Manorhouse Assisted Living & Memory Care — 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

Manorhouse Assisted Living & Memory Care was inspected 15 times between September 30, 2020 and December 15, 2025 by the Virginia Department of Social Services. 8 of those visits ended with violations cited and 7 with none. Across that history VDSS cited 17 violations under 15 distinct standards. 5 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. 11 of these 15 are still on the state's site; the other 4 have since dropped off it and are reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type

Assisted Living Facility

License type

Two Year

License expires

12/19/2026

Administrator

Luann Paul

Licensing inspector

Yvonne Randolph

Inspector phone

(804) 441-1180

Approved for

Non-Ambulatory · Assisted Living · Special Care Unit

Inspection History

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

December 15, 2025Inspection1 violation

Inspection dates

12/15/2025

Areas reviewed

Comments

Type of inspection: Mandated Monitoring. Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/15/25, 1:55 pm to 4:00 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 86 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 6 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 4 Observations by licensing inspector: file documentation, medication administration and storage, staff-resident interaction, resident activities(group and individual), facility cleanliness and maintenance, etc Additional Comments/Discussion: verification of liability insurance An exit meeting was conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standards or law, and a violation is 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 will be addressed in order to return the facility to compliance and maintain future compliance with applicable standards 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 Yvonne Randolph, Licensing Inspector at (804) 441-1180 or by email at yvonne.randolph@dss.virginia.gov

Violations

22VAC40-73-1110-B

Based on files reviews, the facility did not ensure that six months after placement of the resident in the safe, secure environment and annually thereafter, the licensee, administrator, or designee shall perform a review of the appropriateness of each resident's continued residence in the special care unit.

Evidence

The date of admission for resident # 4 was documented as 5/2/23. A review of appropriateness performed six months after placement and an annual review for 2024 was not documented in the file of resident # 4.

Plan of correction

Regulation review of standard 22VAC40-73-(10)-1110-B with nursing leadership. Date to be corrected-12-16-25 Chart audit of all Memory Care residents to ensure the appropriateness of each resident's continued residence in special care unit are completed according to standard 22VAC40-73-(10)-1110-B, Date to be corrected -12-31-25

August 13, 2025Inspection1 violation

Inspection dates

08/13/2025

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

Type of inspection: Monitoring. Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 8/18/25, 9:15 a to 10:25 a The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 7/25/25 regarding allegations in the area of: Resident Care and Related Services Number of interviews conducted with staff: 1 Observations by licensing inspector: Incident report, photographs An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation supported non-compliance with standards or law, and a violation was issued. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation will be addressed in order to return the facility to compliance and maintain future compliance with applicable standards 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 Yvonne Randolph, Licensing Inspector at (804) 441-1180 or by email at yvonne.randolph@dss.virginia.gov

Violations

22VAC40-73-460-D

Based on documentation review, the facility id not ensure supervision of resident schedules, care, and activities, including attention to specialized needs, such as prevention of falls.

Evidence

The facility self-reported an incident on 7/25/25 involving a resident fall. Resident # 1 fell out of wheelchair while being transported in the facility's van. Facility staff did not ensure the stability of the wheelchair prior to transport allowing the wheelchair to fall to the side.

Plan of correction

Steps that we took post the wheelchair incident of 7-24-25 Immediately following the incident Facilities Director met with the van driver to review how wheel-chair was secured in van, over the shoulder seat belt strap was in use, both housing units for the straps to hook onto the wheelchair were in use, it was determined that one of the housings was not allowing for proper tension of the strap to secure the wheelchair, allowing the chair to tip to the side. Facilities Director immediately removed the housing unit and replaced with a new one, at which time he tested the tension of the newly installed unit and found the tension to be secure.

July 30, 2025Complaint survey0 violations

Areas reviewed

22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS

Comments

Type of inspection: Complaint Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7/30/2025 1:15 p to 1:45 p The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection Number of. records reviewed:1 Observations by licensing inspector: File documentation A complaint was received by VDSS Division of Licensing on 7/24/25 regarding allegations in the areas of: Admission, Discharge and Retention The evidence gathered did not support the allegations of non-compliance with the standards, 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 Yvonne Randolph, Licensing Inspector at (804) 441-1180 or by email at yvonne.randolph@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

October 15, 2024Inspection2 violations

Inspection dates

10/15/2024

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: 10/15/24, 9:45 am to 12 noon 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: 63 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 and 2 medication passes Number of staff records reviewed: 4 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: medication storage and administration, building maintenance and cleanliness, activity, per the activity schedule, menu, staff/resident interaction, etc An exit meeting was conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standards or law, and violations 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 violations will be addressed in order to return the facility to compliance and maintain future compliance with applicable standards 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 Yvonne Randolph, Licensing Inspector at (804) 662-7454 or by email at name@dss.virginia.gov

Violations

22VAC40-73-250-C

Based on file reviews, the facility did not ensure that each staff person or household member required to be evaluated annually submit the results of a risk assessment, documenting that the individual is free of tuberculosis in a communicable form as

Evidence

d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence. An annual tuberculosis screening was not documented in three staff files. Facility staff reviewed the files and was unable to locate the documentation

Plan of correction

Procedures will be implemented to ensure documentation of staff TB risk assessment is completed annually to maintain compliance. Responsible party: administrator or designee

22VAC40-73-1100-A

Based on file reviews, the facility did not ensure that prior to placing a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia in a safe, secure environment, the facility shall obtain the written approval .

Evidence

The approval form for resident # 3 was not dated, it could not be determined if the approval was obtained prior to placement of the resident in the safe, secure environment.

Plan of correction

Procedure will be implemented to ensure prior to admission or transfer to memory care that written approval is signed and appropriately dated. Responsible Party: administrator or designee

November 3, 2023Inspection0 violations

Inspection dates

11/03/2023

Areas reviewed

Comments

Type of inspection: Renewal Unannounced Mandated Date of inspection the licensing inspector was on-site at the facility for each day of the inspection: 11/3/23, 9:30 am - 12:30 pm The Acknowledgement of Inspection form was emailed for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 81 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 5 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 4 Observations by licensing inspector: Medication administration and storage, activities, lunch meal, staff/resident interaction, An exit meeting was 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 Yvonne Randolph Licensing Inspector at (x804) 662-7454 or by email at Yvonne.randolph@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

August 15, 2023Complaint survey0 violations

Inspection dates

08/15/2023

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 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: The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 8/10/23 regarding allegations in the area(s) of: Administration and Administrative Services, Staffing and Personnel, Resident Care and Related Services, Building and Grounds Number of residents present at the facility at the beginning of the inspection: The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Resident Room and Bathroom An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support allegations of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact YVONNE RANDOLPH, Licensing Inspector at 804-662-7454 or by email at yvonne.randolph@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

July 31, 2023Inspection1 violation

Inspection dates

07/31/2023,08/15/2023

Areas reviewed

22VAC40-73 BUILDINGS AND GROUND

Comments

Type of inspection: Monitoring, Non-Mandated Date(s) of the inspection : 7/31/23 and 8/15/23 Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The licensing inspector completed a tour of the resident’s room. Number of interviews conducted with residents:1 Number of interviews conducted with staff: 1 A self-reported incident was received by VDSS Division of Licensing on 6/26/23 followed by a complaint on 7/28/23 regarding an allegation in the areas: Building and Grounds Observations by licensing inspector: Resident room - signaling system An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported one, but not all of the allegations; area(s) of non-compliance with standard(s) or law. A violation notice was issued and can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Yvonne Randolph, Licensing Inspector at (804) 662-7454 or by email at yvonne.randolph@dss.virginia.gov

Violations

22VAC40-73-870-E

Based on an investigation of a self reported incident and a subsequent complaint, all equipment is not kept in good repair and condition.

Evidence

An incident report was received on 6/26/23 documenting that the resident pulled the call cord for assistance. It was discovered that the pull cord was not working due to dead battery. It was also confirmed during interviews with the complainant and facility staff that the pull cord had been installed incorrectly (upside down).

Plan of correction

Replaced and call bell reinstalled properly Plan of correction: Batteries to be tested bi-annually for all call boxes

July 10, 2023Inspection0 violations

Inspection dates

07/10/2023

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

Type of inspection: Monitoring Unannounced Non-mandated Date of inspection the licensing inspector was on-site at the facility for the inspection: 7/10/23 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of interviews conducted with staff: 1 A self-reported incident was received by VDSS Division of Licensing on 6/21/23 regarding allegations in the area of Resident Care and Related Services. A subsequent report of the incident was received from a community partner. The evidence gathered during the investigation did not support any 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. Should you have any questions, please contact Yvonne Randolph, Licensing Inspector at 804-441-1180or by email at yvonne.randolph@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

May 26, 2023Inspection2 violations

Inspection dates

05/26/2023

Areas reviewed

Comments

Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 5/26/23, 11:25 am to 2:15 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of residents present at the facility at the beginning of the inspection: 89 Number of staff records reviewed: 5 Number of resident records reviewed: 10 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: Activity in memory support, medication pass, postings, physical plant (inside and outside) 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 Yvonne Randolph, Licensing Inspector at 804-441-1180 or by email at yvonne.randolph@dss.virginia.gov

Violations

22VAC40-73-1100-C

Based on a review of resident files, the facility did not document the order of priority followed for the approval of placement of two residents in the safe and secure environment.

Evidence

The written approval form for residents # 4 and # 10 did not have an explanation of why the written approval was not obtained from each individual higher on the list of priority.

Plan of correction

All Approval for Placement forms corrected 5-30-23 Reviewed with Admissions Dept as well as Nursing Dept the correct completion of Approval for Placement forms moving forward.

22VAC40-73-450-C

1. Based on a review of resident files, the individualized service plan (ISP) for one resident did not have a description of an identified need based upon the admission physical examination.

Evidence

The physical examination for resident # 3 dated 2/7/23 documented two falls in the last 30 days. A fall risk goal was not found during a review of the ISP for resident # 3.
Based on a review of resident files, the ISP for one resident contained a goal for a need that was not identified. Evidence: The ISP for resident #1 contained a fall risk goal indicating a history of falls. The fall risk assessment for resident # 1 dated 12-14-22 did not document a risk or history of falls.

Plan of correction

1. Reviewed with ISP trained employees that resident #3 based on Physical exam did not have a fall risk goal. Fall risk goal has been corrected based on the Physical Exam on 5-30-23 2. Reviewed with ISP trained employees that resident #1 had a goal identified but was not captured in the fall risk assessment. This has been corrected on 5-30-23

January 9, 2023Complaint survey4 violations

Inspection dates

01/09/2023

Areas reviewed

None22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 RESIDENT CARE AND RELATED SERVICES63.2 FACILITIES AND PROGRAMS

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: 1-09-2023, 12:00 p.m. – 1:45 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 October 26, 2022 regarding allegations in the areas 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: 87 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; area(s) of non-compliance with standard(s) or law were: Administration and Administrative Services; 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 Alexandra Poulter, Licensing Inspector at (804) 662-9771 or by email at alex.poulter@dss.virginia.gov

Violations

22VAC40-73-450-A

Based on record review and interview, 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

Resident #1 admitted 7-25-2022. Resident #1’s ISP in the record with dates identified of needs as 7-25-2022 was not identified as the preliminary plan of care.
Additionally, Resident #1’s ISP did not document concerns for resident’s behaviors regarding exit-seeking or wandering behaviors; however, documentation in the Nurse’s Notes dated 7-22-2022 and Physician’s Progress Notes dated 8-05-2022 documented exit-seeking behaviors, as well as interviews with Staff.

Plan of correction

Complete a thorough review of all ISPs and UAIs to ensure all needs are captured and addressed to reflect safety and appropriate placement. Ensure that all ISPs and UAIs are completed in the required time frame with signature reviews of responsible parties.

22VAC40-73-40-A

Based on record review and interview with staff, the facility failed to ensure compliance with the facility’s own policies.

Evidence

Policy Number 050-050 titled, “Confused & Wandering Residents” dated 5-01-2017 documented, “Individuals identified as confused or potentially wandering residents (“wanderers”) will be expected to wear identification bracelets.”
Resident #1 admitted 7-25-2022 and was identified on physician’s orders dated 7-31-2022 “Advise 24 h sitter c¯ [with] exit seeking”. An additional progress note by the physician dated 8-05-2022 documented, “...continues to exit seek”.
Interview with Staff #2 confirmed that Resident #1 exhibited wandering and exit-seeking behaviors from prior to his admission to the Assisted Living Facility (ALF), when he resided in Independent Living at the same community, and that his wandering and exit seeking behaviors continued until the time of his discharge from the ALF.
Staff #1 confirmed that Resident #1 did not wear an identification bracelet during his admission to the ALF from 7-25-2022 to 10-05-2022.

Plan of correction

Review Policy 050-050 to ensure identification bracelets are accessible for “potential wandering residents”. Review with staff the policy and process.

22VAC40-73-650-B

Based on record review, the facility failed to ensure physician or other prescriber orders included the identification of the diagnosis, condition, or specific indications for administering each drug.

Evidence

Resident #1’s physician’s orders dated 9-28-2022 documented, “Seroquel 25 mg tablet... ½ tab nightly for 1 week…” and did not identify the diagnosis, condition, or specific indications for administering the drug.
Resident #1’s physician’s orders dated 7-29-2022 documented, “Aveed 750 mg/3mL Inject 3mL IM once every 10 weeks” and did not identify the diagnosis, condition, or specific indications for administering the drug.

Plan of correction

All MAR audit review to ensure physician orders identify - Diagnosis - Condition - Specific indications for administering drugs/ medications. Will utilize our Pharmacy to assist with this oversight.

63.2-1808-A

Based on record review and interviews, the facility failed to ensure any resident of an assisted living facility has the rights and responsibilities enumerated in this section, including freedom to select health care services from reasonably available resources.

Evidence

Resident #1 admitted to the facility on 7-25-2022 under the care of Physician #1. The facility implemented a change of physician for Resident #1 without the consent of the Power of Attorney [POA]. A family member who was not the POA for Resident #1 offered consent for the change of physician.

Plan of correction

Educate staff that only POA has the authority to give consent for change of physician

November 10, 2022Inspection4 violations

Inspection dates

11/10/2022

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: 11-10-2022, 10:30 a.m. – 11:40 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 September 29, 2022 regarding allegations in the area of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 89 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 Alexandra Poulter, Licensing Inspector at (804) 662-9771 or by email at alex.poulter@dss.virginia.gov

Violations

22VAC40-73-450-E

Based on record review, the facility failed to ensure the individualized service plan (ISP) was signed and dated by the licensee, administrator, or his designee, (i.e., the person who has developed the plan), and by the resident or his legal representative.

Evidence

Resident #1’s ISP with dates identified as 7-25-2022 and not identified as a “preliminary” ISP was not signed or dated by the licensee, administrator, or designee; nor by the resident or his legal representative. This ISP for Resident #1 was the only ISP of record for Resident.

Plan of correction

Complete a thorough review of all ISPs and UAIs to ensure all needs are captured and addressed to reflect the individual needs of each resident.

22VAC40-73-220-A

Based on record review and interview with staff, the facility failed to ensure before private duty personnel services are initiated, the facility obtained in writing the information on the type and frequency of the services to be delivered to the resident by the private duty personnel, as well as provide orientation and training to private duty personnel regarding the facility’s policies and procedures.

Evidence

Resident #1 admitted 7-25-2022 to the facility. The documentation provided regarding Resident #1’s Private Duty Personnel (PDP) services did not include documentation of the type and frequencies of services, nor did the resident’s record contain the orientation and training undergone by PDP staff.
Staff #1 confirmed the absence of this required documentation for the PDP during exit.

Plan of correction

Develop a plan to ensure orientation of private duty sitter and ensuring that community receives in writing the type and frequency of the services to be delivered to the resident. 1) Review UAI and ISP of current resident with private duty staff, care plan review 2) Signature of private duty staff understanding what is required to care for the resident 3) Documentation reflecting orientation and training regarding building protocols with signature training received.

22VAC40-73-460-D

Based on record review and interview with staff, the facility failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs, such as wandering from the premises.

Evidence

Resident #1 admitted 7-25-2022 to the facility. The following Nurse’s Notes (by physician) documented Resident #1 wandering incidents: a. 7-31-2022 7 a.m. – 3 p.m. shift: “Pt. [Resident #1] was brought back to the facility @ 10:45 am from [Street Name]. [Resident #1] was pleasantly confused, [Resident #1] stated “I am looking for my mama”… b. 8-29-2022 11 p.m. – 7 a.m. shift: “Resident [#1] found out front of facility by staff member around 0530 [5:30 a.m.]. Resident [#1] was able to pull open the locked sliding front door with his hands per resident [#1]…
Staff #1 confirmed the aforementioned incidents of wandering.

Plan of correction

Procedures to be developed and implemented for residents that are potential to wander ensuring appropriate placement and safety 1) Identify risk via UAI and ISP documentation 2) Plans to be put into place to ensure safety

22VAC40-73-450-C

Based on record review and interview with staff, the facility failed to ensure the comprehensive individualized service plan (ISP) included a description of identified needs based upon the assessment of psychosocial, behavioral, and emotional functioning, and other sources.

Evidence

Resident #1 admitted 7-25-2022. Resident #1’s current and only ISP in the record (undated) did not address exit-seeking behaviors as seen in the Nurse’s Notes as well as Physician’s Progress notes. The Nurse’s Notes and Progress Notes documented: a. Nurse’s Notes - 8-01-2022 7 a.m. – 3 p.m. shift: “… advise 24 hr sitter with exit seeking [POA] aware. b. Progress Notes – 8-05-2022: “[Resident #1] continues to exit seek…” c. Progress Notes – 8-10-2022: “[Resident #1] Continues to exhibit exit-seeking…” d. Nurse’s Notes - 9-28-2022 11 p.m. – 7 a.m. shift: On the 25th of September 2022 – [Resident #1] had to be redirected several times to return to [Resident #1’s] room, between the hours of 12-2:30 a.m. [Resident #1] kept exit seeking, going down the stairs near his room, which leads to the memory unit. [Resident #1] wasn’t fully dressed, tee shirt, boxers & shoes. After leaving [Resident #1’s] room for the 3rd time, I suggested we go for a walk…”
Resident #1’s UAI was updated 9-29-2022 with “Exit Seeking behavior noted” however, there is not an updated ISP to reflect this identified need.

Plan of correction

Complete and thorough review of all ISPs and UAIs to ensure all needs are captured and addressed to reflect safety and appropriate placement. Ensure that all ISPs and UAIs are completed in the required time frame with signature reviews of responsible parties.

June 6, 2022Inspection2 violations

Inspection dates

06/06/2022

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: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/06/2022 , Time : 2:15 p.m. to 6;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: 78 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 05 Number of interviews conducted with residents: Interviews conducted during building tour.. Number of interviews conducted with staff: 03 Observations by licensing inspector: Medication pass and activities observation Additional Comments/Discussion: N/A 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

22VAC40-73-250-D

VIOLATION: Based upon the record review, the facility failed to maintain the health information for each staff record.

Evidence

Staff record #1 failed to have an initial T.B. assessment in the record within seven days prior to the first day of work. During the exit conference the facility was provided the opportunity to provide the requested evidence in order to dispute the cited violation.

Plan of correction

Not published by VDSS.

22VAC40-73-560-I

VIOLATION : Based upon the record review, the facility failed to have a current picture of each resident available for identification purpose.

Evidence

Record # 1 failed to have a current picture of the resident or a narrative physical description of the resident.

Plan of correction

Not published by VDSS.

December 16, 2020Complaint survey0 violations

Inspection dates

Dec. 16, 2020 and Jan. 13, 2021

Areas reviewed

22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-80 COMPLAINT INVESTIGATION

Technical assistance

Upon review of the documents provided by the facility, the facility informed the assigned Virginia Commonwealth Licensing Inspector and the VDH COVID-19 Facilities Management Team Representative that there have been no new admissions to the facility within the time frame of 12/11/2020 to 1/13/2021. Per VDH guidelines, new admissions are highly discouraged during an outbreak. However, if you are to accept new admissions, it is recommended that they be quarantined in a "warm" or exposed unit or isolated in their rooms for 14 days. On the 15th day, it is recommended that they be tested for COVID and if the result comes back negative, they can be released from room isolation. You cannot "test out" of this quarantine. The resident's symptoms should be monitored and the staff caring for these residents should follow enhanced droplet precautions during the 14 day quarantine period.

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. This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A complaint inspection was initiated on 12/16/2020 and concluded on 1/13/2021. A complaint was received by the department regarding allegations in the areas of 22VAC40-73-100, Infection control program. The administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation did not support the allegation of non-compliance with standards or law.

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

December 9, 2020Inspection0 violations

Inspection dates

Dec. 9, 2020 and Dec. 15, 2020

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 EMERGENCY PREPAREDNESS

Comments

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 12/09/2020 and concluded on 12/15/2020. The administrator was contacted by telephone to initiate the inspection. The administrator of record reported that the current census was eighty one (81). The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed four(4) resident records, four (4) staff records, infection control COVID-19 Essential Guidance for Assisted Living Facilities, staff hire dates, job titles, credentials, personal data information ,most recent TB screening, current first aide, current CPR certification, current orientation, initial training, staff training records, annual health inspection, annual fire inspection, MARS, UAIs, ISPs, resident agreements, and VDH recommendations submitted by the facility to ensure documentation was complete. The information gathered during the inspection determined no violations with applicable standards or law. No violations were issued.

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

September 30, 2020Complaint survey0 violations

Inspection dates

Sept. 30, 2020 and Oct. 1, 2020

Areas reviewed

22VAC40-73 GENERAL PROVISIONS22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES63.2 Facilities and Programs22VAC40-80 COMPLAINT INVESTIGATION

Comments

This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A complaint inspection was initiated on 09/30/2020 and concluded on 10/01/2020. A complaint was received by the department regarding allegations in the areas of resident care. The administrator of record was contacted by telephone to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation did not support the allegation concerning resident care and related services of non- compliance with standards or law.

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.