Virginia DSS · Assisted Living Facility

The Pearl at Watkins Centre

📍 650 Watkins Centre Parkway, Midlothian, VA, 23112

ID 44949One Year licenseActive
31
Inspections
On record
15
With violations
Visits that cited something
16
Clean visits
Nothing cited
28
Violations cited
Individual findings
21
Standards cited
Distinct rules
14
Complaint visits
Prompted by a complaint

The Pearl at Watkins Centre was inspected 31 times between November 19, 2020 and June 1, 2026 by the Virginia Department of Social Services. 15 of those visits ended with violations cited and 16 with none. Across that history VDSS cited 28 violations under 21 distinct standards. 14 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. 26 of these 31 are still on the state's site; the other 5 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
04/30/2027
Administrator
Ashley Beckley
Licensing inspector
Yvonne Randolph
Inspector phone
(804) 441-1180
Approved for
Non-Ambulatory · Special Care Unit · Assisted Living

Inspection History

31

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

June 1, 2026Complaint survey0 violations
Inspection dates
06/01/2026
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
Type of inspection: Complaint. Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 6/1/2026, 12:50 pm to 1:31 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 5-26-26 regarding allegations in the areas of: Staffing And Supervision, Resident Care And Related Services, Additional Requirements For Facilities That Care For Adults With Serious Cognitive Impairments Number of residents present at the facility at the beginning of the inspection: 44 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of interviews conducted with residents: Random-3 Number of interviews conducted with staff: Random - 4 Observations by licensing inspector: staffing schedules, activity calendar, menus, lunch meal, dining room, common area, resident/staff interaction, postings An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Yvonne Randolph, Licensing Inspector at (804) 441-1180 or by yvonne.randolph@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
March 30, 2026Complaint survey3 violations
Inspection dates
03/30/2026,04/10/2026
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Complaint Dates of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 3-30-26 10:40 am to 11:40 am, 4-10-26 1:00 pm to 1:54 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 3-6-26 regarding allegations in the areas of Personnel and Resident Care And Related Services Number of residents present at the facility at the beginning of the inspection: 43 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% sample review of MARs for compliance Number of staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: medication administration records, lunch meal, staffing, facility maintenance and cleanliness, file documentation, resident-staff interaction Additional Comments/Discussion: Virginia Health Professions search completed for all staff documented as administering medications on staff assignment sheets, staff schedule submitted with renewal application and signatures on MARS An exit meeting will be conducted to review the inspection findings. 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 also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violations will be addressed in order to return the facility to compliance and maintain future compliance with applicable standards or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. 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 Yvonne Randolph, Licensing Inspector at (804) 441-1180 or by email at yvonne.randolph@dss.virginia.gov
Violations
22VAC40-73-670-1
Based on file review and interviews, the facility failed to ensure that when staff administers medication each staff shall be licensed by the Commonwealth of Virginia to administer medications or be registered with the Virginia Board of Nursing as a medication aide.
Evidence
  1. The file review found the job title for staff # 1 on the Job Description and New Associate Record form listed as Med Tech.
  2. The Staff Information form submitted on 4/10/26 with the renewal application list the job title for staff # 1 as Med Tech.
  3. Staff #1 was not found during a search of the Virginia Department of Health Professions license lookup website.
  4. Staff #2, #3 and #4 confirmed during the inspection on 4-10-26 that staff #1 was not licensed, registered or acting as a medication aide on a provisional basis.
Plan of correction
All employee files have been reviewed and correct job title and job descriptions have been signed and are in line with training and/or any CURRENT certifications that the employee has.
22VAC40-73-640-A
Based on a documentation review, the facility failed to ensure that their Medication Management Plan address the qualification requirements of 22VAC40-73-670 for all staff who are responsible for administering medications.
Evidence
  1. .
  2. A review of the medication administration records (MARs) for the facility found that medication is administered by staff registered or acting as a medication aide on a provisional basis.
  3. The Medication Policies and Procedures for the facility was requested and reviewed by the licensing inspector on 4/10/26 and 4/13/26.
  4. The Medication Policies and Procedures does not address the administration of medication by medication aides.
Plan of correction
On 04/10/2026 community conducted an audit of all staff currently administering medications. During this audit, the community verified each employee credentials and ensured that all individuals administering medications are licensed by the Commonwealth of Virginia. Facility/Community will adopt and utilize the template for medication management plan sent to communities from VDSS on 4/15/2026 moving forward, as the active plan for medication management, addressing qualifications/requirements, of 22VAC40-73-670 for all staff responsible for administering medications.
22VAC40-73-680-A
Based on a documentation review, the facility failed to ensure that staff who are licensed, registered or acting as a medication aide on a provisional basis as specified in 22VAC40-73-670 shall administer drugs to those residents who are dependent on medication administration as documented on the UAI.
Evidence
  1. Staff #2, #3 and #4 confirmed during the inspection on 4-10-26 that staff #1 was not licensed, registered or acting as medication aides on a provisional basis.
  2. Staff Assignment sheets for January 2026 and February 2026 document staff #1 as the Med Tech administering medications on the 3 pm to 11 pm shift on 1/1/26, 1/9/26, 1/12/26, 1/14/26, 1/17/26, 1/18/26, 1/20/26 and 2/2/26; as 1 of 2 Med Techs on the 3 pm to 11 pm shift on 1/6/26, 1/8/26, 1/13/26, 1/21/26, 1/28/26 and 1/29/26.
  3. A sample review of medication administration records (MARs) and Controlled Drug logs for January 2026, February 2026 and March 2026 found that staff #1 administered: (1) Lorazepam5 mg at 8 pm to resident #1 on 1/12/26,1/13/26, 1/14/26, 1/17/26. 1/18/26 and 1/20/26; (2) Morphine 100/5 mil to resident #2 on 2/9/26 at 4 pm and 8 pm; (3) Morphine 20 mg/ml to resident #3 on 2/5/26 at 10 pm; (4) Tramadol 50 mg to resident #4 on 3/2/26, 3/3/26, 3/6/26 and 3/9/26 at 8 pm and at 8 am on 3/3/26; (5) Acetaminophen 500 mg to resident #4 on 3/1/26, 3/2/26, 3/6/26. 3/9/26 at 8 pm.
Plan of correction
ALL employee credentials are to be verified by the DHP website prior to a job offer letter being sent to a applicant for employment. All verifications will be completed at the time of application receipt.. All employees will be kept in a file with the BOM or representative for records tracking on dates of renewal. All license/certification renewals will be due at a minimum on the day prior to their expiration or employee will be removed from the schedule until provided to BOM and executive director/administrator.
February 13, 2026Inspection3 violations
Inspection dates
02/13/2026
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: 2/13/26, 11:40 am to 2:25 pm Number of residents present at the facility at the beginning of the inspection: 41 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: 4 Number of interviews conducted with residents: NA- Safe, Secure Environment Number of interviews conducted with staff: 4 Observations by licensing inspector: medication passes and storage, required file documentation, staff/resident/family interaction, facility maintenance and upkeep, lunch meal, required postings An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standards or law, and violations are documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violations will be addressed in order to return the facility to compliance and maintain future compliance with applicable standards or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. 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 Yvonne Randolph, Licensing Inspector at 804-441-1180 or by email at yvonne.randolph@dss.virginia.gov
Violations
22VAC40-73-720-A
Based on file reviews, the facility did not ensure that Do Not Resuscitate Orders for withholding cardiopulmonary resuscitation from a resident is included on the individualized service plan.
Evidence
  1. The file review for resident 1 found Do Not Resuscitate Orders dated 2/7/25. The written order was not on resident 1 service plan dated 2/25/25.
Plan of correction
All resident files will be reviewed to ensure that their CODE STATUS is updated and present on their ISP at the time of completion and upon admission.
22VAC40-73-1100-C
Based on files reviews, the facility did not ensure that written approval was obtained following the order of priority prior to placement of a resident in the safe, secure environment.
Evidence
  1. The section of the Approval For Placement In Special Care Unit form to document why written approval was not obtained from each individual higher on the list of priority was blank.
Plan of correction
Administrator will ensure that any approval for placement in specialty care unit form is completed, leaving no un-answered order of priority on the form.
22VAC40-73-1090-A
Based on file reviews, the facility did not ensure that prior to admission to a safe, secure environment, the resident shall have been assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare.
Evidence
  1. The file documented that Resident 4 was admitted to the safe, secure environment on 11/18/25. The assessment was completed on 12/10/25 which is after the date of admission
Plan of correction
Any future resident will have an assessment completed by community staff, trained in the completion of UAI and ISP development within a minimum of 24 hours before their move into the community.
February 13, 2026Inspection0 violations
Inspection dates
02/13/2026
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 2/13/26, 11:40 am to 12:30 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 12/20/25 regarding allegations in the area of: Resident Care And Related Services. The facility also self-reported the incident to local APS. Number of residents present at the facility at the beginning of the inspection: 41 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 staff: 1 Observations by licensing inspector: file documentation, staffing An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation did not support non-compliance with standards or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Yvonne Randolph, Licensing Inspector at (804) 441-1180 or by email at yvonne.randolph@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
November 6, 2025Complaint survey0 violations
Inspection dates
11/06/2025
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES
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: 11/6/25, 11:30 a to 12:30 p 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 10/24/25 regarding allegations in the areas of: Personnel, Staffing and Supervision, Administration and Administrative Services and Resident Care and Related Services The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of interviews conducted with staff: 4 Observations by licensing inspector: resident supervision, manager on duty posting Additional Comments/Discussion: AIT and DON on site An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Yvonne Randolph, Licensing Inspector at (804) 441-1180 or by email at yvonne.randolph@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
October 15, 2025Complaint survey0 violations
Inspection dates
10/15/2025,11/06/2025
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: 11/6/25, 11:30 a to 12:30 a and 10/15/2025 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 10/10/2025 regarding allegations in the areas of: Personnel, Staffing and Supervision, Administration and Administrative Services and Resident Care and Related Services The facility self reported the allegations related to Resident Care and Related Services on 10/8/25. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of interviews conducted with staff: 1 Number of interviews with resident/responsible party: 1 Observations by licensing inspector: file documentation, resident movement An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Yvonne Randolph, Licensing Inspector at (804) 441-1180 or by email at yvonne.randolph@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
August 12, 2025Complaint survey1 violation
Inspection dates
08/12/2025
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
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: 8/12/25, 11am- 12pm 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 8/7/25 regarding allegations in the area of: Admission, Retention And Discharge Of Residents and Additional Requirements For Facilities That Care For Adults With Serious Cognitive Impairments Number of interviews conducted with staff: 2 Observations by licensing inspector: Policy And Procedures, Disclosure Statement, Resident Agreement An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation of non-compliance with standards or law. However, a violation 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 will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Yvonne Randolph, Licensing Inspector at (804) 441-1180 or by email at yvonne.randolph@dss.virginia.gov
Violations
22VAC40-73-50-A
Based on review of the disclosure statement, the facility did not ensure that the disclosure statement include required information about the facility.
Evidence
  1. Facility policy is that residents being admitted to the memory care unit must have a legally appointed representative through a valid Power of Attorney (POA) or other court recognized document (e.g. guardianship).
  2. Section III ( Admission, Transfer and Discharge Criteria) of the disclosure statement does not address the admission criteria of a legally appointed representative or other court recognized document.
Plan of correction
Not published by VDSS.
June 24, 2025Inspection1 violation
Inspection dates
06/24/2025
Comments
Type of inspection: Monitoring Date the licensing inspector was on-site at the facility for each day of the inspection: 6/24/2025 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 6/4/25 followed by two complaints on 6/9/25 and 6/24/25 regarding allegations in the area of Resident Care And Related Services Number of resident records reviewed: 1 Number of staff records reviewed: 1 private duty staff person Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: file documentation An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. However, a violation not related to the self-report/complaints 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 will be addressed in order to return the facility to compliance and maintain future compliance with applicable standards or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Yvonne Randolph, Licensing Inspector at (804) 441-1180 or by email at yvonne.randolph@dss.virginia.gov
Violations
22VAC40-73-220-A
Based on documentation review, the facility did not ensure that the requirements of 22VAC40-73- 250 D 1 through D 4 regarding tuberculosis areapplied to private duty personnel and that the tuberculosis assessment is no more than 30 days
Evidence
  1. Standard 22VA40-73-250 D 3. states staff and each household member, no more than 30 daysprior to coming into contact with the resident, shall submit the results of a tuberculosis risk assessment documenting the absence of tuberculosis in a communicable form. The individualized service plan for resident # 1documents a move-in date of 8/27/24. The risk assessment for private duty staff # 1 is dated 11/28/22, which is more than 30 days prior to having contact with resident # 1.
Plan of correction
Community did complete a TB risk assessment form after private sitter began. In future, beginning immediately, community will ensure that all private sitters and direct care staff have TB risk assessment form completed before they have direct care access to any and all residents in community setting.
April 2, 2025Complaint survey2 violations
Inspection dates
04/02/2025
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
Type of inspection: Complaint Date of inspection the licensing inspector was on-site at the facility for each day of the inspection: 4/2/25 The Acknowledgement of Inspection form was emailed to the facility for each date of the inspection. Complaint s were received by VDSS Division of Licensing on 3/12/25 and 3/27/25 regarding allegations in the areas of: Administration and Administrative Services, Personnel, Resident Care and Related Services, Building and Grounds, Staffing and Supervision, Emergency Preparedness and Additional Requirements for Facilities that Care for Adults With Serious Cognitive Impairments Number of residents present at the facility at the beginning of the inspection: 41 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of staff records reviewed: 12 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: medication storage, administration and availability; file documentation, fire extinguishers, staff certifications and training, hazardous materials storage and accessibility An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation supported one of the allegations; areas of non-compliance with standards or law were: Administration and Administrative Services, and Building and Grounds. A violation notice was issued; any violations 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 violations will be addressed in order to return the facility to compliance and maintain future compliance with applicable standards and law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Yvonne Randolph, Licensing Inspector at (804) 441-1180 or by email at yvonne.randolph@dss.virginia.gov.
Violations
22VAC40-73-860-I
Based on a documentation review, the facility did not ensure that each facility shall store cleaning supplies and other hazardous materials in a locked area.
Evidence
  1. The facility is a secure memory care environment. On 3/20/25 a visiting family member found Zep cleaner that was left in the room of resident # 1. This is a repeat violation, the standard was cited previously during an inspection on 2/7/25 for an incident involving resident # 2.
Plan of correction
Incident on 2/13/2025 and 3/20/2025 were not perceived as incidents that required reporting to inspector. Statues and standards were reviewed by executive director and managers on duty. All reports to inspector reviewed as mandatory within less than 24 hours. Educated all reporting staff.
22VAC40-73-70-A
Based on documentation reviews, the facility did not ensure that each facility shall report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety or welfare of any resident.
Evidence
  1. Allegations were received regarding incidents that occurred on 2/13/25 and 3/20/25. Reports of the incident were not received within 24 hours of occurrence, the reports were emailed to the licensing inspector upon request on 4/8/25.
Plan of correction
Staff education was completed on 2/7/2025 and again on 3/20/2025 on the safe storage of all cleaning products and products containing chemical/hazardous materials. Housekeeping/facilities staff has a location that all cleaning supplies must be left in. Staff educated on leaving supplies on locked cart when not in use(in-between trash dumping and sanitization) and in locked area when cleaning is not being conducted.
February 7, 2025Inspection1 violation
Inspection dates
02/07/2025
Areas reviewed
22VAC40-73 BUILDINGS AND GROUND
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: 2/7/25, 1: 55 pm to 2:15 pm The Acknowledgement of Inspection form was signed and emailed to the facility for each date of the inspection. A self reported incident report was received by VDSS Division of Licensing on regarding allegations in the area of: Building and Grounds: Number of residents present at the facility at the beginning of the inspection: The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 1 Number of interviews conducted with residents :0 Number of interviews conducted with staff: 1 Observations by licensing inspector: the building and grounds, activity area storage cabinet An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported non--compliance with standard or law, and a violation was issued. Any violation not related to the self report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Yvonne Randolph, Licensing Inspector at (804) 662-74 or by email at yvonne.randolph@dss.virginia.gov
Violations
22VAC40-73-860-I
Based on observation, the facility did not ensure that each facility shall store cleaning supplies and other hazardous materials in a locked area.
Evidence
  1. The facility is a secure memory care environment. On 1/18/25 the facility self-reported an incident of a resident breaking into a cabinet and gaining access to bleach. An inspection at the facility on 2/7/25 found the cabinet unsecured with no locking device. (picture taken), Resident was seen in the local emergency room, the diagnosis was listed as "ingestion of bleach”.
Plan of correction
Immediate staff in-service provided on the safe storage of all cleaning and housekeeping supplies. Cabinet that had been accessed by the resident and handle broken has since been removed from “community” area. A full sweep of all resident accessible areas has been completed and there are no cleaning or housekeeping supplies that are not behind a locked entry. Residents have no access to any kind of supplies currently. POC date: Immediate. 02/10/2025.
September 9, 2024Inspection0 violations
Inspection dates
09/09/2024
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
Type of inspection: Monitoring, Non-mandated Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 9/9/24, 1pm to 2:30 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 8/26/24 regarding allegations in the areas of: Personnel, Staffing And Supervision and Additional Requirements for Facilities That Care for Adults With Serious Cognitive Impairments. 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: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: staff/resident interaction, building and grounds, file documentation, family visitation Additional Comments/Discussion: A subsequent referral regarding the incident was received from local social services on 9/5/24 An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation did not support non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Yvonne Randolph, Licensing Inspector at (804 662-7454 or by email at yvonne.randolph@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
August 5, 2024Inspection2 violations
Inspection dates
08/05/2024
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 IMPAIRMENTS
Comments
Type of inspection: Monitoring Mandated. Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 8/5/24, 11:00 a to 2:30 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: 43 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: 4 Number of interviews conducted with residents:0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Facility cleanliness, staff/resident interaction, medication administration documentation and storage, Additional Comments/Discussion: An exit meeting was conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standards or law, and violations are documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violations will be addressed in order to return the facility to compliance and maintain future compliance with applicable standards or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Yvonne Randolph, Licensing Inspector at (804) 662-7454 or by email at Yvonne.randolph@dss.virginia.gov 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.
Violations
22VAC40-73-1100-C
Based on a review of file documentation, the facility did not ensure that the facility document that the order of priority was followed and that the documentation shall be retained in the resident's file.
Evidence
  1. The file for residents #1, #2, #3, #4 and # 6 did not contain documentation that the order of priority was followed.
Plan of correction
Education was completed on completing order of priority on form. “APPROVAL FOR PLACEMENT IN SPECIAL CARE UNIT” completed by executive director, on 08/09/2024.
22VAC40-73-680-H
Based on file reviews, the facility did not 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. Retaine eyedrops was not documented as administered at 12 pm on 7/9/24 and 7/13/24 on the July 2024 paper medication administration record(MAR).
  2. Aren mouthwash was not documented as administered at 2 pm on 7/9/24 and 7/13/24 on the July 2024 paper MAR.
  3. The electronic MAR emailed on 8/5/24 document "late entry" for Retaine at 12 pm and Aren at 2 pm
  4. The paper MAR and electronic MAR did not support that the medications were documented at the time the medication was administered.
Plan of correction
In-service completed with Med Techs regarding documentation following a missed medication or a medication that is received “late.” Staff educated on following orders exactly as prescribed and within specified time allowed.
August 5, 2024Complaint survey0 violations
Inspection dates
08/05/2024
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES
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: 8/5/24, 11am to 2:30 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Four complaints were received by VDSS Division of Licensing on 7/31/24 regarding the same incident and allegations in the areas of: Personnel and Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 43 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: 1 Number of interviews conducted with residents: 0 -All residents are cognitively impaired Number of interviews conducted with staff: 1 Number of Collateral interviews: 1 Observations by licensing inspector: staff/resident interaction, facility cleanliness, file documentation An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation did not support non-compliance with standards or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Yvonne Randolph, Licensing Inspector at (804) 662-7454 or by email at Yvonne.randolph@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
March 19, 2024Inspection0 violations
Inspection dates
03/19/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
Type of inspection: Monitoring, Self-Reported Incident Date of inspection the licensing inspector was on-site at the facility for each day of the inspection: 3/19/24 9:30 a- 1:15 p The Acknowledgement of Inspection form was left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 32 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: File documentation, staff supervision/interaction with residents A self-reported incident was received by VDSS Division of Licensing on 2/8/24 followed by an on-line complaint on 2/26/24 regarding allegations in the area(s) of: Resident Care and Related Services and Additional Requirements for Facilities that Care for Adults with Serious Cognitive Impairments An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation did not support non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Yvonne Randolph, Licensing Inspector at 804-662-7454 or by email at yvonne.randolph@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
March 19, 2024Inspection2 violations
Inspection dates
03/19/2024
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 IMPAIRMENTS
Comments
Type of inspection: Renewal Date of inspection the licensing inspector was on-site at the facility for each day of the inspection: 3/19/24, 9:30 a to 1:15 p The Acknowledgement of Inspection form was emailed for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 32 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: 2 Observations by licensing inspector: medication administration, resident/staff interaction, required posting, visitor protocol, facility maintenance and cleanliness, lunch meal Additional Comments/Discussion: Administrator was on site during the inspection An exit meeting was conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Yvonne Randolph, Licensing Inspector at 804-662-7454 or by email at yvonne.randolph@dss.virginia.gov
Violations
22VAC40-73-110-1
Based on a review of background checks for all staff hired since 11/1/23, background checks did not meet the requirements specified in the Regulations for Background Checks for Assisted Living Facilities and Adult Day Care Centers (22VAC 40-90)
Evidence
  1. 1, Section 63.2-1720 of t he Code of Virginia requires all employees of assisted living facilities, as defined by § 63.2-100 of the Code of Virginia, to obtain a criminal history record report from the Department of State Police.
  2. Nine staff did not have a back ground check form the Department of State Police.
Plan of correction
Background checks as specified in regulations for background checks for Assisted Living and Adult Day Care Services; Background checks for new employees have been submitted through the Virginia State Police Registry on 03/19/2024, through a sister community, in Harrisonburg. Background checks had been ran through “Checkr” a system used by our recruiting software.
22VAC40-73-940-A
Based on an interview, the facility did not comply with the Virginia Statewide Fire Prevention Code (13VAC5-51) as determined by at least an annual inspection by the appropriate fire official.
Evidence
  1. Staff # 4 reported that the facility did not have an annual fire inspection report.
Plan of correction
Annual Fire Inspection not available: We were unable to locate the current Chesterfield County inspection report. We were able to locate a third-party inspection that was used completed in September 2023. Fire Marshall is scheduled to complete the inspection on March 28, 2024.
January 9, 2024Complaint survey2 violations
Inspection dates
01/09/2024
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Complaint Date of inspection the licensing inspector was on-site at the facility for each day of the inspection: 1/9/2024 The Acknowledgement of Inspection form was emailed for each date of the inspection. A complaint was received by VDSS Division of Licensing on 1/8/24 regarding allegations in the areas of: Personnel and Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 2 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 5 Observations by licensing inspector: Medication pass 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 and Personnel. A violation notice was issued. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Yvonne Randolph, Licensing Inspector at 804-662-7454 or by email at yvonne.randolph@dss.virginia.gov
Violations
22VAC40-73-670-1
Based on a review of the staff information sheet, one staff responsible for medication administration is not licensed by the Commonwealth of Virginia to administer medications or registered with the Virginia Board of Nursing as a medication aide.
Evidence
  1. A review of the license verification website for the Virginia Board of Health Professions found that staff # 2 is not listed as a registered medication aide or licensed in the Commonwealth of Virginia to administer medications.
Plan of correction
File created to ensure that all staff have credentials appropriate for working in ALF in Virginia, including date of certification and date certification expires. Staff #2 has successfully completed the Medication Technician/Aide class through pharmacy and is awaiting test date for boards. Employees will not pass medications until certificate and license is received by community and reviewed. POC date: Immediate. 02/15/2024. Business Office Manager has also received additional training and learning opportunities to verify validity of licensure, verification process of licensure, and will ensure upkeep of employee files; utilizing a schedule for review processes monthly.
22VAC40-73-200-C
Based on a review of the staff information sheet and emails, one staff did not meet the direct care staff requirements within two months of employment.
Evidence
  1. The staff information sheet received by email on 1-16-23 documented a hire date of 10/3/2 and confirmed that staff # 1 is a direct care staff and has been employed for more than two months.
  2. In an email dated 1/18/24, the administrator confirmed that staff # 1 has not met at least one of the direct care qualifications.
Plan of correction
File created to ensure that all staff have credentials appropriate for working in ALF in Virginia, including date of certification and date certification expires. Floor staff will complete the necessary certificate training before being permitted to work on unit, either supervised or unsupervised. The individual named, Staff #1, completed PCA training. However, Staff #1, is no longer employed by TP@WC.
January 9, 2024Complaint survey0 violations
Inspection dates
01/09/2024
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
Type of inspection: Complaint Date of inspection the licensing inspector was on-site at the facility for each day of the inspection: 1/9/2023 The Acknowledgement of Inspection form was emailed for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 34 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: medication administration, lunch meal A complaint was received by VDSS Division of Licensing on 1/8/24 regarding allegations in the area(s) of: Administration And Administrative Services, Resident Care And Related Services, Additional Requirements For Facilities Care For Adults With Serious Cognitive Impairment. An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation did not support allegations of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Yvonne Randolph, Licensing Inspector at 804-662-7454 or by email at yvonne.randolph@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
October 3, 2023Inspection0 violations
Inspection dates
10/03/2023
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring, Non-Mandated Date and time f inspection the licensing inspector was on-site: 10/3/2023, 10 am The Acknowledgement of Inspection form was left at the facility on the date of the inspection. A self-reported incident was received by VDSS Division of Licensing on (date) regarding allegations in the area(s) of: Resident Care an Related Services The evidence gathered during the investigation did not support 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.For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact (Yvonne Randolph, Licensing Inspector at (x804) 662-7454 or by email at Yvonne.randolph@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
November 21, 2022Inspection0 violations
Inspection dates
11/21/2022
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
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: 11/21/22, 10:45 am- 12:55 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: 44 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: 2 Observations by licensing inspector: Lunch meal, medication storage and administration, postings, facility maintenance and cleanliness Additional Comments/Discussion: N/A 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 Yvonne Randolph, Licensing Inspector at 804-662-7454 or by email at yvonne.randolph@dss.virginia.gov Violation Notice Issued: No A copy of this document will be sent to the licensee/provider for signature.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
July 26, 2022Complaint survey0 violations
Inspection dates
07/26/2022
Areas reviewed
22VAC40-73 Resident Care And Related Services
Comments
Type of inspection: Complaint - A complaint was received by VDSS Division of Licensing regarding allegations in the area of: Resident Care And Related Services Date of inspection and time the licensing inspector was on-site at the facility: 7/26/2022 The Acknowledgement of Inspection form was signed and left at the facility on the date of the inspection Number of residents present at the facility at the beginning of the inspection: 36 The licensing inspector completed a tour of the secure outdoor area. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Outdoor area, physician orders 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 Yvonne Randolph, Licensing Inspector at 804-662-7454 or by email at yvonne.randolph@dss.virginia@dss.virginia.gov Violation Notice Issued: No A copy of this document will be sent to the licensee/provider for signature.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
March 17, 2022Inspection1 violation
Inspection dates
03/17/2022
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 1Subjectivity
Comments
A renewal inspection was conducted on 3/17/2022. The facility administrator reported that the current census is 31 residents. Licensing staff reviewed three staff files and three resident files for compliance along with the menu, activity schedule, staff schedule, emergency food supply, dietician report, health care oversight, medication administration and storage. The lunch meal was observed (corn beef and cabbage for St. Patrick's Day). Information gathered during the inspection determined one non-compliance with applicable standards or law, and the violation is documented on the violation notice issued to the facility.
Violations
22VAC40-73-680-D
Based on an inspection of medication administration on 3/17/2022, dietary supplements were not administered in accordance with the physician's or other prescriber's orders for one resident.
Evidence
  1. Physician orders for resident # 1had orders for two diet supplements - Juice Plus Fruit (2 capsules) and Juice Plus Vegetable Blend (2 tablets) to be taken daily. The supplements were not on the medication cart or available for administration.
Plan of correction
Wellness Director notified son the day of inspection regarding the need for medications, Vegetable and Fruit Supplement. Son will bring in medication to community within 24 Hours. NP was notified of the missed medication day of inspection. Wellness Director/Designee will conduct an audit of all resident medications to be completed by April 4th, 2022. Any missing medications identified will be obtained and issues identified will be corrected. Medication Staff to include Medication Aides and Nurses will be in-serviced by the Wellness Director by April 8th, 2022, on process of ordering medications from outside pharmacy and process of auditing medication cart. Wellness Director/Designee to perform medication cart audits weekly x 4 weeks to ensure that there are an appropriate amount of medications available to each resident. Any concerns that are identified during audits will corrected and reported to the Executive Director/Designee. The Executive Director/Designee will perform random audits of the medication cart weekly x 8 weeks and any concerns will be discussed with the Wellness Director/Designee and corrected. Documentation will be kept in Plan of Correction Binder located in the Executive Director's office.
November 17, 2021Inspection0 violations
Inspection dates
11/17/2021
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity
Comments
An inspection was completed at the facility to investigate a complaint received by the Department regarding allegations in the areas of Resident Care and Related Services and Additional Requirements For Facilities That Care For Adults With Serious Cognitive Impairments. The facility had self reported the incident/situation prior to receipt of the complaint. The licensing inspector reviewed resident file information, staff communication logs, interviewed staff, reviewed photos and hospital reports to complete the investigation. Licensing staff unsuccessfully made attempts to contact other community agencies involved. The self reported incident was closed on 3/3/2022 as not valid. The evidence gathered during the investigation did not support allegations of non-compliance with standards or law.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
October 21, 2021Complaint survey0 violations
Inspection dates
10/21/2021
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity
Comments
A non-mandated complaint inspection was initiated on 10/22/2021 and concluded 11/1/2021. A complaint was received by the department in the area of staffing and supervision. The administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed/telephoned the administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the allegation but did not support non-compliance with the standards as the required staffing ratio was met. The allegations were shared with the administrator for appropriate action/intervention.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
September 28, 2021Inspection0 violations
Inspection dates
09/28/2021
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
A non-mandated focus monitoring inspection was completed on 9/28/2021 to follow-up on compliance with an Intensive Plan of Correction issued in May 2021. The licensing inspector conducted an on-site medication cart/storage audit that was not completed during the 8/31/21 inspection. No violations of the standards were noted.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
August 31, 2021Inspection0 violations
Inspection dates
08/31/2021
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
A non-mandated focus monitoring inspection was attempted on 8/31/2021 at 10 am to monitor compliance with the IPOC (Intensive Plan of Correction) issued in June 2021. The administrator was contacted by telephone to initiate the inspection. The licensing inspector could not complete the on-site portion of the inspection due to COVID protocols. The licensing inspector was provided and reviewed staff training, medication observation checklists/audit forms and random medication administration records (MARs) for signatures/refusals/documentation. Medication refresher class for medication aides is delayed due to COVID. No violations cited.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
August 31, 2021Complaint survey0 violations
Inspection dates
08/31/2021
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
A non-mandated complaint inspection was attempted on 8/31/2021. A complaint was received by the department regarding visitation to the residents/access to the building. The administrator was contacted by telephone to initiate the investigation. The licensing inspector was unable to complete the on-site portion of the inspection due to COVID protocols. The licensing inspector found posted at the front entrance and took a photograph of procedures put in place to ensure access to the building. Observations were also made of visitation to the building during the day and after hours, no problems were observed with access. No violation was cited.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
April 12, 2021Complaint survey2 violations
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDING AND GROUNDS
Comments
This inspection was conducted by licensing using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A complaint was received regarding the administration of medication, resident rooms, staff qualifications and communication with families. Previous risk violations cited during inspections initiated in November 2020 and January 2021 were reviewed for compliance. The violations cited during this inspection are in areas of the standards cited during a January 2021 inspection. All other risk violations were found in compliance. Evidence gathered during the complaint investigation supported one of the allegations. A violation was also cited unrelated to the complaint. Any violations cited are documented on the Violation Notice.
Violations
22VAC40-73-680-D
Based on a review of medication administration records for four residents, two medications for one resident were not 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 physician orders for resident # 2 for March 2021 found physician orders with a start date of 3/25/2021 for (1) acetaminophen 2 tabs by mouth 3xs a day x 5 days; and (2) ibuprofen 2 tablet by mouth 3xs daily x 5 days. The medications were not documented as being given in March 2021. Staff # 1 documented on 3/30/2021 "med not available from pharmacy".
Plan of correction
100% audit of all POS to ensure accurate instructions/orders are reflected in MAR. All Med Techs will have a Med Tech refresher class to include the importance of documentation A designated Lead Med Tech will be assigned and trained to receive and process new orders to pharmacy. Med techs will be in-serviced on the process of receiving medications. Quarterly POS reviews by MD
22VAC40-73-680-I
Based on a review of medication administration records (MARs) for four residents, staff failed to document the effectiveness of a medication that was administered for one resident.
Evidence
  1. Resident # 4 was administered lorazepam 1 mg on 3/29/2021 at 8:40 pm, staff # 1 documented N/A for results/effectiveness of medication.
Plan of correction
100% audit of all POS to ensure accurate instructions/orders are reflected in MAR. All Med Techs will have a Med Tech refresher class to include the importance of documentation A designated Lead Med Tech will be assigned and trained to receive and process new orders to pharmacy. Med techs will be in-serviced on the process of receiving medications. Quarterly POS reviews by MD
March 30, 2021Inspection2 violations
Areas reviewed
22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity
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 03/30/2021 and concluded on 04/8/2021. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census is 28 residents. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed three (3) resident records, three (3) staff records, medication administration records, physician orders, fire and health inspection reports, fire drills, staff schedules, etc. submitted by the facility for compliance. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility.
Violations
22VAC40-73-1090-A
Based on a review of three residents files, licensing staff could not determine if one resident was assessed prior to admission to the safe, secure environment by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare.
Evidence
  1. The physician assessment form for resident # 1 did not have a complete resident's name (only the first name and an initial), a date of birth for the resident, or an address/telephone number for the individual who completed the form.
Plan of correction
Staff to be in-serviced on completion requirements and accuracy of new resident paperwork.
22VAC40-73-450-C
Based on a review of three resident files, the individualized service plan (ISP) for one resident did not address the identified needs of the resident.
Evidence
  1. The individualized service plan submitted for resident # 3 states that the resident is on a "no concentrated sweets" diet, the physician orders submitted by the facility state CCHO (Consistent Carbohydrate diet).The original date of the physician order is 11/25/2019.
  2. The physician orders submitted by the facility for resident # 3 state that the antipsychotic is liquid, the individualized service plan submitted states "to be crushed and placed in food". The original date of the physician order is 2/16/2021.
Plan of correction
Audits of all special diets to ensure accuracy of ISP to physicial order. Quarterly audits to be completed by dietician.
February 9, 2021Inspection3 violations
Inspection dates
Feb. 9, 2021
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Technical assistance
Clarification of Standard 40-73-150.F given
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 self reported incident was received by the Department regarding a resident elopement. A complaint investigation was initiated on 2/9/2021. The inspector also did a follow-up on the on site administrator. Evidence gathered during the investigation supported allegations of non-compliance with applicable standards or laws, and the violations are documented on the violation notice issued to the facility.
Violations
22VAC40-73-150-B-1
Based on a remote inspection on 2/9/2021, the facility failed to notify the Department in writing within 14 days of a change in the facility's administrator.
Evidence
  1. The licensing administrator was informed during a telephone call with Staff B on 2/4/2021 that the facility had a new administrator in training. During a telephone call to the facility on 2/16/2021, Staff A identified herself as the new administrator. The required written notification has not been received as of 3/19/2021.
Plan of correction
Facility will perform written notification to Department of Change in administrator.
22VAC40-73-460-A
Based on the investigation of a self reported incident, the facility failed to assume general responsibility for the health, safety and well being of residents placing a resident at risk of harm.
Evidence
  1. During the complaint investigation of a self reported incident received on 2/9/2021, the incident report documented "Resident observed using a key to go into the business office where he remained for 12 minutes. He then used a fob key card to open the secured door in common area." In an email dated 2/23/2021, staff reported "we have no idea how he got a key" and that the fob key was assigned to a staff member that terminated employment at the facility on 12/20/2021. The facility is in a secure memory care environment for residents with a diagnosis of serious cognitive impairment. Resident # 1's ability to obtain access to the key to the business office and the fob key placed the resident at potential risk of health, safety and well being.
Plan of correction
In service all staff: 1.Awareness of keys/fobs to be maintained in secure area. 2. In service BOM (Business Office Manager) and FD (Facility Director) on the importance in Maintaining current record of terminated employees. 3 Reviewed the following topics: Terminated staff keys/fobs shall be collected and deactivated immediately after 3. Reviewed the following topics: Terminated staff keys/fobs shall be collected and deactivated immediately after termination, Any lost keys/fobs will be reported to ED (Executive Director) and or FD; Fobs will be deactivated and locks will be rekeyed to ensure that unauthorized access is prohibited. 4. Audit completed on all currently programmed fobs to ensure all terminated associates fobs were deactivated. 5. Identified that locks to all management office were on same key and these locks were rekeyed.
22VAC40-73-460-D
Based on an investigation of a self reported incident, the facility failed to provide supervision of resident schedules, care and activities including attention to specialized needs, such as prevention of falls and wandering from the facility.
Evidence
  1. A self reported incident was received on 2/9/2021 regarding a resident elopement. The report documented that " resident was observed by RMA (VB) in the foyer area (the opposite side of the secured door) attempting to get back into the community." The report also documented that the facility had camera footage of the incident that was reviewed. The licensing inspector requested screen shots from the facility's administrator on 2/11/2021 of the incident to document the length of time that the resident (#1)was outside of facility. As of 3/19/2021, the requested information has not been received. The facility did not provide the requested screen shots to assist with the investigation or any documentation to support that supervision was provided to prevent wandering from the facility.
Plan of correction
Staff educated to conduct 2 hour checks as required and to document in YARDI. Care plans to be reviewed to ensure that each resident is scheduled for 2 hour checks for proper associate documentation.
January 22, 2021Inspection2 violations
Inspection dates
Jan. 22, 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 self report was received by the Department regarding a medication error. A complaint was later received afterwards in regards to the medication error. An investigation was initiated on 1/22/2021. The licensing inspector reviewed medication administration records and physician orders. Evidence gathered during the investigation supported the report of the medication error and non-compliance with applicable standards or laws, and violations are documented on the violation notice issued to the facility
Violations
22VAC40-73-680-D
Based on a review of medication administration records (MARs) and physician orders for resident # 1, medications were not 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 # 1 has a physician order for December 2020 and January 2021 to take Valsartan/HCTZ 320-12.5 mg tab "take one tablet by mouth every day for hypertension". It was self reported by the facility and documented on the MARs for December 2020 and January 2021 for resident # 1 that Valsartan/HCTZ was not administered per the physician orders from 12/23/2020 to 1/20/2020.
Plan of correction
1. In-service will be conducted with all RMA (Registered Medication Aide) on the following: Protocol for the acceptance of medications from pharmacy. Protocol for notification of missing medications 2. Weekly review of medication Exceptions Report will be conducted by ED (Executive Director) beginning 3/26/2021. To be completed by WD (Wellness Director) once hired. 3. Monthly review of POS(Physician Orders) for accuracy. CSS/WD on 4/13/2021. MD on 4/21/2021. 4. Quarterly audits will be performed by pharmacy. Southern Pharmacy completed audit on 2/2/21. 5. Monthly audits of Med Exception reports, signed POs, clinical in-services . SR Ed on 4/13/2021.
22VAC40-73-680-I
Based on a review of medication administration record (MAR) for one resident, facility staff failed to document the reason for a medication omission.
Evidence
  1. A review of the December 2020 and January 2021 medication administration records (MARs) for resident # 1 found that a medication (Valsartan/HCTZ) was not administered from 12/23/20 to 1/20/2021. The MARs did not document a reason for the medication not being administered.
Plan of correction
In-service will be conducted with all RMA on the following: Proper documentation of missing medications/med exceptions in EMAR (Electronic Medication Administration Record). tifi Protocol for notification of missing medications Weekly review of Medication Exceptions report will be conducted by the ED (Executive Director). ED beginning 3/26/2021, to be completed by WD (Wellness Director) once hired.
November 19, 2020Complaint survey1 violation
Inspection dates
Nov. 19, 2020
Areas reviewed
22VAC40-73 PERSONNEL
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. An complaint inspection was initiated on11/19/2020 and concluded on 12/8/2020 to investigate allegations regarding on-site facility management, holiday visitation and infection control. The identified administrator was contacted by email to initiate the inspection. Based on a review of facility on-site management schedules and emails from facility staff, one of the allegations was determined to be valid. Information gathered during the inspection determined that one allegation was valid and a violation was cited and is documented on the violation notice issued to the facility. The provider's response(s) for the "plan of correction" were not received as of 1/5/2021 and will not appear on this Violation Notice."
Violations
22VAC40-73-150-F
Based on a review of management schedules for two Virginia licensed assisted living facilities, the facility failed to maintain an administrator on a full-time basis as the on-site agent of the licensee who is responsible for the day-to-day administration and management of the facility. b. There is no on site administrator listed on the December 2020 schedule for facility # 1 for the following dates: 12/1/2020, 12/7/2020. 12/7-11/2020, 12/14/2020, 12/23/2020, 12/24/2020, 12/25/2020, 12/28/2020. These dates note either "The Phoenix at Lake Lanier" or "Holiday" or "Home". Staff # 2 is listed as the on-site administrator with "Travel to Midlothian" noted on December 2, 2020 and December 17, 2020. The Phoenix at Lake Lanier is located in Georgia. The November 2020 and December 2020 schedules submitted by the facility for review did not support the presence an administrator on site on a full-time basis.
Plan of correction
Not published by VDSS.