Bickford of Suffolk — 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

Bickford of Suffolk was inspected 22 times between July 8, 2021 and March 6, 2026 by the Virginia Department of Social Services. 18 of those visits ended with violations cited and 4 with none. Across that history VDSS cited 78 violations under 53 distinct standards. 10 inspections were prompted by a complaint.

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

VDSS publishes inspections on a rolling window. 21 of these 22 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

One Year

License expires

08/08/2026

Administrator

Kendra Thomas

Licensing inspector

Darunda Flint

Inspector phone

(757) 807-9731

Approved for

Non-Ambulatory · Special Care Unit · Assisted Living

Inspection History

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

March 6, 2026Complaint survey1 violation

Inspection dates

03/06/2026

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-80 COMPLAINT INVESTIGATION

Technical assistance

22VAC40-73-100

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: 03/06/2026 ( arrival 9:36 a.m. / departure 2:29 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 03/04/2026 regarding allegations in the area(s) of: Administration and Administrative Services Number of residents present at the facility at the beginning of the inspection: 98 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 0 Number of interviews conducted with residents: Number of interviews conducted with staff: 2 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. However, violation(s) not related to the complaint(s) but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of these inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Darunda Flint, Licensing Inspector at (757) 807-9731 or by email at darunda.a.flint@dss.virginia.gov

Violations

22VAC40-73-860-I

Based on observation and staff interviewed, the facility failed to ensure it stored cleaning supplies and other hazardous materials in a locked area.

Evidence

During a tour with staff # 1, the cleaning cart containing household chemicals, cleaning chemicals was left unlocked and unattended in the hallway on the safe secure unit.
Staff #1 acknowledged the cart contained hazardous materials and was not locked and not supervised.

Plan of correction

Plan of Correction: Executive Director corrected date of inspection – March 6,2026 ensuring that all chemical housekeeping supplies are in a locked secure closet on both assisted living and memory care unit. This also includes the housekeeping cleaning cart. The housekeeper was counseled on safe chemical security and storage. Divisional Director of Operations conducted training with Executive Director on process for all chemicals. Executive Director to do weekly audits on proper storage of all chemicals. In addition, Divisional Director of Operations to do quarterly audits to verify proper process is being followed. Date to be corrected by: March 6, 2026

March 6, 2026Complaint survey1 violation

Inspection dates

03/06/2026

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION

Comments

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03/06/2026 (arrival 9:36 a.m. / 2:29 p.m.) The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 01/28/2026 regarding allegations in the area(s) of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 98 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation(s) of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint(s) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of these inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Darunda Flint, Licensing Inspector at (757) 807-9731 or by email at darunda.a.flint@dss.virginia.gov

Violations

22VAC40-73-640-A

Based on record reviewed and staff interviewed, the facility failed to follow its medication management plan to ensure resident’s prescription medications and any over-the-counter drugs and supplements ordered are filled and refilled in a timely manner to avoid missed dosages.

Evidence

During a complaint inspection, conducted on 03/06/2026 regarding medications, resident #1’s 12/27/2025 progress note documented resident #1 received new orders for Tamiflu and Albuterol.
Staff #3 acknowledged faxing the new medication orders to the pharmacy on 12/27/2025. However, staff #3 stated the pharmacy is closed on weekends and the new orders should have been faxed to the backup pharmacy per the facilities medication policy.
Resident #1’s 12/28/2025 and 12/29/2025 progress notes documented the facility was still waiting for pharmacy to supply resident’s new medication.
Staff #1 acknowledged resident #1’s record noted the Tamiflu and Albuterol medications were not available to administer on the aforementioned dates.

Plan of correction

Plan of correction: The Divisional Director Of Health And Wellness will provide education to the HWD on proper processes Ensuring that all orders from the MD/NP are followed once received. The HWD corrected prior to this inspection date of March 6,2026 The HWD will provide education to the RMA’s and LPN’s to ensure that they are following the Med Management policy. The HWD will perform weekly audits of all new orders to ensure that they are received in a timely manner. The Divisional Director of Health and Wellness will perform weekly audits x 1 month to ensure new medications are received in a timely manner. Date to be corrected by March 6,2026

September 24, 2025Inspection3 violations

Inspection dates

09/24/2025

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/24/2025 ( arrival 1:24 p.m. / departure 4:25 p.m.) The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 07/23/2025 regarding allegations in the area(s) of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 61 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents:0 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Darunda Flint, Licensing Inspector at (757) 807-9731 or by email at darunda.a.flint@dss.virginia.gov

Violations

22VAC40-73-120-A

Based on record review and staff interview, the facility failed to ensure a staff’s record included documentation of orientation and training required within the first seven working days of employment.

Evidence

On 09/24/2025 staff #2’s record did not include documentation of orientation and training within seven workings day of employment. Staff #2’s date of hire was documented as 06/15/2025. Staff # 2’s termination was documented as 08/12/2025
Staff #3 acknowledged staff #2’s record did not include documentation of required orientation and training.

Plan of correction

Divisional Director of Operations to re-educate the Executive Director on Bickford’s policy on onboarding/orientation and training that is to be completed within the first seven working days of employment. The Executive Director is to audit training records to ensure all employees are current with required orientation and training with documentation verifying completion. The Executive Director is responsible for ensuring all staff have required orientation and training completed and documented in employee training file within the first 7 days of employment. The Divisional Director of Operations will audit the next five newly hired employees within 7 days of hire and audit annually thereafter to ensure required orientation and training is completed and documented in employee training files.

22VAC40-73-550-C

Based on record review and interview, the facility failed to ensure any resident of an assisted living facility has the rights and responsibilities as provided in Â§ 63.2-1808 of the Code of Virginia and this chapter to include the right to be treated with courtesy, respect, sensitivity, and dignity.

Evidence

Licensing Inspector received two incident reports dated -7/23/2025 and 09/19/2025 regarding an allegation of resident physical abuse that documented that the resident was shoved and pushed by a staff member. 2 On 09/24/2025, review of the facility's Investigative Form- General document dated 07/29/2025 noted staff #1was approached by resident #1’s family member concerning a video the family member viewed regarding abuse towards resident #1. The following was noted to be observed in the video: Staff #2 was observed in the video entering resident #1’s room and putting on gloves to assist resident #1 with their activities of daily living. Staff #2 is seen in the video grabbing resident #1’s right hand. Staff #2 then places their hand behind resident #1’s back and then pushing resident #1 upright while pulling on resident #1’s hand. Resident #1 became agitated and attempted to sit back down. Staff #2 then yanks resident #1 to their feet and then forcefully placed the residents’ hands on their walker. At the same time staff #2 then got behind resident #1 and grabbed the resident by the bicep. Staff #2 then proceeded to forcefully push resident #1 to the bathroom. Throughout the entire video, resident #1 is seen attempting to go back to the couch. However, staff #2 continued to push resident #1 towards the bathroom. Resident #1 almost fell at one point due to being pushed by staff #2. However, staff #2 then yanked resident #1’s arms and continued to push the resident towards the bathroom never letting resident loose. Once staff #2 forced resident #1 into the bathroom, the video goes off. Approximately thirty seconds after entering the bathroom the resident’s walker is seen being thrown towards the bathroom door. Approximately fifteen seconds later, the resident comes back into the video frame as the resident is being thrown onto the commode. Resident #1 is seen not sitting on the commode but rather laying on the commode, and resident #1 appears to have struck their head.

Plan of correction

Resident was assessed with no apparent injury noted. Service Plan updated to reflect current needs of resident. Divisional Director of Operations to assign mandatory all-staff training on resident rights to be completed in company’s training portal (Relias) with a completion date of January 5,2026. Divisional Director of Operations to track completion of the all- staff training on resident rights, including the branch leadership team.

22VAC40-73-440-A

Based on record review and interview, the facility failed to ensure the UAI for residents be completed prior to admission, at least annually, and whenever there is a significant change in the resident's condition.

Evidence

On 09/24/2025, resident #1’s UAI (dated 02/25/2025) indicates the resident requires mechanical help only with toileting. Resident #1’s individualized service plan dated 02/26/2025 notes the resident utilizes mobility bars and 1 BFM assist with transfers on and off of the toilet. Staff # 3 could not provide an updated UAI.

Plan of correction

Divisional Director of Health and Wellness will conduct an in-service to ensure that the branch leadership understands the UAI/ISP process, all ADL’s are noted properly on UAI/ISP and are completed prior to admission, at least annually and whenever there is a significant change in a residents condition. Health and Wellness Director and Executive Director will conduct an audit on all UAI’s and Service Plans to ensure that they are in unison of each other. The Health and Wellness Director is responsible for ensuring UAI’s and Service Plans are completed as required and reflect the current needs of residents. The Divisional Director of Health and Wellness will review UAI’s and Service Plans on the next 5 resident admissions and annually thereafter to ensure UAI’s and Service Plans reflect the current needs of residents.

August 8, 2025Inspection12 violations

Inspection dates

08/08/2025 , 08/13/2025

Areas reviewed

22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

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: 08/08/2025 (arrival 8:00 a.m. / 5:08 p.m. departure) and 8/13/2025 (arrival 11.00 a.m. / departure 3:52 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: 62 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 4 Observations by licensing inspector: Lunch and activity were observed. A medication pass observation was completed for 4 residents. The following were reviewed: staff and resident records, call bells, water temperatures, medication carts, and a first aid kit. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Darunda Flint, Licensing Inspector at 757-807-9731 or by email at Darunda.a.flint@dss.virginia.gov

Violations

22VAC40-73-950-A

Based on staff interviewed and records reviewed, the facility failed to develop a written emergency preparedness and response plan that shall address documentation of initial and annual contact with the local emergency coordinator to determine (i) local disaster risks, (ii) communitywide plans to address different disasters and emergency situations, and (iii) assistance, if any, that the local emergency management office will provide to the facility in an emergency.

Evidence

Staff #3 could not provide annual documentation of emergency preparedness review with a local emergency coordinator.

Plan of correction

Not published by VDSS.

22VAC40-73-410-A

Based on records reviewed and staff interviewed, the facility failed to ensure upon admission it would provide an orientation for new residents and their legal representatives. Acknowledgement of having received the orientation shall be signed and dated by the resident and as appropriate his legal representative, and such documentation shall be kept in the resident’s record.

Evidence

Resident #3 was admitted to the facility on 12/16/2024. The acknowledgement of orientation in the resident’s record was dated 01/15/2025.

Plan of correction

ED will ensure annual Resident Rights will be reviewed and signed by the resident or legal representative .

22VAC40-90-40-B

Based on the employee record review, the facility failed to ensure no employee was permitted to work in a position that involves direct contact with a resident until a background check was received as required in the Regulation for Background Checks for Assisted Living Facilities and Adult Day Care Centers (22VAC40-90), unless such persons works under the direct supervision of another employee for whom a background check has been completed in accordance with the requirements of the background check regulation (22VAC40-90).

Evidence

On 08/08/2025, staff #5’s date of hire date was noted as 06/11/2025. The facility did not have documentation of a background check for staff #5. 2.Staff #3 acknowledged the aforementioned was not in staff # 5’s record.

Plan of correction

- ED will complete an audit to ensure valid backgrounds checks are on file and completed. ED will ensure all backgrounds are completed for news ongoing.

22VAC40-73-440-A

Based on review of resident records, the facility failed to complete the Uniform Assessment Instrument (UAI) prior to admission, or at least annually. and whenever there is a significant change in the resident's condition.

Evidence

Residents #3 was admitted to the facility on 12/16/2024. The UAI in resident #3’s file was dated 01/14/2025.

Plan of correction

HWC/HWC will complete a UAI for all residents 30 days prior to admission and annually. Effective 9-22-2025

22VAC40-73-550-G

Based on record review and interview, the facility failed to annually review the rights and responsibilities of residents with each resident, or their legal representative or responsible individual as stipulated in subsection H of this section and each staff person.

Evidence

Staff #6 confirmed there was not a review of the residents’ rights and responsibilities in resident #3’s record. 2.Staff #6 confirmed the last review for resident rights and responsibilities for resident #4 was completed on 05/08/2024. 3.Staff #6 confirmed the last review for resident rights and responsibilities for resident #6 was completed on 03/25/2024.

Plan of correction

ED will ensure annual Residents Rights will be reviewed and signed by the resident or legal representative. Effective 9-22-2025

22VAC40-73-1110-A

Based on record review and interview, the facility failed to ensure prior to admitting a resident with serious cognitive impairment due to a primary psychiatric diagnosis of dementia to a safe, secure environment, the licensee, administrator, or designee shall determine whether placement in the special care unit is appropriate. The determination and justification of the decision shall be in writing and shall be retained in the resident’s file.

Evidence

Staff #6 confirmed resident #3 (admitted 12/16/2024 to safe secure unit). The administrator’s justification upon review assessment in resident #3’s record was dated 01/14/2025. Resident #3 did not have prior documentation of the determination and justification on whether placement in the special care unit appropriate by the licensee, administrator, or designee in their record.

Plan of correction

Not published by VDSS.

22VAC40-73-870-A

Based on observation, the facility failed to ensure the interior and exterior of all buildings shall be maintained in good repair and kept clean and free of rubbish.

Evidence

During a tour of the facility, there was an electrical power washer, and scattered trash in the memory care unit courtyard.
Staff #1 acknowledged the aforementioned in the memory care unit courtyard.

Plan of correction

Maintenance Director will conduct weekly audits and log the findings. regarding the interior and exterior of the building to ensure areas are safe, clean and free of any debris or trash.

22VAC40-73-310-D

Based on resident record review, the facility failed to provide written assurance to the resident or his legal representative, ensuring that the facility has the appropriate license to meet the resident’s care needs at the time of admission.

Evidence

The record of resident #3 did not have a copy of the signed written assurance in the record.
Staff #6 acknowledged the aforementioned was not in resident #3’ record.

Plan of correction

ED and FA will ensure all Written Assurance documents are provided and signed before or upon admission.

22VAC40-73-120-A

Based on record review and interview, the facility failed to ensure the orientation and training required in subsections B and C of this section occur within the first seven working days of employment.

Evidence

Staff #3 confirmed the record of Staff #4 (hired 07/15/2025) did not complete their staff orientation and initial training within the first seven working days of employment. 2.Staff #3 confirmed staff # 6 (hired 06/11/2025) orientation form did not contain a signature and that staff#6 did not complete their staff orientation and initial training within the first seven working days of employment.

Plan of correction

-ED and HW will ensure all required staff orientation and initial training will be completed within 7 days of hire.

22VAC40-73-1110-B

Based on record review and interview, the facility failed to ensure six months after placement of the resident in the safe, secure environment and annually thereafter, the licensee, administrator, or designee perform a review of the appropriateness of each resident's continued residence in the special care unit.

Evidence

The record for resident #3, admitted 12/16/2024 into the safe, secure environment does not contain a six month review of appropriateness of placement and continued residence in the special care unit.
Staff #6 acknowledged resident 3 record did not contain the aforementioned.

Plan of correction

HWC/HWD will complete the Review of Appropriateness for all Special Care Resident’s every 6 months and placed in the resident record. Effective 9-22-2025

22VAC40-73-390-A

Based on documentation review, the facility failed to provide a written agreement at or prior to the time of admission.

Evidence

Resident # 3 was admitted to the facility on 12/16/2024 and the signed agreement in the file was dated 01/14/2025.

Plan of correction

Not published by VDSS.

22VAC40-73-980-A

Based on observation, the facility failed to ensure a first aid kit for the building contained items as identified in the standard.

Evidence

The building first aid kit did not include the following items: roller gauze, adhesive tape, antiseptic wipes/ointment, disposable single-use breathing barriers or shields for use with rescue breathing or CPR.
Staff #2 acknowledged the aforementioned items were not contained in the first aid kit.

Plan of correction

ED and/or HWD will audit first aid kits monthly for all items required and refill as needed and maintain supplies in the community as well as expired items effective 9-23-2025

November 25, 2024Inspection1 violation

Inspection dates

11/25/2024

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

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: 11/25/2024 from 11:50 am to 12:25 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 11/20/2024 regarding allegations in the area(s) of: Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 62 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Additional Comments/Discussion: Exits of safe, secure environment observed. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations

22VAC40-73-460-D

Based on interview and record review, the facility failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs.

Evidence

On 11/19/2024, Resident #1 exited the safe, secure environment around 10:30 am.
Resident #1 was located in a vehicle in the parking lot of the facility around 11:15 am.

Plan of correction

All BFM/Staff Training on elopement processes and drills, this includes protocol when door alarms, rounding and physical head count of every resident in house. Missing resident drills will continue to happen randomly quarterly with full procedure effective from start to finish. Maintenance Coordinator to sphere head drills.

October 9, 2024Inspection0 violations

Inspection dates

10/09/2024

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/09/2024 from 12:43pm to 1:25pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 09/08/2024 regarding allegations in the area(s) of: Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 64 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 Additional Comments/Discussion: Follow-up on a self-reported incident. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

September 17, 2024Complaint survey4 violations

Inspection dates

09/17/2024

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND

Comments

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/17/2024 from 11:00 am to 1:45 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 09/05/2024 regarding allegations in the area(s) of: Resident Care and Related Services and Buildings and Grounds. Number of residents present at the facility at the beginning of the inspection: 62 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s); area(s) of non-compliance with standard(s) or law were: Resident Care and Related Services. A violation notice was issued; any violation(s) not related to the complaint(s) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations

22VAC40-73-550-C

Based on observation and discussion, the facility failed to ensure any resident of an assisted living facility has the rights and responsibilities as provided in § 63.2-1808 of the Code of Virginia.

Evidence

Resident #1 admitted to the facility on 10/13/2023.
Resident #1 indicated via the “Photo and Audio/Video Release” (signed 10/18/2023) that they are not to be featured in publications and media for the facility.
Resident #1 is observed in a photo and or video posted by the facility on one of their social media platforms on the following days: 11/3/2023, 1/5/2024, 1/25/2024, and 3/5/2024.
Staff #1 acknowledged there were photos/video of Resident #1 on social media posted by the facility despite the “Photo and Audio/Video Release” denial signed 10/18/2023.

Plan of correction

After reviewing all move in documents, ED to communicate with branch personnel being HWD, HWC, Family Advocate and Happiness Coordinator should a family choose to opt out of photos. This will be added to a list for branch leadership knowing’s.

22VAC40-73-460-H

Based on observation and documentation, the facility failed to ensure that personal assistance and care are provided to each resident as necessary so that the needs of the resident are met, including assistance or care with housekeeping.

Evidence

Resident #1’s ISP indicates the facility will clean their apartment weekly and as needed including removal of trash.
Staff #1 verified housekeeping documents on a paper posted on the back of resident apartments when the unit is cleaned.
Resident #1’s housekeeping documentation on the back of their apartment door indicates their apartment is to be cleaned on Wednesdays/Thursdays.
From May 15, 2024 to September 17, 2024, the following dates were listed on the posting in Resident #1’s apartment to document weekly cleaning: 5/15/24, 5/22/24, 5/29/24, 6/5/24, 6/12/24, 6/19/24, 7/3/24, 7/10/24, 7/24/24, 8/21/24, 9/4/24, 9/11/24. There were approximately 6 weeks missing from the documentation of weekly cleaning.

Plan of correction

ED and HWD to connect with Housekeeping and Maintenance personnel to train and educate on the housekeeping processes and documentation of duties. ED to ensure housekeeping is not only documenting for communication to residents, but also in a log for branch records. Training with the caregiver staff about this process to provide additional support.

22VAC40-73-460-E

Based on documentation, the facility failed to regularly observe each resident for changes in physical, mental, emotional, and social functioning. Any notable change in a resident's condition or functioning, including illness, injury, or altered behavior, and any corresponding action taken shall be documented in the resident's record. The facility shall provide appropriate assistance when observation reveals unmet needs.

Evidence

The May MAR for Resident #1 notes the resident began to refuse multiple medications beginning 05/02/2024.
Progress notes for Resident #1 also indicate the resident was refusing medications and or food on several occasions to include notes written on 05/04/2024, 05/06/2024, and 05/12/2024.
Resident #1’s record indicated the resident did not see their mental health provider until 05/21/2024 for medication management and examination.
There was no indication in Resident #1’s records their primary care physician was notified of this change and altered behavior of Resident #1.

Plan of correction

Training in-service with caregiver staff to focus on proper communication processes when change occurs with residents, to include noting in AH, but to also let the nursing team know as well. HWD and HWC to follow up with providers and families to communicate changes in conditions.

22VAC40-73-580-F

Based on record review, the facility failed to implement interventions as soon as a nutritional problem is suspected. These interventions shall include the following: weighing residents at least monthly to determine whether the resident has significant weight loss (i.e., 5.0% weight loss in one month, 7.5% in three months, or 10% in six months); and notifying the attending physician if a significant weight loss is identified in any resident who is not on a physician-approved weight reduction program and obtaining, documenting, and following the physician's instructions regarding nutritional care.

Evidence

Resident #1 had a significant weight loss of over 5% in one month from May 2024 (documented weighing 124.2 pounds) to June 2024 (documented weighing 117.4 pounds).
There was no documentation interventions were put into place nor was Resident #1’s attending physician notified of the significant weight loss.
There also were no monthly weights obtained in November 2023 or December 2023 for Resident #1.

Plan of correction

HWD to ensure monthly weights are completed and reviewed. Training with caregiver staff to communicate by not only noting in August Health, but also to the nursing team to ensure change in conditions have been presented. HWD to contact residents care provider and responsible party to inform of the changes. Lastly, HWD to present solutions and to formulate a plan of action for the resident with guidance from primary care provider. In addition, training support to all caregivers and nursing team on proper documentation process.

September 17, 2024Complaint survey1 violation

Inspection dates

09/17/2024

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/17/2024 from 11:00 am to 1:45 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 08/29/2024 regarding allegations in the area(s) of: Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 62 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation(s) of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations

22VAC40-73-470-F

Based on record review and interview, the facility failed to when the resident suffers serious accident, injury, illness, or medical condition, or there is reason to suspect that such has occurred, medical attention from a licensed health care professional shall be secured immediately. The resident's physician, if not already involved, next of kin, legal representative, designated contact person, case manager, and any responsible social agency, as appropriate, shall be notified as soon as possible but no later than 24 hours from the situation and action taken, or if applicable, the resident's refusal of medical attention.

Evidence

Resident #1 and Resident #2 had labs completed on 08/22/2024.
The results for Resident #1 and Resident #2 indicated both had critically low glucose on 08/23/2024; however, there was no documentation that their physician was notified of these findings within 24 hours.

Plan of correction

Facility will ensure to notify all parties involved, that are required to be notified, no later than 24 hours from any situation involving a resident that requires reporting.

August 27, 2024Complaint survey0 violations

Inspection dates

08/27/2024

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 08/27/2024 from 12:00 pm to 2:00 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 08/16/2024 regarding allegations in the area(s) of: Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 64 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

July 18, 2024Complaint survey4 violations

Inspection dates

07/18/2024; 07/29/2024

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

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: 07/18/2024 from 12:00 pm to 1:17 pm and 07/29/2024 from 10:30 am to 12:40 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 07/18/2024 regarding allegations in the area(s) of: Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 62 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 5 Number of staff records reviewed: 2 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation(s) of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations

22VAC40-73-325-B

Based on record review, the facility failed to ensure a fall risk rating is completed after a fall.

Evidence

Resident #2 fell per nursing notes on 01/17/2024; however, there is not a completed fall risk rating in the record of Resident #2 after the fall.

Plan of correction

Resident #2 record updated with fall risk rating.

22VAC40-73-200-D

Based on record review and interview, the facility failed to obtain a copy of the certificate issued or other documentation indicating that the person has met one of the requirements of subsection C of this section, which shall be part of the staff member's record in accordance with 22VAC40-73-250.

Evidence

Staff #3 works at the facility and was hired on 03/06/2023 as direct care staff; however, their record does not include a copy of the certificate issued or other documentation indicating that the person has met one of the requirements of subsection C of this section.

Plan of correction

Staff #3 documentation has been obtained to satisfy the requirements of section C.

22VAC40-73-680-D

Based on record review, the facility failed to ensure medications be administered in accordance with the physician's or other prescriber’s instructions

Evidence

Resident #5’s Metoprolol order was changed on 06/13/2024 to receive 12.5 mg twice daily with the parameters to hold for SBP<110 or HR<55 and to notify provider if SBP <101 or >160.
Resident #5’s June 2024 MAR shows there were 22 occasions from 06/14/2024-06/26/2024 Resident #5’s Metoprolol was held due to the parameters; however, there was no documentation the provider was notified.
Resident #5’s June 2024 MAR shows there were 3 occasions from 06/14/2024-06/26/2024 Resident #5’s Metoprolol was documented as administered; however, the medication should have been held due to the parameters.

Plan of correction

Facility will ensure medications be administered in accordance with the physician’s or other prescriber’s instructions.

22VAC40-73-470-F

Based on record review and interview, the facility failed to ensure when the resident suffers serious accident, injury, illness, or medical condition, or there is reason to suspect that such has occurred, medical attention from a licensed health care professional be secured immediately.

Evidence

Notes in Resident #4’s chart indicates the resident sustained a skin tear during a transfer with staff on 03/18/2024; however, it is documented treatment for the skin tear was initiated on 03/29/2024.

Plan of correction

Facility will ensure to document any incident in a timely manner to ensure treatment plan is being followed.

July 16, 2024Inspection13 violations

Inspection dates

07/16/2024; 07/18/2024

Areas reviewed

Comments

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/16/2024 from 8:20 am to 3:40 pm and 07/18/2024 from 8:50 am to 12:00 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: 62 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 4 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 3 Observations by licensing inspector: Lunch and an activity were observed. A medication pass observation was completed for 4 residents. The following were reviewed: resident and staff records, medication carts, call bells, and water temperatures. 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations

22VAC40-73-350-B

Based on record review, the facility failed to ascertain, prior to admission, whether a potential resident was a registered sex offender and failed to document that this was ascertained and the date the information was obtained.

Evidence

The sex offender screening for Resident #4 (admitted 05/02/2024) was completed on 05/06/2024.
The sex offender screening for Resident #6 (admitted 10/13/2023) incorrectly spelled the last name of the resident.

Plan of correction

Resident sex offender screening will be ascertained prior to admission as part of a move in process for all new residents.

22VAC40-73-260-A

Based on record review, the facility failed to ensure each direct care staff member maintain 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

Staff #1 (hire date 04/13/2022) and Staff #4 (hire date 12/29/2023) work as direct care staff and do not have documentation of a current certification in first aid in their staff records.

Plan of correction

First Aide/CPR class scheduled for July 31st, 2024, for all staff in need of certification. This will be done on a 6-month rotation in future.

22VAC40-73-720-A

Based on record review, the facility failed to ensure a valid written Do Not Resuscitate (DNR) order has been issued by the resident's attending physician; and that the written order is included in the individualized service plan.

Evidence

Resident #1 had a DNR order completed 05/01/2023; however, Resident #1’s ISP (dated 01/25/2024) indicated the resident was a full code.
Resident #5 had a DNR order completed 11/09/2023; however, Resident #5’s ISP (dated 07/02/2024) does not indicate the resident’s code status.
Resident #6’s ISP (dated 04/14/2024) indicates the resident has a DNR; however, there is not a DNR order in the resident’s record.
Resident #7 had a DNR order completed 04/25/2023; however, Resident #7’s ISP (dated 04/19/2024) does not indicate the resident’s code status.

Plan of correction

Resident #1 and Resident #5, and #7 status updated to reflect the correct status. Resident #6 record updated with correct order.

22VAC40-73-320-A

Based on record review, the facility failed to ensure the physical examination include results of a risk assessment documenting the absence 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:
The admitting physical examination for Resident #6 (dated 09/26/2023) includes a TB risk assessment completed on 04/17/2023.
The admitting physical examination for Resident #8 (dated 09/12/2023) includes a TB risk assessment indicating the resident has medical conditions increasing risk for progression to TB disease. There was no documentation that TB testing was completed or followed-up on.

Plan of correction

Resident TB screening and Follow-ups are part of a move in process for all new residents.

22VAC40-73-250-D

Based on record review, the facility failed to ensure each staff person on or within seven days prior to the first day of work at the facility and each household member prior to coming in contact with residents submit the results of a risk assessment, documenting the absence 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. The risk assessment shall be no older than 30 days. Evidence:
Staff #3 was hired on 05/29/2024; however, Staff #3’s initial TB risk assessment was completed 07/01/2024.
Staff #4 was hired on 12/29/2023; however, there was not a completed TB risk assessment for Staff #4.

Plan of correction

Staff onboarding process implemented to ensure TB screenings completed at time of onboarding.

22VAC40-73-870-A

Based on observation, the facility failed to ensure that the interior and exterior of all buildings shall be maintained in good repair and kept clean and free of rubbish.

Evidence

Outside Resident #1 and Resident #16’s apartments, there is a section of missing baseboard trim. Along the missing section, there is a grey, black substance noted.
There is a missing window in Resident #17’s apartment. The opening is boarded with wood. The window was originally reported to be damaged on 09/13/2023.

Plan of correction

Baseboard has been replaced and black substance cleaned.

22VAC40-90-40-C

Based on record review, the facility failed to ensure any person required by this chapter to obtain a criminal history record report be ineligible for employment if the report contains convictions of the barrier crimes.

Evidence

The criminal history record report for Staff #8 (hired 07/10/2024) was completed on 06/28/2024 and shows 3 convictions of misdemeanor barrier crimes.

Plan of correction

Staff #8 was terminated.

22VAC40-73-640-A

Based on observation, the facility failed to implement their written plan for medication management which includes methods to prevent the use of outdated medications and plan for proper disposal of medication.

Evidence

The following expired medications were observed in the medication carts at the facility: PRN Furosemide 20 mg tablets expired 07/11/2024 for Resident #3, PRN Acetaminophen 325 mg tablets expired 07/03/2024 for Resident #9, PRN Meclizine 25 mg tablets expired 07/12/2024 for Resident #10, Aspirin 81 mg tablets expired 9/2023 and Simvastatin 10 mg tablets expired 06/26/2024 for Resident #11, Atorvastatin 40 mg tablets expired 06/17/2024 for Resident #12, PRN Acetaminophen 325 mg tablets expired 06/20/2024 for Resident #13, PRN Acetaminophen 500 mg tablets expired 06/20/2024 for Resident #14, PRN Naproxen 220 mg tablets expired 06/20/2024 for Resident #15, and Lorazepam .5 mg tablets expired 06/29/2024 for Resident #18.

Plan of correction

All expired medications have been removed from medication cart in accordance of the written plan for medication management which includes methods to prevent the use of outdated medications and plan for proper disposal, will be performed in future.

22VAC40-73-1140-B

Based on record review, the facility failed to ensure within four months of the starting date of employment in the safe, secure environment, direct care staff attend at least 10 hours of training in cognitive impairment that meets the requirements of subsection C of this section.

Evidence

Staff #4 (hired 12/29/2023) did not have at least 10 hours of training in cognitive impairment within four months of their hire date.

Plan of correction

Implementation of training policy and procedures for all new staff.

22VAC40-90-40-F

Based on record review, the facility failed to ensure a criminal history record report issued by the State Police shall not be accepted by the facility if the report is dated more than 90 days prior to the date of employment.

Evidence

The criminal history record report for Staff #7 (hired on 02/20/2024) was completed more than 90 days prior to the date of employment on 11/02/2023.

Plan of correction

Staff #7 is no longer employed by facility.

22VAC40-73-390-A

Based on record review, the facility failed to ensure at or prior to the time of admission, there be a written agreement/acknowledgment of notification dated and signed by the resident or applicant for admission or the appropriate legal representative, and by the licensee or administrator.

Evidence

Resident #6 admitted to the facility on 10/13/2023; however, the written agreement for Resident #6 was signed on 04/22/2024.

Plan of correction

Resident admission agreement will be signed and dated by all appropriate parties at the time of or prior to move as part of a move in process for all new residents.

22VAC40-73-210-A

Based on record review, the facility failed to ensure all direct care staff shall attend at least 18 hours of training annually with the exception of direct care staff who are licensed health care professionals or certified nurse aides attend at least 12 hours of annual training.

Evidence

Staff #2 (hire date 07/10/2017) works as an RMA/CNA and did not have at least 12 hours of annual training in 2023.

Plan of correction

Annual training auditing and implementation process in place.

22VAC40-73-650-A

Based on record review and interview, the facility failed to ensure no medication, dietary supplement, diet, medical procedure, or treatment be started, changed, or discontinued by the facility without a valid order from a physician or other prescriber.

Evidence

Resident #7 was admitted to hospice services on 09/25/2022.
Staff #6 indicated family of Resident #7 stated the resident was discharged from hospice services on 05/19/2024.
Resident #7’s record did not have any discharge note or order from hospice services in their record.
Staff #6 was unable to provide documentation of discharge during the onsite inspection.

Plan of correction

Resident #7’s record now has a discharge from hospice order.

June 13, 2024Inspection4 violations

Inspection dates

06/13/2024

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: 06/13/2024 from 10:45 am to 12:50 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 06/05/2024 regarding allegations in the area(s) of: Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 62 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 2 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations

22VAC40-73-250-D

Evidence

d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. The risk assessment shall be no older than 30 days. Evidence:
Staff #3 was hired on 09/27/2023; however, there was not an initial TB risk assessment in their record.

Plan of correction

Audited staff records for TB screening and updated accordingly.

22VAC40-73-680-E

Based on record review and interview, the facility failed to ensure medical procedures or treatments ordered by a physician or other prescriber be provided according to their instructions and documented. The documentation shall be maintained in the resident's record.

Evidence

Resident #1’s physician ordered for labs to be completed on 05/17/2024. The labs for Resident #1 were completed on 06/06/2024 with the results available to the physician on 06/13/2024.

Plan of correction

Physicians’ orders and labs will be carried out as per state regulations and Bickford policy. HWD will communicate any obstacles as it relates with MD/NP to orders and document.

22VAC40-73-260-A

Evidence

Staff #2 works as direct care staff and does not have documentation of a current certification in first aid in their staff record.

Plan of correction

CPR and first aid class to be held in next 60 days at the community for all staff members.

22VAC40-73-130-A

Based on interviews and record review, the facility failed to ensure all staff who are mandated reporters under § 63.2-1606 of the Code of Virginia report suspected abuse, neglect, or exploitation of residents in accordance with that section.

Evidence

On 06/05/2024, Resident #1 alleged staff twisted their arm while assisting the resident to bed the night prior.
Staff #1 confirmed Adult Protective Services was not notified of this allegation of abuse.

Plan of correction

All future suspected abuse will be reported to APS in accordance with state regulations and Bickford policy.

June 13, 2024Complaint survey2 violations

Inspection dates

06/13/2024

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Comments

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/13/2024 from 10:45 am to 12:50 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 05/28/2024 regarding allegations in the area(s) of: Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 62 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation(s) of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations

22VAC40-73-460-A

Based on record review and discussion, the facility failed to assume general responsibility for the health, safety, and well-being of the residents.

Evidence

During a review of Resident #1’s record, it is documented the resident has hit another resident in the chest on 05/10/2024.
During a review of Resident #1’s record, it is documented the resident punched another resident in the face on 06/12/2024. The resident sustained a bloody nose and skin tear to upper lip.

Plan of correction

Resident #1 has a companion/sitter 7 days a week. Psyche NP is following on behavior maintenance. BFM’s educated on approach to resident.

22VAC40-73-1100-A

Based on record review, the facility failed to obtain the written approval of one of the following persons listed in the standard of placing a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia in a safe, secure environment.

Evidence

Resident #1 admitted to the safe, secure environment on 11/16/2023 and did not have documentation of approval for placement in a special care unit in their record.

Plan of correction

Resident #1 file audited, and documentation of approval completed and uploaded in resident’s file.

April 18, 2024Inspection0 violations

Inspection dates

04/18/2024

Areas reviewed

22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Technical assistance

22VAC40-73-110

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: 04/18/2024 from 10:38 am to 11:22 am. 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 3/27/2024 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: 62 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the (allegation(s)/self-report) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

October 11, 2023Inspection2 violations

Inspection dates

10/11/2023

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Comments

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/11/2023. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Two self-reported incidents were received by VDSS Division of Licensing on 9/13/2023 and 9/26/2023 regarding allegations in the area(s) of: Part V Admission, Retention and Discharge of Residents, Part VI Resident Care and Related Services, and Part X Additional Requirements for Facilities that Care for Adults with Serious Cognitive Impairments. Number of residents present at the facility at the beginning of the inspection: 61. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the self-report; area(s) of non-compliance with standard(s) or law were: Part VI Resident Care and Related Services. A violation notice was issued; any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations

22VAC40-73-70-A

Based on record review and discussion, the facility failed to report to the regional licensing office within 24 hours of any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident.

Evidence

During a review of Resident #1’s record, it is documented that on 7/21/23 police were called to the facility as Resident #1 was unable to be redirected after throwing several objects. The resident also broke two courtyard windows.
Staff #1 acknowledged the facility did not make a report regarding this incident to the regional licensing office.

Plan of correction

The insufficiency will be corrected as follows: - Executive Director/Health and Wellness Director will send a report to regional licensing office within 24 hours of any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident. The following measures will be taken to ensure problems do not occur again: - 10/19/2023 - Educated staff on reporting procedures when any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident has occurred. A notification needs to be sent to Executive Director/Health and Wellness Director. Persons responsible to implement and monitor corrective measure to ensure compliance: - Executive Director/Health and Wellness Director

22VAC40-73-460-D

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

Evidence

On 9/13/23, Resident #1 who resided in the safe, secure environment broke a window in another resident’s apartment and exited the facility. Resident #1 was found “face down in the mud” in a neighboring housing community.

Plan of correction

The insufficiency will be corrected as follows: - Service plans updated to reflect supervision of resident schedules, care, and activities, including attention to specialized needs, such as wandering from the premises. The following measures will be taken to ensure problems do not occur again: - Director will review ISP’s when completed to ensure they properly reflect supervision of resident schedules, care, and activities, including attention to specialized needs. Persons responsible to implement and monitor corrective measure to ensure compliance: - Executive Director/Health and Wellness Director

July 10, 2023Inspection9 violations

Inspection dates

07/10/2023

Areas reviewed

Comments

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7/10/2023. 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: 56 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 4 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations

22VAC40-73-930-D

Based on record review and interview, the facility failed to document the rounds that were made, which shall include the name of the resident, the date and time of the rounds, and the staff member who made the rounds for residents with an inability to use the signaling device.

Evidence

During a review of the evening rounding documentation in the safe, secure environment on 07/10/2023, staff were unable to provide documentation of rounds no less often than every two hours for each resident with an inability to use the signaling device after 06/20/2023.

Plan of correction

The insufficiency will be corrected as follows: Resident Apartment night time Safety Checks Daily Log (VA) implemented for residents in Mary B’s per Bickford policy. The following measures will be taken to ensure problems do not occur again: ISP’s will identify need for safety checks due to inability to use signaling device in safety section. Executive Director/Health and Wellness Director will review the night time safety check daily log daily. Persons responsible to implement and monitor corrective measure to ensure compliance: Executive Director/Health and Wellness Director.

22VAC40-73-680-C

Based on observation and interview, the facility failed to ensure medications be administered not earlier than one hour before and not later than one hour after the facility's standard dosing schedule, except those drugs that are ordered for specific times, such as before, after, or with meals.

Evidence

At 10:20 am on 07/10/2023, Staff #2 was observed administering 9:00 am scheduled medications to Resident #4. At approximately 10:23 am, Staff #2 indicated 11 residents had not received their 8:00 am medications with 15 residents having not received their 9:00 am scheduled medications as well. The MAR indicated this was around 104 medications and or treatments over one hour after their dosing schedule.

Plan of correction

The insufficiency will be corrected as follows: Medications will be given according to doctor’s orders no earlier or later than one hour from standard dosing schedule. The following measures will be taken to ensure problems do not occur again: Weekly Med variance reports to be run to ensure compliance with medication times and follow up with physician(s) to investigating whether we can adjust or change times to be in compliance if needed. Educate BFM’s regarding medication management through annual in-service, and individually when necessary. Persons responsible to implement and monitor corrective measure to ensure compliance: Health and Wellness Director and Health and Wellness Coordinator.

22VAC40-73-640-A

Evidence

The following expired medications were observed in the medication carts at the facility: PRN Hydrochlorothiazide 12.5 tablets expired 06/30/2023 for Resident #1, Arthritis Pain 650 mg tablets expired 07/02/2023 for Resident #4, PRN Famotidine 20 mg tablets expired 07/03/2023, PRN Gas Relief 80 mg tablets expired 07/03/2023, and PRN Naproxen Sodium 220 mg tablets expired 07/02/2023 for Resident #9, PRN Loperamide 2 mg capsules expired 07/08/2023, Alphagan Solution expired 04/2023, and PRN Acetamin 500 mg tablets expired 04/26/2023 for Resident #10, PRN Omeprazole 40 mg capsules expired 06/22/2023 for Resident #11, PRN Acetamin 500 mg tablets expired 07/03/2023 for Resident #12, PRN Loratadine 10 mg tablets expired 05/29/2023 for Resident #13, PRN Acetaminophen 325 mg tablets expired 07/02/2023 for Resident #14, PRN Acetaminophen 650 mg tablets expired 06/24/2023, PRN Esomepra 40 mg capsules expired 06/24/2023, and PRN Ibuprofen 800 mg tablets expired 06/24/2023 for Resident #15, and Methocarbam 750 mg tablets expired 07/06/2023 for Resident #16.

Plan of correction

The insufficiency will be corrected as follows: Residents #1,#4,#9, #10,#11,#12,#13,#14,#15, and #16 expired medications were removed from cart 7/10/2023. The following measures will be taken to ensure problems do not occur again: Health and Wellness Director and Health and Wellness Coordinator will perform weekly medication cart audits and remove expired medications. Persons responsible to implement and monitor corrective measure to ensure compliance: Health and Wellness Director/Executive Director.

22VAC40-73-260-A

Evidence

Staff #3 (hire date 05/01/2023) works as direct care staff and does not have documentation of a current certification in first aid in their staff records.

Plan of correction

The insufficiency will be corrected as follows: Staff #3 will attend First Aid Class on 8/1/23. The following measures will be taken to ensure problems do not occur again: BFM’s will complete first aid within 30 days of hire. Persons responsible to implement and monitor corrective measure to ensure compliance: Executive Director.

22VAC40-73-680-D

Based on record review, the facility failed to ensure medications be administered in accordance with the physician's or other prescriber’s instructions.

Evidence

Resident #7 has an order to be administered 1 Midodrine 10 mg tablet by mouth 3 times daily with food with a parameter to hold for SBP >110. Per Resident #7’s MAR, the resident’s SBP was greater than 110 and the resident was administered Midodrine on the following days: 07/01/2023 (1 dose), 07/03/2023 (2 doses), 07/05/2023 (1 dose), and 07/06/2023 (1 dose). Per Resident #7’s MAR, the resident’s SBP was less than 110 and the resident was not administered Midodrine on the following days: 07/02/2023 (2 doses), 07/04/2023 (2 doses), and 07/05/2023 (1 dose).

Plan of correction

The insufficiency will be corrected as follows: Health and Wellness Director met with RMA’s and reviewed physician’s order for resident #7’s Midodrine. The following measures will be taken to ensure problems do not occur again: Order’s will be reviewed, processed, and approved in quickMAR for accuracy upon receipt. Weekly Med Audits to be done to ensure order accuracy and med cart orderliness. Persons responsible to implement and monitor corrective measure to ensure compliance: Executive Director/Health and Wellness Director/Health and Wellness Coordinator.

22VAC40-73-330-A

Based on record review, the facility failed to ensure a mental health screening be conducted prior to admission if behaviors or patterns of behavior occurred within the previous six months that were indicative of mental illness, intellectual disability, substance abuse, or behavioral disorders and that caused, or continue to cause, concern for the health, safety, or welfare either of that individual or others who could be placed at risk of harm by that individual.

Evidence

Resident #3 admitted to the facility on 06/14/2023. The hospital discharge summary (dated 06/14/2023) indicates Resident #3 has history of dementia with behavioral disturbances and wandering. The mental health screening for Resident #3 (dated 06/14/2023) indicates the screening is not applicable despite the information reflected in the discharge summary.

Plan of correction

The insufficiency will be corrected as follows: Resident #3 mental health screening completed on 7/14/23. The following measures will be taken to ensure problems do not occur again: Director will audit chart upon move in to ensure a mental health screening was conducted prior to admission if the admission meets the criteria for needing completion. Persons responsible to implement and monitor corrective measure to ensure compliance: Executive Director/Health and Wellness Director.

22VAC40-73-520-I

Based on observation, the facility failed to ensure the current month's schedule of activities be posted in a conspicuous location in the facility or otherwise be made available to residents and their families.

Evidence

During the tour of the facility on 7/10/2023, the safe, secure environment did not have the current month’s activity calendar posted.

Plan of correction

The insufficiency will be corrected as follows: 7/11/2023 Happiness Coordinator posted the current month’s schedule of activities in the safe, secure environment. The following measures will be taken to ensure problems do not occur again: Happiness Coordinator/Executive Director will audit the safe, secure environment daily to ensure the current month’s activity calendar is posted. Persons responsible to implement and monitor corrective measure to ensure compliance: Happiness Coordinator/Executive Director.

22VAC40-73-610-B

Based on observation, the facility failed to post the menus for meals and snacks for the current week in an area conspicuous to residents.

Evidence

During the tour of the facility on 7/10/2023, the menus for snacks for the current week were not posted in an area conspicuous to residents.

Plan of correction

The insufficiency will be corrected as follows: 7/11/2023 Breadbasket Manager posted the current week’s menu for meals and snacks in an area conspicuous to residents. The following measures will be taken to ensure problems do not occur again: Breadbasket Manager/Executive Director will audit daily to ensure the current week’s menu for meals and snacks are posted in an area conspicuous to residents. Persons responsible to implement and monitor corrective measure to ensure compliance: Breadbasket Manager/Executive Director.

22VAC40-73-430-H-1

Based on record review and interview, the facility failed to ensure a dated discharge statement signed by the licensee or administrator that contains the information listed in the standard to be provided to the resident and, as appropriate, his legal representative and designated contact person at the time of discharge.

Evidence

The record for Resident #8 did not contain a written discharge statement.
Staff #5 acknowledged Resident #8 did not have a written discharge statement retained in the resident’s records.

Plan of correction

The insufficiency will be corrected as follows: Executive Director will ensure a dated discharge statement signed by the licensee or administrator that contains the information listed in the standard to be provided to the resident or legal representative at the time of discharge. The following measures will be taken to ensure problems do not occur again: Director will audit chart upon discharge to ensure a discharge statement was provided to the resident or legal representative at the time of discharge. Persons responsible to implement and monitor corrective measure to ensure compliance: Executive Director.

May 4, 2023Complaint survey3 violations

Inspection dates

05/04/2023

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 SERVICES

Technical assistance

22VAC40-73-325-C

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: 05/04/2023 from 10:50 am to 12:55 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 04/19/2023 and 05/02/2023 regarding allegations in the area(s) of: Part II Administration and Administrative Services, Part III Personnel, and Part IV Staffing and Supervision. Number of residents present at the facility at the beginning of the inspection: 54 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of interviews conducted with staff: 4 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s); area(s) of non-compliance with standard(s) or law were: Part II Administration and Administrative Services and Part III Personnel. 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations

22VAC40-73-130-A

Based on interviews, the facility failed to ensure all staff who are mandated reporters under § 63.2-1606 of the Code of Virginia report suspected abuse, neglect, or exploitation of residents in accordance with that section.

Evidence

Through interviews with Staff #1 and Staff #2, it was alleged that Staff #4 punched Resident #1 in their stomach on 4/27/23. Staff #1 confirmed Adult Protective Services has not been notified of this incident at the time of inspection.

Plan of correction

The insufficiency will be corrected as follows: 5/5/23 reported to APS. Executive Director/Health and Wellness Director will send a report to Adult Protective Services to report within 24 hours when an allegation of abuse has allegedly occurred. The following measures will be taken to ensure problems do not occur again: 5/12/2023 - Educated staff on reporting procedures when any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident has occurred. A notification needs to be sent to Executive Director/Health and Wellness Director. Persons responsible to implement and monitor corrective measure to ensure compliance: Executive Director/Health and Wellness Director.

22VAC40-73-70-A

Evidence

Through interviews with Staff #1 and Staff #2, it was alleged that Staff #4 punched Resident #1 in their stomach on 4/27/23. There was no documentation of this allegation in Resident #1’s record nor was this incident reported to the regional licensing office.
During a review of Resident #1’s record, it is documented that the resident fell on 3/21/23 and was sent to the ER where they received 5 staples to the back of their head. The Progress Notes for Resident #1 also documented Resident #1 was bitten by another resident on their finger. The facility did not make a report regarding either of these incidents about Resident #1 to the regional licensing office.

Plan of correction

The insufficiency will be corrected as follows: 5/4/23 reported incident to VDSS. Executive Director/Health and Wellness Director will send a report to VDSS licensing inspector to report within 24 hours. The following measures will be taken to ensure problems do not occur again: 5/12/2023 - Educated staff on reporting procedures when any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident has occurred. Also educated staff on when a resident is sent out 911. A notification needs to be sent to Executive Director/Health and Wellness Director. Persons responsible to implement and monitor corrective measure to ensure compliance: Executive Director/Health and Wellness Director.

22VAC40-73-130-B

Based on discussion, the facility failed to notify the resident's contact person or legal representative when a report is made relating to the resident as referenced in subsection A of this section, without identifying any confidential information.

Evidence

Through interviews with Staff #1 and Staff #2, it was alleged that Staff #4 punched Resident #1 in their stomach on 4/27/23. Staff #1 confirmed the facility has not notified the resident’s contact person or legal representative of this incident at the time of the inspection.

Plan of correction

The insufficiency will be corrected as follows: 5/5/23 reported to family. Executive Director/Health and Wellness Director will notify the resident’s contact person or legal representative when an allegation of abuse has allegedly occurred. The following measures will be taken to ensure problems do not occur again: 5/12/2023 - Educated staff on reporting procedures when any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident has occurred. A notification needs to be sent to Executive Director/Health and Wellness Director. Persons responsible to implement and monitor corrective measure to ensure compliance: Executive Director/Health and Wellness Director.

February 14, 2023Complaint survey4 violations

Inspection dates

02/14/2023

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: 02/14/2023 from 10:00 am to 11:30 am. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 02/02/2023 regarding allegations in the area(s) of: Part II Administration and Administrative Services, Part V Admission, Retention and Discharge of Residents, and Part VI Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 42 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 interviews conducted with staff: 7 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s); area(s) of non-compliance with standard(s) or law were: Part II Administration and Administrative Services and Part VI 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations

22VAC40-73-150-C

Based on interviews and record review, the administrator failed to demonstrate responsibility for the general administration and management of the facility and overseeing the day-to-day operation of the facility which includes ensuring staff and volunteers comply with residents' rights.

Evidence

Through interviews with floor staff, Staff #1, and Staff #2, it was determined SafelyYou video of fall events was utilized for training purposes during an all-staff meeting.
The SafelyYou policy for video use and documentation indicates SafelyYou services for consented residents will be accessible to authorized users which may include members of the Leadership Team.
The Resident Consent to Fall Detection Program for those that opt into SafelyYou services does not include consent authorizing the video documentation for general staff training.

Plan of correction

The insufficiency will be corrected as follows: Director/Health & Wellness Director will go over resident’s rights during all Staff In-Service on March 2nd, 2023. Director will ensure only direct care staff will view future SafelyYou video effective 2/14/2023. The following measures will be taken to ensure problems do not occur again: 2/14/2023 Only direct care staff has access to view SafelyYou videos. Persons responsible to implement and monitor corrective measure to ensure compliance: Director/Health & Wellness Director.

22VAC40-73-560-F

Based on interview, the facility failed to ensure all records are treated confidentially and that information shall be made available only when needed for care of the resident.

Evidence

The facility utilizes the SafelyYou video monitoring system to identify resident health or safety risk, including fall detection and intervention for residents with cognitive impairment upon obtaining responsible party consent. The SafelyYou policy for video use and documentation indicates “SafelyYou video of Fall Events is considered part of the Resident’s Medical Record.”
The utilization of residents’ medical record via SafelyYou video footage was not treated confidentially when shared as part of a general all-staff training.
Interviews with floor staff, Staff #1, and Staff #2 confirmed SafelyYou video of fall events was utilized for training purposes during an all-staff meeting.

Plan of correction

The insufficiency will be corrected as follows: Director will ensure any resident SafelyYou video will be viewed privately. Effective 2/14/2023. The following measures will be taken to ensure problems do not occur again: 2/14/2023 Only direct care staff has access to view SafelyYou videos confidentially. Persons responsible to implement and monitor corrective measure to ensure compliance: Director/ Health & Wellness Director.

22VAC40-73-680-D

Based on record review and interview, the facility failed to ensure medications be administered in accordance with the physician's or other prescriber’s instructions and consistent with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing.

Evidence

Resident #1’s record indicates the dosage of the resident’s Sertraline order changed from 150 mg to 100 mg on 01/14/2023; however, the MAR for Resident #1 documents the resident was administered 150 mg of Sertraline from 01/14/2023 to 02/02/2023. The MAR was adjusted on 02/02/2023 to the correct 100 mg dosage.
Staff #1 and Staff #2 acknowledged the MAR does not reflect the resident’s Sertraline order dosage change from 150 mg to 100 mg from 01/14/2023 to 02/02/2023, and indicates the resident received 150 mg of Sertraline during that time.

Plan of correction

The insufficiency will be corrected as follows: Health & Wellness Director corrected the MAR to match the physicians order on 2/2/2023. The following measures will be taken to ensure problems do not occur again: Health & Wellness Director will ensure med cart audits are done on a weekly basis to ensure medication labels matches the MAR. Effective 2/14/23. Persons responsible to implement and monitor corrective measure to ensure compliance: Health & Wellness Director.

22VAC40-73-680-B

Based on observation, the facility failed to ensure medications include the prescription label or direction label attached.

Evidence

On 2/9/2023, the facility received a verbal order to change Resident #1’s Sertraline order from 100 mg to 150 mg. The MAR was updated to reflect this change; however, the medication on the cart (Sertraline 100 mg tablet) reads “take 1 tablet by mouth daily.”
Staff #3 acknowledged the label on the Sertraline for Resident #1 does not reflect the current order.

Plan of correction

The insufficiency will be corrected as follows: Health & Wellness Director corrected the medication label on 2/14/2023. The following measures will be taken to ensure problems do not occur again: Persons responsible to implement and monitor corrective measure to ensure compliance: Health & Wellness Director will ensure med cart audits are done on a weekly basis to ensure medication labels matches the MAR. Effective 2/14/23. Persons responsible to implement and monitor corrective measure to ensure compliance: Health & Wellness Director.

January 5, 2023Inspection0 violations

Inspection dates

01/05/2023

Areas reviewed

22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS

Technical assistance

22VAC40-73-530

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: 01/05/2023 from 10:25 am to 10:45 am. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 12/26/2022 regarding allegations in the area(s) of: Part VII Resident Accommodations and Related Provisions, Part VIII Buildings and Grounds, and Part IX Emergency Preparedness. Number of residents present at the facility at the beginning of the inspection: 55 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Additional Comments/Discussion: Reviewed units damaged by flooding in addition to the 4 units beside damaged units. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

July 12, 2022Inspection7 violations

Inspection dates

07/12/2022

Areas reviewed

Comments

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7/12/2022 from 8:54 am to 3:45 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: 57 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 4 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations

22VAC40-73-440-B

Based on record review, the facility failed to ensure that the uniform assessment instrument is completed as required by 22VAC30-110 for private pay individuals.

Evidence

The UAIs for Resident #1 (dated by the facility on 5/20/22), Resident #3 (dated 6/28/22), Resident #4 (dated by the facility on 7/27/22), and Resident #6 (date by the facility on 7/11/22) were not signed for approval by the administrator or designee.

Plan of correction

The insufficiency will be corrected as follows: Director has reviewed and signed UAI’s from residents charts. The following measures will be taken to ensure problems do not occur again: Nurse Coordinator will give UAIs to Director to sign and review after each completion of a new UAI for all residents prior to placing in residents chart. Nurses and Director will conduct an audit on all residents UAI’s (10 each week for the next 6 weeks) to ensure each resident current UAI is reviewed and signed by Director. Persons responsible to implement and monitor corrective measure to ensure compliance: Nurse Coordinator/Director.

22VAC40-73-260-A

Evidence

Staff #1 (hire date 7/10/19), Staff #2 (hire date 7/13/17), and Staff #3 (hire date 2/17/22) work as direct care staff and do not have documentation of a current certification in first aid in their staff records.

Plan of correction

The insufficiency will be corrected as follows: Director has staff member signed up for CPR/First Aide renewal class in August. The following measures will be taken to ensure problems do not occur again: Director will have reoccurring CPR/First Aide Training classes offered every other month for new hires and any staff members requiring renewal. Persons responsible to implement and monitor corrective measure to ensure compliance: Director.

22VAC40-73-640-A

Based on documentation, the facility failed to implement their written plan for medication management which includes methods to ensure that each resident's prescription medications and any over-the- counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages.

Evidence

During review of the July MAR for Resident #7, Melatonin 3mg tab (2 tabs to be administered every night) and Trazodone 50mg tab (1/2 tab to be administered every night) have not administered to Resident #7 from 07/01/2022-07/11/2022 as the medication was not available.

Plan of correction

The insufficiency will be corrected as follows: Nurse Coordinator ensured missing medication is onsite for resident per orders 7/13/2022. The following measures will be taken to ensure problems do not occur again: Nurse Coordinator will audit med carts weekly to ensure any medications running low will be reordered in a timely manner to prevent missing medications for residents. Persons responsible to implement and monitor corrective measure to ensure compliance: Nurse Coordinator/Director.

22VAC40-73-720-A

Evidence

Upon review of Resident #2’s record, there are inconsistencies in regards to the resident’s code status. Resident #2 has a signed POST order (dated 11/11/21) with their last ISP (dated 2/15/22) indicating the resident as a DNR. However, the MAR as well as the last signed physician order sheet (signed 4/6/22) indicate the code status for Resident #2 as a Full Code.
Upon review of Resident #3’s record, the Physical Examination (dated 6/22/22) indicates the code status of the resident as a DNR. A document titled “Resident Emergency Code Status” (dated 6/22/22) also states the code status of the resident is a DNR; however, it is not signed by the resident and only by the physician and Staff #5. The resident does not have a Durable DNR order indicating this is the wish of the resident in their record.

Plan of correction

The insufficiency will be corrected as follows: Nurse Coordinator corrected Residents #2, Medication List and POS has been reflected with the correct code status. Nurse Coordinator ensured resident #3 has current durable DNR form signed by resident and physician. The following measures will be taken to ensure problems do not occur again: Nurse Coordinator and Director will audit all resident charts to ensure proper Full Code and DNR forms are reflected in residents charts and medication lists. (10 residents each week for the next 6 weeks). Persons responsible to implement and monitor corrective measure to ensure compliance: Nurse Coordinator/Director.

22VAC40-73-650-B

Based on record review, the facility failed to ensure physician or other prescriber orders, both written and oral, for administration of all prescription and over-the-counter medications and dietary supplements include the name of the resident, the date of the order, the name of the drug, route, dosage, strength, how often medication is to be given, and identify the diagnosis, condition, or specific indications for administering each drug.

Evidence

The following medications on Resident #2’s MAR did not include a diagnosis: Multivitamin Adlt 50+ tab, Polyeth Glyc Pow 3350 NF, Gabapentin 300mg tab, Lidocaine Pa 4% pad, and Losartan Pot 50mg tab.
The following medications on Resident #3’s MAR did not include a diagnosis: Donepezil 10mg tab and Escitalopram 10mg tab.
The following medications on Resident #4’s MAR did not include a diagnosis: Eliquis 2.5mg tab, Latanoprost Sol 0.005% solution, Melatonin 3mg tab, Memantine 10mg tab, Metoprol Tar 25mg tab, PolyB/Trim Oph solution, Prorenal +D tabs, Quetiapine 25mg tab, Rivastigmine 4.5mg tab, Rosuvastatin10mg tab, Acetaminophen 325mg tab, Albuterol AER HFA, Cetirizine 10mg tab, Pantoprazole 40mg tab, and Mupirocin oin 2%.
The following medications on Resident #9’s MAR did not include a diagnosis: Aspirin Low 81mg tab, Losartan Pot 100mg tab, Preservision AREDs 2 caps, and Therems Multivit Tab.

Plan of correction

The insufficiency will be corrected as follows: Nurse Coordinator connected with pharmacy to ensure medications has diagnosis listed for Residents #2, #3, #4, and #9 on their medication list/POS on 7/14/2022. The following measures will be taken to ensure problems do not occur again: Nurse Coordinator will audit all residents POS for the upcoming month to ensure all medications has diagnosis. (20 residents medication list for the next 3 weeks.) Completed by 8/24/2022. Persons responsible to implement and monitor corrective measure to ensure compliance: Nurse Coordinator/Director.

22VAC40-73-610-B

Based on observation, the facility failed to post the menus for meals and snacks for the current week in an area conspicuous to residents.

Evidence

At the time of the inspection on 7/12/22, the menu for 7/12/22 was observed to be posted in the dining room; however, the menus for meals and snacks for the current week were not posted in an area conspicuous to residents.

Plan of correction

The insufficiency will be corrected as follows: The current weeks snacks are posted in bistro area for residents to see. Completed 7/14/2022, ongoing. Weekly meal menus are on the Flat Screen TV in dining room showcased for all residents and families to see. Completed 7/14/2022, ongoing. The following measures will be taken to ensure problems do not occur again: Kitchen Manager will ensure all snacks menus are ready to be posted day before the new week. Persons responsible to implement and monitor corrective measure to ensure compliance: Director/Kitchen Manager.

22VAC40-73-520-I

Based on observation, the facility failed to ensure the current month's schedule be posted in a conspicuous location in the facility or otherwise be made available to residents and their families.

Evidence

During the tour of the facility on 7/12/22, the safe, secure environment was observed to have the June 2022 activity calendar and the daily activities for 7/11/22 posted.

Plan of correction

The insufficiency will be corrected as follows: The current months schedule has been posted up to date in conspicuous location for residents and families to see on 7/13/2022. The following measures will be taken to ensure problems do not occur again: Activities Director will ensure all activities calendar are ready to be posted day before the new month starts. Persons responsible to implement and monitor corrective measure to ensure compliance: Director/Activities Director.

March 31, 2022Complaint survey3 violations

Inspection dates

03/31/2022, 04/26/2022

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 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Comments

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 3/31/2022 from 12:45 PM to 2:35 PM and concluded 04/26/2022 from 9:10 AM to 11:30 AM. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 03/24/2022 regarding allegations in the area(s) of: Part II Administration and Administrative Services, Part IV Staffing and Supervision, Part V Admission, Retention and Discharge of Residents, and Part VI Resident Care and Related Services. 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: 10 Number of staff records reviewed: 3 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: Part II Administration and Administrative Services, Part V Admission, Retention and Discharge of Residents, and Part VI 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations

22VAC40-73-70-A

Based on interview and record review, the facility failed to ensure any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident to the regional licensing office within 24 hours.

Evidence

On 4/26/2022, Staff #5 stated Resident #8 was sent out on 4/21/22 after a fall. There was only documentation in the 24 hour book on 4/21/22 that the resident fell with complaints of pain in head and back and was sent to the hospital. There was no additional information in Resident #8’s chart indicating or findings into the cause of the fall. Staff #5 was unable to provide an update on the resident’s condition or determine if the incident was reported to the regional licensing office. The assigned licensing inspector had not received notification of the incident prior to or at the time of inspection.

Plan of correction

The insufficiency will be corrected as follows: Director/Nurse Coordinator will send a report to VDSS licensing inspector to report within 24 hours. The following measures will be taken to ensure problems do not occur again: 6/11/2022 - Educated staff on reporting procedures when a resident is sent out 911. A notification needs to be sent to Director/Nurse Coordinator. Persons responsible to implement and monitor corrective measure to ensure compliance: Director/Nurse Coordinator.

22VAC40-73-460-H

Based on record review, the facility failed to ensure that personal assistance and care are provided to each resident as necessary so that the needs of the resident are met.

Evidence

Documentation for showers between 4/1/2022-4/24/2022 were reviewed to ensure bathing is occurring at least twice a week, but more often if needed or desired. The following are the documented completion or attempts of bathing on the records reviewed: Resident #1 - 4/1, 4/5, Resident #2 - 4/4, Resident 3 - 4/4 (refused), 4/7, 4/10, 4/11, 4/14. 4/18, Resident 4 - 4/6 (refused), 4/10, 4/13 (refused), 4/17, 4/23 (refused) Resident #5 - 4/8 (refused), 4/10, 4/17, 4/10 (refused), 4/22, Resident #6 - 4/6, Resident #7 - 4/11, 4/18, Resident #8 - 4/5 (refused), 4/8, 4/15, 4/188, 4/19 (refused), Resident #9 - 4/1, 4/5, 4/15 (refused), Resident #10 - 4/4 (refused), 4/7 (refused). The documentation for Resident #1, Resident #2, Resident #6, Resident #7, Resident #9 and Resident #10 does not indicate the residents are receiving bathing at least twice a week.

Plan of correction

The insufficiency will be corrected as follows: Director and Nurse Coordinator will create a shower book to document resident showers and refusals. Staff will have to sign and report resident showers. Shower book will display resident scheduled shower days. Complete by 6/24/2022 The following measures will be taken to ensure problems do not occur again: Nurse Coordinator will check shower book weekly to ensure showers are addressed and properly given to resident. Director will check shower book monthly. Persons responsible to implement and monitor corrective measure to ensure compliance: Nurse Coordinator/Director.

22VAC40-73-325-B

Based on interview and record review, the facility to ensure that a fall risk rating was completed at least annually and/or after a fall.

Evidence

On 4/26/2022, Staff #5 stated Resident #8 was sent out on 4/21/22 after a fall. Upon review of Resident #8’s record, there was not documentation of a fall risk rating being completed in the record prior to or after this fall.

Plan of correction

The insufficiency will be corrected as follows: Nurse Coordinator will complete a fall risk rating on resident. Complete by 6/18/2022. The following measures will be taken to ensure problems do not occur again: Nurse Coordinator will perform an audit on the resident’s chart and ensure fall rating is completed. Nurse Coordinator will complete fall risk rating every 180 days, after every fall, and as needed. Persons responsible to implement and monitor corrective measure to ensure compliance: Nurse Coordinator.

July 8, 2021Inspection4 violations

Inspection dates

July 8, 2021 , July 9, 2021 , July 20, 2021 and July 21, 2021

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 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity22VAC40-90 The Criminal History Record Report

Comments

A renewal inspection was initiated on 07-08-2021 and concluded on 07-21-2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 47. The inspector emailed the Administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed 3 resident records, 3 staff records, activities calendar, menus, staff schedules, fire and health inspection reports, fire drills, healthcare oversight, and dietary oversight submitted by the facility to ensure documentation was complete. The inspector conducted the on-site portion of the inspection on 07-20-2021. An exit interview was conducted with the Administrator on the date of inspection, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. Information gathered during the inspection determined non-compliances with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations

22VAC40-73-450-C

Based on record review and interview, the facility failed to ensure the Individualized Service Plan (ISP) included a description of the residents? identified needs.

Evidence

Resident #2’s current Uniform Assessment Instrument (UAI) dated 03-28-2021 documented the need for physical and mechanical assistance with eating and dressing. The resident also had a physician’s order dated 09-24-2020 which documented, “Hospice eval and treat;” and a physician’s order dated 11-04-2020 for 2 Liters of oxygen as needed daily.
Resident #2’s current ISP dated 05-06-2021 did not include documentation of the resident’s need for oxygen; the type of mechanical device needed for eating and dressing, or a description of the type of services that are provided by hospice.
Resident #3’s current UAI dated 02-08-2021 documented the need for supervision and mechanical assistance with transferring; however, the resident’s current ISP dated 02-08-2021 did not include the type of supervision needed for transferring.
Staff #1 and staff #2 acknowledged the aforementioned ISP’s did not include a description of the residents? identified needs.

Plan of correction

The insufficiency will be corrected as follows: Resident #2 ISP has been updated to reflect the use of Oxygen, type of mechanical device needed for eating and dressing, and type of services provided by Hospice. Resident #3 ISP has been updated to include the type of supervision needed for transferring. The following measures will be taken to ensure problems do not occur again: The following measures will be taken to ensure problems do not occur again: RN Coordinator will audit residents that are on oxygen to ensure instructions are reflected on their ISP. RN Coordinator will audit all residents that need feeding assistance ISPs. ISPs are to include the type of mechanical device needed for eating and dressing, or a description of the type of services that are provided by hospice. RN Coordinator will audit all residents that need transferring assistance ISPs. ISPs are to include the type of assistance. Persons responsible to implement and monitor corrective measure to ensure compliance: RN Coordinator/Director

22VAC40-73-660-B

Based on observation, record review, and interview, a resident was permitted to keep medications in their room when the Uniform Assessment Instrument (UAI) indicated that the resident was not capable of self-administering medication.

Evidence

On 07-20-2021, during a tour of the facility with staff #1, the following medications were observed in residents? rooms: A. Afrin nasal spray was located on a nightstand in resident #5 and resident #6’s shared bedroom (Room #114); B. Calmoseptine Ointment, skin Protective Ointment; and Pain Relieving Cream was located on the bathroom counter in resident #3 and resident #4’s shared bathroom (Room #206).
Resident #3’s current UAI dated 02-08-2021, resident #4’s current UAI dated 02-05-2021, resident #5’s current UAI dated 05-03-2021, and resident #6’s current UAI dated 04-29-2021 documented medications are to be administered by professional nursing staff. The residents? UAI’s did not document that the aforementioned medications could be self- administered.
Staff #1 observed and acknowledged that resident #3, resident #4, resident #5, and resident #6 were not permitted to keep medications in their room for self-administration based on their current UAI’s.

Plan of correction

The insufficiency will be corrected as follows: All OTC medications were removed from residents apartment. Contacted resident family to notify of procedures of having OTC medications. The following measures will be taken to ensure problems do not occur again: RN Coordinator will perform bi-weekly room checks of all residents room for the next 3 months. Any OTC medication will be removed and family will be contacted to follow procedures for resident to have OTC medications. Director will send out monthly e-mail to families regarding OTC Medications. Persons responsible to implement and monitor corrective measure to ensure compliance: RN Coordinator/Director

22VAC40-73-680-D

Based on record review and interview, the facility failed to ensure medications are administered in accordance with the physician's instructions, and in accordance with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing.

Evidence

Resident #1’s signed physician’s orders dated 06-01-2021 and 07-01-2021 documented, ?Lactobacillu Tab- Take one tablet by mouth twice daily for general health.?
Resident #1’s June 2021 and July 2021 Medication Administration Record (MAR) documented staff administered one tablet of Lactobacillu once daily on 06-01-2021 through 07-07-2021, and not twice daily as ordered by the physician.
Resident #2’s signed physician’s orders dated 06-01-2021 documented, ?Acetamin 500mg- Take two tablets (1000mg) by mouth every eight hours for pain;“ and ”Amlodipine 10mg- Take 1 tablet by mouth every day for HTN *Hold for SBP [Systolic Blood Pressure] <120.?
Resident #2’s June 2021 MAR documented: A. Staff administered Acetamin 500mg on 06-01-2021 through 06-27-2021, at 8:00 AM, 3:00 PM, and 11:00 PM; and B. Staff administered Amlodipine 10mg on 06-18-2021 (Blood Pressure 104/60).
Resident #3’s signed physician’s orders dated 06-01-2021 documented: A. “Humalog Kwik Inj 100/ML ” Inject per s/s before meals and at bedtime for DMII“ 201-240= 4U, 251-300=6U”? B. Eliquis 5mg and Metoprol 25mg “every 12 hours” and Floranex “every 8 hours;” and C. “Trulicity Inj 4.5/0.5 ” Inject-0.5ML (4.5MG) subcutaneously once weekly for DM2.?
According to the current Virginia Board of Nursing registered medication aide curriculum ?18VAC90-60-110. Standards of practice. A medication aide shall not: Administer by subcutaneous route, except for insulin medications, glucagon, or auto-injectable epinephrine.? Resident #3’s June 2021 and July 2021 MAR documented: A. Staff administered 4 units of insulin on 06-15-2021 with a blood sugar reading of 271; B. Staff administered the following medications on 06-01-2021 through 06-30-2021: Eliquis 5mg at 9:00 AM and 8:00 PM; Floranex at 9:00 AM, 3:00 PM, and 11:00 PM; and Metoprol 25mg at 9:00 AM and 8:00 PM; and C. Trulicity Inj 4.5/0.5 injections were administered by Registered Medication Aides (RMA) on 06-03-2021, 06-24-2021, 07- 01-2021, and 07-08-2021 by staff #3, and 06-10-2021 and 06-17-2021 by staff #4.
Staff #3 stated the “RMA’s administer the Trulicity Injections” to resident #3.
Staff #1 and staff #2 acknowledged resident #1, resident #2, and resident #3’s aforementioned medications were not administered as ordered by the physician.

Plan of correction

The insufficiency will be corrected as follows: Resident’s MAR have been updated to reflect current physician orders RN/LPN staff to administer Trulicity The following measures will be taken to ensure problems do not occur again: RN Coordinator will perform audits on all current resident’s physician orders and will ensure orders correctly reflect the MAR RN Coordinator will reeducate with staff regarding POS and parameters and when to hold medications per physician orders Persons responsible to implement and monitor corrective measure to ensure compliance: Director/RN Coordinator

22VAC40-90-50-B

Based on record review and interview, the operator of the facility failed to ensure that each criminal history record report was verified by matching the name to establish that all information pertaining to the individual cleared through the Central Criminal Records Exchange is exactly the same as another form of identification such as a driver's license.

Evidence

Staff #1 provided a list of newly hired staff with dates of hire; to include staff #5 (date of hire 06-22-2021) and staff #6 (date of hire 08-06-2020), as well as a copy of their driver’s licenses.
Staff #5’s last name was entered at the first name, and first name was entered as the last name on the criminal history record report dated 06-14-2021. The name did not match what was shown on staff #5’s driver’s license.
Staff #6’s middle name (as shown on the driver’s license) was entered in as the last name on the criminal history record report dated 07-21-2020.
Staff #1 acknowledged the names on the aforementioned criminal history record reports did not match the name shown on the driver’s license.

Plan of correction

The insufficiency will be corrected as follows: Background checks were re-submitted to match staff drivers license. The following measures will be taken to ensure problems do not occur again: Director will ensure all new hires background checks are to match Driver’s License. Persons responsible to implement and monitor corrective measure to ensure compliance: Director