2025
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/18/2025 10:00am- 11:30 am The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 11/22/2025 regarding allegations in the area(s) of: Admission, Retention and Discharge of Residents Number of residents present at the facility at the beginning of the inspection: 72 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents:0 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the (allegation(s)/self-report) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
November 18, 2025Complaint survey1 violation
Inspection dates
11/18/2025
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/18/2025 3:00 pm- 3:30 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 10/29/2025 regarding allegations in the area(s) of: Administration and Administrative Services Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 72 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: 2 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 supported some, but not all of the (allegation(s)/self-report); area(s) of non-compliance with standard(s) or law were: Administration If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of these inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Violations
22VAC40-73-140-E
Based on record review and staff interview, the facility failed to ensure that for a facility licensed for both residential and assisted living care, the administrator shall be licensed as an assisted living facility administrator or nursing home administrator by the Virginia Board of Long-Term Care Administrators pursuant to Chapter 31 (§ 54.1-3100 et seq.) of Title 54.1 of the Code of Virginia.
Evidence
  1. The facility is licensed for residential and assisted living level of care.
  2. On 10/29/2025 the LI received a complaint alleging the facility’s administrator’s Administrator In Training license expired in April 2025.
  3. During the inspection on 11/18/2025, Staff #1 self-identified as the administrator of record.
  4. During the 11/18/2025 inspection, the Licensing Inspector searched the Virginia Department of Health Profession’s license lookup webpage for Staff #1’s name. The results revealed that Staff #1’s Acting Administrator in Training license expired on 04/14/2025.
  5. During the interview on 11/18/2025, Staff #1 acknowledged that Staff #1’s license expired on 04/14/2025. Staff #1 stated there have been no arrangements made to complete the licensure process required to become a licensed assisted living facility administrator.
Plan of correction
Not published by VDSS.
November 18, 2025Complaint survey6 violations
Inspection dates
11/18/2025, 12/17/2025
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/18/2025 2:15pm- 2:30 pm and 12/17/2025 1:30 pm- 3:00 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 10/20/2025 regarding allegations in the area(s) of: Admission, Retention and Discharge of Residents Resident Care and Related Services Resident Accommodations and Related Provisions Buildings and Grounds Number of residents present at the facility at the beginning of the inspection: 76 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: The Licensing Inspector reviewed resident charts and inspected resident bedrooms. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation(s) of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint(s) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of these inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Violations
22VAC40-73-870-D
Based on observations made during a tour of the building and interviews with residents and staff, the facility failed to ensure buildings shall be kept free of infestations of insects and vermin.
Evidence
  1. The Licensing Inspector observed live and crawling bed bugs on the bedroom wall of resident bedroom #3 on 12/16/2025. Photographic evidence taken during the inspection.
  2. Staff # 1 acknowledged the facility has an on-going pest control issue (bed bugs) which is being addressed. Interview with Collateral #1 confirmed the building is being treated for an insect infestation.
Plan of correction
Not published by VDSS.
22VAC40-73-320-B
Based on records reviewed and staff interviewed, the facility failed to ensure a risk assessment for tuberculosis was completed annually on each resident as
Evidence
  1. d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence:
  2. The most recent TB assessment in the file for Resident #1 (date of admission 6/1/2018) was dated 9/4/2024.
  3. Staff #1 acknowledged the TB assessment dated 9/4/2024 was the most recent.
Plan of correction
Not published by VDSS.
22VAC40-73-430-J
Based on a review of resident records and interviews, the facility failed to provide within 60 days of the date of discharge with each resident a final statement of account, any funds due, and return money, property, or things of value held in trust or custody by the facility.
Evidence
  1. Resident # 1’s date of discharge from the facility was 10/11/2025, per the Discharge Notification statement. The resident’s representative/next of kin was provided with a final statement of account within 60 days of the discharge.
  2. Resident # 2’s date of discharge from the facility was 7/29/2025, per the Discharge Notification statement. The resident nor the resident’s representative was not provided with a final statement of account within 60 days of discharge.
  3. Staff #1 acknowledged that neither Resident #1 nor Resident #2 received a final statement within 60 days of their discharge.
Plan of correction
Not published by VDSS.
22VAC40-73-740-D
Based on record review and staff interview, the facility failed to ensure that each resident has their own clothing.
Evidence
  1. The Division received a complaint on 10/20/2025 regarding the facility discarding the personal belongings for Resident #1.
  2. A review of Resident #1’s file contained an incident report which detailed that on 9/17/2025, Resident #1’s roommate moved out of the facility and some of Resident #1’s belongings were inadvertently packed and taken with the roommate’s clothing.
  3. During the inspection Staff #1 acknowledged the incident occurred and the resident’s family had not been monetarily compensated for the items.
Plan of correction
Not published by VDSS.
22VAC40-73-430-H-1
Based on documentation review and staff interview, the facility failed to ensure that a copy of a written discharge statement signed by the administrator was retained in resident records which contained the date notice of discharge was provided to or by the facility or the resident, the reason for discharge and the date of the actual discharge from the facility.
Evidence
  1. The records for Resident #1 and Resident #2 contained discharge statements which did not document the reason for the discharge, the actions taken by the facility to assist the resident in the discharge and relocation process.
  2. The discharge statement for Resident # 2 did not contain the actual date of the discharge.
  3. Staff #1 acknowledged the discharged resident statements did not contain the required information.
Plan of correction
Not published by VDSS.
22VAC40-73-680-E
Based on resident record review and staff interview, the facility failed to ensure that medical procedures or treatments ordered by a physician or other prescriber shall be provided according to the prescriber’s instructions and documented and the documentation shall be maintained in the resident’s record.
Evidence
  1. Documentation in the file for Resident #1 noted on 6/6/2025, the resident’s physician ordered for the resident to have GI consult – Colonoscopy. There was no evidence in the resident’s file that the resident had seen the specialist or received a colonoscopy.
  2. Staff # 1 acknowledged the facility did not have documentation the resident was seen by a GI specialist or received a colonoscopy.
Plan of correction
Not published by VDSS.
October 27, 2025Inspection0 violations
Inspection dates
10/27/2025
Areas reviewed
22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/27/2025 9:22 am- 1:17 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 10/23/2025 and 1 10/25/2025 regarding allegations in the area(s) of: Buildings and Grounds Number of residents present at the facility at the beginning of the inspection: 85 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 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: LI toured the facility, conducted interviews with staff and residents. Additional Comments/Discussion: n/a An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
October 17, 2025Complaint survey5 violations
Inspection dates
10/17/2025
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/17/2025 3:45 pm- 5:20 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 10/17/2025 regarding allegations in the area(s) of: Admission Retention and Discharge Number of residents present at the facility at the beginning of the inspection: 72 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: The licensing inspector conducted an inspection of the resident record and the facility. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation(s) of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint(s) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of these inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Violations
22VAC40-73-320-A
Based on a record review, the facility failed to ensure the resident had a physical examination by an independent physician within the 30 days preceding admission which contained the resident’s weight and blood pressure.
Evidence
  1. The physical for Resident #1 dated 8/15/2025 did not document the resident’s height or weight.
  2. Photographic evidence obtained at the time of
Plan of correction
Not published by VDSS.
22VAC40-73-450-C
Based on resident record review, the facility failed to include a description of identified needs and date identified based upon the Uniform Assessment Instrument (UAI) on the comprehensive Individualized Service Plan (ISP) and the resident’s admission physical examination.
Evidence
  1. The UAI (2/7/2025) for Resident # 1 states the resident has the following needs which were not identified on the resident’s most recent ISP (8/21/2025): disorientation- some spheres all the time (time and place), wandering, short-term memory loss and judgment problems.
  2. The physical (8/15/2025) for Resident #1 stated the resident was allergic to Tylenol. This was not identified on the resident’s ISP which stated the resident did not have any known allergies.
  3. Staff #1 acknowledged the above needs were not addressed on the resident’s ISP.
  4. Photographic evidence obtained at the time of inspection.
Plan of correction
Not published by VDSS.
22VAC40-73-680-E
Based on a review of resident records and interviews with staff, the facility failed to ensure medical procedures or treatments ordered by a physician shall be provided according to his instructions and documented. The documentation shall be maintained in the resident's record.
Evidence
  1. The MAR for Resident #1 documented the resident’s blood glucose was 441 on 10/6/2025. The physician’s order states if the blood glucose is greater than 400 the physician should be notified. There was no documentation the facility contacted the physician as directed by the physician’s order.
  2. Staff #1 and #2 could not provide documentation the facility contacted the physician.
  3. Photographic evidence obtained at the time of inspection.
Plan of correction
Not published by VDSS.
22VAC40-73-680-I
Based on physician’s order, staff interviews and Medication Administration Record (MAR), the facility failed to include the dosage of medication administered.
Evidence
  1. Resident #1 was prescribed Insulin Lispro 100 unit.ML pen to be administered on a sliding scale 4 times a day before meals and at bedtime. 151-200= 2 units, 201-250= 4 units, 251-300= 6 units, 301-350= 8 units and 351-400=10 units. The October 2025 MAR for Resident #1 documented the resident’s blood glucose as being: 255 on 10/5/2025 at 7:30 am, 244 on 10/6/2025 at 7:30 am, 335 on 10/7/2025 at 7:30 am, 221 on 10/8/2025 at 7:30am, 174 on 10/11/2025 at 7:30 am, 325 on 10/12/25 at 7:30 am, 158 on 10/13/2025 at 7:30am, 270 on 10/14/2025 at 7:30 am, 270 on 10/14/2025 at 7:30 am, 187 on 10/15/2025 at 7:30 am, 178 on 10/16/2025 at 7:30 am, 126 on 10/17/2025 at 7:30 am. Resident #1’s documented blood glucose was: 125 on 10/4/2025 at 11:30 am, 202 on 10/6/2025 at 11:30 am, 314 on 10/18/2025 at 11:30 am, 325 on 10/14/2025 at 11:30 am, 146 on 10/15/2025 at 11:30 am, 153 on 10/17/2025 at 11:30 am. Resident #1’s documented blood glucose was: 228 on 10/2/2025 at 8:00 pm, 228 on 10/4/2025 at 8:00 pm, 242 on 10/4/2005 at 8:00 pm, 238 on 10/5/2025 at 8:00 pm, 441 on 10/6/2025 at 8:00 pm, 227 on 10/7/2025 at 8:00 pm, 288 on 10/9/2025 at 8:00 pm. The number of units administered to Resident #1 on the above dates and times were not documented on the MAR provided to the inspector at the time of the inspection.
  2. Staff #1 and Staff #2 acknowledged the MAR is not documented to reflect the number of units administered to the resident.
  3. Photographic evidence obtained at the time of inspection.
Plan of correction
Not published by VDSS.
22VAC40-73-460-D
Based on facility documentation and interview with staff, the facility failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs, such as prevention of falls and wandering from the premises.
Evidence
  1. The October 2025 Medication Administration Record for Resident #1 documented that the resident was out of the facility on the following days at an unknown location: 10/2/2025, 10/4/2025, 10/5/2025, 10/9/2025, and 10/13/2025. The physical for Resident #1 documented the resident as having dementia.
  2. Staff #1 acknowledged that Resident #1 exits the facility and walks the area.
  3. Photographic evidence obtained at the time of inspection.
Plan of correction
Not published by VDSS.
October 7, 2025Inspection5 violations
Inspection dates
10/07/2025
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/7/2025 11:00 am- 1:20 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 10/6/2025 regarding allegations in the area(s) of: Personnel and Resident Care and Related Services The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 2 Number of interviews conducted with residents: 2 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 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 Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Violations
22VAC40-73-550-G
Based on a review of staff records, the facility failed to ensure the rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each staff person, including written acknowledgment of having been so informed, which shall include the date of the review and shall be filed in the staff person's record.
Evidence
  1. The last Resident Rights review documented in the record for Staff #2 was dated 5/28/2024.
  2. Staff #1 acknowledged the last documented review of Resident’s Rights in the file provided to the Licensing Inspector was dated 5/28/2024. Staff #1 acknowledged Resident’s Rights training had been provided to Staff # 2 since 5/28/2024, however the documentation of the training could not be located at the time of the inspection.
Plan of correction
Not published by VDSS.
22VAC40-73-110-1
Based on a review of documentation and interviews, it was determined that the facility did not ensure all staff shall be considerate and respectful of the rights, dignity, and sensitivities of persons who are aged, infirm, or disabled.
Evidence
  1. On 10/6/2025, the facility self-reported an allegation of physical abuse made by the family of Resident #1. Resident #1 was interviewed by Licensing Inspector, and the resident denied any physical abuse by Staff #2, however the resident did indicate the staff member spoke to the resident in an inappropriate manner by teasing and using misgendering names towards the resident which upset him.
  2. Staff #1 acknowledged that Staff #2 had been placed on suspension while the facility conducted an internal investigation.
Plan of correction
Not published by VDSS.
22VAC40-73-325-B
Based on the record reviewed, the facility failed to ensure that a fall risk assessment was reviewed and updated after a resident experiences a fall.
Evidence
  1. The file for Resident #1 documented a fall which resulted in the resident going to the emergency room on 8/19/2025. There was no fall assessment in the resident’s file pertaining to the fall.
  2. Staff #1 acknowledged the file for Resident #1 did not contain a fall risk assessment for the resident’s fall which occurred on 8/19/2025.
Plan of correction
Not published by VDSS.
22VAC40-73-450-E
Based on review of resident records the facility failed to ensure that each resident’s individualized service plan (ISP) contained a signature and date of the resident or their legal representative.
Evidence
  1. The ISP for Resident #1 (with an administrator signature date of 7/22/2025), did not contain a resident signature.
  2. Staff #1 acknowledged the ISP did not contain the resident’s or legal representative signature.
Plan of correction
Not published by VDSS.
22VAC40-73-450-F
Based on record reviewed, the resident’s individualized service plan (ISP) did not include all assessed needs.
Evidence
  1. The ISP for Resident #1 (with an administrator signature date of 7/22/2025), did not address all the resident’s assessed needs as documented on the Uniform assessment instrument (UAI) dated 3/31/2025. The UAI indicated the resident required mechanical help and physical assistance with bathing. The ISP for Resident #1 only indicated the resident required mechanical assistance. The UAI indicated the resident required human help-physical assistance with dressing, the ISP stated the resident required no assistance. The UAI indicated the resident required mechanical and physical assistance for toileting the ISP indicated the resident required mechanical assistance. The UAI indicated the resident required mechanical and human help with walking the ISP indicated the resident required mechanical assistance.
  2. Staff #1 acknowledged the ISP did not addressed all of the resident’s assessed needs which were documented on the UAI.
Plan of correction
Not published by VDSS.
September 27, 2025Complaint survey3 violations
Inspection dates
09/27/2025
Areas reviewed
22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 9/27/2024 8:45 am – 2:15 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 10/2/2024 regarding allegations in the area(s) of: Buildings and Grounds Emergency Preparedness Number of residents present at the facility at the beginning of the inspection: 74 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents:2 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the complaint of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Violations
22VAC40-73-870-D
Based on observations made during a tour of the building and interviews with residents and staff, the facility failed to ensure buildings shall be kept free of infestations of insects and vermin.
Evidence
  1. The Licensing Inspector observed a live and crawling bed bug on the bedroom wall of resident #1 on the date of the inspection.
  2. Staff # 1 acknowledged the facility has an on-going contract for pest control contract but there continue to be reports of bed bugs.
Plan of correction
1. Immediate Correction Immediate pest control treatment was conducted in all areas where infestation was observed, affected resident rooms were deep-cleaned and sanitized following extermination procedures. Residents were monitored for any pest-related health concerns and offered temporary relocation when appropriate. 2. Identification of Others A facility-wide inspection was conducted to determine the presence of pests in any additional resident rooms, common areas, or service areas. Interviews with residents and staff were used to identify any ongoing or previously unreported issues. Pest sightings were crossed-checked with facility maintenance and housekeeping logs. 3. Systemic Changes A licensed pest control company has been contracted to provide regular monthly services and as-needed emergency response. The housekeeping department implemented a daily sanitation checklist focused on high-risk areas (e.g., kitchens, trash storage, and laundry). 4. Staff Training Pest control service reports and housekeep logs will be reviewed weekly and discussed in monthly Quality Assurance and Performance Improvement (QAPI) meetings. Resident satisfaction and environmental quality will be monitored through monthly Resident Council meetings and routine surveys. 5. Monitoring The facility will maintain a Pest Incident Log to document, respond to, and track all future pest activity.
22VAC40-73-980-H
Based on observation, staff and collateral interviews, the facility failed to ensure the food supply was current.
Evidence
  1. During the on-site inspection the facility’s current rotating emergency food stock, peanut butter, which was most of the emergency food, was expired with an expiration date of 6/20/2021.
  2. Staff #3 acknowledged the food was expired.
Plan of correction
1. Immediate Correction All expired food items were immediately removed and discarded. Kitchen and food storage areas were thoroughly cleaned and re-inspected. Meals were reviewed to ensure that no expired food had been served. 2. Identification of Others A complete audit of all food storage areas, including dry storage, refrigerators, and freezers, was conducted and food supplies were checked for current expiration dates and compliance with storage guidelines. All dietary staff were interviewed to assess food rotation practices and identify gaps. 3. Systemic Changes Posted visual reminders for expiration date checks were placed in storage and prep areas. A Food Inventory Rotation Log was implemented for all food storage areas. 4. Staff Training All dietary staff received retraining on food safety, proper labeling, and checking expiration dates. A dedicated staff member is now assigned to conduct weekly checks of all food items. 5. Monitoring The Dietary Manager or designee will perform weekly audits of food storage areas for 90 days, then monthly thereafter.
22VAC40-73-870-A
Based on observations made during a tour of the building, the facility failed to ensure the interior and exterior of all buildings shall be maintained in good repair and kept clean and free of rubbish.
Evidence
  1. On 9/27/2024, during the inspection of the facility, the Licensing Inspector observed carpet that was worn and taped down throughout the building (hallways leading to resident bedrooms, dining room, and common rooms used by the residents).
  2. Staff #3 acknowledged the carpet was worn.
Plan of correction
a. The facility administrator has immediately conducted a comprehensive inspection of all interior and exterior areas of the facility. b. Identified issues, including but not limited to , damaged walls, flooring, windows, and exterior surfaces, have been repaired or scheduled for repair. c. All areas have been cleaned, and rubbish has been removed to ensure a safe and pleasant environment for residents. 2. a. A facility-wide audit of building conditions was conducted to identify any other areas not in compliance with the regulation. b. Any additional deficiencies found were promptly addressed with appropriate corrective actions. 3. a. A Building Maintenance Policy has been developed and implemented, which includes: Regular inspections of the interior and exterior of the facility. A schedule for routine maintenance and prompt repair of identified issues. Procedures for reporting and addressing maintenance concerns. b. Staff responsible for maintenance have been trained on the new policy and procedures. 4. a. The facility administrator or designee will conduct monthly inspections of building conditions to ensure ongoing compliance. b. Results of inspections will be reviewed at the facility's monthly Quality Assurance meetings, and any issues will be addressed immediately.
August 27, 2025Inspection0 violations
Inspection dates
08/27/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 8/27/2025 9:50 am- 12:48 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 7/31/2025 regarding allegations in the area(s) of: Resident Care and Related Services The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
August 27, 2025Complaint survey3 violations
Inspection dates
08/27/2025, 10/27/2025
Areas reviewed
22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 08/27/2025 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 8/8/2025 regarding allegations in the area(s) of: Resident Care and supervision 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: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. However, violation(s) not related to the complaint(s) but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Violations
22VAC40-73-680-I
Based on a review of the resident record as well as staff interview, the facility failed to ensure that the Medication Administration Record (MAR) shall include the initials of direct care staff administering the medication.
Evidence
  1. The August 2025 MAR for Resident # 1 for August 18, 2025, did not contain documentation of staff initials to indicate the resident received the following medications and supplements: Divalproex Dod ER 500 mg, Ensure High Protein, Levetiracetam 500 mg, Melatonin 3 mg, Midodrine HCL 5 mg, Rosuvastatin Calcium 20 mg, and Tamsulosin HCL 0.4 mg. The MAR also did not contain initials for August 22, 2025, to indicate if Resident #1 received the prescribed Midodrine HCL 5 mg and Olanzapine 5 mg. There were no notes or documentation on the MAR to indicate why the prescribed medications were not administered or why the MAR did not contain staff initials.
  2. Staff #1 acknowledged the August 2025 MAR for Resident #1 did not contain the proper documentation.
Plan of correction
Not published by VDSS.
22VAC40-73-870-A
Based on observation and staff interviewed, the facility failed to ensure the interior of the building was maintained in good repair and kept clean and free of rubbish.
Evidence
  1. The facility parking lot has multiple potholes and uneven pavement. A resident fell in a pothole on 4/8/2025 as documented in the Nurse’s Notes in the file of Resident #1.
  2. During the on-site inspections on 8/17/2025 and 10/27/2025 the Licensing Inspector observed at least 5 large potholes at least 12 inches in diameter and at least 2 inches deep.
  3. Staff #2 acknowledged to the Licensing Inspector on 10/27/2025, the parking lot is in need of repair.
Plan of correction
Not published by VDSS.
22VAC40-73-325-B
Based on the record reviewed, the facility failed to ensure that a fall risk assessment was reviewed and updated after a resident experiences a fall.
Evidence
  1. The resident file for Resident #1 contained documentation that the resident fell in a pothole in the facility parking lot on 4/8/2025.
  2. There was no fall risk assessment in the file associated with the 4/8/2025 fall.
  3. Staff #1 acknowledged there was no fall risk assessment in the file for the documented fall on 4/8/2025.
Plan of correction
Not published by VDSS.
August 27, 2025Complaint survey2 violations
Inspection dates
08/27/2025
Areas reviewed
22VAC40-73 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: 8/27/2025 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 8/5/2025 regarding allegations in the area(s) of: Personnel Resident Care and Related Services The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. However, violation(s) not related to the complaint(s) but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Violations
22VAC40-73-450-A
Based on record review, the facility failed to ensure on or within seven days prior to the day of admission, a preliminary plan of care be developed to address the basic needs of the resident that adequately protects his health, safety, and welfare.
Evidence
  1. The resident record for Resident #1 admitted 6/6/2025, did not contain an initial ISP for the resident. The ISP in the resident file contained an ISP dated 8/1/2025.
  2. Staff #1 acknowledged the ISP for Resident #1 was dated 8/1/2025.
Plan of correction
Not published by VDSS.
22VAC40-73-310-H
Based on record reviewed and staff interviewed, the facility failed to ensure in accordance with 63.2-1805 D Code of Virginia, it did not admit or retain individuals with any prohibitive conditions without required documentation.
Evidence
  1. Resident #1 has been prescribed Sertraline 50 mg. There was no psychotropic treatment plan in the resident’s file presented to the inspector at the time of the inspection.
Plan of correction
Not published by VDSS.
July 7, 2025Inspection2 violations
Inspection dates
07/07/2025
Areas reviewed
22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7/7/2025 12:30 pm- 4:00 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 7/1/2025 regarding allegations in the area(s) of: Resident Care and Related Services The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 2 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported 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 Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Violations
22VAC40-73-870-A
Based on observations made during the tour of the building, the facility failed to make sure the interior and exterior of the building is maintained in good repair.
Evidence
  1. The ceiling was torn out exposing pipes and the sprinkler system in the residents common tv area and the hallway which leads directly through the facility (photos taken by licensing inspector at the time of inspection).
  2. Staff # 1 acknowledged the ceiling was in need of repair due to a leak in the facility’s sprinkler system.
Plan of correction
Not published by VDSS.
22VAC40-73-680-I
Based on a review of the resident record as well as staff interview, the facility failed to ensure that the Medication Administration Record (MAR) shall include the initials of direct care staff administering the medication.
Evidence
  1. The June 2025 MAR for Resident # 1 for June 9, 2025, did not contain documentation of staff initials to indicate the 8:00 am dose of Metoprolol Tartrate 25 mg was administered. There were no initials for the June 22 & 28, 2025, 6:00 pm doses of Atorvastatin 80 mg, Benztropine MES 035 mg, Dulcolax 100 mg, Metoprolol Tartrate 25 mg, and Risperidone 2 mg, to indicate the medications were administered.
  2. Staff #1 acknowledged the June 2025 MAR for Resident #1 did not contain the proper documentation.
Plan of correction
Not published by VDSS.
July 7, 2025Complaint survey4 violations
Inspection dates
07/07/2025
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7/7/2025 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 4/8/2025 regarding allegations in the area(s) of: Admission, Retention and Discharge The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Licensing Inspector review resident and staff records. Additional Comments/Discussion: n/a An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation(s) of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint(s) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Violations
22VAC40-73-140-E
Based on staff record review and staff interview, the facility failed to have an administrator licensed as an assisted living facility administrator on record.
Evidence
  1. Staff #1 has an acting Administrator-in-Training License which expired 4/14/2025. The licensing office was not informed the facility appointed an acting administrator.
  2. Staff #1 acknowledged the license was expired.
Plan of correction
Not published by VDSS.
22VAC40-73-560-D
Based on record review and interview with staff, the facility failed to ensure the complete resident record included copies of all agreements between the facility and the resident and official acknowledgment of required notifications signed by all parties involved.
Evidence
  1. The resident record for Resident #1 who was discharged 7/22/2024, did not contain the resident’s complete record. The record did not contain the original resident agreement or the resident fund agreement.
  2. Staff #1 acknowledged the resident record provided to the Licensing Inspector at the time of the inspection was not complete and the record did not contain the original resident agreement or the resident fund agreement, as those documents were missing from the resident’s file.
Plan of correction
Not published by VDSS.
22VAC40-73-430-J
Based on a record review, the facility failed to ensure that within 60 days of discharge, each resident or legal representative shall be given a final statement of account and any refunds due.
Evidence
  1. The Licensing Division received a complaint regarding resident funds not being returned by the facility. The resident record for Resident #1 contained a discharge notification statement dated 7/22/2024. The statement did not indicate that the resident or legal representatives were provided with a final statement of account or that the facility returned any money within 60 days of discharge.
  2. Staff #2 acknowledged Social Security payments in the amount of $4572 for Resident #1 were returned to the Social Security Administration on 7/15/2025, as Staff #2 emailed a copy of the SSA receipt.
Plan of correction
Not published by VDSS.
22VAC40-73-430-H-1
Based on documentation review and staff interview, the facility failed to ensure that a copy of a written discharge statement signed by the administrator was retained in resident records which contained the date notice of discharge was provided to or by the facility or the resident, the reason for discharge and the date of the actual discharge from the facility.
Evidence
  1. The records for Resident #1 and Resident #2 contained discharge statements which did not document the date on which the resident, his legal representative or designated contact person was notified of the planned discharge and the name of the legal representative or designated contact person who was notified, the reason for the discharge, and the date of the actual discharge from the facility and the resident’s destination.
Plan of correction
Not published by VDSS.
February 10, 2025Inspection10 violations
Inspection dates
02/10/2025, 02/11/2025, 02/12/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
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: 74 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 4 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 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 Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Violations
22VAC40-73-870-A
Based on a tour of the building, the facility failed to ensure the interior and exterior of all buildings shall be maintained in good repair and kept clean and free of rubbish.
Evidence
  1. The light above the resident’s bed in room # 50 did not have light bulbs or a cover for the light.
  2. The carpet throughout the building was taped at the seams.
  3. Staff # 1 and # 6 acknowledged the items were in need of repair.
Plan of correction
1. a. The facility administrator has immediately conducted a comprehensive inspection of all interior and exterior areas of the facility. b. Identified issues, including but not limited to, damaged walls, flooring, windows, and exterior surfaces, have been repaired or scheduled for repair. c. All areas have been cleaned, and rubbish has been removed to ensure a safe and pleasant environment for residents. 2. a. A facility-wide audit of building conditions was conducted to identify any other areas not in compliance with the regulation. b. Any additional deficiencies found were promptly addressed with appropriate corrective actions. 3. a. A Building Maintenance Policy has been developed and implemented, which includes: Regular inspections of the interior and exterior of the facility. A schedule for routine maintenance and prompt repair of identified issues. Procedures for reporting and addressing maintenance concerns. b. Staff responsible for maintenance have been trained on the new policy and procedures. 4. a. The facility administrator or designee will conduct monthly inspections of building conditions to ensure ongoing compliance. b. Results of inspections will be reviewed at he facility's monthly Quality Assurance meetings, and any issues will be addressed immediately.
22VAC40-73-320-A
Based on record reviewed and staff interviewed, the facility failed to ensure within 30 days preceding admission, a person shall have a physical examination by an independent physician which includes the results of a risk assessment documenting the absence of tuberculosis in a communicable form as
Evidence
  1. d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: The resident record for Resident # 5 (D.O.A. 1/21/2025) contained a physical examination report dated 1/21/2025 which did not contain all the required elements in Standard 22VAC40-73-320-A.
Plan of correction
1. The facility administrator has immediately conducted a comprehensive review of all resident records. For residents where the physical examination report was not completed within the required timeframe or was missing required elements, the administrator has: Scheduled the necessary physical examinations with an independent physician. Ensured that the examination reports include all required elements, including the tuberculosis risk assessment. Obtained and filed the completed reports in the respective resident records. 2. A facility-wide audit of resident records was conducted to identify any other instances of non-compliance. Any discrepancies found were promptly addressed by scheduling the necessary physical examinations and ensuring documentation is complete. 3. A Physical Examination and Tuberculosis Screening Policy has been developed and implemented, which includes: All new residents must have a physical examination by an independent physician within 30 days preceding admission. The examination report must include all required elements as specified in 22VAC40-73-320 A, including the tuberculosis risk assessment. Documentation of the examination and risk assessment must be maintained in the resident's record. Staff responsible for admissions and record-keeping have been trained on the new policy and procedures. 4. The facility administrator or designee will conduct monthly audits of resident records to ensure compliance with the new policy. Results of audits will be reviewed at the facility's monthly Quality Assurance meeting, and any issues will be addressed immediately.
22VAC40-73-860-G
Based on observation and staff interviewed, the facility failed to ensure the hot water taps available to residents shall be maintained within a range of 105 degrees Fahrenheit (F) to 120 degrees F.
Evidence
  1. During an inspection of the facility on 2/12/2025, the hot water temperature in rooms # 10 and # 25 was 125 degrees F.
  2. Staff # 7 acknowledged the temperature readings for the resident rooms.
Plan of correction
1. The facility administrator has immediately conducted a comprehensive inspection of all hot water taps used by residents. Where temperatures were found to be outside the required range, adjustments have been made to the water heating system to ensure compliance. Temperatures at all taps have been re-checked and documented to confirm they are within the 105 degree F to 120 degree F range. 2. A facility-wide audit of all hot water taps was conducted to identify any other instances of non-compliance. Any discrepancies found were promptly addressed by adjusting the water heating system and ensuring temperatures are within the required range. 3. A Hot Water Temperature Monitoring Policy has been developed and implemented, which includes: Regular monitoring of hot water temperatures at taps available to residents. Immediate corrective actions if temperatures fall outside the 105 degree F to 120 degree F range. Documentation of temperature checks and any corrective actions taken. Staff responsible for monitoring and maintaining hot water temperatures have been trained on the new policy and procedures. 4. The facility administrator or designee will conduct weekly audits of hot water temperatures at taps used by residents to ensure compliance with the new policy. Results of audits will be reviewed at the facility's monthly Quality Assurance meetings, and any issues will be addressed immediately.
22VAC40-73-660-A-1
Based on observation the facility failed to ensure that the medication storage area was locked.
Evidence
  1. On 2/11/2025, while inspecting the facility with the administrator, the medication cart located in the main tv room was observed to be unlocked.
  2. Staff # 1 and Staff # 4 both acknowledged the cart was unlocked.
Plan of correction
1. a. The facility administrator has immediately conducted a comprehensive inspections of all medication storage areas. b. All medication storage areas have been secured with appropriate locking mechanism to ensure compliance with regulation 22VAC40-73-660-A. c. Staff responsible for medication administration have been always reminded of the importance of securing medication storage areas. 2. a. A facility-wide audit of medication storage areas was conducted to identiy any other instances of non-compliance. b. Any additional deficiencies found were prompltly addressed by securing the affected areas and ensuring compliance. 3. a. A Medication Storage Policy has been developed and implemented, which included: b. ALL medication storage areas shall be locked at all times. c. The individual responsible for medication administration shall keep the keys to the storage areas on their persond. d. Regular inspections of medication storage areas will be conducted to ensure compliance. e. Staff responsible for medication administration have been trained on the new polkcy and procedures. 4. a. The facility administrator or designee will conduct weekly audits of medication storage areas to ensure compliance. with the new policy. b. Results of audits will be reviewed at the facility's monthly Quality Assurance meeting, and any issues will be addressed immediately.
22VAC40-73-250-D
Based on the review of facility records and staff interviews the facility failed to ensure that each staff person on or within seven days prior to the first day of work at the facility and prior to coming in contact with residents shall submit the results of a risk assessment, documenting the absence of tuberculosis in a communicable form.
Evidence
  1. The staff record for Staff # 5 (D.O.H. 9/13/2024) contained a TB assessment with a date of 10/28/2024.
  2. Staff #1 acknowledged the TB assessment was dated 10/28/2024 and not submitted withing the first seven days of the staff member coming in to contact with residents.
Plan of correction
1. a. The facility administrator has immediately conducted a comprehensive review of all staff records. b. Identified staff members without a TB risk assessment completed within the required timeframe have been scheduled for assessment. c. Results of the assessments have been documented and placed in the respective staff records. 2. a. A facility-wide audit of staff records was conducted to identify any other instances of non-compliance. b. Any discrepancies found were promptly addressed by scheduling the necessary TB risk assessments and ensuring documentation is complete. 3. a. A Staff Health Compliance Policy has been developed and implemented, which includes: All new staff must completed a TB risk assessment within seven days prior to their first day of work. Annual TB risk assessments are required for all staff. Documentation of assessments must be maintained in staff records. b. Staff responsible for maintaining health records have been trained on the new policy and procedures. 4. a. The facility administrator or designee will conduct monthly audits of staff health records to ensure compliance with the new policy. b. Results of audits will be reviewed at the facility's monthly Quality Assurance meetings, and any issues will be addressed immediately.
22VAC40-73-750-E
Based on observations made during the tour of the building, the facility failed to have sufficient bed and bath linens in good repair so that residents always have clean sheets.
Evidence
  1. During the on-site inspection of the occupied resident rooms with the administrator on 2/10/2025, beds in rooms # 3 and # 4 did not contain sheets.
  2. Staff # 1 acknowledged the beds did not contain sheets.
Plan of correction
1. a. The facility administrator has immediately conducted an inventory of all bed and bath linens. b. Any linens found to be in poor repair have been removed from circulation and replaced with clean, serviceable items. c. A sufficient supply of linens has been ensured to meet the needs of all residents. 2. a. Facility-wide audit of linen supplies and conditions was conducted to identify any other instances of insufficient or poor-quality linens. b. Any discrepancies found were promptly addressed y replacing inadequate linens and ensuring an adequate supply for all residents. 3. a. A Linen Management Policy has been developed and implemented, which includes: Regular inspection and maintenance of linens to ensure they are in good repair. Procedures for replacing linens that are no longer serviceable. A system for tracking linen inventory to ensure an adequate supply is maintained. b. Staff responsible for linen management have been trained on the new policy and procedures. 4. a. The facility administrator or designee will conduct weekly audits of line supplies and conditions to ensure compliance with the new policy. b. Results of audits will be reviewed at the facility's monthly Quality Assurance meetings, and any issues will be addressed immediately.
22VAC40-73-610-B
Based on observation and interview, facility failed to ensure menus for meals and snacks for the current week shall be dated and posted in an area conspicuous to residents and any substitutions or additions shall be recorded on the posted menu.
Evidence
  1. On 2/10/2025, documented the scheduled breakfast as waffles, eggs, sausage, fruit, coffee/water. The residents were served eggs, croissant, sausage, oatmeal. There were no waffles or fruit served to any of the residents in the dining room. The posted menu did not note the substitutions.
Plan of correction
1. a. The facility administrator has immediately reviewed the current week's menu and ensured it is dated and posted in a conspicuous areas accessible to al residents. b. Any substitutions or additions to the menu have been recorded on the posted menu. 2. a. A complete audit of all menu postings for the past 6 months was conducted. b. Any discrepancies found were promptly addressed by ensuring by ensuring all menus were properly dated, posted, and included any substitutions or additions. 3. a. A new Menu Posting Policy has been implemented, which includes: Menu will be dated and posted in a conspicuous area accessible to all residents. Any substitutions or additions to the menu will be recorded on the posted menu. A record of the menus serviced will be kept for tow years. b. Staff responsible for menu planning and posting have been trained on these requirements. 4. a. The facility administrator or designee will conduct weekly audits of menu postings to ensure compliance. b. Results of audits will be reviewed a the facility's monthly Quality Assurance meetings, and any issues will be addressed immediately.
22VAC40-73-325-B
Based on record reviewed, the facility failed to ensure that a fall risk assessment was reviewed and updated after every fall.
Evidence
  1. Resident # 7 had documented falls on 4/1/2024, 6/19/2024, 7/19/2024, 10/3/2024, and 11/25/2024. There was one undated fall risk assessment in the resident’s record.
  2. Staff # 1 acknowledged the only fall risk assessment in the resident’s record was the one undated assessment.
Plan of correction
1. a. The facility administrator has immediately conducted a comprehensive review of all resident records. b. Identified residents who experienced a fall without a subsequent updated fall risk assessment have been scheduled for re-assessment. c. Updated fall risk assessments have been completed and documented in the respective resident records. 2. a. A facility-wide audit of resident records was conducted to identify any other instances of non-compliance. b. Any discrepancies found were promptly addressed by scheduling the necessary physical examinations and ensuring documentation is complete. 3. a. A fall Risk Assessment Policy has been developed and implemented, which includes: At least annually; When the condition of the resident changes; and After a fall. Documentation of the updated assessments must be maintained in the resident's record. b. Staff responsible for conducting and documenting fall risk assessments have been trained on the new policy and procedures. 4. The facility administrator or designee will conduct monthly audits of resident records to ensure compliance with the new policy. Results of audits will be reviewed at the facility's monthly Quality Assurance meetings, and any issues will be addressed immediately.
22VAC40-73-350-B
Based on review of resident records, the facility failed to ascertain, prior to admission, whether a potential resident is a registered sex offender.
Evidence
  1. The resident record for Resident # 8 did not contain verification of a sex offender check conducted prior to admission.
  2. Staff #1 acknowledged there was no documentation in the file for staff to review during the time of the inspection.
Plan of correction
1. The facility administrator has immediately conducted a comprehensive review of all resident records. For residents where the sex offender screening was not documented, the administrator has ascertained whether the individual is a registered sex offender and has documented the results and the date the information was obtained. 2. A facility-wide audit of resident records was conducted to identify any other instances of non-compliance. Any discrepancies found were promptly addressed by performing the necessary screenings and ensuring documentation is complete. 3. A Sex Offender Screening Policy has been developed and implemented, which includes: All new residents must have a sex offender screening completed prior to admission. Documentation of the screening results and the date obtained must be maintained in the resident's record. Staff responsible for admissions have been trained on the new policy and procedures. 4. The facility administrator or designee will conduct monthly audits of resident records to ensure compliance with the new policy. Results of audits will be reviewed at the facility's monthly Quality Assurance meetings, and any issues will be addressed immediately.
22VAC40-73-450-F
Based on a review of resident records the facility failed to ensure that each resident's individualized service plan (ISP) contained a description of all needs/services identified.
Evidence
  1. The ISP for Resident # 5 documented the resident as being a low fall risk however the fall risk assessment documented the resident as being a high fall risk.
  2. Staff #1 acknowledged the ISP did not contain the correct fall risk information.
Plan of correction
1. a. The facility administrator has immediately conducted a comprehensive review of all resident ISPs. b. For residents whose ISPs did not include a description of all identified needs and services, the administrator has: c. Scheduled meetings with the resident and, as appropriate, their family, legal representative, and other involved parties to discuss and identity all current needs and services. d. Updated the ISPs to include detailed descriptions of all identified needs and the corresponding services to be provided. e. Ensured that the updated ISPs are signed and dated by the administrator and the resident or their legal representative. 2. a. A facility-wide audit of all resident ISPs was conducted to identify any other instances of non-compliance. b. Any discrepancies found were promptly addressed by updating the ISPs to include all identified needs and services. 3. a. A Comprehensive ISP Development Policy has been developed and implemented, which includes: Ensuring that all identified needs and services are documented in the ISP. Involving the resident and, as appropriate, their family, legal representative, and other involved parties in the development and review of the ISP. b. Regularly reviewing and updating the ISP to reflect any changes in the resident's needs or services. c. Staff responsible for developing and maintain ISPs have been trained on the new policy and procedures. 4. a. The facility administrator or designee will conduct monthly audits of resident ISPs to ensure compliance with the new policy. b. Results of audits will be reviewed at the facility's monthly Quality Assurance meetings, and any issues will be addressed immediately.
January 7, 2025Inspection8 violations
Inspection dates
01/07/2025
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
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: 1/7/2025 10:30 am- 12:30 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 1/4/2025 regarding allegations in the area(s) of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 68 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 3 Number of interviews conducted with staff: 3 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 Alyshia Walker, Licensing Inspector at 757-670-05 or by email at Alyshia.Walker@dss.virginia.gov
Violations
22VAC40-73-350-B
Based on resident record review, the facility failed to ascertain, prior to admission, whether a potential resident is a register sex offender.
Evidence
  1. Resident #1 was admitted 3/1/2024. The Sex Offender check was dated 7/17/2024.
Plan of correction
1. Immediate Correction: The resident's status has since been verified through the state's sex offender registry. No issues were identified, documentation of this verification has been added to the resident's admission file. 2. Identification of Others: A full audit of all current residents' records will be conducted to ensure proper verification of sex offender registry status is present. 3. Systemic changes: The admission checklist will be revised to include mandatory verification of sex offender status via the Virginia State Sex Offender Registry prior to admission. 4. Staff training: Admissions staff will be trained on this updated process. 5. Monitoring: The Administrator or designee will audit 100% of new admissions monthly for the next 3 months to ensure compliance.
22VAC40-73-440-F
Based on interviews conducted with facility staff and the review of facility records the facility failed to ensure that a resident’s UAI was completed within 90 days prior to admission to the assisted living facility.
Evidence
  1. Resident #1 was admitted on 3/1/2024. The resident record presented to the Licensing Inspector during the inspection contained a UAI dated 10/2/2023 which was used at the resident’s admission to the facility.
Plan of correction
1. Immediate Correction: The facility immediately arranged for a qualified assessor to complete the resident's UAI. 2. Identification of Others: An audit of all admissions over the past 6-12 months was completed to verify that a current (within 90 days)UAI was on file for each resident. 3. Systemic Changes: The facility's admission process was updated to include a mandatory review and verification of a valid UAI prior to accepting any new resident. 4. Staff Training: Admission staff were retrained on the regulatory requirement and new procedures. 5. Monitoring: The Administrator or designee will conduct an admission packet review for al new residents within 48 hours of move-in to ensure a valid UAI is on file.
22VAC40-73-450-F
Based on record review and interview with staff, the facility failed to ensure individualized service plans (ISPs) were reviewed and updated as needed for a significant change of a resident’s condition.
Evidence
  1. Resident #1 was admitted 3/1/2024. The UAI dated 9/10/2024 stated the resident had a diagnosis of cognitive decline and was prescribed Memantine HCL for dementia. The Assessment of Serious Cognitive Impairment dated 12/9/2024 noted the resident had periods of confusion and had poor insight. The most recent ISP dated 11/8/2024, which the facility was using to provide services, was not updated to reflect these significant changes in the resident’s condition.
Plan of correction
1. Immediate Correction: The ISPs of affected residents were immediately reviewed and updated to reflect their current condition, care needs, and service requirements. 2. Identification of Others: A facility-wide audit of resident records was conducted to identify residents who had experienced significant changes (hospitalizations, mobility decline, behavioral changes, etc.) withing the past 90 days. 3. Systemic Changes: The Change of Condition Notification Policy was revised to include immediate ISP review and documentation requirements. 4. Staff Training: Clinical and care staff received in-service training on recognizing significant changes and triggering ISP updates. 5. Monitoring: The Administrator or designee will review all incident reports, hospital transfers, and clinical progress notes weekly to identify potential significant changes.
22VAC40-73-210-B
Based on the on-site record review and staff interview the facility failed to ensure in a facility licensed for both residential and assisted living care, all direct care staff shall attend at least 18 hours of training annually. (Exception: Direct care staff who are licensed health care professions or certified nurse aides shall attend at least 12 hours of annual training).
Evidence
  1. The staff record for Staff # 3 (date of hire: 5/25/2022) did not contain documentation the staff member received required training for the year 5/25/2022 through 5/24/2023.There was no training record for the time period in the staff member’s record.
Plan of correction
Not published by VDSS.
22VAC40-73-410-A
Based on record review the facility failed to ensure upon admission, the assisted living facility provided orientation for new residents.
Evidence
  1. Resident #1 was admitted 3/1/2024. The resident did not receive orientation per the dated Resident Orientation form until 7/1/2024.
Plan of correction
1. Immediate Correction: All current residents who did not have documented orientation at admission were identified, each of these residents was given a complete orientation, including a review of resident rights, emergency procedures, services offered, and house rules, orientation forms were completed and filed in the resident's records. 2. Identification of others: A full audit of resident admission records from the pas 12 months was conducted, any files missing orientation documentation were flagged, and corrective action was taken as above. 3. Systemic Changes: The facility's Admission Checklist was revised to include a mandatory orientation section with a signature line for bother staff and resident, admission staff were retrained on the orientation procedure and documentation requirements. A Resident Orientation Packet was created, containing information on rights, services, emergency protocols, grievance procedures, and contact information for key personnel. 4. Staff Training: Admission staff were retained on the orientation procedure and documentation requirements. 5. Monitoring: The Administrator or designee will review all new admission packets within 72 hours move-in to confirm that orientation is completed and documented.
22VAC40-73-390-A
Based on resident record review, the facility failed to have a written agreement signed and dated by the resident or the appropriate legal representative and by licensee or administrator on or prior to the time of admission.
Evidence
  1. Resident #1 was admitted on 3/1/2024. The resident agreement was signed on 7/1/2024.
Plan of correction
1. a. The facility administrator has immediately reviewed the admission record of the affected resident (s). b. Written assurance of licensure has now been issued, signed by the administrator, acknowledged by the resident or legal representative, and filed in the resident's record. c. A complete audit of all resident admission records from the past 6 months was conducted. d. Any resident record found mission this documentation was corrected by obtaining the required assurance and signatures retroactively where possible. 2. a. The Admission Packet has been revised to include a standardized "Licensure Assurance Form" to be signed by the Administrator and acknowledged by the resident/legal representative prior to admission. b. A new Admission Documentation Checklist now includes verification of this document before finalizing any admission. c. The administrator or designee will verify that the assurance is completed and filed before a resident is officially admitted. 3. a. The Admissions Coordinator or designee will conduct monthly audits of new admission records for the next 6 months to ensure compliance. b. Results of audits will be reviewed a the facility's monthly QA meetings, and any issues will be addressed immediately.
22VAC40-73-320-A
Based on a record review, the facility failed to ensure the resident had a physical examination by an independent physician within the 30 days preceding admission.
Evidence
  1. Resident #1 was admitted on 3/1/2024. The file presented at the time of inspection contained a physical dated 1/25/2024.
Plan of correction
1. Immediate Correction: The resident's primary care provider was contacted, and a physical examination was completed and documented immediately, the completed physical exam form was filed in the resident's medical record. 2. Identification of Others: A complete audit of admission records for the past 6-12 months was conducted to identify any residents lacking documentation of a pre-admission physical, any missing or incomplete physicals were obtained and added to the respective resident files. 3. Systemic Changes: The Admission Policy was updated to include a mandatory verification of the pre-admission physical examination, a Pre-Admission Checklist was implemented to ensure all required documentation is obtained before move-in. 4. Staff Training Admissions staff received retraining on the regulation requiring a physical exam within 30 days prior to ad admission. 5. Monitoring: The Administrator or designee will audit all new admission packets within 48 hours of move-in to confirm that a valid physical examination is on file.
22VAC40-73-320-A
The facility failed to ensure a mental health screening was conducted prior to admission if behaviors or patterns of behavior occurred within the previous six months that were indicative of mental illness, intellectual disability, substance abuse or behavioral disorders and that caused or continue to cause, concern for the health safety, or welfare to that individual.
Evidence
  1. Resident #1 was admitted into the facility on 3/1/2024. The resident file did not have evidence a mental health screening had been conducted prior to admission. The UAI dated 10/3/2023, which was used to evaluate the resident for appropriateness for admission, indicated Resident #1 had behavior within the previous six months that were indicative of mental illness or behavioral disorders that caused or continue to cause, concern for the health, safety, or welfare either of that individual or others as the resident had been admitted to a behavioral health hospital due to having suicidal ideation.
Plan of correction
1. Immediate Correction: The resident has been evaluated by a qualified mental health professional to assess current behavioral and mental health status. 2. Identification of Others: The facility will conduct a comprehensive review of all residents admitted within the last 12 months to determine if any met the criteria for a required pre-admission mental health screening. 3. Systemic Changes: The facility's pre-admission assessment tool will be revised to include a specific section addressing recent behaviors indicative of mental illness, intellectual disability, substance abuse or behavioral disorders. 4. Staff Training: Admissions staff will be trained to identify concerning behaviors and initiate the referral process for a mental health screening prior to admission when applicable. 5. Monitoring: The Administrator or designee will audit all new admissions monthly for 90 days to ensure required mental health screenings are conducted prior to admission when indicated.
September 27, 2024Complaint survey5 violations
Inspection dates
09/27/2024
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint 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 9/20/2024 regarding allegations in the area(s) of: Staffing and Supervision Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 74 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: Number of interviews conducted with staff: 4 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation(s) of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint(s) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Violations
22VAC40-73-390-A
Based upon documentation review, the facility failed to ensure at or prior to the time of admission, there shall be a written agreement signed by the resident or legal representative.
Evidence
  1. Resident #1 was admitted to the facility on 12/29/2023. The resident agreement was dated 9/3/2024.
Plan of correction
1. a. The facility administrator has immediately reviewed the admission record of the affected resident (s). b. Written assurance of licensure has now been issued, signed by the administrator, acknowledged by the resident or legal representative, and filed in the resident's record. c. A complete audit of all resident admission records from the pat 6 months was conducted. d. Any resident record found missing this documentation was corrected by obtaining the required assurance and signatures retroactively where possible. 2. a. The Admission Packet has been revised to include a standardized "Licensure Assurance Form" to be signed by the Administrator and acknowledged by the resident/legal representative prior to admission. b. A new Admission Documentation Checklist now includes verification of this document before finalizing any admission. c. The administrator or designee will verify that the assurance is completed and filed before a resident is officially admitted. 3. a. The Admissions Coordinator or designee will conduct monthly audits of new admission records for the next 6 months to ensure compliance. b. Results of audits will be reviewed at the facility's monthly QA meetings, and any issues will be addressed immediately.
22VAC40-73-40-A
Based on record review and interview, the licensee failed to ensured compliance with all regulations for licensed assisted living facilities and with the facility’s own policies and procedures.
Evidence
  1. Resident #1 Experienced a medical emergency on 9/18/2024. The Licensing Inspector conducted an on-site inspection on 9/27/2024 and requested the related incident report. Staff #1 was unable to provide a written incident report which outlined the specific responsibilities and actions as outlined in the facility’s Resident Emergency Plan Policy which states the designated staff person responsible shall document the emergency and all actions taken.
Plan of correction
1. a. The facility administrator has immediately conducted a comprehensive review of all resident records, policies, and procedures to identify any areas of non-compliance. b. Necessary corrections have been made to ensure that all resident records are complete, accurate, and in compliance with applicable regulations and facility policies. 2. a. A facility-wide audit of all resident records and policies was conducted to identify any other instances of non-compliance. b. Any discrepancies found were promptly addressed, and corrective actions were implemented to ensure compliance. 3. a. The a facility's policies and procedures have been reviewed and updated to ensure they align with current regulations and best practices. b. A comprehensive training program has been developed and implemented for all staff to reinforce the importance of compliance with regulations and facility policies. c. A designated compliance officer has been appointed to oversee ongoing adherence to regulations and policies. 4. a. Regular audits of resident records and facility operations will be conducted on a quarterly basis to ensure continued compliance. b. The results of these audits will be reviewed by the facility's Quality Assurance Committee, and any necessary corrective actins will be taken promptly.
22VAC40-73-310-B
Based on records reviewed and staff interviewed, the facility failed to ensure documented interview between the administrator or designee responsible for admission and retention, between the individual, and the legal representative, if any was in the record for a resident.
Evidence
  1. The records for Resident # 1 (D.O.A. 12/29/2023), did not include documentation an interview occurred.
Plan of correction
1. a. The facility administrator has immediately reviewed the admission record of the affected resident (s). b. Written assurance of licensure has been issued, signed by the administrator, acknowledged by the resident or legal representative, and filled in the resident's record. c. A complete audit of all resident admission records from the past 6 months was conducted. d. Any resident record found missing this documentation was corrected by obtaining the required assurance and signatures retroactively where possible. 2. a. The Admission Packet has been revised to include a standardized "Licensure Assurance Form" to be signed by the Administrator and acknowledged by the resident's legal representative prior to admission. b. A new Admission Documentation Checklist now includes verification of this document before finalizing any admission. c. The administrator or designee will verify that the assurance is completed and filed before a resident is officially admitted. 3. a. The Admission Coordinator or designee will conduct monthly audits of new admission records for the next 6 months to ensure compliance. b. Results of audits will be reviewed at the facility's monthly QA meetings, and any issues will be addressed immediately.
22VAC40-73-310-D
Based on record review and staff interviewed, the facility failed to ensure prior to admission of a resident, the facility administrator provided written assurance to the resident that the facility has the appropriate license to meet the care needs at the time of admission. Acknowledgement of this document should be signed by the resident or a legal representative and kept in the resident’s record.
Evidence
  1. Resident #1 was admitted on 12/29/2023, the resident’s file did not contain documentation of written assurance being provided to the resident or responsible party.
Plan of correction
1. a. The facility administrator has immediately reviewed the admission record of the affected resident (s). b. Written assurance of licensure has now been issued, signed by the administrator, acknowledged by the resident or legal representative, and filed in the resident's record. c. A complete audit of all resident admission records from the past 6 months was conducted. d. Any resident record found missing this documentation was corrected by obtaining the required assurance and signatures retroactively where possible. 2. a. The Admission Packet has been revised to include a standardized "Licensure Assurance Form" to be assigned by the Administrator and acknowledged by the resident/legal representative prior to admission. b. A new Admission Documentation Checklist now includes verification of this document before finalizing any admission. c. The administrator or designee will verify that the assurance is completed and filed before a resident is officially admitted. 3. a. The Admissions Coordinator or designee will conduct monthly audits of new admission records for the next 6 months to ensure compliance. b. Results of audits will be reviewed at the facility's monthly QA meetings, and any issues will be addressed immediately.
22VAC40-73-280-A
Based on documents reviewed and staff interviewed, the facility failed to ensure it had 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 the resident assessments and individualized service plans.
Evidence
  1. The Disclosure Form for Resident #1 documented the 11:00 p.m. to 7:00 a.m. shift would have 2 direct care staff members on duty.
  2. The staff schedule for 9/18/2024 documented Staff #2 was scheduled to work from 11:00 p.m.- 7:00 a.m. and Staff #3 was scheduled to work from 11:00 p.m.- 7:00 a.m. The timecard for Staff #3 documented the staff member worked form 3:05 a.m. to 7 a.m. and not the scheduled 11:00 pm -7:00 am.
  3. Staff # 3 verified their hours worked as 3:05 am – 7:00 am.
  4. From 11:00 pm to 3:05 am there was only 1 direct staff member on duty to provide emergency medical assistance to Resident #1 who eventually passed away in the facility.
  5. Resident # 1 experienced a medical emergency at approximately 2:21 am. The resident required PRN oxygen to be administered and later CPR. The one staff member had to assist the resident with connecting the oxygen, calling 911, performing PR and ensuring the safety of the remaining 71 residents of the facility.
Plan of correction
1. Staffing Assessment and Adjustment: a. A comprehensive staffing analysis was conducted to compare resident needs, as outlined in their assessments and ISPs, with current staff levels and competencies. b. Based on this analysis, staffing adjustments have been made to ensure proper staff-to-resident ratios during all shifts. 2. Training and Education: a. All current staff are undergoing mandatory retraining on key areas including: i. Understanding and implementing resident ISPs. ii. Identifying and responding to physical, mental , and psychological needs. b. A structured orientation and ongoing training schedule have been implemented for new hires, focusing on: i. Dementia care ii. Mental health awareness iii. Basic and advanced caregiving skills c. Training is documented and reviewed quarterly. 3. Competency Evaluations: a. All staff are being evaluated for competency in the areas related to their job duties, especially in implementing individualized care plans. b. Those not meeting competency standards will receive targeted coaching or be reassigned as appropriate. 4. Hiring Plan: a. A recruitment initiative is underway to ensure sufficient staff coverage on all shifts, including: i. Partnering with local job boards, training programs, and staffing agencies. ii. Offering hiring and retention incentives where appropriate. 5. Ongoing Monitoring and Oversight: a. The Administrator or designee will conduct weekly audits of staff performance and alignment with resident ISPs for 60 days. b. Monthly team meetings will review staffing concerns, training needs, and resident care outcomes. c. A quarterly Quality Assurance (QA) review will assess overall compliance and adjust plans as needed.
September 27, 2024Inspection1 violation
Inspection dates
09/27/2024
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES
Comments
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 9/20/2024 regarding allegations in the area(s) of: Incident Report Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 75 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: Licensing Inspector also spoke with hospice nurse. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alyshia Walker, Licensing Inspector at 757-670-0504 by email at Alyshia.Walker@dss.virginia.gov
Violations
22VAC40-73-70-A
Based on a review of documentation and interviews, it was determined that the facility failed to ensure that the facility reported to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident.
Evidence
  1. A self-report was received by the licensing inspector on 9/20/2024, that Resident #1 was discovered missing from the facility on 9/15/2024, and had not returned as of the date of the self-report.
  2. The administrator of the facility also reported on 9/20/2024, that Resident #2 had unexplained bruising on their arm, and above their wrist (size of a silver dollar), and on the right thigh.
  3. The reports for the above incidents were not received within 24 hours of the incidents occurring.
  4. Staff #1 acknowledged the above incidents were not reported to the division of Licensing within 24 hours of the incidents occurring.
Plan of correction
Not published by VDSS.
July 30, 2024Inspection10 violations
Inspection dates
07/30/2024
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7/30/2024 7:30 am- 1:46 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 74 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Number of staff records reviewed: 13 Number of interviews conducted with residents:2 Number of interviews conducted with staff: 5 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alyshia Walker, Licensing Inspector at 757-690-0504 or by email at Alyshia.Walker@dss.virginia.gov
Violations
22VAC40-73-260-A
Based on a review of staff records, the facility failed to ensure each direct care staff member who does not have current certification in first aid as specified in subdivision 1 of this subsection shall receive certification in first aid within 60 days of employment.
Evidence
  1. The employee files for Staff #4 (D.O.H. 4/30/2024), and Staff #5 (D.O.H. 5/28/2024), did not contain verification of First Aid certification.
Plan of correction
1. Immediate Correction All direct care staff without current first aid certification were identified and scheduled for certification training. Documentation of completed certifications was placed in personnel files. 2. Identification of Others A full review of all direct care staff certifications was completed to ensure compliance. Any missing certifications were addressed promptly. 3. Systemic Changes A tracking system was implemented to monitor first aid certification status and deadlines. Hiring procedures now require scheduling certification withing the first 60 days. 4. Staff Training Human Resources and supervisors were retrained on certification requirements and tracking responsibilities. 5. Monitoring The Executive Director will review certification status monthly to ensure ongoing compliance.
22VAC40-73-320-A
Based on record reviewed and staff interviewed, the facility failed to ensure within 30 days preceding admission, a person shall have a physical examination by an independent physician which includes the results of a risk assessment documenting the absence of tuberculosis in a communicable form as
Evidence
  1. d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: Resident # 5’s date of admission was 7/3/2024. The TB assessment in the resident file for licensing inspectors to review at the time of inspection was dated 7/23/2024.
Plan of correction
1. a. The facility administrator has immediately conducted a comprehensive review of all resident records. b. For residents whose physical examination reports were not completed within the required timeframe or were missing required elements, the administrator has: c. Scheduled the necessary the necessary physical examinations with an independent physician. d. Ensured that the examination reports include all required elements, including the tuberculosis risk assessment. e. Obtained and filed the completed reports in the respective resident records. 2. a. A facility-wide audit of resident records was conducted to identify any other instances of non-compliance. b. Any discrepancies found were promptly addressed by scheduling the necessary physical examinations and ensuring documentation is complete. 3. a. a Physical Examination and Tuberculosis Screening Policy has been developed and implemented, which includes: b. All new residents must have a physical examination by an independent physician within 30 days preceeding admission. c. The examination report must include all required elements as specified in 22VAC40-73-320 A including the tuberculosis risk assessment. d. Documentation of the examination and risk assessment must be maintained in the resident's record. e. Staff responsible for admissions and record-keeping have been trained on the new policy and procedures. 4. a. The facility administrator or designee will conduct monthly audits of resident records to ensure compliance with the new policy. b. Results of audits will be reviewed at the facility's monthly Quality Assurance meetings, and any issues will be addressed immediately.
22VAC40-73-250-D
Based on a review of staff records the facility failed to ensure that each staff person submit the results of a tuberculosis (TB) risk assessment on or within seven days prior to the first day of work at the facility and that each staff person submit the results of a risk assessment annually.
Evidence
  1. The file for Staff #4 (D.O.H. 4/30/2024), and Staff # 5 (D.O.H. 5/28/2024), did not contain TB risk assessments.
Plan of correction
1. Immediate Correction: Obtained missing TB risk assessment results for identified staff and filed in personnel records. 2. Identification of Others: Conducted an audit of all staff files to identify any other missing or overdue TB risk assessments. Any deficiencies were promptly corrected. 3. Systemic Changes: Revised the hiring and annual health assessment processes to include verification of completed TB risk assessments before the first workday and annually. A tracking system was implemented to monitor due dates. 4. Staff Training Human Resources and supervisory staff were retrained on TB risk assessment requirements and documentation procedures. 5. Monitoring The Executive Director or designee will review TB risk assessment compliance monthly and report findings to the Quality Assurance Committee.
22VAC40-73-410-A
Based on record reviewed and staff interviewed, the facility failed to ensure the record included an acknowledgment of receiving orientation signed and dated by the resident or legal representative and kept in the resident’s record.
Evidence
  1. On 7/30/2024, Resident # 5’s record did not include signed and dated documentation of an orientation for new residents which included information regarding mealtimes, the use of the call bell system.
Plan of correction
1. Immediate Correction All current residents who did not have documented orientation at admission were identified, each of these residents was given a complete orientation, including a review of resident rights, emergency procedures, services offered, and house rules, orientation forms were completed and filed in the resident's records. 2. Identification of Others A full audit of resident admission records from the past 12 months was conducted, any files mission orientation documentation were flagged, and corrective action was taken as above. 3. Systemic Changes The facility's Admission Checklist was revised to include a mandatory orientation section with a signature line for both staff and resident, admission staff were retrained on the orientation procedure and documentation requirements. A Resident Orientation Packet was created, containing information on rights, services, emergency protocols, grievance procedures, and contact information for key personnel. 4. Staff Training Admission staff were retrained on the orientation procedure and documentation requirements 5. Monitoring The Administrator or designee will review all new admission packets within 72 hours of move-in to confirm that orientation is completed and documented.
22VAC40-73-40-B
Based on the employee record review, the facility failed to ensure the criminal history record report was obtained on or prior to the 30th day of employment for each employee.
Evidence
  1. The staff files reviewed at the time of inspection for Staff members # 11 (D.O.H. 4/30/2024), #9 (D.O.H. 4/16/2024), #13 (D.O.H. 5/01/2024), and # 10 (D.O.H. 4/16/2024), did not contain criminal history reports.
Plan of correction
1. Immediate Correction: Obtained missing TB risk assessment results for identified staff and filed in personnel records. 2. Identification of Others: Conducted an audit of all staff files to identify any other missing or overdue TB risk assessments. Any deficiencies were promptly corrected. 3. Systemic Changes: Revised the hiring and annual health assessment processes to include verification of completed TB risk assessments before the first workday and annually. A tracking system was implemented to monitor due dates. 4. Staff Training: Human Resources and supervisory staff were retrained on TB risk assessment requirements and documentation procedures. 5. Monitoring: The Executive Director or designee with review TB risk assessment compliance monthly and report findings to the Quality Assurance Committee. 5. Monitoring: The Administrator or designee will conduct monthly audits of new hire files for the next 90 days to ensure criminal background checks are filed in a timely manner.
22VAC40-90-30-B
Based on the staff record review, the facility failed to ensure the sworn statement or affirmation shall be complete for all applicants for employment.
Evidence
  1. The staff files reviewed at the time of the inspection did not contain Sworn Disclosures for Staff #8, Staff #9, and Staff #10.
Plan of correction
1. Immediate Correction: The incomplete sworn statement was corrected and completed for the identified staff member. A copy was placed in the personnel file. 2. Identification of Others: A full audit of all current employee files was conducted. Any missing or incomplete sworn statements were obtained and filed. 3. Systemic Changes: The hiring checklist was updated to require verification of a completed sworn statement before any applicant may begin employment. No applicant may start work without this document on file. 4. Staff Training: Human Resources staff were retrained on employment file requirements, including proper handling of sworn statements and affirmations. 5. Monitoring: The Executive Director or designee will review all new hire files weekly for 90 days to ensure compliance, then monthly thereafter.
22VAC40-73-120-A
Based on the review of facility records and interviews conducted with facility staff, the facility staff failed to ensure that the orientation and required training occurred within the first seven working days of employment.
Evidence
  1. Staff #4’s (D.O.H. 4/30/2024), record did not contain documentation that the staff member received orientation.
Plan of correction
1. Immediate Correction All staff members identified as not having completed orientation within the required timeframe have now received and completed the full orientation and required training. 2. Identification of Others A full audit of current staff files was conducted to identify any other employees who did not complete orientation within the first 7 working days. 3. Systemic changes The onboarding process has been revised to ensure that all new employees are scheduled for orientation immediately upon hire. 4. Staff training Human Resources and department managers will be trained on enforcing and tracking orientation timelines. 5. Monitoring The Administrator or designee will conduct monthly audits of new hire records for the next 90 days to ensure compliance with orientation requirements.
22VAC40-73-680-I
Based on resident record review and review of the Medication Administration Record (MAR), the facility failed to have all items required by standards on the MAR.
Evidence
  1. Resident #3’s July 2024 MAR did not contain documentation verifying whether the resident’s prescribed DOK 100 mg was administered on 7/5/2024 and 7/9/2024. Resident #3’s July 2024 MAR did not contain documentation verifying whether the resident’s prescribed Hydroxyzine PAM 50 mg was administered as order on 7/5/2024 (am and noon doses) and 7/9/2024. Resident #3’s July 2024 MAR did not contain documentation verifying whether the resident’s prescribed Risperidone 0.5 mg was administered as prescribed on 7/5/2024 and 7/9/2024. Resident #4’s July 2024 MAR did not contain documentation verifying whether the resident’s prescribed Metronidazole 500 mg was administered as prescribed on 7/2/2024, 7/3/2024, 7/5/2024 (2 doses). 7/11/2024, 7/15/2024, 7/20/2024, and 7/20/2024. Resident #4’s July 2024 MAR did not contain documentation verifying whether the resident’s prescribed Propranolol 10 mg was administered as prescribed on 7/5/2024 and 7/14/2024. Resident #4’s July 2024 MAR did not contain documentation verifying whether the resident’s prescribed Risperidone 2 mg tablet was administered as prescribed on 7/5/2024. Resident #2’s July 2024 MAR did not contain documentation verifying whether the resident’s prescribed Aspirin 81 mg was administered on 7/5/2024 and 7/9/2024. Resident #2’s July 2024 MAR did not contain documentation verifying whether the resident’s prescribed Certavite tablet was administered on 7/5/2024 and 7/9/2024. Resident #2’s July 2024 MAR did not contain documentation verifying whether the resident’s prescribed Clozapine 100 mg tablet am doses were administered on 7/5/2024 and 7/9/2024. Resident #2’s July 2024 MAR did not contain documentation verifying whether the resident’s prescribed Propranolol 10 mg on 7/5/2024, 7/9/2024. Resident #2’s July 2024 MAR did not contain documentation verifying whether the resident’s prescribed Vitamin B-6 on 7/5/2024 and 7/9/2024. There were no responses recorded on the electric MARS to explain the missing initials for MARS for residents #3, #4, and #2.
Plan of correction
1. Immediate Correction All MARs identified as missing required information (e.g., resident name, medication name, dosage, route, time, prescribing physician, start/stop dates, and staff initials/signatures) were reviewed and corrected immediately. 2. Identification of Others A full audit of all current resident MARs will be completed by to ensure that each record includes all components required by state and facility regulations. 3. Systemic Changes The MAR template used by the facility will be reviewed and revised, if necessary, to ensure it captures all regulatory elements. 4. Staff Training Ongoing staff training will be provided quarterly to reinforce the importance of accurate and complete MAR documentation. 5. Monitoring The Medication Manager or designee will conduct weekly MAR audits for the next 60 days to verify compliance.
22VAC40-73-350-B
Based on review of resident records, the facility failed to ascertain, prior to admission, whether a potential resident is a registered sex offender.
Evidence
  1. The record for Resident #5 (D.O.A. 7/2/2024) contained a sex offender verification dated 7/17/2024.
Plan of correction
1. a. The facility administrator has reviewed all current resident records to identify any instances where the sex offender screening was not conducted prior to admission. b. For any identified residents, the administrator has conducted the necessary sex offender screenings and documented the results and the date the information was obtained in the respective resident records. 2. a. The facility has updated its admission policies and precures to include a step for verifying whether a potential resident is a registered sex offender prior to admission. b. A checklist has been implemented to ensure that this verification is completed and documented for all prospective residents. 3. a. All staff involved in the admission process have been trained on the updated policies and procedures regarding sex offender screenings. b. Training includes the importance of conducting these screenings and properly documenting the results. 4. a. The facility will conduct monthly audits of resident records to ensure compliance with the updated admission procedures. b. Any discrepancies identified during audits will be addressed promptly, and corrective actions will be implemented as necessary.
22VAC40-73-620-A
Based on record review, the facility failed to implement its written plan for medication management, specifically regarding its methods to ensure accurate counts of all controlled substances whenever assigned medication staff changes.
Evidence
  1. A review of the Controlled Substance Verification/Shift Count Sheet for the medication cart failed to ensure counts of all controlled substances occurred between oncoming staff and off going staff as the sheet was missing the required staff signatures.
Plan of correction
Not published by VDSS.
April 8, 2024Complaint survey2 violations
Inspection dates
04/08/2024, 04/16/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 4/8/2024 and 4/16/2024 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 2/23/2024 regarding allegations in the area(s) of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 77 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint(s) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Violations
22VAC40-73-680-B
Based on observation and staff interview, the facility failed to ensure medication shall remain in the pharmacy issued container, with the prescription label or direction label attached, until administered to the resident.
Evidence
  1. On 4/08/2024, during an on-site observation of the medication pass with Staff #1, the licensing inspection observed pre-poured medications for 2 residents in the top drawer of the medication cart.
Plan of correction
1. Re-education for all Certified Medication Aides on the medication management policy. They have been re-educated those medications are not to be pre-poured under any circumstance, And, 1. Re-education for all Certified Medication Aides on the medication management policy. They have been re-educated those medications are not to be pre-poured under any circumstance, And, that all medications are to remain in the pharmacy packaging until administering medication to the prescribed resident. The medication administration has been reviewed with each Medication-Aide and signed by each Medication Aide stating that they understand the policy. Any Medication Aide found pre-pouring medication going forward will be suspended for three days without pay and a second offense will result in termination. 2. The Administrator and Unit Coordinator will routinely make unannounced cart inspections to observe the Med-Techs to look for any pre-poured medications in the carts. 3. If, any pre-poured medications are found the Med-Tech will be subject to disciplinary actions.
22VAC40-73-310-H
Based on record review and staff interview, the facility failed to ensure it did not admit or retain individuals with psychotropic medications without a treatment plan.
Evidence
  1. Resident #1 was prescribed Risperdone 2 mg, and Trazodone 50mg. The resident’s file did not contain psychotropic treatment plans for the prescribed medications.
Plan of correction
1. Counseling and re-education were provided to the staff members responsible for placing existing treatment plans in every resident chart that is on psychotropic medication. Any new residents entering the facility on psychotropic medication will have a treatment plan placed in their chart. 2. A new process has been developed, implemented whereas all residents’ charts have been audited and psychotropic treatment plans have been placed in each resident’s chart.
April 8, 2024Complaint survey3 violations
Inspection dates
04/08/2024, 04/16/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 4/8/2024, 4/16/2024 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 2/25/2024 regarding allegations in the area(s) of: Resident Care and Related Services Buildings and Grounds Number of residents present at the facility at the beginning of the inspection: 77 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents:3 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint(s) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions please contact Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov.
Violations
22VAC40-73-870-B
Based on smell and staff interviewed, the facility failed to ensure the building was well-ventilated and free from foul, stale, and musty odors.
Evidence
  1. On 4/8/2024 and 4/16/2024 during a physical plant inspection of the facility, the facility had a strong smell of urine throughout the entire facility.
Plan of correction
1.Additional staffing has. been added to all departments. An evening and overnight shift has been added to laundry and housekeeping staff. 2. The facility has invested in better cleaning solutions to enhance the cleaning and overall appeal of the facility. 3. The Director of Operations and the Administrator has educated housekeeping staff on proper measuring of cleaning solutions for optimum cleaning results. 4. The leadership team makes routine rounds daily to inspect the facility for smells and odors.
22VAC40-73-870-D
Based on observations made during a tour of the building, the facility failed to ensure buildings shall be kept free of infestations of insects and vermin.
Evidence
  1. The licensing inspector observed a moving bed bug in a resident bedroom #49.
  2. The licensing inspector interviewed several residents who stated there were roaches in their bedroom and bathroom.
Plan of correction
1. A contractor has been retained to stray twice weekly for roaches and bedbugs. The contract began in April. 2. Residents with personal refrigerators have been informed of the new policy going into effect on July 1, they will no longer be able to have personal refrigerators in their rooms. This will help elevate the roach issues. 3. Residents are not allowed to eat in their room unless they are sick. 4. Maintenance will spray in between the twice weekly visits as needed.
22VAC40-73-870-A
Based on observation and staff interviewed, the facility failed to ensure the interior of the building was maintained in good repair and kept clean and free of rubbish.
Evidence
  1. The faceplate to an electrical outlet was missing in resident bedroom.
  2. The ceiling in the hallway near resident room #23 was patched and in need of repair.
  3. Staff #3 acknowledged the missing faceplate and ceiling were in need of repair.
Plan of correction
1. The faceplate to the electrical outlet has been replaced in the resident room by maintenance as reported. Each resident room has been inspected by the Director of Operations along with the Administrator and maintenance department. Walk-throughs are performed monthly and documented by maintenance. 2. The ceiling in the hallway in front of room #23 has been repaired by maintenance. 3. The ceiling has been repaired by maintenance. The place plate has been replaced by maintenance.
April 8, 2024Inspection17 violations
Inspection dates
04/08/2024, 04/11/2024, 04/16/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 4/8/2024 7:56 am- 2:00 pm, 4/11/2024 7:30 am- 2:00 pm, 4/16/2024 1:46 pm- 4:52 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 77 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 6 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 5 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Violations
22VAC40-73-320-B
Based on the review of facility records with the facility Administrator, the facility failed to ensure that a risk assessment for tuberculosis was completed annually on each resident.
Evidence
  1. Resident # 5’s date of admission was 6/2/23. The TB assessment in his chart dated 5/10/23 was incomplete as it did not state if the resident required TB testing.
  2. Resident #3’s date of admission was 6/8/20. The file did not contain a TB evaluation for the licensing inspector to review.
  3. Resident #6’s date of admission was 4/2/19. The most recent TB evaluation in the file was dated 6/18/21.
  4. Resident #8’s date of admission was 3/18/19. The file did not contain a TB evaluation for the licensing inspector to review.
Plan of correction
1.TB risk assessment has been completed on each resident and placed in their records. 2. All new admission will TB risk assessments completed at the time of admission. 3. All TB assessment will be completed annually on all residents and placed in their charts.
22VAC40-73-440-B
Based on record reviewed and staff interviewed, the facility failed to ensure it was in compliance with the requirements set forth in 22VAC30-110.
Evidence
  1. On 4/11/24, Resident #5’s uniformed assessment instrument (UAI) dated 4/8/24 was completed by a facility staff. The document was not signed by the administrator or designee.
Plan of correction
1.Resident in question UAI has been signed by the Administrator. 2.All other resident records have been reviewed and the updated UAI’s are being signed by the Administrator. 3.An entirely new charting system is in the process of being implemented to ensure that all vital and pertinent information is in all resident files. 4.This process was begun prior to the completion of this survey. 5. Any outdated UAI’s have been sent to the appropriate agency for update and upon receiving the new updated UAI’s the Administrator will sign immediately.
22VAC40-73-120-A
Based on the review of facility records and interviews conducted with facility staff, the facility staff failed to ensure that the orientation and required training occurred within the first seven working days of employment.
Evidence
  1. The staff orientation checklist for Staff members #1 and #3 were blank.
  2. Staff #5’s record did not contain any documentation that the staff member received orientation.
Plan of correction
1. Counseling and re-education were provided to the staff members responsible for the new hire process. 2. All new staff have been hired and trained in the process for new hires. The administrator will review all new hire information along with the Business Office Manager to ensure that all documents are completed and signed.
22VAC40-73-250-D
Based on a review of staff records the facility failed to ensure that each staff person submit the results of a tuberculosis (TB) risk assessment on or within seven days prior to the first day of work at the facility and that each staff person submit the results of a risk assessment annually.
Evidence
  1. The files for Staff members #1 (D.O.H. 3/20/2024), #3 (D.O.H. 4/8/24), #5 (D.O.H. 12/18/2023), and #6 (D.O.H. 10/11/2021) did not contain TB risk assessments.
  2. The file for Staff #4 did not contain an annual TB risk assessment. The most recent assessment was dated 1/28/2022.
  3. The file for Staff #6 did not contain an annual TB risk assessment. The most recent assessment was dated 4/22/2022.
Plan of correction
1. An audit of all employee files was begun prior to the completion of this audit to bring all files into compliance, and to ensure that relevant documents are in each employee’s file. 2. A TB risk assessment has been completed on every employee to ensure that all employee records comply. 3. All employee files will be audited by the administrator quarterly according to month of hire to ensure that all files are complying.
22VAC40-73-680-I
Based on resident record review and review of the Medication Administration Record (MAR), the facility failed to have all items required by the Standards on the MAR.
Evidence
  1. On 4/8/2024 during the on-site inspection, the licensing inspector observed Staff# 3 administering medication without having the MAR or copy of the physician’s orders for the medications being administered.
  2. Staff members #2 and #3 acknowledged the computer system was not working properly and therefore the EMARs for the residents were not available.
Plan of correction
1.We have hired an LPN whose responsibility will be auditing and reviewing resident charts, physician orders, the MAR, and the medication cart supply. 2.Staff have been re-educated to correct policy and procedure on how to properly administer medication. 3.The pharmacy has been contacted to send a copy of all resident’s physician orders to facility for backup.
22VAC40-73-490-A
Based on staff interview the facility failed to ensure a licensed health care professional, practicing within the scope of his profession, shall provide healthcare oversight at least every three months, or more often if indicated, based on his professional judgement of the seriousness of a resident’s needs or stability of a resident’s condition.
Evidence
  1. On 4/8/24, the most current Healthcare Oversight the facility was able to provide during the on-site inspection was for the quarter ending 3/28/23.
Plan of correction
1. The Administrator has spoken with the Medical Director and expressed the need for residents to be seen more frequently. 2. The Medical Director has assigned a NP to the facility on a weekly basis. 3. The Administrator is currently exploring other providers for the resident care needs. 4. The Healthcare Oversight was performed on 01/17/2024. The next scheduled oversight is scheduled for 10/2024.
22VAC40-73-450-C
Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) included all assessed needs.
Evidence
  1. The record for Resident #5 did not contain a comprehensive ISP.
Plan of correction
1.All resident medical records have been audited by a licensed contractor and all resident ISP’s have been updated according to standards. 2. The residents ISP will be placed on a spreadsheet according to their admission date for quarterly review, and when there is a change in the resident’s condition.
22VAC40-73-450-C
Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) included all assessed needs.
Evidence
  1. The record for Resident #5 did not contain a comprehensive ISP.
Plan of correction
1. All resident medical records have been audited by a licensed contractor and all resident ISP’s have been updated according to standards. 2. The residents ISP will be placed on a spreadsheet according to their admission date for quarterly review, and when there is a change in the resident’s condition.
22VAC40-73-450-E
Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) shall be signed and dated by the resident or the legal representative.
Evidence
  1. The ISP for Resident #3 with a review date of 3/22/24 did not contain a resident of legal representative signature.
  2. The ISP for Resident #7 with a review date of 4/8/24 did not contain a resident of legal representative signature.
  3. The ISP for Resident #9 with a review date of 3/1/2024 did not contain a resident or legal representative signature.
  4. The ISP for Resident #10 with a review date of 3/25/24 did not contain a resident of legal representative signature.
Plan of correction
Not published by VDSS.
22VAC40-73-450-F
Based on staff interview and review of resident records, the facility failed to update the ISP (Individualized Service Plan) at least once every 12 months.
Evidence
  1. The ISP for Resident #1 had an end date timeframe of 4/2/2020.
  2. The ISP for Resident #2 had an end date timeframe of 4/9/2022.
  3. The ISP for Resident #6 was not reviewed every 12 months. The ISP was reviewed 8/4/22 and on 4/8/24. There was no review documented in 2023.
  4. The ISP for Resident #9 was not reviewed every 12 months. The ISP was reviewed 4/1/2020 and on 3/1/2024. There were no annual ISP reviews documented for 2021, 2022, or 2023.
  5. The ISP for Resident #10 was not reviewed every 12 months. The ISP was reviewed on 12/30/2021 and 3/25/2024. There were no annual ISP reviews documented for 2022 or 2023.
Plan of correction
1. A quarterly review of resident files has been scheduled to ensure ISPs are consistently up to date. 2. The facility is in the process of purchasing an EMR, which will allow us to receive alerts when ISPs are due to be renewed. Until then a spreadsheet with renewal dates will be created to facilitate tracking ISP documentation. 3. Prior to the date of this survey the facility hired a Nurse Consultant to begin auditing all residents Individualized Service Plans (ISP) and bring them into compliance. 4. The Administrator is registered to take the certification course on 08/08/2024 to become trained to become educated to assist in the ISP process that the facility remains in compliance going forward.
22VAC40-73-310-B
Based on records reviewed and staff interviewed, the facility failed to ensure a documented interview between the administrator or designee responsible for admission and retention, the individual, and the legal representative, if any was in the record for a resident.
Evidence
  1. Resident #5’s record did not include documentation of an interview. The Resident’s date of admission was 6/2/23.
Plan of correction
1. New processes have been put in place for all new admissions going forward, including the initial admission assessment which will be completed by the administrator and the Business Office Manager. 2. New admissions will be oriented to the facility by the administrator and again by the clinical staff during the initial head-to-toe evaluation process upon admission.
22VAC40-73-410-A
Based on record reviewed and staff interviewed, the facility failed to ensure the record included an acknowledgement of having received the orientation and shall be signed and dated by the resident, and as appropriate the legal representative and shall be kept in the resident’s record.
Evidence
  1. On 4/8/24, Resident #5’s record did not include documentation of an orientation for new residents which included information regarding mealtimes, the use of the call system, and the emergency response procedures.
Plan of correction
Not published by VDSS.
22VAC40-73-290-B
Based on observation, the facility failed to ensure the posting of the name of the current on-site person in charge.
Evidence
  1. On the date of the inspection 4/8/2024, there was no posting of the on-site person in charge.
  2. Staff member #1 acknowledged there was no posting.
Plan of correction
1.Upon entering the facility. A board displaying the names, position, and phone numbers of each Leadership Member. 2. The board was updated prior to the final inspection date of this survey. At any time, if any of the leadership member change, the board will be updated to reflect the change immediately.
22VAC40-73-440-A
Based on a review of resident records, the facility failed to ensure complete Uniform Assessment Instruments (UAIs) records were reviewed at least annually.
Evidence
  1. The last documented UAI for Resident #1 was dated 2/9/2022.
  2. The last documented UAI for Resident #2 was dated 3/23/2023.
  3. The last documented UAI for Resident #3 was dated 11/3/2020 and there was no assessor signature.
  4. The last documented UAI for Resident #7 was dated 2/28/2023 and there was no assessor signature.
  5. The last documented UAI for Resident #8 was dated 3/21/2024 and there was no assessor signature.
  6. The last documented UAI for Resident #9 was dated 11/10/2022 and there was no assessor signature.
  7. The last documented UAI for Resident #10 was dated 3/1/2024. The resident’s date of admission was 5/25/2018. There were no UAI assessments documented in the resident file for 2022 or 2023.
Plan of correction
1. A quarterly review of resident’s files has been scheduled to ensure UAI’s are consistently up to date. 2. The facility is in the process of purchasing and EMR, which will allow us to receive alerts when UAI’s are due to be renewed. Until then, a spreadsheet with renewal dates is being created to facilitate tracking UAI’s renewals. 3. A new Business Office Manager along with a new Nurse Consultant has begun the process prior to the completion of this survey, auditing every resident UAI to bring them all into compliance. 4. All UAI’’s will be setup on quarterly schedules according to their admission dates to better stay on top of this process going forward. 5. New tracking systems are also being incorporated.
22VAC40-73-250-C
Based on a review of staff records, the facility failed to verify that each staff person has received a copy of his or her current job description.
Evidence
  1. Staff members #1 and #5’s file did not contain documentation of a signed job description.
Plan of correction
1. Prior to final inspection date the administrator had begun auditing all employee files to bring them all into compliance. 2. All employees were given a new hire packet which included job descriptions, new 2024 tax forms, Resident Rights, and other required forms. 3. All employees were required to sign all new forms during the monthly mandatory staff meeting to ensure going forward that all employees remain in compliance.
22VAC40-73-610-B
Based on observation of facility postings, the facility failed to ensure that menus for meals and snacks for the current week shall be dated and posted in an area conspicuous to residents.
Evidence
  1. During the on-site inspection on 4/8/2024, there was no menu for the month posted.
  2. Staff member # 1 acknowledged there was no menu posted.
Plan of correction
1. Menus for all three meals and snacks are posted outside the dining room doors upon entering the dining room. 2. Larger calendars have been ordered to go on the dining room door for residents to better see what is being served for each meal and snack.
22VAC40-73-520-I
Based on observations made during a tour of the building, the facility failed to ensure the current month's activity schedule shall be posted in a conspicuous location in the facility.
Evidence
  1. During the on-site inspection on 4/8/2024, the posted activities calendar was observed to be for February 2024.
  2. Staff member #2 acknowledged there was no current activity schedule posted.
Plan of correction
1. The activity calendar is posted on the wall across from the nursing station. 2. Three-38 inches by 50 inches jumbo activities calendars have been ordered to display daily activities. 3. The next months calendar will always be prepared ahead of time in the event that any activities need to be changed.
December 18, 2023Complaint survey16 violations
Inspection dates
12/18/2023, 02/12/2024
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS
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: 12/8/2023, 2/12/2024 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 11/21/2023 regarding allegations in the area(s) of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 75 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 16 Number of staff records reviewed:3 Number of interviews conducted with residents:2 Number of interviews conducted with staff: 4 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint(s) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Violations
22VAC40-73-680-M
Based on observations made during the medication cart audit, the facility failed to ensure medications ordered for PRN administration shall be available.
Evidence
  1. The December 2023 MAR for Resident #14 and physician’s orders indicate the resident has been prescribed Tramadol 50 mg to be administered by mouth every 8 hours as needed for pain.
  2. A medication cart audit with Staff #3 determined there was no Tramadol on the cart to be administered to the resident.
  3. Staff #3 acknowledged there was no Tramadol 50 mg for Resident # 14.
Plan of correction
1. We have hired an LPN whose responsibility will be auditing and reviewing resident charts, physician orders, the MAR, and the medication cart supply. 2. We had an outside pharmacist complete an additional pharmacy oversight review on 3/14/24. They will continue to come quarterly, and reports will be reviewed by the LPN as well as the administrator.
22VAC40-73-150-B-2
Based on interviews conducted, the facility failed to immediately notify the Virginia Board of Long-Term Care Administrators and or the regional licensing office that the licensed administrator resigned, was discharged, or became unable to perform his duties and that a new licensed administrator has been employed or that the facility is operating without an administrator licensed by the Virginia Board of Long-Term Administrators, whichever is the case, and provide the last date of employment of the previous licensed administrator.
Evidence
  1. During the on-site inspection on 12/8/2023, Staff #1 notified the Licensing Inspector that her last day would be on 12/20/2023.
  2. During the on-site inspection on 2/12/2024, the Licensing Inspector was informed by Staff # 5 the facility does not have an administrator and has not had an administrator since Staff #1’s departure.
Plan of correction
1. The facility will notify the Virginia Board of Long Term Care Administrators and the regional licensing office immediately of any changes in administrator. 2. We have hired an administrator, and her start date is 3/20/24. The licensing office will also be informed.
22VAC40-73-610-B
Based on observation of facility postings the facility failed to ensure that menus for meals and snacks for the current week shall be dated and posted in an area conspicuous to residents.
Evidence
  1. The posted menu for the month of February 2024 did not include snacks.
Plan of correction
1. Snacks were added to the menu postings.
22VAC40-73-440-A
Based on a review of resident records, the facility failed to ensure complete Uniform Assessment Instruments (UAIs) records were reviewed at least annually.
Evidence
  1. The last UAI for Resident #15 was completed in 2020.
  2. Staff #2 acknowledged the facility did not have a current UAI for the resident.
Plan of correction
1. A quarterly review of resident files has been scheduled to ensure UAI’s are consistently up to date. 2. The facility is in the process of purchasing an EMR, which will allow us to receive alerts when UAI’s are due to be renewed. Until then, a spreadsheet with renewal dates is being created to facilitate tracking UAI renewals.
22VAC40-73-210-C
Based on the on-site record review and staff interview the facility failed to ensure training for the first year shall commence no later than 60 days after employment.
Evidence
  1. The staff records for Staff # 3 and #4 contained training logs which were blank.
Plan of correction
1. Counseling and re-education were provided to the staff member responsible for the new hire process. 2. All new hire files will be submitted to the Assistant Director for review by the end of the business day.
22VAC40-73-60-B
Based on record review, the facility failed to ensure its use of electronic records or signatures complied with the provision of the Uniform Electron Transaction Act.
Evidence
  1. A review of the May 2023 electronic Medical Administration Record for Resident #14 documented Staff #6’s electronic signature was used on 5/18/23, 5/19/23, 5/22/23, 5/25/23, 5/26/23, and 5/29/23 to document medication was administered to the resident.
  2. An email received from the facility to the Licensing Inspector verified Staff #6’s last day employed at the facility was 5/17/2023.
Plan of correction
1. Re-education on use of electronic signatures was provided to medication aides. 2. A process for a weekly review of the MAR is being established (i.e. nursing supervisor will audit the MAR on a weekly basis to identify errors and discrepancies and carry out counseling and/or disciplinary action as needed.
22VAC40-73-40-B
Based on staff record review, the facility failed to obtain the criminal history record report on or prior to the 30th day of employment for two employees.
Evidence
  1. During the inspection conducted on December 8, 2023 and February 12, 2024, a record review indicated:
  2. The date of hire for Staff #3 was 04/17/2023; the staff’s record did not contain a completed criminal history record report.
  3. The date of hire for Staff #4 was 11/29/2023; the staff’s record did not contain a completed criminal history record report.
Plan of correction
1. Counseling and re-education were provided to the staff member responsible for the new hire process. 2. A new process has been established, whereas upon hiring a new employee, a copy of the criminal background request form will be attached to the new hire packet that is sent to the timekeeper. The timekeeper will upload the request form to the HR file and note that it has been completed. All new hire files will be submitted to the Assistant Director for review by the end of the business day. 3. We have requested access from the Virginia State Police to complete criminal background checks online, which will facilitate the tracking process and ensure they are completed in a timely manner.
22VAC40-73-290-B
Based on observation, the facility failed to ensure the posting of the name of the current on-site person in charge.
Evidence
  1. On the date of the inspection 2/12/2024, there was no posting of the on-site person in charge.
  2. Staff member #4 acknowledged there was no posting.
Plan of correction
1. Person in charge has been posted. 2. Director of Operations, Assistant Director of Operations, Office Manager will be responsible for updating posting on a daily basis.
22VAC40-73-520-I
Based on observations made during a tour of the building, the facility failed to ensure the current month's activity schedule shall be posted in a conspicuous location in the facility.
Evidence
  1. During the on-site inspection on 2/12/2024, the posted activities calendar was observed to be for November 2023.
  2. Staff # 3 acknowledged the activities calendar was not for the current month.
Plan of correction
1. The activity schedule was posted and will be posted monthly.
22VAC40-73-450-F
Based on staff interview and review of a resident record, the facility failed to update the ISP (Individualized Service Plan) at least once every 12 months.
Evidence
  1. The resident records for Residents #14 and #15 did not contain ISPs.
  2. Staff # 2 acknowledged the residents did not have current ISPs.
Plan of correction
1. A quarterly review of resident files has been scheduled to ensure ISP’s are consistently up to date. 2. The facility is in the process of purchasing an EMR, which will allow us to receive alerts when ISP’s are due to be renewed. Until then, a spreadsheet with renewal dates will be created to facilitate tracking ISP documentation.
22VAC40-73-680-B
Based on observation and staff interview, the facility failed to ensure medication shall remain in the pharmacy issued container, with the prescription label or direction label attached, until administered to the resident.
Evidence
  1. On 12/8/2023, during an on-site medication cart audit, with Staff #3, the licensing inspector observed pre-poured medications for 13 residents.
  2. Staff #3 acknowledged the medications had been pre-poured for the 11:00 am medication pass.
Plan of correction
1. Medication aides were re-educated on medication management policy, specifically that medications are not to be pre-poured and should remain in the pharmacy-issued container until administered to the resident. Staff were informed that observation of pre-pouring would result in disciplinary action.
22VAC40-73-260-C
Based on record review and interview with staff, the facility failed to ensure each direct care staff member maintained current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. The certification must either be in adult first aid or include adult first aid. To be considered current, first aid certification from community colleges, hospitals, volunteer rescue squads, or fire departments shall have been issued within the past three years.
Evidence
  1. The staff records for Staff members # 3 and #4 did not contain evidence of current First Aid certification.
  2. Staff #5 was able to provide the requested documentation during the time of the inspection.
Plan of correction
1. CPR/First Aid class has been scheduled for 3/14/24. Staff who required refresher training have been enrolled. 2. Quarterly CPR/First Aid classes at the facility have been scheduled in advance to ensure new hires receive training and existing staff remain current. 3. A quarterly review of personnel files has been scheduled to ensure certification and trainings remain current. 4. All new hire files will be submitted to the Assistant Director for review by the end of the business day. The Assistant Director will maintain a list of new employees who require training.
22VAC40-73-670-2
Based on record review and interview, the facility failed to ensure that an applicant, for registration as a medication aide, does not act as a medication aide on a provisional basis for longer than 120 days.
Evidence
  1. Staff #3’s staff record contained documentation that indicated their provisional medication aide status began September 13, 2023. No documentation was provided during the inspection to confirm that Staff #3 has successfully passed the required competency evaluation to become a medication aide.
Plan of correction
1. An electronic HR database has been implemented to streamline the process of tracking employee licenses and certifications, alerting us prior to the expiration date. 2. Personnel files will be audited on a quarterly basis.
22VAC40-73-640-A
Based on record review, the facility failed to implement its written plan for medication management, specifically regarding its methods to ensure accurate counts of all controlled substances whenever assigned medication staff changes.
Evidence
  1. A review of the Controlled Medication Count Record for the medication carts #1, #2 and #3 for the month of February 2024 documented inconsistencies in staff signing off on control medication counts from shift to shift.
Plan of correction
1. Medication aides were re-educated on the process of accurately accounting for controlled substances at the change of shift. Staff were informed that inconsistencies in the mediation administration record would result in disciplinary action. 2. A process for a weekly review of the MAR is being established (i.e., nursing supervisor will audit the MAR on a weekly basis to identify errors and discrepancies and carry out counseling and/or disciplinary action as needed.
22VAC40-73-680-I
Based on resident record review and review of the Medication Administration Record (MAR), the facility failed to have all items required by the Standards on the MAR.
Evidence
  1. A review of Resident #14’s October 2023 MAR did not document the staff member who administered the resident’s Acetaminophen 500mg, Atorvastatin 40mg, Divalproex SOD DR 250 mg, Famotidine 20 mg, Metformin HCL 1,000 mg, Pregabalin 75 mg and Vitamin C on 10/29/23 and 10/30/23. The medication administration spaces on the MAR were blank and there was no further explanation for the missing information documented on the MAR.
  2. The September 2023 MAR did not contain the initials of the staff member who administered medication to Resident #14 over 80 times. The medication administration spaces on the MAR were blank and there was no further explanation for the missing information documented on the MAR.
  3. A review of Resident # 8’s December 2023 MAR was missing blood glucose numbers and units of insulin administered for 12/1, 12/3, 12/4, and 12/6. There was no further explanation for the missing information documented on the MAR.
Plan of correction
1. We have hired an LPN whose responsibility will be auditing and reviewing resident charts, physician orders, the MAR, and the medication cart supply. 2. We had an outside pharmacist complete an additional pharmacy oversight review on 3/14/24. They will continue to come quarterly, and reports will be reviewed by the LPN as well as the administrator.
22VAC40-73-120-A
Based on the review of facility records and interviews conducted with facility staff failed to ensure that the orientation and required training occurred within the first seven working days of employment.
Evidence
  1. The orientation dates on the orientation sheet in the staff records for Staff #3 and #4 were blank and there was no signature that the orientation was conducted.
Plan of correction
1. Counseling and re-education were provided to the staff member responsible for the new hire process. 2. All new hire files will be submitted to the Assistant Director for review by the end of the business day.
May 10, 2023Complaint survey0 violations
Inspection dates
05/10/2023, 07/19/2023
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 5/10/2023 3:00pm-4:00pmand documentation review on 7/10/2023 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 5/25/2023 regarding allegations in the area(s) of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 98 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed:0 Number of interviews conducted with residents:2 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 10, 2023Complaint survey0 violations
Inspection dates
05/10/2023
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 5/10/2023 from 3:00pm- 4:00pm 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 5/3/2023 regarding allegations in the area(s) of: Buildings and Grounds Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 98 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: 3 Number of interviews conducted with staff: 4 Additional Comments/Discussion: Licensing Inspector inspected the kitchen, laundry area, nurses’ station, and rooms on every hallway in addition to common areas. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alyshia E. Walker, Licensing Inspector at (757)670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
March 13, 2023Inspection16 violations
Inspection dates
03/13/2023, 05/10/2023
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 3/13/2023 7:54 am- 5:05 pm and 5/10/2023 3:00 pm- 4:00 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 79 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 5 Number of interviews conducted with residents:4 Number of interviews conducted with staff: 5 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alyshia E. Walker, Licensing Inspector at (757)670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Violations
22VAC40-73-70-A
Based on resident record review and interviews with staff, the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of one resident.
Evidence
  1. During on-site inspection and record review of Resident #8’s record, an incident report was in the file which documented that the resident was found on the floor in front of his wheelchair with a laceration on the back of his head. Hospice was contacted. The facility did not notify the local licensing office of the incident.
  2. The facility was placed on Fire Watch by the local Fire Marshall on 6/28/22. The local licensing office was not notified of the incident.
Plan of correction
1. Admin will contact the licensing office of all injuries that require hospital visit. 2. Admin will contact licensing office if we have to be on Fire Watch, we will report the date and possible duration and reason for that event.
22VAC40-73-410-A
Based on record reviewed and staff interviewed, the facility failed to ensure the record included an acknowledgement of having received the orientation and shall be signed and dated by the resident, and as appropriate the legal representative and shall be kept in the resident’s record.
Evidence
  1. On 3/13/23, resident #6’s record did not include documentation of an orientation for new residents which included information regarding mealtimes, the use of the call system, and the emergency response procedures.
Plan of correction
Upon completion of admission, the orientation document will be signed and dated by resident or legal representative and filed in resident record. All resident records will be reviewed annually to assure all documents are current and signed.
22VAC40-73-250-D
Based on record reviewed and staff interviewed, the facility failed to ensure a subsequent tuberculosis (TB) evaluations and reports was in the record for two staff members.
Evidence
  1. On 3/13/23, staff #1 TB results in the record was dated, 1/29/21 and 12/21/21, staff’s date of hire noted as 2/10/17.
  2. Staff #8’s record did not include a current TB, staff’s date of hire noted as 4/13/22.
Plan of correction
Administrator or designee will request new hired staff to present TB report before starting the new hire documents.
22VAC40-73-870-E
Based on observation and staff interviewed, the facility failed to ensure all furnishings, fixtures, and equipment was in good repair.
Evidence
  1. On 3/13/23, during a tour of the facility with staff #5, the facility’s signaling system/call bell was not working. The call bell in room #11 and #12 was pulled but there was no response and did not light up outside the door. Staff #5 went to the nursing station where the calls terminate. Once in the room, staff discovered the system was turned off. Once the system was turned back on, the call bells for several rooms could be observed with the light on outside the room doors and the sound of call bells ringing could be heard throughout the building
Plan of correction
The call bell system is working. It has been tested from several rooms and light signals comes on in the hallway. A lock has been put on the call bell system box to assure that it does not get switched off. The system is operating as it should.
22VAC40-73-320-B
Based on record reviewed and staff interviewed, the facility failed to ensure a risk assessment was completed annually for a resident as
Evidence
  1. by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it for a resident. Evidence: On 3/13/23, resident #8’s, record did not include a current risk assessment for tuberculosis (TB). The assessment in the record was dated 8/31/21.
Plan of correction
Risk assessments for TB will be reviewed every 6 months and updated annually.
22VAC40-73-410-A
Based on record reviewed and staff interviewed, the facility failed to ensure the record included an acknowledgement of having received the orientation and shall be signed and dated by the resident, and as appropriate the legal representative and shall be kept in the resident’s record.
Evidence
  1. On 3/13/23, resident #6’s record did not include documentation of an orientation for new residents which included information regarding mealtimes, the use of the call system, and the emergency response procedures.
Plan of correction
Upon completion of admission, the orientation document will be sign and dated by resident or legal representative and filed in resident record. All residents records will be reviewed annually to assure all documents are current and signed.
22VAC40-73-980-A
Based on observation and staff interviewed, the facility failed to ensure the first aid kit for the building included all required items.
Evidence
  1. On 3/13/23, a check of the facility’s first aid kit was conducted with staff #2. The kit did not include roller gauze of any sizes. The kit also did not include antiseptic wipes or ointment.
Plan of correction
The first aid kit has been inventoried and restocked with supplies that are required and the check list has been updated.
22VAC40-73-320-B
Based on record reviewed and staff interviewed, the facility failed to ensure a risk assessment was completed annually for a resident as
Evidence
  1. by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it for a resident. Evidence: On 3/13/23, resident #8’s, record did not include a current risk assessment for tuberculosis (TB). The assessment in the record was dated 8/31/21.
Plan of correction
Risk assessments for TB will be reviewed every 6 months and updated annually.
22VAC40-73-440-K
Based on record reviewed and staff interviewed, the facility failed to ensure it was in compliance with the requirements set forth in 22VAC30-110.
Evidence
  1. On 3/13/23, Resident #8’s uniformed assessment instrument (UAI) dated 10/11/22 was completed by a facility staff. The document was not signed by the administrator or designee.
Plan of correction
Administrator or designee will sign all UAI's upon completion of review.
22VAC40-73-680-B
Based on observation and staff interview, the facility failed to ensure medication shall remain in the pharmacy issued container, with the prescription label or direction label attached, until administered to the resident.
Evidence
  1. On 3/13/2023, during an on-site observation of the medication pass with Staff #10, the licensing inspection observed repoured medications for 17 residents in the top drawer of 2 medication carts.
Plan of correction
Admin and RMA's will ensure that no medication will be repoured. All medications will be poured at the time of administering.
22VAC40-73-860-G
Based on observations and staff interviewed, the facility failed to ensure the hot water at taps available to residents was maintained within a range of 105 degrees Fahrenheit (F) to 120 degrees F.
Evidence
  1. On 3-13-23, during a tour of the facility with staff #5, the water temperature in bathroom for room #21 was 150 degrees F. The temperatures in room #37 and #38 were observed with a temperature of 130 degrees F.
  2. Staff # 5 and # 3 acknowledged the hot water temperatures were not maintained within a range of 105- 120 degrees F.
Plan of correction
Not published by VDSS.
22VAC40-73-450-F
Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) shall be signed and dated by the resident or the legal representative.
Evidence
  1. On 3/13/23, resident #7’s ISP in the record had and end date/review date of 7/20/22. The 11/1/18.
  2. Resident #8’s record included a comprehensive hospice assessment dated 10/11/22 and document from a medical clinic dated 12/15/21 documenting resident’s allergy to Ativan and Aricept. The resident’s medication administration record (MAR) for March 2023 documented resident prescribed Lorazepam (Ativan). The record included an order from hospice to discontinue Ativan in November 2022. The resident’s ISP dated 11/10/22 did not include documentation of the resident’s allergy to Aricept and Lorazepam (Ativan).
Plan of correction
1. Administrator and designee will sign all ISP's upon completion of review. 2. Facility will notify pharmacy of known allergies and it will be indicated on ISP and UAI by Admin or designee.
22VAC40-73-450-E
Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) shall be signed and dated by the resident or the legal representative.
Evidence
  1. On 3/13/23, resident #8’s ISP dated 11/10/22 was not signed by the resident or a legal representative.
Plan of correction
Not published by VDSS.
22VAC40-73-310-H
Based on record review and staff interview, the facility failed to ensure it did not admit or retain individuals with psychotropic medications without a treatment plan.
Evidence
  1. Resident #6’s March MAR documented the resident was prescribed Zoloft. The resident’s file did not contain a psychotropic treatment plan for the medication.
Plan of correction
Treatment plans will be added to ISP to address psychotropic medications.
22VAC40-73-210-F
Based on records reviewed and staff interviewed, the facility failed to ensure at least two of the required hours of training focused on infection control. When adults with mental impairment reside in the facility, at least four of the required hours shall focus on topics related to residents’ mental impairment for three staff members.
Evidence
  1. Record review for staff # 1, (date of hire 2/10/17), #10 (date of hire 4/1/21) and #9 (date of hire 6/18/21) did not include documentation of the required two (2) hours of infection control and four (4) hours of mental impairment training.
  2. Staff #1 and #2 acknowledged the staff members records did not include the required training hours.
Plan of correction
1. Administration has scheduled several required in-services for staff including infection control. In-services will be conducted on site by Home Health Agency.
22VAC40-73-310-B
Based on records reviewed and staff interviewed, the facility failed to ensure a documented interview between the administrator or designee responsible for admission and retention, the individual, and the legal representative, if any was in the record for a resident.
Evidence
  1. Resident #6’s record did not include documentation of an interview. The resident’s date of admission noted as 4/16/23.
Plan of correction
Administrator or designee will document "interview" on initial assessment of new and potential residents.
March 13, 2023Complaint survey0 violations
Inspection dates
03/13/2023, 05/10/2023
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Other Self- Report Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 3/13/2023 and 5/10/2023 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 2/24/2023 regarding allegations in the area(s) of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 98 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
October 12, 2022Complaint survey11 violations
Inspection dates
10/12/2022
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Other Self Report Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/12/2022 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 09/30/2022 regarding allegations in the area(s) of: Resident Care Number of residents present at the facility at the beginning of the inspection: 83 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 2 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alyshia E. Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Violations
22VAC40-73-440-H
Based on record review the facility failed to ensure the uniformed assessment instrument (UAI) was reviewed annually.
Evidence
  1. The most recent UAI review date for Resident # 3 was 8/1/2021.
  2. The most recent UAI review date for Resident # 1 was 2/10/2021.
Plan of correction
Administrative Staff will continue to communicate with Hampton APS via e-mail and fax to ensure that UAI reviews are done in a timely manner. Request for updates will remain in the residents file for proof of request until current UAI has been received from APS.
22VAC40-73-440-A
Based on review of resident record, the facility failed to ensure that uniform assessment instruments (UAIs) are completed as required.
Evidence
  1. Resident # 2’s most recent UAI was incomplete in the areas of activities of daily living.
Plan of correction
Administrative Staff will continue to keep UAI’s at the nurse’s station and Administrators office in the event paperwork is misfiled it can be replaced accordingly. Administrative staff will monitor and follow up with Nurses for review of their resident records.
22VAC40-73-430-H-1
Based on record review the facility failed to complete a discharge statement which contains the information listed in standard to the resident and, as appropriate, his legal representative and designated contact person at the time of discharge.
Evidence
  1. The record for Resident #2 did not list the date the discharge statement was provided to the resident and as appropriate, legal representative and designated contact person.
Plan of correction
The AIT will oversee resident discharges and ensure discharge information is documented and given to resident and or responsible party.
22VAC40-73-470-A
Based on record reviewed and staff interview, the facility failed to ensure, either directly or indirectly, that the health care service needs of a resident was met.
Evidence
  1. Resident #1’s physician ordered labs to be done on 8/22/2022. The record did not include documentation these services were performed.
Plan of correction
RCC will be responsible for ensuring that results from labs etc, are placed in residents medical folder for follow up.
22VAC40-73-550-C
Based on document review, interview with APS, the facility failed to ensure that a resident of an assisted living facility had the rights and responsibilities as provided in 63.2-1608 of the Code of Virginia.
Evidence
  1. The licensing office received a self-report from Staff #1 on 9/20/2022, informing the agency Resident #3 reported being sexually assaulted by Resident #2.
  2. On 10/11/2022, Licensing Inspector (LI) conducted interview with assigned Adult Protective Services worker, Collateral #1.
  3. On 10/12/2022, LI conducted on-site inspection and reviewed the facility documentation, ISPs, Shift Communication Log notes, Nurses Notes, etc.
  4. Facility Shift Communication Log notes dated 9/13/2022, 9/14/2022, 9/15/2022, 9/16/2022, 9/16/2022, 9/17/2022, and 9/18/2022 document that Resident # 3 informed various staff members of the facility that his roommate Resident #2 was sexually harassing him and making sexual advances towards him. The Shift Communication Log notes further document Resident #3 sleeping in the common areas at night due to reported feelings of being unsafe in his room as Resident #2 was sexually harassing him.
  5. The facility did not have any documentation that Resident #3’s reported concerns were addressed.
Plan of correction
Administrator will meet with all staff regarding documentation of incidents and reporting to the Administrator. The Assistant Administrator will monitor nurses notes weekly to address any documented concerns with the Administrator for follow up. A MANDITORY Inservice “RESIDENT RIGHTS’ with the Ombudsman will be mandatory will all staff.
22VAC40-73-450-F
Based on record review and staff interview, the facility failed to ensure the individualized service plan (ISP) shall be reviewed and updated at least once every 12 months and as needed as the condition of the resident changes.
Evidence
  1. Resident #1 ‘s ISP was last reviewed on 2/1/22 and Resident #3’s ISP was last reviewed on 9/16/2021.
Plan of correction
Facility has contracted with a Registered Nurse to assist administrative staff and nurses. Contracted nurse will help with reminders for updates. Contracted nurse will oversight.
22VAC40-73-350-B
Based on record review, the facility failed to ascertain, prior to each resident’s admission whether a potential resident is a registered sex offender.
Evidence
  1. Resident #2’s admission date was 6/28/2021 and the sex offender inquiry was completed on 7/1/2021.
Plan of correction
Administrative staff will ensure sex offender inquiry is done on all potential residents prior to admission. all resident paperwork has been filed accordingly.
22VAC40-73-870-A
Based on observation, the facility failed to maintain the interior and exterior of the building in good repair and keep it clean and free of rubbish.
Evidence
  1. The carpet squares in the dining area near the vending machines were lifting, dirty and out of place.
  2. The light bulb was out (above the bed to the left near the door) in room #42.
  3. Men’s bathroom caulking in the shower and around toilet was black.
  4. The paint on the ceiling in the men’s bathroom ceiling was peeling.
  5. Paint on wall in room # 35 is peeling.
  6. Rusty planters on the outside deck area.
Plan of correction
The carpet squares have been replaced. Light bulb has been replaced. Caulking in men’s bathroom has been re-caulked. Room has been painted. Planters on deck area have been disposed of. The Director of Operations will follow up with maintenance with maintenance log to ensure that maintenance repairs are done in a timely manner. Dir. Of Operations, AIT and maintenance will do weekly walkthroughs.
22VAC40-73-260-A
Based on record review, the facility failed to ensure that each all staff maintain current certification in first aid.
Evidence
  1. The record for Staff # 3 contained a copy of a first aid card with an expiration date of 7/30/2022.
Plan of correction
Administrative staff will continue to schedule trainings for employees to meet required training. CPR/First Aid scheduled 01-25-2023
22VAC40-73-250-D
Based on record review, the facility failed to ensure that each staff person submit the results of a tuberculosis (TB) risk assessment on or within seven days prior to the first day of work at the facility.
Evidence
  1. The record for Staff # 4 (D.O.H.02/02/2022) did not contain an initial TB risk assessment.
Plan of correction
Administrative staff will ensure all required paperwork is in employee file prior to first day of working. AIT will monitor state required paperwork .
22VAC40-73-750-B
Based on observation, the facility failed to supply a comfortable mattress for each resident.
Evidence
  1. The mattress in room #9 (bed next to window) was sunken in.
Plan of correction
Mattress has been replaced by maintenance. Dir. Of Operations, AIT and maintenance will do weekly walkthroughs to keep up with routine maintenance. All findings will be documented in maintenance log for request and repair date. Dir. Of Operations will follow up on completed and requested repairs.
June 23, 2022Inspection12 violations
Inspection dates
06/23/2022,06/24/2022,06/28/2022,07/05/2022,07/11/2022,07/12/2022
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND222VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Renewal An unannounced on-site renewal inspection was conducted on 6-23-22 (Ar 7:50 a.m./dep 5:35 p.m). The facility census was 86, a tour of the facility was conducted, breakfast and dinner meal observed (the dining room is not sufficient for all residents, the facility does not have multiple seating times). Emergency preparedness and supplies reviewed, staff and resident records reviewed, staff and resident interviews conducted, medication pass observation conducted, water temperature observed, fire and health inspections reviewed (not current) and other protocol documents reviewed. The Acknowledgement of Inspection form was sent via email to the Administrator following the on-site inspection and following all documents requested and received (6-24-22, 6-28-22 and 7-5-22. Acknowledgement form also sent following preliminary exit review of violations on 7-11-22. 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 Willie Barnes Licensing Inspector at 757-439-6815 or by email at willie.barnes@dss.virginia.gov
Violations
22VAC40-73-450-C
Based on record reviewed and staff interviewed, the facility failed to ensure the resident’s individualized service plan (ISP) included all assessed needs for six of seven residents’ records.
Evidence
  1. Resident #2’s uniformed assessment instrument (UAI) dated 10-9-21 documented toileting need as human help/physical assistance, walking as mechanical help with a cane, mobility assessed as mechanical help/supervision with cane, and money management by POA. The ISP with ending/review date of 11-11-22 did not include these assessed needs.
  2. Resident #3’s UAI dated 9-10-21 (9-29-21) documented dressing need as human help/physical assistance, incontinent of bowel and bladder, stairclimbing not performed, and resident assessed as disoriented some spheres all time for “Time”, short-term memory lost and judgement issues. The resident’s signed physician’s order dated 2-9-22 documented resident is allergic to Tetracylines and Fluarix. These assessed needs and allergy information were not documented on resident’s ISP dated10-5-21.
  3. Resident #4’s ISP dated 9-23-21 did not document resident’s money management by a local agency and the change to the facility as the resident’s money representative.
  4. Resident #5’s need for the use of Oxygen was not documented on the 4-29-22 ISP.
  5. Resident #6’s ISP dated 1-6-22 did not include resident’s tomato allergy, physician document dated 2-9-22.
  6. Resident #7’s UAI dated 6-7-21 documented stairclimbing not performed, the ISP dated 10-5-21 did not include stairclimbing.
  7. Staff #2 acknowledged the aforementioned residents’ ISPs did not include all assessed needs.
Plan of correction
Administrator and Administrator's assistant will review, document and update ISP's according to UAI. Facility pharmacy nurse will also oversight each plan.
22VAC40-73-940-A
Based on document reviewed and staff interviewed, the facility failed to ensure the facility complied with the Virginia Statewide Fire Prevention Code (13VAC5-51) as determined by at least an annual inspection by the appropriate fire official. Reports of the inspections shall be retained at the facility for at least two years.
Evidence
  1. On 6-23-22, the fire inspection document provided was dated 5-13-21.
  2. Staff #1 acknowledged the facility did not have a current fire inspection.
Plan of correction
Director of Operations will continue to schedule fire inspections 30 days prior to expiration to ensure inspection is completed prior to expiration.
22VAC40-73-860-G
Based on observation and staff interviewed, the facility failed to ensure the hot water at taps available to residents was maintained within a range of 105 degrees Fahrenheit (F). to 120 degrees F.
Evidence
  1. On 6-23-22 during a tour of the facility with staff #5 and #8, water temperatures were conducted in three rooms. The water temperature in room #37 was 133.0 degrees F.
  2. Staff #5 and #8 acknowledged the water temperature did not meet the required temperature range.
Plan of correction
Hot water tank has been adjusted for appropriate water temperature. Maintenance will be responsible for charting weekly water temperatures, make necessary adjustments. Paperwork will be reviewed monthly by the Administrator and Director of Operations.
22VAC40-73-320-B
Based on document reviewed and staff interviewed, the facility failed to ensure a risk assessment for tuberculosis (TB) was completed annually on each resident as
Evidence
  1. d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it for four of seven residents. Evidence:
  2. On 6-23-22, resident #5’s risk assessment for tuberculosis (TB) in the record was dated 8-5-19, resident’s date of admit noted as 5-3-19. Resident #1’s TB was dated 6-17-21, resident’s date of admit was noted as 11-1-18. Resident #4’s TB was dated 6-18-21, resident’s date of admit was noted as 1-25-19. Resident #6’s TB was dated 6-17-21, resident’s date of admit was noted as 1-6-20.
  3. Staff #2 acknowledged the TB’s were not completed.
Plan of correction
Not published by VDSS.
22VAC40-73-610-E
Based on staff interviewed, the facility failed to ensure a copy of a diet manual containing acceptable practices and standards for nutrition was kept current and readily available to personnel responsible for food preparation.
Evidence
  1. On 6-23-22 during a tour of the kitchen with staff #5 and #7, when asked to see the facility’s nutrition manual, staff did not have a copy.
  2. Staff #5 and #7 acknowledged the facility did not have a copy of a diet manual in the kitchen.
Plan of correction
Facility food manager will be responsible for keeping diet manual current and accessible to dietary staff. Manual has been placed in the kitchen.
22VAC40-73-450-F
Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service was updated as needed as the condition of the resident changes for two of seven residents.
Evidence
  1. Resident #6’s record documented skilled nursing for wound care services 1-13-22; physical therapy services 1-7-22 thru 2-18-22. The record also included physician’s order dated 4-18-22 for occupational therapy (OT) and physical therapy (PT) services for unsteady gait BLE metatarsal amputees; additional physician notes dated 3-4-22 and 4-15-22. Staff #1 and 2 stated resident had toes amputated and did not need special shoes and family member took care of resident's medical appointments. Resident was observed wearing regular sneakers. 2.Resident #7’s ISP dated 10-5-21 did not document wound care needs, venous ulcer LLE, resident receiving outpatient services from wound care clinic, document in record dated 9-15-21 and 10-15-21. Staff #6 stated resident receives skilled nursing wound care services from a home health provider. The record did not include documentation of home health visits. The record also included physical order dated 4-25-22 for consult PT/OT evaluation and treat; frequent falls.
  2. Staff #2 acknowledged the aforementioned resident’s ISP reviewed on 6-23-22 were not updated to include resident change in condition and services received. Records were updated after reviewed by inspector on 6-23-22.
Plan of correction
Administrator's assistant is working with Home Health agency to detail their services thru contract to chart in designated area of residents file. Home Health agency to communicate with RCC and Administrator to keep ISP's current.
22VAC40-73-440-H
Based on document reviewed and staff interviewed, the facility failed to ensure an annual reassessment, using the UAI, shall be utilized to determine whether a resident’s needs can continue to be met by the facility and whether continued placement in the facility is in the best interest of the resident.
Evidence
  1. Resident #4’s uniformed assessment instrument (UAI) in the record was last dated 4-6-20. The resident’s date of admit was noted as 1-25-19.
  2. Staff #1 and #2 acknowledged the aforementioned resident did not have an annual reassessment using the UAI to determine continue placement in the facility.
Plan of correction
Administrator's assistant will continue to request UAI's from APS and CSB 30 days prior to expiration date to ensure UAI's are done in a timely manner.
22VAC40-73-290-A
Based on documents reviewed and staff interviewed, the facility failed to ensure the written work schedule include the names and job classifications of all staff working each shift, with an indication of whomever is in charge at any given time.
Evidence
  1. On 6-23-22, the staff schedules provided did not include all required information. The business office schedule, the May 2022 housekeeping/laundry schedule, the June 2022 kitchen morning and evening schedule, the June 2022 CNA (7-3), (3-11), and 11-7 schedule, June 2022 Med-tech (7-3), (3-11), and 11-7 schedule noted first name only of staff. The job classification of the business office staff, CNA and kitchen staff were not documented on the schedule.
  2. The schedule also did not indicate who was in charge at any given time.
Plan of correction
Not published by VDSS.
22VAC40-90-40-B
Based on document received and staff interviewed, the facility failed to ensure the criminal history record report was obtained on or prior to the 30th day of employment for each employee.
Evidence
  1. On 6-23-22, 6-24-22, 6-28-22, 7-5-22 and 7-12-22, the facility provided information for new hires. There were seven staff members whose criminal history report was not obtained on or prior to the 30the day of employment. Staff date of hire range from 3-30-21 to 4-13-22.
  2. Staff #1 stated “needing to grab up staff” when possible because of staffing concerns.
Plan of correction
RCC will indicate on schedule, new hires will be shadowed by another staff member with CRC on file until new hire CRC comes in.
22VAC40-73-470-A
Based on record reviewed and staff interviewed, the facility failed to ensure, either directly or indirectly, that the health care service needs of residents are met for a resident.
Evidence
  1. On 6-23-22, resident #2’s physical examination dated 11-1-21 documented physician’s recommendation for home health services. The record did not contain documentation of resident’s home health services.
  2. Staff #2 acknowledged the aforementioned resident’s record did not include documentation of completion of the physician’s recommendation for home health services.
Plan of correction
To ensure physician's recommendation for Home Health documented on History & Physical. Admission coordinator will be responsible for scheduling Home Health on Admission Day.
22VAC40-73-100-C-2
Based on observation and staff interviewed, the facility failed to ensure blood glucose monitoring practices that are consistent with CDC recommendations were utilized during blood glucose check for a resident.
Evidence
  1. On 6-23-22 at 08:03, during the medication pass observation with staff #4, resident #4’s blood glucose was observed taken using a glucometer labeled “HM”. Staff stated it was the house glucometer that was used when a resident did not have a glucometer. The glucometer was removed from a container on the medication cart and placed on top of the medication cart. The staff did not clean the glucometer prior to and after the finger stick.
  2. Staff #1 stated the staff was new and may need to be retrained.
Plan of correction
RCC will ensure that a resident individual glucometers will be labeled. Additional infection control for medication aides has been scheduled for Aug.9th.
22VAC40-73-580-A
Based on document reviewed and staff interviewed, the facility failed to ensure when a portion of the assisted living facility is subject to inspection by the Virginia Department of Health, the facility shall be in compliance with those regulations, as
Evidence
  1. by an initial and subsequent annual report from the Virginia Department of Health. The report shall be retained at the facility for a period of at least two years. Evidence:
  2. On 6-23-22, the health inspection document provided to the inspector was dated 6-21-21.
  3. Staff #1 acknowledged not having a current health inspection.
Plan of correction
The Director of operations will be responsible for scheduling Health Dept. inspections 30 days prior to expiration date to ensure inspection is completed prior to expiration.
May 24, 2021Inspection2 violations
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 EMERGENCY PREPAREDNESS
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 and IPOC follow-up was initiated on 05/24/2021 and concluded on 05/24/2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census. The inspector emailed the Administrator a list of item required to complete the inspection. The inspector reviewed 3 resident records, 3 staff records, staff schedules , Fire Inspection, Health Department Inspection Report and additional documentation provided by the facility. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility.
Violations
22VAC40-73-440-A
Based on resident record review the facility failed to ensure the uniform assessment instrument was updated annually.
Evidence
  1. While reviewing resident record #2 the last review of the uniform assessment instrument was completed on 06/26/2020.
Plan of correction
Not published by VDSS.
22VAC40-73-450-E
Based on resident record review the facility failed to ensure the individualized service plan shall be signed and dated by the resident or his legal representative.
Evidence
  1. While reviewing resident record #3, the records individualized service plan completed 04/01/2021 was not signed by the resident or his legal representative.
Plan of correction
Not published by VDSS.
September 22, 2020Complaint survey0 violations
Inspection dates
Sept. 22, 2020
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS
Comments
This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A complaint inspection was initiated on 09/22/2020 and concluded on 09/22/2020. A complaint was received by the department regarding allegations in the areas of 22VAC40-73-(2) ADMINISTRATION AND ADMINISTRATIVE SERVICES, 22VAC40-73-(6) RESIDENT CARE AND RELATED SERVICES, 22VAC40-73-(7) RESIDENT ACCOMODATIONS AND RELATED PROVISIONS, 22VAC40-73-(7) RESIDENT ACCOMODATIONS AND RELATED PROVISIONS. The Administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the Administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation did not support the allegation of non-compliance with standards or law.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
September 22, 2020Complaint survey3 violations
Inspection dates
Sept. 22, 2020 , Oct. 1, 2020 and Oct. 7, 2020
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A complaint inspection was initiated on 09/22/2020 and concluded on 10/07/2020. A complaint incident was received by the department regarding allegations in the areas of 22VAC40-73-(6) RESIDENT CARE AND RELATED SERVICES and 22VAC40-73-(2) ADMINISTRATION AND ADMINISTRATIVE SERVICES. The Administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the Administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the allegation(s) of non-compliance with standards or law, and violations were issued. Any violations not related to the (complaint(s)/self-report) but identified during the course of the investigation can be found on the violation notice.
Violations
22VAC40-73-40-A
Based on staff interviews and record review, the licensee failed to ensure compliance with all regulations for licensed assisted living facilities and terms of the license issued by the department; with relevant federal, state, and local laws; with other relevant regulations; and with the facility's own policies and procedures.
Evidence
  1. #1: On 10/07/2020 while reviewing the facility policy, "Resident Medication Orders" reads, "All medication orders, prescription and non-prescription medications shall...b) Be obtained upon admission, when orders change and every three months thereafter". Evidence #2: While reviewing resident #1's medication administration record (MAR) for the month of March, 2020 the (MAR) reads,"suspended 09 Mar 2020 to 10 Mar 2020: hospital".Upon resident #1's return from the hospital, the (MAR) reflected multiple medications discountinued. The Licensing Inspector requested discontinue orders provided by resident #1's physician. Based on statements provided by staff #1, #2 and #3 and of the last day of the inspectyion the facility did not request nor obtain physician orders for any medications discontinued between 03/10/2020 and 03/19/2020.
Plan of correction
Not published by VDSS.
22VAC40-73-680-D
Based on resident record review the facility failed to ensure medications shall be administered in accordance with the physician's or other prescriber's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing.
Evidence
  1. On 10/07/2020 while reviewing the medication administration record (MAR) for resident #1, the record evidences 10 out of 21 prescribed medications were not administered between March 10th, 2020- March 19th, 2020. Based on staff interviews provided by staff #1, #2 and #3, the facility did not have discontinue orders for the following medications that were reflected on the medication administration record as/or discontinued and not administered: Asprin Chew 81mg- take 1 tablet by mouth once daily, Clonazepam Tablet 0.5mg- take one tablet by mouth twice daily, Clonazepam Tablet 0 5mg -take 2 tablets=1mg by mouth every night at bed time Clozapine tablet 100mg-take 2 Clonazepam Tablet 0.5mg take 2 tablets 1mg by mouth every night at bed time, Clozapine tablet 100mg take 2 tablets=200mg by mouth twice daily, Fiberlax 625mg-take 1 tablet by mouth once daily, Lidocain Oin 5%-apply 3 times a day to affected areas for pain, Morphine Sulfate 15mg ER-take 1 tablet by mouth every 12 hours, Tamoxifen tablet 20mg- take 1 tablet by mouth daily.
Plan of correction
Not published by VDSS.
22VAC40-73-680-I
Based on resident record review the facility failed to ensure the medication administration record included diagnosis, condition, or specific indications for administering the drug or supplement.
Evidence
  1. #1: On 10/07/2020 during review of the medication administration record (MAR) for resident #1, the (MAR) did not contain the diagnosis, condition, or specific indications for administering the drug or supplement for all medications administered during the months of February, March, April, May, June or July, 2020.
Plan of correction
Not published by VDSS.