Virginia DSS · Assisted Living Facility

Tribute at One Loudoun

📍 20335 Savin Hill Drive, Ashburn, VA, 20147

ID 44027One Year licenseActive
37
Inspections
On record
26
With violations
Visits that cited something
11
Clean visits
Nothing cited
103
Violations cited
Individual findings
63
Standards cited
Distinct rules
18
Complaint visits
Prompted by a complaint

Tribute at One Loudoun was inspected 37 times between November 20, 2020 and April 14, 2026 by the Virginia Department of Social Services. 26 of those visits ended with violations cited and 11 with none. Across that history VDSS cited 103 violations under 63 distinct standards. 18 inspections were prompted by a complaint.

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

VDSS publishes inspections on a rolling window. 30 of these 37 are still on the state's site; the other 7 have since dropped off it and are reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type
Assisted Living Facility
License type
One Year
License expires
04/15/2026
Administrator
Melissa Fortner
Licensing inspector
Amanda Velasco
Inspector phone
(703) 397-4587
Approved for
Non-Ambulatory · Assisted Living · Special Care Unit

Inspection History

37

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

April 14, 2026Complaint survey9 violations
Inspection dates
04/14/2026
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 STAFFING AND SUPERVISION22VAC40-80 COMPLAINT INVESTIGATION
Technical assistance
Postings – Menus and Most Recent Inspection discussed. Letter of Licensure for Renewal Application requested and provided to facility upon expiration of 04/15/2026. 22VAC40-73-70-A: When medication errors are identified, they should also be submitted as Self-Reported incidents.
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: 04/14/2026 9:50 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 03/09/2026 regarding allegations in the area(s) of: 1. Resident Accommodations and Related Provisions Number of residents present at the facility at the beginning of the inspection: 113 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 0 Number of interviews conducted with residents:0 Number of interviews conducted with staff: 5 Observations by licensing inspector: Resident Records – Meals - Activities Additional Comments/Discussion: The LI shared concerns with staff regarding the length of time required to obtain documents during inspection. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegations 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. 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 Amanda “AJ” Velasco, Licensing Inspector at (703) 397 4587 or by email at amanda.velasco@dss.virginia.gov.
Violations
22VAC40-73-450-C
Based on resident record review and staff interview, the facility failed to ensure the individualized service plan (ISP) was completed within 30 days and included a description of identified needs and date, a written description of services, how the services will be provided, the expected outcome, time frame, and date achieved.
Evidence
  1. The records of Resident 3, admitted 12/24/2025, and Resident 4, admitted 01/23/2026, contained ISP’s that indicated both Resident 3 and Resident 4 self-administered medication.
  2. Resident 3’s ISP was completed on 12/26/2025. Resident 4’s ISP was completed on 01/25/2026.
  3. Both Resident 3 and Resident 4’s physical examination reports indicate that they are unable to self-administer medication. The Medication Administration records for February 2026 and March 2026 indicate that the facility was administering medication to Resident 3 and Resident 4.
  4. In an interview with the LI on 04/14/2026, Staff 3, Staff 4, and Staff 6 confirmed that neither Resident 3 or Resident 4 were able to self-administer medication, had not been self-administering medication, and the ISP’s had not been updated to reflect the change in condition.
Plan of correction
What action has been done to correct? The ISP paperwork of Resident #3 and Resident #4 were corrected. How will recurrence be prevented? Tribute at One Loudoun ISP assessors were re-in serviced on protocol of verifying work to achieve accuracy. Person responsible: Executive Director
22VAC40-73-290-B
Based on direct observation and staff interview, the facility failed to ensure a procedure for posting the name of the current on-site person in charge in the facility that is conspicuous to the residents and the public was developed and implemented.
Evidence
  1. Upon arrival to the facility at 9:50 AM on 04/14/2026, the LI observed the posted person in charge to be Staff 4 from 9:00 AM to 5:00 PM. Staff 4 was seen arriving at the building around 10:30 AM.
  2. In subsequent interviews with the LI on 04/14/2026, Staff 1 and Staff 5 stated that Staff 4 was off site and would be in shortly.
  3. In an interview with the LI on 04/14/2026, Staff 4 confirmed that the posted person in charge, Staff 4, was not on site from 9:00 AM to 10:30 AM despite being the current, posted person in charge for 9:00 AM to 5:00 PM.
  4. Photo evidence obtained.
Plan of correction
What action has been done to correct? To ensure coverage during timeframes involving intermittent off-site appointments, a backup appointee of the first-floor Med Tech position will be implemented. How will recurrence be prevented? An in-service for all Med Tech and Concierge associates will be conducted regarding the revised person-in-charge procedure, that includes the new backup coverage. Person responsible: Executive Director/designee
22VAC40-73-640-A
Based on resident record review and staff interview, the facility failed to ensure a written plan for medication management was kept current, implemented, and addressed procedures for administering medication including required components.
Evidence
  1. The facility’s medication management plan, submitted on 04/03/2026, and confirmed on site by Staff 4 and Staff 6, states the following: a. Residents will have a profile of medications in the electronic health record, and a generated MAR. b. New orders will be sent to the pharmacy and then transcribed to the electronic health record. c. When the medication arrives, a reconciliation will be completed to ensure accuracy.
  2. Resident 2’s signed order summary, dated 12/31/2025, includes an order for Remedy Protect topical started on 02/14/2025 for a pressure ulcer. Resident 2’s current medication administration record contains an order for Remedy Protect topical for a pressure ulcer started on 02/09/2026.
  3. In an interview with the LI on 04/14/2026, Staff 4 and Staff 6 stated that the medication was incorrectly transcribed to the electronic health record when the pharmacy’s changed in February of 2026, confirming that the mistake was not caught during reconciliation.
Plan of correction
What action has been done to correct? Resident #2’s prior Remedy Protect topical order, which was mistakenly shown as current during the pharmacy changeover, has been discontinued. How will recurrence be prevented? Should there be another pharmacy change for Tribute at One Loudoun, pre-implementation plans will include sufficient medication order reconciliation. Person responsible: Executive Director
22VAC40-73-650-B
Based on resident record review and staff interview, the facility failed to ensure physician or other prescriber orders included the name of the resident, date of the order, the name of the drug, route, dosage, strength, how often the medication is to be given, and identify the diagnosis, condition, or indications for administering.
Evidence
  1. On 04/14/2026, Staff 3 provided the signed medication orders, Medication Administration Record (MAR) and Time Variance Reports for Resident 1, Resident 2, Resident 3, and Resident 4 for February 2026 and March 2026.
  2. In an interview with the LI on 04/14/2026, Staff 6 confirmed the facility was using an open or flexible medication pass time with a window given rather than a specific time.
  3. The facility’s medication management plan, submitted on 04/03/2026, and confirmed on site by Staff 4 and Staff 6, states that “…or liberal medication pass times such as morning, afternoon, evening or bedtime. Specific medication times may be adjusted based on physician/hcp order or resident preference if allowable.”
  4. Resident 1’s signed order summary, dated 01/08/2026, contains nine (9) physician orders that do not contain specific instructions for liberal medication passes.
  5. Resident 2’s signed order summary, dated 12/31/2025, contains 14 physician orders that do not contain specific instructions for liberal medication passes.
  6. Resident 3’s signed order summary, dated 02/25/2026, contains nine (9) physician orders that do not contain specific instructions for liberal medication passes.
  7. Resident 4’s signed order summary, dated 03/31/2026, contains 10 physician orders that do not contain specific instructions for liberal medication passes.
Plan of correction
Not published by VDSS.
22VAC40-73-440-A
Based on resident record review and staff interview, the facility failed to ensure that all residents and applicants were assessed face to face using the UAI instrument at admission, annually, and whenever there is a significant change in the resident's condition.
Evidence
  1. The records of Resident 3, admitted 12/24/2025, and Resident 4, admitted 01/23/2026, contained UAI’s that indicated both Resident 3 and Resident 4 self-administered medication.
  2. Resident 3’s UAI was completed on 12/10/2025. Resident 4’s UAI was completed on 01/25/2026.
  3. Both Resident 3 and Resident 4’s physical examination reports indicate that they are unable to self-administer medication. The Medication Administration records for February 2026 and March 2026 indicate that the facility was administering medication to Resident 3 and Resident 4.
  4. In an interview with the LI on 04/14/2026, Staff 3, Staff 4, and Staff 6 confirmed that neither Resident 3 or Resident 4 were able to self-administer medication, had not been self-administering medications, and the UAI’s had not been updated to reflect the change in condition.
Plan of correction
What action has been done to correct? The UAI paperwork of Resident #3 and Resident #4 were corrected. How will recurrence be prevented? Tribute at One Loudoun UAI assessors were re-in serviced on protocol of verifying work to achieve accuracy. Person responsible: Executive Director
22VAC40-73-680-H
Based on resident record review and staff interview, the facility failed to ensure all medications administrations to residents were documented on the medication administration record (MAR) at the time of administration.
Evidence
  1. On 04/14/2026, Staff 3 provided the signed medication orders, Medication Administration Record (MAR) and Time Variance Reports for Resident 1, Resident 2, Resident 3, and Resident 4 for February 2026 and March 2026.
  2. Resident 1’s MAR and Time Variance report for February of 2026 indicates that there was five (5) doses on 03/12/2026, 03/22/2026, 03/24/2026, 03/25/2026, and 03/26/2026, two (2) doses on 03/10/2026, and three (3) doses on 03/31/2026 that were documented as administered on time but entered the EMAR system late.
  3. Resident 4’s Time Variance report for February 2026 indicates that all doses (72 total) between 02/01/2026 and 02/08/2026 were documented on the system at times that were either earlier or later than the documented administration time.
  4. Resident 2’s Time Variance report for February 2026 indicates that all administered doses (119 total) between 02/01/2026 and 02/08/2026 were documented on the system at times that were either earlier or later than the documented administration time.
  5. Resident 2’s MAR and Time Variance report for February of 2026 indicates that there was one (1) dose of scheduled medication on 02/17/2026, 02/18/2026, 02/23/2026, 02/28/2026, 03/02/2026, 03/04/2026, 03/10/2026, 03/17/2026, and 03/23/2026 that were documented as administered on time but entered the EMAR system late.
  6. Resident 2’s Time Variance report for February 2026 indicates that all administered doses (83 total) between 02/01/2026 and 02/08/2026 were documented on the system at times that were either earlier or later than the documented administration time.
  7. Resident 3’s MAR and Time Variance report for March of 2026 indicates that there were (3) doses on 02/21/2026 and 03/29/2026, two (2) doses on 03/01/2026, and one dose (1) dose on 03/14/2026, 06/16/2026, and 03/21/2026 that were documented as administered on time but entered the EMAR system late.
  8. Resident 4’s Time Variance report for February 2026 indicates that all doses (96 total) between 02/01/2026 and 02/08/2026 were documented on the system at times that were either earlier or later than the documented administration time.
  9. Resident 4’s MAR and Time Variance report for March of 2026 indicates that there were six (6) doses on 03/19/2026, four (4) doses on 03/03/2026, and five (5) doses on 03/31/2026 that were documented as administered on time but entered the EMAR system late.
  10. In an interview with the LI on 04/14/2026, Staff 3, Staff 4, and Staff 6 confirmed that neither Resident 3 or Resident 4’s medication was not documented on the medication administration record (MAR) at the time of administration.
Plan of correction
What action has been done to correct? No immediate action for Residents #1, #2, #3, and #4, as there was no negative effect on the residents; the issue was related to documentation compliance. How will recurrence be prevented? An in-service for all Med Techs and Clinical Leaders will be conducted on the protocol for ensuring medication administration documentation occurs at the time of administration. Should there be another pharmacy change for Tribute at One Loudoun, pre-implementation plans will include the protocol for ensuring medication administration documentation occurs at the time of administration. Person responsible: Executive Director
22VAC40-73-680-D
Based on resident record review and staff interview, the facility failed to ensure medication was administered in accordance with the physician or other prescribers’ instructions.
Evidence
  1. On 04/14/2026, Staff 3 provided the signed medication orders, Medication Administration Record (MAR) and Time Variance Reports for Resident 1, Resident 2, Resident 3, and Resident 4 for February 2026 and March of 2026.
  2. Resident 2’s MAR for March of 2025 indicates that the following doses were not administered because the medication was unavailable: a. Remedy Special Protect Paste: 02/25/2026 b. Nystatin: 03/07/2026, 03/24/2026, 03/25/2026
  3. Resident 3’s MAR for March of 2025 indicates that the following doses were not administered because the medication was unavailable: a. Levothyroxine75 MCG: 02/20/2026, 02/23/2026. 02/25/2026, 02/27/2026, 02/28/2026, 03/01/2026, 03/02/2026, 03/04/2026, 03/06/2026, 03/07/2026, 03/08/2026 b. Eliquis Tab 2.5 MG: 02/22/2026 (two doses), 02/23/2026, 02/25/2026,
  4. Resident 3’s MAR also indicated that one (1) dose of Nystatin was not administered on 03/07/2026, but a reason was not given.
  5. Resident 4’s MAR for March of 2025 indicates that the following doses were not administered because the medication was unavailable: a. Pantoprazole Tab 40 MG, 03/05/2026, 03/11/2026, 03/26/2026 b. Biotin Forte Tab 5 MG, 03/01/2026 and 03/27/2026 c. Bupropion HCL XL 300 MG Tab, 03/26/2026 and 03/27/2026 d. Hydrocort Tab 5 MG, 03/26/2026 and 03/27/2026 e. Sertraline Tab 50 MG, 03/26/2026 and 03/27/2026 f. Levothyroxine Tab 75 MCG, 03/26/2026 and 03/27/2026 g. Atorvastatin Tab 20 MG, 03/26/2026 h. Famotidine Tab 20 MG, 03/26/2026
  6. In an interview with the LI on 04/14/2026, Staff 3, Staff 4, and Staff 6 confirmed that neither Resident 3 nor Resident 4’s medication was administered in accordance with the physician or other prescribers’ instructions.
Plan of correction
What action has been done to correct? No immediate action for Resident’s #2, #3, and #4 due to lapse of time. Responsible parties of Resident’s #2, #3, and #4 notified of February 2026 and March 2026 findings. How will recurrence be prevented? An in-service for all Med Techs and Clinical Leaders will be conducted regarding protocols for 1) avoiding unavailable medications and 2) ensuring medications are administered in accordance with physician/prescriber instructions. Should there be another pharmacy change for Tribute at One Loudoun, pre-implementation plans will include protocols for 1) avoiding unavailable medications and 2) ensuring medications are administered in accordance with physician/prescriber instructions. Person responsible: Executive Director
22VAC40-73-650-A
Based on resident record review and staff interview, the facility failed to ensure a medication, dietary supplement, diet, medical procedure, or treatment had a valid order from a physician or prescriber to be started, changed, or discontinued by the facility.
Evidence
  1. Resident 2’s signed order summary, dated 12/31/2025, includes an order for Remedy Protect topical started on 02/14/2025 for a pressure ulcer.
  2. In a follow-up email the LI on 04/23/2026, Staff 4 provided the stop order for the medication dated 07/09/2025.
  3. Resident 2’s current medication administration record contains an order for Remedy Protect topical for a pressure ulcer started on 02/09/2026. The medication was administered as scheduled, except 02/25/2026, until 03/31/2026.
  4. In an interview with the LI on 04/14/2026, Staff 4 and Staff 6 stated that the medication was incorrectly transcribed to the electronic health record when the pharmacy’s changed in February of 2026, resulting in the medication being restarted on 02/09/2026.
Plan of correction
What action has been done to correct? Specific instructions for liberal medication passes have now been added to the orders of residents #2, #3, and #4. How will recurrence be prevented? All future orders that qualify for a liberal medication pass will include specific instructions. Person responsible: Executive Director/designee
22VAC40-73-680-C
Based on resident record review and staff interview, the facility failed to ensure medication was administered no earlier than one hour before and not later than one hour after the facility's standard dosing schedule.
Evidence
  1. On 04/14/2026, Staff 3 provided the signed medication orders, Medication Administration Record (MAR) and Time Variance Reports for Resident 1, Resident 2, Resident 3, and Resident 4 for February 2026 and March 2026.
  2. Resident 1’s Time Variance Report and MAR indicated that the following medication was administered more than one hour before or after the medication was scheduled: a. 02/07/2026: Amlodipine Tab 5 MG, Carvedilol Tab 25 MG, Clonidine Tab 0.1 MG, Torsemide Tab 20 MG, and Valsartan Tab 160 MG – scheduled for 8:00 AM and administered at 10:27 AM
  3. Resident 3’s Time Variance Report and MAR indicated that the following medication was administered more than one hour before or after the medication was scheduled: a. 02/01/2026: Divalproex Cap 125 MG DR, Eliquis Tab 2.5 MG, Ferrous Sulf Tab 325 MG EC, Levothyroxine Tab 100 MCG, and Metoprolol Tab 25 – scheduled for 9:00 AM, administered at 10:23 AM b. 02/03/2026: Divalproex Cap 125 MG DR, Eliquis Tab 2.5 MG, Ferrous Sulf Tab 325 MG EC, Levothyroxine Tab 100 MCG, and Metoprolol Tab 25 – scheduled for 9:00 AM, administered at 10:03 AM c. 02/05/2026: Divalproex Cap 125 MG DR, Eliquis Tab 2.5 MG, Ferrous Sulf Tab 325 MG EC, Levothyroxine Tab 100 MCG, and Metoprolol Tab 25 MG – scheduled for 9:00 AM, administered at 10:19 AM d. 02/06/2026: Divalproex Cap 125 MG DR, Eliquis Tab 2.5 MG, Ferrous Sulf Tab 325 MG EC, Levothyroxine Tab 100 MCG, and Metoprolol Tab 25 – scheduled for 9:00 AM, administered at 10:22 AM e. 02/08/2026: Bumetanide Tab 1 MG, Divalproex Cap 125 MG DR, Eliquis Tab 2.5 MG, Ferrous Sulf Tab 325 MG EC, Levothyroxine Tab 100 MCG, and Metoprolol Tab 25 – scheduled for 9:00 AM, administered at 11:55 AM
  4. Resident 4’s Time Variance Report and MAR indicated that the following medication was administered more than one hour before or after the medication was scheduled: a. 02/04/2026: Hydrocort Tab 5 MG – scheduled for 4:00 PM and administered at 5:22 PM b. 02/07/026: Pantoprazole Tab 40 MG – scheduled for 7:30 AM, administered at 9:20 AM c. 02/08/026: Pantoprazole Tab 40 MG – scheduled for 7:30 AM, administered at 8:43 AM d. 02/08/2026: Alendronate Tab 70 MG, Aspirin Low Tab 81 MG EC, Biotin Forte Tab 5 MG, Sertraline Tab 50 MG, and Vitamin D3 125 MG Cap (5,000IU) – scheduled for 9:00 AM and administered at 10:03 AM e. 02/08/2026: Hydrocort Tab 5 MG – scheduled for 8:00 AM and administered at 10:03 AM.
  5. In an interview with the LI on 04/14/2026, Staff 3, Staff 4, and Staff 6 confirmed that neither Resident 3 or Resident 4’s medication was administered earlier than one hour before or later than one hour after the facility's standard dosing schedule.
Plan of correction
What action has been done to correct? No immediate action for Resident’s #1, #3, and #4 due to lapse of time. Responsible parties of Resident’s #1, #3, and #4 notified of February 2026 findings. How will recurrence be prevented? An in-service for all Med Techs and Clinical Leaders will be conducted on the protocol for ensuring medications are administered no earlier than one hour before and not later than one hour after the facility’s standard dosing schedule. Should there be another pharmacy change for Tribute at One Loudoun, pre-implementation plans will include the protocol for ensuring medications are administered no earlier than one hour before and not later than one hour after the facility’s standard dosing schedule. Person responsible: Executive Director
March 11, 2026Inspection2 violations
Inspection dates
03/11/2026
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS
Technical assistance
22VAC40-80-160-D: The applicant or licensee shall at all times afford the department's representative reasonable opportunity to inspect all the facility's or agency's buildings, books, and records.
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03/11/2026 12:30 PM to 2:00 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 02/25/2026 regarding allegations in the area(s) of: 1. Resident Accommodations and Related Provisions 2. Staffing and Supervision Number of residents present at the facility at the beginning of the inspection: 107 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: 3 Observations by licensing inspector: Resident and Staff Records Additional Comments/Discussion: Both resident and staff involved in self-reported incident were not available at the facility at the time of inspection. Pre-liminary (on-site) exit meeting was conducted with staff both in person and on the phone. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. However, violation(s) not related to the self-report but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. 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 Amanda “AJ” Velasco, Licensing Inspector at (703) 397 4587 or by email at amanda.velasco@dss.virginia.gov.
Violations
22VAC40-73-460-H
Based on staff record review, the facility failed to ensure that personal assistance and care were provided to each resident as necessary so that the needs of the resident are met, including assistance or care with activities such as bathing, toileting, and housekeeping.
Evidence
  1. On 02/25/2026, Staff 3 reported that Resident 1 alleged that Staff 2 smacked Resident 1 on the bottom while providing incontinent care at the end of November 2025 or beginning of December 2025.
  2. Resident 1 was on respite at the facility from 11/29/2025 to the week of 02/24/2026.
  3. Staff 2 was employed from 01/06/2025 to 12/21/2025.
  4. Staff 2’s record, provided on site by Staff 1, contained multiple written statements from other staff members that detailed Staff 2 refusing and/or not completing resident care tasks. The written statements are summarized as follows: a. A typed document signed “Night Shift” stated that there were ongoing issues when Staff 2 was in the building. These issues, including resident trash cans not being emptied, residents being left wet, residents not having their clothing changed, and residents being left on top of their blankets. The note contained an illegible signature and was dated 11/14/2025. b. A handwritten document signed and dated by Staff 5 on 11/14/2025 that stated that Staff 2 was leaving trash in the hallway and elevator area, and that Staff 2 was not checking on or toileting residents despite requests to do so. c. A handwritten note signed and dated by Staff 6 on 12/03/2026 that stated that both Resident 2 and Resident 3 had scheduled morning showers that had not been completed, and both Resident 2 and Resident 3 were upset. Staff 6 stated that Staff 6 was asked to provide care by Staff 7, and that Resident 3’s shower was completed later that evening. d. A typed email between Staff 7 and Staff 1 on 12/08/2026 details additional concerns reported on 12/03/2026. Staff 7’s email states that Resident 2 and Resident 3 were assigned to Staff 2. The email states that Resident 2 was found on 12/03/2026 in the same clothes as the day before, with no under garments. The email states that when the shower was given to Resident 2, Staff 6 observed overflowing trash and breakfast/lunch trays not removed from the apartment. The email states that upon arrival to Resident 3’s room, Resident 3 was soiled and needed a shower. e. A written statement dated 12/10/2025 by Staff 1 confirms that multiple reports from other team members and residents were received regarding Staff 2 not emptying the trash, not appropriately dressing residents, not answering resident call pendants and having an attitude with both staff and residents when asked to provide care.
  5. Corrective Action Notices for Staff 2 regarding incompletion of tasks on 12/08/2025 (updated on 12/10/2025), 11/26/2025, and 10/21/2025 were located within Staff 2’s provided record.
Plan of correction
What action has been done to correct? Concerns of personal care/assistance voiced by any staff were evaluated and resolved if attention was needed. Staff member 2 was no longer with the community when Resident 1 voiced concern. How will recurrence be prevented? Assisted Living and Memory Care Coordinators will conduct daily rounds and monitor activities of daily living (ADL) documentation in the electronic medical record daily to ensure compliance. Person responsible: Executive Director
22VAC40-73-130-A
Based on staff record review and staff interview, the facility failed to ensure that all staff who are mandated reporters reported suspected abuse, neglect, or exploitation of residents.
Evidence
  1. During an on-site review of staff records, it was observed that Staff 2’s record contained multiple written statements from other staff members that detailed Staff 2 refusing and/or not completing resident care tasks for multiple residents including Resident 2, Resident 3, and Resident 4 between October of 2025 and December of 2025.
  2. During the preliminary exit meeting held on site with two licensing staff on 03/11/2026, Staff 1, Staff 2, and Staff 3 acknowledged that a report was not completed for the alleged neglect by Resident 1.
Plan of correction
What action has been done to correct? Staff member 2 had ceased employment with Tribute at One Loudoun as of 12/21/2025. How will recurrence be prevented? Mandated reporter requirements re-reviewed with Wellness Director, and other leadership team members. Person responsible: Executive Director
March 11, 2026Inspection3 violations
Inspection dates
03/11/2026
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03/11/2026 2:00 PM to 3:25 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 02/11/2026 regarding allegations in the area(s) of: 1. Resident Accommodations and Related Provisions Number of residents present at the facility at the beginning of the inspection: 107 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: Record review. Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. However, violation(s) not related to the self-report but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. 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 Amanda “AJ” Velasco, Licensing Inspector at (703) 397 4587 or by email at amanda.velasco@dss.virginia.gov.
Violations
22VAC40-73-440-A
Based on resident record review and staff interview, the facility failed to ensure that the UAI was completed at admission, annually, as needed and for significant change in condition.
Evidence
  1. On 02/18/2026, the facility submitted a self-reported incident regarding a bruise on the right eye of Resident 1 sustained after getting caught in the enabler bar on Resident 1’s bed.
  2. Resident 1 record contained a UAI dated 03/16/2025 and updated 09/16/2025.The UAI indicates that Resident 1 needs human help only, not mechanical, with transferring.
  3. In an interview with two LI’s on 03/11/2026, Staff 1 confirmed that Resident 1 does need mechanical assistance for transferring, and that the enabler had been in place since prior to the start of Staff 1’s employment in January of 2025.
  4. During the preliminary exit meeting held on site with two licensing staff on 03/11/2026, Staff 1, Staff 2, and Staff 3 confirmed that the UAI had not been updated to reflect Resident 1’s change in condition.
Plan of correction
What action has been done to correct? The UAI for Resident 1 updated to current. How will recurrence be prevented? New UAI and care plan process being implemented at Tribute at One Loudoun Person responsible: Executive Director
22VAC40-73-450-F
Based on resident record review and staff interview, the facility failed to ensure that the individualized service plan (ISP) was reviewed and updated annually and as needed and for significant change in condition.
Evidence
  1. On 02/18/2026, the facility submitted a self-reported incident regarding a bruise on the right eye of Resident 1 sustained after getting caught in the enabler bar on Resident 1’s bed.
  2. Resident 1 record contained an ISP dated 03/17/2025. The ISP did not include Resident 1’s need for mechanical assistance with transferring, or the use of an assistive device.
  3. In an interview with two LI’s on 03/11/2026, Staff 1 confirmed that Resident 1 does need mechanical assistance for transferring, and that the enabler had been in place since prior to the start of Staff 1’s employment in January of 2025.
  4. During the preliminary exit meeting held on site with two licensing staff on 03/11/2026, Staff 1, Staff 2, and Staff 3 confirmed that the ISP for Resident 1 was not reviewed and updated.
Plan of correction
What action has been done to correct? The ISP for Resident 1 updated to current. How will recurrence be prevented? New UAI and care plan process being implemented at Tribute at One Loudoun Person responsible: Executive Director
22VAC40-73-480-E
Based on resident record review and staff interview, the facility failed to ensure that physician or other prescriber’s orders, services provided, evaluations of progress, and other pertinent information regarding the rehabilitative services were recorded in the resident’s record.
Evidence
  1. On 02/18/2026, the facility submitted a self-reported incident regarding a bruise on the right eye of Resident 1. The report states that the right eye was traced back to Resident 1 being found by a caregiver with Resident 1’s head, shoulder, and arm through the enabler bar on Resident 1’s bed.
  2. During a record review and interview with two LI’s on 03/11/2026, Staff 1 confirmed that Resident 1’s enabler bar, used for transferring assistance, was not documented in Resident 1’s record.
  3. During the preliminary exit meeting held on site with two licensing staff on 03/11/2026, Staff 1, Staff 2, and Staff 3 acknowledged that physician or other prescriber’s orders, services provided, evaluations of progress, and other pertinent information regarding the rehabilitative services were not recorded in the resident’s record.
Plan of correction
What action has been done to correct? The Resident 1 record contains all pertinent information regarding the rehabilitative services. How will recurrence be prevented? Tribute at One Loudoun has met with rehab partner Bayada and process to be in place for rehab documentation in Tribute charts. Person responsible: Executive Director
March 11, 2026Complaint survey7 violations
Inspection dates
03/11/2026
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY22VAC40-80 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: 03/11/2026 9:30 AM to 12:30 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 02/25/2026 regarding allegations in the area(s) of: 1. Staffing and Supervision 2. Resident Accommodations and Related Provisions 3. Additional Requirements for Facility that Care for Adults with Serious Cognitive Impairment Number of residents present at the facility at the beginning of the inspection: 107 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 4 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 7 Observations by licensing inspector: Resident Activities in the Safe, Secure Unit Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegations 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. 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 Amanda “AJ” Velasco, Licensing Inspector at (703) 397 4587 or by email at amanda.velasco@dss.virginia.gov.
Violations
22VAC40-73-520-I
Based on direct observation, document review, and staff interview, the facility failed to ensure there was a written schedule of activities that included changes noted on the schedule.
Evidence
  1. On 03/11/2026, the LI observed the posted activities to include 10:00 AM – Words in a Word and 11:00 AM – Chair Volleyball. On 03/11/2026, the LI observed the unit playing Hangman at 10:55 AM and a musician began playing at 11:05 AM.
  2. In an interview with two LI’s on 03/11/2026, both Staff 1 and Staff 2 confirmed that the schedule had not been updated to reflect changes in programming.
  3. During the onsite preliminary exit meeting with two LI’s on 03/11/2026, Staff 4, Staff 5, and Staff 6 acknowledged that the written schedule of activities had not been updated.
Plan of correction
What action has been done to correct? The Lifestyle Director has implemented a process to ensure that any schedule changes to the calendar occur daily. How will recurrence be prevented? The Lifestyle Director has implemented a process to ensure that any schedule changes to the calendar occur daily and the Lifestyle Assistants have been trained. Person responsible: Director of Lifestyles
22VAC40-73-1120-F
Based on resident record review and staff interview, the facility failed to ensure that there was a designated person responsible for managing or coordinating the structured activities program in the safe, secure unit.
Evidence
  1. Staff 11, the designated activities person, resigned on 01/09/2026.
  2. Staff 1, the current designated activities person, began employment on 02/02/2026, per the staff record.
  3. Per interviews with Staff 2, Staff 3, and Staff 1, there was not a qualified designated activities person from 01/09/2026 to 02/02/2026.
Plan of correction
What action has been done to correct? The team continued programming with Executive Director support, and a qualified director was hired as soon as possible. How will recurrence be prevented? We will work within our options to ensure that the designated person is qualified. Person responsible: Executive Director
22VAC40-73-520-G
Based on direct observation, staff record review, and staff interview, the facility failed to ensure that the staff person or volunteer leading the activity had a general understanding of the following: attention spans and functional levels of the residents; methods to adapt the activity to meet the needs and abilities of residents, various methods of engaging and motivating residents to participate, and the importance of providing appropriate instruction, education, and guidance throughout the activity.
Evidence
  1. On 03/11/2026 from approximately 11:00 AM to 11:30 AM, two LI’s observed activities in the safe, secure unit at the facility. Upon the arrival, 18 residents were located in the activity room playing a version of Hangman with Staff 2, while two (2) residents were located in the adjacent dining area, across the hallway with no line of sight to the activity being conducted. During the activity, one to two participants were seen actively participating, while approximately eight residents were sleeping during the activity. At one point, Staff 2 called on a resident that was observed sleeping, and when there was no response stated out loud “Still sleeping?” before laughing and continuing the game.
  2. Around 11:05 AM, a contract musician began to play music with a guitar. There was no transition or introduction to the activity, and simultaneously, no expectations given to residents. The musician apologized for the loud music, stating that the residents needed to wake up.
  3. In a follow-up email with Staff 2 on 03/11/2026, two LI’s asked specific questions related to the four topics listed above. Staff 2 stated their previous experience included various customer service positions, outside of the senior living population.
  4. Staff 2’s training record was reviewed. Of 23 hours of training, Staff 2’s record contained 1 hour of activity-specific training from September of 2025.
  5. In an interview with Staff 3, another activity staff member that shares a position with Staff 2, Staff 3 was asked the same questions. Staff 3 stated they had previous volunteer experience from school, and while they had limited training, it’s important to try things out to see if they work. If it doesn’t work, Staff 3 will research other solutions online.
  6. Staff 3’s training record was reviewed and contained 3.2 hours of training for the last year of employment, none of which were related to activities.
  7. During the onsite preliminary exit meeting with two LI’s on 03/11/2026, Staff 4, Staff 5, and Staff 6 acknowledged that Staff 2 and Staff 3 do not have a general understanding of understanding of attention spans and functional levels of the residents; methods to adapt the activity to meet the needs and abilities of residents, various methods of engaging and motivating residents to participate, and the importance of providing appropriate instruction, education, and guidance throughout the activity.
Plan of correction
What action has been done to correct? General understanding, instruction, and guidance of activities has been reviewed with both Lifestyle Assistants providing programming in Memory Care by the Director of Lifestyle. How will recurrence be prevented? Specific courses from two educational sources are being assigned to both Lifestyle Assistants over the next 3 months; the sources are Relias and Teepa Snow. Person responsible: Director of Lifestyles
22VAC40-73-1030-A
Based on direct observation and staff interview, the facility failed to ensure minimum awake and on duty direct care staffing in the special care unit as required based on resident census.
Evidence
  1. On 03/11/2026, Staff 4 confirmed the census in the safe, secure unit as 29.
  2. The schedule and time clock indicate there were three direct care staff members, along with one registered medication aide. Staff 13 was clocked out for break from 11:01 AM to 11:31 AM.
  3. On 03/11/2025, two LI’s were in the safe, secure unit at the facility. The LI’s observed Staff 8 in the activity room with 20 residents (two of which were in the adjacent dining area) until approximately 11:05 when Staff 9 arrived. When staff 9 arrived, Staff 8 left the area. The LI’s walked up and down the hallway, attempting to locate another staff member. Another care staff member was not seen until approximately 11:30 when Staff 10 arrived and was in the dining area with Staff 2.
  4. After leaving the safe, secure unit around 11:30 AM, two LI’s observed Staff 9 in the lobby area on the first floor, outside of the safe, secure unit.
  5. In an interview with two LI’s on 03/11/2026, Staff 2 stated there were typically three staff assisting and Staff 2 was unsure where they were at the time of inspection.
Plan of correction
What action has been done to correct? Schedule and Time cards were checked affirming that Tribute at One Loudoun had ensured the correct number of minimum awake and on duty direct care staffing in the special care unit as required per resident census. The resident census on 3/11/2026 was 29; the staffing was 3 caregivers and 1 med tech which more than adequately meets the minimum the DSS standard. How will recurrence be prevented? Due to the floor’s large footprint and to ensure all Memory Care staff can know the whereabouts of each other, an additional assignment (activity companion) has been implemented and as well as a check-in system with the med tech if exiting or entering the neighborhood floor. Person responsible: Executive Director
22VAC40-73-1140-E
Based on direct observation and staff interview, the facility failed to ensure that the staff outside of the administrator and direct care staff completed two hours of training on the nature and needs of residents with cognitive impairments relevant to the population in care.
Evidence
  1. Staff 1 was hired on 02/02/2026 to the activities deoparrtment. Staff 1’s record did not contain two hours of training on the nature and needs of residents with cognitive impairments relevant to the population in care within the first month of employment.
  2. Staff 3 was originally hired on 01/29/2025 as a server but transferred to activities on 08/26/2025. Staff 2’s record contained training titled Dementia Training dated 02/05/2026; however, the number of hours was not listed.
  3. During the onsite preliminary exit meeting with two LI’s on 03/11/2026, Staff 4, Staff 5, and Staff 6 acknowledged that Staff 1’s training had not been completed during the first month of hire, and that Staff 3’s training hours were not listed and able to document that two hours were received within the first month of employment.
Plan of correction
What action has been done to correct? Scheduling all Memory Care staff not already compliant for two hours of dementia/cognitive training in Relias. How will recurrence be prevented? Our new employee hire orientation will have two hours of training on the nature and needs of residents with cognitive impairments due to dementia. Person responsible: Business Office Director
22VAC40-73-870-B
Based on direct observation and staff interview, the facility failed to ensure that the building was free of foul and musty odors.
Evidence
  1. During an onsite tour of the facility on 03/11/2026, two LI’s observed a foul odor on the memory care unit hallway directly to the right of the hallway.
  2. During the onsite preliminary exit meeting with two LI’s on 03/11/2026, Staff 4, Staff 5, and Staff 6 acknowledged that the facility had a foul odor on the memory care hallway.
Plan of correction
What action has been done to correct? On 3/11/2026, nursing and housekeeping staff promptly collaborated to clean and sanitize a public area following a bowel incontinence incident involving a resident. How will recurrence be prevented? Memory Care team will receive in-service training focused on teamwork and prompt response to ensure the environment remains odor-free. Person responsible: Executive Director
22VAC40-73-870-A
Based on direct observation and staff interview, the facility failed to ensure the buildings and grounds were maintained in good repair.
Evidence
  1. During an onsite tour of the facility on 03/11/2026, two LI’s observed multiple areas of the floorboards peeling with what appeared to be water damage on the 2nd floor, safe, secure unit. In some areas, the paint leading up the corners from the floorboard was also peeling.
  2. In an interview with two LI’s on 03/11/2026, Staff 7 confirmed that the material on the floorboards was damaged due to the liquid used when needing to clean carpets.
  3. During the onsite preliminary exit meeting with two LI’s on 03/11/2026, Staff 4, Staff 5, and Staff 6 acknowledged that the building was not in good repair.
  4. Photo evidence obtained.
Plan of correction
What action has been done to correct? Vendor proposals for replacing the wooden cove base (where the wall meets the flooring) are being sought to resolve the bubbling of the wood and paint. How will recurrence be prevented? The material used for the wooden cove base replacement will be solid wood vs. a wood material. Person responsible: Director of Building Services
February 4, 2026Inspection10 violations
Inspection dates
02/04/2026, 02/05/2026
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 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Technical assistance
950, 610 990-C: Ensure resident emergency drills cover all applicable resident emergencies. Reviewed staff training requirements. Use of VDSS Direct Care Staff training recommended.
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: 02/04/2026 10:35 AM to 3:45 PM 02/05/2026 9:15 AM to 3:55 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: 108 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: 4 Number of interviews conducted with residents: 7 Number of interviews conducted with staff: 4 Observations by licensing inspector: Meals, Activities, and Medication Pass Additional Comments/Discussion: Please submit renewal application prior to expiration. 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. 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 Amanda “AJ” Velasco, Licensing Inspector at (703) 397 4587 or by email at amanda.velasco@dss.virginia.gov.
Violations
22VAC40-73-260-A
Based on staff record review and staff interview, the facility failed to ensure current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department was maintained for each staff member.
Evidence
  1. Staff 3 (Hired 01/06/2025), Staff 4 (Hired 10/31/2025), and Staff 5’s (Hired 11/17/2025) records did not contain current certification in first aid.
  2. In an interview with the LI on 02/04/2026, Staff 1 confirmed that Staff 3, Staff 4, and Staff 5 did not have current certification in first aid.
Plan of correction
What action has been done to correct? Staff 3, 4, and 5 have been promptly notified of the requirement to come into compliance with the first aid certification. How will recurrence be prevented? All direct care staff records will be audited. Anyone not in compliance will be notified to promptly come into compliance with the first aid certification. Person responsible: Wellness Director Due date: April 15, 2026
22VAC40-73-650-B
Based on resident record review and staff interview, the facility failed to ensure physician or other prescriber orders included the name of the resident, date of the order, the name of the drug, route, dosage, strength, how often the medication is to be given, and identify the diagnosis, condition, or indication for administration.
Evidence
  1. Resident 2’s record contained orders for the following three medications that do not include a diagnosis, condition, or indication for administration. a. Torsemide 20 MG Tablet: Take 1 tablet by mouth daily b. Lasix 40 MG Tablet: Take 1 tablet by mouth once daily. c. Mirtrazapine 15 MG: Take 1 tablet by mouth once at bedtime
  2. In an interview with the LI on 02/05/2026, Staff 1 confirmed that the orders did not contain the diagnosis, condition, or indication for administration.
Plan of correction
What action has been done to correct? Resident 2’s orders now contain a diagnosis, condition, and/or indication for administration relative to the three stated medications. How will recurrence be prevented? An audit will occur of resident physician/prescriber orders to ensure resident-ordered meds are in compliance with this standard. Any order out of compliance will be resolved. Person responsible: Wellness Director Due date: March 27, 2026
22VAC40-73-50-A
Based on resident record review and staff interview, the facility failed to ensure a disclosure statement, on the form developed by the department, was prepared and provided to the prospective resident and prospective resident's legal representative.
Evidence
  1. Resident 8’s (Admitted 12/17/2025) record contained a disclosure statement not on the approved form developed by the department.
  2. In an interview with the LI on 02/05/2026, Staff 1 confirmed that the disclosure form was not on the form developed by the department.
Plan of correction
What action has been done to correct? Resident/POA to be offered revised Tribute at One Loudoun Disclosure statement in compliance with the form developed by the department. How will recurrence be prevented? New Move-In packet now includes the revised Tribute at One Loudoun Disclosure statement now in compliance with the form developed by the department. Person responsible: Director of Sales and Marketing Due date: February 27, 2026
22VAC40-73-200-C
Based on staff record review and staff interview, the facility failed to ensure direct care staff met one of the requirements upon hire or within two months of employment.
Evidence
  1. Staff 3 was hired on 01/20/2025 as a direct care staff member. Staff 3’s record did not contain documentation of the required qualifications upon hire or within two months of employment.
  2. Staff 5 was hired on 10/31/2025 as a direct care staff member. Staff 5’s record did not contain documentation of the required qualifications upon hire or within two months of employment.
  3. In an interview with the LI on 02/04/2026, Staff 1 confirmed that Staff 3 and Staff 5 did not have the required qualifications upon hire or within two months of employment.
Plan of correction
What action has been done to correct? Staff 3 and 5 qualifications were reviewed immediately and addressed per the standards of 22VAC40-73-200-C. How will recurrence be prevented? All current direct care staff credentials will be audited. All direct care staff will meet the qualifications of 22VAC40-73-200-C. Person responsible: Executive Director Due date: March 27, 2026
22VAC40-73-680-I
Based on resident record review and staff interview, the facility failed to ensure the medication administration record (MAR) included all 13 required components listed in this subsection.
Evidence
  1. Resident 2’s record contains orders for Carvedilol 25 MG and Amlodipine 5 MG that require blood pressure and/or pulse monitoring prior to administration.
  2. Resident 2’s MAR does not contain blood pressure readings for 12/03/2025, 12/05/2025, 12/11/2025, 12/12/2025, and 12/14/2025.
  3. Staff 2 provided a printed list of vitals for November and December, dated as printed on 12/13/2025. The list has handwritten blood pressure and pulse numbers next to the empty boxes, including 12/03/2025, 12/05/2025, 12/11/2025 and 12/12/2025. Staff 2 stated that this information was provided to the family, but not entered in the MAR.
  4. In an interview with the LI on 03/05/2026, Staff 1 confirmed the MAR did not contain all 13 required components including specific indications for administering the drug.
Plan of correction
What action has been done to correct? The MAR for Resident 2 now contains all 13 required components including specific indications for administering the medication. How will recurrence be prevented? All resident MAR’s will be audited to ensure the presence of all 13 required components included. Person responsible: Wellness Director Due date: March 27, 2026
22VAC40-73-680-D
Based on resident record review and staff interview, the facility failed to ensure medication was administered in accordance with the physician or other prescribers’ instructions and consistent with the standards of practice approved by the Virginia Board of Nursing.
Evidence
  1. Resident 7’s record contains an order for Amlodipine Tab 2.5MG with parameters. The order reads “Take 1 tablet by mouth once daily for high blood pressure **Hold for SBP less than 120 and/or DBP less than 70**.”
  2. Resident 7’s Medication Administration Record (MAR) for December of 2025 and January of 2026 indicate that Resident 7’s blood pressure and pulse were not taken on the following dates: a. 12/02/2025-12/04/2025 b. 12/06/2025-12/14/2025 c. 12/22/2025-12/16/2025 d. 12/30/2025-12/31/2025 e. 01/01/2026-01/09/2026 f. 01/12/2026-01/19/2026 g. 01/21/2026-01/22/2026 h. 01/25/2026-01/31/2026
  3. Resident 7’s December 2025 MAR shows that Amlodipine 2.5 mg was administered daily throughout the month, except on 12/17/2025 and 12/18/2025, without obtaining blood pressure readings prior to administration as indicated in the physician’s order.
  4. Resident 7’s MAR for January 2026 shows that Amlodipine 2.5 mg was administered daily throughout the month except for 01/14/2026, 01/20/2026, and 01/25/2026-01/26/2026, without obtaining blood pressure readings prior to administration as indicated in the physician’s order.
  5. In an interview with the LI on 02/05/2026, Staff 1 confirmed that Resident 7’s medication was not administered in accordance with physician or prescriber’s orders.
Plan of correction
What action has been done to correct? Medication regimen and medication record for Dec 2025 and January 2026 reviewed with Resident 7 and POA. Physician notified; no new orders. How will recurrence be prevented? Medication aide competency tests completed on all current medication aides. A medication refresher course was completed with applicable staff on February 19, 2026. Person responsible: Wellness Director Due date: March 27, 2026
22VAC40-73-720-A
Based on resident record review and staff interview, the facility failed to ensure a valid written order has been issued by the resident's attending physician and the written order is included in the individualized service plan (ISP) in order to carry out a Do Not Resuscitate (DNR) order.
Evidence
  1. Resident 3’s ISP, dated 01/01/2026, did not include their DNR orders. Resident 3’s DNR orders were dated 10/03/2023.
  2. Resident 5’s ISP, dated 08/10/2025, did not include their DNR orders. Resident 5’s DNR orders were dated 06/19/2025.
  3. In an interview with the LI on 02/05/2026, Staff 1 confirmed that the ISP’s for Resident 3 and Resident 5 did not include the DNR orders.
Plan of correction
What action has been done to correct? Resident 3 and 5 ISP’s now include the DNR order listed. How will recurrence be prevented? An audit of all current resident ISP’s will be completed to ensure any applicable DNR order is included per this standard. Any ISP out of compliance will be resolved. Person responsible: Wellness Director Due date: March 27, 2026
22VAC40-73-450-E
Based on resident record review and staff interview, the facility failed to ensure the individualized service plan (ISP) was signed and dated by the licensee, administrator, or his designee and by the resident or his legal representative.
Evidence
  1. Resident 3’s ISP, dated 01/01/2026, was not signed by the licensee, administrator, or his designee and by Resident 3 or their legal representative.
  2. Resident 2’s ISP, dated 09/23/2025, was not signed by the licensee, administrator, or his designee and by Resident 2 or their legal representative.
  3. Resident 5’s ISP, dated 08/10/2025, was not signed by the licensee, administrator or his designee, and by Resident 5 or their legal representative.
  4. In an interview with the LI on 02/05/2026, Staff 1 confirmed that the ISP for Resident 3, Resident 2, and Resident 5 was not signed by the licensee, administrator or his designee and the resident or their legal representative.
Plan of correction
What action has been done to correct? Resident 2, 3, and 5 ISP’s were signed per the standard. How will recurrence be prevented? An audit of all current resident ISP’s will be completed to ensure signatures are present per this standard. Any ISP out of compliance will be resolved. Person responsible: Wellness Director Due date: March 27, 2026
22VAC40-73-210-B
Based on staff record review and staff interview, the facility failed to ensure all direct care staff attended at least 18 hours of training annually.
Evidence
  1. Staff 6 was hired on 01/20/2025 as a direct care staff member. Staff 6’s record contained 8.75 hours of the required annul training.
  2. In an interview with the LI on 02/04/2026, Staff 1 confirmed that Staff 6 did not have the required 18 hours of training annually.
Plan of correction
What action has been done to correct? Staff 6 was promptly notified of the requirement to come into compliance with the mandatory 18 hours of annual training. How will recurrence be prevented? All direct care staff training records will be audited. Anyone not in compliance will be notified to promptly come into compliance with the mandatory 18 hours of annual training. Person responsible: Wellness Director Due date: March 27, 2026
22VAC40-73-870-G
Based on direct observation and staff interview, the facility failed to ensure grounds were properly maintained to include mowing of grass and removal of snow or ice.
Evidence
  1. On 02/04/2026, the LI observed both the front patio area off the bistro and the memory care patio (2nd floor) off of the kitchen to be covered in snow and ice.
  2. Photo evidence obtained.
  3. In an interview with the LI on 02/04/2026, Staff 7 confirmed that the snow and ice had not been properly removed from the grounds.
Plan of correction
What action has been done to correct? In addition to the proper removal of snow and ice from the main parking lot and sidewalks, removal of snow and ice occurred immediately from both the front patio area off the bistro and the memory care patio (2nd floor) off of the kitchen. How will recurrence be prevented? All patios are now included as critical areas for snow and ice removal equal in priority with the parking lot and sidewalks. Person responsible: Director of Building Services Due date: February 5, 2026
November 13, 2025Inspection3 violations
Inspection dates
11/13/2025
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS
Technical assistance
Ensure adequate resident supervision w/ visitors that may trigger behaviors.
Comments
Type of inspection: Monitoring A self-reported incident was received by VDSS Division of Licensing on 10/28/2025 regarding allegations in the area(s) of: 1. Resident Accommodations and Related Provisions Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/13/2025 9:30 AM to 12:30 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: 97 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 Observations by licensing inspector: Safe, Secure Unit. Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-reported incident 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 Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Violations
22VAC40-73-930-D
Based on resident record review and staff interview, the facility failed to ensure that the individualized service plan included an inability to use the signaling device and daily rounds made by care staff were documented.
Evidence
  1. In an interview with two LI’s, Staff 1 stated that Resident 1 resided in the safe security unit and did not have access to and could not use a signaling device.
  2. Resident 1’s ISP, dated 11/04/2025, did not include the inability to use the signaling device.
  3. Resident 1’s record did not contain documentation of rounds once the resident has gone to bed each evening until the resident has arisen each morning.
  4. In an interview with two LI’s, Staff 1 confirmed that Resident 1’s record did not contained a record of documentation of rounds.
Plan of correction
What action has been done to correct? Updated Resident 1 individualized service plan to include the inability to use the signaling device. Implemented daily documented rounds via manual log for resident involved in this self-reported incident. Educated direct care staff associated with this resident incident. How will recurrence be prevented? Update like resident individualized service plans as applicable to include the inability to use the signaling device. Implemented daily documented rounds via manual log for all applicable residents with an inability to use the signaling device, in addition to any other services. Educated all direct care staff on new daily rounds and associated documentation. Person responsible: Wellness Director.
22VAC40-73-460-D
Based on resident record review and staff interview, the facility failed to ensure supervision of specialized needs such as prevention of falls.
Evidence
  1. On 10/28/2025, the facility reported injuries of unknown origin sustained by Resident 1 on 10/27/2025.
  2. Resident 1’s record contained an after-visit summary, dated 10/29/2025, stated the reason for the visit was “fall” and “head injury” with a diagnosis of fall, facial hematoma, severe dementia, renal insufficiency, and hyperglycemia.
  3. Staff 1 provided a photo of Resident 1’s injury which included bruising on both eyes and redness, bruising, and a bump in the center of Resident 1’s forehead.
  4. Upon review of Staff 2 and Staff 3’s written statements obtained between 10/27/2025 and 10/31/2025, it was determined that Staff 2 noticed the injury around lunchtime, while Staff 3 noticed the injury around 4PM. Additionally, Staff 3’s statement indicated that the day shift (7 AM to 3 PM) including Staff 2, did not indicate any observations.
  5. Resident 1’s ISP, dated 11/04/2025, indicates that Resident 1 has a high fall risk potential, and that the resident is unable to use the emergency response system stating there is a possible need for frequent monitoring.
  6. In an interview with two LI’s, Staff 1 stated that they could not determine a cause of Resident 1’s injuries indicating insufficient supervision despite Resident 1’s need for frequent monitoring and high fall risk potential.
Plan of correction
What action has been done to correct? Implemented daily documented rounds via manual log for resident involved in this self-reported incident. Educated direct care staff associated with this resident incident. How will recurrence be prevented? Implemented daily documented rounds via manual log for all applicable residents with an inability to use the signaling device, in addition to any other services. Educated all direct care staff on new daily rounds with associated documentation. Person responsible: Wellness Director.
22VAC40-73-40-A
Based on resident record review and staff interview, the facility failed to ensure compliance with the facility’s own policies and procedures.
Evidence
  1. On 10/28/2025, the facility reported injuries of unknown origin sustained by Resident 1 on 10/27/2025.
  2. After reviewing statements from Staff 2 and Staff 3, it was determined that Staff 2 noticed the injury around lunchtime, while Staff 3 noticed the injury around 4PM. Staff 3’s statement indicated that the day shift, including Staff 2, did not notice any observations.
  3. The facility’s “Change in Condition” policy states that staff will report any observations that indicate a possible change of condition the WD or ED.
  4. A timeline of the incident was provided by Staff 1. The timeline stated that Staff 2 failed to report a change in condition.
  5. In an interview with two LI’s, Staff 1 confirmed that Staff 2 did not report a change in condition, according to the facility’s own policy.
Plan of correction
What action has been done to correct? Education on resident change of condition policy occurred with direct care staff associated with resident incident. How will recurrence be prevented? All direct care staff re-educated on resident change of condition policy. Person responsible: Executive Director
November 13, 2025Complaint survey0 violations
Inspection dates
11/13/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 10/30/2025 regarding allegations in the area(s) of: 1. Resident Accommodations and Related Provisions Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/13/2025 12:30 PM to 2:00 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: 97 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Safe, Secure Unit. Additional Comments/Discussion: Staff member mentioned in complaints could not be identified. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
July 28, 2025Complaint survey3 violations
Inspection dates
07/28/2025
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 EMERGENCY PREPAREDNES22VAC40-80 COMPLAINT INVESTIGATIONS
Technical assistance
280-B – Written Staffing Plan: Ensure AL specific staffing numbers are included in the plan.
Comments
Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 07/04/2025 regarding allegations in the area(s) of: 1. Staffing and Supervision 2. Resident Care and Related Services 3. Resident Accommodations and Related Provisions Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/28/2025 12:10 PM 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: 99 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the complaint of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Violations
22VAC40-73-460-B
Based on resident record review and staff interview, the facility failed to ensure care and provision and service delivery was resident centered to the maximum extent possible and included prompt response by staff to resident needs.
Evidence
  1. In an interview with the LI on 07/28/2025, Resident 1 stated that Resident 1 had experienced long call bell times, including waiting over an hour on the morning of 07/28/2025.
  2. In an interview with the LI on 07/28/2025, Staff 1 stated that the expected response time is 15 minutes.
  3. A Resident Event Report was reviewed for Resident 1’s call bell times for the months of June 2025 and July 2025. The report indicated the longest response time was 238 minutes and average response time was 22 minutes. In the report, there were 27 instances that were over 20 minutes. Of those 27 instances, there were 9 instances over an hour, including a 62-minute response time on 07/28/2025 at 6:51 AM.
  4. In an interview with the LI on 07/28/2025, Staff 1 and Staff 2 acknowledged that the facility failed to ensure prompt response by staff to resident needs.
Plan of correction
What has been done to correct? Education on prompt call bell response time occurred to all direct care staff. How will recurrence be prevented? The Tribute at One Loudoun call bell system is being upgraded the week of August 25. With this upgrade, call bell alerts will go directly to each direct care staff’s smartphone, replacing the previous two-step system in which announcements were relayed to staff through walkie-talkies. Person responsible: Executive Director Due date: September 19, 2025
22VAC40-73-280-A
Based on facility document review and staff interview, the facility failed to ensure that there was staff sufficient in numbers to provide services to attain and maintain the physical, mental, and psychosocial well-being of each resident and to ensure compliance with this chapter.
Evidence
  1. In an interview with the LI on 07/28/2025, Staff 1 provided a copy of the written staffing plan and scheduling template for Assisted Living Staff for the LI to review. Staff 1 stated that Shift 1 (7AM to 3PM) and Shift 2 (3PM to 11PM) required four (4) direct care staff members and Shift 3 (11PM to 7AM) required three 3 direct care staff members.
  2. After a review of the Schedule and the Care Staff Assignments for May 2025 and June of 2025. There were 30 shifts that did not have the required number of staff members. The dates are as follows: a. Shift 1 – 05/18/2205, 06/10/2025, 06/15/2025, 06/23/2025, 06/25/2025, 06/29/2025 b. Shift 2 – 05/04/2025, 05/05/2025, 05/09/2025, 05/12/2025, 05/13/2025, 05/18/2025, 05/21/2025, 05/24/2025, 05/25/2025, 06/15/2025, 06/22/2025, 06/28/2025. c. Shift 3 – 05/04/2025, 05/05/2025, 05/09/2025, 05/10/2025, 05/18/2025, 05/21/2025, 05/24/2025, 06/10/2025, 06/15/2025, 06/22/2025, 06/23/2025, 06/25/2025
  3. In an interview with the LI on 07/28/2025, Staff 1 and Staff 2 acknowledged that there were not sufficient staff in numbers to provide services to attain and maintain the physical, mental, and psychosocial well-being of each resident and to ensure compliance with this chapter.
Plan of correction
What has been done to correct? Additional staff have been hired in anticipation of increased census and to ensure continuity of care and adequate coverage. How will recurrence be prevented? Proactive recruitment efforts are now in place. Wellness Director retrained on Virginia regulations for staffing requirements. In addition, revised staffing plans now include the assignment of other nursing clinical team members and nursing leadership (back-up staffing plan) to designated direct care areas as needed, on an episodic basis, to ensure that residents’ needs are consistently met. Person responsible: Wellness Director. Due date: September 19, 2025
22VAC40-73-680-D
Based on resident record review and staff interview, the facility failed to ensure that medications were administered in accordance with the physician’s or other prescriber’s orders.
Evidence
  1. Resident 1’s record contains signed physician orders Amiodarone Tab 200 MG, started 03/04/2025 that state the following, “Take 1 Tablet by Mouth once daily for AFIB. **HOLD FOR SBO LESS THAN 110 or HR LESS THAN 60.”
  2. Resident 1’s June 2025 Medication Administration Record (MAR) indicates that the resident’s HR was less than 60, but the medication was still administered on 06/02/2025, 06/11/2025, 06/20/2025, and 06/29/2025.
  3. Resident 1’s record contains signed physician orders Amlodipine Tab 5 MG, started 03/04/2025, that state the following, “Take 1 tablet by mouth once daily for hypertension. **HOLD FOR SBP < 110 and HR LESS THAN 60**.”
  4. Resident 1’s June 2025 MAR indicates that the resident’s HR was greater than 60 and the SBP was greater than 110, but Amlodipine was withheld on 06/08/2025 and 06/28/2025.
  5. Resident 1’s record contains signed physician orders Metoprolol TAR Tab 25 MG, started 04/19/2025, that state the following, “Take 1 tablet by mouth twice daily for hypertension. **HOLD FOR SBP LESS THAN 110 or PULSE LESS THAN 60…”
  6. Resident 1’s June 2025 MAR indicates that the resident’s pulse was less than 60, but Metroprolol was still administered on 17 dates in June of 2025.
  7. Resident 1’s July 2025 MAR indicates that the resident’s pulse was less than 60, but Metoprolol was still administered on 12 dates in July of 2025. There was one additional date in July of 2025 in which Resident 1’s SBP was less than 110 and the medication was still administered.
  8. In an interview with the LI on 07/28/2025, Staff 1 and Staff 2 confirmed that the medication listed above was not administered according to physician orders.
Plan of correction
What has been done to correct? Residents’ antihypertensive medication orders have been clarified to ensure compliance by facility staff. How will recurrence be prevented? A medication administration competency will be completed on all registered medication aides. Person responsible: Wellness Director Due date: September 19, 2025
July 28, 2025Complaint survey1 violation
Inspection dates
07/28/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 06/27/2025 regarding allegations in the area(s) of: 1. Resident Care and Related Services 2. Resident Accommodations and Related Provisions Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/28/2025 10:15 AM to 12:10 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: 8 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: 3 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. However, violation(s) not related to the complaint but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Violations
22VAC40-73-200-C
Based on staff record review and staff interview, the facility failed to ensure that direct care staff met one of the requirements of this subsection at hire or within two months of employment.
Evidence
  1. Staff 3 was hired as a direct care staff member on 05/16/2025.
  2. Staff 3’s record contains a Personal Care Aide (PCA) training certificate dated 02/20/2021 from [Collateral Contact 1]. The facility was unable to provide documentation Collateral Contact 1 is an approved DMAS training organization.
  3. In an interview with the LI on 07/28/2025, Staff 1 and 2 acknowledged that Staff 3 did not meet one of the requirements of the subsection at hire or within two months of employment.
Plan of correction
What has been done to correct? The staff member will be removed from the schedule until their qualifications meet 22VAC40-73-200. How will recurrence be prevented? All current direct care staff credentials will be audited. All direct care staff will meet the qualifications of 22VAC40-73-200. Person responsible: Wellness Director. Due date: September 19, 2025
June 2, 2025Complaint survey3 violations
Inspection dates
06/02/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-80 COMPLAINT INVESTIGATION
Technical assistance
720-A: Ensure DNR orders are included on the ISP. 680-I: Ensure MAR’s include all required information.
Comments
Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 05/02/2025 regarding allegations in the area(s) of: Resident Accommodations and Related Provisions Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/02/2025 1:55 PM to 4:10 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: 111 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 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: N/A Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the complaint of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Violations
22VAC40-73-680-E
Based on resident record review and staff interview, the facility failed to ensure that treatments ordered by a physician or other prescriber shall be provided in accordance with the physician’s or other prescriber’s orders.
Evidence
  1. Resident 1’s, admitted 05/28/2024, record contained an order dated 04/07/2025 for blood work including “CBC, CMP, Vit D, Vi B12, Hemogloin [sic] A1C.”
  2. Resident 1’s chart contained another order dated 04/11/2025 for the same bloodwork, with a handwritten note at the bottom of the page that stated, “Resident refused 2nd time 05/23/2025.”
  3. In an interview with the LI on 06/02/2025, Staff 1 was unable to provide documentation bloodwork for Resident 1 was completed as ordered.
  4. Resident 1’s record contains a signed physician order summary dated 01/29/2025. The physician order summary contains the following related orders: a. Blood Sugar Check (Started 08/30/2024): “Check and record bs before meals and at bedtime for DM”
  5. Resident 1’s MAR for March 2025 indicates a blood sugar check was not completed 49 times out of the scheduled 93 times.
  6. In an interview with the LI on 06/02/2025, Staff 1 confirmed that Resident 1’s treatment orders for a blood sugar check were not provided in accordance with physician orders.
Plan of correction
What Has Been Done to Correct? Resident no longer resides in community. How Will Recurrence Be Prevented? HWD will review new orders within 24 hours to ensure accuracy. HWD will promptly notify provider when there is a discrepancy in medication orders and request clarification. Person Responsible: Health and Wellness Director Due Date: Initial completion date – 06/11/2025 Ongoing review
22VAC40-73-680-D
Based on resident record review and staff interview, the facility failed to ensure that medications were administered in accordance with the physician’s or other prescriber’s orders.
Evidence
  1. Resident 1’s record contains a signed physician order summary dated 01/29/2025. The physician order summary contains the following related orders: a. Candesartan Cilexetil (started 12/12/2024): “Take one tablet by mouth every morning for hypertension. -Hold if blood pressure is less than 110/60” b. Natglinide (Started 12/12/2024): “Take one tablet by mouth 3 times a day before meals.”
  2. Resident 1’s MAR for April 2025 indicates Candesartan was not administered on 04/23/2025 when Resident 1’s blood pressure was 104/97 but was administered on 04/22/2025 when the Resident’s blood pressure was 90/80.
  3. Resident 1’s MAR for May 2025 indicates that the Candesartan was not administered on 05/06/2025, when Resident 1’s blood pressure was 107/64.
  4. On 05/13/2025, the facility submitted an incident report that confirms Nateglinide was administered after Resident 1’s lunch.
  5. In an interview with the LI on 06/02/2025, Staff 1 confirmed that medication, Candesartan and Nateglinide, for Resident 1 was not administered according to physician orders.
Plan of correction
What Has Been Done to Correct? Resident no longer resides in community. How Will Recurrence Be Prevented? HWD will re-educate mediation aids on proper medication administration. HWD will preform random medication administration checks weekly to ensure proper administration and documentation. All administered medications will be administered one (1) hour before and up to one (1) hour after the prescribed time to accommodate the resident’s schedule unless otherwise indicated by the resident’s physician. Person Responsible: Health and Wellness Director Due Date: Initial completion date – 06/11/2025 Ongoing review
22VAC40-73-450-F
Based on resident record review and staff interview, the facility failed to ensure that the comprehensive individualized service plan (ISP) was updated at least once every 12 months.
Evidence
  1. Resident 1’s record contains an ISP, and Uniform Assessment Instrument (UAI) dated 04/01/2025. The ISP states, “Description of the needs is based upon the UAI…” and does not contain goals based on the UAI. The following discrepancies are noted: a. The UAI indicates that Resident 1 needs mechanical help and physical assistance with bathing. The ISP does not include mechanical help for bathing. b. The UAI indicates that Resident 1 needs mechanical help and physical assistance with toileting. The ISP does not include mechanical help for toileting. c. The UAI indicates that Resident 1 is incontinent less than weekly with bowel and bladder. The ISP does not include any goals for Incontinence. d. The UAI indicates the resident needs mechanical assistance and supervision with walking. The ISP does not include a goal for walking. Under Mobility/ Ambulation, supervision is not listed.
  2. In an interview with the LI on 05/28/2025, Staff 1 acknowledged that the annual ISP did not include a description of services needed based upon the UAI.
Plan of correction
What Has Been Done to Correct? Residents no longer resides in community. How Will Recurrence Be Prevented? HWD will ensure all resident service plans meet the needs of the individual and are accurately reflected. Those needs will be mirrored on the individualized service plan and the uniform assessment instrument. HWD will update residents UAI and ISP as needed to reflect changes as needed. Person Responsible: Health and Wellness Director Due Date: Current resident records reviewed and updated to reflect current care needs. Initial review completion date – 06/25/2025 Ongoing review and update to reflect residents current status / needs
June 2, 2025Inspection1 violation
Inspection dates
06/02/2025
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES
Technical assistance
Reviewed options for plan of correction including license modification request.
Comments
Type of inspection: Monitoring Date: 06/03/2025 1:45 PM to 1:55 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of resident records reviewed: N/A Number of staff records reviewed: N/A Number of interviews conducted with residents: N/A Number of interviews conducted with staff: 2 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered 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 Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at amanda.velasco@dss.virginia.gov.
Violations
22VAC40-73-45-A
Based on the information gathered, the facility failed to have the minimum amount of liability insurance coverage required to be maintained by an assisted living facility.
Evidence
  1. Upon request, the facility did not provide documentation of the insurance including the minimum required liability insurance coverage.
  2. During an interview on 06/03/2025, Staff 1 acknowledged the facility did not have the appropriate insurance coverage.
Plan of correction
Not published by VDSS.
May 28, 2025Inspection5 violations
Inspection dates
05/28/2025
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 EMERGENCY PREPAREDNESS
Technical assistance
Reviewed staff training requirements.
Comments
Type of inspection: Monitoring A self-reported incident was received by VDSS Division of Licensing on 04/04/2025 regarding allegations in the area(s) of: 1. Resident Care and Related Services Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/28/2025 10:00 AM to 1:18 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: 110 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: 0 Number of interviews conducted with staff: 5 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-reported incident 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 Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Violations
22VAC40-73-325-C
Based on resident record review and staff interview, the facility failed to ensure that documentation of an analysis of the fall and interventions that were initiated to prevent or reduce the risk of subsequent falls was completed when a resident falls.
Evidence
  1. Resident 1’s progress notes indicate Resident 1 had a fall on 04/03/2025, 04/02/2025, 03/20/2025, and 03/16/2025. Resident 1’s record did not show documentation of analysis of the fall and interventions that were initiated to prevent or reduce the risk of subsequent falls.
  2. In an interview with the LI on 05/28/2025, Staff 1 confirmed that documentation of the analysis of the fall and interventions that were initiated to prevent or reduce the risk of subsequent falls was not completed.
Plan of correction
All residents are evaluated for fall risk and their Individualized Service Plan will be developed/updated accordingly. Should a resident experience a fall, staff will provide immediate care and follow through with service planning. 6/11/2025 and ongoing The HWD or designee who completed the Post – Fall Assessment may select interventions to be implemented and will communicate the implementations to care staff until a full-Service Plan update can be completed 6/11/2025 and ongoing
22VAC40-73-460-F
Based on resident record review, collateral contact interview, and staff interview, the facility failed to ensure that the legal representative was notified of any incident of a resident falling whether it results in injury.
Evidence
  1. Resident 1’s record contained an internal occurrence report, dated 04/03/2025, that checked the “no” box next to if the family member/ responsible party was notified.
  2. In an interview with the LI on 05/28/2025, Collateral Contact 1 confirmed they were not aware of the incident on 04/03/2025.
  3. In an interview with the LI on 05/28/2025, Staff 1 acknowledged that Collateral Contact 1 was not notified of Resident 1’s fall on 04/03/2025.
Plan of correction
The Health & Wellness Director or designee will notify the residents’ family and/or responsible party immediately, providing information about the Community’s response to the resident’s fall. Staff has been re-educated on fall and incident protocols. 6/11/2025 and ongoing The Health & Wellness Director or designee on each shift will monitor the resident and make a brief narrative charting entry for 72 hours follow a resident fall updating POA and or medical provider of any changes as needed. ED will audit fall interventions as needed to ensure compliance. 6/11/2025 and ongoing The Health & Wellness Director or designee will complete a fall analysis of any resident who meets the criteria of assisted living fall upon admission and post fall. 6/11/2025 and ongoing The Health & Wellness Director or Designee will ensure the residents’ Individualized Service Plan is updated as needed with interventions following a fall. 6/11/2025 and ongoing
22VAC40-73-190-C
Based on staff record review and staff interview, the facility failed to ensure that staff members received training on their duties and responsibilities prior to being placed in charge.
Evidence
  1. In an incident report submitted to the LI on 04/04/2025 by Staff 1, Staff 3 is indicated as the person in charge at the time of the incident.
  2. Staff 3’s record did not contain training documentation that they were informed of their duties and responsibilities prior to being placed in charge.
  3. In an interview with the LI on 05/28/2025, Staff 1 confirmed that Staff 3’s did not have training on their duties and responsibilities prior to being placed in charge.
Plan of correction
The specific duties and responsibilities of the designated direct care staff member in charge shall be determined by the administrator. 6/11/2025 and ongoing Prior to being placed in charge, the staff member shall be informed of and receive training on his/her duties and responsibilities and be provided with written documentation of such duties and responsibilities. 6/11/2025 and ongoing The staff member in charge shall be capable of protecting the physical and mental well-being of the residents. 6/11/2025 and ongoing The administrator or designee shall ensure that the staff member in charge is prepared to carry out his duties and responsibilities and respond appropriately in case of an emergency. 6/11/2025 and ongoing
22VAC40-73-460-A
Based on resident record review and staff interview, the facility failed to assume general responsibility for the health, safety, and well-being of the resident.
Evidence
  1. On 04/04/2025, Staff 1 submitted an incident report to the licensing inspector via email that stated “…The Med tech and night staff were unable to get resident up from floor. Covered him up with a blanket and provided pillow until morning staff came in to assist with getting him up.” The date of the incident was 04/03/2025.
  2. In an interview with the LI on 05/28/2025, Staff 1 acknowledged that that they did not take responsibility for the health, safety, and well-being of the resident.
Plan of correction
ED, HWD, and or designee will assume general responsibility for the health, safety, and well-being of all residents. 6/11/2025 and ongoing ED, HWD, and or designee will ensure care provision and service delivery shall be resident centered to the maximum extent possible and to include personalization of resident’s care and services tailored to the resident’s needs. 6/11/2025 and ongoing HWD will regularly review each resident for changes in physical, mental, emotional, and social functioning and update care plan to reflect any changes. Care plan updates will be communicated to staff through care stream. 6/11/2025 and ongoing HWD has updated all resident care plans to reflect the current level of care. HWD will ensure the residents’ Individualized Service Plan will be updated or amended to reflect any change in care needs. Staff will have access to all changes via care streams. 6/11/2025 and ongoing Notification and acknowledgement of residents’ rights will be reviewed by residents, staff, and family members upon arrival and annually. All staff have been re-educated on resident rights. 6/11/2025 and ongoing
22VAC40-73-280-B
Based on facility document review and staff interview, the facility failed to ensure a written staffing plan that specifies the number and type of direct care staff was maintained.
Evidence
  1. On 05/28/2025, the LI requested a copy of the written staffing plan. Staff 1 provided the staffing policy dated 06/08/2021.
  2. In an interview with the LI on 05/28/2025, Staff 2 was unable to provide the facility's updated written staffing plan consistent with the standard during the onsite visit on 05/28/2025.
Plan of correction
The community will maintain a staffing plan that meets the needs and acuity of care levels for our residents. ED will review the staffing plan to ensure compliance. 6/11/2025 and ongoing Communities with Memory Care secured areas will provide additional care staff as outlined in state regulations. 6/11/2025 and ongoing HWD will review the schedule, care needs, and staffing to ensure adequate staffing daily. The ED will review the same weekly to ensure community is following state regulations and company policy to determine staffing needs for the community on a regular basis. 6/11/2025 and ongoing
May 28, 2025Complaint survey2 violations
Inspection dates
05/28/2025
Areas reviewed
222VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-80 COMPLAINT INVESTIGATION
Technical assistance
22VAC40-73-460E: Ensure appropriate assistance when observation reveals unmet needs. 22VAC40-73-460B: Ensure prompt response to resident needs as appropriate to the circumstances. 22VAC40-73-530C: Ensure resident’s have access to their personal rooms.
Comments
Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 05/02/2025 regarding allegations in the area(s) of: 1. Administration and Administrative Services 2. Personnel 3. Staffing and Supervision 4. Resident Care and Related Services 5. Resident Accommodations and Related Provisions Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/28/2025 1:20 PM to 7:45 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: 110 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: 2 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 5 Observations by licensing inspector: Resident rooms Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the complaint of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Violations
22VAC40-73-660-A
Based on direct observation and staff interview, the facility failed to ensure that the storage area for medication and dietary supplements was locked.
Evidence
  1. On 05/28/2025, the LI observed an unlocked medication cart on the 3rd floor.
  2. In an interview with two LI’s on 05/28/2025, Staff 1 and 2 confirmed it was Cart 1 on the 3rd floor. Staff 1 acknowledged that the cart was unlocked.
  3. Photo evidence obtained.
Plan of correction
1) ED. HWD, or designee will ensure medications will be stored in a manner that ensures the maintenance of the medication’s integrity and safety of all residents residing in the Community. 6/6/2025 and ongoing 2) The storage area shall be locked when not in use and or attended. 6/6/2025 and ongoing 3) The individual responsible for medication administration shall always keep the keys to the storage area on his person. 6/6/2025 and ongoing 4) A medicine cabinet, container, or compartment shall be used for storage of medications and dietary supplements prescribed for residents when such medications and dietary supplements are administered by the facility. Medications shall be stored in a manner consistent with current standards of practice. 6/6/2025 and ongoing 5) Schedule II drugs and any other drugs subject to misuse must be kept in a separate locked storage compartment. 6/6/2025 and ongoing 6) ED, HWD, or designee will complete frequent spot checks to ensure the proper storage of all medications and dietary supplements. 6/6/2025 and ongoing
22VAC40-73-270-1
Based on staff record review and staff interview, the facility failed to ensure that direct care staff were trained in methods of dealing with residents who have a history of aggressive behavior prior to being involved in the care of such residents.
Evidence
  1. Resident 1’s, admitted 06/20/2024, record contained progress notes that detail two incidents of aggression with residents and staff members on 02/09/2025 and 02/14/2025.
  2. Resident 2’s UAI, dated 04/20/2024, listed Resident 2’s behavior as “Abusive/Aggressive/Disruptive – Less than Weekly” with a comment typed under “Type of inappropriate behavior” that states “Inappropriate touching, comments/ personal space”.
  3. Resident 1 and Resident 2’s progress notes indicate an altercation between Resident 1 and Resident 2 occurred on 02/20/2025.
  4. Upon review of the schedule for 02/09/2025 through 02/22/2025, Staff 5 and Staff 6 were the scheduled direct care staff for 02/20/2025.
  5. Staff 5’s, hired 10/06/2024, record did not contain any training in methods of dealing with residents who had aggressive behavior prior to providing care for Resident 1 and Resident 2.
  6. Staff 6’s, hired 09/16/2024, record did not contain any training in methods of dealing with residents who had aggressive behavior prior to providing care for Resident 1 and Resident 2.
  7. In an interview with the LI on 05/28/2025, Staff 1 acknowledged that Staff 5 and Staff 6 did not have any training prior to providing care residents who had aggressive behavior prior to providing care for Resident 1 and Resident 2.
Plan of correction
1. All care staff, including medication staff will be trained in accordance with state regulations Upon hire and annually 2. BOD, ED, or designee will ensure staff have appropriate training upon hire and annually. 7/15/2025 and quarterly 3. BOD, ED, or designee will monitor training by maintaining a training tracker to be reviewed by the ED and BOD quarterly. 7/15/2025 and quarterly 4. HWD will retrain current associates will be retrained on aggressive behaviors in residents and how to address those behaviors 6/11/2025 and annually
March 20, 2025Inspection13 violations
Inspection dates
03/20/2025
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 IMPAIRMENTSARTICLE 1 – SUBJECTIVITY63.2- (1) GENERAL PROVISIONS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE
Technical assistance
Resident Records – Access by Residents and/or Legal Representatives
Comments
Type of inspection: Renewal Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03/20/2025 8:15 AM to 6:00 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 6 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 0 Observations by licensing inspector: Medication Pass, Meals, and Activities on Both Assisted Living and Memory Care Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Violations
22VAC40-73-600-B
Based on direct observation and staff interview, the facility failed to ensure that there was at least four hours between breakfast and lunch meals.
Evidence
  1. During a tour of the facility on 03/20/2025, the LI observed breakfast being served in the memory care unit at 9:30 AM.
  2. The scheduled mealtimes for the Safe, Secure Unit are 830-10 AM, 12 noon to 130 PM, 5pm to 630 PM.
  3. In an interview with the LI, Staff 2 stated that residents were sat for lunch around 12:00 PM and served around 12:30 PM. Staff 2 confirmed that there was less than 4 hours between breakfast and lunch.
Plan of correction
Memory Care mealtime adjusted to 8:30 12:30 and 5:30 Memory Care Director will monitor to ensure that mealtimes are adhered. Memory Care Director or designee will ensure residents are seated and served at designated times. Completed by 4/30/25
22VAC40-73-530-C
Based on direct observation, resident record review and staff interview, the facility failed to ensure that residents had freedom of movement between common areas and to their personal spaces.
Evidence
  1. During a tour of the Safe, Secure Unit on 03/20/2025, the LI observed 10 locked rooms while the residents were eating breakfast.
  2. In an interview with the LI, Staff 15 confirmed that all the resident doors remain locked when the residents are not in the room. Staff 15 stated that not all residents have a Fob (bracelet) to access the room. Staff 15 confirmed that residents are required to ask for access to their room.
  3. In an interview with the LI, Staff 1 confirmed the doors on the Safe, Secure unit remain locked and select residents have Fob (bracelet) access to their rooms.
Plan of correction
Memory Care Director will ensure residents have freedom of movement in the common area and personal space. Residents who have been evaluated as able to unlock room doors will be given a fob for access. Memory Care Director will audit /assess quarterly to ensure continued ability of residents to access room on own with fob. All other resident rooms will be unlocked for resident accessibility to those who are unable to use a fob. Completed by 5/5/25
22VAC40-73-560-E
Based on direct observation and staff interview, the facility failed to ensure that all resident records were kept in a locked area.
Evidence
  1. During a tour of the facility, the LI observed an unlocked office with the door open adjacent to the common area. Inside the office, a desk contained resident information.
  2. In an interview with the LI, Staff 1 acknowledged that the door was open and unlocked. Staff 1 confirmed the office belonged to Staff 17. Staff 1 stated that Staff 17 provided services for the residents.
  3. Photo evidence obtained.
Plan of correction
Executive Director and or designee will ensure staff keeps resident files and document in a secure cabinet, drawer or behind a locked door when staff not present. Executive Director and or designee will monitor throughout the day to ensure all staff are compliant with securing resident documents. Completed by 4/30/25
22VAC40-90-40-B
Based on staff record review and staff interview, the facility failed to ensure that the criminal history record report was obtained for all employees on or prior to the 30th day of employment.
Evidence
  1. Staff 7’s, hired 07/05/2023, Criminal Record Report was received 09/22/2023.
  2. Staff 8’s, hired 10/18/2023, Criminal Record Report was received 11/21/2023.
  3. In an interview with the LI on 03/20/2025, Staff 10 confirmed that the Criminal Record Reports were received after the 30th day of employment.
Plan of correction
Not published by VDSS.
22VAC40-73-210-G
Based on staff record review and staff interview, the facility failed to ensure that documentation of training received included the number of hours of training and was kept by the facility in a manner that allows for the identification of the individual staff member.
Evidence
  1. The LI requested the annual training documentation for Staff 11, 12, 13, and 14.
  2. Staff 1 provided a transcript for Staff 11, Staff 12, Staff 13, and Staff 14 from Relias. The transcript did not include the number of hours of training.
  3. In an interview with the LI on 03/20/2025, Staff 3 confirmed the transcript did not include the number of hours of training.
Plan of correction
Executive Director and or design will print out certificates from Relias monthly and maintain certificates in binder separated by individual staff members Completed by 5/5/25
22VAC40-90-30-B
Based on staff record review and staff interview, the facility failed to ensure that a sworn statement or affirmation was completed for all applicants for employment.
Evidence
  1. Staff 5’s, hired 02/26/2025, Sworn Statement or Affirmation was signed and dated on 03/03/2025.
  2. In an interview with the LI, Staff 1 confirmed that the Sworn Statements or Affirmations were completed after the hire date.
  3. Staff 7’s, hired 07/05/2023, Sworn Statement or Affirmation was completed after employment began.
  4. Staff 9’s, hired 06/05/2023, Sworn Statement of Affirmation was signed and not dated.
  5. Staff 4’s, hired 06/05/2024, Sworn Statement or Affirmation was signed and not dated.
  6. In an interview with the LI on 03/20/2025, Staff 10 could not confirm the dates for Staff 7, 9 or 4’s completion of the Sworn Statement or Affirmation.
Plan of correction
BOD will audit staff for compliance of Sworn Disclosure or Affirmation. Any missing Sworn Disclosures will be signed and date. Going forward BOD will ensure Sworn Disclosure is completed on or before hire date. BOD will audit staff records quarterly for compliance. Completed by 5/5/25
22VAC40-73-950-A
Based on facility document review and staff interview, the facility failed to ensure the local emergency coordinator was contacted.
Evidence
  1. The LI requested a copy of the contact requesting required information from the local emergency coordinator.
  2. In an interview with the LI, Staff 1 provided the corporate contact for the facility’s emergency management.
  3. In an interview with the LI, Staff 16 confirmed that the local emergency coordinator had not been contacted.
Plan of correction
Maintenance Director reached out to Loudoun County and obtained the information for the local Emergency Coordinator for any updates that pertained to TOL. Information and contact was placed in the Emergency binder. .Maintenance Director will annually reach out to Emergency Coordinator for any updates and add to the Emergency binder. Completed
22VAC40-73-450-C
Based on resident record review and staff interview, the facility failed to ensure that the comprehensive individualized service plan (ISP) contained a description of identified needs based upon the uniform assessment instrument (UAI).
Evidence
  1. Resident 1, admitted 12/02/2024, record contains a UAI dated 02/14/2025. The UAI states that the Resident 1 needs mechanical assistance for transferring, mechanical assistance/ human supervision for bathing, and mechanical assistance for toileting. Resident 1’s UAI states that Resident 1 needs mechanical assistance only for walking and mobility, and mechanical assistance with supervision for stairclimbing.
  2. Resident 1’s ISP, dated 02/14/2025, does not include the mechanical assistance on bathing, toileting, and transferring. The ISP states that Resident 1 is independent for mobility/ambulation.
  3. Resident 6’s UAI, dated 03/03/2025, states that Resident 6 needs mechanical assistance for toileting and mechanical assistance with supervision for bathing.
  4. Resident 6’s ISP, dated 03/03/2025, does not include mechanical assistance for toileting or bathing.
  5. In an interview with the LI on 03/20/2025, Staff 1 and 2 acknowledged that Resident 1 and Resident 6’s ISP does not contain a description of services from the UAI.
Plan of correction
450-C HWD will audit and ensure that all current residents ISP reflects the identified needs based upon the UAI. HWD will ensure that future UAI identified needs are reflected on ISP. Completed by 5/15/25
22VAC40-73-610-B
Based on direct observation and staff interview, the facility failed to ensure that menus for meals and snacks for the current week were dated and posted in an area conspicuous to residents.
Evidence
  1. During a tour of the dining area in the facility, the LI did not observe a posted menu.
  2. In a meeting with the LI, Staff 1 confirmed that the weekly menu was posted in the dining area.
  3. During a later observation of the dining area, the LI noted the weekly menu containing the breakfast, lunch, and dinner menu. The menu did not contain snacks.
  4. In an interview with the LI, Staff 1 confirmed that the menu did not contain snacks.
  5. Photo evidence obtained.
Plan of correction
Weekly menus will be dated and posted at the entrance to the dining room. Culinary Director and or designee will switch out menus before Sunday morning breakfast each week. Weekly menu will include snacks available. Culinary Director or Designee will monitor daily to ensure posting. Completed by 4/30/25
22VAC40-73-720-A
Based on resident record review and staff interview, the facility failed to ensure that written Do Not Resuscitate (DNR) was included on the resident’s individualized service plan (ISP).
Evidence
  1. Resident 1’s record contains a Durable DNR Order dated 11/29/2024.
  2. Resident 1’s ISP, dated 02/14/2025, has a handwritten note at the top that says “Do Not Intubate.” The DNR order is not on the ISP.
  3. Resident 3’s record contains a Durable DNR Order dated 11/10/2022.
  4. Resident 3’s ISP, dated 08/19/2024, does not include the DNR.
  5. Resident 7’s record contains a Durable DNR Order dated 04/07/2023.
  6. Resident 7’s ISP, dated 03/17/2025, does not include the DNR.
  7. In an interview with the LI, Staff 1 and Staff 2 acknowledged that Resident 1, Resident 3, and Resident 7’s ISP did not contain a DNR.
Plan of correction
HWD will audit and ensure all current ISPs reflect the DNR status. HWD will ensure that future resident ISP reflects DNR status. HWD will audit quarterly to ensure all residnets with DNR have status reflected on ISP. Completed by 4/30/25
22VAC40-73-600-A
Based on direct observation, the facility failed to ensure that time between the evening and breakfast meals did not exceed 15 hours.
Evidence
  1. During a tour of the facility on 03/20/2025, the LI observed Residents being sat for breakfast around 9:15 AM.
  2. The scheduled mealtimes for the Safe, Secure Unit are 830-10 AM, 12 noon to 130 PM, 5pm to 630 PM.
  3. In an interview with the LI, Staff 2 stated that dinner the prior evening (03/19/2025) was served around 5:15 PM. Staff 2 confirmed there were more than 15 hours between the dinner and breakfast meal.
Plan of correction
Memory care mealtimes adjusted to 8:30 12:30 and 5:30. Memory Care Director will monitor to ensure that mealtimes are adhered. Memory Care Director or designee will ensure residents are seated and served at designated times. Completed by 4/30/25
22VAC40-73-860-I
Based on direct observation and staff interview, the facility failed to ensure hazardous materials were stored in a locked area.
Evidence
  1. During a tour of the facility, the LI observed an unlocked office with the door open adjacent to the common area that contained a fridge. Inside the fridge, a canister of chewing tobacco was sitting in the door.
  2. In an interview with the LI, Staff 1 acknowledged that the door was unlocked. Staff 1 confirmed that the office began to Staff 17. Staff 1 stated that Staff 17 was hosting activities on a different floor at the time of observation.
  3. Photo evidence obtained.
Plan of correction
Executive Director and/or designee will ensure all hazardous materials will remain in a locked area. Staff member inserviced…. keeping door, cabinet, and refrigerator area locked at all times when staff not present. Completed by 4/30/25
22VAC40-73-310-M
Based on facility document review, resident record review, and staff interview, the facility failed to ensure that there was a hospice agreement between the assisted living facility and any hospice program that provides care in the facility.
Evidence
  1. Staff 3 provided a highlighted list containing the names of six (6) residents that are currently on hospice.
  2. The LI requested the current hospice agreements.
  3. In an interview with the LI, Staff 1 stated that hospice contracts were between the resident(s) and the hospice provider, not the facility.
Plan of correction
Executive Director and or designee will ensure that any hospice service provided in the community will have in place an agreement signed by the community and the hospice agency. The agreement will outlining the services provided by the hospice. The resident care plans will reflect acknowledgement of hospice services. All current residents who are on hospice care will have acknowledgement of hospice services on their care plan. All future residents placed on hospice will have acknowledgement of hospice service on their care plan. HWD will audit quarterly to ensure hospice acknowledgement is on ISP. Completed by 5/5/25
February 10, 2025Complaint survey3 violations
Inspection dates
02/10/2025
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 PROVISIONS63.2- (1) GENERAL PROVISIONS63.2- (16) PROTECTION OF ADULTS AND REPORTING22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 01/28/2025 regarding allegations in the area(s) of: Resident Care and Related Services Resident Accommodations and Related Provisions Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 02/10/2025 10:30 AM to 01:10 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: 105 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: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: Lobby, Bistro Area, Dining Additional Comments/Discussion: Additional Off-Site Interviews Conducted. This inspection was completed in conjunction with Loudoun County Adult Protective Services. 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: 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 Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Violations
63.2-1606-A
Based on resident interview, collateral contact interview and staff interview, the facility failed to ensure matters giving reason to suspect the abuse, neglect or exploitation of adults shall be reported immediately upon the reporting person's determination that there is such reason to suspect.
Evidence
  1. In an interview with the Licensing Inspector on 02/10/2025, Staff 1 stated that on 01/24/2025, Collateral Contact 1 asked Staff 1 to talk to Resident 1 because Resident 1 had red marks on their arms. Staff 1 stated that Collateral Contact 1 stated something happened to Resident 1 “down there” while pointing to the pelvic area.
  2. In an interview with the Licensing Inspector on 02/10/2025, Staff 1 confirmed that they did not report the suspicion of abuse to Adult Protective Services.
Plan of correction
Executive Director or designee will report any report of suspicion of abuse or neglect to APS and the state licensing inspector in appropriate time guideline. Executive Director will complete an in service on reporting suspicion of abuse or neglect by 4/30/25.
22VAC40-73-440-A
Based on resident record review and staff interview, the facility failed to ensure that the Uniform Assessment Instrument (UAI) was completed annually.
Evidence
  1. Resident 1’s, admitted 08/29/2023, record contains a UAI dated 08/22/2023.
  2. In an interview with the Licensing Inspector on 02/10/2025, Staff 1 and 2 stated that there was not another UAI completed or available. Staff 1 and 2 confirmed that the UAI dated 08/22/2023 is the most recent copy.
Plan of correction
Resident UAI will be updated by 4/25/25 by the HWD or designee. All resident records will be reviewed to ensure that UAIs have been completed in the last year or updated accordingly by the HWD or the designee by 4/30/25. HWD will monitor the UAIs to ensure accuracy and compliance.
22VAC40-73-70-A
Based on resident record review and staff interview, the facility failed to ensure that any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident is reported to the regional licensing office within 24 hours.
Evidence
  1. On 01/29/2025, Staff 1 notified the department of an incident report via email. The incident report states “APS Worker [Collateral Contact 2] reported that there had been a report of bruising and possible abuse. APS requested to speak to [Resident 1] …”
  2. In an interview with the LI, Staff 1 confirmed that they were notified about the injury on 01/24/2025 by Collateral Contact 1. Staff 1 confirmed that the report was not submitted within 24 hours to the regional licensing office.
Plan of correction
The Executive Director or designee will inform the state inspector via email a report of any incident that negatively affects a resident within 24 hours. Inservice completed by Regional HWD and SVPO of Compliance on Reporting Incidents 4/16/25.
January 30, 2025Complaint survey2 violations
Inspection dates
01/30/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 01/08/2025 regarding allegations in the area(s) of: Personnel and Staffing and Supervision. Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 01/30/2025 1:30 PM to 4:00 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 106 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1* Number of interviews conducted with staff: 4 Observations by licensing inspector: Activities and Meals. Additional Comments/Discussion: One interview conducted with an additional resident that refused. 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 staffing and supervision. 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 Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Violations
22VAC40-73-460-B
Based on resident record review, staff interview, and facility document review, the facility failed to ensure prompt response to care as determined by circumstance.
Evidence
  1. In an interview with the LI on 01/30/2025, Staff 1 stated there is not a policy or written requirement for call bell response times. Staff 1 stated that they try to answer them as timely as they can, and the goal is to answer within 15 minutes.
  2. In the resident handbook on page 3, the Resident Services information states the following under “what do I do if I’m waiting for a response to my pendant?”
  3. During an on-site review of the call-bell records for January 2025, the LI observed multiple call bell responses totaling 60+ minutes in the evening hours between 3:00 PM and 7:00 PM.
  4. In an interview with the LI, Staff 1 and 2 confirmed that the dinner time is 4:30 PM to 6:00 PM with a lot of residents wanting to head to dinner early.
  5. In an email to the LI on 02/24/2025, the administrator provided the call bell response time for 12/24/2024 to 01/08/2025. There were 15 responses over 15 minutes.
  6. In an interview with the LI on 01/30/2025, Resident 1 stated that the facility needs more help, and that there was one night Resident fell out of bed and waited a long time for someone to come. Resident 1 stated that they believe the average response time is 20-30 minutes. Resident 1 stated they believed the facility doesn’t prioritize and gave the example that they will come in to turn the pendent off, take out the trash, and then aid.
  7. In separate interviews with the LI on 01//30/2025, both Staff 3 and 4 confirmed that the facility generally has three to four direct care staff at any time. Staff 3 and 4 said that when they have three care staff, they are short, and the work is difficult to answer everyone timely and safely. Staff 3 stated that they have heard residents complain about the wait time.
  8. In the resident council notes for August 24, there is a question documented conversation between Resident 3 and Staff 1. It goes as follows: a. Resident 3: “Is there a shortage of help overnight because it seems dire as many people need help getting back in bed or going to the restroom.” b. Staff 1: “We meet the state standard, and we have enough staff, and we are constantly hiring staff dur to turnover. Is there a particular time this occurs and then I can look into it.”
  9. In the resident council notes for August 24, there is a question documented conversation between “Family of [Room Number]” and Staff 1. It goes as follows: a. “Family of [Room Number]”: “The rule book says there is a 15-minute callback when the button is pushed. Is there anyway to tell the difference between an emergency and something like a lost remote.” b. Staff 1: There’s no way to differentiate. c. “Family of [Room Number]”: When is it time to revaluate the system as the wait time exceeds by at least 4x d. Staff 1: It is something to investigate the time logs. It is hard to find staff just to come in for the 2 hours it is before and after meals. e. “Family of [Room Number]”: When does it become unfair for residents to wait 2 hrs- when is it responsible to reevaluate the system.
  10. In the resident council notes for December 24, there is a question documented conversation between the residents and staff. It goes as follows: a. Resident 1: “I am new here, but it has been hard to get someone to help me in the morning, this morning I didn’t even call someone I just got myself out of bed and ready. b. Staff 5: “I will look into call times”
  11. In an interview with the LI on 01/30/2025, Staff 2 stated that the pendants must be physically reset and that can contribute to long call bell times. Staff 2 gave an example that if a call bell is taken with a resident while they are on leave, the facility is unable to reset the button until it is back in the building.
Plan of correction
Ed or designee will monitor call bell system periodically to ensure that call bells are answered timely to meet the needs of the residents. March 18,2025.
22VAC40-73-280-B
Based on staff interview, the facility failed to ensure a written staffing plan that specifies the number and type of direct care staff required to meet the day-to-day, routine direct care needs and any identified special needs for the residents in care was maintained.
Evidence
  1. On 01/30/2025, the LI requested a copy of the written staffing plan. Staff 1 stated that the facility does not have a written staffing plan that includes the specific number of direct care staff needed. Staff 1 did not provide a copy of the written staffing plan.
  2. In an email to the LI on 02/11/2025, Staff 1 provided a policy titled “GP12 - Staffing, Emergency Training, CPR and First Aid Training” dated 06/01/2024. The policy did not include the specific type and number of direct care staff needed to meet the routine direct care and identified special needs for the residents.
Plan of correction
The ED or the designee, will at a minimum, quarterly, review the resident acuity to determine staffing needs for each shift on AL. At a minimum there will be 4 caregivers and 2 med techs on 1st and 2nd shift and at least 2 caregivers and 1 med tech on third shift. The ED or designee, will at a minimum, quarterly, review the resident acuity on MC to determine staffing needs for each shift. At a minimum MC will meet the staffing ratio standard in2 2VAC40-73-1130.
January 29, 2025Complaint survey7 violations
Inspection dates
01/29/2025, 01/30/2025
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 PREPAREDNESS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 12/15/2024 regarding allegations in the area(s) of: 1. Admission, Retention, and Discharge of Residents 2. Resident Care and Related Services 3. Resident Accommodations and Related Provisions Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 01/29/2025: 10:55 AM to 2:40 PM 01/30/2025: 10:00 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: 107 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: 5 Observations by licensing inspector: Lunch Meals, Buildings & Grounds Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: 1. Admission, Retention, and Discharge of Residents 2. Resident Care and Related Services 3. Resident Accommodations and Related Provisions 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 Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Violations
22VAC40-73-560-C
Based on resident record and staff interview, the facility failed to ensure that any physician’s notes and progress reports in the possession of the facility shall be retained in the resident’s record.
Evidence
  1. In a phone interview with the LI, Staff 3 confirmed that Resident 1 was receiving psychiatric services, and had documented information regarding care and behaviors on paper logs and paper progress notes.
  2. In an interview with the LI, Staff 1 provided Resident 1’s record. Resident 1’s record did not contain any physician progress notes or paper logs, Staff 1 stated that there was no additional documentation available.
Plan of correction
The ED or designee will ensure that all current and former resident records including physician notes/progress notes. They will be maintained in the resident records or discharged resident files.
22VAC40-73-70-A
Based on resident record and staff interview, the facility failed to ensure that a report was sent to the regional licensing office within 24 hours for any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident.
Evidence
  1. Resident 1’s record contains a progress note, dated 11/07/2024, written by Staff 4 that states “Resident called 911 and stated ‘[Resident 1] was being held against [Resident 1’s] will, wanting to harm himself.”
  2. In an interview with the LI on 01/29/2025, Staff 4 stated that a sheriff arrived and was escorted to Resident 1’s room. Staff 4 confirmed that Resident was observed unharmed, with additional injury or incidents to report.
  3. In an interview with the LI on 01/29/2025, Staff 1 confirmed that an incident report was not written or reported.
Plan of correction
ED or designee will ensure that licensing office receives notification of any incident where an outside agency was called by resident, staff or family member. Notification will include all required information.
22VAC40-73-450-A
Based on resident record review and staff interview, the facility failed to ensure that a preliminary plan of care developed to address the basic needs of the resident that adequately protects his health, safety, and welfare was developed on or within seven (7) days prior to the day of admission and signed by the resident or his legal representative.
Evidence
  1. Resident 1’s, admitted 11/04/2024, record contains an Individualized Service Plan (ISP) dated 10/20/2024. The ISP was not signed by Resident 1 or Resident 1’s legal representative.
  2. In an interview with the LI on 01/29/2024, Staff 1 acknowledged that Resident 1’s ISP was completed 14 days prior to admission.
Plan of correction
ED or designee will ensure that the initial plan of care is signed by the Resident/legal representative. HWD will audit all current residents records to ensure current care plans are signed/received or acknowledged as approved by legal representative and documented in the record.
22VAC40-73-340-B
Based on facility document review, resident record review, and staff interview, the facility failed to ensure that a determination has been made that a facility can meet the needs of the individual based upon the physical examination report prior to admitting the resident.
Evidence
  1. In an interview with the LI on 01/29/2025, Staff 1 stated that they were unaware of Resident 1’s behaviors until after Resident 1’s admission on 11/04/2024.
  2. In a phone interview with the LI on 01/29/2025, Staff 3 stated that they completed Resident 1’s admission assessment at [Hospital]. Staff 3 stated that they spoke to the specialists regarding Resident 1’s care needs, including having behaviors that resulted in the furniture needing to be removed from the hospital room.
  3. Resident 1’s record contained a Mental Health Screening Determination Form dated 10/22/2024. Under “Part II. Psychosocial and Behavioral History, the first question states “If there are indication of mental health problems within the past 6 months, has the referring party provided a documented psychosocial and behavioral history that describes the prospective resident’s psychological, social, emotional, and behavioral functioning?” The box “No” is circled. The second question stated, “Did the facility consider the information contained in the psychosocial and behavioral history in making a decision about whether the facility can meet the needs of the individual?” The answer was blank, including whether it was reviewed and the date of the review.
  4. Resident 1’s record contained hospital discharge paperwork dated as faxed on 10/29/2024. The hospital discharge paperwork stated “KICKED OUT OF [Another Facility]/DEMENTIA/COMBATIVE]” under the reason for admission.
  5. Resident 1’s record contained a Report of Physical Examination with multiple attached psychiatric progress notes dated between -10/07/2024 and 10/24/2024 containing documentation of resident’s behavioral issues including irritability, delusions, agitation, refusals of care, and confusion.
  6. Resident 1’s record confirmed a “lifetime Memoir” questionnaire. The following boxes were checked for that the resident’s typical disposition: “Pleasant, anxious, argumentative, angry, confused negative and other.” Under other, the written text stated, “Moods change day-by-day.” “Yes” box was checked for the question, “Does the resident exhibit any behaviors that should be noted such as reluctance to bathe, change clothes, anxiety, etc?” The questionnaire lists the residents triggers as “Delayed response…dirty home…foul odors in home.”
  7. In an interview with the LI, Staff 1 stated that they are not sure who reviewed that information or when it was reviewed and/or received.
  8. In an interview with the LI on 01/29/2025, Staff 1 confirmed the resident was provided a notice of discharge on 11/08/2024.
  9. Resident 1’s record contained a Discharge Notification and Statement that indicated the reason for discharge was “Unable to meet Resident needs nor family.”
  10. In an interview with the LI on 01/29/2025, Staff 1 provided email communication sent by Staff 1 to Resident 1’s legal representative on 11/08/2024. The letter states that the Resident 1 “Presents an immediate serious risk to the health, safety, or welfare of himself or others” with the next line stating “Resident has flooded [Resident 1’s] room, barricaded himself in [Resident 1’s] room, tore [Resident 1’s] room apart, removed all furniture to hallway, refuses medications and assistance, calls 911, disruptive behaviors in the community ongoing.”
Plan of correction
The ED or designee will review all admission paperwork, including any psychosocial/mental health history, prior to approval for placement in the community to ensure needs can be met. All current residents with mental health/behaviors are being monitored monthly or as needed by psych. All residents who exhibit mental health behaviors will be referred to psych services for an evaluation. Evaluations will be maintained in the resident records.
22VAC40-73-680-D
Based on resident record and staff interview, the facility failed to ensure medications were administered in accordance with the physician’s or other prescriber’s orders.
Evidence
  1. Resident 1’s record, admitted 11/04/2024, contains a Report of Resident Physical Examination, dated 10/28/2024, with a medication list that contains an active order for “Patient Own Me (PATIENT’S OWN)” that states “See Detail.” On a separate page, attached to the Report of Resident Physical Examination, “NUPLAZID 34 MG CAPSULES” is typed next to “Patient’s Own Medication (PATIENT’S OWN MEDICATION).”
  2. Resident 1’s record contains hospital discharge medication orders, dated for “Nuplazid 1 MG” that state “34 mg by mouth at bedtime” and “Trazodone 100 mg.”
  3. Resident 1’s Medication Administration Record (MAR) for November 2024 lists an order for Nuplazid 34 MG, started on 11/08/2024, that states “TAKE ONE CAPSULE BY MOUTH EVERY NIGHT AT BEDTIME FOR [Diagnosis]”. The MAR documents Nuplazid as not being administered 11/04/2024 through 11/07/2024.
  4. Resident 1’s MAR for November 2024 lists an order for Trazadone 100 MG, started 11/08/2024, that states “TAKE ONE TABLET BY MOUTH EVERY NIGHT AT BEDTIME FOR MOOD/SLEEP.” Resident 1’s MAR documents Trazadone as not being administered 11/07/2024.
  5. Resident 1’s record contains a signed order, dated 11/11/2024, that states “Stop Nuplazid 34 MG)” and “Start Trazodone 100 MG.”
  6. In an interview with the LI on 01/30/2024, Staff 1 and 2 acknowledged both Nuplazid and Trazodone were included on the admission orders. Staff 1 stated that they did not know why the medication was not administered 11/04/2024 through 11/07/2024.
Plan of correction
The HWD will ensure that all medications are administered according to the physicians or other prescriber instructions. Proper medication administration procedures will be reviewed with all med techs during the Med Tech Refresher at least 1 time a year.
22VAC40-73-50-B
Based on facility document review and staff interview, the facility failed to ensure that written acknowledgement of the receipt of the disclosure by the resident or the resident’s legal representative was retained in the resident’s record.
Evidence
  1. Resident 1’s, admitted 11/04/2024, record did not contain written acknowledgement of the receipt of the disclosure by Resident 1 or Resident 1’s legal representative.
  2. In an interview with the LI on O1/19/2024, Staff 1 acknowledged there was not a disclosure form in the record.
Plan of correction
ED or designee will ensure all future residents/legal representatives receive and acknowledge the disclosure. The Disclosure will be maintained in the resident record.
22VAC40-73-640-A
Based on facility document review, resident record review, and staff interview, the facility failed to ensure the facility's own medication management plan was implemented.
Evidence
  1. Resident 1’s, admitted 11/04/2024, had signed orders for Nuplazid 34 MG dated 10/28/2024 and hospital discharge orders Trazadone 100 mg dated 11/04/2024.
  2. Resident 1’s record contains communication from [Pharmacy] that states “Please clarify ‘Patient Own Med’ at bedtime. Thank you.”
  3. Resident 1’s Medication Administration Record (MAR) indicates that both Nuplazid and Trazadone were not administered 11/04/2024 through 11/07/2024. Both medicines were administered on 11/08/2024.
  4. The facility’s medication management plan contains a section titles “Med 30 – Medication Errors.” The policy states “A medication error is defined as…6) missed dose. 7) Not initiating an order.” The procedure states the following: “…2) The resident’s prescribing physician is immediately notified of the medication error…3) Document and follow instructions given by the resident’s physician…6) Enter a narrative note on resident status during every shift for 72 hours after a medication error occurs…7) The responsible party is notified of the error.”
  5. Resident 1’s record did not contain any of the required information including confirmation of notification to the physician and any physician instructions, narrative notes for 72 hours after a medication error, or notification to the responsible party.
  6. In an interview with the LI, Staff 1 acknowledged that the admission orders were not initiated, and stated that maybe the medication was not provided by the family. Staff 1 confirmed there was no additional documentation available regarding additional orders, progress notes, or communication regarding the medication error.
Plan of correction
The HWD will ensure that the Medication Management Plan is followed. The HWD will inservice all med techs on the Medication Management Plan by April1, 2025.
January 14, 2025Complaint survey1 violation
Inspection dates
01/14/2025, 01/29/2025
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS
Comments
Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 01/07/2025 regarding allegations in the area(s) of: 1. Administration and Administrative Services 2. Staffing and Supervision 3. Buildings and Grounds. Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 01/14/2025 9:20 AM to 9:35 AM 01/29/2025 9:30 AM 10:50 AM 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: 107 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: Postings and/or Visitor Guidance, Cleaning Supplies/ Protocol Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all the allegations; area(s) of non-compliance with standard(s) or law were Administration and Administrative Services. A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. 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 Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Violations
22VAC40-73-100-A
Based on facility document review and staff interview, the facility failed to ensure that the developed infection control program was implemented.
Evidence
  1. On 01/02/2025, Staff 1 reported a gastrointestinal outbreak via email to the LI.
  2. On 01/29/2025, the LI requested a copy of the infection control program. Number 2 of the facility’s infection control program under “Infection Control 20 – Gastrointestinal Illness/Norovirus states the following “Upon a suspected GI Illness outbreak, the following notification steps are taken…Contact the appropriate county health department for guidance.
  3. In an interview with the LI on 01/14/2025, Staff 1 confirmed that they had switched to disposable serving ware and contacted the health department for guidance.
  4. In an interview with the LI on 01/29/2025, Staff 1 stated that the health department approved their current protocol that was being implemented.
  5. Number 5 of the facility’s infection control program under “Infection Control 20 – Gastrointestinal Illness/Norovirus”, the policy states “Upon a suspected outbreak of GI Illness, the following measures are taken …f) After receiving approval from the Administrator/Executive Director, the following should be implemented until at least 48 hours AFTER the symptoms in all members of the Community have resolved: i) Cancel all group activities. ii) Close the dining services and implement room delivery on disposable ware…”
  6. In an interview with the LI on 01/29/2025, Staff 1 stated that they did not cancel all group activities and close the dining services because that was not discussed with the health department. Staff 1 confirmed that their policy states to cancel all group activities and close the dining service if there is a suspected outbreak.
  7. Number 4-A of the facility’s infection control program under “Infection Control 29 – Reporting of Infectious Disease/Outbreak” states “…the Community will follow any recommendations by the epidemiologist at the local health department to control the outbreak. The Community will document all actions taken.”
  8. In an interview with the LI on 01/29/2025, the facility stated that the guidance given was discussed verbally and confirmed that the actions taken were not documented.
Plan of correction
The community will follow the established corporate approved Infection Control Plan. All staff will be in serviced on the Infection Control Plan upon hire and annual thereafter. The Infection Control Plan will be reviewed annually by the corporate qualified designee.
December 5, 2024Inspection0 violations
Inspection dates
12/05/2024
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND
Comments
Type of inspection: Monitoring A self-reported incident was received by VDSS Division of Licensing on 10/19/2024 regarding allegations in the area(s) of resident care and related services. Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/05/2024 9:15 AM to 11:20 AM 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: 102 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: 4 Observations by licensing inspector: Room/Courtyard/Mail Room Tours Additional Comments/Discussion: Off-site interviews conducted via telephone on 12/11/2024 and 12/17/2024. 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 Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
August 5, 2024Complaint survey2 violations
Inspection dates
08/05/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 06/08/2024 regarding allegations in the area(s) of resident care and related services and resident accommodations and related provisions. Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 08/05/2024, 10:15 AM to 12:00 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0, resident refused interview at time of inspection. Number of interviews conducted with staff: 2 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. However, violation(s) not related to the complaint but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Violations
22VAC40-73-290-B
Based on direct observation from the LI, the facility failed to ensure the current on-site person in charge was posted, in a place in the facility that is conspicuous to the residents and the public.
Evidence
  1. At the front desk in the lobby, the manager on duty was listed as Staff 3.
  2. Staff 4 confirmed that Staff 3 was not in the building or available, and that Staff 1 was the designated staff in charge.
Plan of correction
Designated person in charge will be listed at the front desk on the Designated Person in Charge tree. The Concierge will ensure the posting is located at the front desk every morning and visible to the public.
22VAC40-73-450-C
Based on resident record review and staff interview, the facility failed to ensure the comprehensive individualized service plan included the following a written description of what services will be provided to address identified needs, and if applicable, other services, and who will provide them.
Evidence
  1. In a phone interview conducted by the LI on 08/05/2024, Staff 2 confirmed the following regarding the care of Resident 1: a. Resident 1 will talk loudly or yell due to hearing loss, which is sometimes deemed as aggressive when paired with her behaviors. b. Resident 1 has behaviors that are not triggered by certain staff. The behaviors include throwing items, refusal of care, and swatting or swinging at staff that attempt to provide care. Staff 2 has been providing on the job training and modeling of how to support this resident. Staff 2 stated they are on a “try, try, and try again” plan of action with offering support with ADL’s, room cleaning, and eating breakfast. c. Resident 1 is currently undergoing psychiatric treatment to address concerns in behavior, and they have noticed that there is a decrease in behaviors once medication is leveled out. Staff 2 stated that they are continue to monitor and adjusting medications as needed.
  2. Resident 1’s Uniform Assessment Instrument (UAI) lists the following under psychosocial: a. “Behavior Pattern: Appropriate” b. “Type of Inappropriate Behavior: Yelling, Smacking”
  3. Resident 1’s ISP does not have a detailed description of needs or services provided. a. Under Neurocognitive, the description of service to be provided is “Resident does not have hearing impairment.” b. Under Psychosocial, the description of service to be provided is “Resident has current or history of frequent disruptive, aggressive, or socially inappropriate behavior, either verbally or physically improper. May require professional consultation or staff training.”
  4. Staff 2 confirmed the system they use is does not give the ability to customize ISPs as much as necessary.
Plan of correction
Resident 1 UAI and ISP will be updated to reflect inappropriate behaviors and services provided. All residents UAI and ISP will be reviewed to ensure inappropriate behaviors are addressed, services to be provided and are customized as needed. Staff will receive continued training on methods and approaches to deal with inappropriate behaviors. RSD will review all UAI and ISPs on going to ensure compliance.
August 31, 2023Complaint survey0 violations
Inspection dates
08/31/2023
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: LI entered the facility at 9:25 am on 8/31/2023 and exited at 10:25 am on 8/31/2023. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 8/4/2023 regarding allegations in the area(s) of administration and administrative services and admission, retention, and discharge of residents. Number of resident records reviewed: 15 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 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 allegations of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jamie Eddy, Licensing Inspector at (703) 479-5247or by email at jamie.eddy@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
March 30, 2023Complaint survey0 violations
Inspection dates
03/30/2023
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: LI entered the facility at 11:34 am on 3/30/2023 and exited at 12:15 pm on 3/30/2023. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 3/21/2023, regarding allegations in the area(s) of resident care. Number of residents present at the facility at the beginning of the inspection: 100. 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: 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 allegations of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jamie Eddy, Licensing Inspector at (703) 479-5247 or by email at jamie.eddy@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
February 7, 2023Inspection3 violations
Inspection dates
02/07/2023
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE
Technical assistance
A completed Renewal Application must be submitted prior to the expiration of the current license. The facility should receive an application in the mail, however if an application has not been received one can be obtained from the DSS web site or by calling the main office at (276) 206-0492.
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: LI entered the facility at 8:55 am on 2/7/2023 and exited at 5:00 pm on 2/7/2023. 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: 96 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 plus 2 discharged resident records Number of staff records reviewed: 5 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 0 Observations by licensing inspector: LI observed medication administration. LI observed residents eating breakfast and lunch. 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 Jamie Eddy, Licensing Inspector at (703) 479-5247 or by email at jamie.eddy@dss.virginia.gov
Violations
22VAC40-73-720-A
Based upon a review of records, the facility failed to ensure that the written order for Do Not Resuscitate (DNR) is included in the Individualized Service Plan (ISP).
Evidence
  1. The ISP for Resident #9 contained in the record does not include the DNR order.
Plan of correction
It is duly noted that Resident #9’s Care Plan did not address the DNR (Do Not Resuscitate) order. Nursing staff will update Care Plan to include the DNR status by 2/20/2023. Nursing will audit all care plans of all residents who are DNR to ensure the DNR is addressed in the Care Plan by 2/21/2023. Nursing will ensure that all future Residents or current Residents who have an order for DNR will be addressed on the Care Plan.
22VAC40-73-260-A
Based upon a review of records, the facility failed to ensure that each direct care staff member who does not have current certification in first aid shall receive certification in first aid within 60 days of employment.
Evidence
  1. According to the staff record, Staff #3 was hired as a care partner on 6/27/2022. There was no documentation of certification in first aid only certification in CPR (cardiopulmonary resuscitation).
Plan of correction
It is duly noted that the community did not ensure that staff #3 has a current First Aid (FA) certification. Before staff #3 can work again she will need to provide proof of FA certification. Acting Business Office Director (BOD) will audit and ensure all staff has the required FA training by 2/20/2023. All future staff will be required to show proof of FA within 60 days of hire.
22VAC40-73-840-B
Based upon a review of pet records the facility failed to ensure that pets living on the assisted living premises shall have regular examinations and immunizations, appropriate for the species, by a licensed veterinarian.
Evidence
  1. The record for Pet #3 indicated that a rabies vaccination was due 7/26/2022. There was no documentation of an updated rabies vaccination in the record.
Plan of correction
It is duly noted that Pet #3 did not have the required documentation of up-to-date immunization. Pet #3’s family will obtain documentation by 2/25/2023. All future Pets will maintain documentation of immunization
November 1, 2022Inspection0 violations
Inspection dates
11/01/2022
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 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: LI entered the facility at 10:56 am on 11/1/2022 and exited the facility at 12:15 pm on 11/01/2022. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 10/24/2022 regarding allegations in the area(s) of admission, retention, and discharge of residents and resident care and related services. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Additional Comments/Discussion: 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 Jamie Eddy, Licensing Inspector at (703) 479-5247 or by email at jamie.eddy@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
March 22, 2022Inspection0 violations
Inspection dates
03/22/2022,03/25/2022
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Licensing Inspector (LI) conducted unannounced focused monitoring visit, that began on 3/22/2022 and ended on 3/25/2022, to ensure correction of violations cited during 2/4/2022 renewal study. Reviewed resident records, observed medication administration, and reviewed documents of re-education training on medication administration. All previous violations were found to have been corrected. No additional violations cited today. Exit interview held. Thank you for your cooperation and if you have any questions please call 703-479-5247 or contact me via e-mail at jamie.eddy@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
February 9, 2022Inspection1 violation
Inspection dates
02/09/2022,03/25/2022
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Licensing Inspector (LI) conducted unannounced inspection in response to self-reported incidents that began on 2/9/2022 and concluded on 3/25/2022. Reviewed resident records staff records, inspected facility transport van, reviewed other documents and conducted staff interviews. Violation notice issued and assessed risk assigned to violations reviewed during the exit interview. Areas of non-compliance are identified on the violation notice. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word "corrected" is not acceptable. The plan of correction must contain: 1) steps to correct the non-compliance with the standard(s), 2) measures to prevent the non-compliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s). Thank you for your cooperation and if you have any questions please call 703-479-5247 or contact me via e-mail at jamie.eddy@dss.virginia.gov.
Violations
22VAC40-73-460-A
Based upon a review of documents and interviews, the facility failed to provide adequate care to protect the health, safety, and well-being of residents.
Evidence
  1. On 2/3/2022 LI received an incident report from the administrator regarding an incident that took place on 2/2/2022 at approximately 10:35 am, involving a resident who was injured during a van transport for a resident outing.
  2. LI spoke with the administrator via telephone on 2/4/2022 regarding the incident that was self-reported to LI on 2/2/2022. According to the administrator, the van was making a right turn when the back door of the van opened and the resident fell out. The administrator stated that the “back door to the van appears not to have been latched properly and that the wheelchair was not adequately secured (buckled down) inside the van.” The administrator commented to LI that she believes that “the wheelchair became loose, moved and hit the back door and the force caused the door to open and the resident fell out.” The administrator reported that local police did respond to the incident. The administrator stated that the resident suffered “four broken ribs, a broken collar bone, and a head laceration requiring four staples in the back of his head and that the injuries were non-life threatening.” According to the administrator, the driver of the van has been employed with the facility for a couple of years but the van is a new van. LI was told by the administrator that along with the resident who was injured and the van driver, there were four other residents on the van plus another staff member.
  3. The written statement from the van driver made on 2/4/2022 and provided to LI on 2/9/2022 stated that the driver “loaded passenger on the bus, strapped (resident) floor belts on to wheel chair and drove off from Savin Hill Drive. Made turn onto Russell Branch drive and (Staff #2) said that (resident) had fallen on the ground, stopped bus and went to help him. I’m so sorry for this happening.”
  4. LI interviewed Staff #2 on 2/9/2022. LI asked Staff #2 to provide details of what she saw when the residents were being loaded onto the van. Staff #2 acknowledged that she did not see the van driver fastening all four of the floor belts to the resident’s wheelchair and did not see the van driver latching the door because “I was getting the other residents loaded onto the van and buckling them into their seats.” LI asked Staff #2 if she saw the resident fall out of the van and what she did when she realized the resident had fallen out. According to Staff #2, “as the van was turning onto Russell Branch Parkway, I heard a gust of wind, turned around and saw the backdoor was open and resident was on the ground.” Staff #2 reported she then stood up and told the driver to stop the bus. Staff #2 stated that once the bus was stopped, she got off the bus and attended to the resident, who was “lying on the ground in a fetal position and out of his wheelchair. The resident’s wheelchair was lying on the side walk to the left of the resident.” According to Staff #2 she began to assess the resident for injuries. The written statement for Staff #2 that was provided to the facility states “We were pulling out of the stop sign and I look back and hear a loud thump and noise. I see the bus door open and (resident) outside on the road. We stopped the bus and I ran to him. He was answering all my questions! He said he was doing okay and remembers everything. From what I remember, resident was buckled and his brakes on his wheelchair locked.” The written statement of Staff #2 contradicts what was reported in her interview with LI on 2/9/2022 regarding her knowledge and observation of the resident being buckled and his wheelchair secured. Due to extensive information additional evidence is on a separate page.
Plan of correction
It is duly noted that the facility failed to provide adequate care to protect the health, safety, and well-being of Resident #1 while providing transportation in the facility bus. As noted in the Inspection Summary, the driver of the vehicle avers that he properly secured the resident in the van and also properly secured the back door of the vehicle consistent with his training prior to operating the vehicle. The driver had been driving residents at this community for over two years. During our investigation, we have not been able to ascertain the truth of the driver's statement. Despite the statements of the driver, because of the serious nature of the injuries suffered by the resident as a result of the driving of the vehicle, Tribute at One Loudoun has completed the following plan of correction: First, the driver of the vehicle has been terminated from his employment at the community. Second, the van was removed from service and sent to the manufacturer for a full inspection of all equipment to ensure the equipment is operable as intended. Once the van is returned to the community, the community will conduct an additional inspection to ensure all fasteners are functioning. This additional inspection will be conducted by at least maintenance personnel and supervised by the Executive Director. Third, enhanced training is being provided to all community drivers, including but not limited to, door latching, wheelchair tie down, wheelchair seatbelts and lift gate operations. Initial safety training will continue to occur upon hire and/or initial assignment to drive and bi-annually thereafter. The enhanced training will include a requirement that if there are two team members in the van for an excursion, each team member will be required to verify the secure fastening of the residents. Training records are a permanent part of the employee record. All potential drivers will be subjected to ongoing training and this enhanced training before the van will be put back into service. The training will be conducted by the Maintenance Director and supervised by the Executive Director.
February 2, 2022Inspection0 violations
Inspection dates
02/02/2022,02/04/2022
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
On 2/2/2022 Licensing Inspector (LI) conducted unannounced focused monitoring visit to ensure correction of violations cited during 10/4/2021,12/13/2021 complaint inspection. LI reviewed staff training regarding resident fall protocols and annual review of residents rights. All previous violations were found to have been corrected. No additional violations were cited. Exit interview held. Thank you for your cooperation and if you have any questions please call 703-479-5247 or contact me via e-mail at jamie.eddy@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
February 1, 2022Inspection4 violations
Inspection dates
02/01/2022,02/04/2022
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 ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity32.1 Reported by persons other than physicians63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS
Technical assistance
A completed Renewal Application must be submitted prior to the expiration of the current license. The facility should receive an application in the mail, however if an application has not been received one can be obtained from the DSS web site or by calling the main office at (276) 206-0492.
Comments
An unannounced renewal study began on 2/1/2022 and ended on 2/4/2022. At the time of entrance 90 residents were in care. The sample size consisted of 10 resident records, five staff records, and six pet records. Resident and staff records and other documentation were reviewed. Criminal Background Checks of all staff hired since the previous inspection conducted on 3/19/2021 were reviewed. Residents were observed eating breakfast and lunch and engaging in activities including daily chronicle and exercises. Medication administration was observed. Violation notice issued, risk ratings reviewed and exit interview held. Areas of non-compliance are identified on the violation notice. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word "corrected" is not acceptable. The plan of correction must contain: 1) steps to correct the non-compliance with the standard(s), 2) measures to prevent the non-compliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s). Thank you for your cooperation and if you have any questions please call 703-479-5247 or contact me via e-mail at jamie.eddy@dss.virginia.gov.
Violations
22VAC40-73-680-D
Based upon a review of records, the facility failed to ensure that medications shall be administered in accordance with the physician's or other prescriber's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing.
Evidence
  1. The January 2022 Medication Administration Record (MAR) for Resident #6 documents that on 1/3/2022 the resident did not receive the 4am scheduled dose of Oxycodone HCL 15mg. The Individual Controlled Substance Record indicates that the the 4am dosage was not administered to Resident #6 on 1/3/2022.
Plan of correction
It is duly noted that the facility did not follow the facility's medication management policy for Resident #6 on 1/3/2022 due to a staffing challenge created when the scheduled medication care partner did not report to work and the Resident Services Director (RSD) was not notified in order for a replacement to be found. The care partners and medication care partners will be re-educated on following the posted staff schedule as well as how and when to notify the RSD, if there are any missing staff members on a given shift. In addition, an audit will be completed on all narcotic medication administration records by February 14, 2022, to ensure that all medications are given as prescribed by the physician's orders. All narcotic medication administration records will be audited monthly by the RSD, or designee, to ensure compliance. The RSD, or designee, will re-educate nurses and medication care partners on the facility's medication management policy by March 11, 2022.
22VAC40-73-680-C
Based upon a review of records, the facility failed to ensure that medications shall 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
  1. According to the physician's order, Resident #6 is to receive Oxycodone HCl 15mg every four hours. The dosing schedule on the Medication Administration Record indicates that the medication is to be administered at 12am (midnight), 4am, 8am, 12noon, 4pm, and 8pm. The Individual Controlled Substance Record indicates that on the following dates, Resident #6 received Oxycodone more than an one hour after the ordered dosing schedule:
  2. On 1/09/2022, the 4am dosage of Oxycodone was administered at approximately 6:10am.
  3. On 1/10/2022, the 4 am dosage of Oxycodone was administered at approximately 6:10am.
  4. On 1/10/2022, the 8am dosage of Oxycodone was administered at approximately 9:39am.
  5. On 1/10/2022, the 12noon dosage of Oxycodone was administered at approximately 1:56pm.
Plan of correction
It is duly noted that the facility did not follow the facility's medication management policy when administering medications late four times on two days for Resident #6. The Resident Services Director (RSD), or designee, will re-educate nurses and medication care partners on the facility's medication management policy by March 11, 2022. A medication refresher course will be held for the medication care partners. Medication administration will be monitored by RSD, or designee to endure prescribed medications are given as physician's ordered.
22VAC40-73-640-A
Based upon a review of records, the facility failed to ensure that the written medication management plan was implemented to ensure that each resident's prescription medications are refilled in a timely manner to avoid missed dosages.
Evidence
  1. The medication management plan states that medications will be reordered seven days prior to "running out" in order to avoid missed dosages.
  2. The February 2022 Medication Administration Record (MAR) for Resident #4 indicates that on 2/1/2022, the resident did not receive the scheduled morning dose of Aspirin EC 81 milligrams (mg) because "med not available, waiting for pharmacy to deliver."
  3. The February 2022 MAR for Resident #7 indicates that on 2/1/2022, the resident did not receive the scheduled dose of Ozempic 1mg (4mg/3mL) to be administered subcutaneously once a week on Tuesdays because "med not available; waiting for it to be delivered."
Plan of correction
It is duly noted that the facility did not follow the facility's medication management policy with regards to reordering medications seven days prior to running out for Resident #4 and #7. All medication care partners and nurses were re-educated on the facility's Medication Refill Policy by March 11, 2022. The Resident Services Director (RSD) or designee, will conduct monthly medication administration audits and weekly medication cart audits to ensure all medications are available to administer as prescribed by the physician.
22VAC40-73-930-D
Based upon a review of records and interview with administrative staff, the facility failed to ensure that for each resident with an inability to use the signaling device, this inability shall be included in the resident's individualized service plan and the plan shall specify a minimal frequency of daily rounds to be made by direct care staff to monitor for emergencies or other unanticipated resident needs.
Evidence
  1. The Memory Care Director (MCD) confirmed during an interview on 2/2/2022 that Resident #5 does not have the capacity to use the call bell system. The Individual Service Plan for Resident #5 did not include the inability of the resident to use the call bell system and did not identify the minimal frequency of rounds to be made by direct care staff to monitor for emergencies or other unanticipated needs for Resident #5.
Plan of correction
It is duly noted that the facility did not include in Resident #5 Individual Service Plan (ISP), the inability to use the call bell system and did not identify the minimal frequency of rounds to be made by direct care staff to monitor for emergency or other unanticipated needs for Resident #5. Resident #5's ISP will be updated by the Memory Care Director or designee to reflect the inability to use a call bell system and will include the minimum frequency of rounds by direct care staff to monitor for emergencies or other unanticipated needs of the resident by February 14, 2022. The Memory Care Director or designee will audit all Memory Care residents ISP's to ensure that the inability to use the call bell system is addressed with frequency of rounds by direct staff to monitor for emergencies or other unanticipated needs of the residents by February 28, 2022. All new Memory Care residents will be assessed by the Memory Care Director or designee for the capability to use the call bell system and will have the capability addressed on their ISPs. The residents will be reassessed every six months or whenever there is a change with findings addressed on the ISP.
October 4, 2021Complaint survey2 violations
Inspection dates
10/04/2021,12/13/2021
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
A non-mandated complaint inspection was initiated on 10/04/2021 and concluded on 12/13/2021. A complaint was received by the department regarding allegations in the areas of resident care. The administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation support the allegations of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice. Please specify how the deficient practice will be or has been corrected. Just writing the word "corrected" is not acceptable. The plan of correction must contain: 1) steps to correct the non-compliance with the standard(s), 2) measures to prevent the non-compliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s). Thank you for your cooperation and if you have any questions please call 703-479-5247 or contact me via e-mail at jamie.eddy@dss.virginia.gov.
Violations
22VAC40-73-460-A
Based upon a review of records, the facility failed to ensure the health, safety, and well-being of the resident by failing to follow fall response procedures developed by the facility.
Evidence
  1. According to the facility’s Fall Response Procedures dated 6/8/2021, a resident who has sustained a fall can be assisted up to a chair if the head did not receive any trauma or injury, nor was struck during the fall. Progress notes for 9/10/2021 report that Resident #1’s head was struck when he fell and that Staff #1 observed a red mark on the right temple area. Interview with Adult Protective Services Worker revealed that Resident #1 was returned to his bed despite having had struck his head.
  2. According to the facility’s Fall Response Procedures dated 6/8/2021, a resident who has sustained a fall can be assisted up to a chair if the resident denies pain. The progress notes indicate that Resident #1’s pain level was an 8 out of 10 and Resident #1 reported “increased right leg pain.” Interview with Adult Protective Services Worker revealed that Resident #1 was returned to his bed despite having had reported increased right leg pain.
  3. According to the facility’s Fall Response Procedures dated 6/8/2021, “if a resident had trauma resulting in deformity, exhibits any change in level of consciousness, or received obvious head or significant trauma, the Resident Services Director or Care Partners will summon Emergency Medical Services (call 911).” Interview with Staff #1 confirmed that 911 was not called for Resident #1, who had hit his head and reported increased pain in his right leg. Resident #1 was taken to the ER after Collateral Contact #1 received a text message from Resident #1 indicating that he had suffered a fall and Collateral Contact #1 contacted 911 at approximately 5:40 pm on 9/10/2021.
Plan of correction
1. It is duly noted that the facility nurse did not follow the facility's fall response procedures; the nurse is no longer employed by the facility. 2. The Resident Services Director, or designee, will re-educate nurses, medication care partners, and care partners on the facility's fall response procedures.
22VAC40-73-550-C
Based upon a review of records and interviews, the facility failed to ensure that any resident of an assisted living facility has the rights and responsibilities as provided in § 63.2-1808 of the Code of Virginia and this chapter. According to §63.2-1808 of the Code of Virginia-Rights and Responsibilities of residents of assisted living facilities: A-6 In the event a medical condition should arise while he is residing in the facility, is afforded the opportunity to participate in the planning of his program of care and medication treatment at the facility and the right to refuse treatment.
Evidence
  1. According to the progress notes entered at approximately 1:27 pm on 9/10/2021, Resident #1 sustained a fall from standing and hit his head on the right side. Staff #1 assessed the Resident and observed “some redness on Rt temple.” The progress notes indicate that the Resident did not lose consciousness and was alert and oriented times three. The progress notes reported that the Resident had normal range of motion of left upper and lower extremities and that “Rt sided weakness and limited ROM of RUE and RLE is baseline for resident.” According to the progress notes, “Resident reports increased Rt leg pain and requests medications.” The documented pain level was 8 out of 10 for the resident. The resident requested and was administered pain medications and placed back into bed.
  2. According to the interview with Staff #1 from 11/1/2021, when being assessed for possible injuries from the fall on 9/10/2021, Resident #1 had “difficulty communicating whether the pain he was experiencing was new or old pain and would not answer questions being asked of him.” Staff #1 commented that Resident #1 “does not communicate well when he is in pain.” Staff #1 stated she did observe a pink mark on the right temple area of the Resident #1. According to Staff #1, there had been a previous incident in which Resident #1 was in pain and requested to be sent out to the hospital. Staff #1 was asked if Resident #1 was offered the option of going to the hospital or did Resident #1 communicate that he did not want to go to the hospital. Staff #1 responded “he did not ask to go to ER and I did not offer.” Staff #1 commented that based upon her assessment of Resident #1 it was determined that Resident #1 did not need to be sent out to the hospital.
  3. According to an interview with Collateral Contact #1 on 10/28/2021, Staff #1 left a voicemail message at approximately 1:17 pm on 9/10/2021, asking for a return call in regards to Resident #1, but the voicemail message did not mention that Resident #1 had fallen. At approximately 5:40 pm, Collateral Contact #1 received a text message from Resident #1 that stated “Do I fall bad.” The Collateral Contact contacted 911 and requested that Resident #1 be sent out to the hospital for evaluation. According to Collateral Contact #1, on 9/10/2021, Resident #1 was diagnosed with a fractured right hip and had surgery within 12 hours of the diagnosis. Resident #1 also suffered a fractured right elbow. Collateral Contact #1, reported that surgery for the fractured elbow was not going to be performed.
Plan of correction
1. It is duly noted that the facility nurse did not ensure the resident's rights and responsibilities as provided in §63.2-1808 of the Code of Virginia.; the nurse is no longer employed by the facility. 2. The Resident Services Director, or designee, will re-educate nurses, medication care partners, and direct care partners on the resident's rights and responsibilities as provided in §63.2-1808.
August 18, 2021Inspection3 violations
Inspection dates
08/18/2021,09/30/2021
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
A non-mandated self-report inspection was initiated on 8/18/2021 and concluded on 9/30/2021. A self-reported incident was received by the department regarding allegations in the area of resident care. The administrator was contacted by telephone and by email to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the self-report of non-compliance with standards or law, and violations were issued. Any violations not related to the self-report but identified during the course of the investigation can be found on the violation notice. Areas of non-compliance are identified on the violation notice. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word "corrected" is not acceptable. The plan of correction must contain: 1) steps to correct the non-compliance with the standard(s), 2) measures to prevent the non-compliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s). Thank you for your cooperation and if you have any questions please call 703-479-5247 or contact me via e-mail at jamie.eddy@dss.virginia.gov.
Violations
22VAC40-73-450-F
Based upon a review of records, the facility failed to ensure that individualized service plans shall be reviewed and updated as needed as the condition of the resident changes.
Evidence
  1. The Individualized Service Plan (ISP) dated 7/14/2021 for Resident #1 indicates under the identified need of psychosocial services “resident has current or history of wandering that does not jeopardize safety. Current or history of wandering within the residence or facility and may wander outside but does not jeopardize health of safety (of self or others). May have behavior management in place”; services are to be provided by caregiver and direct care staff in the resident’s apartment and throughout the community, and the goal is that “resident will maintain or maximize current level of functioning with wandering.” The progress notes for Resident #1 would indicate Resident #1 current plan for addressing the psychosocial unmet need, should be updated due to change in Resident #1 condition. The progress notes for the following dates for Resident #1 indicate that Resident #1 has exhibited aggressive/disruptive behaviors that jeopardize herself and other residents: A. 7/5/2021 at approximately 3:42 pm, resident noted to be “very close and affectionate towards male residents and gets very upset when redirected, she is refusing care and meals if she is fixed to a male resident.” B. 7/6/2021 at approximately 9:10pm, “resident noted wants to be close to male residents, private aid redirects her.” C. 7/7/2021 at approximately 6:04 pm, “Resident engaged with PDA (private duty aide), ate her meals, and took her schedule meds, notes to still chase male resident but able to be redirected by private duty. POA (power of attorney) updated, team aware to monitor resident’s whereabouts.” D. 7/9/2021 at approximately 12:47 pm, “Resident noted wearing T-shirt as a skirt at breakfast time, when PDA arrived she helped resident to changed clothes, resident love to be closer and she want to sat down on male resident lap and private caregiver redirects her and offered her some drinks.” E. 7/11/2021 at approximately 9:06 pm, “Staff reported to nurse that resident was witnessed to be engaged in activity of sexual nature with another resident, residents were separated and redirected.” F. 7/25/2021 at approximately 11:43 am, “Resident was observed approaching another female resident and agitating her, she then slapped her hand.” G. 8/3/2021 at approximately 4:38 pm, “Staff reported to writer that resident came inside Room 2036, the sister found out that resident was inside the room kissing the other resident.” H. 8/8/2021 at approximately 3:59 pm “Resident’s sister Sally came to visit around 3:10pm, after not finding resident in TV area or her suite she proceeded to walk the lobby and heard some moaning noise coming near Suite 2007, she then saw the resident’s shoe near 2007 door and observed her sister with male resident in bed having intercourse.” The progress notes for this incident indicate “resident unable to recall episode, other male resident was redirected.” I. 8/12/2021 at approximately 4:08 pm “Resident continues to approach other male residents, difficult to redirect.” J. 8/24/2021 at approximately 6:02pm “Resident was in verbal argument with another resident, the other resident struck out her fist and made contact to the chest area. Resident does not have any marks to chest area.” Due to extensive information additional evidence is found on a seperate form.
Plan of correction
The Individualized Service Plan (ISP) for Resident #1 and Resident #2 were updated to reflect the change of condition. The Resident Services Director (RSD), or designee, will ensure the ISP is updated when there is a significant change upon review for all residents.
22VAC40-73-460-H
Based upon a review of records, 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 dressing.
Evidence
  1. According to progress notes for 7/9/2021 for Resident #1 “resident noted wearing T-shirt as her skirt at breakfast time” and on 8/5/2021 the progress note stated “staff reported resident walking on the hallway naked yesterday and today.”
  2. The Uniform Assessment Instrument (UAI) dated 6/21/2021 indicates that Resident #1 needs human help and supervision with dressing.
  3. The Individualized Service Plan (ISP) for Resident #1, dated 7/14/2021, documents that Resident #1 as an identified need of dressing, the description of the services to be provided indicate that the “resident can dress/undress and select clothing but may need to be reminded/supervised”, the person who will provide services is documented on the ISP as the caregiver and/or direct care staff, and the services will be provided in the resident’s apartment and the goal listed on the ISP is that “resident will maintain and/or maximize current level of functioning with dressing.”
Plan of correction
The community will 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 dressing. The Resident Services Director (RSD), or designee, will ensure personal assistance and care are provided; including dressing.
22VAC40-73-440-A
Based upon a review of records, the facility failed to ensure that a UAI shall be completed whenever there is a significant change in the resident’s condition.
Evidence
  1. Resident # 1 lives in a secured care unit due to a serious cognitive impairment. The Uniform Assessment Instrument (UAI) for Resident #1 dated 6/21/2021 documents that Resident #1 is disoriented to time, place, and person some of the time. The UAI for Resident #1 indicated that the resident’s behavior pattern is “wandering/passive less than weekly.” The progress notes document that on the following dates, Resident #1 exhibited the following disruptive or aggressive behaviors: A. 7/5/2021 at approximately 3:42 pm, resident noted to be “very close and affectionate towards male residents and gets very upset when redirected, she is refusing care and meals if she is fixed to a male resident.” B. 7/6/2021 at approximately 9:10pm, “resident noted wants to be close to male residents, private aid redirects her.” C. 7/7/2021 at approximately 6:04 pm, “Resident engaged with PDA (private duty aide), ate her meals, and took her schedule meds, notes to still chase male resident but able to be redirected by private duty. POA (power of attorney) updated, team aware to monitor resident’s whereabouts.” D. 7/9/2021 at approximately 12:47 pm, “Resident noted wearing T-shirt as a skirt at breakfast time, when PDA arrived she helped resident to changed clothes, resident love to be closer and she want to sat down on male resident lap and private caregiver redirects her and offered her some drinks.” E. 7/11/2021 at approximately 9:06 pm, “Staff reported to nurse that resident was witnessed to be engaged in activity of sexual nature with another resident, residents were separated and redirected.” F. 7/25/2021 at approximately 11:43 am, “Resident was observed approaching another female resident and agitating her, she then slapped her hand.” G. 8/3/2021 at approximately 4:38 pm, “Staff reported to writer that resident came inside Room 2036, the sister found out that resident was inside the room kissing the other resident.” H. 8/8/2021 at approximately 3:59 pm “Resident’s sister Sally came to visit around 3:10pm, after not finding resident in TV area or her suite she proceeded to walk the lobby and heard some moaning noise coming near Suite 2007, she then saw the resident’s shoe near 2007 door and observed her sister with male resident in bed having intercourse.” The progress notes for this incident indicate “resident unable to recall episode, other male resident was redirected.” I. 8/12/2021 at approximately 4:08 pm “Resident continues to approach other male residents, difficult to redirect.” J.8/24/2021 at approximately 6:02pm “Resident was in verbal argument with another resident, the other resident struck out her fist and made contact to the chest area. Resident does not have any marks to chest area.” Due to extensive information, additional evidence is documented on a seperate form.
Plan of correction
The Uniform Assessment Instrument (UAI) for Resident #1 and Resident #2 were updated to reflect the significant change in the resident's condition. The Resident Services Director (RSD), or designee will ensure the UAI is updated when there is a significant change upon review for all residents.
July 19, 2021Complaint survey0 violations
Inspection dates
July 19, 2021 and July 23, 2021
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
A non-mandated complaint inspection was initiated on 7/19/2021 and concluded on 7/23/2021. A complaint was received by the department regarding allegations in the areas of resident care. The administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed that administrator a list of documentation required to complete the investigation. The licensing inspector conducted the on-site observation at the facility on 7/19/2021. The evidence gathered during the investigation did not support the allegations of non-compliance with the standards or law.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
March 18, 2021Inspection0 violations
Inspection dates
March 18, 2021 and March 31, 2021
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A focused monitoring inspection was initiated on 3/18/2021 and concluded on 3/31/2021 to ensure correction of violations cited during 1/26/2021, 2/25/2021 complaint inspection. The administrator was contacted by telephone to initiate the inspection. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed 10 resident records. Interviews were conducted with the administrator. All previous violations were found to have been corrected. The information gathered during the inspection determined no violations with applicable standards or law. No violations were issued. The exit interview was conducted via telephone on 3/31/2021 with the administrator. Thank you for your cooperation and if you have any questions please call 703-479-5247 or contact me via e-mail at jamie.eddy@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
March 15, 2021Inspection0 violations
Inspection dates
March 15, 2021 and March 19, 2021
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity32.1 Reported by persons other than physicians63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS
Comments
This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 3/15/2021 and concluded on 3/19/2021. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 73. The inspector emailed the administrator a list of items required to complete the inspection process. The inspector reviewed four resident records, four staff records, staff schedule, fire drill reports, annual health and fire inspections, and dietary and healthcare oversight reports submitted by the facility to ensure documentation was complete. LI reviewed the Criminal Background Checks for all staff hired since the last monitoring inspection conducted on 3/10/2021. The entrance and exit interviews were completed with the administrator. The exit interview took place on 3/19/2021 via telephone with the administrator and resident services director. The information gathered during the inspection determined no violations with applicable standards or law. No violations were issued.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
January 26, 2021Complaint survey7 violations
Inspection dates
Jan. 26, 2021 and Feb. 25, 2021
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
This inspection was completed by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A complaint inspection was initiated on 1/25/2021 and concluded on 2/25/2021. A complaint was received by the department regarding allegations in the areas of staffing quantity, medication administration, and resident care. The administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the administrator a list of documentation require to complete the investigation. LI reviewed nine resident records. LI interviewed two residents, one family member, and conducted the entrance and exit interviews with the administrator and Resident Care Director. The evidence gathered during the investigation supported the allegations of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice. Areas of non-compliance are identified on the violation notice. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word "corrected" is not acceptable. The plan of correction must contain: 1) steps to correct the non-compliance with the standard(s), 2) measures to prevent the non-compliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s). Thank you for your cooperation and if you have any questions please call 703-479-5247 or contact me via e-mail at jamie.eddy@dss.virginia.gov
Violations
22VAC40-73-280-A
Based upon a review of resident records, staff work schedule, interviews, and documentation made on the Medication Variance Report by staff, the facility failed to ensure there were staff sufficient in numbers to provide services to attain and maintain the physical, mental, and psychosocial well-being of each resident as determined by resident assessments and individualized service plans, and to ensure compliance with this chapter.
Evidence
  1. The Medication Variance Report (MVR) indicates that the following medications were given more than one hour after the dosing schedule due to med tech administering medications on the 4th floor on 1/3/2021: Resident #1: 8am medications administered at approximately 9:33 am Resident #5: 9am medications administered at approximately 10:55 am Resident #8: 8am medications administered at approximately 9:38am According to the MVR, 4pm medications were administered greater than one hour after the dosing schedule on 1/14/2021 for the following residents because the med tech assigned to administer medications was ?in a meeting at the time.? Resident #3: 4pm medications were administered at approximately 6:10pm Resident #9: 4pm medications were administered at approximately 5:40pm The MVR indicates that on 1/16/2021, 8am and 9am medications were administered greater than one hour after the dosing schedule for the following residents due to "short staff." Resident #3: 8am medications were administered at approximately 1:02pm Resident #4: 9am medications were administered at approximately 12:59pm Resident #5: 8am medications were administered at approximately 11:37am Resident #6: 8am medications were administered at approximately 10:23am Resident #8: 8am medications were administered at approximately 12:38pm Resident #9: 8am medications were administered at approximately 2:49pm According to the work schedule provide by the facility, the staffing assignments for 1/16/2021 had the nurse on duty administering medications to the first floor from 7am to 3pm. The MVR and the January 2021 MARS indicate that the nurse on duty also administered medications to residents on the COVID unit located on the 4th floor (Residents #3,#4,#5,#6,#8, and #9). The shortage of staff on 1/16/2021 resulted in 8am medications being administered greater than one hour after the dosing schedule. On 2/22/2021, LI requested a copy of the January 2021 work schedule that would indicate any changes to the schedule such as call outs or substitutions. LI never received the requested document.
Plan of correction
It is duly noted that the staffing may not have been at full capacity for residents 1, 3-7, 8 and 9 to attain and maintain the physical, mental, and psychosocial well-being of each resident during the time period in which the community was experiencing a COVID-19 virus outbreak that affected 49 residents and team members. We are taking the following steps for performance improvement to ensure compliance in this area of concern. The Executive Director (ED) will review staffing numbers with Resident Services Director (RSD) to ensure sufficient numbers are schedule to provide services to attain and maintain the physical, mental, and psychosocial well-being of each resident. The ED shall engage the clinical consultants for process improvement opportunities related to staff.
22VAC40-73-460-B
Based upon interviews with residents and family members and review of facility reports, the facility failed to provide care and provision of services to residents that includes prompt response by staff to resident needs as reasonable to the circumstances.
Evidence
  1. Resident #1 was moved to the COVID unit on 1/8/2021 and according to a collateral contact #1 it had been requested that her lift chair and incontinence pads be moved to the new room as the chair is needed to help with transferring and the incontinence pads to help with bladder incontinence. According to an interview with a collateral contact #1, the chair and the incontinence pads were moved approximately after 1pm on 1/9/2021. Collateral contact #1 reported that Resident #1 needed help in the bathroom on 1/20/2021 and called a family member when there was no response from the staff. According to collateral contact #1 a family member of Resident #1 stayed on the phone for approximately 45 minutes until staff arrived to help. An interview with collateral contact #1 revealed information that during the night of 1/12/2021 and early morning of 1/13/2021, the resident had pressed her call button for help because she could not breathe but no one came quickly. LI requested the Call Bell Response Reports on 2/3/2021 to determine the length of time staff were taking to respond to call bells. LI was not provided the requested report and was informed on 2/11/2021 that a system error had occurred with the call bell system which would not allow retrieval of the requested information. The administrator stated that the call bell system had to be rebooted which “would cause a loss of date.” Due to the reboot the facility was not able to provide the requested information. Interview with collateral contact #1 reported during the evening of 1/9/2021, a male resident wandered into the room of Resident #1 on the 4th floor COVID Unit. According to collateral contact #1, Resident #1 pushed her call bell multiple times with no response. Resident #1 then walked the male resident down the hall “without finding anyone in the area.” Collateral contact #1 reported that Resident #1 sat with the male resident and waited for someone to return the area. Collateral contact #1 was unable to state how long Resident #1 had to wait for staff to arrive and did not know the name of the staff person who did arrive. The staff member who came to aide Resident #1 allegedly stated that she was ? covering the 2nd floor that night.? Multiple interviews with collateral contact #2 yielded information regarding a lack of prompt response by staff to resident’s needs in regards to an order from the nurse practitioner (NP). The collateral contact reported that a resident complained of dizziness to the NP on 1/25/2021 and the NP put in a request for staff to take the resident’s vitals on 1/25/2021. Collateral contact #2 indicated that the resident did question staff about the NP’s request for the vitals be checked but the resident’s vitals were never checked.
Plan of correction
It is duly noted that resident responses for assistance may have been temporarily delayed during the time period in which the community was experiencing a COVID-19 virus outbreak that affected 49 residents and team members. We are taking the following steps for performance improvement to ensure compliance in this area of concern. The Resident Services Director (RSD), or designee, will re-educate the care partners on the importance of prompt response to resident needs. The RSD shall engage the pharmacy partner and clinical consultants for process improvement opportunities related to prompt response by staff to resident needs.
22VAC40-73-680-C
Based upon a review of resident records and interviews, the facility failed to ensure that medications shall 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
  1. According to the Medication Variance Report (MVR) medications for the following residents were administered either greater than one hour before or greater than one hour after the dosing schedule. Resident #1: 6am medications: 1/11/2021 administered at approximately 8:30am 8am medications: 1/2/2021-administered at approximately 10:27am 1/3/2021-administered at approximately 9:33am 1/10/2021-administered at approximately 12:52pm Resident #2: 8am medications: 1/7/2021 administered at approximately 9:28am 1/10/2021-administered at approximately 12:26pm 1/18/2021-administered at approximately 11:19am 8pm medications: 1/17/2021 administered at approximately 10:41pm Resident #3: 8am medications: 1/8/2021 administered at approximately 11:02am 1/10/2021 administered at approximately 12:47pm 1/16/2021 administered at approximately 1:02pm Resident #4: 9am medications: 1/4/2021 administered at approximately 10:17am 1/8/2021 administered at approximately 10:28am 1/16/2021 administered at approximately 12:59pm 8pm medications: 1/17/2021-administered at approximately 1:37pm 1/22/2021 administered at approximately 9:28pm 1/26/2021 administered at approximately 10:54 pm Resident #5: 8am medications: 1/3/2021 administered at approximately 10:55am 1/16/2021 administered at approximately 11:37am 5pm medications: 1/28/2021 were administered at approximately 7:50pm Resident #6: 8am medications: 1/5/2021 administered at approximately 10:30am 1/8/2020 administered at approximately 11:37am 1/11/2021 administered at approximately 12:35pm 1/12/2021 administered at approximately 10:44am 1/15/2021 administered at approximately 9:56am 1/16/2021 administered at approximately 10:23am 1/17/2021-administered at approximately 10:43am 1/182021 administered at approximately 10:05am 9am/9:30am medications: 1/11/2021 administered at approximately 12:35pm 1/12/2021 administered at approximately 10:44am 1/22/2021 administered at approximately 11:04am On 1/30/2021 a medication to be administered between 7am and 2:59pm was administered at approximately 5:05pm 6pm medications: 1/9/2021 administered at approximately 10:10pm 8pm medications: 1/19/2021 administered at approximately 10:22pm 1/20/2021 administered at approximately 10:19pm 1/21/2021 administered at approximately 10:33 pm Resident #7: 2am medications: 1/4/2021 administered at approximately 4:14am 8am medications: 1/5/2021 administered at approximately 10:31am 1/10/2021 administered at approximately 10:06am 1/21/2021 administered at approximately 12pm Resident #8: 8am medications: 1/3/2021 administered at approximately 9:38am 1/10/2021 administered at approximately 11:04am 1/16/2021 administered at approximately 12:38pm 1/17/2021 administered at approximately 1:33pm 5pm medications: 1/22/2021 administered at approximately 6:27pm 1/27/2021 administered at approximately 9:37pm Resident #9: 7:30am medications: 1/3/2021 administered at approximately 10:43am 1/17/2021 administered at approximately 12:57pm 1/22/2021 administered at approximately 8:57am 1/29/2021 administered at approximately 8:55am 8am medications: 1/3/2021 administered at approximately 1:36 pm 1/16/2021 administered at approximately 2:49pm 1/25/2021 administered at approximately 2:18pm 4pm medications: 1/14/2021 administered at approximately 5:40pm 1/22/2021 administered at approximately 6:04pm
Plan of correction
It is duly noted that Medication Administration Records (MARS) for residents 1-9 did not consistently include documentation for the timely administration of medications during the time period in which the community was experiencing a COVID-19 virus outbreak that affected 49 residents and team members. We are taking the following steps for performance improvement to ensure compliance in this area of concern. The Resident Services Director (RSD), or designee, will re-educate the medication care partners on the importance of timely administration of medications and treatments including timely documentation. The RSD shall engage the pharmacy partner and clinical consultants for process improvement opportunities related to timely administration of medications.
22VAC40-73-680-D
Based upon a review of resident records, the facility failed to ensure that medications shall be administered in accordance with the physician's or other prescriber's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing.
Evidence
  1. Resident #2 a physician’s order for 9 units of Humalog to be given at approximately 8am was written on 1/10/2021, according to the January 2021 Medication Administration Records (MARS). The MARS indicates that on January 17, 2021 at approximately 8am, Resident #2 did not receive the dosage of the current order for 9 units of Humalog but received a discontinued order for a 13 unit dosage of Humalog. The physician’s order for the 13 units of Humalog to be given at 8am was, according to the MARS, stopped on 1/5/2021. On 2/16/2021 the Licensing Inspector (LI) requested a copy of the physician’s order to discontinue the 13units of Humalog at 8am. The facility did not provide the requested physician? s discontinuation order. A physician’s order for 4units of Humalog to be administered at approximately 8pm was written, according to the MARS, on 1/13/2021. The MARS indicates that on 1/15/2021 and 1/16/2021, Resident #2 did not receive the current ordered dosage of 4units of Humalog but received a discontinued order for 8units of Humalog to be given at approximately 8pm. The physician’s order for 8 units of Humalog to be administered at approximately 8pm was stopped, according to the MARS, on 1/5/2021. On 1/13/2021 and 1/14/2021, the MARS indicates that Resident #2 was administered at approximately 8pm the current order of 4 units of Humalog in addition to the discontinued order of 8 units of Humalog. On 2/16/2021 the Licensing Inspector (LI) requested a copy of the physician’s order to discontinue the 8units of Humalog at 8pm. The facility did not provide the requested physician’s discontinuation order. Resident #1:-- According to the January 2021 MARS, Resident #1 had a physician's order for Famotidine 20milligrams (mg) twice a day for four weeks to be given at approximately 8am and 8pm. A physician’s order for Famotidine 20mg, two tablets daily to be given at approximately 9am, had been written on 4/10/2020. On 1/10/2021, Resident #1 was administered one 20mg tablet of Famotidine and two 20mg tablets of Famotidine at approximately 12:52pm. On 1/11/2021, 1/12/2021, and 1/13/2021, Resident #1 was administered one 20mg tablet of Famotidine at approximately 8am and two 20mg tablets at approximately 9am, according to the January 2021 MAR. On 2/16/202 and 3/9/2021, LI requested a copy of the discontinuation order for Famotidine 20mg two tablets once a day, but the facility failed to provide the physician’s discontinuation order.
Plan of correction
It is duly noted that documentation for residents 1,2 reflects medications were not delivered in accordance with the physician's instructions and consistent with the standards of practice as outlined in the current registered medication aide curriculum by the Virginia Board of Nursing during the time period in which the community was experiencing a COVID-19 virus outbreak that affected 49 residents and team members. We are taking the following steps for performance improvement to ensure compliance in this area of concern. The Resident Services Director (RSD), or designee, will re-educate the medication care partners on insulin management and importance of double checking for new orders, particularly with high risk medications. The RSD shall engage the pharmacy partner and clinical consultants for process improvement opportunities related to time medication administration.
22VAC40-73-680-E
Based upon a review of resident records, the facility failed to ensure that medical procedures or treatments ordered by a physician or other prescriber shall be provided according to his instructions.
Evidence
  1. Resident #3: A physician's order was written on 10/16/2020 for resident to be repositioned "every two hours for skin breakdown treatment." The Medication Variance Report (MVR), is a report obtained from the facility’s electronic medication system CareSuite by Quick Mar and is used to document the exact times of medication administration, administration of treatment orders, and administration of orders for vitals was reviewed. According to the MVR, repositioning was not completed as ordered by physician for the following dates and times: 12 am repositioning: 1/19/2021 completed at approximately 2:36 am 1/27/2021 completed at 3:53am, at the same time as the 2am repositioning 1/28/2021 completed at 3:00am, at the same time as the 2am repositioning 2 am repositioning: 1/12/2021 completed at approximately 4:05am 1/13/2021 completed at approximately 3:57am 1/21/2021 completed at approximately 5:42am, at the same time as the 4am repositioning 1/27/2021 completed at 3:53am, at the same time as the 12 am repositioning 4 am repositioning: 1/16/2021 completed at approximately 5:36am 1/21/2021 completed at approximately 5:42am 8 am repositioning: 1/8/2021 completed at approximately 11:02am, same time as the 10am repositioning 1/10/2021 completed at approximately 1:59pm, same time as the 10am and 12 pm repositioning 10am repositioning: 1/10/2021 completed at approximately 1:59pm, same time as the 8am and 12pm repositioning 1/16/2021 completed at 1:02pm, same time as the 12pm repositioning 12pm repositioning: 1/10/2021 completed at approximately 1:59pm same time as the 8am and 10am repositioning 1/16/2021 completed at approximately 1:02pm, same time as the 10am repositioning 2pm repositioning: 1/18/2021 completed at approximately 9:18am 4pm repositioning: 1/14/2021 completed at approximately 6:10pm 8pm repositioning: 1/15/2021 completed at approximately 10:22pm Resident #2-A physician’s order was written on 1/7/2021 for blood sugar to be checked and recorded before meals and at bedtime for diabetes. Blood sugar checks and recordings were not administered according to the physician’s order for the following dates and times: 7:30am blood sugar checks 1/10/2021-completed at approximately 12:36pm 1/18/2021-completed at approximately 11:19am 1/22/2021-completed at approximately 10:30am 11:30am blood sugar checks: 1/22/2021-completed at approximately 12:54 pm 4:30pm blood sugar checks: 1/22/2021 completed at approximately 6:47pm
Plan of correction
It is duly noted that resident 3 did not have medical procedures or treatments ordered by a physician documented in the health record during the time period in which the community was experiencing a COVID-19 virus outbreak that affected 49 residents and team members. We are taking the following steps for performance improvement to ensure compliance in this area of concern. The Resident Services Director (RSD), or designee, will re-educate the medication care partners on the importance of following physician's orders for procedures or treatments. The RSD shall engage the pharmacy partner and clinical consultants for process improvement opportunities related to the importance of following physician's orders for procedures and treatments.
22VAC40-73-680-H
Based upon a review of resident records, the facility failed to ensure that at the time the medication is administered, the facility shall document on a medication administration record (MAR) all medications administered to residents, including over-the-counter medications and dietary supplements.
Evidence
  1. The Medication Variance Report (MVR) indicates that documentation of the administration of medications was not done at the time of administration for the following residents: Resident #2: 1pm medications (Prednisone) 1/8/2021 the documented time given was approximately 2:39pm but staff noted on MVR that medication was ?given on time late entry.? 2pm medications (Sodium Bicarb) 1/30/2021 the documented time given was approximately 5:04pm but staff noted on MVR that medication was ?given on time late entry.? 8pm medications (Humalog, Simvastatin, Sodium Bicarb) 1/21/2021 the documented time given was approximately 9:31pm but staff noted on MVR that medications were ?given on time.? 1/26/2021-the documented time given was approximately 9:36 pm but staff noted on MVR that medications ?given on time late entry.? Resident #3: 8am and 9am medications (Acetaminophen, Ascorbic Acid, Chlorhexidine, Donepezil, Eliquis, Sertraline, Triple Antibiotic Ointment, Vit. D3, and Zinc Gluconate): 1/17/2021-the documented time given was approximately 1:40pm but staff noted on MVR that medications were ?given on time late entry.? 8pm and 9pm medications (Chlorhexidine, Eliquis, Verapamil, 1/8/2021 the documented time given was approximately 10:06 pm but staff noted on MVR that medications were ?given on time late entry.? 1/10/2021 the documented time given was approximately 10:10pm but staff noted on MVR that medications were ? given on time but late entry.? 1/20/2021 the documented time given was approximately 10:16/10:17pm but staff noted on MVR that medications were “given on time but late entry.” Resident #4: 8am medications (Amlodipine, Aspirin, Donepezil, Memantine, Sertraline, Tamsulosin HCL, Vit. D3, and Zinc Gluconate) 1/14/2021 the documented time given was approximately 9:37am but staff noted on MVR that medications were given ? on time.? Resident #5: 6pm medications (Propranolol, Simvastatin) 1/16/2021-the documented time administered was approximately 7:56pm but staff noted on MVR that medication was ? given on time late entry.? Resident #6: 8am medications and 9:30 am medications (Artificial Tears, Aubagio, Baclofen, Calcium 600+VitD, Digestive Advantage Lactose, Docusate, Evening Primrose Oil, Fexofenadine HCL, Fluticasone spray, Olopatadine HCL, One Daily for Women, Turmeric Caps, Vit. D, and Vit. D3) 1/7/2021 the documented time administered was 2:05 pm but staff noted on MVR that medications were ?gave on time.? 5pm medications (Baclofen) 1/26/2021 the documented time administered was approximately 9:38pm but staff noted on MVR that medications were administered as “given on time late entry.” Resident #7: 8am medications (Acetaminophen, Ascorbic Acid, Barrier Cream, Cranberry, Famotidine, Ferrous Sulfate, Memantine, Multi-vitamin, Omeprazole, Polyethylene Glycol, Quetiapine Fumarate, Senna Plus, Symbicort, Tramadol, Venlafaxine HCL, Vitamin B-12, Vitamin D3, and Zinc Sulfate) 1/1/2021 the documented time administered was approximately 12:34 pm but staff noted on MVR that medications were 1/1/2021-the documented time administered was approximately 12:34 pm but staff noted on MVR that medications were “on time late entry.” Due to the volume of information gathered, a separate document has been created and is available upon request from the Fairfax Licensing Office.
Plan of correction
It is duly noted that the Medication Administration Records (MARS) did not consistently include the time medications were administered to residents 2, 3,6,7, and 9 during the time period in which the community was experiencing a COVID 19-virus outbreak that affected 49 residents and team members. We are taking the following steps for performance improvement to ensure compliance in this area of concern. The Resident Services Director (RSD), or designee, will re- educate the medication care partners on the importance of timely administration of medications and treatments including timely documentation. The RSD shall engage the pharmacy partner and clinical consultants for process improvement opportunities related to timely medication administration documentation.
22VAC40-73-680-I
Based upon a review of resident records, the facility failed to ensure that the Medication Administration Records (MARS) shall include: initials of direct care staff administering the medication.
Evidence
  1. The January 2021 Medication Administration Records (MARS) did not include the initials of the staff person administering the medications for the following residents on the following dates: Resident #3: 12am medications (Acetaminophen) 1/11/2021 the initials of the staff person administrating the medication were missing on the MARS 1/17/2021 the initials of the staff person administering the medications were missing on the MARS 6:30am medications (Levothyroxine) 1/17/2021 the initials of the staff person administering the medications were missing on the MARS 1/30/2021 the initials of the staff person administering the medications were missing on the MARS 1/31/2021 the initials of the staff person administering the medications were missing on the MARS 4pm medications (Acetaminophen) 1/2/2021 the initials on the MARS indicates the med tech administered the medications, but the pass notes on the MARS document that the medications were administered by Staff #1. 8pm medications (Eliquis, Magic Mouthwash, Verapamil) 1/2/2021-the initials on the MARS indicates the med tech administered the medications, but the pass notes on the MARS document that the medications were administered by Staff #1 Resident #4: 8am medications (Amlodipine, Ascorbic Acid, Aspirin, Donepezil, Ensure, Memantine, Mucinex, Sertraline, Tamsulosin, Vit. D3, and Zinc Gluconate) 1/17/2021-- the initials of the staff person administering the medications were missing on the MARS Resident #6: 6:30am medications (Levothyroxine) 1/18/2021- the initials of the staff person administering the medications were missing on the MARS 9:30am medications (Artificial Tears, Aubagio, Baclofen, Calcium 600+VitD, Digestive Advantage Lactose, Docusate, Evening Primrose Oil, Fexofenadine HCL, Fluticasone spray, Olopatadine HCL, One Daily for Women, Turmeric Caps, Vit. D, and Vit. D3) 1/9/2021 The Medication Variance Record (MVR) indicates that the person administrating the medications was the nurse on duty, but the initials on the MARS document it was the med tech who administered the medications. 6pm medications (Baclofen) 1/5/20210- the initials of the staff person administering the medications were missing on the MARS 1/8/2021-- -the initials on the MARS indicates the med tech administered the medications, but the pass notes on the MARS document that the medications were administered by the nurse on duty. 1/10/2021-- -the initials on the MARS indicates the med tech administered the medications, but the pass notes on the MARS document that the medications were administered by the nurse on duty. 1/15/2021-- the initials on the MARS indicates the med tech administered the medications, but the pass notes on the MARS document that the medications were administered by the nurse on duty.. 1/16/2021-- the initials on the MARS indicates the med tech administered the medications, but the pass notes on the MARS document that the medications were administered by the nurse on duty. Resident #7: 2am medications (Acetaminophen) 1/8/2021-- the initials of the staff person administering the medications were missing on the MARS 6am medications (Levothyroxine) 1/8/2021-- the initials of the staff person administering the medications were missing on the MARS 1/11/2021-- the initials of the staff person administering the medications were missing on the MARS 1/18/2021-- the initials of the staff person administering the medications were missing on the MARS Resident #9: 2pm medications (Ascorbic Acid) 1/22/2021-- the initials of the staff person administering the medications were missing on the MARS
Plan of correction
It is duly noted that the Medication Administration Records (MARS) did not include initials of direct care staff administering medications to residents 3, 4, 6, and 7 during the time period in which the community was experiencing a COVID-19 virus outbreak that affected 49 residents and team members. We are taking the following steps for performance improvement to ensure compliance in this area. The Resident Services Director (RSD), or designee, will re- educate the medication care partners on ensuring their initials are documented on the MARS. The RSD shall engage the pharmacy partner and clinical consultants for process improvement opportunities related to initials on the MARS.
December 14, 2020Inspection2 violations
Inspection dates
Dec. 14, 2020 and Jan. 26, 2021
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A focused monitoring inspection was initiated on 12/14/2020 and concluded on 01/26/2021. A self-reported incident was received by the department regarding allegations in the areas of resident care. The administrator was contacted by email to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. LI reviewed two residents records and the staff work schedule. LI interviewed the resident care coordinator. The evidence gathered during the investigation supported the self-report of non-compliance with standards or law, and violations were issued. The exit interview was completed by telephone on 1/26/2021 with the administrator and resident care coordinator. Areas of non-compliance are identified on the violation notice. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word "corrected" is not acceptable. The plan of correction must contain: 1) steps to correct the non-compliance with the standard(s), 2) measures to prevent the non-compliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s). Thank you for your cooperation and if you have any questions please call 703-479-5247 or contact me via e-mail at jamie.eddy@dss.virginia.gov.
Violations
22VAC40-73-650-A
Based upon a review of resident records and interview with administration, the facility failed to ensure that no medication, dietary supplement, diet, medical procedure, or treatment shall be started, changed, or discontinued by the facility without a valid order from a physician or other prescriber. Medications include prescription, over-the-counter, and sample medications.
Evidence
  1. On 11/23/2020, a physician's order for Resident #1 was written for Trazadone 25mg (milligrams) by mouth twice a day. The December 2020 Medication Administration Record indicated that the order was discontinued on 12/02/2020. No physician's order for the discontinuation of the Trazadone 25mg by mouth twice a day was found in the record of Resident #1.
Plan of correction
It is duly noted that no order to discontinue from the physician was found for the Trazadone 25mg for Resident #1 on 12/2/2020. It is duly noted that the medication was discontinued with no negative outcome for the resident. The Resident Services Director (RSD), or designee, will re-educate the team member that discontinued the medication without a written order on ensuring that no medication, dietary supplement, diet, medical procedure, or treatment shall be started, changed or discontinued by the facility without a valid order from a physician or other prescriber. The RSD, or designee, will re- educate medication technicians on ensuring that no medication, dietary supplement, diet, medical procedure, or treatment shall be started, changed, or discontinued by the facility without a valid order from a physician or other prescriber. The Consultant Pharmacist will conduct a review of medication carts and resident records.
22VAC40-73-680-D
Based upon a review of resident records, the facility failed to ensure that medications shall be administered in accordance with the physician's or other prescriber's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing.
Evidence
  1. According to the physician's order, Lorazepam is to be administered to Resident #2 as follows: 1mg (milligram) 1 Tablet by mouth twice a day as needed. The December 2020 Medication Administration Record (MAR) documented that on 12/1/2020, Resident #2 received 1mg of Lorazepam three times at approximately 10:31 am, 5:45 pm, and 8:31 pm. No negative reaction to the extra dosage were documented.
Plan of correction
It is duly noted that on 12/2/2020, Resident #2 received three doses of Lorazepam 1mg and that this dosage was administered outside the physician's order to administer twice a day. It is duly noted that the resident did not have any negative reaction to the extra dose. The Resident Services Director (RSD), or designee will re-educate the team member that administered the medication on medication administration and following physician's or other prescriber's instructions. The RSD, or designee, will re-educate medication technicians on medication administration and following physician's or other prescriber's instructions. The Consultant Pharmacist will conduct a review of medication carts and resident records. The Consultant Pharmacist, or designee, will conduct a medication pass observation for Medication Care Partners.
December 14, 2020Complaint survey0 violations
Inspection dates
Dec. 14, 2020 and Jan. 26, 2021
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION
Comments
This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A complaint inspection was initiated on 12/14/2020 and concluded on 01/26/2021. A complaint was received by the department regarding allegations in the areas of staff quantity and infection control procedures. The administrator was contacted by email to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. LI reviewed seven resident records, staff work schedule, reports of response time to residents call bell alarms, and the infection control policy. LI interviewed the administrator and the resident care coordinator. The exit interview was completed on 01/26/2021 via telephone with the administrator and resident care coordinator. The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. Complaint regarding staffing quantity and infection control is deemed not valid as a preponderance of evidence gathered during the investigation did not support the allegations.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
November 20, 2020Inspection4 violations
Inspection dates
Nov. 20, 2020 and Dec. 2, 2020
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A focused monitoring inspection was initiated on 11/20/2020 and concluded on 12/02/2020. A self-reported incident was received by the department regarding allegations in the areas of resident care. The administrator was contacted by email to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The exit interview was held on 12/02/2020 by telephone. Two resident records and one staff record was reviewed. The administrator and resident services director were interviewed. Copies of written statement by the staff member involved was collected. The evidence gathered during the investigation supported the self-report of non-compliance with standards or law, and violations were issued. Areas of non-compliance are identified on the violation notice. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word "corrected" is not acceptable. The plan of correction must contain: 1) steps to correct the non-compliance with the standard(s), 2) measures to prevent the non-compliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s). Thank you for your cooperation and if you have any questions please call 703-479-5247 or contact me via e-mail at jamie.eddy@dss.virginia.gov.
Violations
22VAC40-73-680-B
Based upon staff member's written statement and interview with administration, the facility failed to ensure that medications shall remain in the pharmacy issued container with the prescription label or direction label attached, until administered to resident.
Evidence
  1. According to the written statement of 11/20/2020, provided by Staff #1, as she was preparing to administer medications to Resident #1, ?On my way going, I saw that it still remain 9 minutes to enter his apartment so I went to the forth floor to administer medication to another resident. Unfortunately I met the resident in help of ADL’s and distress waving, so I help her (Room 4008) and with five (Resident #1) medications in my hand.? Later in the written statement, Staff #1 stated ?though responding to the request, I literally forget that the medication of Mr. Paul was still in the medication cup in my hands and accidentally threw the cups in the trash can by the right side of the medication cart.?
Plan of correction
It is duly noted that the facility failed to ensure that medications shall remain in the pharmacy issued container with the prescription label or direction label attached, until administered to resident. The Resident Services Director, or designee, will re-educate medication aides on the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing.
22VAC40-73-680-D
Based upon the staff member’s written statement and interview with administration, the facility failed to ensure that medications shall be administered in accordance with the physician's or other prescriber's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing.
Evidence
  1. According to the November 2020 Medication Administration Record (MAR), Resident #1 is scheduled to receive the following medications at approximately 6 am and 6:30 am: Esomerprazole Levothyroxine, Nifedipine ER, and Oxycontin. On 11/18/2020 at approximately 8:30 am, Resident #1 reported to staff that he had not received his 6 am and 6:30 am medications. The MAR was reviewed by staff and the MAR indicated that all medications were administered. The staff member assigned to administer medications was contacted and the staff member reported that she had administered the medications to Resident #1. Upon a second interview, the staff member indicated that she had not administered the 6 am and 6:30 am medications. The staff member provided a written statement on 11/20/2020 in which she stated ?though responding to the request, I literally forget that the medication of Mr. Paul was still in the medication cup in my hands and accidentally threw the cups in the trash can by the right side of the medication cart.? The staff member explained to the administrator that she was asked to help with other residents when trying to administer medications to Resident #1, got distracted, and failed to administer the 6 am and 6:30 am medications to Resident #1.
Plan of correction
It is duly noted that the facility failed to ensure that medications were administered in accordance with the prescriber's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum by the Virginia Board of Nursing. The Resident Services Director, or designee, will re-educate medication aides on the standards of practice outlined in the current registered medication aide curriculum by the Virginia Board of Nursing.
22VAC40-73-680-H
Based upon a review of records, the facility failed to ensure that at the time the medication is administered, the facility shall document on a medication administration record (MAR) all medications administered to residents, including over- the-counter medications and dietary supplements.
Evidence
  1. The Medication Administration Record (MAR) for 10/9/2020 and 10/14/2020 did not contain the initials of the staff member administering medication that would indicate that Resident #1 had been administered the 6 am dosage of Oxycontin 15mg (milligrams) 1 Tablet every 8 hours. However, the Individual Resident’s Controlled Substance Record states that at approximately 9:40 am on 10/9/2020 and at approximately 6 am on 10/14/2020, Resident #1 was administered the prescribed order of Oxycontin 15mg 1 Tablet every 8 hours. The MAR for 11/15/2020 did not contain the initials of the staff member administering medication that would indicate that Resident #1 had been administered as ?as needed? prn dosage of Oxycodone 5/325mg (milligrams). The Individual Resident’s Controlled Substance Report Record has documented that at approximately 09:30 am on 11/15/2020 Resident #1 was administered 1 Tablet Oxycodone 5/325mg.
Plan of correction
It is duly noted that the facility failed to ensure that at the time the medication is administered, the facility documents on a MAR (Medication Administration Record) all medications administered to residents, including over-the-counter medications and dietary supplements. The Resident Services Director, or designee, will re-educate medication aides on the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing.
22VAC40-73-680-I
Based upon a review of records, the facility failed to ensure that the Medication Administration Record (MAR) shall include for “as needed” (prn) medications the following: symptoms for which medication was given, exact dosage given, and effectiveness.
Evidence
  1. The Individual Resident’s Controlled Substance Record document for Resident #1 indicates that on 11/15/2020 at approximately 9:30 am, Resident #1 was administered 1 Tablet of Oxycodone 5/325mg (milligrams) as needed (prn). The Medication Administration Record (MAR) for 11/15/2020 does not contain the initials of the staff member who administered the physician’s order of Oxycodone 5/325 mg (milligrams) 1 Tablet every 6 hours prn for Resident #1, nor does the MAR include the symptoms for which the medication was given, the exact dosage given, and the effectiveness of the Oxycodone 5/325 mg that was administered at approximately 9:30am to Resident #1.
Plan of correction
It is duly noted that the facility failed to ensure that the MAR (Medication Administration Record) included for "as needed" (PRN) medications the following: symptoms for which the medication was given, exact dosage given and effectiveness. The Resident Services Director, or designee, will re-educate medication aides on the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing.