Virginia DSS · Assisted Living Facility

The Virginian(Fairfax Co)

📍 9229 Arlington Blvd., Fairfax, VA, 22031

ID 45167One Year licenseActive
20
Inspections
On record
14
With violations
Visits that cited something
6
Clean visits
Nothing cited
55
Violations cited
Individual findings
43
Standards cited
Distinct rules
4
Complaint visits
Prompted by a complaint

The Virginian(Fairfax Co) was inspected 20 times between March 29, 2021 and April 22, 2026 by the Virginia Department of Social Services. 14 of those visits ended with violations cited and 6 with none. Across that history VDSS cited 55 violations under 43 distinct standards. 4 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.

Every inspection listed here is currently published on the VDSS site.

Provider Information

Facility type
Assisted Living Facility
License type
One Year
License expires
10/24/2026
Administrator
Avanel Jarka
Licensing inspector
Amanda Velasco
Inspector phone
(703) 397-4587
Approved for
Special Care Unit · Assisted Living · Non-Ambulatory

Inspection History

20

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

April 22, 2026Complaint survey1 violation
Inspection dates
04/22/2026
Areas reviewed
22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-80 COMPLAINT INVESTIGATION
Technical assistance
Home Health Notes/ Change of Ownership Application/ Rounding Log Documentation
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 04/22/2026 11:15 AM to 12:05 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 04/08/2026 regarding allegations in the area(s) of: 1. Buildings and Grounds 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: 1 Observations by licensing inspector: Services communication regarding signaling devices. Additional Comments/Discussion: Rounding logs for AL residents were reviewed. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegations of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of these inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Amanda “AJ” Velasco, Licensing Inspector at (703) 397 4587 or by email at amanda.velasco@dss.virginia.gov.
Violations
22VAC40-73-930-B
Based on facility document review and staff interview, the facility failed to ensure there was a signaling device that terminates at a central location that is continuously staffed and permits a staff to determine the origin of the signal in buildings licensed to care for 20 or more residents.
Evidence
  1. On 04/08/2026, the LI received a complaint indicating that the facility’s signaling device was not functioning. In a self report submitted on 04/10/2026, the facility confirmed that the device had been operating intermittently and had stopped working entirely as of 04/10/2026. The facility notified the LI on 04/12/2026 that the signaling device had been restored to full functionality.
  2. Communication with the service provider, Collateral Contact 1, was provided by Staff 1 and reviewed by the LI.
  3. In an interview with the LI on 04/22/2026, Staff 1 confirmed that the facility failed to ensure there was a signaling device accessible to residents at all times from 04/08/2026 to 04/12/2026.
Plan of correction
On 4/12/26 Sentrix repaired and replaced the system and the system is functional. Platform is reporting calls initiated by the residents. In addition the community is scheduled to replace the entire system by Q4 with the Pal Care system, as Sentrix is not responding to our service needs consistently.
October 9, 2025Inspection0 violations
Inspection dates
10/09/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-80 SANCTIONS
Technical assistance
Intensive Plan of Correction (IPOC) reviewed. Ensure IPOC tools are being reviewed.
Comments
Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/09/2025 11:30 AM to 12:30 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 100 (10/03/2025) 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: 1 Observations by licensing inspector: Selective staff, resident, and private duty aide records were reviewed to ensure compliance with Intensive Plan of Correction (IPOC). 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 Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
October 9, 2025Complaint survey2 violations
Inspection dates
10/09/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-80 COMPLAINT INVESTIGATION
Technical assistance
120-A(2): Terms of License Re: Name of Owner
Comments
Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 10/03/2025 regarding allegations in the area(s) of: 1. Staffing and Supervision 2. Admission, Retention, and Discharge of Residents Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/09/2025 12:30 PM to 2:40 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: 100 (10/03/2025) 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 (Selective) 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: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the complaint of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Violations
22VAC40-73-50-A
Based on resident record review and staff interview, the facility failed to ensure that the information on the disclosure form was kept current.
Evidence
  1. Resident 1’s (admitted 06/30/2025) and Resident 4’s (admitted 03/05/2025) disclosure statement indicates the following staffing pattern for the assisted living unit. a. 7AM to 3PM: 8 eight (8) staff composed of CNA’s, MT’s, and LPN’s b. 3 PM to 11PM: eight (8) staff composed of CNA’s, MT’s, and LPN’s c. 11PM to 7AM: four (4) staff composed of CNA’s, MT’s, and LPN’s
  2. Resident 2 (admitted 04/30/2025), Resident 3’s (admitted 04/30/2025) disclosure statements indicate the following staffing pattern for the assisted living unit: a. 7AM to 3PM: 20 staff composed of CNA’s, DCA’s, RMA’s, RN’s, and LPN’s b. 3 PM to 11PM: 13 staff composed of CNA’s, DCA’s, RMA’s, and LPN’s c. 11PM to 7AM: nine (9) staff composed of CNA’s and RMA’s
  3. In an interview with the LI, Staff 1 confirmed that the disclosure statement signed by Resident 1 and Resident 4 is the current disclosure form; however, Staff 2 confirmed that an LPN is not currently scheduled on the third shift (11PM to 7AM).
Plan of correction
Corrected by Interim ED on 10/20/2025 – information is kept in out community relation office.
22VAC40-73-280-B
Based on facility document review and staff interview, the facility failed to ensure that a written staffing plan that specifies the number and type of staff required to meet the day-to-day, routine direct care needs and any identified special care needs was maintained.
Evidence
  1. Staff 2 provided the facility’s policy titled “GP12 – Staffing, Emergency Training, Cardiopulmonary Resuscitation (CPR) and First Aid Training.” The policy does not include a specific number or type of staff.
  2. In an interview with the LI on 10/09/2025, Staff 2 stated that they use an online system to determine the number of care hours needed for resident care needs; however, it does not list the type of staff that will be used to fill the hours. Staff 2 confirmed that the written staffing plan does not specify the number and type of staff required to meet the day-to-day, routine direct care needs.
Plan of correction
Staffing guidelines submitted and disclosed in the marketing materials. New leadership started for the community on 10/13 and 10/20 to ensure the needs of the residents are met and staffing is always efficient
October 3, 2025Inspection7 violations
Inspection dates
10/03/2025, 10/09/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY63.2- (1) GENERAL PROVISIONS22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSING PROCESS
Technical assistance
CHOW Files: Residents should maintain H&P, MH Screening, S/O check, and Safe, Secure Unit documents. Keep current TB, resident rights, UAI, ISP. All other documents will need to be completed again. All staff records new except TB. Standards Discussed: 325-A, 720-A, 440-A, 450-D, 930-D.
Comments
Type of inspection: Renewal Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/03/2025 8:45 AM to 5:30 PM 10/09/2025 10:00 AM to 11:30 AM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 100 (10/03/2025) The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 4 Number of interviews conducted with residents: 5 Number of interviews conducted with staff: 10 Observations by licensing inspector: Meals, Activities, Medication pass observation on both Assisted Living and Safe, Secure Unit. Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Violations
22VAC40-73-550-G
Based on staff record review and staff interview, the facility failed to ensure that the rights and responsibilities of residents in assisted living facilities were reviewed annually with each resident and each staff person and
Evidence
  1. of this review was dated, acknowledged by the resident or staff person, and filed in the record of the resident or staff person. Evidence:
  2. The records of Staff 6, re- hired on 05/19/2025 and Staff 8, re-hired on 05/19/2025, contained a review of the rights and responsibilities of assisted living residents completed on 09/19/2024.
  3. In an interview with the LI on 10/03/2025, Staff 1, Staff 2, Staff 4, Staff 9, and Staff 14 acknowledged that Staff 6 and Staff 8’s records did not contain acknowledgement of the rights and responsibilities of residents in assisted living facilities.
Plan of correction
Assisted Living Residents were properly informed of resident rights and responsibilities on 10/13/2025 with management in attendance. Records are kept in Resident Lifestyle Director’s office and will continued to be updates with change in census.
22VAC40-73-320-A
Based on resident record review and staff interview, the facility failed to ensure that the physical examination report included a statement that specifies whether the individual is or is not capable of administering medication.
Evidence
  1. Resident 7’s report of physical examination, dated 02/07/2025, does not indicate whether the individual is or is not capable of administering medication.
  2. Resident 2’s report of physical examination, dated 02/13/2025, does not indicate whether the individual is or is not capable of administering medication.
  3. In an interview with the LI on 10/03/2025, Staff 1, Staff 2, Staff 4, Staff 9, and Staff 14 acknowledged that the physical examination reports did not include indications of whether Resident 2 and Resident 7 could self-administer.
Plan of correction
Audit ongoing and corrections implemented to ensure residents who are assessed as self-medication, is appropriate. Audit of all apartments was completed on 11/5/2025 and will continue to ensure compliance with regulations.
22VAC40-73-860-I
Based on direct observation and staff interview, the facility failed to ensure that cleaning products and other hazardous items were stored in locked areas.
Evidence
  1. During a tour of the facility with Staff 4, the LI observed the following items in accessible areas on the Assisted Living Unit: a. Virex Disinfectant Cleaner, Activity Room b. Virex Disinfectant Cleaner, Bistro/Library c. Simple Green, Laundry Room Closet d. Laundry Detergent, Laundry Room
  2. During a tour of the facility with Staff 4, the LI observed the following items in accessible areas on the Assisted Living Unit: a. Hand Sanitizer, two bottles in the dining room – one on the medication cart, and one by the sink.
  3. The photo evidence was reviewed and acknowledged during the exit meeting with Staff 1, Staff 2, Staff 4, Staff 9, and Staff 14.
  4. Photo evidence obtained.
Plan of correction
Training and documentation completed on 10/15/2025. Continually auditing to ensure compliance.
22VAC40-90-40-B
Based on staff record review and staff interview, the facility failed to ensure that criminal records were obtained prior to the 30th day of employment.
Evidence
  1. Staff 6’s, hired on 05/19/2025, record contained a criminal record report completed on 10/03/2025.
  2. In an interview with the LI on 10/03/2025, Staff 1 confirmed that Staff 6 had been employed since 03/05/2014 with the Virginian but all staff were re-hired in May of 2025 due to a management company change. Staff 1 confirmed that no additional criminal record report could be located, and one was not completed at the rehiring on 05/19/2025.
Plan of correction
Completed on 10/3/2025. Audit conducted to ensure all employees are compliant with regulations and criminal records on file.
22VAC40-73-650-B
Based on direct observation, resident record review, and staff interview, the facility failed to ensure that physician orders included the route or specific indications for administering each drug.
Evidence
  1. During a medication pass observation, the LI observed Staff 10 administer a patch to Resident 11’s left shoulder area. The LI observed that the box and the order stated to apply to the affected area. In an interview with the LI, Staff 10 confirmed the order, and the medication box did not list the specific indications on administering each drug. Staff 10 stated that Resident 11 had previously expressed pain to the left shoulder, which is how they knew where to place the patch.
  2. Resident 11’s record contained an order for Lidocaine Outer 5% Patch that states “Apply one patch every day for pain.”
  3. In an interview with the LI on 10/09/2025, Staff 1 confirmed that the physician’s order did not contain the specific indications for administering the medication.
Plan of correction
Corrected immediately on site – day of inspection. Continually educating, training and auditing to ensure administration is correct per order. Med review will be completed as of 11/15/2025.
22VAC40-73-860-D
Based on direct observation and staff interview, the facility failed to ensure that any operable window was effectively screened.
Evidence
  1. During a tour of the facility with Staff 4, the LI observed the following areas containing operable windows with no screens: a. East B-side common area b. Bistro/Library area c. Dining Area (3rd Floor)
  2. In an interview with the LI on 10/03/2025, Staff 2 and Staff 13 stated that the windows were in the process of being cleaned; however, the facility did not provide documentation of the duration of the project including when the screens were removed and when they were going to be replaced.
  3. On 10/09/2025, the LI observed that the windows still did not have the screens replaced.
  4. Photo evidence obtained.
Plan of correction
installation of missing screens was placed on 10/20/2025. Cap Ex project planned for 2026 replacement of all facility windows.
22VAC40-73-680-D
Based on direct observation, resident record review, and staff interview, the facility failed to ensure that medication was administered in accordance with physician or prescriber orders.
Evidence
  1. During a medication pass observation on the Safe, Secure unit, the LI observed Staff 6 administer medication to Resident 11 and Resident 12 after crushing the medication. Staff 6 stated that all resident medication was crushed.
  2. Resident 11 and Resident 12’s records did not contain orders to crush medication.
  3. In an interview with the LI, Staff 11 confirmed that Resident 11 and Resident 12’s records did not contain crush orders. Staff 11 confirmed that medication was not administered per physician or prescriber’s orders.
Plan of correction
Education and documentation completed on 10/20/2025. Audit of charts ongoing and working on attaining crush orders where applicable.
June 12, 2025Inspection2 violations
Inspection dates
06/12/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY
Technical assistance
Ensure all forms are completed in their entirety.
Comments
Type of inspection: Monitoring A self-reported incident was received by VDSS Division of Licensing 02/18/2025 regarding allegations in the area(s) of: 1. Resident Care and Related Services 2. Staffing and Supervision Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/12/2025 8:35 AM to 1:17 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: 155 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 4 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 6 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. However, violation(s) not related to the self-reported incident but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Violations
22VAC40-73-70-C
Based on facility document review and staff interview, the facility failed to ensure a written report of each incident was submitted to the regional licensing office within seven (7) days from the date of the incident.
Evidence
  1. On 02/18/2025, the facility initially notified the licensing inspector via email of an allegation of abuse between two staff members and Resident 2 that occurred in December of 2024.
  2. The written incident report was not received by the licensing staff until 03/05/2025. On 03/05/2025, two reports of abuse allegations were submitted regarding the following incidents: a. Incident occurs early December (possibly first week) between Resident 2, Staff 3, Staff 5 and Staff 6. b. Incident occurred 02/11/2025 or 02/12/2025 between Resident 1 and Staff 3 and Staff 4.
  3. In an interview with the LI on 06/12/2025, Staff 7 confirmed that the reports were not submitted within (7) days of each incident.
Plan of correction
A. Staff Training on Reporting Procedures The community will conduct formal training for all team members on the policies and procedures regarding incident reporting. This training will emphasize the requirement to notify the Regional Licensing Office of reportable incidents in writing within seven calendar days from the date of occurrence. • Responsible Party: HR Coordinator and Clinical Coordinator • Completion Date: 7/31/2025 • Documentation: Attendance logs, training materials, signed acknowledgments ________________________________________ B. Implementation of Reporting Protocol Effective immediately, any staff member witnessing or involved in a reportable incident will follow a standardized reporting protocol. This protocol includes internal documentation, supervisory notification, and timely escalation to ensure external reporting compliance within the mandated 7-day window. • Responsible Party: Supervisors and Department Heads • Monitoring: All incident reports will be reviewed by administration to ensure proper and timely submission. • Start Date: 6/12/2025 ________________________________________ C. Ongoing Staff Education To maintain compliance, all employees will receive refresher training on reporting requirements during quarterly in-services. Training will also be incorporated into new employee onboarding. • Responsible Party: HR Coordinator • Frequency: Quarterly and upon hire • Verification: Staff training records maintained. ________________________________________ D. Oversight and Quality Assurance The HR and Clinical Coordinators will conduct routine audits of incident reports and reporting timelines. Regular communication strategies — including monthly town hall trainings across all shifts — will be used to reinforce reporting expectations. • Responsible Party: HR and Clinical Coordinators • Ongoing Monitoring: Monthly audits and feedback loops • Documentation: Audit logs, communication memos, staff meeting minutes
22VAC40-73-130-A
Based on resident record review and staff interview, the facility failed to ensure that all staff who are mandated reporters reported suspected abuse, neglect, or exploitation in accordance with § 63.2-1606 of the code of Virginia.
Evidence
  1. On 03/05/2025, one suspicion of abuse allegation, reported by Staff 3, were submitted regarding the following incidents. The report states that in early December (possibly the first week) Staff 3 witnessed Staff 5 and Staff 6 were holding down Resident 2 while incontinence care was provided.
  2. In an interview with the LI on 06/23/2025, Staff 7 confirmed the reports were not submitted in accordance with § 63.2-1606 of the code of Virginia.
Plan of correction
A. Immediate Solution: In response to the specific incident cited, the facility immediately took the following actions: • The staff member involved was promptly re-educated on the mandatory reporting requirements under §63.2-1606. • The resident involved was assessed to ensure their safety and well-being. • A root cause analysis was conducted to determine why the mandated report was not made in a timely manner. Responsible Party: Administrator, Clinical Coordinators ________________________________________ B. Expand Scope: To ensure no other residents have been affected by underreporting or delayed reporting: • A retrospective review of all incident logs and documentation from the past 90 days was conducted to identify any unreported or misclassified incidents that may meet the criteria for mandated reporting. • Staff were surveyed/interviewed to confirm understanding of their responsibilities as mandated reporters. Conducted by Health and Wellness Nurse and Associate Executive Director. Responsible Party: Director of Nursing, AED and Health and Wellness Director. Date Completed: 6/12/2025 ________________________________________ C. Systemic Change: To prevent recurrence and ensure full compliance: • Mandated Reporter Policy is being implemented, clearly defining abuse, neglect, and exploitation, and outlining the process for internal reporting and external notification to APS. Staff will sign off on completion. • Mandatory training on §63.2-1606 was provided to all staff, including definitions, real-world scenarios, reporting timelines, and consequences for failure to report. • This training has been integrated into new employee orientation and will be shared during the year. Responsible Party: ED and clinical coordinators. ________________________________________ D. Monitoring: To ensure ongoing compliance and effectiveness of corrective actions: • Audits of incident reports will be conducted to verify that all qualifying incidents have been reported to VDSS/APS in accordance with the law. • In-services will reinforce staff responsibilities as mandated reporters. • Staff competency on mandated reporting will be reviewed annually as part of performance evaluations. Responsible Party: ED, Quality Assurance Committee Monitoring Start Date: 6/12/2025 Review Frequency: Monthly and ongoing
December 3, 2024Complaint survey7 violations
Inspection dates
12/03/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-80 THE LICENSE22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint A complaint was received by the VDSS Division of Licensing on 10/29/2024 regarding allegations in the area(s) of: 1. Administration and Administrative Services 2. Resident Care and Related Services 3. Resident accommodations and Related Provisions Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/03/2024 11:45 AM to 5:30 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: 150 The licensing inspector completed a selective tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 7 Observations by licensing inspector: Resident Room Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the complaint of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and laws shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov.
Violations
22VAC40-73-470-F
Based on resident record review and staff interview, the facility failed to ensure that the circumstances involved, and medical attention received or refused when the resident suffers a serious accident or injury was documented in the resident’s record including the date and time of occurrence, the personnel involved, and documentation of the date, time, and caller who completed notification to the physician, next of kin legal representative, designated contact person and any responsible social agency, as appropriate.
Evidence
  1. In an interview with the LI on 12/03/2024, Staff 4 confirmed they responded to a fall for Resident 1 on 09/21/2024. Staff 4 provided an email that was sent to Staff 2 and 3 on 09/21/2024 documenting the incident.
  2. In an interview with the LI on 12/03/2024, Staff 6 confirmed they responded to a fall for Resident 1 on 10/20/2024. Staff 6 provided an email that was sent to Staff 2 on 10/20/2024 documenting the incident.
  3. Upon review of Resident 1’s record, there was no documentation of either incident including the date and time of occurrence, the personnel involved, and documentation of the date, time, and caller who completed notification to the physician, next of kin legal representative, designated contact person and any responsible social agency, as appropriate.
  4. Staff 1 and 2 confirmed that there as no written documentation in the Resident’s record because they are considered to be Independent Living status.
Plan of correction
Corrective Action: This citation relates to the Standards for Assisted Living being applied to an Independent Living Resident living in a room identified as a licensed Assisted Living unit. We will begin the process of decertification of our second floor where Independent Living Residents reside. Plan for continued compliance: Immediately moving forward the Administrator, Assisted Living Director and Director of Nursing will ensure that Independent Living residents will no longer be co-mingled in areas designated with the with the Department as licensed Assisted Living units. All requirements of The Standards for Assisted Living Facilities will be fully implemented for all licensed Assisted Living suites, as required in the regulations, with the goal of obtaining 100% compliance. We will immediately begin the process of decertification of the second floor. The Administrator and Quality Assurance Team will monitor monthly compliance and ongoing for continued compliance. Date to be Corrected: May 3, 2025
22VAC40-73-40-A
Based on resident record review and staff interview, the facility failed to ensure compliance with all regulations for licensed assisted living facilities and terms of the license issued by the department and the facility’s own policies and procedures.
Evidence
  1. The Virginian is licensed as an Assisted Living Facility by the Virginian Department of Social Services (VDSS). The facility’s license currently covers the following areas: “This license covers the care provided in the areas below: Floor 1 (Northwest and Southwest wings) Floor 2 Floor 3.”
  2. Resident 1 resides on the second floor, licensed by VDSS.
  3. Resident 1’s agreement, dated 12/26/2019, states the following: “The portion of the Community in which you will reside is licensed by the Virginia Department of Social Services as an Assisted Living Facility.”
  4. Resident 1’s agreement contains an Assurance of Care signed 12/14/2019 assigning the resident to “Independent Living.” The Assurance of Care states “Independent and Assisted Living are licensed under the Virginia Department of Social Services. Our Health Care Center maintains licensure under the Virginia State Department of Health. The Resident has been evaluated by our medical assessment team who can assure that the Resident’s needs can be met by the assigned level of care at this time. It is The Virginian’s policy to monitor resident’s changing needs on a regular basis. If a Resident’s needs at some future point cannot be met at the assigned level of care noted above, the Resident or Power of Attorney will be notified.”
  5. Resident 1’s record contained a Uniform Assessment Instrument (UAI) dated 07/08/2021 that stated Resident 1 received medication administration both without assistance and administered/monitored by nursing staff. Under “Describe help/Name of helper:” a written note said “Self-medications administers.” A note to the write stated “Diabetic Management RMA/LPN 10/5/21”.
  6. Individualized Service Plan (ISP), dated as last updated 07/07/2022, listed the Description of Needs and Date Identified as “Assistance with medication D/T Inability to Administer Insulin.”
  7. In an interview with the LI on 12/03/2024, Staff 1 stated that Resident 1 was no longer receiving medication administration assistance; however, did not have any documentation that reflected the change in medication administration. Staff 1 confirmed that there was not another agreement that detailed the level of care change. Staff 1 confirmed that the facility considered Resident 1 an Independent Living Resident even though Staff 1 confirmed Resident 1 resides in a licensed assisted living room.
  8. Staff 1 provided the facility’s policy for the Morning Watch Program. The policy states “The Virginian offers to Residents a Voluntary Morning Watch Program. A sensor, installed in each IL room, will detect motion every morning, prior to 9:00 a.m., signaling that the Resident is up and out of bed.” Additional evidence available on attached page.
Plan of correction
Corrective Action: This citation relates to the Standards for Assisted Living being applied to an Independent Living Resident living in a room identified as a licensed Assisted Living unit. The resident referenced in the violation notice was an independent resident with an Independent Living Residency Agreement, identifying that their choice to reside as Independent Living Resident as her Right under Virginia Code to do so. This resident successfully lived independently, not receiving services for ADL’s, medications, or care oversight since December of 2019. The Virginian Policies & Procedures referenced were Assisted Living Policies and Procedures. After this occurrence the Resident and Responsible Party agreed that the next level of care would be their next step and entered into an Assisted Living Residency Agreement for supportive care. Plan for continued compliance Immediately moving forward the Administrator, Assisted Living Director and Director of Nursing will ensure that Independent Living residents will no longer be co-mingled in areas designated with the with the Department as licensed Assisted Living units. All requirements of The Standards for Assisted Living Facilities will be fully implemented for all licensed Assisted Living suites, as required in the regulations, with the goal of obtaining 100% compliance. We will immediately begin the process of decertification of the second floor. The Administrator and Quality Assurance Team will monitor monthly compliance and ongoing for continued compliance. Date to be Corrected: May 3, 2025
22VAC40-73-70-A
Based on resident record review and staff interview, the facility failed to ensure that any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any residents was reported to the regional licensing office within 24 hours.
Evidence
  1. In an interview with the LI on 12/03/2024, Staff 4 confirmed they responded to a fall for Resident 1 on 09/21/2024. Staff 4 provided an email that was sent to Staff 2 and 3 on 09/21/2024 documenting the incident.
  2. In an interview with the LI on 12/03/2024, Staff 6 confirmed they responded to a fall for Resident 1 on 10/20/2024 that resulted in the resident being sent to the hospital for injuries sustained. Staff 6 provided an email that was sent to Staff 2 on 10/20/2024 documenting the incident.
  3. Staff 1 provided the facility policy for incident reporting. The policy states “It is the policy of the Virginian to insure all adverse occurrences of accidents are promptly investigated, documented, and reported. An incident is any happening that is not consistent with the routine operation of the facility or the routine care of a particular resident. Also included are: adverse patient care/service outcomes, medication and treatment errors, personal injury or endangerment, patient and/or family injuries including falls, motor vehicle accidents while on property conducting business, environmental safety hazards, malfunctions, or failures including equipment, unusual occurrences, suicidal attempts or threats.
  4. In an interview with the LI on 12/03/2024, Staff 1 confirmed incident reports were not documented or submitted because the resident has Independent Living Status.
Plan of correction
Corrective Action: This citation relates to the Standards for Assisted Living being applied to an Independent Living Resident living in a room identified as a licensed Assisted Living unit. We will begin the process of decertification of our second floor where Independent Living Residents reside. Plan for continued compliance: Immediately moving forward the Administrator, Assisted Living Director and Director of Nursing will ensure that Independent Living residents will no longer be co-mingled in areas designated with the with the Department as licensed Assisted Living units. All requirements of The Standards for Assisted Living Facilities will be fully implemented for all licensed Assisted Living suites, as required in the regulations, with the goal of obtaining 100% compliance. We will immediately begin the process of decertification of the second floor. The Administrator and Quality Assurance Team will monitor monthly compliance and ongoing for continued compliance. Date to be Corrected: May 3, 2025
22VAC40-73-440-A
Based on resident record review and staff interview, the facility failed to ensure that the Uniform Assessment Instrument (UAI) was completed at least annually and whenever there is a significant change in the resident’s condition.
Evidence
  1. Resident 1’s record contains a UAI dated as assessed on 07/08/2020 and reassessed on 07/08/2021. The UAI indicates that the resident was reassessed to have medication administered/monitored by professional nursing staff. There is a handwritten notation that states “[Diagnosis] management RMA, LPN 10/05/2021”
  2. In an interview with the LI on 12/03/2024, Staff 2 stated that Resident 1 was not receiving assistance with medication. Staff 2 confirmed that Resident 1 would sometimes call for assistance with checking Resident 1’s blood pressure.
  3. In an interview with the LI on 12/03/2024, Staff 1 stated that they do not have an updated UAI for Resident 1.
Plan of correction
Corrective Action:This citation relates to the Standards for Assisted Living being applied to an Independent Living Resident living in a room identified as a licensed Assisted Living unit. The resident referenced in the violation notice was an independent resident with an Independent Living Residency Agreement, identifying that their choice to reside as Independent Living Resident as her right under Virginia Code to do so. This resident successfully lived independently, not receiving services for ADL’s, medications, or care oversight since December of 2019. After this occurrence the Resident and Responsible Party agreed that the next level of care would be their next step and entered into an Assisted Living Residency Agreement for support care. The Virginian has a consistent record of performing timely and appropriate Uniform Assessment Instruments on all residents receiving Assisted Living care, and this resident has been evaluated accordingly. Plan for continued compliance:Immediately moving forward the Administrator, Assisted Living Director and Director of Nursing will ensure that Independent Living residents will no longer be co-mingled in areas designated with the with the Department as licensed Assisted Living units. All requirements of The Standards for Assisted Living Facilities will be fully implemented for all licensed Assisted Living suites, as required in the regulations, with the goal of obtaining 100% compliance. We will immediately begin the process of decertification of the second floor. The Administrator and Quality Assurance Team will monitor monthly compliance and ongoing for continued compliance. Date to be Corrected: December 20, 2024 and May 3, 2025
22VAC40-73-450-F
Based on resident record review and staff interview, the facility failed to ensure that the individualized service plan (ISP) was reviewed and updated at least once every 12 months and as needed for a significant change in the resident’s condition.
Evidence
  1. Resident 1’s record contains an ISP signed and dated by Resident 1 in November of 2021. The ISP contains a staff signature under the updates section on 10/06/2021, 01/10/2022, 04/01/2022, and 07/07/2022.
  2. In an interview with the LI on 12/03/2024, Staff 1 stated that they do not have an updated ISP for Resident 1.
Plan of correction
Corrective Action: This citation relates to the Standards for Assisted Living being applied to an Independent Living Resident living in a room identified as a licensed Assisted Living unit. The resident referenced in the violation notice was an independent resident with an Independent Living Residency Agreement, identifying that their choice to reside as Independent Living Resident as her right under Virginia Code to do so. This resident successfully lived independently, not receiving services for ADL’s, medications, or care oversight since December of 2019. After this occurrence the Resident and Responsible Party agreed that the next level of care would be their next step and entered into an Assisted Living Residency Agreement for support care. The Virginian staff has consistently executed its policies and procedures to make the requisite updates to the individualized service plans for all residents receiving Assisted Living level of care. This resident’s plan was updated accordingly upon transition to Assisted Living. Plan for continued compliance: Immediately moving forward the Administrator, Assisted Living Director and Director of Nursing will ensure that Independent Living residents will no longer be co-mingled in areas designated with the with the Department as licensed Assisted Living units. All requirements of The Standards for Assisted Living Facilities will be fully implemented for all licensed Assisted Living suites, as required in the regulations, with the goal of obtaining 100% compliance. We will immediately begin the process of decertification of the second floor. The Administrator and Quality Assurance Team will monitor monthly compliance and ongoing for continued compliance. Date to be Corrected: December 24, 2024 and May 3, 2025
22VAC40-73-460-B
Based on resident record review and staff interview, the facility failed to ensure that care provision and service delivery was resident entered to the maximum extent possible and included prompt response by staff to resident needs as reasonable to the circumstances.
Evidence
  1. In an interview with the LI on 12/03/2024, Staff 4 confirmed that Staff 4 responded to a call bell alert on 09/21/2024 for Resident 1. Staff 4 stated that Resident 1 had fallen on the floor. Staff 4 stated that an email was sent to notify the staff that Resident 1 had fallen.
  2. Staff 4 provided an email that Staff 4 sent to Staff 3 and Staff 2 on 09/21/2024 that stated “I just want to notify you that [Resident Room Number and First Name of Resident 1 with a different last name] had a fall this morning. [Resident 1] said [Resident 1] didn’t hit [Resident 1’s] head and other parts so [Resident 1] is in the facility at this time. I started my shift at 9:00 AM this morning. When I found [Resident 1] on the floor it was more than two hours at that time [Resident 1] was lying on the floor according to call light and resident.”
  3. Staff 1 and 3 provided a copy of the call bell log for Resident 1 from the dates of 09/01/2024 to 12/01/2024. Resident 1’s call bell log has an initiation call on 09/21/2024 at 07:12:14 AM and a response date/time of 09/21/2024 at 09:42:36 AM. The total response time was two (2) hours and 30 minutes.
  4. In an interview with the LI on 12/03/2024, Staff 1 stated that Staff 1 had determined that the response time was actually only 40 minutes and that all Independent Living Status residents are told to expect longer call bell response times.
  5. In an interview with the LI on 12/03/2024, Staff 6 confirmed that Staff 6 responded to a fall for Resident 1 on 10/20/2024. Staff 6 provided an email that was sent to Staff 2 on 10/20/2024 documenting the incident. The email stated “Hello [Staff 2], Just wanted to keep you in the loop. [Resident 1] was found by [Resident 1’s] daughter around 3 PM today on the floor. Resident was sent out to [Hospital’s Name]. [Resident 1] will probably need a follow-up call tomorrow.” Staff 6 stated that Resident 1’s daughter was on the phone with 911 when Staff 6 arrived in the room. Staff 6 stated that Resident 1 was lying on their right side in between the dining and kitchen area, covered in feces and urine, and was responsive but not alert. Staff 6 stated that Resident 1 was mumbling and groaning. Staff 6 stated that they saw no visible injuries; however, they could not tell how long the resident had been on the floor.
  6. In an interview with the LI on 12/03/2024, Resident 1 stated that they do not remember the fall at all. Resident 1 expressed their concern that they could not remember the fall, or recall any of the week leading up to the incident.
  7. Resident 1’s discharge notes from [Hospital Name] has the dates of admission from 10/20/2024 to 10/25/2024. The discharge notes contain a trauma consult dated 10/20/2024 at 5:08 PM. The trauma consult stated the following in the comments under Physical Exam: a. Constitutional: “Comments: Covered in stool.” b. HENT [Head Ear Nose Throat]: “Comments: Bruising over right eye and around Jaw. Dried vomit over mouth/nose.” c. Chest: “Comments: Abrasion to right chest wall.” d. Musculoskeletal: “Comments: Left foot laterally rotated. Dried stool lower half of body. Abrasion to left thigh, right knee. Pressure injuries over right upper quadrant of abdomen, right hip, left thigh/knee.” Additional evidence provided on attached page.
Plan of correction
Corrective Action: The resident referenced in the violation notice was an independent resident with an Independent Living Residency Agreement, identifying their choice to reside as Independent Living Resident as her right under Virginia Code to do so. This resident successfully lived independently, not receiving services for ADL’s, medications, or care oversight since December of 2019. This citation relates to the Standards for Assisted Living being applied to an Independent Living Resident living in a room identified as a licensed Assisted Living unit. Over the entire period of regulatory oversight of The Virginian, we have not received any citations regarding our practice permitting Independent Living and Assisted Living to co-mingle with the community without applying regulatory expectations of The Standards for Assisted Living Facilities for those residents that had Independent Living Residency Agreements. Understanding that this practice is no longer acceptable, we will begin the process of decertification of our second floor where Independent Living Residents reside. Plan for continued compliance: Immediately moving forward the Administrator, Assisted Living Director and Director of Nursing will ensure that Independent Living residents will no longer be co-mingled in areas designated with the with the Department as licensed Assisted Living units. All requirements of The Standards for Assisted Living Facilities will be fully implemented for all licensed Assisted Living suites, as required in the regulations, with the goal of obtaining 100% compliance. We will immediately begin the process of decertification of the second floor. The Administrator and Quality Assurance Team will monitor monthly compliance and ongoing for continued compliance. Date to be Corrected: May 3, 2025
22VAC40-73-390-C
Based on resident record review and staff interview, the facility failed to ensure that the original agreement or acknowledgment was updated whenever there are changes to the information referenced or identified in the agreement and dated and signed by both the licensee or administrator and the resident or the resident’s legal representative.
Evidence
  1. Resident 1’s record contains a Resident Agreement signed and dated on 12/14/2019 by Resident 1.
  2. Resident 1’s agreement identifies the resident’s room as [Room Number], a room on the fourth floor, currently not licensed by VDSS.
  3. In an interview with the LI on 12/03/2024, Staff 1 confirmed that Resident 1 residents in a different room, [Room Number], than identified in the agreement. Staff 1 stated that there was no additional agreement documenting the room change, and all updates, including rent increases, were all sent through email notification and no response is required.
Plan of correction
Corrective Action: This citation relates to the Standards for Assisted Living being applied to an Independent Living Resident living in a room identified as a licensed Assisted Living unit. We will begin the process of decertification of our second floor where Independent Living Residents reside. Plan for continued compliance: This resident transitioned to Assisted Living, and this transition has been documented accordingly in the resident’s record. Immediately moving forward the Administrator, Assisted Living Director and Director of Nursing will ensure that Independent Living residents will no longer be co-mingled in areas designated with the with the Department as licensed Assisted Living units, and that all Assisted Living resident files continue to be updated in accordance with 22VAC40-73-390(C). All requirements of The Standards for Assisted Living Facilities, for this resident, and all others will be fully implemented for all licensed Assisted Living suites, as required in the regulations, with the goal of obtaining 100% compliance. We will immediately begin the process of decertification of the second floor. The Administrator and Quality Assurance Team will monitor monthly compliance and ongoing for continued compliance. Date Corrected: December 24, 2024 and May 3, 2025
September 30, 2024Inspection15 violations
Inspection dates
09/30/2024, 10/01/2024
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 PREPAREDNESSARTICLE 1 – SUBJECTIVITY63.2- (1) GENERAL PROVISIONS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION
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: 09/30/2024 9:25 AM to 4:00 PM 10/01/2024 9:00 AM to 5:18 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 100 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 4 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 8 Observations by licensing inspector: Meals, Activities, Medication Pass/ Medication Cart Audit (All observed on both Assisted Living and Special Care Unit) Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Violations
22VAC40-73-720-A
Based on resident record review and staff interview, the facility failed to ensure that the written Do Not Resuscitate (DNR) order is included in the individualized service plan.
Evidence
  1. Resident 5, admitted 08/31/2022, had an active DNR order dated 04/12/2024. Resident 5’s ISP, completed 04/05/2024, did not include a copy of the DNR order.
  2. Resident 6, admitted 05/02/2022, had an active DNR order dated 05/03/2022. Resident 6’s ISP, dated 04/29/2024, did not include a copy of the DNR order.
  3. Resident 7, admitted 12/06/2023, had an active DNR order dated 12/06/2023. Resident 7’s ISP, dated 12/07/2023, did not include a copy of the DNR orders.
  4. Resident 8, admitted 03/25/2024, had an active DNR order dated 03/07/2024. Resident 8’s ISP, dated 03/27/2024, did not include a copy of the DNR orders.
  5. Resident 10, admitted 09/13/2024, had an active DNR order dated 10/29/2023. Resident 10’s ISP, dated 09/30/2024, did not contain a copy of the ISP.
  6. In an interview with the LI on 10/01/2024, Staff 2 stated that the ISP’s are kept in a separate binder. Staff 2 confirmed that the DNR orders are not included with the ISP.
Plan of correction
The Administrator, Director of Health Services, Director of Assisted Living and Director of Memory Care have verified that all residents had a DNR order and form uploaded into their electronic medical record. All ISPs for residents with a DNR order is accurately reflected in the ISP written summary; however, at this time are unable to copy and paste orders into the ISP and have reached out to PCC for support. In the meanwhile, we have printed every ISP and attached a copy of the DNR orders. Plan for continued compliance: Administrator, Assisted Living Director and Quality Assurance Team will continue this process until an EMR solution is established and will monitor compliance with a goal of 100% compliance daily and ongoing. Date Corrected: November 1, 2024
22VAC40-73-120-C
Based on staff record review and staff interview, the facility failed to ensure that all staff received an orientation with the first seven working days of employment.
Evidence
  1. The records of Staff 5, 6 and 8 did not contain documentation of the Assisted Living Facility Orientation completed within the first seven working days of employment.
  2. Staff 5’s, hired 12/06/2023, staff record contains a file checklist listing the “Required Training Within the First 7 Days” with 13 subsections. These 13 subsections are not filled out, and the boxes for the initials are blank. Below the “Required Training Within the First 7 days” box, there is a statement that says, “I have reviewed and ensured the required trainings have been completed:” and the signature box and date is empty.
  3. Staff 6’s, hired 09/04/2022, staff record contains a file checklist listing the “Required Training Within the First 7 Days” with 13 subsections. These 13 subsections are not filled out, and the boxes for the initials are blank. Below the “Required Training Within the First 7 days” box, there is a statement that says, “I have reviewed and ensured the required trainings have been completed:” and the signature box and date is empty
  4. Staff 8’s, hired 02/10/2024, staff record contains a file checklist listing the “Required Training Within the First 7 Days” with 13 subsections. These 13 subsections are not filled out, and the boxes for the initials are blank. Below the “Required Training Within the First 7 days” box, there is a statement that says, “I have reviewed and ensured the required trainings have been completed:” and the signature box and date is empty
  5. Staff 2 provided a blank Licensed Nurse Competency checklist as the Assisted Living Facility orientation that did not include the required components of the required 7-day training; however, stated that they do not have another orientation.
Plan of correction
Corrective Action: The Administrator and Human Resources team will ensure that the DSS Staff Orientation form is used to track training during the first 7 days of employment, ensuring that requirements are met. Any training conducted in the electronic training portal will be added in writing to the DSS form. Plan for continued compliance: Administrator, Human Resources Director and Quality Assurance Team will monitor compliance with a goal of 100% compliance ongoing. Date Corrected: November 17, 2024
22VAC40-73-350-C
Based on resident record review and staff interview, the facility failed to ensure that each resident or his legal representative is fully informed annually that they should exercise whatever due diligence they deem necessary with respect to information on any sex offenders registered, including how to obtain that information and written acknowledgement of having been informed is maintained in the resident’s record.
Evidence
  1. The records for Residents 2, 5, 6 7, 8, 9, 10 and 11 did not contain annual notification that they should exercise whatever due diligence they deem necessary with respect to information on any sex offenders registered, including how to obtain that information.
  2. During the preliminary exit with the LI on 10/01/2024, Staff 2 confirmed that this information was not in the record of the residents.
Plan of correction
Corrective Action: Corrective action has been ensured by the Administrator. The community has established a notification for residents and/or legal representatives as required and has begun obtaining signatures of acknowledgement. Plan for continued compliance: The facility has scheduled calendar reminders annually to support compliance. Administrator and Quality Assurance Team will monitor compliance with a goal of 100% compliance monthly and ongoing. Date Corrected: January 31, 2025
22VAC40-73-660-A
Based on direct observation, the facility failed to ensure that the medicine cabinet used for storage of medications and dietary supplements prescribed for residents was locked.
Evidence
  1. During a tour of the special care unit, the LI observed the medication cart located in an activity area on the special care unit as unlocked.
  2. The nearest staff were assisting the residents for lunch in a connecting, adjacent room. The Li notified Staff 3 that the cart was unlocked.
  3. Photo evidence obtained.
Plan of correction
Corrective Action: The Administrator, Director of Health Services and Director of Memory Care have counseled and retrained all Medication Aides of the importance and safety of always maintaining compliance without variance. Plan for continued compliance: Moving forward the Director of Health Services, Director of Memory Care and Supervisors on Duty will conduct spot checks throughout each shift to ensure compliance. The Administrator and Quality Assurance Team will monitor compliance with a goal of 100% compliance daily and ongoing. Date Corrected: October 10, 2024
22VAC40-73-950-A
Based on facility document review and staff interview, the facility failed to ensure documentation of initial and annual contact with the local emergency coordinator was included in the written emergency preparedness and response plan.
Evidence
  1. The LI requested a copy of contact with the Fairfax County Office of Emergency Management (OEM), the facility’s local emergency coordinator.
  2. In an interview with the LI on 09/30/2024, Staff 1 stated that they had utilized the Northern Virginia Emergency Response System, NVERS.
  3. The NVERS websites states the following: NVERS facilitates a cross-jurisdictional and multi-disciplinary approach to preparedness. This resilient partnership of public safety systems saves lives, time, and economic resources during major emergencies and disasters in Northern Virginia.”
  4. In an interview with the LI on 09/30/2024, Staff 1 confirmed that they did not contact the OEM and stated that they believed that NVERS conducted the contact for them.
Plan of correction
Corrective Action: Corrective action has been completed by the Administrator. Written documentation of compliance obtained. Previously approved Emergency Preparedness Plan was approved, and no changes were required during this review and approval. Plan for continued compliance: Moving forward the Administrator has scheduled annual reviews with the Department of Emergency Management and Security. The Administrator and Quality Assurance Team will monitor compliance with a goal of 100% compliance daily and ongoing. Date Corrected: October 10, 2024
22VAC40-73-100-A
Based on facility document review and staff interview, the facility failed to ensure that there was an annual review of the infection prevention policies and procedures for any necessary updates completed by the administrator in conjunction with a licensed health care professional to ensure compliance with applicable guidelines and regulations.
Evidence
  1. On 09/30/2024, Staff 4 provided the infection control policy binder. The infection control binder was created by Med-Pass and listed as “UPDATE: December 2023.”
  2. The “Record of Reviews and Revisions” page, listed as revised in October 2018, was blank. Staff 4 stated they were unsure if it had been reviewed.
  3. During the preliminary exit on 09/30/2024, Staff 1 stated that this was not the most up to date version of the infection control policy and that the review had not been completed because the facility had been in transition.
Plan of correction
Corrective Action: The Administrator, Director of Nursing and Regional Clinical Specialist have updated and reviewed the Infection Control Manual and verified compliance by signed documentation. Plan for continued compliance: Moving forward the Director of Nursing and Administrator will schedule annual reviews to evaluate and confirm infection control and prevention follows regulations. Administrator and Quality Assurance Team will monitor compliance monthly and ongoing for continued compliance. Date Corrected: January 6, 2025
22VAC40-73-220-A
Based on staff record review, resident record review, and staff interview, the facility failed to ensure information on the type and frequency of the services to be delivered to the resident by private duty personnel were obtained in writing, review the information to determine if it was acceptable, and provide notification to the home care organization in writing regarding any needed changes.
Evidence
  1. Staff 2 provided the binder for private duty employees working at the facility.
  2. The binder contained the records for 18 private duty employees.
  3. The records did not contain written information on the type and frequency of services provided by the private duty personnel.
  4. Staff 2 stated that the service plan for each resident was provided to the private duty personnel for review; however, this information was not documented.
Plan of correction
Corrective Action: The Administrator and Assisted Living Director provide orientation to every Private Duty Aid (PDA) prior to the delivery of services to the resident and review the residents ISP thoroughly with them as well. Moving forward we will obtain the PDA’s signature on the service plan and place an ISP binder in each resident’s room as a reference to ensure care needs and services are always available for the PDA. Plan for continued compliance: Administrator, Assisted Living Director and Quality Assurance Team will monitor compliance with a goal of 100% compliance ongoing. Date Corrected: November 14, 2024
22VAC40-73-240-F
Based on staff record review and staff interview, the facility failed to ensure that all volunteers attended an orientation prior to beginning volunteer service and documentation that they had received and understood the orientation was signed and dated.
Evidence
  1. Staff 9 provided the volunteer record for three active volunteers, Staff 11, 12, and 13.
  2. Staff 11’s record contained a volunteer orientation checklist that was not signed or dated.
  3. Staff 12 and Staff 13’s record did not contain a volunteer orientation.
  4. In an interview with the LI on 10/01/2024, Staff 9 stated that they could not verify if 11 or 12 was completed because they started volunteering prior to their employment; however, they believed Staff 13 was completed but did not have a signed form.
Plan of correction
Corrective Action: The Administrator and Director of Life Enrichment have corrected all Volunteer records, except for 1 remaining record. The remaining volunteer has been ill and unable to participate as a volunteer while recovering and is expected to complete the requirements in the next 2 weeks. In the future volunteers will not be permitted to participate until all requirements are met. Plan for continued compliance: Administrator and Director of Life Enrichment will monitor compliance with a goal of 100% compliance daily and ongoing. Date Corrected: January 13, 2024
22VAC40-73-950-E
Based on facility document review and staff interview, the facility failed to ensure that a semiannual review on the emergency preparedness and response plan for all staff, residents, and volunteers was implemented.
Evidence
  1. Staff 1 and 2 provided the semi-annual elopement drill for staff was completed on 07/17/2024 and 01/17/2024.
  2. In an interview with the LI on 10/30/2024, Staff 2 confirmed that the emergency plan was reviewed during resident emergency (elopement) drills and that there were none done last year.
Plan of correction
Corrective Action: The Administrator and Director of Plant Operations conducted a Town Hall with staff and residents on duties and responsibilities during and emergency on March 21, 2024, and July 17, 2024, conducted an entire community Evacuation Drill also including residents and staff with documentation of participation. Additionally, we have 2 Relias training modules on Emergency Response and Preparedness that every employee must complete. Moving forward HR will include document of completion and participation in the employee record. Plan for continued compliance: Administrator, Human Resources Director and Quality Assurance Team will monitor compliance with a goal of 100% compliance ongoing. Date Corrected: October 10, 2024
22VAC40-73-410-A
Based on resident record review and staff interview, the facility failed to ensure that an orientation was provided for new residents and their legal representatives including emergency response procedures, mealtimes, and use of the call system.
Evidence
  1. Resident 10’s, admitted 09/13/2024, record contains an orientation that was completed on 09/13/2024 and signed by the legal representative and the facility, but not the resident.
  2. On June 12, 2024, the facility signed a plan of correction that stated the following “Corrective action has been ensured by the Assisted Living Director, Memory Care Director and Life Enrichment Director. Moving forward the Life Enrichment Director will provide each new resident and/or their legal representative New Resident Orientation upon admission. Orientation will include emergency response procedures, mealtimes, and use of the call system.”
Plan of correction
Corrective Action: The Administrator, Assisted Living Director, Memory Care Director and Life Enrichment Director will ensure that all Memory Care residents sign their orientation as required by the licensing inspector moving forward. The community standard has been to defer the signing of the orientation form due to severe cognitive impairment to the resident’s legal representative after providing orientation to both the resident and legal representative. Plan for continued compliance: Administrator, Assisted Living Director and Quality Assurance Team will monitor compliance with a goal of 100% compliance ongoing. Date Corrected: November 17, 2024
22VAC40-73-680-M
Based on direct observation, resident record review, and staff interview, the facility failed to ensure that medication ordered for as needed (PRN) administration were available at the facility.
Evidence
  1. Resident 4 had a PRN order that states Benzonatate Oral Capsule 100 mg that stated “Give 1 capsule by mouth every 06 hours as needed FOR COUGH”
  2. During the medication cart audit for the Assisted Living unit, Staff 4 could not locate the medication for Resident 4. Staff 4 pointed to the screen and confirmed that there had not been a new order received and stated that it was last administered on 08/04/2024.
  3. Resident 1 had an order for Epinephrine Injection Solution Auto-injector 0.3 mg that states “Inject 0.3 ml intramuscularly every 24 hours as needed FOR BEE STING.”
  4. During the medication cart audit on the Memory Care Unit, the Epinephrine medication for Resident 1 expired on 08/2024. There was not another medication available in the cart.
  5. Photo evidence obtained.
Plan of correction
Corrective Action: The Administrator, Director of Health Services, Director of Assisted Living and Director of Memory Care have counseled and retrained all Medication Aides of the importance of the availability of all medications that are ordered and that there are no expired medications on hand and always maintaining 100% compliance. Plan for continued compliance: Moving forward the Director of Health Services, Director of Assisted Living, Director of Memory Care and Supervisors on Duty will conduct medication spot checks throughout each shift to ensure compliance. The Administrator and Quality Assurance Team will monitor compliance with a goal of 100% compliance daily and ongoing. Date Corrected: October 10, 2024
22VAC40-73-40-A
Based on facility document review and staff interview, the facility failed to ensure compliance with the facility’s own policies and procedures.
Evidence
  1. The facility’s Private Duty Nursing policy states the following “If the private duty employee is employed through an agency, that agency must comply with the following provisions prior to the placement upon request…3. Agency must provide a copy of their Certificate of Insurance for liability and worker’s compensation.”
  2. The facility’s binder for private duty employees contained the records of 11 private duty employees from local agency but did not contain the Certificate of Insurance for Thrive at Home- Home Health.”
  3. Staff 1 confirmed that this was the policy for the private duty binders, and that the binder contained all the information they had for each private duty employee.
  4. The facility’s “Elopement-Missing Resident Drill Evaluation” states “Drills to be completed quarterly for Memory Care communities/neighborhoods and semi-annually for Assisted Living. Drills are to be completed for each shift.”
  5. Staff 1 confirmed that this was the facility policy. Staff 2 and 3 confirmed that the drills have not been completed quarterly for the memory care community.
Plan of correction
Corrective Action: The Administrator and Community Directors will ensure that all company policies and procedures are followed. Plan for continued compliance: Administrator and Quality Assurance Team will monitor compliance monthly over the next 3 months, with a goal of 100% compliance ongoing. Date Corrected: October 17, 2024
22VAC40-73-930-D
Based on resident record review and staff interview, the facility failed to ensure that if a resident is unable to use the signaling device or call system, the resident’s individualized service plan (ISP) documents the inability and specifies the minimum frequency of daily rounds to be made by direct care staff to monitor for emergencies or other unanticipated resident needs.
Evidence
  1. Resident 11’s, admitted 01/18/2023, record contains an ISP dated 03/17/2024. Resident 11’s ISP states “Resident is unable to utilize the emergency response system; may have frequent monitoring in place.”
  2. Resident 11’s ISP does not specify the minimum frequency of daily rounds to be made by direct care staff to monitor for emergencies or other unanticipated resident needs.
  3. In an interview with the LI on 10/01/2024, Staff 2 acknowledged that the ISP for Resident 11 and Resident 8 did not contain or specify the frequency of daily rounds to be made due to the resident’s inability to use the signaling device.
Plan of correction
Corrective Action: The Administrator and Director of Memory Care have confirmed which residents are unable to use a signaling device. All ISPs for these residents identify that rounds are performed and documented during the times of 8 pm and 7 am every 2-hours in the task records. For residents that are unable to use a signaling device, we have added this standard for the entire 24-hour period of each day. The ISP will be updated to include the frequency of monitoring during a 24-hour day. Plan for continued compliance: The Administrator, Director of Memory Care and Quality Assurance Team will monitor compliance with a goal of 100% compliance daily and ongoing. Date Corrected: December 1, 2024
22VAC40-73-1030-C
Based on staff record review and staff interview, the facility failed to ensure that within 4 months of the starting date of employment, direct care staff working in the special care unit attended six hours of training in working with individuals who have a cognitive impairment.
Evidence
  1. Staff 8, hired 02/10/2024, is assigned to the special care unit.
  2. Staff 8’s record did not contain the required 6 hours of training in working with individuals who have a cognitive impairment.
  3. Staff 2 and 3 stated that the training was scheduled for Staff 8; however, stated that it had not been completed within 4 months of employment.
Plan of correction
Corrective Action: Staff 8 did have over 6 hours of dementia training in her transcript; however, some of the content was not accepted. The Administrator, Memory Care Director and Human Resources will provide each new staff member with 6 hours of dementia specific training approved by the Licensing Inspector prior to scheduling them for providing resident care. Plan for continued compliance: Administrator, Memory Care Director and Quality Assurance Team will monitor compliance with a goal of 100% compliance ongoing. Date Corrected: November 17, 2024
22VAC40-73-970-E
Based on facility document review and staff interview, the facility failed to ensure that a record of the fire and emergency evacuation drills is retained in the facility for two years and included the identity of the person conducting the drill, the number of staff participating, and the number of residents participating.
Evidence
  1. Staff 14 provided the record of fire drills for the facility from January of 2024 through the inspection date of 09/30/2024.
  2. The Fire Drill Report for 01/31/2024 has a question mark next to the “number of staff on duty” and the “number of residents in the building.” Next to “number of staff on duty, the “number participated” stated “(illegible) team/nursing front desk.” The “staff member who called” was blank. The Fire Drill Report did not contain the number of residents participating in the drill.
  3. The Fire Alarm Report for 02/29/2024 had “All” next to “Number of staff involved with alarm” and “Full Staff” with “number of staff involved with alarm.” The “number of residents evacuated due to alarm” was “0”. The Fire Alarm report did not contain the number of residents participating in the drill.
  4. There was no documentation of a fire drill conducted in March of 2024.
  5. The Fire Alarm Report for 04/14/2024, stated “All Personal Onsite” for the “number of staff involved with the alarm.” The “number of employees on duty” was blank with a circle around the line. The “number of residents evacuated due to the alarm” stated “employees responded in HCC, with “shelter in place” policy. The Fire Alarm Report did not contain the number of residents participating in the drill.
  6. The Fire Drill Report for 05/23/2024 was blank for the “number of residents in the building”.
  7. The Fire Drill Report for 06/25/2024 was blank under “number of staff on duty,” “number participated,” and “number of residents in building.” The Fire Drill Report did not contain the number of residents participating in the drill.
  8. The Fire Alarm Report for 07/04/2024 stated that the “number of residents evacuated due to alarm” was “N/A.” The Fire Alarm Report did not contain the number of residents participating in the drill.
  9. The Fire Drill Report for 08/29/2024 was blank for “number of residents in building.” The Fire Drill Report did not contain the number of residents participating in the drill.
  10. In an interview with the LI, Staff 14 confirmed these were the forms required to be completed during a fire drill.
  11. In an interview with the LI, Staff 1 acknowledged that the number of residents participating, the number of staffing participating, and the identity of the person conducting the drill was not consistently recorded on the referenced reports.
Plan of correction
Corrective Action: The Administrator and Director of Plant Operations have revised the Fire and Emergency Evacuation and Drill form has been revised to meet compliance. Plan for continued compliance: Administrator and Director of Plant Operations will monitor accurate documentation after every drill, with a goal of 100% compliance monthly and ongoing. Date Corrected: January 6, 2025
June 12, 2024Inspection10 violations
Inspection dates
06/12/2024
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 PREPAREDNESS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION
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: 06/12/2024: 9:40 AM to 5:55 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: 100. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 4 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 3 Observations by licensing inspector: Activities, Meals, Medication Pass, Community Event. Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Amanda Velasco, Licensing Inspector at (703) 397 4587 or by email at Amanda.Velasco@dss.virginia.gov
Violations
22VAC40-73-830-E
Based on facility record review and staff interview, the facility failed to ensure a written response was provided to the council prior to the next meeting regarding any recommendations made by the council for resolution of problems or concerns.
Evidence
  1. The Resident Council Notes from June 10th, 2024, stated “Meeting Notes from May 13th, 2024, were read.”
  2. Staff 10 stated that concerns from the resident council meetings are read and addressed during meetings, but not provided to the residents in writing.
Plan of correction
Corrective Action: Corrective actions has been ensured by the Administrator, moving forward the Life Enrichment Director will provide all residents with written responses to all concerns noted by the Resident Council with plan of correction to resolve or correct their concerns. Plan for continued compliance: Administrator and Quality Assurance Team will monitor with a goal of 100% compliance monthly and ongoing. Date Corrected: July 8, 2024
22VAC40-73-860-I
Based on direct observation, the facility failed to ensure cleaning supplies and other hazardous materials were stored in a locked area.
Evidence
  1. In the unlocked laundry room of the special care unit across from room 123, there was a bottle of laundry detergent and lotion with a prescription label half ripped off in the unlocked cabinet above the laundry machines.
  2. Staff 2 was notified and locked the cabinet doors.
  3. Photo evidence taken.
Plan of correction
Corrective Action: Corrective action has been ensured by the Memory Care Director. The Memory Care Director will re-educate team members and family members using laundry rooms, procedure for securing hazardous materials, i.e. laundry detergent. Moving forward the Director and staff will conduct daily rounds and oversight ensuring 100% compliance. Plan for continued compliance: Administrator, Memory Care Director and Quality Assurance Team will monitor compliance with a goal of 100% compliance ongoing. Date Corrected: June 12, 2024
22VAC40-73-620-B
Based on facility document review, the facility failed to ensure the special diet oversight included a certification that the requirements of this subsection were met.
Evidence
  1. The special diet oversight was completed on 06/03/2024.
  2. The special diet oversight did not contain a statement certifying that the requirements of this subsection were met.
Plan of correction
Corrective Action: Corrective actions has been ensured by the Administrator, Registered Dietician and Assisted Living Director, moving forward the Assisted Living and Registered Dietician will ensure the special diet oversight includes a certification that the requirements of this subsection are met. Plan for continued compliance: Administrator and Quality Assurance Team will monitor compliance with a goal of 100% compliance ongoing. Date Corrected: June 13, 2024
22VAC40-73-290-B
Based on direct observation and staff interview, the facility failed to ensure the posting of the current on-site person in charge in a place that is conspicuous to the residents and the public.
Evidence
  1. During the building and grounds tour, it was observed that the person in charge was not posted in a conspicuous area to residents and the public.
  2. Staff 1 stated that the manager on duty is not posted during the week while they are all on site; however, it gets posted on the weekend when the management team is rotating coverage.
Plan of correction
Corrective Action: Corrective actions has been ensured by the Assisted Living Director, moving forward the Director will provide a daily posting of On-Site Person in Charge in a conspicuous area for all residents and guests. Plan for continued compliance: Administrator and Quality Assurance Team will monitor compliance with a goal of 100% compliance daily and ongoing. Date Corrected: June 13, 2024
22VAC40-73-460-B
Based on resident record review and staff interview, the facility failed to ensure prompt response by staff to resident needs as reasonable to the circumstances.
Evidence
  1. The Resident Council meeting notes from June 10th, 2024, state that the concerns for Nursing/Caregiving are “Long wait after pressing call button. Residents stated that they expect at least half an hour wait. They feel this is because staff is busy serving in the dining room or helping some of the new residents whose needs demand more attention.”
  2. Staff 1 confirmed the caregiving staff do assist in the dining room during meal, but other caregivers are assigned to support residents not in dining room during meals.
  3. Staff 1 provided the Call Light- Answering Policy from the facility’s policy and procedure manual. The policy states “Residents will have their requests answered promptly by staff when their call light system for communication is activated.”
  4. Staff 1 stated that they try to answer within 10 to 12 minutes.
  5. Staff 1 provided the call bell logs from May 01st, 2024 to June 12th, 2024, for residents 3, 5, 6, 7, 8, and 9.
  6. The call bell logs for residents over 12 minutes are as follows: Resident 3: 18 m average/ 43 total calls 05/13/2024: 2 h 14 m 06/10/2024: 2 h 3 m 05/28/2024: 1 h 57 m 06/10/2024: 37 m 05/19/2024: 34 m 05/22/2024: 33 m 05/22/2024: 27 m 05/15/2024: 21 m 05/19/2024: 21 m 06/01/2024: 21 m 05/08/2024: 19 m 05/09/2024: 19 m 05/14/2024: 16 m 05/14/2024: 16 m 05/04/2024: 15 m 05/21/2024: 14 m 05/23/2024: 14 m Resident 5: 16 m average/ 4 total calls 05/13/2024: 27 m 05/20/2024: 17 m 05/22/2024: 15 m Resident 6: 13 m average/ 39 total calls 05/03/2024: 49 m 06/02/2024: 38 m 05/26/2024: 36 m 06/05/2024: 36 m 06/11/2024: 32 m 05/05/2024: 29 m 05/25/2024: 29 m 05/03/2024: 22 m 05/04/2024: 21 m 05/26/2024: 20 m 06/10/2024: 20 m 05/13/2024: 18 m 05/26/2024: 13 m Resident 7: 58 m average/ 17 total calls 05/06/2024: 9 h 11 m *LOA w/ Pendant 05/06/2024: 2 h 42 m 05/05/2024: 1 h 49 m 05/05/2024: 51 m 06/08/2024: 34 m 05/24/2024: 19 m 05/03/2024: 17 m Resident 8: 26 m average/ 1 total call 06/12/2024: 26 m Resident 9: 8 m average/ 7 total calls 05/16/2024: 16 m 05/28/2024: 15 m 05/21/2024: 13 m
Plan of correction
Corrective Action: Corrective action has been established by the Administrator, moving forward the Assisted Living Director will run a call light response report and evaluate timely response to resident call lights. All team members will be re-educated on timely response expectations and standards. Any variances will be properly addressed. This daily audit will continue until 100% compliance is achieved. Additional audits will be conducted as needed and reviewed by the Quality Assurance Team. Plan for continued compliance: Administrator and Quality Assurance Team will monitor compliance monthly and ongoing for continued compliance. Date Corrected: June 13, 2024
22VAC40-73-410-A
Based on resident record review, the facility failed to provide an orientation for new residents and their legal representatives, including emergency response procedures, mealtimes, and use of the call system upon admission.
Evidence
  1. The resident records were reviewed for Residents 1, 3, 4, 5, 6, 7, 8, and 9.
  2. All 8 files did not include a resident orientation at time of admission.
  3. Staff 10 showed a blank resident orientation form and confirmed the orientations had not been completed.
Plan of correction
Corrective Action: Corrective action has been ensured by the Assisted Living Director, Memory Care Director and Life Enrichment Director. Moving forward the Life Enrichment Director will provide each new resident and/or their legal representative New Resident Orientation upon admission. Orientation will include emergency response procedures, mealtimes, and use of the call system. within 72 hours of Orientation a daily posting of On-Site Person in Charge in a conspicuous area for all residents and guests. Plan for continued compliance: Administrator, Assisted Living Director and Quality Assurance Team will monitor compliance with a goal of 100% compliance ongoing. Date Corrected: June 17, 2024
22VAC40-73-260-C
Based on direct observation and staff interview, the facility failed to ensure that a listing of all staff who have current certification in first aid or CPR was posted in the facility, so the information is readily available to all staff.
Evidence
  1. During the building and grounds tour, it was observed that a list of staff certified in first aid or CPR was not posted in the facility in an area that was readily available to all staff.
  2. Staff 1 confirmed that a list of staff with first aid or CPR certifications was not posted in the facility.
Plan of correction
Corrective Action: Corrective action has been ensured by the Assisted Living Director, Memory Care Director and Director of Nursing. A listing of all staff who have current certification in first aid and CPR is now posted and readily available to all staff. Staff have been re-educated on this posting requirement. Plan for continued compliance: Administrator and Quality Assurance Team will monitor compliance with a goal of 100% compliance daily and ongoing. Date Corrected: June 13, 2024
22VAC40-73-970-A
Based on facility document review and staff interview, the facility failed to ensure that fire and emergency evacuation drill frequency and participation shall be in accordance with the current addition of the Virgina Statewide Fire Prevention Code and that the drills required for each shift in a quarter shall not be completed in the same month.
Evidence
  1. The fire drills for the months of January, February, March, and April were completed during the 1st (7 AM to 3:00 PM) shift.
  2. The January fire drill was completed on 01/31/2024 at 11:00 AM.
  3. The February fire drill was completed on 02/29/2024 at 3:00 PM.
  4. The March fire drill was completed on 03/28/2024 at 1:21 PM.
  5. The April fire drill was completed on 04/14/2024 at 2:45 PM.
  6. A copy of the May 2024 was requested. Staff 1 confirmed there was no drill completed in May of 2024.
Plan of correction
Corrective Action: Corrective action has been ensured by the Administrator. Facilities Team has been re-educated on the Virginia Licensing Standards for Fire Drills vs. National Life Safety Code. The facility system for managing fire drills has been updated to include monthly review of compliance with the Quality Assurance Team until 100% compliance is consistently demonstrated. Plan for continued compliance: Administrator and Quality Assurance Team will monitor compliance with a goal of 100% compliance monthly and ongoing. Date Corrected: June 12, 2024
22VAC40-73-980-H
Based on direct observation and staff interview, the facility failed to ensure that at least 48 hours of the emergency food and drinking water supply was on site at any given time.
Evidence
  1. Staff 9 showed the emergency food and water storage to the licensing inspector.
  2. The emergency water storage area was currently under renovation and unlabeled.
  3. The water storage was empty.
  4. Staff 9 stated they were in the process of replenishing the emergency water bottle supply. Staff 9 stated that there were water bottles on every floor but there was not enough for all residents for 48 hours on site.
Plan of correction
Corrective Action: Corrective actions has been ensured by the Administrator and Food and Beverage Director, moving forward the Food and Beverage Director will maintain 48- hours of emergency food and drinking water supply on-site. Audits will be conducted monthly, with a compliance goal of 100%. Plan for continued compliance: Administrator, Food and Beverage Director and Quality Assurance Team will monitor compliance monthly and on-going with a goal of 100% compliance. Date Corrected: July 12, 2024
22VAC40-73-700-1
Based on resident record review, the facility failed to ensure that when oxygen therapy is provided, the facility has a valid physician or other prescriber’s order that includes the oxygen source such as compressed gas or concentrators.
Evidence
  1. Resident 3 had physician orders started on 03/11/2024 for oxygen therapy that state “Home continuous o2 at 2L/min via NC to maintain o2 sats >92% for COPD.”
  2. The order did not include the oxygen source.
Plan of correction
Corrective Action: Corrective action has been ensured by the Assisted Living Director and Director of Nursing and residents receiving oxygen therapy orders have been corrected by the ordering physicians. Moving forward, the nursing personnel and physicians have been provided on the policy for Oxygen Therapy orders. Plan for continued compliance: Director of Nursing, Assisted Living Director and Quality Assurance Team will monitor compliance with a goal of 100% compliance daily and ongoing. Date Corrected: June 17, 2024
June 12, 2024Inspection0 violations
Inspection dates
06/12/2024
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 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: 06/12/2024: 8:55 AM to 9:40 AM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 05/15/2024 regarding allegations in the area(s) of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 100. 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 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 Amanda Velasco, Licensing Inspector at (703) 397 4587 or by email at Amanda.Velasco@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
November 1, 2023Inspection0 violations
Inspection dates
11/01/2023
Areas reviewed
22VAC40-73 BUILDINGS AND GROUNDS
Comments
An announced inspection was conducted on 11/1/23 to observe resident rooms and common areas. No violations were cited during the inspection and an exit meeting was held. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (703) 431-4247 or by email at m.massenberg@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
August 18, 2023Complaint survey1 violation
Inspection dates
08/18/2023
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 8/18/23 (1:05pm – 5:50 pm). The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by the licensing office on 7/21/23; regarding Staffing and Supervision, Resident Care and Related Services, and Building and Grounds. Building and grounds were inspected, interviews were conducted and facility documentation was reviewed. The evidence gathered during the investigation supported some, but not all of the allegations; the area of non-compliance was: Resident Care and Related Services. A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (703) 431-4247 or by email at m.massenberg@dss.virginia.gov.
Violations
22VAC40-73-460-B
Based on documentation, the facility failed to ensure a prompt response by staff to resident needs as reasonable to the circumstances.
Evidence
  1. August call bell reports were reviewed for Residents #1, #2, #3, and #4. Resident # 1's call bell report indicated that there was one occasion when it took staff at least 20 minutes to respond to the resident's call bell (out of one call alarm). Resident #2’s call bell report indicated that there were 14 occasions when it took staff at least 20 minutes to respond to the resident’s call bell (out of 20 call alarms). Resident #3’s call bell report indicated that there were eight occasions when it took staff at least 20 minutes to respond to the resident’s call bell (out of 37 call alarms). Resident #4’s call bell report indicated that there were two occasions when it took staff at least 20 minutes to respond to the resident’s call bell (out of 16 call alarms).
Plan of correction
Not published by VDSS.
July 18, 2023Inspection1 violation
Inspection dates
07/18/2023, 08/18/2023
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Unannounced focused monitoring inspections were conducted on 7/18/23 and 8/18/23 to follow-up on a facility reported incident. Resident records and facility documentation were observed. Interviews were conducted. Violation was discussed and an exit meeting was held. 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (703) 431-4247 or by email at m.massenberg@dss.virginia.gov.
Violations
22VAC40-73-680-D
Based on documentation and interview, the facility failed to administer medications in accordance with the physician's or other prescriber’s instructions and consistent with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing.
Evidence
  1. On 7/7/23, Resident #1’s Gabapentin and MS Contin were administered to Resident #2. Resident #2’s record did not contain any physician’s orders for the administration of Gabapentin or MS Contin.
Plan of correction
Not published by VDSS.
June 14, 2023Inspection2 violations
Inspection dates
06/14/2023
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE
Comments
An unannounced renewal inspection was initiated on 6/14/23 and completed on 6/16/23 . At the time of entrance, 92 residents were in care. Meals, medication administration, an activities were observed. Building and grounds were inspected. Records were reviewed. The sample size consisted of 10 resident records and five staff records. Exit meeting held. 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (703) 431-4247 or by email at m.massenberg@dss.virginia.gov.
Violations
22VAC40-73-250-D
Based on record review, the facility failed to ensure that each staff member annually submits the results of a tuberculosis risk assessment, documenting the absence of tuberculosis in a communicable form as
Evidence
  1. d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: The records of Staff #1, Staff #2, and Staff #4 did not contain the results of a tuberculosis risk assessment completed within the past year.
Plan of correction
Immediate Action: On 6/21-23/23 Human Resource Director Audited all employee records to verify Tuberculosis Annual compliance of all team members. Systems added to process to prevent occurrences in the future: 6/23-27/23 Human Resource Director or designee, will develop and implement as system and data base that ensures annual requirements are met. The Human Resource Director will provide monthly audits to ensure compliance with annual Tuberculosis Risk Assessments and provide reports to the Executive Director and staff Supervisors. Responsibility: 6/27/23 and ongoing, The Human Resource Director will be responsible for implementing this system and providing daily/monthly oversight by auditing team member compliance in database. The Executive Director will provide additional oversight monthly, verifying that the system established is properly implemented and effective over the next 3 months or as needed.
22VAC40-73-640-A
Based on record review, the facility failed to implement the medication management plan: methods to ensure that each resident's prescription medications and any over-the-counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages.
Evidence
  1. Medication administration records (MARs) were reviewed during the inspection. Resident #2's June MAR stated that her Losartan was not administered on 6/2/23 (9 AM and 9 PM administrations), as the facility was waiting to receive the medication from the pharmacy. Resident #7's June MAR stated that her Pantoprazole was not administered on 6/3/23, as the medication was documented as being "unavailable." Resident #8's June MAR stated that his Famotidine was not administered on 6/11/23 or 6/12/23, as the medication was documented as being "unavailable."
Plan of correction
Immediate Action: On 6/26/23 Meeting Pharmacy regarding delay in medication fills and delivery. Audited resident Medications to verify adequate supply available for all prescribed. Systems added to process to prevent occurrences in the future: 6/27/23 Daily the Medication Aid will verify and initial that medication quantity will be evaluated, any supply with 7-days or less supply will be ordered. The Health Care Manager (Nurse) will have a tracking system to verify and confirm delivery. Pharmacy has re-established a relationship with the backup local pharmacy. Responsibility: 6/27/23 and ongoing, The Health Care Manager will be responsible for implementing this system and providing daily oversight by auditing MAR's, PCC missed medication reports, and pharmacy delivery reports. This will identify medication availability concerns early before a dose is missed. The Assisted Living Director will provide additional oversight on a weekly basis verifying that the system and procedures are successfully implemented and effective over the next 3 months or as needed.
May 12, 2023Inspection0 violations
Inspection dates
05/12/2023
Areas reviewed
22VAC40-73 BUILDING AND GROUNDS
Comments
An announced other inspection was conducted on 5/12/23. Resident rooms were observed, building and grounds were inspected. No violations were cited during the inspection. An exit meeting was held. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (703) 431-4247 or by email at m.massenberg@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
January 31, 2023Inspection1 violation
Inspection dates
01/31/2023, 03/03/2023
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
An unannounced monitoring inspection was initiated on 1/31/23 in response to a facility reported incident. One resident record and facility documentation were observed. Building and grounds were inspected. Interviews were conducted. Violation discussed and an exit meeting was held. 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (703) 431-4247 or by email at m.massenberg@dss.virginia.gov
Violations
22VAC40-73-460-D
Based on record review and interview, the facility failed to provide supervision of resident schedules, care, and activities including attention to specialized needs, such as wandering from the premises.
Evidence
  1. Resident #1 was admitted into the memory care unit on 1/18/23. The resident record contained an Assessment of Serious Cognitive Impairment form, dated 1/15/23, that states that Resident #1 has a serious cognitive impairment with an inability to recognize danger or protect his own safety and welfare. On 1/23/23, Resident #1 eloped from the facility. Law Enforcement and the resident’s family were contacted. Resident #1 was located the same day at his previous address, which is approximately three miles from the facility.
Plan of correction
Not published by VDSS.
October 14, 2022Inspection0 violations
Inspection dates
10/14/2022
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND
Comments
An unannounced focused monitoring inspection was conducted on 10/14/22 to follow-up on high-risk violations that were cited on 6/23/22. Building and grounds were inspected and resident rooms were observed. No violations were cited during the inspection. An exit meeting was held. Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (703) 431-4247 or by email at m.massenberg@dss.virginia.gov For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
June 22, 2022Inspection4 violations
Inspection dates
06/22/2022
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 1Subjectivity63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE
Technical assistance
Documentation was discussed with the provider.
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: 6/2/22 (9:05 AM – 7:40 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: 137 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of interviews conducted with residents: 5 Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (703) 431-4247 or by email at m.massenberg@dss.virginia.gov
Violations
22VAC40-73-320-A
Based on record review, the facility failed to ensure the physical examination form, completed within 30 days preceding admission, includes all of the required information.
Evidence
  1. The record for Resident #1, admitted 5/25/22, was reviewed during the inspection. Resident #1's record contained a tuberculosis risk assessment, dated 6/10/22. Facility documents included a summary sheet with information about Resident #1’s chest x-ray and PPD that were completed before her admission. The summary sheet did not include the signature of the screeners, nor were the results on a screening form consistent with a tuberculosis screening form published by the Virginia Department of Health. The record for Resident #2, admitted 4/14/22, contained a tuberculosis risk assessment, dated 6/14/22. The tuberculosis risk assessment was not completed within 30 days preceding her admission. Resident #8’s physical examination form, dated 5/13/22, did not include her height or weight. Resident #8’s tuberculosis risk assessment, dated 6/7/22, was not completed within 30 days preceding her admission (5/19/22).
Plan of correction
No Resident was harmed by this violation. The Residents' history and physical forms have been reviewed for compliance and missing documentation has been corrected within our progress notes. We have met with the Admissions team to ensure all forms will be completed in a timely manner. Signatures of TB screeners will be included going forward. Admissions staff will ensure that every field of the History and Physical form will be completed, to include height and weight. The Head nurses of Assisted Living and Memory units will perform a final review of these forms prior to admission to ensure compliance. All documentation for new Assisted Living and Memory admissions will be delivered/sent to the Lead nurses of both Assisted Living and Memory, (depending on the level of care) at minimum of three business days prior to admission. The Administrator will be informed of any anomalies.
22VAC40-73-460-D
Based on documentation and record review, the facility failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs, such as wandering from the premises.
Evidence
  1. Resident #11 eloped from the special care unit on 2/23/22 by walking out of a door that was propped open by contractors. Resident #11 left the building and went approximately 0.3 miles to the home of a friend. Resident #11's ISP, updated 11/2/21, states that the resident needs assistance with transfers and ambulation due to an unsteady gait.
Plan of correction
The Residents in question were found unharmed in a short space of time. New alarms on all doors leading out of the Memory unit and all produce audible alarms when pushed. Hourly rounding by the Lead nurse or designee is being performed to ensure attendance and safety. Any anomalies will be immediately reported to the Administrator and Director of the Memory unit. Education to staff about elopement commenced immediately, across all shifts.
22VAC40-73-860-I
Based on observation, the facility failed to ensure that hazardous materials are kept in a locked area.
Evidence
  1. Brush on hair remover cream and Systane eye drops were observed in the bathroom of Resident #2 of the memory care unit. Resident #2's record included an assessment of serious cognitive impairment form, dated 4/5/22, that states that she has a serious cognitive impairment with an inability to recognize danger or protect her own safety and welfare.
Plan of correction
No Resident was harmed by this violation. An immediate sweep of all rooms was performed by the Head Nurse and Director of the Memory unit to ensure a safe environment. As part of our renovation process, a work order was immediately placed for the remaining under-the-sink cabinets to be secured with safety locks. Conversations with families began immediately to inform them of the seriousness of bringing in liquids and creams for loved ones and they reacted supportively. Letters to families are being sent to explain and confirm this policy. The Director of the Memory unit created an audit form, which will ensure that assigned staff perform daily safety checks. Audit forms will be reviewed by the Director of Memory, who will ensure daily compliance for the next three months.
22VAC40-73-970-A
Based on documentation, the facility failed to ensure that fire and emergency evacuation drill frequency and participation is in accordance with the current edition of the Virginia Statewide Fire Prevention Code (13VAC5-51). The drills required for each shift in a quarter shall not be conducted in the same month.
Evidence
  1. The current Virginia Statewide Fire Prevention Code requires fire drills to be conducted quarterly on each shift. Fire drill documentation was requested during the inspection, but no documentation was provided to confirm that fire drills had been conducted in the ALF within the past three months.
Plan of correction
No Resident was harmed by this violation. An unannounced drill was held on the day shift, June 29, 2022 for the entire building, with all staff in compliance. Residents were escorted to areas q shift as required. without incident. Documentation was set up by a Plant designee, to ensure monthly drills would continue quarterly on each shift throughout the next year. The Interim Director of Plant Operations would confirm the scheduling and compliance of these drills for the next 12 months.
October 5, 2021Inspection1 violation
Inspection dates
10/05/2021
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
A non-mandated self-report inspection was initiated on 10/5/21 and concluded on 11/8/21. A self-reported incident was received by the department regarding an allegation in the area of: Resident Care and Related Services. The administrator was contacted by telephone to conduct the inspection. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The licensing inspector conducted on-site observations at the facility on 10/5/21 and 10/15/21. The evidence gathered during the investigation supported the self-report of non-compliance with standards or law, and a violation was issued. Any violations not related to the self-report but identified during the course of the investigation can be found on the violation notice.
Violations
22VAC40-73-460-D
Based on record review and documentation, the facility failed to supervise resident schedules, care, and activities, including attention to specialized needs, such as prevention of falls and wandering from the premises.
Evidence
  1. Resident #1 eloped from the special care unit on 10/1/21. A facility staff member reported observing Resident #1 walking in the parking lot at approximately 11:30 AM. The staff member asked Resident #1 where she was going, and she replied that she was going to the store. The staff member was able to redirect the resident back to the unit. Facility staff reported that Resident #1 was able to leave the unit, as a door on the unit was unsecured. The record for Resident #1 contains an assessment of serious cognitive impairment, dated 10/28/20, that states that she has a severe cognitive impairment and that she is unable to recognize danger or protect her own safety and welfare. Resident #1's record also contains a Uniform Assessment Instrument (UAI), dated 8/6/21. The UAI indicates that Resident #1 engages in wandering or passive behavior weekly or more.
Plan of correction
Not published by VDSS.
August 20, 2021Inspection0 violations
Inspection dates
08/20/2021, 08/26/2021
Areas reviewed
22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity
Comments
Announced focused visits were conducted on 8/20/21 and 8/26/21. The facility's updated secure unit was inspected. Resident rooms were observed and measured. Building and grounds were inspected. The standards for the safe, secure environment were discussed with the administrator. No violations were cited during the inspection.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
March 29, 2021Inspection1 violation
Inspection dates
03/29/2021
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
A non-mandated self-report inspection was initiated on 3/29/21 and concluded on 8/6/21. A self-reported incident was received by the department regarding an allegation in the area of: Resident Care and Related Services. The administrator was contacted by telephone to conduct the inspection. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The licensing inspector conducted on-site observations at the facility on 6/17/21 and 7/14/21. The evidence gathered during the investigation supported the self-report of non-compliance with standards or law, and a violation was issued. Any violations not related to the self-report but identified during the course of the investigation can be found on the violation notice.
Violations
22VAC40-73-460-D
Based on record review and documentation, the facility failed to ensure supervision of resident schedules, care, and activities, including attention to specialized needs, such as prevention of falls and wandering from the premises.
Evidence
  1. Resident #1 eloped from the special care unit on 3/28/21. Facility staff reported that Resident #1 was able to leave the unit by following a visitor, while he was exiting the unit. Resident #1 reportedly asked for a ride from the visitor, but the visitor declined the request. Resident #1 then reportedly walked away in the rain. Shortly after Resident #1 was discovered to be missing by facility staff, her daughter called to report that Resident #1 was at a friend’s house. The house is approximately a quarter of a mile from the facility. The record for Resident #1 contains an assessment of serious cognitive impairment, dated 10/28/20, that states that Resident #1 has a serious cognitive impairment and that she is unable to recognize danger or protect her own safety and welfare.
Plan of correction
1. No harm came to this Resident, who was immediately assessed by our nursing department. 2. The egress doors were immediately checked by Plant Operations to ensure they were in working order. 3. We educated our community about the egress delay, and staff and family members know to wait on the outside of the door, to ensure no one has followed them. All staff are now in the habit of doing so, and we have educated family members as well. 4. We are in the process of investigating different types of locking mechanisms for our renovated unit, to be completed within a few months. In the meantime, the Fire Marshal's office has approved our current system. We will strive to maintain stricter vigilance when visitors and staff are leaving the unit.