13
Inspections
On record
4
With violations
Visits that cited something
9
Clean visits
Nothing cited
13
Violations cited
Individual findings
13
Standards cited
Distinct rules
3
Complaint visits
Prompted by a complaint

Paramount Senior Living at Manassas was inspected 13 times between January 30, 2021 and March 5, 2026 by the Virginia Department of Social Services. 4 of those visits ended with violations cited and 9 with none. Across that history VDSS cited 13 violations under 13 distinct standards. 3 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. 12 of these 13 are still on the state's site; the other 1 has since dropped off it and is reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type
Assisted Living Facility
License type
Two Year
License expires
03/31/2026
Administrator
Matthew Sutermesiter
Licensing inspector
Sarah Pearson
Inspector phone
(540) 680-9469
Approved for
Non-Ambulatory · Special Care Unit

Inspection History

13

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

March 5, 2026Complaint survey0 violations
Inspection dates
03/05/2026
Areas reviewed
Resident Care and Related Services
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 3/5/2026 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 2/10/2026 regarding allegations in the area(s) of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 59 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 5 Number of staff records reviewed: 0 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 4 Observations by licensing inspector: The LI observed residents participating in activity programs and eating meals. 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 Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
March 4, 2026Inspection6 violations
Inspection dates
03/04/2026; 03/05/2026
Areas reviewed
22VAC40-73 Administration and Administrative Services22VAC40-73 Personnel22VAC40-73 Staffing and Supervision22VAC40-73 Admission, Retention and Discharge of Residents22VAC40-73 Resident Care and Related Services22VAC40-73 Resident Accommodations and Related Provisions22VAC40-73 Building and Grounds22VAC40-73 Emergency Preparedness22VAC40-73 Additional Requirements for Facilities that Care for Adults with Cognitive Impairments22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 Sworn Statement
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: March 4th 9:45am-4:30pm and 5th, 2026 9:30am-12:00pm 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: 59 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 4 Observations by licensing inspector: The LI observed residents eating meals and participating in activity programs. 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. 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 Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov
Violations
22VAC40-73-980-H
Based on observation and staff interview, the facility failed to ensure the availability of 48 hours of emergency drinking water was on site at any given time.
Evidence
  1. On the date of the inspection on 3/4/2026 the LI observed 42 gallons of water on site and there were 59 residents residing at the facility on this day.
  2. Staff 4 confirmed there was 42 gallons of drinking water on site on 3/4/2026.
Plan of correction
22VAC40-73-980H Additional water ordered 3/6/2026 to bring facility up to required amount. Dining Director will perform monthly checks and report status to ED to ensure available water is sufficient to standard per regulation and resident census and within expiration limits. ED to audit quarterly, during the months of January, April, July, and October.
22VAC40-73-550-G
Based on resident record review and staff interview, the facility failed to ensure the rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each resident or his legal representative or responsible individual as stipulated in subsection H of this section and each staff person.
Evidence
  1. of this review shall be the resident’s, his legal representative’s or responsible individuals, or staff person’s written acknowledgement of having been so informed, which shall include the date of the review and shall be filed in the resident’s or staff person’s record. Evidence:
  2. The LI asked staff 4 for documented annual review of rights and responsibilities of residents of assisted living facilities on the day on inspection on 3/4/2026 for resident 4 admitted 2/17/2025, resident 5 admitted 3/1/2024 and resident 6 admitted 9/16/2024. Staff 4 gave the LI signed annual rights and responsibilities of resident of assisted living facilities that were all signed and dated 3/5/2026 for resident 4, 5 and 6.
  3. Staff 4 stated the staff person responsible for ensuring rights and responsibilities of residents of assisted living facilities are signed by residents or legal representatives had fallen off of getting them completed.
Plan of correction
22VAC40-73-550G Activities Director to manage resident annual rights review. New binders are in place with ED to audit quarterly, during the months of January, April, July, and October. 100% review of missing annual rights reviews completed with 100% of outdated residents/responsible parties contacted with copies of resident rights.
22VAC40-73-350-B
Based on resident record review and staff interview, the facility failed to ascertain, prior to admission, whether a potential resident is a registered sex offender.
Evidence
  1. Resident 1 was admitted 2/11/2026. The LI asked staff 4 for proof of ascertaining whether resident 1 is a registered sex offender on the day of the inspection on 3/4/2026. Staff 4 gave the LI a Virginia State Police search results for all offenders for resident 1 dated 3/4/2026.
Plan of correction
22VAC40-73-350B 1. Sex offender search performed and results added to resident file. Admissions manager to use check list for all documentation going forward. ED to review admission sex offender results prior to resident admissions beginning 4/20/2026. ED to audit 5 resident charts weekly for compliance beginning week of 4/20/2026.
22VAC40-73-580-A
Based on facility record review and staff interview, the facility failed to ensure an annual inspection by the Virginia Department of Health (VDH) was completed.
Evidence
  1. The LI asked staff 4 for the annual VDH inspection report for the kitchen.
  2. Staff 4 gave the LI the Food Establishment Inspection Report from VDH dated 10/2/2024.
  3. Staff 4 confirmed a call to VDH was made during the inspection on 3/4/2026 to schedule the inspection.
Plan of correction
Not published by VDSS.
22VAC40-73-720-A
Based on resident record review, the facility failed to include the do not resuscitate order in the Individualized Service Plan (ISP).
Evidence
  1. Resident 2 admitted 6/7/2024, had a do not resuscitate order dated 2/18/2026. The ISP dated 1/31/2026 indicated resident 2 was a full code and life saving measures (CPR) will be initiated in the event of cardiac or respiratory arrest until emergency medical services arrive on scene to take over.
Plan of correction
22VAC40-73-720A 1. DON added DNR order to resident 2 ISP. DON completed review of all ISPs for code status by 3/31/26. ED to audit 5 resident charts weekly for compliance beginning week of 4/20/2026.
22VAC40-73-450-F
Based on resident record review, the facility failed to update the Individualized Service Plan (ISP) as needed for significant changes of resident’s condition.
Evidence
  1. Resident 1 admitted 2/11/2026, had a fall risk evaluation completed at admission that states the resident scored 10 points or higher and the resident is a high risk for falls. The ISP for resident 1, dated 2/11/2026, does not indicate resident 1 is a high risk for falls.
  2. Resident 2 admitted 6/7/2024, had an order for a hospice consult on 2/16/2026. The ISP for resident 2, dated 1/31/2026, did not include hospice services being provided to resident 2.
Plan of correction
22VAC40-73-450F 1. DON added fall risks to resident ISP. ED to audit resident ISPs for fall risks 2. DON updated ISP to include hospice services. DON completed review of all ISPs for fall risks and hospice services by 3/31/26. ED to audit 5 resident charts weekly for compliance beginning week of 4/20/2026.
March 4, 2026Inspection0 violations
Inspection dates
03/04/2026
Areas reviewed
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: 3/4/2026 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 2/6/2026 regarding allegations in the area(s) of: Number of residents present at the facility at the beginning of the inspection: 59 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: NA Number of interviews conducted with staff: 1 Observations by licensing inspector: NA Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
January 5, 2026Inspection0 violations
Inspection dates
01/05/2026
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-90 Background Checks for Assisted Living Facilities
Technical assistance
22VAC40-73-580-F
Comments
Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: January 5, 2026 from 11:30am to 1:53pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-report was received by VDSS Division of Licensing on 10/30/25 regarding allegations in the area(s) of: Resident Care and Related Services and Personnel. Number of residents present at the facility at the beginning of the inspection: 61 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 2 Number of interviews conducted with residents: 0 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 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 Tierra Sanders, Licensing Inspector at 804-724-4703 or by email at Tierra.Sanders@dss.virginia.gov
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
January 5, 2026Inspection0 violations
Inspection dates
01/05/2026
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS
Comments
Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: January 5, 2026 from 1:54pm to 2:10pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-report was received by VDSS Division of Licensing on 11/03/2025 regarding allegations in the area(s) of: ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS. Number of residents present at the facility at the beginning of the inspection: 61 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: N/A Additional Comments/Discussion: Resident agreement reviewed. 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 Tierra Sanders, Licensing Inspector at 804-724-4703 or by email at Tierra.Sanders@dss.virginia.gov
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
March 14, 2025Inspection0 violations
Inspection dates
03/14/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Other Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 3/14/2025 2:45 p.m. – 6:00 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 12/1/2024 regarding allegations in the area(s) of: resident care Number of residents present at the facility at the beginning of the inspection: 58 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: Building and grounds and resident rooms 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. 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 (Jeff Marnien), Licensing Inspector at (540) 571-0189 or by email at Jeffrey.marnien@dss.virginia.gov
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
March 14, 2025Complaint survey0 violations
Inspection dates
03/14/2025
Areas reviewed
22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 3/14/2025 6:00 p.m. – 6:30 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 1/29/2025 regarding allegations in the area(s) of: building maintenance; staff accommodations. Number of residents present at the facility at the beginning of the inspection: 58 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: 2 Observations by licensing inspector: Building and grounds and kitchen operations. 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 allegation of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact (Jeff Marnien), Licensing Inspector at (540) 571-0189 or by email at Jeffrey.marnien@dss.virginia.gov.
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
March 13, 2025Inspection5 violations
Inspection dates
03/13/2025, 03/14/2025
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS63.2- (18) FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 3/13/2025 9:25 a.m. – 4:20 p.m., 3/14/2025 10:10 a.m. – 2:40 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 73 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed:3 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: Building and grounds, dining services, activities conducted, resident medication pass, laundry services, and housekeeping services. Additional Comments/Discussion: Facility policies and a hospice agreement were reviewed. 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 Jeff Marnien, Licensing Inspector at (540) 571-0189 or by email at Jeffrey.marnien@dss.virginia.gov
Violations
22VAC40-73-830-E
Based on document review and staff interview, the facility failed to provide a written response to the council prior to the next meeting regarding any recommendations made by the council for resolution of problems or concerns.
Evidence
  1. During an interview with staff 4 on 3/13/2025, the Licensing Inspector (LI) requested to view resident council minutes from December 2024, January 2025, and February 2025
  2. The LI requested to see a written response to the council addressing concerns or questions brought up during the council meetings.
  3. Staff 4 confirmed, 3/13/2025, that a written response was not provided to the council prior to the next meeting.
Plan of correction
a) Responses to the concerns and recommendations voiced at the February 19th Resident Council Meeting were posted prior to the planned March 19th Council Meeting. b) The Executive Director and/or relevant department managers will prepare responses to each concern or recommendation and communicate those responses to the Activity Manager and Executive Director. c) The Activity Manager and/or Executive Director will provide and post that response in writing no later than two-weeks prior to the next scheduled resident council meeting. Responses and meeting minutes will be retained by the Activity Director in the Resident Council Binder. d) This plan of correction has been fully implemented and noncompliance was corrected as of 4/15/2025.
22VAC40-73-680-K
Based on resident record review and staff interview, the facility failed to ensure that the use of PRN (as needed) medications is prohibited, unless medication aides administer PRN medication when the facility has obtained from the resident’s physician or other prescriber a detailed medication order that shall include and directions as to what to do if symptoms persist.
Evidence
  1. LI reviewed resident 2’s physician active orders (dated 3/14/2025). All PRN medications currently prescribed for resident 1 did not include physician instructions on what to do if symptoms persist.
  2. Staff 5 confirmed, 3/14/2025, the PRN orders did not include instructions if symptoms persist.
Plan of correction
a) All orders for PRN medications have been reviewed and include instructions for what med aides will do if the PRN medication is not effective or the symptoms persist. b) Resident Care Manager and Assistant Resident Care Manager will ensure continued compliance by educating the nursing team of the need for specific instructions for any new or changed PRN orders. c) Resident Care Manager and Assistant Resident Care Manager will routinely review new and/or changed PRN orders for specific instructions if ineffective. d) This plan of correction will be fully implemented and noncompliance corrected by 06/09/2025
22VAC40-73-840-B
Based on record review, the facility failed to ensure pets have had all recommended or required immunizations.
Evidence
  1. During an interview with staff 4 on 3/13/2025, the LI requested to see the immunization records for the pet living in the community.
  2. Staff 4 provided the immunization record dated 1/24/2024. The record recorded the Bordetella vaccination expired 6/10/2023, heartworm test expired 11/19/2024, Ultra Lepto expired 6/10/2023, and the semiannual wellness exam expired 5/20/2024.
  3. Staff 4 confirmed, 3/13/2025, these tests had expired.
Plan of correction
a) A list of current vaccinations for the pet in the community was received on 3/13/2025. This pet has passed away and no longer resides at the community. b) Current vaccination records will be provided to the Admissions Manager, prior to move-in. The vaccination records will be scanned to the Executive Director and Business Office Manager for review and approval. Once approved, the Business Office Manager will add the pets record to the vaccination tracker which will be reviewed no less than quarterly to ensure vaccination records are up-to-date. The Business Office Manager will request updates to the pet records from the resident, prior to the expiration dates as indicated, if not already provided. c) Noncompliance was corrected and this plan of correction has been fully implemented as of 6/6/2025
22VAC40-73-870-E
Based on observation and staff interview, the facility failed to ensure all furniture was kept in good repair.
Evidence
  1. LI during building tour, 3/13/2025, observed an outside bench with a sitting surface that was jagged and had wood sticking straight up.
  2. LI showed staff 4 photo evidence of the bench and staff 4 confirmed, 3/13/2025, the bench was not safe to sit on.
  3. Photo evidence 1.
Plan of correction
a) The bench was repaired on 3/14/2025. Picture shown to the inspector at that time. (See photo attached to this plan of correction) b) Routine rounds will be made to ensure internal and external furnishings are safe and in good repair. Staff will be educated to report any unsafe furniture, fixtures or equipment to the executive director and/or maintenance manager promptly. c) Executive Director and Maintenance Manager will complete weekly rounds to ensure a safe environment is maintained. d) Noncompliance was corrected on 3/14/2025 and the plan of correction will be fully implemented by 6/9/2025
22VAC40-73-1140-B
Based on record review and staff interview the facility failed to ensure direct care staff working in a safe, secure environment receive 10 hours of training in cognitive impairment within the first four months of their start date.
Evidence
  1. Staff 2 was hired on 10/12/2024 and four months after hire was February 12, 2025. LI reviewed staff records on 3/14/2025 and observed staff 2’s training log recorded six hours of dementia training within the first four months of hire.
  2. Staff 4 confirmed on 3/14/2025 staff 2 did not obtain ten hours of dementia training within the first four months of hire.
Plan of correction
a) Staff 2 will complete an additional four-hour dementia training class on 6/7/2025 to ensure 10 hours are completed. b) 4 hours of dementia training will be completed for all direct care workers on the day of orientation. Direct Care staff will be scheduled an additional 6-hour dementia training class before their 4th month. c) The Executive Director will provide the dementia training in accordance with the standard and ensure new direct care workers complete 10 hours before the 4th month of hire by auditing new hire training records no less than monthly. d) The plan of correction and noncompliance will be fully implemented by 6/09/2025
October 3, 2024Complaint survey0 violations
Inspection dates
10/3/2024
Areas reviewed
22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/3/2024 12:50pm – 2:36 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 regarding allegations in the area of: Resident care Number of residents present at the facility at the beginning of the inspection: 66 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: 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 allegation of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact (Jeff Marnien), Licensing Inspector at (540) 571-0189 or by email at Jeffrey.marnien@dss.virginia.gov Violation Notice Issued: No
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
March 25, 2024Inspection0 violations
Inspection dates
03/25/2024
Areas reviewed
Administration and Administrative ServicesPersonnelStaffing and SupervisionAdmission, Retention and Discharge of ResidentsResident Care and Related ServicesBuildings and GroundsEmergency PreparednessMixed PopulationSafe, Secure Environment
Comments
Date of Inspection: March 25, 2024 Type of Inspection: Renewal Inspection If you have any questions or email changes, please do not hesitate to contact me at laura.lunceford@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov. Census 70 Number of records reviewed and interviews conducted- 15 records (staff and resident), 9 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. The Licensing Inspector observed the residents during snack time, lunch and many activities. The Licensing Inspector reviewed the following at the time of inspection: dietician report, resident council minutes, menus, activities calendars, fire drills, pharmacy revie and healthcare oversight.
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
May 22, 2023Inspection1 violation
Inspection dates
05/22/2023
Areas reviewed
Administration and Administrative ServicesPersonnelStaffing and SupervisionAdmission, Retention and Discharge of ResidentsResident Care and Related ServicesBuildings and GroundsEmergency PreparednessMixed PopulationSafe, Secure Environment
Comments
Date of Inspection: May 22, 2023 Type of Inspection: Monitoring Inspection If you have any questions or email changes, please do not hesitate to contact me at laura.lunceford@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov. Census 67 Number of records reviewed and interviews conducted- 10 records (staff and resident), 9 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. The Licensing Inspector observed the residents during activities and meal times. The Licensing Inspector reviewed the following at the time of inspection: menus, fire drills, activity calendars, health care oversight and dietician report. The Licensing Inspector and the Administrator discussed the risk assessment ratings for the violations for this inspection. Please complete the “plan of correction” and “date to be corrected” for each violation cited on the violation notice and returned it to the office. You will need to specify how the deficient practice will be or has been corrected. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s).
Violations
22VAC40-73-220-B
Based on resident record review and staff interview, it was determined that the facility failed to have the necessary documentation for a private caregiver as required.
Evidence
  1. Resident A uses a private caregiver within the facility. There is no documentation provided the show qualifications, training, services provided and criminal background check.
Plan of correction
The record for the private caregiver will be completed as required. Any private caregivers will have the documentation as required.
March 18, 2022Inspection1 violation
Inspection dates
03/18/2022
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 PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Comments
Date of Inspection: March 18, 2022 Type of Inspection: Renewal Inspection If you have any questions or email changes, please do not hesitate to contact me at laura.lunceford@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov. Census 74 Number of records reviewed and interviews conducted- 3 resident record and 3 staff records, 8 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. The residents were observed during activities and lunch. The fire drills, menu boards, activities calendars and health care oversight reports were reviewed at the time of inspection.
Violations
22VAC40-73-710-B
Based on direct observation by the Licensing Inspector and facility staff, it was determined that there was restraint equipment being used for a resident in care.
Evidence
  1. Resident 3 had Halo Rail devices attached to the bed. The resident has serious cognitive impairment and is not able to safely use these devices for positioning.
Plan of correction
The Halo Rail devices were immediately removed from Resident 3 bed. The devices were difficult to see as the bedding blocked the view. All residents in care for both assisted living and the secured unit will have the apartments checked for devices to ensure safety.
January 30, 2021Inspection0 violations
Inspection dates
Jan. 30, 2021 and Feb. 1, 2021
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Criminal History Record Report
Comments
This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A monitoring inspection was initiated on January 30, 2021 and concluded on February 2, 2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 64. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 4 resident records, 4 staff records, activities calendar, staff schedules, fire drills, health care oversight, and training submitted by the facility to ensure documentation was complete. The information gathered during the inspection determined no violations with applicable standards or law. No violations were issued.
Violations
No violations cited
The inspector documented no violation of standards at this inspection.