Elizabeth House Assisted Living — Virginia Inspection Report

Inspections

On record

With violations

Visits that cited something

Clean visits

Nothing cited

Violations cited

Individual findings

Standards cited

Distinct rules

Complaint visits

Prompted by a complaint

Elizabeth House Assisted Living was inspected 21 times between January 14, 2022 and June 18, 2026 by the Virginia Department of Social Services. 7 of those visits ended with violations cited and 14 with none. Across that history VDSS cited 18 violations under 17 distinct standards. 10 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.

Every inspection listed here is currently published on the VDSS site.

Provider Information

Facility type

Assisted Living Facility

License type

Two Year

License expires

06/30/2026

Administrator

William Hager

Licensing inspector

Belinda Dyson

Inspector phone

(804) 840-8313

Approved for

Non-Ambulatory · Assisted Living

Inspection History

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

June 18, 2026Complaint survey1 violation

Inspection dates

06/18/2026

Areas reviewed

22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 6/18/2026 10:00a.m.-11:30 a.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 6/9/2026 regarding allegations in the areas of: Resident Care and Related Services, Admission, Retention and Discharge of Residents, Administration and Administrative Services, General Provisions. Number of residents present at the facility at the beginning of the inspection: 51 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: NA Number of interviews conducted with residents: NA Number of interviews conducted with staff: 1 Observations by licensing inspector: All required postings, documentation on the resident’s situation that warranted hospitalization and discharge. Additional Comments/Discussion: Staff member was given the opportunity to ask questions. 2 Licensing Inspectors investigated the complaint. An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the complaint; area of non-compliance with standard or law was: Administration and Administrative Services A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. 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 Belinda Dyson, Licensing Inspector at (804) 840-8313 or by email at Belinda.Dyson@dss.virginia.gov

Violations

22VAC40-73-70-A

Facility did not report to the regional licensing office within 24 hours an incident that negatively affected a resident.

Evidence

An incident on June 5th was not reported to the licensing office timely. Licensing office was made aware after a complaint was filed regarding the incident.

Plan of correction

Not published by VDSS.

June 9, 2026Complaint survey0 violations

Inspection dates

06/09/2026

Areas reviewed

22VAC40-73 GENERAL PROVISIONS22VAC40-73 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: 6/9/2026 12:00p.m.-12:30 p.m. and 6/18/2026 10:00 a.m.-11:30 a.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 6/4/2026 regarding allegations in the areas of: Staffing, Personnel, Resident Care and Related Services, General Provisions, Building and Grounds Number of residents present at the facility at the beginning of the inspection: 51 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: NA Number of staff records reviewed: NA Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 3 Observations by licensing inspector: Staff schedules, exterminator reports, lunch meal observed on 2 different inspection days, all required postings, Additional Comments/Discussion: Housekeeping staff on duty, staff members were given the opportunity to ask questions. License for Administrator as a registered medication aide was observed. Facility uses electronic medication administration system. Activities were in progress. Administrator informed Inspectors that on 6/9/2026 new staff hired were receiving new hire orientation and first aid and CPR training. 2 Licensing Inspectors investigated this complaint. An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation complaint 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 Belinda Dyson, Licensing Inspector at (804) 840-8313 or by email at Belinda.Dyson@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

May 7, 2026Inspection5 violations

Inspection dates

05/07/2026

Areas reviewed

Comments

Type of inspection: Renewal Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/07/2026 10:00 a.m.-1:15 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 54 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: All required postings, activities in progress, lunch meal, medication administration, medications administration records (electronic), physician’s orders, housekeeping and maintenance were on the premises as well as Hospice Nurse. Additional Comments/Discussion: Staff members were given the opportunity to ask questions. Licensing Inspector was accompanied by another Licensing Inspector. An exit meeting was conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of these inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Belinda Dyson, Licensing Inspector at (804) 840-8313 or by email at Belinda.Dyson @dss.virginia.gov

Violations

22VAC40-73-440-A

Residents’ records reviewed did not have documentation of the uniform assessment instrument being completed in accordance with Assessment in Assisted Living Facilities.

Evidence

During a review of resident’s records, three out of four records reviewed, #1, #2, #3 did not have a uniform assessment instrument to review and resident’s #4 uniform assessment was incomplete.

Plan of correction

The administrator had all UAI's for the residents in the administrator's office within the residential files kept in administrator's office. The previous resident care coordinator did not have her UAI's updated in the medical office files for whatever reason, which were the files presented to the DSS inspector. The UAI that had a section unchecked is now also completed in its entirety.

22VAC40-73-450-A

There was no preliminary or comprehensive plan of care documented for resident’s records reviewed.

Evidence

During a review of resident’s records, 4 records did not have an individualized service plan to review, they were resident records #1 #2 #3 #4.

Plan of correction

All ISP's have been updated on the correct DSS form, and the administrator has placed them in both the administrator's office residential files, as well as the Resident Care Coordinators residential office files.

22VAC40-73-250-C

All required information for staff records was not available for review.

Evidence

Staff records #1, # 2, and #3 did not have documentation of receiving a copy of job description.

Plan of correction

The administrator has ensured that all employees listed have updated job descriptions, orientation completion forms, updated disclosure statements, as well as TB screenings updated or scheduled to be administered and read by 5/30/26.

22VAC40-73-120-B

All staff records did not have documentation of orientation and training to the facility’s policies and procedures.

Evidence

During a review of staff records #1, #2, did not have any documentation of assisted living facility orientation

Plan of correction

In the future, the administrator will be sure to have HR provide the administrator at the assisted living facility with all documentation for new hires, as new-hire employee orientation is completed at the skilled nursing facility, but have communicated with the HR that it is imperative that the assisted living facility maintain copies of all needed employee documents as well in the future.

22VAC40-73-490-A-2

There was no preliminary or comprehensive plan of care documented for resident’s records reviewed.

Evidence

During a review of resident’s records, 4 records did not have an individualized service plan to review, they were resident records #1 #2 #3 #4.

Plan of correction

The healthcare oversight was completed on 4/16/26 and emailed to the administrator by the regional nurse back in April 2026. In the recent busy days, the administrator had not yet printed it off and filed but had the healthcare oversight completed at the time of DDS inspection.

March 5, 2026Complaint survey0 violations

Inspection dates

03/05/2026

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: 3/5/2026 10:45 a.m.-11:45a.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint/self-reported incident was received by VDSS Division of Licensing on 2/27/2026 regarding allegations in the area(s) of: 22VAC40-73-(7) RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS Number of residents present at the facility at the beginning of the inspection: 53 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: NA Number of interviews conducted with residents: NA Number of interviews conducted with staff: 1 Observations by licensing inspector: Additional documentation Additional Comments/Discussion: Staff member was given the opportunity to ask questions. An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Belinda Dyson, Licensing Inspector at (804) 840-8313 or by email at Belinda.Dyson@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

January 9, 2026Inspection0 violations

Inspection dates

01/09/2026

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: 1/9/2026 10:00 a.m.-11:00a.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 12/16/2026 regarding allegations in the area(s) of: Personnel and Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 56 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: NA Number of staff records reviewed: NA Number of interviews conducted with residents:NA Number of interviews conducted with staff: 1 Observations by licensing inspector: all required postings, police report # included in self report Additional Comments/Discussion: Administrator has scheduled an additional pharmacy review for 1/15/2026. Staff members received additional in service training. One staff was terminated. Staff was given the opportunity to ask questions. An exit meeting was 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 Belinda Dyson, Licensing Inspector at (804) 840-8313 or by email at Belinda.Dyson@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

November 17, 2025Inspection0 violations

Inspection dates

11/17/2025

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: 11/17/2025 11:00 a.m.-12:15 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A (complaint/self-reported incident) was received by VDSS Division of Licensing on 10/30/2025 regarding allegations in the area(s) of: personnel and resident care and related services. Number of residents present at the facility at the beginning of the inspection: 52 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: NA Number of staff records reviewed: 1 Number of interviews conducted with residents: NA Number of interviews conducted with staff: 2 Observations by licensing inspector: All required postings Additional Comments/Discussion: Staff members were given the opportunity to ask questions. An exit meeting was 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 Belinda Dyson, Licensing Inspector at (804) 840-8313 or by email at Belinda.Dyson@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

July 2, 2025Inspection0 violations

Inspection dates

07/02/2025

Areas reviewed

22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 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: 7/2/2025 10:30 a.m.-11:50 a.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 6/6/2025 & 6/24/2025 regarding allegations in the area(s) of GENERAL PROVISIONS, ADMINISTRATION AND ADMINISTRATIVE SERVICES, PERSONNEL, RESIDENT CARE AND RELATED SERVICES Number of residents present at the facility at the beginning of the inspection: 47 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: NA Number of interviews conducted with residents: NA Number of interviews conducted with staff: 1 Observations by licensing inspector: A review of the written documentation of the alleged incident Additional Comments/Discussion: Staff members were given the opportunity to ask questions. An exit meeting was 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 Belinda Dyson, Licensing Inspector at (804) 840-8313 or by email at Belinda.Dyson@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

April 16, 2025Inspection0 violations

Inspection dates

04/16/2025,04/24/2025

Areas reviewed

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: 4/16/2025 10:00 a.m.-1:30 p.m. and 4/24/2025 10:30 a.m.-11:15 a.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 49 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents:2 Number of interviews conducted with staff: 3 Observations by licensing inspector: All required postings, Medication Administration pass, medications, physician's orders, lunch meal, activities, emergency supplies, housekeeping staff were on duty, maintenance request logs observed. Additional Comments/Discussion: Staff members were given the opportunity to ask questions. 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 Belinda Dyson, Licensing Inspector at (804) 840-8313 or by email at Belinda.Dyson@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

November 18, 2024Complaint survey0 violations

Inspection dates

11/18/2024,11/21/2024

Areas reviewed

22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

Type of inspection: Complaint. Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/18/2024 1:00 p.m.-2:00 p.m. and 11/21/2024 from 12:30 p.m.-1:00 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 10/28/2024 regarding allegations in the area(s) of: GENERAL PROVISIONS, ADMINISTRATION AND ADMINISTRATIVE SERVICES, PERSONNEL, STAFFING AND SUPERVISION, ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS, RESIDENT CARE AND RELATED SERVICES Number of residents present at the facility at the beginning of the inspection: 43 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: NA Number of interviews conducted with residents: NA Number of interviews conducted with staff: 3 Observations by licensing inspector: All required postings Additional Comments/Discussion: Staff members were given the opportunity to ask questions 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 Belinda Dyson, Licensing Inspector at (804) 662-9780 or by email at Belinda.Dyson@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

August 16, 2024Complaint survey0 violations

Inspection dates

08/16/2024,08/21/2024

Areas reviewed

22VAC40-73 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 GROUNDS

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: 8/16/2024 10:30a.m.-11:00 a.m. and 8/21/2024 10:15 a.m.-11:30 a.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint/self-reported incident was received by VDSS Division of Licensing on 6/20/2024, 8/14/2024 regarding allegations in the area(s) of: STAFFING AND SUPERVISION, ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS, RESIDENT CARE AND RELATED SERVICES RESIDENT ACCOMMODATIONS AND RELATED PROVISION, BUILDINGS AND GROUNDS Number of residents present at the facility at the beginning of the inspection: 37 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: NA Number of interviews conducted with residents: NA Number of interviews conducted with staff: 2 Observations by licensing inspector: Facility was clean, housekeeping staff on duty Additional Comments/Discussion: Staff members were given the opportunity to ask questions. 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. Use the following last two statements on every Inspection Summary: For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact (name), Licensing Inspector at (804) 662-9780 or by email at Belinda.Dyson@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

May 3, 2024Inspection0 violations

Inspection dates

05/03/2024

Areas reviewed

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: 5/3/2024 10:20 a.m.-2:00 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 36 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 4 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 4 Observations by licensing inspector: Lunch meal, activities, medication administration, physician’s orders, first aid kit supplies Additional Comments/Discussion: Administrator and staff members were given the opportunity to ask questions. Inspector was accompanied by Licensing Inspector. 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 Belinda Dyson, Licensing Inspector at (804) 662-9780 or by email at belinda.dyson@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

March 13, 2024Inspection0 violations

Inspection dates

03/13/2024

Areas reviewed

22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS

Comments

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03/13/2024 10:30 -11:15 a.m. 3/27/2024 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint/self-reported incident was received by VDSS Division of Licensing on 3/5/2024 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: 36 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: NA Number of staff records reviewed: NA Number of interviews conducted with residents: NA Number of interviews conducted with staff: 1 Observations by licensing inspector: Additional Comments/Discussion: Administrator and staff members were given the opportunity to ask questions. Inspector was accompanied by Licensing Administrator and another Inspector. 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 Belinda Dyson, Licensing Inspector at (804) 662-9780 or by email at belinda.dyson@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

October 4, 2023Complaint survey0 violations

Inspection dates

10/04/2023,10/27/2023

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES

Comments

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/4/2023 1:00 p.m.-1:45 p.m. and on 10/27/2023 12:45 p.m.-1:30 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 10/3/2023 regarding allegations in the area(s) of: Administration and Administrative Services. Number of residents present at the facility at the beginning of the inspection: 32 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: NA Number of staff records reviewed: NA Number of interviews conducted with residents: NA Number of interviews conducted with staff: 3 Observations by licensing inspector: Administrator of record was on site at the facility and letter of documentation was received by this Department Additional Comments/Discussion: New Administrator was given the opportunity to ask questions An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the (allegation) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Belinda Dyson, Licensing Inspector at (804) 662-9780 or by email at belinda.dyson@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

June 14, 2023Inspection0 violations

Inspection dates

06/14/2023,06/26/2023

Areas reviewed

22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS

Comments

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/14/2023 9:30-1:00 p.m.; 06/26/2023 10a.m.-11:30 a.m., 7/6/2023 9:44 a.m.-12:00 p.m The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint/self-reported incident was received by VDSS Division of Licensing on 6/14/2023 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: 36 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 5 Number of staff records reviewed: NA Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 4 Observations by licensing inspector: Additional Comments/Discussion: Administrator and staff members were given the opportunity to ask questions. Inspector was accompanied by Licensing Administrator and another Inspector. 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 Belinda Dyson, Licensing Inspector at (804) 662-9780 or by email at belinda.dyson@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

June 14, 2023Complaint survey0 violations

Inspection dates

06/14/2023,06/15/2023

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUNDS

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: 06/14/2023, 9:30 a.m.-1:00 p.m. 06/15/2023 9:50 a.m.-10:30 a.m. 06/26/2023 10:00 a.m.-11:00 a.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident/ complaint was received by VDSS Division of Licensing on 6/12/2023 regarding allegations in the area(s) of: 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: 36 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident’s record reviewed: 1 Number of staff interviewed: 2 Number of interviews conducted with residents:1 Number of interviews conducted with staff: 2 Observations by licensing inspector: Resident’s Individualized Service Plan, Uniform Assessment Instrument, room, clothing, personal appearance, documentation. Additional Comments/Discussion: Resident is a PACE participant. PACE has been working with the resident’s adjustment to the facility since admission in February. Facility sent a self-report on 6/12/2023 before the complaint the lodged. 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 Belinda Dyson, Licensing Inspector at (804) 662-9780 or by email at belinda.dyson@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

June 14, 2023Inspection4 violations

Inspection dates

06/14/2023

Areas reviewed

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: 6/14/2023 9:30 a.m.-1:00 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 36 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 4 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 4 Observations by licensing inspector: Lunch meal, activities, medication administration, physician’s orders, first aid kit supplies Additional Comments/Discussion: Administrator and staff members were given the opportunity to ask questions. Inspector was accompanied by Licensing Administrator. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Belinda Dyson, Licensing Inspector at (804) 662-9780 or by email at belinda.dyson@dss.virginia.gov

Violations

22VAC40-73-870-A

During a tour of the physical plant, all areas were not clean.

Evidence

Observations in hallways throughout were areas of soiled or dark stained carpet.

Plan of correction

Hallways have been deep cleaned to remove areas of soiled/dark stained carpet. Housekeeping notified to keep carpet cleaning in common areas on a monthly schedule.

22VAC40-73-250-D

During a review of staff records three of four records reviewed did not have current or initial tuberculosis test or screening results documented.

Evidence

Staff #1 last TB results is dated 3/8/2022. Staff #2 and #3 did not have an initial TB results or screening to review upon hire. They were hired on 7/3/2022 and 5/17/2022 respectively.

Plan of correction

Audit of all employee files reviewed for current tuberculosis test or screening. Any findings out of compliance were addressed. Tests will be kept in separate notebook divided by months to ensure that we remain in compliance with the annual screening. Tuberculosis is part of the orientation packet and completed during orientation.

22VAC40-73-550-G

During a review of resident's records, four our of eight records reviewed did not have documentation of annual review of residents rights and responsibilities.

Evidence

Resident's records #1, #5, #6 and #8 rights were dated 1/19/2022.

Plan of correction

Audit of all current resident files reviewed for their annual review of resident rights. Any resident missing the annual review will be completed and placed in resident’s file. Annual review of resident rights will be offered several times to accommodate the schedules of our residents.

22VAC40-73-210-B

During a review of staff records, one out of eight records reviewed did not have documentation of required annual training hours.

Evidence

Staff record #1 did not have documentation of 18 hours of required training. None were noted in the record.

Plan of correction

Will ensure that employee’s 18 hours of required annual training is in employee records.

February 10, 2023Complaint survey1 violation

Inspection dates

02/10/2023

Areas reviewed

AREAS OF STANDARDS¿ 22VAC40-73 GENERAL PROVISIONS¿ 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES¿ 22VAC40-73 PERSONNEL¿ 22VAC40-73 STAFFING AND SUPERVISION¿ 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS¿ 22VAC40-73 RESIDENT CARE AND RELATED SERVICES¿ 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS¿ 22VAC40-73 BUILDINGS AND GROUND¿ 22VAC40-73 EMERGENCY PREPAREDNESS¿ 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS¿ ARTICLE 1 – SUBJECTIVITY¿ 32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS¿ 63.2 GENERAL PROVISIONS¿ 63.2 PROTECTION OF ADULTS AND REPORTING¿ 63.2 LICENSURE AND REGISTRATION PROCEDURES¿ 63.2 FACILITIES AND PROGRAMS¿ 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES¿ 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION¿ 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT¿ 22VAC40-80 THE LICENSE¿ 22VAC40-80 THE LICENSING PROCESS¿ 22VAC40-80 COMPLAINT INVESTIGATION¿ 22VAC40-80 SANCTIONS

Comments

The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. However, violation(s) not related to the complaint but identified during the 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 Should you have any questions, please contact Vashti Colson, Licensing Inspector at (804) 662-9432 or by email at Vashti .Colson @dss.virginia.gov

Violations

22VAC40-73-560-F

: Based upon the complaint inspection, the facility failed to ensure that all records shall be made available for inspection by the department's representative.

Evidence

During the February 10, 2023, complaint inspection, the department’s representative met with the designated staff member to initiate the complaint inspection. Upon notice, the designated staff member informed the department’s representative that she did not have access to the resident records. During the exit conference with the designed staff member, the administrator arrived and informed the department’s representative that she did not have access to the records and that she could email the requested documents.

Plan of correction

All discharged resident files are kept locked in the administrator’s office. Files have been reorganized and Staff educated on the location of discharged files.

June 10, 2022Inspection2 violations

Inspection dates

06/10/2022

Areas reviewed

22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS

Comments

Type of inspection: Renewal. Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/10/2022 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 28 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed:06 Number of staff records reviewed:05 Number of interviews conducted with residents:02 Number of interviews conducted with staff: 02 Observations by licensing inspector: daily activities and medication administration 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 Vashti Colson, Licensing Inspector at (804) 662-9432 or by email at Vashti. Colson @dss.virginia.gov

Violations

22VAC40-73-260-A

VIOLATION: Based upon the record review, the facility failed to maintain first aid certification for each direct care staff member.

Evidence

Staff record #2 failed to have First Aid/CPR certification. During the exit conference , the facility failed to provided evidence that would dispute the cited violation.

Plan of correction

RMA's will review medication management plan and complete a four hour medication aide refresher course facilitated by pharmacy within 30 days or come off schedule . RMAS will receive weekly med pass observation to ensure standards are followed.

22VAC40-73-680-D

VIOLATION: Based upon the observation of 2:00 p.m. medication pass that occurred on June 10, 2022, the facility failed to administer all medications in accordance with the physician's or prescriber's instructions or per the practice outlined in the current registered medication aide curriculum.

Evidence

Upon entering Resident X's room for the 2:00 p.m. medication pass observation, the inspector and Med Tech #1 observed a medication cup , containing two small brown pills, sitting on the night stand beside the resident's bed. Resident X and the Med Tech #1 confirmed that the medication was Resident X's Senna pills that were left over from the June 10, 2022, morning medication pass.

Plan of correction

Employee files will be audited by the administrator for completion or First Aid/AED certification staff that do not have First Aid certification within two weeks will be removed from the schedule. New hires will be enrolled in first AID/AED courses to be completed within 30 days of hire.

May 13, 2022Inspection2 violations

Inspection dates

05/13/2022

Areas reviewed

Comments

Type of inspection: Monitoring Date(s) of inspection: 05-13-2022 Time the licensing inspector was on-site at the facility for each day of the inspection: 4:30 p.m. – 6:54 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-report was received by VDSS Division of Licensing on regarding allegations in the area(s) of: Staffing and Supervision Resident Care and Related Services Buildings/Grounds Number of residents present at the facility at the beginning of the inspection: 28 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 05 Number of staff records reviewed: 04 Number of interviews conducted with residents: 02 Number of interviews conducted with staff: 02 Observations by licensing inspector: buildings/grounds Additional Comments/Discussion: Focused inspection on self-reported incidents. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the self-report; area(s) of non-compliance with standard(s) or law were: 1) Personnel A violation notice was issued; any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Vashti Colson, Licensing Inspector at (804) 662-9432 or by email at Vashti.Colson@dss.virginia.gov

Violations

22VAC40-73-250-C

VIOLATION: Based upon the staff record review, the facility failed to maintain all required documentation in each staff record.

Evidence

Staff record #1 and staff record #2 failed to have each of the following items: a date of hire, a criminal record report, a sworn disclosure statement, and an orientation training document. Risk Rating: B-1

Plan of correction

Staff record #3 no longer employed. Staff record #2 Date of Hire : 04/26/2022, Criminal Record report -4-26-2022. Sworn Disclosure statement -04-19-22. Orientation training document - 04-26-2022.

22VAC40-73-250-B

VIOLATION: Based upon the staff record review, the facility failed to retain all staff records at the facility.

Evidence

The facility failed to have two out of four staff records available during the monitoring inspection. Staff record #3 and staff record #4 were not accessible during the monitoring inspection. Risk Rating: B-1

Plan of correction

Staff record #3 and Staff record #4 , no longer employed

May 13, 2022Complaint survey0 violations

Inspection dates

05/13/2022

Areas reviewed

Comments

Type of inspection: Complaint Date(s) of inspection: 05-13-2022 Time the licensing inspector was on-site at the facility for each day of the inspection: 4:30 p.m. – 5:09 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on March 24, 2022, regarding allegations in the area(s) of: 1) Admission, Retention and Discharge of Residents 2) Staffing and Supervision Number of residents present at the facility at the beginning of the inspection: 28. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: N/A Number of staff records reviewed: N/A. Number of interviews conducted with residents: 01. Number of interviews conducted with staff: 01. Observations by licensing inspector: Buildings/grounds Additional Comments/Discussion: The incident /allegations occurred in the nursing home facility. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the complaint 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 Vashti Colson, Licensing Inspector at (804) 662-9432 or by email at Vashti.Colson@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

January 14, 2022Complaint survey3 violations

Inspection dates

01/14/2022

Areas reviewed

Comments

Type of inspection: Complaint Date(s): January 14, 2023 Time the licensing inspector was on-site at the facility for each day of the inspection: 1:53 p.m. to 5:08 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 01/04/2022 regarding allegations in the area(s) of: Resident Care and Related Services Staffing and Supervision Administration and Administrative Services Number of residents present at the facility at the beginning of the inspection: 20. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 08 Number of staff records reviewed:0. Number of interviews conducted with residents:0. Number of interviews conducted with staff: 01. Observations by licensing inspector: Resident Records, buildings/grounds, Infection Control Policies and MARS/Physician Orders. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all the allegations; area(s) of non-compliance with standard(s) or law were: Resident Care and Related Services Staffing and Supervision Administration and Administrative Services A violation notice was issued; any violation(s) not related to the complaints but identified during the investigation can also be found on the violation notice. The licensee can submit a plan of correction to indicate how the cited violation(s) will be addressed 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 Vashti Colson, Licensing Inspector at (804) 662-9432 or by email at Vashti.Colson@dss.virginia.gov

Violations

22VAC40-73-40-A

VIOLATION: Based upon observation and policy review, the facility failed to adhere to their policies and procedures concerning visitation during the COVID-19 Pandemic.

Evidence

Upon entering the facility on January 14, 2022, the facility failed to have staff accessible to provide entrance screenings for each visitor that entered the facility by conducting temperature checks, questions about possible symptoms, visitor attestation forms/educational packets, and accessible face mask covering. Per the facility’s Visitation During the COVID-19 Pandemic policy states the following: The Visit:
The staff member supervising the visitation will greet visitor(s) and supply them with an appropriate face mask (3ply or N95 is required) and have them perform hand hygiene with ABHR.
Visitor(s) will be screened using the visitor attestation form and will be provided with an educational packet.
Visitors will be asked to read and sigh the Visitation agreement. (attached) A) Agreement must be signed in order to move forward with the visit. B) Explain to the visitor(s) that any breach in agreement will result in the visit being terminated.

Plan of correction

Temperature stations, attestation forms, hand sanitizer, 3 ply face masks, are readily available to all visitors of staff Visitation agreement no longer mandatory as COVID requirements have been lifted

22VAC40-73-280-A

VIOLATION: Based upon observation and staff interviews, the facility failed to have sufficient staff in numbers.

Evidence

Upon entering the facility, the licensing representative was greeted by a family member that was searching for a direct care staff member to provide direct care assistance to a resident in room #201. The only staff member available at the time of the family’s request was a dietary staff member who attempted to locate a C.N.A., P.C.A. or Med Tech. Upon speaking with both dietary and direct care staff members, in each interview, staff members expressed concerns about staffing shortages. The administrator also confirmed, during the interview session, that the facility had staffing shortages and that she was in negotiations with a staffing agency to address the identified staffing issues. Risk Rating: B-1

Plan of correction

Staffing is stable through new staff and or agency usage.

22VAC40-73-290-A

VIOLATION: Based upon the record review, the facility failed to maintain a written work schedule that identified the names and job classification of all staff working each shift, with an indication of the in-charge person at any given time.

Evidence

The master schedule submitted to the licensing inspector on January 14, 2022, failed to have the following item:
Indication of the in -charge staff member at any given time. Risk rating: A-1

Plan of correction

Master schedule revised to indicate in -charge staff member. ED, RCC, and Med Tech on duty in lobby daily.