Virginia DSS · Assisted Living Facility

The Kensington Falls Church

📍 700 W. Broad Street, Falls Church, VA, 22046

ID 42579Two Year licenseActive
11
Inspections
On record
7
With violations
Visits that cited something
4
Clean visits
Nothing cited
13
Violations cited
Individual findings
13
Standards cited
Distinct rules
4
Complaint visits
Prompted by a complaint

The Kensington Falls Church was inspected 11 times between January 28, 2021 and July 31, 2025 by the Virginia Department of Social Services. 7 of those visits ended with violations cited and 4 with none. Across that history VDSS cited 13 violations under 13 distinct standards. 4 inspections were prompted by a complaint.

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

VDSS publishes inspections on a rolling window. 10 of these 11 are still on the state's site; the other 1 has since dropped off it and is reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type
Assisted Living Facility
License type
Two Year
License expires
08/02/2026
Administrator
Amy Feather
Licensing inspector
Ishmel Paige
Inspector phone
(804) 963-0360
Approved for
Special Care Unit · Non-Ambulatory · Assisted Living

Inspection History

11

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

July 31, 2025Complaint survey0 violations
Inspection dates
07/31/2025
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: 7/31/25 (3:30 PM - 4:50PM) A complaint was received by the Fairfax Licensing Office on 7/7/25 regarding allegations in the area(s) of: Personnel, Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 109 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: Two Number of interviews conducted with residents: None Number of interviews conducted with staff: 12 Observations by licensing inspector: Activity Additional Comments/Discussion: 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. 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 Marshall Massenberg, Licensing Inspector at (804) 543-5188 or by email at Marshall.x.massenberg@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 30, 2025Complaint survey0 violations
Inspection dates
05/30/2025, 06/03/2025, 06/26/2025
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 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: 5/30/25 (9:50 AM - 4:15 PM), 6/3/25 (12:50 PM - 5:00 PM), 6/26/25 (1:50 PM – 3:30 PM). The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Complaints were received by VDSS Division of Licensing on 5/1/25 regarding allegations in the following areas of the regulations: Part III, Part VI, Part VII Number of residents present at the facility at the beginning of the inspection: 100 Number of resident records reviewed: One Number of interviews conducted with residents: One Number of interviews conducted with staff: Three Observations by licensing inspector: Activities, Building and Grounds 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 Marshall Massenberg, Licensing Inspector at (804) 543-5188 or by email at marshall.x.massenberg@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 30, 2025Complaint survey0 violations
Inspection dates
05/30/2025, 06/03/2025, 06/26/2025
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS
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: 5/30/25 (9:50 AM - 4:15 PM), 6/3/25 (12:50 PM - 5:00 PM), 6/26/25 (1:50 PM – 3:30 PM). The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Complaints were received by VDSS Division of Licensing on 5/1/25, 5/7/25, 5/8/25, 5/9/25, 5/12/25, and 5/22/25 regarding allegations in the following areas of the regulations: Part II, Part III, Part IV, Part V, Part VI, Part VII, Part VIII, Part IX, and Part X Number of residents present at the facility at the beginning of the inspection: 100 Number of resident records reviewed: Two Number of interviews conducted with residents: One Number of interviews conducted with staff: Four Observations by licensing inspector: Meals, Activities, Building and Grounds 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 Marshall Massenberg, Licensing Inspector at (804) 543-5188 or by email at marshall.x.massenberg@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 30, 2025Complaint survey1 violation
Inspection dates
05/30/2025, 06/03/2025, 06/26/2025
Areas reviewed
22VAC40-73 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: 5/30/25 (9:50 AM - 4:15 PM), 6/3/25 (12:50 PM - 5:00 PM), 6/26/25 (1:50 PM - 3:30 PM). The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Complaints were received by VDSS Division of Licensing on 5/9/25, regarding allegations in the area(s) of: Administration and Administrative Services, Admissions and Discharges, Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 100 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: Three Number of interviews conducted with residents: One Number of interviews conducted with staff: Two An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all, of the allegations of non-compliance with standard(s) or law. Substantiated complaint area(s): Resident Care and Related Services. A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (804) 543-5188 or by email at Marshall.x.massenberg@dss.virginia.gov.
Violations
22VAC40-73-450-H
Based on record review, the facility did not ensure that the services specified in the individualized service plan (ISP) are provided to each resident.
Evidence
  1. Resident #1's ISP states that the resident's weight/vitals would be taken by facility staff monthly. No documentation was provided, during the inspection, to indicate that Resident #1's weight/vitals were taken by facility staff each month.
Plan of correction
Resident #1 was an independent resident who was living in the community by choice to live with her partner who required assisted living and subsequent memory care services. Resident #1 received a discharge notice on April 30, 2025, and moved from the community prior to this inspection. Resident #1 was independent in all areas of care and did not require an individualized service plan (ISP), as per Virginia Standards for Licensed Assisted Living Facilities. The community chose to provide the staff with an ISP for this resident so they would be aware of her personal and social history, as well as preferences. Moving forward, if an independent resident refuses monthly weights or vitals, the Director of Nursing or designee will ensure their individualized service plan is updated to reflect this change.
May 30, 2025Inspection1 violation
Inspection dates
05/30/2025, 06/03/2025
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 GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS63.2 GENERAL PROVISIONS63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 5/30/25 (9:50 AM - 4:15 PM), 6/3/25 (12:50 PM - 5:00 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: 100 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: Six Number of interviews conducted with residents: Three Number of interviews conducted with staff: Four Observations by licensing inspector: Meals, Activities, Medication Administration 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 Marshall Massenberg, Licensing Inspector at (804) 543-5188 or by email at Marshall.x.massenberg@dss.virginia.gov.
Violations
22VAC40-73-680-M
Based on documentation and interview, the facility did not ensure that medications ordered for PRN administration were available and properly stored at the facility.
Evidence
  1. Resident #1's Artificial Tears, ordered 7/31/24, were not available for administration, at the time of the medication cart inspection on 5/30/25. Facility staff confirmed that Resident #1's PRN Artificial Tears were not present, at the time of the medication cart inspection.
Plan of correction
PRN Artificial Tears eyedrops for Resident #1 were received by the community on the day of the inspection, May 30, 2025. Delivery of the medication had been confirmed by Remedi, the delivering pharmacy, on May 23, 2025, but were not received until May 30. The regularly performed monthly audit results for PRN and expired medications was reviewed by the Director of Nursing again on May 30, after learning the eyedrops for Resident #1 were not yet in the building. The pharmacy reviewed the orders and confirmed that any additional PRN medications that they had previously been notified were expired, would be delivered in the community's next delivery. The Director of Nursing and Wellness Nurse confirmed all those medications were received on May 30 and May 31. Remedi, the community's contracted pharmacy is to complete an audit of the medications prescribed within the community monthly. PRN medications that are expiring are listed and the pharmacy is to deliver new medications. Along with the pharmacy audit, the Nursing team will track the delivery of the expired PRN medications and follow up with the pharmacy daily until medications are received. Moving forward, the Director of Nursing or their designee will confirm the appropriate audits are taking place and will complete their own audit of randomly selected PRN medications on a quarterly basis. The Executive Director or their designee is responsible for ensuring implementation and ongoing compliance with this plan of correction.
January 20, 2025Inspection2 violations
Inspection dates
01/20/2025
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: Date: 01/20/2026 Time In: 10:03am Time Out: 12:50pm 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 01/06/2026 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: 106 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 3 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: LI observed group activities, lunch, staff records and resident 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 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. 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.
Violations
22VAC40-73-120-A
Based on record review and staff interview, the facility failed to ensure that orientation and training required in subsections B and C of this section shall occur within the first seven working days of employment. Until this orientation and training is completed; the staff person may only assume job responsibilities if under the sight supervision of a trained direct care staff person or administrator.
Evidence
  1. On 01/06/2026, the facility self-reported an allegation of abuse regarding Resident 1 and Staff 5 on 01/01/2026.
  2. During the onsite inspection on 01/20/2026, Staff 1 indicated Staff 5 was unsupervised with Resident 1 during the time of the incident at approximately 6:45pm on 01/01/2026.
  3. Staff 5’s record (hire date: 12/17/2025) did not include documentation confirming the completion of orientation or initial training.
  4. Staff 5’s record included three handwritten “shadow/training” dates for 12/18/2025, 12/23/2025, and 12/24/2025; however, there was no indication of what training was covered during those dates.
  5. During the onsite inspection on 01/20/2026, Staff 1 acknowledged Staff 5 was still within the first seven working days of employment and Staff 5 was unsupervised during the time of the reported incident with Resident 1 on 01/01/2026.
Plan of correction
Staff 5, a licensed CNA with 10+ years of caregiving experience, hired on 12/18/2025, completed her floor orientation within 7 working days. Staff 5 was oriented by a licensed CNA with 10 years of experience who signed off on her competencies and confirmed with confidence Staff 5’s ability to provide care. On 1/20/2026, community was unable to present Staff 5’s record of orientation and initial training due to Staff 5 retaining documents for her own records. The CNA who trained Staff 5 confirmed this training completed before the date of incident, 01/01/2026, and therefore, Staff 5 was able to be unsupervised. TMS Manager completed audit of new-hire training records from last 90 days on 2/1/26, confirming all new-hires are in compliance, and signed documentation is in their personnel file. TMS Manager or Designee will utilize VDSS Record of Initial AL Staff Training from the DSS Training Resources to ensure all staff complete required initial training and orientation within their first 7 working days. ED or Designee will review weekly for the next 90-days.
22VAC40-73-260-A
Based on staff record review and staff interview, the assisted living facility failed to ensure that each direct care staff member maintains a current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department.
Evidence
  1. During the onsite inspection on 1/20/2026, Staff 3’s record indicated they were hired on 09/14/2023 as direct care staff.
  2. Staff 3’s record includes a certificate of completion from the American Safety and Health Institute for First Aid; however, the certificate expired on 11/2025.
  3. Staff 1 and Staff 2 acknowledged that the First Aid certification for Staff 3 was expired.
Plan of correction
Staff 3’s CPR and First Aid training and recertification was completed on 2/6/2026. Community TMS Manager completed a full staff audit of CPR status on 2/1. TMS or designee to continue review of CPR status at least 30 days in advance of the expiration date. Team members found to be approaching expiration of CPR will be instructed to recertify prior to the expiration date. ED or designee will review CPR status Monthly for the next 90 days.
September 20, 2024Inspection4 violations
Inspection dates
09/20/2024, 10/04/2024
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUNDS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Technical assistance
Documentation was discussed with the provider.
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: 9/20/24 (11:15 AM – 1:02 PM), 10/4/24 (2:30 PM – 5:00 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 9/6/24 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: Two Number of staff records reviewed: One Number of interviews conducted with residents: One Number of interviews conducted with staff: Two Observations by licensing inspector: Building and Grounds, Facility documentation An exit meeting will be conducted to review the inspection findings. The evidence gathered during the initial inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The applicant has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to maintain future compliance with applicable standard(s) or law. If the applicant 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 should the facility be issued a license to operate. 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 a licensed facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (804) 543-5188 or by email at Marshall.x.Massenberg@dss.virginia.gov.
Violations
22VAC40-73-1140-B
Based on observation and interview, the facility did not ensure that each staff member attends at least 10 hours of training in cognitive impairment within four months of the starting date of employment in the safe, secure, environment.
Evidence
  1. Staff #1’s record indicates that she was hired in November 2023 and attended facility orientation on 11/14/23 – 11/15/23.
  2. Staff #1’s hiring authorization form states that she was hired as a CNA for memory care and assisted living.
  3. Staff #1’s training records indicate that she attended a total of 8.5 hours of training in cognitive impairment, within her first four months of working in the special care unit.
Plan of correction
The Team Member Services Manager and Executive Director reviewed the current onboarding process and training tracker process in place for staff. An audit of the team members responsible for medication administration was completed by the Team Member Services Manager on September 22. An audit for the remaining Memory Care Team Members will be completed by October 20. Additional dementia training workshops have been scheduled for October 23 and 26. Moving forward, the Team Member Services Manager has added an additional due date in our computer-based training program to ensure an additional four hours of dementia training are completed before each Memory Care new hire reaches the end of their fourth month. Moving forward, the Team Member Services Manager will complete an additional audit of each new hire’s training status at the beginning of their fourth month and prompt our Memory Care Team Members to complete any needed dementia training prior to the end of the next month. If not completed by the end of the fourth month, new team members will be taken off the schedule. Team member files will continue to be audited annually at the time of their annual performance evaluation to ensure training status is compliant or the Team Member will be taken off the schedule. The Executive Director, or their designee, is responsible for ensuring implementation and ongoing compliance with this plan of correction.
22VAC40-73-680-C
Based on documentation, the facility did not ensure that medications are administered within one hour before, or one hour after, the facility’s standard dosing schedule. Exception: Drugs that are ordered for specific times, such as before, after, or with meals.
Evidence
  1. Facility documentation states that Resident #1 consumed a portion of Resident #2’s medications during an attempted medication administration at approximately 7:05 PM on 9/5/24.
  2. Documentation states that the medications consumed included “Benztropine, Calcium Citrate, Eliquis, Lamotrigine, Ativan, Melatonin, Trazadone and Tacrolimus.”
  3. Resident #2’s Medication Administration Record (MAR) indicates that her evening administrations of Benztropine, Calcium Citrate, Eliquis, Lamotrigine, Ativan, Melatonin, Trazadone, and Tacrolimus are scheduled for 9:00 PM and none of them were ordered for specific times.
Plan of correction
The Director of Nursing investigated as to why the medications for Resident #1 were administered outside the appropriate window. The team member was disciplined regarding the additional medication error. Staff #1 was relieved of her medication administration duties as of September 22. The Director of Nursing held a mandatory Nursing Team meeting on October 3 and included an in-service review of the “Medication Management” policy, covering specific medication administration, documentation and job descriptions. Emphasis was given to the directives regarding administration times and the proper steps to take if there were repeated refusals or difficulties in having the residents take the medications. The Director of Nursing has also been conducting unannounced individual medication administration observations with each team member passing medication and a one-on-one meeting with each to review any concerns. Any discrepancies between the documented administration time and the individual needs of those residents has been or will be addressed immediately. These meetings will be completed by October 31. The Director of Nursing or designee will continue to conduct unannounced medication administration observations weekly for 3 months (through January 15, 2025) to confirm medications are given according to the Medication Administration Policy and within the appropriate administration window. Any concerns will be documented and reviewed with the Executive Director weekly. Moving forward, the Director of Nursing or designee will continue to perform our regular monthly unannounced medication administration observations. The Medication Administration Policy and Job Description will continue to be signed and dated by each new team member hired for medication administration. These documents will also be reviewed annually with each team member responsible for medication administration. The Executive Director or their designee is responsible for ensuring implementation and ongoing compliance with this plan of correction.
22VAC40-73-680-B
Based on documentation, the facility did not ensure that medications remain in the pharmacy issued container, until administered to the resident.
Evidence
  1. Facility incident report, dated 9/5/24, indicated that Resident #2’s medications were crushed in apple sauce, and then placed on a table in order for Staff #1 to take a resident’s blood pressure.
  2. While the crushed medications/apple sauce were on the table, Resident #1 took the medication cup from the table and consumed some of it, as “a small amount of medication and applesauce was left remaining in cup.”
  3. Resident #1’s record contained an assessment of serious cognitive impairment form, completed May 2017, stating that the resident has a serious cognitive impairment with an inability to recognize danger or protect her own safety and welfare.
  4. Resident #1 was taken to the hospital for evaluation. Hospital records state that Resident #1 completed an 8-hour observation in the emergency department without difficulty.
Plan of correction
The Director of Nursing was in the building and was notified immediately when Staff #1 became aware Resident #1 had consumed Resident #2’s medications. The Physician and Family were contacted and Resident #1 was sent to the Emergency Department for observation and returned without treatment or consequence. The Director of Nursing and Executive Director self-reported to the Department of Social Services the next morning. Staff #1 was relieved of her medication administration duties as of September 22. The Director of Nursing and Executive Director met and agreed that the team should be instructed to perform all parameter tasks prior to preparing the medications to avoid putting medications down prior to administration. The Director of Nursing held a mandatory Nursing Team meeting on October 3 and included an in-service review of the “Medication Management” policy, covering specific medication administration, documentation and job descriptions. Emphasis was given to the directives to take blood pressures, blood sugars or any other vitals required for medication parameters, prior to preparing the medications for administration. The Director of Nursing has also been conducting unannounced individual medication administration observations with each team member passing medication and a one-on-one meeting with each to review any concerns. Any concerns regarding methodology of administration or the taking of vitals to confirm parameters will be addressed immediately. These meetings will be completed by October 31. The Director of Nursing or designee will continue to conduct unannounced medication administration observations weekly for 3 months (through January 15, 2025) to confirm medications are given according to the Medication Administration Policy and parameter tasks are done prior to medication preparation. Each Team Member responsible for medication administration will be observed at least once a month. Any concerns will be documented and reviewed with the Executive Director weekly. Moving forward, the Director of Nursing or designee will continue to perform our regular monthly unannounced medication administration observations. Each Team Member responsible for medication administration will be observed quarterly. The Medication Administration Policy and Job Description will continue to be signed and dated by each new team member hired for medication administration. These documents will also be reviewed annually with each team member responsible for medication administration. The Executive Director or their designee is responsible for ensuring implementation and ongoing compliance with this plan of correction.
22VAC40-73-670-1
Based on record review, the facility did not ensure that each staff person who administers medication is authorized by § 54.1-3408 of the Virginia Drug Control Act. All staff responsible for medication administration shall: be licensed by the Commonwealth of Virginia to administer medications; or be registered with the Virginia Board of Nursing as a medication aide, except as specified in subdivision 2 of this section
Evidence
  1. Resident #2’s September Medication Administration Record (MAR) lists Staff #1 as one of the staff members that administered medications to the resident.
  2. Staff #1’s record included documentation that she has a current license from Maryland as a Medication Technician.
  3. No documentation was provided, during the inspection, to indicate that Staff #1 was licensed by the Commonwealth of Virginia or registered with the Virginia Board of Nursing to administer medications.
  4. Facility staff confirmed that no Virginia license/registration was present in Staff #1’s record to authorize the staff person to administer medication in Virginia.
Plan of correction
The Team Member Services Manager contacted team member (Staff #1) immediately and informed them that the Maryland Medication Certification is nontransferable and that they will not be able to work as a medication aid unless registered with the Virginia Board of Nursing to administer medications. Staff #1 was relieved of her medication administration duties as of September 22. An audit of the team members responsible for medication administration was completed by the Team Member Services Manager on September 22, to confirm all had appropriate training and licensure. A Nursing Team meeting was held on October 3 and included an in-service review of the “Medication Management” policy, licensure and training requirements. These documents will be reviewed annually and will be reviewed with each new team member. Moving forward, the Team Member Services Manager and Director of Nursing or their designee will confirm the current licensure and training of each new team member prior to their being added to the schedule for medication administration. The Team Member Services Manager will complete an audit of each team member file annually at the time of their annual performance evaluation to ensure licenses are current. The Executive Director or their designee is responsible for ensuring implementation and ongoing compliance with this plan of correction.
June 3, 2024Inspection1 violation
Inspection dates
06/03/2024
Areas reviewed
Administration and Administrative ServicesPersonnelStaffing and SupervisionAdmission, Retention and Discharge of ResidentsResident Care and Related ServicesResident Accommodations and Related ProvisionsBuilding and GroundsEmergency PreparednessAdditional Requirements for Facilities that Care for Adults with Cognitive ImpairmentsBackground Checks for Assisted Living FacilitiesSworn Statement
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: 06/03/2024-06/04/2024 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: 111 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: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: Licensing Inspector observed residents participating in various activity programs and eating breakfast and lunch. LI also observed medication being administered to residents. Additional Comments/Discussion: 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. 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 Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov
Violations
22VAC40-73-210-B
Based on record review and staff interview, the facility failed to ensure direct care staff attended 12 hours of training annually.
Evidence
  1. Training record for Staff 4, hired on 6/19/2018 only had 7.25 hours of recorded training from 1/1/2023-6/4/2024.
  2. Staff 5 stated “she doesn’t have the hours.”
Plan of correction
Staff #4, who was 4.75 hours short of the required 12 hours of annual training, will submit documentation for the community’s assigned training or give evidence of equivalent training by the end of the month. The Team Member Services Manager (HR Manager) is conducting a thorough audit and is currently through 50% of the team member training records. This will be completed by July 15. Moving forward, in addition to the HR Manager, Supervisors will be responsible for tracking and enforcing training compliance for their departments via the organization’s training website. Annual training hours will be incorporated into the team member annual evaluation process. Monthly compliance reports will be prepared by the HR Manager and sent to the supervisors and the executive director. Monthly training compliance warnings will be emailed and text to team members that are out of compliance. Team members that continue to be out of compliance will receive disciplinary action and/or be removed from the schedule until in compliance. The Executive Director or their designee is responsible for ensuring implementation and ongoing compliance with this plan of correction.
June 7, 2023Inspection0 violations
Inspection dates
06/07/2023
Areas reviewed
Administration and Administrative ServicesPersonnelStaffing and SupervisionAdmission, Retention and Discharge of ResidentsResident Care and Related ServicesResident Accommodations and Related ProvisionsBuilding and GroundsEmergency PreparednessAdditional Requirements for Facilities that Care for Adults with Cognitive ImpairmentsBackground Checks for Assisted Living FacilitiesSworn Statement
Comments
Date of Inspection: June 7, 2023 Type of Inspection: Monitoring Inspection Census 105 Number of records reviewed and interviews conducted- 8 records, 3 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. The LI observed residents involved in activity programs and eating lunch. This Licensing Inspector also observed medication administration pass. If you have any questions or email changes, please do not hesitate to contact me at sarah.pearson@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 24, 2022Inspection1 violation
Inspection dates
05/24/2022,05/27/2022
Areas reviewed
Administration and Administrative ServicesPersonnelStaffing and SupervisionAdmission, Retention and Discharge of ResidentsResident Care and Related ServicesBuilding and GroundsEmergency Preparedness
Comments
Date of Inspection: May 24, 2022 Type of Inspection: Renewal Inspection If you have any questions or email changes, please do not hesitate to contact me at laura.lunceford@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov. Census 113 Number of records reviewed and interviews conducted- 4 resident records and 4 staff records, 5 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. The Licensing Inspector observed the residents during lunch, exercising and activities. the Licensing Inspector reviewed the following documents during the inspection: fire drills, healthcare oversight, activity schedule and menus. The Licensing Inspector and the Administrator discussed the risk assessment ratings for the violations for this inspection. Please complete the “plan of correction” and “date to be corrected” for each violation cited on the violation notice and returned it to the office. You will need to specify how the deficient practice will be or has been corrected. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s).
Violations
22VAC40-73-650-B
Based on resident record review and staff interview, it was determined that the facility failed to have diagnoses and conditions for medications administered to residents in care.
Evidence
  1. Resident A, B, C and D physician order sheets did not have diagnoses for medications ordered for administration.
Plan of correction
The Executive Director met with the General Manager of the house pharmacy. The pharmacy personnel have audited all the physician orders in the system and corrected those missing a diagnosis for a reason for administration with physician approval. We are working with out electronic medication administration software provider to implement those updates within our system as quickly as possible. Moving forward, the pharmacy has updated our community controls to ensure all incoming physician orders have the appropriate diagnosis code in the correct field so that it does not fall off when dosage or timing is altered. The pharmacy will require all in coming PRN orders to have reasons or indications for administration prior to completing the order. They will also follow up with the physicians or clinical prescribing personnel who escribe or send orders without diagnoses. The Nursing team will be ensuring we receive proper diagnoses or reasons for administration when receiving orders from prescribing providers at the community, prior to forwarding to the pharmacy. The pharmacy will monitor this during their monthly audits to ensure compliance. The Executive Director, the Director of Nursing or their designee is responsible for ensuring implementation and ongoing compliance with this plan of correction.
January 28, 2021Inspection3 violations
Inspection dates
Jan. 28, 2021 , Jan. 29, 2021 and Feb. 1, 2021
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity63.2 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 LICENSE
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 monitoring inspection was initiated on 1/28/2021 and concluded on 2/01/2021. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 86. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed 5 resident records and 5 staff records. Criminal record checks and sworn statements of all staff hired since last inspection and other documentation submitted by the facility was reviewed to ensure documentation was complete. 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
22VAC40-73-320-A
Based on record review, facility failed to ensure that within the 30 days preceding admission, a person shall have a Physical Examination (PE) and shall contain any known allergies and description of the person's reactions, and results of a risk assessment documenting the absence of tuberculosis (TB) in a communicable form.
Evidence
  1. Resident #1 was admitted on 12/17/2020 with a PE dated 12/8/2020 with a documented allergy to chlorhexidine without a documented reaction.
Plan of correction
Resident #1 was admitted on 12/17/2020 with a Physical Examination noting an allergy to chlorhexidine without a documented reaction. The resident and their primary physician were asked what the allergic reaction might be, and it was unknown. In the future, all Physical Examination forms for new admissions with allergies noted will be inspected by our Sales Team to ensure reactions are described or if reactions are unknown, that it is noted on the exam form. The Director of Nursing or their designee will ensure proper completion prior to admission and the Executive Director or their designee of Nursing or their designee will ensure proper completion prior to admission and the Executive Director or their designee is responsible for ensuring the implementation and ongoing compliance of this plan of correction.
22VAC40-73-450-A
Based on record review, facility failed to ensure that on or within seven days prior to the day of admission a preliminary plan of care shall be developed to address the basic needs of the resident that adequately protects his health, safety, and welfare.
Evidence
  1. Resident #3 was admitted on 9/13/2020 with an ISP dated 9/14/2020, after admission.
Plan of correction
Resident #3 was admitted on 9/13/2020 and had an Individualized Service Plan (ISP) completed but not signed on that date. The resident arrived on the evening of 9/13 and the family requested to wait until the next day to review the ISP. The preliminary plan of care was printed for the care team on 9/13/2020 and then finalized after meeting with the family on 9/14/2020. Moving forward the Director of Care or their designee will complete and finalize the ISP on the day a resident moves in or within 7 days prior. The Director of Nursing will ensure that this Standard is covered in the ISP training for all those developing the plans of care. The Executive Director or designee is responsible for ensuring implementation and ongoing compliance with this plan of correction.
22VAC40-90-30-C
Based on record review, facility failed to ensure that any person making a materially false statement on the sworn statement or affirmation shall be guilty of a Class 1 misdemeanor.
Evidence
  1. Staff #20 was hired on 6/24/2020 with a Sworn Statement in record signed and dated on 6/4/2020 documented an answered "No" to a question regarding previous conviction; and the Virginia Criminal Record for Staff #20 dated 6/17/2020 documents a guilty misdemeanor in 2012.
Plan of correction
Staff #20 reported to having misunderstood the question on the sworn statement at the time of completion. Upon initial application, weeks prior to completing the sworn statement, Staff #20 fully disclosed their previous conviction. Moving forward, all Sworn Statements will be reviewed by the hiring manager or Human Resources personnel prior to applicant leaving the building to ensure proper completion, consistent with initial applications. The Business Office Assistant or the Human Resource Director will conduct monthly audits on the last 30 days of new employee paperwork to ensure compliance. The Executive Director or designee is responsible for ensuring implementation and ongoing compliance with this plan of correction.