Virginia DSS · Assisted Living Facility

Brookdale Staunton

📍 1900 Hillsmere Lane, Staunton, VA, 24401

ID 45329One Year licenseActive
10
Inspections
On record
6
With violations
Visits that cited something
4
Clean visits
Nothing cited
13
Violations cited
Individual findings
11
Standards cited
Distinct rules
0
Complaint visits
Prompted by a complaint

Brookdale Staunton was inspected 10 times between November 23, 2020 and March 30, 2026 by the Virginia Department of Social Services. 6 of those visits ended with violations cited and 4 with none. Across that history VDSS cited 13 violations under 11 distinct standards.

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

VDSS publishes inspections on a rolling window. 8 of these 10 are still on the state's site; the other 2 have since dropped off it and are reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type
Assisted Living Facility
License type
One Year
License expires
12/23/2026
Administrator
April Sprouse
Licensing inspector
Margaret Woods-Kane
Inspector phone
(804) 724-9618
Approved for
Non-Ambulatory · Special Care Unit · Assisted Living

Inspection History

10

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

March 30, 2026Inspection0 violations
Inspection dates
03/30/2026
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 ADDITIONAL REQUIREMENTS for FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS63.2- (16) Protection of adults and reporting
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: March 30, 2026 from 3:00 p.m. until 4:00 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 01/16/2026 regarding allegations in the area(s) of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 91 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Licensing inspector toured facility, reviewed schedule, and reviewed resident records for those mentioned in the self-report. Additional Comments/Discussion: None 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 Angie Via, Licensing Inspector at (540) 682-1739 or by email at Angela.Via@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
December 22, 2025Inspection4 violations
Inspection dates
12/22/2025
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 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: December 22, 2025, from 10:30 a.m. until 4:30 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 93 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 4 Observations by licensing inspector: The Licensing Inspector toured the community and observed the residents during activities and meals. The Licensing Inspector reviewed the following at the time of inspection: sample of resident and employee records, medication administration, fire drills, emergency drills, pharmacy review, menus, activity calendars, verified appropriate amount of liability insurance, and dietician report. Additional Comments/Discussion: None 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 Angela Via, Licensing Inspector at (540) 682-1739 or by email at Angela.Via@dss.virginia.gov
Violations
22VAC40-73-970-A
Based on record review and staff interview, the facility failed to ensure fire drills were completed on each shift in a quarter in accordance with the Virginia Statewide Fire Prevention Code (13VAC5-51).
Evidence
  1. During a record review on 12/22/2025, the LI observed that fire drills were conducted 4/30/2025 on second shift, 5/29/2025 on first shift, and 6/30/2025 on first shift. No fire drills were completed during third shift from April 2025 through June 2025.
  2. During a record review on 12/22/2025, the LI observed that fire drills were conducted 7/30/2025 on third shift, 8/28/2025 on first shift, and 9/29/2025 on third shift. No fire drills were completed during second shift from July 2025 through September 2025.
  3. Staff 1 confirmed that fire drills were not completed on each shift during the quarter as required.
Plan of correction
22VAC40-73-970A 1. Fire Drills were completed on all shift for last quarter. They were completed on 10/30/2025 at 130pm, 11/28/2025 at 920pm, and 12/26/2025 at 1140pm. 2.The Maintenance Director was re-educated by the Executive Director on fire drill times/shift times and regulations reviewed on 12/22/2025. 3. To assist with ongoing compliance, the Executive Director set up a schedule for Drills to be completed for each quarter. The Maintenance Director or designee will turn in all fire drill documentation to the Executive Director for Review monthly. 4. Fire Drills will be reviewed in Monthly Safety Meeting to validate compliance and discuss any areas identified for further re-education with staff. This will be an ongoing process to ensure compliance with Quarterly drills.
22VAC40-73-310-B
Based on resident record review and staff interview, the facility failed to ensure a documented interview was completed, prior to admission, between the administrator or a designee responsible for admission and retention decisions, the individual, and his legal representative, if any.
Evidence
  1. Record for resident 2, admitted 10/30/2025, contained a documented interview between the administrator and individual on 11/3/2025, which was after the resident was admitted to the facility.
  2. During an interview with LI on 12/22/2025, staff 1 confirmed record for resident 2 contained a documented interview after the admission date, which does not meet the standard.
Plan of correction
The following is a summary of the Plan of Correction for Brookdale Staunton. This Plan of Correction is in regards to the Corrective Action Report dated December 22nd 2025. This Plan of Correction is not to be construed as an admission of or agreement with the findings and conclusions in the Statement of Deficiencies, or any related sanction or fine. Rather, it is submitted as confirmation of our ongoing efforts to comply with statutory and regulatory requirements. In this document, we have outlined specific actions in response to identified issues. We have not provided a detailed response to each allegation or finding, nor have we identified mitigating factors. 22VAC40-73-310B 1. The interview for resident #2 is unable to be corrected. 2. The Executive Director and Business office Manager completed an audit for all current resident’s records. No further discrepancies identified. 3. To assist with ongoing compliance the Business office Manager and Executive Director will audit all new admission charts on day of physical admission to validate interviews are completed with each resident prior to or on day of admission. 4. Audits will be reviewed monthly during Monthly Community Action Plan Meetings through the next 6 months.
22VAC40-73-410-A
Based on resident record review and staff interview, the facility failed to provide an orientation, upon admission, for new residents and their legal representatives, which included emergency response procedures, mealtimes, and use of the call system. Acknowledgment of having received the orientation must be dated by the resident and, as appropriate, his legal representative, with documentation kept in the resident's record.
Evidence
  1. Record for resident 2, admit date 10/30/2025, did not contain a documented orientation that was signed by the resident or legal representative.
  2. Record for resident 5, admit date 5/8/2025, did not contain a documented orientation that was signed by the resident or legal representative.
  3. Record for resident 6, admit date 2/13/2024, contained a documented orientation that was signed by the resident or legal representative on 2/16/2024.
  4. During an interview with the LI on 12/22/2025, staff 3 confirmed there was no documented orientation for residents 2 and 5 and documented orientation for resident 6 was dated after admission.
Plan of correction
22VAC40-73-410A 1. Orientation for Residents 2, 5, and 6 was Memory Care residents and unable to be corrected due to after admission dates. All current residents’ records were audited by the Health and Wellness Director and designee for completion and no further discrepancies were identified. 2. The Business Office Manager or designee will complete orientation on day of admission and provide all information to Residents Reasonable Party. Confirmations of delivery of orientation material will be placed in the Residents file with orientation check list. 3. Executive Director or Designee will audit all new admission charts on day of admission to validate compliance. 4. Audits will be reviewed monthly during Monthly Community Action Plan Meetings for the next 6 months.
22VAC40-73-720-A
Based on record review and staff interview, the facility failed to ensure Do Not Resuscitate (DNR) Orders for withholding cardiopulmonary resuscitation from a resident in the event of cardiac or respiratory arrest were only carried out in a licensed assisted living facility when both a valid written order had been issued by the resident's attending physician and the written order was included on the individualized service plan.
Evidence
  1. Resident 5, admitted 5/8/2025, had a signed physician’s Do Not Resuscitate (DNR) order dated 5/8/2025.
  2. Individualized service plan (ISP) for resident 5 was not updated with the DNR code status in the resident paper record.
  3. During an interview with LI on 12/22/2025, staff 2 confirmed that resident 5’s ISP in the resident paper record did not contain the physician ordered code status as required.
Plan of correction
22VAC40-73-720A 1. Resident #5 ISP was immediately corrected and updated to match DNR code status in the residents’ orders and paper record. 2. HWD/Designee audited all current residents’ charts and ISPs to validate Do Not Resuscitate orders matched their ISP. 3. To assist with ongoing compliance the HWD/Designee will audit DNR status and ISP with any change in orders and monthly for 6 months to validate they have been updated and match residents care needs. 4. Audits will be reviewed in monthly for 6 months in the Clinical Care Reviews (CCR) meetings for compliance.
December 11, 2024Inspection3 violations
Inspection dates
12/11/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS63.2 GENERAL PROVISIONS63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/11/2024 09:15am-3:15pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 96 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed:3 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: The licensing inspector observed residents at meals and during activities, medications administration. The inspector reviewed health care oversight, dietary oversight, fire drills, and reviews of the emergency preparedness plan. Additional Comments/Discussion: None 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 Jessica Gale, Licensing Inspector at 540-571-0358 or by email at Jessica.gale@dss.virginia.gov
Violations
22VAC40-73-860-I
Based on direct observation the facility failed to ensure chemicals and other hazardous materials are stored in a locked area.
Evidence
  1. During the facility tour on 12/11/2024 the licensing inspector observed the following: • A housekeeping cart unattended in a resident hallway unlocked and containing sani-cloths, bathroom cleaner, a jug of pine sol, and 3 bottles of cleaning solution. • The second-floor resident laundry area contained a bottle of carpet and upholstery cleaner, and a bottle of bathroom cleaner. • The staff lounge located in a resident area was unlocked and contained a container of bleach wipes on the counter and a spray bottle of spot remover on top of the lockers.
  2. Photo evidence taken.
Plan of correction
1.The Housekeeper was immediately educated by the Executive Director onkeeping the housekeeping cart locked. It was identified the lock was not working and the Maintenance Director immediatley fixed the lock as well. The chemicals in the second floor laundry area was immediatley removed and door locked. The bleach wipes and spot remover was locked in a secure cabnet and the staff lounge was locked. 2. Staff were educated by the Executive Director on storage of chemicals in assisted living and need to ensure all carts, laundry rooms, break rooms, and maintenance areas are to remain locked at all times. 3. The Executive Director/ Designee will make rounds throughout the facility randomly several times a day to ensure all chemicals are secured and doors to special areas are locked. 4. Results of rounds will be reviewed in daily stand up meetings for 3 months to ensure compliance discuss any issues identified.
22VAC40-73-960-B
Based on direct observation the facility failed to ensure that the fire and emergency evacuation plan includes all required information.
Evidence
  1. The facility fire and emergency evacuation plan does not include areas of refuge or assembly areas.
  2. Photo evidence taken.
Plan of correction
1. The fire and emergency evacuation plan was updated to include areas of refuge and assembly areas. 2. Staff were inserviced by the Executive Director on the updated emergency evacuation plan changes and areas of refuge and assembly areas. 3. The Maintenance Director updated all evacuation plans throughout the facility with the new plans. 4. The emergency evacuation plans will be reviewed and staff educated by the Executive Director/Designee with required disaster trainings.
22VAC40-73-970-A
Based on record review and staff interview, the facility failed to ensure that fire drills are completed in accordance with the current edition of the Virginia Statewide Fire Prevention Code (13VAC5-51).
Evidence
  1. During a review of fire drills the following drills were documented: • 07/30/2024 10:45am (first shift) • 08/29/2024 3:00pm (second shift) • 09/30/2024 10:55am (first shift) • 10/28/2024 3:30pm (second shift) • 11/27/2024 3:45pm (second shift)
  2. The shift times for the facility were 7am-3pm 9first shift), 3pm-11pm (second shift), 11pm-7am (third shift).
  3. Documentation of fire drills did not include any drills completed on third shift from July 2024 to November 2024.
Plan of correction
1. A night shift fire drill was conducted on 12/20/2024 at 6:30am. 2. The Maintenance Director was educated by the Executive Director on fire drill times/shift times and regulations reviewed 3. Executive Director set up a schedule for Drills to be completed. The Maintenance Director will turn in all fire drill documentation to the Executive Director for Review monthly. 4. Fire Drills will be reviewed in Monthly safety meeting to ensure compliance.
December 18, 2023Inspection0 violations
Inspection dates
12/18/2023
Areas reviewed
Administration and Administrative ServicesPersonnelStaffing and SupervisionAdmission, Retention and Discharge of ResidentsResident Care and Related ServicesBuildings and GroundsEmergency PreparednessMixed PopulationSafe, Secure Environment
Comments
Date of Inspection: December 18, 2023 Type of Inspection: Renewal Inspection If you have any questions or email changes, please do not hesitate to contact me at laura.lunceford@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov. Census 91 Number of records reviewed and interviews conducted- 10 records (staff and residents), 9 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. The Licensing Inspector observed the residents during different activities and meals. The Licensing Inspector reviewed the following at the time of inspection: fire drills, pharmacy review, resident council reports, emergency drills, dietician report and healthcare oversight.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
December 14, 2022Inspection0 violations
Inspection dates
Dec. 14, 2022
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 ? SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Technical assistance
Discussed two individuals placed via APS in the facility as it related to capacity assistance needed.
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: 12/14/22 The Acknowledgement of Inspection form was signed and left at the facility for the date of the inspection. Number of residents present at the facility at the beginning of the inspection: 96 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility ? yes. Number of resident records reviewed: 9 Number of staff records reviewed: 6 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: Facility clean and odor free. Postings as required. Outside inspections were current as were other required outside reviews/inspections and related drills in all required categories. Residents observed eating lunch and enjoying an activity in memory care. Additional Comments/Discussion: Fire ? 11/15/22 Health -2/9/2022 An exit meeting was 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. Should you have any questions, please contact Sharon DeBoever, Licensing Inspector at (540) 292-5930 or by email at sharon.deboever@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
February 9, 2022Inspection1 violation
Inspection dates
02/09/2022
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 Protection of adults and reporting63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report
Comments
A monitoring inspection was initiated on 02/09/2022 and concluded on 02/09/2022. There were a total of 83 residents in care. The facility was clean and free from any foul odors. The outside postings were current as were related drills. Six resident, one discharge and five staff records were reviewed. An exit interview was conducted with the Administrator and Director of Nursing on the date of inspection, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. There was one violation during this monitoring inspection. Details of non-compliance can be viewed in the violation report of this inspection. If you have any questions, please contact the licensing inspector at (540) 292-5932 or email rhonda.whitmer@dss.virginia.gov.
Violations
22VAC40-73-1090-A
Based on review of residents' records, the facility failed to ensure prior to admission to a safe, secured environment, the documented assessment by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician, indicated the resident as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare.
Evidence
  1. The Assessment of Serious Cognitive Impairment for resident 1, dated 01/07/2022 indicates the resident does not have a serious cognitive impairment due to a primary diagnosis of dementia.
  2. The Assessment of Serious Cognitive Impairment for resident 1, dated 01/07/2022 does not include the address of the resident or the address of the physician who completed the assessment.
Plan of correction
•Resident 1 has a diagnosis of dementia but was not listed on the Assessment of Serious Cognitive Impairment form. Her current physician has reviewed her information and completed a new assessment form with the dementia diagnosis and her address was completed on the form on Feb 15th 2022 to ensure proper compliance. •The HWD and HWC will audit all residents’ forms in the secured unit for any inconsistency with the Assessment of Serious Cognitive Impairment form by February 18th 2022. •For any inconsistency’s identified the HWD and HWC will contact resident current physician for re-evaluation and correction of the Assessment of Serious Cognitive Impairment form. •To assist with ongoing compliance The HWD and HWC will review all new admission to the secure unit to validate the proper completion of the Assessment of Serious Cognitive Impairment form prior to residents moving into the secure unit per the Virginia regulations.
November 22, 2021Inspection1 violation
Inspection dates
11/22/2021
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
A non-mandated self-report inspection was initiated on 11/22/2021 and concluded on 11/24/2021. A self-reported incident was received by the department regarding allegations in the areas of resident care. The Health and Wellness Director was contacted by telephone to conduct the investigation. The evidence gathered during the investigation supported the self-report of non-compliance with standards or law, and a violation was issued.
Violations
22VAC40-73-680-D
Based upon documentation and an interview, the facility failed to ensure one of two residents' medications were administered as ordered by the physician and in accordance with the standards of practice as outlined in the current medication aide curriculum.
Evidence
  1. A major incident report submitted on 11/22/2021 stated on 11/21/2021 at 9:00 pm, staff 1 administered resident 1 the scheduled 10:00pm medications Gabapentin 100; Janumet XR 50-1000mg; Protonix 40mg; Carvedilol 3.125mg; Trazadone 100mg and Duloxetine HCL 50mg, which were for resident 2.
  2. The November Medication Administration Record (MAR) for resident 1 listed the 8:00pm medications as Lipitor 80mg and Melatonin 8mg.
  3. The November Medication Administration Record for resident 2 listed the 10:00pm medication as Gabapentin 100mg; Janumet XR 50-1000mg; Protonix 40mg; Carvedilol 3.125mg; Trazadone 100mg and Duloxetine HCL 50mg.
  4. The LI interviewed staff 2 on 11/21/2021 who stated staff 1 went into the wrong room and didn't verify the resident's name prior to administering the medication.
  5. Section 4.2.A.4 of the current medication aide curriculum states, "Get the medication container from the cart/cabinet and read the label to verify the: right client, right drug, right dose, right route, right time."
Plan of correction
1). Residents MD was notified, POA notified regarding medication administration error. LPN staff #1 no longer works at facility. 2). Current registered and licensed staff will be reeducated on the 7 rights of medication administration by the Health and Wellness Director no later than 12/16/21 3). An medication administration observation will be conducted by the Health and Wellness Director/ designee of current registered and licensed nursing staff to verify the 7 rights of medication administration are being observed no later than 12/16/21 . 4). On a monthly basis for 6 months the Health and Wellness Director / Designee will observe monthly medication administration observations of registered and licensed staff to verify the 7 rights of medication administration are being observed.
September 1, 2021Inspection2 violations
Inspection dates
09/01/2021
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Technical assistance
Ensure medication management plan reflects procedures as it relates to preventing use of discontinued medications.
Comments
A non-mandated self-report inspection was initiated on 09/01/2021 and concluded on 09/03/2021. A self-reported incident was received by the department regarding allegations relating to medication administration. The administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the self-report of non-compliance with standards or law, and violations were issued. Any violations not related to the self-report but identified during the course of the investigation can be found on the violation notice.
Violations
22VAC40-73-680-D
Based on document review, the facility failed to ensure medications are administered in accordance with the physician's or other prescriber's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum.
Evidence
  1. Resident 1 has an order to discontinue Humulin sliding scale insulin effective 08/17/2021.
  2. The facility incident report submitted on 09/01/2021, indicates resident 1 was administered 25 units of Humulin on 08/31/2021 at 2:30pm. The incident report indicates "it was brought to the nurse's attention, by the resident's family member, that he had received 25 units at 2:30pm today."
Plan of correction
1). Resident 1 Insulin orders were clarified reviewed and residents blood sugars were monitored through the night for adverse effects. No adverse effects were noted for Resident 1. Systemic Changes 1). The Health and Wellness Coordinator conducted an in service on Medication administration and reviewed the standards of Practice form outlined in the current registered medication aid curriculum approved by the Virginia Board of Nursing on 9/1-9/3/2021 for Medication aids and Licensed nursing staff. 2). Medication Aid for Resident 1 received a 1:1 education and counseling for medication error on 9/1/2021 and the individual Medication Aid completed additional education for medication administration by 9/10/21. Monitoring 1).To assist with ongoing compliance, the Health and Wellness Director, Health and Wellness Coordinator or designee will review Daily progress notes and PRN documentation to verify medication administration.
22VAC40-73-450-E
Based on review of resident's record, the facility failed to ensure the Individualized Service Plan is signed and dated by the administrator, or his designee and by the resident or his legal representative.
Evidence
  1. The ISP dated 06/28/2021 for resident 1 does not contain a signature and date of the administrator, the person who developed the plan, the resident or his legal representative.
Plan of correction
Resident 1 ISP has been reviewed and the required signatures were obtained from Executive Director, HWD or designee and legal representative no later than 9/21/2021. Current ISP emailed to legal representative and a copy of email was attached to the ISP until signature obtained from the legal representative. Re-training for staff certified to complete ISPs and UAIs was conducted by the Health and Wellness Director (HWD)/designee on 9/10/2021. Retraining consisted of assessments competency for the ISPs and the UAIs, requirements for signatures, and communication of all ISP to residents or legal representatives. The HWD/designee will conduct an audit of current residents ISP’s and UAI’s no later than September 30, 2021, to verify the ISPs and UAIs are completed with signatures. To assist with ongoing compliance, the ISPs and UAIs will be reviewed on a random basis on a weekly basis for four (4) weeks and then on a monthly basis thereafter for six (6) months by the HWD/designee.
August 6, 2021Inspection2 violations
Inspection dates
08/06/2021
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
A non-mandated self-report inspection was initiated on 08/06/21 and concluded on 08/20/20. A self-reported incident was received by the department relating to resident care . The Health and Wellness Director was contacted by telephone to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the self-report of non-compliance with standards or law, and violations were issued. Any violations not related to the self-report but identified during the course of the investigation can be found on the violation notice.
Violations
22VAC40-73-460-D
Evidence
  1. The incident report submitted by the facility on 07/16/21 indicates resident 1 (admitted 11/24/19) was observed walking on along the side of Churchville Avenue a two lane road, by an off duty employee around 7:00pm on 07/15/21. The report indicates resident was asked where he was going and what he was doing and he answered "I am not sure." The report indicates the resident was returned to the facility unharmed by the employee.
  2. An interview with staff 1 and email correspondence received on 08/20/21 confirmed resident was last observed in the building at 6:20 walking down the hallway back towards his room.
  3. According to accuweather.com, the temperature for 07/15/21 ranged from low 64 degrees to high 91 degrees.
  4. The Uniform Assessment Instrument (UAI) for resident 1 dated 07/07/21 indicates resident 1 wanders at times and is disoriented in all spheres, some of the time.
  5. The Individualized Service Plan (ISP) for resident 1 dated 07/07/21 indicates resident requires frequent monitoring due to recent attempts to leave facility, 1:1 and frequent monitoring.
  6. Facility progress notes dated 07/06/21 at 3:34pm indicate resident has exit seeking behaviors; 06/25/21 at 9:42pm resident wandered out of the building twice.
  7. The history and physical for resident 1 dated 06/22/21 indicates resident has a diagnosis of dementia and is not capable of making informed decisions.
  8. Interview with staff 1 on 08/16/21 indicated staff frequently checked on the resident, but there was no documentation on file indicating this was completed.
Plan of correction
1.) Unable to retroactively correct the required documentation and Plans of care for Resident 1. Resident 1 has been discharged from facility on 8/10/2021. 2.) The staff will be educated on wandering/elopement of residents and documentation requirements for 1:1 monitoring and frequent check to be provided by HWD/designee on or before September 10th, 2021. 3.) HWD/designee will audit the residents’ charts and conditions to validate appropriate behaviors and placement for resident’s safety by September 10, 2021. 4.) To assist with ongoing compliance the HWD/designee will review resident’s behaviors and placement for safety on a random basis upon new admissions, re-admissions and residents with changes in condition at least monthly.
22VAC40-73-450-C
Based on record review and an interview, the facility failed to have a comprehensive Individualized Service Plan (ISP) that includes the assessed needs of the resident.
Evidence
  1. The Uniform Assessment Instrument (UAI) for resident 1, dated 07/07/21 indicates resident is disoriented in all spheres, some of the time. This is not addressed on the ISP dated 07/07/21.
  2. The UAI for resident 1, dated 07/07/21 indicates resident is disoriented to all spheres, some of the time. This is not addressed on the ISP dated 07/07/21.
  3. The UAI for resident 1, dated 07/07/21 indicates resident needs mechanical assistance with bathing. The ISP dated 07/07/21 indicates resident is independent with bathing.
  4. The UAI for resident 1, dated 07/07/21 indicates resident does not require assistance with mobility. The ISP dated 07/07/21 indicates mechanical assistance is required but does not identify the type of mechanical support used.
Plan of correction
1.) Unable to retroactively correct the required documentation and Plans of care such as UAI and ISP for Resident 1. Resident 1 has been discharged from facility on 8/10/2021. 2.) Re-training for staff certified to complete ISPs and UAI’s will be conducted by the Health and Wellness Director (HWD)/designee no later than 9/10/2021, to verify understanding of accuracy of assessments for the ISPs and the UAIs. 3.) The HWD/designee will conduct an audit of current residents ISP’s and UAI’s no later than September 10th 2021 to verify the ISPs and UAIs are accurate. 4.) To assist with ongoing compliance, the ISPs and UAIs will be reviewed on a random basis upon new admissions, re-admissions and residents with changes in condition on a weekly basis for 4 weeks and then on a monthly basis thereafter for 6 months by the HWD/designee.
November 23, 2020Inspection0 violations
Inspection dates
Nov. 23, 2020
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 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 Report
Comments
This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 11/23/20 and concluded on 12/04/20. The executive director was contacted by telephone to initiate the inspection. The executive director reported the current census as 93. The inspector emailed the executive director a list of items required to complete the inspection. The inspector reviewed five resident records, five staff records, staff schedule, fire drills, and outside inspections submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined no violations with applicable standards or law. No violations were issued.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.