Virginia DSS · Assisted Living Facility

Birch Ridge (Augusta CO)

📍 54 Imperial Drive, Staunton, VA, 24401

ID 45359One Year licenseActive
24
Inspections
On record
17
With violations
Visits that cited something
7
Clean visits
Nothing cited
89
Violations cited
Individual findings
58
Standards cited
Distinct rules
12
Complaint visits
Prompted by a complaint

Birch Ridge (Augusta CO) was inspected 24 times between November 6, 2020 and March 26, 2026 by the Virginia Department of Social Services. 17 of those visits ended with violations cited and 7 with none. Across that history VDSS cited 89 violations under 58 distinct standards. 12 inspections were prompted by a complaint.

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

VDSS publishes inspections on a rolling window. 22 of these 24 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
02/25/2026
Administrator
Thomas Kirby
Licensing inspector
Angela Via
Inspector phone
(540) 682-1739
Approved for
Non-Ambulatory · Assisted Living

Inspection History

24

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

March 26, 2026Complaint survey5 violations
Inspection dates
03/26/2026
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND32.1- (37) Reported by persons other than physicians22VAC40-80 Complaint Investigation
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: March 26, 2026, from 12:43 p.m. until 2:04 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 3/25/2026 regarding allegations in the area(s) of: Resident Care and Related Services Buildings and Grounds Number of residents present at the facility at the beginning of the inspection: 16 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: 4 Number of interviews conducted with staff: 3 Observations by licensing inspector: The Licensing Inspector toured the community inside and outside, including resident rooms. The Licensing Inspector reviewed the following at the time of inspection: resident record, individualized service plan, and condition and cleanliness of building. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation(s) of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint(s) 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 Angie Via, Licensing Inspector at (540) 682-1739 or by email at Angela.via@dss.virginia.gov
Violations
22VAC40-73-930-D
Based on observation and staff interviews, the facility failed to ensure each resident with an inability to use the signaling was included in the resident's individualized service plan (ISP).
Evidence
  1. During a facility tour on 3/26/2026, LI found resident 1 sitting on a soiled bed in soiled pants asking for help. LI asked resident 1 if she had a pendant to push for assistance, but resident 1 appeared unable to understand how to use the signaling device.
  2. During an interview on 03/26/2026 with LI, staff 2 and 3 were asked if resident 1 was able to use the signaling device to call for assistance. Staff 2 and 3 both stated that resident 1 could not use signaling device to call for help.
  3. ISP for resident 1 did not include the residents’ inability to use the signaling device.
Plan of correction
Not published by VDSS.
22VAC40-73-460-I
Based on direct observation, the failed to ensure resident was dressed in clean clothing and be free of odors related to hygiene.
Evidence
  1. During a facility tour on 3/26/2026, LI found resident 1 sitting on the bed. The bathroom commode was soiled with a large amount of feces. There was feces soiled adult pullup on the seat of the rollator walker. Resident 1’s pants were soiled with feces.
  2. LI could smell a strong odor of feces in resident 1s bathroom, bedroom, and the adjoining hallway.
  3. Photo evidence taken.
Plan of correction
Not published by VDSS.
22VAC40-73-870-A
Based on observation, the facility failed to ensure that the interior of building was maintained in good repair and kept clean.
Evidence
  1. During the facility tour on 03/26/2026, LI observed a soiled commode in room 2 on North Hall, standing water in the bathroom sink of room 8 on South Hall, a dirty bathroom sink and mold in the toilet bowl of room 10 on North Hall, a collapsed ceiling in rooms 12 and 13 on South Hall, and water stains on hallway ceiling on South Hall between rooms 12 and 13.
  2. During an interview on 03/26/2026 with LI, staff 1 acknowledged that rooms 12 and 13 needed repair and stated that maintenance would address the other items.
  3. Photo evidence taken.
Plan of correction
Not published by VDSS.
22VAC40-73-860-I
Based on direct observation and staff interview, facility failed to store hazardous materials in a locked area.
Evidence
  1. During a facility tour on 3/26/2026, LI went into unlocked room 13 and observed a large pile of damp insulation and plugged in unattended power tools.
  2. During an interview on 03/26/2026 with LI, staff 1 acknowledged that the door to room 13 was left unlocked.
  3. Photo evidence taken.
Plan of correction
Not published by VDSS.
22VAC40-73-70-A
Based on record review and staff interview, the facility failed to report to the regional licensing office within 24 hours any major incident that had negatively affected or threatened the life, health, safety, or welfare of any resident.
Evidence
  1. On 03/25/2026, the regional licensing office received a complaint forwarded from the Ombudsman that a water pipe ruptured on February 9, 2026, which caused the ceiling to collapse in two resident rooms. Reporter alleged that a resident had to be moved to another room due to excessive amounts of water on the floor.
  2. The regional licensing office did not receive a self-reported incident for the pipe rupture or relocation of a resident.
  3. During an interview with the licensing inspector (LI) on 03/26/2026, staff 1 was asked if a water pipe had ruptured. Staff 1 confirmed that a water pipe for the sprinkler system, which was located in the ceiling, ruptured on February 9, 2026. The water caused the ceiling in two rooms to be damaged.
  4. During an interview with the LI on 03/26/2026, staff 1 was asked if any residents had to be moved due to the pipe rupture. Staff 1 stated that no residents were living in the rooms with water damage, but one resident had to be moved in an adjoining room, due to water on the floor.
  5. During an interview with LI on 03/26/2026, staff 1 was asked if a self-report was sent to the licensing office regarding the ruptured pipe. Staff 1 confirmed that a self-report was not sent.
Plan of correction
Not published by VDSS.
March 26, 2026Complaint survey4 violations
Inspection dates
03/26/2026
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES32.1- (37) Reported by persons other than physicians22VAC40-80 Complaint Investigation
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: March 26, 2026, from 2:05 p.m. until 3:48 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 3/25/2026 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: 16 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: The Licensing Inspector toured the community inside and outside, including resident rooms. The Licensing Inspector reviewed the following at the time of inspection: resident record, including medication administration record, admission documents, and individualized service plan. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation(s) of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint(s) 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 Angie Via, Licensing Inspector at (540) 682-1739or by email at Angie.via@dss.virginia.gov
Violations
22VAC40-73-350-B
Based on resident record review and staff interviews, the facility failed to ascertain, prior to admission, whether a potential resident was a registered sex offender and document in the resident's record the date this information was ascertained.
Evidence
  1. Record for resident 1, admitted 09/24/2025, contained a registered sex offender search dated 10/08/2025, which is after the day of admission.
  2. During an interview with the LI on 03/26/2026, staff 1 confirmed the registered sex offender search for resident 1 was not completed prior to admission.
Plan of correction
Not published by VDSS.
22VAC40-73-150-F
Based on facility record review and staff interviews, the facility failed to ensure that an administrator serving on a full-time basis (40 hours per week) was the on-site agent of the licensee and was responsible for the day-to-day administration and management of the facility licensed for both residential and assisted living care.
Evidence
  1. The facility is licensed for both residential and assisted living care.
  2. Facility record review contained a Staff Schedule for March 2026 with no documentation of Staff 4 scheduled.
  3. During an interview with LI on 03/26/2026, staff 2 was asked which days she worked last week and the current week. Staff 2 stated that she had worked Tuesday, Wednesday, Thursday, Saturday, and Sunday of the previous week and Thursday and Friday the current week. Staff 2 was asked if she had seen staff 4 in the building during any of the days she worked, and staff 2 confirmed that she did not see staff 4.
  4. During an interview with LI on 03/26/2026, staff 1 was asked which days staff 4 was in the building during the month of March. Staff 1 stated that staff 4’s last day at the facility was March 1, 2026. Staff 1 stated that staff 5 was the new administrator. LI asked staff 1 when staff 5 was in the building in March 2026. Staff 1 stated that staff 5 had not been in the facility for two weeks.
Plan of correction
Not published by VDSS.
22VAC40-73-450-F
Based on resident record review and staff interviews, the facility failed to ensure the comprehensive individualized service plan (ISP) was updated as needed for a significant change of a resident’s condition.
Evidence
  1. During an interview with the LI on 03/26/2026, staff 2 confirmed resident 1 was receiving Hospice services.
  2. Hospice paperwork confirmed Hospice services for resident 1 began on 12/15/2025.
  3. Comprehensive ISP for resident 1, admit date 09/24/2025, did not include Hospice services.
  4. During an interview with LI on 03/26/2026, staff 1 acknowledged that ISP dated 09/24/2025 in resident 1’s record did not include Hospice services and was not updated when the changed occurred.
Plan of correction
Not published by VDSS.
22VAC40-73-680-D
Based on resident record review and staff interview, the facility failed to administer medications in accordance with the physician's or other prescriber’s instructions.
Evidence
  1. Complaint was received on 03/25/2026 that medication for resident 1 (admitted 09/24/2025) were not being administered correctly per physician’s order signed and dated 03/12/2026.
  2. Record for resident 1 contained a physician’s medication order signed and dated 03/12/2026 which indicated to decrease morning dose of Seroquel from 25 mg tablet to 12.5 mg every morning, increase bedtime dose of Seroquel from 50 mg to 75 mg every night at bedtime, and change clonazepam 0.5 mg from one tablet by mouth two times a day as need to every 12 hours as needed for anxiety/agitation. Failure to follow the physician’s order resulted in a total of 12 incorrect administrations of Seroquel during the morning medication pass, 11 incorrect administrations of Seroquel during the evening medication pass, and 11 incorrect administrations of clonazepam daily.
  3. Medication administration record (MAR) for resident 1 for March 2026 indicated that physician’s medication order dated 03/12/2026 was not updated on the MAR and medications were not administered as ordered by physician.
  4. During an interview with LI on 03/26/2026, staff 1 was asked why the physician’s medication order signed and dated for 03/12/2026 for medication changes was not started. Staff 1 stated that she did not know and that Hospice was trying to decide what to do with the medications for resident 1.
Plan of correction
Not published by VDSS.
February 24, 2026Inspection13 violations
Inspection dates
02/24/2026
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS63.2- (17) Licensure and Registration Procedures63.2- (18) Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: February 24, 2026, from 10:25 a.m. until 5:00 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: 18 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 2 Number of interviews conducted with residents: 2 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. 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 Angie Via, Licensing Inspector at (540) 682-1739 or by email at Angela.Via@dss.virginia.gov
Violations
22VAC40-73-990-C
Based on document review and staff interview, the facility failed to ensure at least once every six months staff on duty on each shift participated in an exercise in which procedures for resident emergencies were practiced.
Evidence
  1. On 02/24/2026, LI requested documentation of practice exercises for resident emergencies.
  2. No resident exercises for medical or mental emergencies were practiced.
  3. On 02/24/2026, staff 5 acknowledged that staff did not participate in medical and mental emergencies.
Plan of correction
All staff and residents will participate in semi-annual resident medical and mental health emergency exercises.
22VAC40-73-450-A
Based on resident record review and staff interview the facility failed to ensure that the preliminary plan of care was developed to address the basic needs of the resident to adequately protect the health, safety, and welfare of the resident.
Evidence
  1. Record for resident 1, admitted 01/24/2026, did not contain a preliminary plan of care that addressed behaviors identified in the UAI.
  2. Record for resident 2, admitted 02/02/2026, did not contain a preliminary plan of care that addressed behaviors identified in the UAI.
  3. During an interview with the LI on 02/24/2026, staff 5 acknowledged the facility failed to ensure the preliminary plan of care was developed to address the basic needs of resident 1 and resident 2.
Plan of correction
Charts to be audited by two staff members upon admission to ensure all needs are addressed by the ISP.
22VAC40-73-320-B
Based on resident record reviews and staff interview, the facility failed to ensure risk assessments for tuberculosis (TB) were completed annually.
Evidence
  1. Record for resident 3, admission date 07/19/2019, was reviewed. A TB screening for 2025 was not in the record.
  2. Staff 5 acknowledged that the TB screening had not been completed on an annual basis.
Plan of correction
Spoke with PCP staff and they will help to ensure they are doing TB screenings yearly and add to file for compliance.
22VAC40-73-950-E
Based on facility record review and staff interview, the facility failed to ensure the semiannual review of the emergency preparedness plan for all staff, residents, and volunteers included all six elements of this subsection with the review documented by signing and dating.
Evidence
  1. LI requested the semi-annual review of the emergency preparedness and response plan for staff, residents, and volunteers.
  2. During document review on 02/24/2026, the LI observed the semiannual review of emergency preparedness with staff and residents only occurred once in 2025.
  3. Staff 5 confirmed the reviewed emergency preparedness and response trainings only occurred once on 04/30/2025, not twice as required.
Plan of correction
Will do required semi-annual emergency preparedness drills two times each year.
22VAC40-73-980-A
Based on resident record review and staff interviews, the facility failed to ensure a complete first aid kit was on hand at the facility and contained items with expiration dates that had not already passed.
Evidence
  1. The facility first aid kit was inventoried by LI on 02/24/2026. The first aid kit contained Curad petrolatum dressings which expired 01/2023 and 07/23/2025 respectively, Curad xeroform petrolatum dressings which expired 10/2023, antimicrobial skin cleanser which expired on 09/2023, saline wound wash which expired on 12/2017, Skintegrity wound cleanser which expired on 09/2024, and dermal wound wash which expired on 08/2025.
  2. During an interview with the LI on 02/24/2026, staff 5 acknowledged the Curad petrolatum dressings, Curad xeroform petrolatum dressings, antimicrobial skin cleanser, saline wound wash, Skintegrity wound cleanser, and dermal wound wash were all expired.
  3. Photo evidence taken.
Plan of correction
All Expired items have been removed. We have purchased a new first-aid kit and new flashlight. We have also added a inventory check monthly to make sure nothing is missing or out of date.
22VAC40-73-350-B
Based on resident record review and staff interviews the facility failed to ascertain, prior to admission, whether a potential resident was a registered sex offender and document in the resident's record the date this information was ascertained.
Evidence
  1. Record for resident 2, admitted 02/02/2026, did not contain a registered sex offender search.
  2. During an interview with the LI on 02/24/2026, staff 5 confirmed the registered sex offender search for resident 2 was not completed prior to admission.
Plan of correction
Charts to be audited by two staff member to ensure compliance with required documents for admission.
22VAC40-73-860-I
Based on observation and staff interview, the facility failed to store cleaning supplies in a locked area.
Evidence
  1. During a tour of the facility on 02/24/2026, LI observed an unlocked laundry room containing cleaning liquids, including Clorox spray, Clorox disinfecting wipes, Pledge, Fabuloso, Windex, furniture polish, and Xtra laundry detergent.
  2. During an interview with the LI on 02/24/2026, staff 5 confirmed the laundry room was unlocked when LI toured and should have been secured.
  3. Photo evidence taken.
Plan of correction
All staff members have been educated on the serious nature of leaving any door with chemicals unlocked.
22VAC40-73-970-A
Based on facility 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 02/24/2026, the LI observed that fire drills were conducted 07/17/2025 on 6 a.m. to 6 p.m. shift, 08/17/2026 on 6 a.m. to 6 p.m., and 09/24/2025 on 6 a.m. to 6 p.m. shift. No fire drills were completed during 6 p.m. to 6 a.m. shift from July 2025 through September 2025.
  2. Staff 5 confirmed that fire drills were not completed on each shift during the quarter as required.
Plan of correction
We have ensured that fire drills are done all shifts. Our current shift schedule is only days or nights as we do 12hr shifts.
22VAC40-73-320-A
Based on resident record reviews and staff interviews, the facility failed to obtain a physical examination by an independent physician within 30 days preceding admission with recommendations for care, including medications.
Evidence
  1. The admission date for resident 1 was 01/24/2026. The date of the face-to-face physical examination for resident 1 was 01/24/2026, which did not include a medication list signed by the physician as required.
  2. Staff 4 and 5 acknowledged that the physical examination report for residents 1 was not completed according to the standard.
Plan of correction
Charts to be audited by two staff members upon admission to ensure all required documents are in the charts.
22VAC40-73-250-D
Based on staff record review and staff interview, the facility failed to ensure documented absence of tuberculosis in a communicable form as
Evidence
  1. d by completion of the current screening form published by the Virginia Department of Health or a form consistent with it, on or within seven days prior to the first day of work at the facility. Evidence:
  2. Record for staff 2, hired 11/17/2025, did not contain a tuberculosis (TB) risk assessment, which was required on or within seven days prior to the first day of work at the facility.
  3. Staff 5 acknowledged that the TB risk assessment for staff 2 was not completed on or within seven days prior to the first day of work at the facility.
Plan of correction
Staff TB was completed. Going forward two staff members will go over new hire paperwork to ensure compliance.
22VAC40-73-290-B
Based on direct observation and staff interview, the facility failed to develop and implement a procedure for posting the name of the current on-site person in charge, as provided for in this chapter, in the facility that was conspicuous to both residents and the public.
Evidence
  1. During the facility tour completed on 02/24/2026, the licensing inspector (LI) observed the current staff person in charge posted in the facility for the previous day, 02/23/2026.
  2. During an interview on 02/24/2026 with the LI, staff 5 stated that the person in charge was not updated for the current day and still showed the previous day, 02/23/2026.
  3. Photo evidence taken.
Plan of correction
Med Tech is now responsible for changing daily in charge assignment on white board to reflect current person in charge.
22VAC40-73-440-A
Based on resident record reviews and staff interview, the facility failed to complete a Uniform Assessment Instrument (UAI) prior to admission.
Evidence
  1. Resident 2 was admitted to the facility on 02/02/2026.
  2. During a record review conducted on 02/24/2026, the UAI was reviewed and noted to have a completion date and signature of 02/04/2026, which was after the resident’s date of admission.
  3. During an interview with the LI on 02/24/2026, staff 5 confirmed the UAI for resident 2 was not completed prior to admission.
Plan of correction
Charts to be audited by two staff members to ensure compliance with required documents. All UAl's will be completed prior to or on admission to facility.
22VAC40-73-325-A
Based on resident record review and staff interview the facility failed to ensure that a fall risk rating was completed by the time the comprehensive ISP was completed.
Evidence
  1. The fall risk rating for resident 2, admitted 02/02/2026, was completed on 02/04/2026.
  2. Staff 5 acknowledged that fall risk rating was not completed upon admission.
Plan of correction
Charts to be audited on admission by two staff members to ensure dates are correct and all assessments are to be completed upon or prior to admission.
September 16, 2025Complaint survey3 violations
Inspection dates
09/16/2025
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES63.2- (16) PROTECTION OF ADULTS AND REPORTING22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 9/15/2025 regarding allegations in the area(s) of: staffing and supervision and Resident Care and Related Services. Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 9/16/2025 10:00 a.m. – 11:41 a.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: 20 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 2 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: The licensing inspector reviewed staff communication, the staff schedule, fall risk rating, and facility video footage. Additional Comments/Discussion: None 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 Jessica Gale, Licensing Inspector at (540) 571-0358 or by email at Jessica.Gale@dss.virginia.gov
Violations
22VAC40-73-450-F
Based on record review and staff interview, the facility failed to ensure individualized service plans (ISP) were reviewed and updated at least once every 12 months.
Evidence
  1. Record review completed 9/16/2025 for resident 1 (admitted 7/15/2019) contained an ISP dated 4/12/2024.
  2. During an interview with staff 1, when asked if that was the most current ISP staff 1 answered “yes”.
Plan of correction
ISP tracking excel spreadsheet has been put in place to keep up and alert us on UAI/ISP's
22VAC40-73-440-H
Based on record review and staff interview, the facility failed to ensure the Uniform Assessment Instrument (UAI) was updated annually.
Evidence
  1. Record review completed 9/16/2025 for resident 1 (admitted 7/15/2019) contained a UAI dated 3/20/2024.
  2. During an interview with staff 1, when asked if that was the most current UAI staff 1 answered “yes”.
Plan of correction
UAI tracking excel spreadsheet has been put in place to keep up and alert us on UAI/ISP's.
22VAC40-73-1020-A
Based on observation and staff interview, the facility failed to ensure there were at least two direct care staff members awake and on duty at all times.
Evidence
  1. This facility contained a mixed population of residents.
  2. A complaint was received by the regional licensing office on 9/15/2025 indicating that resident 1 had fallen and was left on the floor for greater than 20 minutes initiating a call to local emergency medical services for assistance.
  3. Personnel from the emergency medical services (EMS) were interviewed regarding the incident and stated that upon entry to the facility at 12:30 a.m. on 9/13/2025 there were no staff present upon entry, the EMS responders searched through the facility for resident 1 and located them in their apartment on the floor. Once the resident was assisted the EMS responders searched the facility and found staff 3 and 4 asleep in the staff area and EMS responders woke them.
  4. Video footage was observed during the inspection and revealed staff 3 and staff 4 both asleep from 12:30 a.m. until 12:45 a.m. when EMS woke them, and again from 4:22 a.m. - 5:16 a.m.
  5. The staff schedule was reviewed and confirmed that staff 3 and staff 4 were the only staff on duty.
  6. During an interview with staff 1 and staff 2 when asked if there were any other staff present on the night shift of 9/12/2025 through 9/13/2025 staff 1 stated “no, just them”.
Plan of correction
Staff members that were sleeping during their shift were terminated the day of the complaint. All other staff members have been educated on the importance of staying awake during their shifts and informed that immediate termination would occur if caught sleeping.
August 29, 2025Inspection1 violation
Inspection dates
08/29/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION
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: 8/29/2025 9:50 a.m. – 10:05 a.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: 20 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 2 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: The licensing inspector reviewed employee files and incident reports. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-reported incident but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jessica Gale, Licensing Inspector at (540) 571-0358 or by email at Jessica.Gale@dss.virginia.gov
Violations
22VAC40-73-150-B-6
Based on direct observation, record review, and staff interview, the facility failed to ensure that the facility was not operated by an acting administrator for more than 90 days.
Evidence
  1. On 5/1/2025 the regional licensing office received a notification that staff 2 would be the acting administrator effective 5/1/2025.
  2. On the day of the inspection, 8/29/2025, during an interview with staff 1, staff 1 confirmed that staff 2 was currently the acting administrator.
  3. Staff 2 operated the facility as the acting administrator for a total of 120 days.
Plan of correction
A permanent Administrator was put in place immediately.
June 25, 2025Complaint survey8 violations
Inspection dates
06/25/2025
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 PROVISIONS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 6/12/2025 regarding allegations in the area(s) of: Resident Discharge, Building and Grounds, Resident Care and Related Services, Incident Reporting, fall prevention. Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 6/25/2025 12:15 p.m. – 2:30 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: 21 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 4 Observations by licensing inspector: The licensing inspector toured the outside and entire of the facility including resident rooms, the licensing inspector observed residents in their rooms, in common areas, and during meals. The licensing inspector reviewed, incident reports, and staff schedules. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: 870-A, 870-B, 460-F, and 860-H. A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSSpublic 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
22VAC40-73-870-B
Based on direct observation, the facility failed to ensure the facility was free from foul odors.
Evidence
  1. Upon entering resident room North one, two licensing staff observed a strong urine odor.
  2. While in the room at 12:45 p.m. two licensing staff observed a soiled brief in the bedroom trashcan.
  3. During an interview with staff 3 when asked how long the brief had been in the trashcan, staff 3 stated “since breakfast time”
  4. Photo evidence taken.
Plan of correction
Room was immediately cleaned upon being informed of the odor. Staff have been informed of necessity of the 2-hours checks to ensure areas are clean and free of any odors.
22VAC40-73-870-A
Based on direct observation the facility failed to ensure that the interior of the building was kept clean and the exterior of the building was maintained in good repair and kept free of rubbish.
Evidence
  1. During the exterior tour on 6/25/2025, two licensing staff observed a broken flowerpot on the front porch, missing siding on the left side of the building showing exposed plywood, a broken recliner in the grass on the back of the building, and a broken rocking chair in the resident courtyard.
  2. During the interior tour on 6/25/2025, the bathroom of resident room, North one, had feces in and around the lid and base of the toilet, a soiled brief in the trashcan, and a dried brown stain on the floor.
  3. Photo evidence taken.
Plan of correction
The flowerpot was replaced. {7/5/25) The siding was replaced. (7/10/25) Recliner was removed. (6/26/25) Broken rocking chair was removed. (6/26/25) Staff have been informed of the necessity of 2-hour rounds and checking all areas of the resident's room especially the bathrooms.
22VAC40-73-860-H
Based on direct observation, the facility failed to ensure that where there was an outdoor area accessible to residents, such as a porch or lawn, that was equipped with furniture in season.
Evidence
  1. During the facility tour on 6/25/2025, two licensing staff observed the front porch of the facility to have three rocking chairs with ripped and soiled cushions, and a rotting wooden side table.
  2. Photo evidence taken.
Plan of correction
Front Porch has had the rocking chair cushions replaced and the table was removed
22VAC40-73-460-D
Based on record review and staff interview, the facility failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs, such as prevention of falls.
Evidence
  1. Resident 1 (admitted 3/29/2024) had a total of 19 falls on the following dates, 1/27/2025, 1/30/2025, 2/11/2025, 3/5/2025, 3/6/2025, 5/10/2025, 6/14/2025 at 7:18 p.m.,8:10 p.m., 9:07 p.m. and 9:50 p.m., 6/15/2025, 6/16/2025 at 10:00 a.m., second fall on 6/16/2025 without a time documented), and 5:30 p.m., 6/18/2025 at 2:30 p.m., 5:50 p.m., 9:11 p.m., and 10:00 p.m., and 6/23/2025.
  2. Record review for resident 1, had four fall risk ratings completed on 6/18/2025, four completed on 6/16/2025, one completed 6/15/2025, four completed on 6/14/2025, one completed on 5/10/2025, one completed on 3/6/2025, one completed on 3/5/2025, one completed on 2/11/2025, one completed 1/27/2025, all indicating resident 1 was a high risk for falls.
  3. The ISP dated 3/20/2024 stated resident 1 was “not considered a fall risk”.
  4. Resident 1 fell 12 times from 6/14/2025 through 6/18/2025
  5. During an interview with staff 1, when asked if there were any interventions implemented following the frequent falls to prevent additional fall staff 1 stated “no”.
Plan of correction
Staff will be educated with fall prevention and interventions to use to help reduce falls. ISP's will be updated with this intervention.
22VAC40-73-70-A
Based on record review and staff interview, the facility failed to report to the regional licensing office within 24 hours any major incident that negatively affected or that threatened the life, health, safety, or welfare of any resident.
Evidence
  1. A complaint received by the regional licensing office on 6/12/2025 alleged that on 5/10/2025 resident 1 (admitted 3/29/2024) fell and had a head injury requiring stitches, and on 6/4/2025 and 6/6/2025 resident 1 was sent to the hospital for evaluation following mental health emergencies.
  2. Record review for resident 1 contained documentation of resident 1 being sent to the hospital on 5/10/2025 for a fall with injury and on 6/4/2025 and 6/6/2025 following a mental health emergency.
  3. During an interview with staff 1, when asked if an incident report was sent for the incidents with resident 1 that occurred on 5/10/2025, 6/4/2025, and 6/6/2025, staff 1 stated “no”.
Plan of correction
Staff will be educated on the necessity of sending in documentation to the licensing board in a timely manner when a resident is sent out to the hospital for any major incident that negatively affects or threatens the life, health, safety or welfare of any resident. Fax number has been added to the fax machine for them to use easily.
22VAC40-73-440-H
Based on record review and staff interview, the annual reassessment, using the Uniform Assessment Instrument (UAI) was not completed to determine whether a resident's needs could continue to be met by the facility and whether continued placement in the facility was in the best interest of the resident.
Evidence
  1. Resident 1 (admitted 3/29/2024) had a Unform Assessment Instrument (UAI) dated 4/15/2024.
  2. During an interview with staff 1 when asked if the UAI for resident 1 had been updated annually, staff 1 stated “the one in the chart is the only one that I have”
  3. During an interview with staff 3, when asked if the following assistance listed on the UAI was correct for resident 1, staff 3 stated “no”; Bathing was listed on the UAI as supervision only, dressing was listed as no assistance needed, and continence was listed as continent, no assistance needed.
  4. When asked how long resident 1 had needed assistance with bathing, dressing, and toileting staff 1 stated “at least three (3) months.”
  5. The UAI for resident 1 also indicated psycho-social status as appropriate and orientation as oriented, however during an interview with staff 1 and staff 3, when asked if resident 1 had abusive/aggressive/disruptive behaviors staff 3 stated “yes”, when asked how frequently resident 1 exhibited those behaviors staff 3 stated “it’s a daily occurrence”. When asked how long resident 1 had exhibited the behaviors staff 1 stated “at least three (3) months.”
Plan of correction
Staff will be educated on the necessity for all resident's UAl's to be updated yearly and needed to determine whether a resident's needs can continue to be meet by this facility and if the placement is in the best interest of that resident.
22VAC40-73-450-F
Based on record review and staff interview, the facility failed to ensure Individualized service plans (ISP) were reviewed and updated at least once every 12 months or as needed for a significant change of a resident’s condition.
Evidence
  1. Resident 1 (admitted 3/29/2024) had an ISP dated 3/20/2024.
  2. During an interview with staff 1 when asked if the ISP for resident 1 had been updated annually, staff 1 stated “the one in the chart is the only one that I have”
Plan of correction
Staff will be educated on the necessity for all resident ISP's to be updated yearly and as needed to reflect any significant changes of the resident's condition.
22VAC40-73-460-F
Based on record review and staff interview, the facility failed to notify the next of kin, legal representative, or designated contact person of a resident falling.
Evidence
  1. Resident 1 (admitted 3/29/2024) had 19 “Unusual Occurrence Incident Reports” following each of resident 1’s falls.
  2. 10 of 19 incident reportsindicated “no” family notification with reason listed as “didn’t have access to resident chart to get phone number”.
  3. During an interview with staff 2, when asked why the family was not notified for 10 of the incidents of resident 1 falling, staff 2 stated “I did not have access to the charts they were in a locked office inaccessible to the staff”
Plan of correction
Staff will be educated on necessity of reaching the next of kin, legal representative and person of contact in a timely manner for all falls/incidents. All the resident information needed is available for all staff. Business Operations Manager lives on site and has keys to all doors for any additional information that may be needed.
June 10, 2025Complaint survey1 violation
Inspection dates
06/10/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS63.2- (1) GENERAL PROVISIONS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 4/17/2025 regarding allegations in the area(s) of: Resident Care and Related Services, activities, meals, call bell response time, building and grounds. Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 6/10/2025 10:15 a.m. – 1:09 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: 22 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: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: The licensing inspector observed residents in common areas, in their apartments, and during meals. The licensing inspector reviewed the menu, meal consumption logs, and activity calendars. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. However, violation(s) not related to the complaint but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact 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 store cleaning supplies and other hazardous materials in a locked area.
Evidence
  1. During the facility tour on 6/10/2025, two licensing staff observed the laundry room door open and unlocked containing the following cleaning supplies; five containers of liquid laundry detergent, three containers of Pine Glo cleaner, five containers of Comet with Bleach cleaner, two bottles of furniture polish, one container of Fabuloso cleaner, one container of bathroom cleaner, one container of Clorox disinfecting wipes, and one gallon of bleach.
  2. Photo evidence taken.
Plan of correction
The latch wasn't catching, maintenance was called same day. Latch was fixed.
January 16, 2025Inspection19 violations
Inspection dates
01/16/2025, 01/17/2025
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 GENERAL PROVISIONS63.2 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
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: 1/16/2025 10:00am-3:10pm, 1/17/2025 10:00am-1:30pm. 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: 18 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: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: The licensing inspector observed residents during meals, in common areas, and in their apartments. The facility fire drills, emergency drills, health care and dietary oversight, health and fire inspections were reviewed. 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
22VAC40-73-270-1
Based on record review and staff interview, the facility failed to ensure direct care staff are trained in methods of dealing with residents who have a history of aggressive behavior or of dangerously agitated states prior to being involved in the care of such residents.
Evidence
  1. During a record review on 1/16/2025, resident 2, admitted 12/17/2024, had a UAI dated 12/12/2024 that indicated resident 2 is abusive/aggressive/disruptive – weekly or more with the type of inappropriate behavior stating, “can be aggressive at times when (they) feel pushed by staff to do things (they) may not want to do.”
  2. Upon request on 1/16/2025, the facility did not provide documentation of training completed for dealing with residents who have a history of aggressive behavior for any staff.
Plan of correction
The new training platform has training for aggressive behavior residents. All staff have been assigned training for this.
22VAC40-73-720-A
Based on record review the facility failed to ensure the written Do Not Resuscitate (DNR) orders for withholding cardiopulmonary resuscitation (CPR) from a resident in the event of cardiac or respiratory arrest was included in the individualized service plan.
Evidence
  1. Resident 1, admitted 10/31/2024, had a DNR order dated 11/13/2024.
  2. The ISP for resident 1, dated 4/5/2024 indicated the code status as Full Code. The ISP stated, “staff will immediately call 911 to activate EMS and start CPR until EMS arrives.”
Plan of correction
All ISP’s will be checked for correct code status and updated to reflect this status.
22VAC40-73-290-B
Based on direct observation the facility failed to implement a procedure for posting the name of the current on-site person in charge in a place in the facility that is conspicuous to the residents and the public
Evidence
  1. Upon entrance to the facility on 1/16/2025 at 10:00am, the posted supervisor in charge was dated for 1/15/2025.
  2. Photo evidence taken
Plan of correction
We have in place checks and balances that several people are in charge of making sure this is done daily. Last of all the administrator checks this on their way into the office each morning. To ensure the white board is updated.
22VAC40-73-860-I
Based on direct observation, the facility failed to store cleaning supplies and other hazardous materials in a locked area.
Evidence
  1. During the facility tour on 1/16/2025, the laundry room door was not locked containing a gallon of laundry detergent beside the washing machine and a shelf of cleaning chemicals including three containers of Comet with bleach, six containers of Clorox disinfecting wipes, three containers of furniture polish, and a spray bottle of disinfectant cleaner.
  2. Photo evidence taken.
Plan of correction
The lock to the laundry room door is being replaced
22VAC40-73-560-I
Based on record review and staff interview the facility failed to ensure a current picture of each resident was readily available for identification purposes.
Evidence
  1. During a record review completed 1/16/2025, resident 2, admitted 12/17/2024, did not have a picture or description in the resident record.
  2. During an interview with staff 1 on 1/16/2025, when asked if there was a picture or description in resident 2’s record, staff 1 stated “probably not”.
Plan of correction
All residents in the building photos have been uploaded to medication management system. All new residents will have photo taken by Administrator and added to system with in 48 hrs of admission
22VAC40-73-970-A
Based on record review and staff interview, the facility failed to ensure fire and emergency evacuation drill frequency and participation was completed in accordance with the current edition of the Virginia Statewide Fire Prevention Code (13VAC5- 51).
Evidence
  1. During the inspection on 1/16/2025, the facility did not provide documentation of any fire drills completed at the facility.
  2. During an interview with staff 1, hired 11/20/2024, when asked when the last fire drill was completed staff 1 stated “not since I’ve been here”.
Plan of correction
Facility is conducting monthly fire drills and using the DSS form to track these events. Fire drills were found from previous administrator after inspector had left.
22VAC40-73-960-B
Based on direct observation the facility failed to ensure the emergency fire and emergency evacuation drawing contained all required information.
Evidence
  1. During the facility tour on 1/16/2025, the fire and emergency evacuation drawing did not contain a secondary evacuation route, areas of refuge, or assembly areas.
  2. Photo evidence taken.
Plan of correction
The evacuation drawing has been updated and put on display above the fire extinguisher.
22VAC40-73-450-E
Based on record review, the facility failed to ensure that the individualized service plan (ISP) is signed and dated by the licensee, administrator, or his designee, (i.e., the person who has developed the plan), and by the resident or his legal representative.
Evidence
  1. The ISP for resident 2 dated 12/12/2024 was not signed by the resident or legal representative.
  2. The ISP for resident 1 dated 4/5/2024, was not signed by the person who developed the plan or the resident or legal representative.
Plan of correction
All ISP’s will be checked for signatures and updated as needed. On admission the Administrator and Designated Staff will check after each other to ensure all signatures have been filled out.
22VAC40-73-290-A
Based on record review, the facility failed to ensure the written work schedule included the names and job classifications of all staff working each shift, with an indication of whomever is in charge at any given time.
Evidence
  1. The current work schedule posted at the time of inspection on 1/16/2025, did not indicate whomever is in charge at any given time.
  2. During an interview with staff 1 on 1/16/2025, when asked if the schedule indicated who is in charge, staff 1 stated “no, it doesn’t.”
Plan of correction
We have updated and kept up with the schedule having all staff in every department on it with job title and classification. We also have it color coated to show who is the charge person on that shift. This was done the day of inspection.
22VAC40-73-520-I
Based on direct observation and staff interviews, the facility failed to ensure the current month's written schedule of activities was posted in a conspicuous location in the facility or otherwise be made available to residents and their families.
Evidence
  1. During the facility tour on 1/16/2025, there was no schedule of activities posted in the facility.
  2. During an interview with staff 1 on 1/16/2025, when asked if there was a written schedule of activities staff 1 stated “yes, but we don’t post that we only post the activity for that day”.
  3. During the inspection on 1/16/2025, staff 1 provided a calendar labeled “January 2025” with one activity listed each day, without an indication of the hour or length of activity.
Plan of correction
Current month activity schedule is placed on the bord with the entire month schedule in view. It has an indication of the length of each activity as well as the location
22VAC40-73-210-C
Based on record review and staff interview, the facility failed to ensure direct care staff training commenced no later than 60 days after employment.
Evidence
  1. Upon request on 1/16/2025, the facility did not provide any training records for Staff 3 hired 4/16/2024.
  2. During an interview with staff 1 on 1/16/2025, when asked if there was any record of direct care training including infection control, staff 1 stated “not that I can find”.
Plan of correction
Facility has signed up with a training service and all active staff have been signed up for education. All new staff is signed up for this education on hire.
22VAC40-73-610-E
Based on direct observation and upon request, the facility failed to ensure there is a copy of a diet manual containing acceptable practices and standards for nutrition, kept current, and readily available to personnel responsible for food preparation.
Evidence
  1. During the facility tour on 1/17/2025, there was no dietary manual present in the kitchen.
  2. Upon request on 1/17/2025, the facility did not provide a dietary manual.
Plan of correction
Diet manual provided by dietician is printed and in the kitchen.
22VAC40-73-450-A
Based on record review, the facility failed to ensure all identified needs were included on the preliminary Individualized Service Plan (ISP).
Evidence
  1. Resident 2 admitted 12/17/2024, had a Uniform Assessment Instrument (UAI) dated 12/12/2024 indicating psycho-social status as abusive/aggressive/disruptive – weekly or more.
  2. The ISP for resident 2 dated 12/12/2024 did not include the psycho-social status.
Plan of correction
All ISP’s will be updated for any identified needs from the UAI as well as to have their psycho-social status included.
22VAC40-73-930-D
Based on record review, the facility failed to ensure that for each resident with an inability to use the signaling device, the inability was included in the resident's individualized service plan.
Evidence
  1. During the inspection on 1/16/2025, staff 1 provided a list of 4 residents with an inability to use a signaling device, including resident 2.
  2. The ISP for resident 2 dated 12/12/2024 did not include the inability to use the signaling device.
Plan of correction
All ISP’s will be updated to reflect inability to use call bell system for residents that are unable to use the call bell system.
22VAC40-73-990-C
Based on record review and staff interview, the facility failed to ensure at least once every six months, all staff currently on duty on each shift shall participate in an exercise in which the procedures for resident emergencies are practiced. Documentation of each exercise shall be maintained in the facility for at least two years.
Evidence
  1. Upon request on 1/16/2025, the facility did not provide documentation of completed exercises in which the procedures for resident emergencies were practiced.
  2. During an interview with staff 1 on 1/16/2025, when asked if there were any exercises for resident emergencies completed, staff 1 stated “not that I can find”.
Plan of correction
Resident emergency six-month review has been reviewed with all staff. Documentation has been put in an education binder for the facility in the Administrators office.
22VAC40-73-260-C
Based on record review and staff interview, the facility failed to ensure a listing of all staff who have current certification in first aid or CPR, was posted in the facility so that the information is readily available to all staff at all times.
Evidence
  1. During the facility tour on 1/16/2025, there was no listing of staff with first aid or CPR posted.
  2. During an interview with staff 1 on 1/16/2025, when asked where the first aid and CPR list was posted, staff 1 stated “I didn’t know it needed to be posted.”
Plan of correction
List of all CPR/First Aide trained staff was posted on day of inspection. As of April 1st, it was made a part of the schedule. Their name is highlighted in color and a key code is at the bottom of the schedule.
22VAC40-73-950-E
Based on record review and staff interview, the facility failed to develop and implement an orientation and semi-annual review on the emergency preparedness and response plan for all staff, residents, and volunteers, with emphasis placed on an individual's respective responsibilities.
Evidence
  1. During the inspection on 1/16/2025, the facility did not provide a semi- annual review of the emergency preparedness and response plan for all staff, residents, or volunteers.
  2. During an interview with staff 1 on 1/16/2025, when asked if there was a semi-annual review of the emergency preparedness and response plan, staff 1 stated, “I don’t think it was done”.
Plan of correction
Not published by VDSS.
22VAC40-73-250-D
Based on record review and staff interview the facility failed to ensure each staff person on or within seven days prior to the first day of work at the facility, submit the results of a risk assessment, documenting the absence of tuberculosis (TB) 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:
  2. Upon request on 1/16/2025, the facility did not provide the results of a risk assessment documenting the individual is free of tuberculosis for staff 3 hired 4/16/2024
  3. During an interview with staff 1 on 1/16/2025, when asked if there was a TB risk assessment completed for staff 3, staff 1 answered no.
Plan of correction
All new staff are required to supply or obtain a TB or free from communicable disease form prior to working on the floor.
22VAC40-73-520-E
Based on record review and staff interviews the facility failed to ensure there were at least 14 hours of scheduled activities available to the residents each week for no less than one hour each day.
Evidence
  1. During the inspection on 1/16/2025, staff 1 provided a calendar labeled “January 2025” with one activity listed each day, without an indication of the hour or length of activity.
  2. During an interview with staff 1, when asked how many scheduled hours of activities are conducted at the facility daily, and if there were 14 scheduled hours of activities weekly, staff 1 stated “I’m not sure, and probably not”.
  3. A group of three staff were interviewed regarding activities in the facility, when asked when the last activity occurred at the facility the staff answered a craft was done at Christmas”.
Plan of correction
Activity Calendar reflects 2 hours of activities done daily. Staff are assigned to do activities daily
October 15, 2024Complaint survey2 violations
Inspection dates
10/15/2024
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/15/2024 11:20am-12:50pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 10/10/2024 regarding allegations in the area(s) of: Staffing and supervision. Number of residents present at the facility at the beginning of the inspection: 19 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: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: The Licensing Inspector observed residents during meals, staff answering call bells, and medication administration, the staff schedule and assignment sheets were also reviewed. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. However, violation(s) not related to the complaint but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jessica Gale, Licensing Inspector at 540-571-0358 or by email at jessica.gale@dss.virginia.gov
Violations
22VAC40-73-870-A
Based on direct observation the facility failed to ensure that the exterior of all buildings shall be maintained in good repair.
Evidence
  1. Upon arrival to the facility during the inspection on 10/15/2024 at 11:20am a shutter on a window to the right of the front door on the front of the facility was falling off and hanging at the bottom.
  2. Photo evidence taken.
Plan of correction
The hanging shutter was from the rain and storm that occurred hours early. The maintenance director fixed the shutter the same day. The administrator and maintenance will regularly work around the property after every inclimate weather.
22VAC40-73-860-I
Based on direct observation and staff interview, the facility failed to ensure cleaning supplies and other hazardous materials in a locked area.
Evidence
  1. During the facility tour on 10/15/2024, the licensing inspector observed the laundry room door next to the resident dining room cracked open with duct tape covering the latch, stopping the door from being secured.
  2. The unsecured laundry room contained a shelf holding 2, gallon jugs of bleach, window cleaner, and various baskets of assorted cleaning supplies.
  3. During an interview on 10/15/2024, staff 3 acknowledged the laundry room door was unlocked and stated, "we can't get into it if its locked".
  4. Photo Evidence taken.
Plan of correction
Chemical storage- tape on the door was removed and the problem was corrected on site. The administrator and wellness coordinator will educate staff on ensuring no tape is attached to the door.
February 16, 2024Inspection1 violation
Inspection dates
02/16/2024
Areas reviewed
Administration and Administrative ServicesPersonnelStaffing and SupervisionAdmission, Retention and Discharge of ResidentsResident Care and Related ServicesBuildings and GroundsEmergency PreparednessMixed Population
Comments
Date of Inspection: February 16, 2024 Type of Inspection: Renewal Inspection If you have any questions or email changes, please do not hesitate to contact me at laura.lunceford@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov. Census 21 Number of records reviewed and interviews conducted- 6 records (staff and resident), 7 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. The Licensing Inspector observed the residents during meals and individual activities. The Licensing Inspector reviewed the following at the time of inspection: menus, activity calendars, dietician report, fire drills, pharmacy review and healthcare oversight. The Licensing Inspector and the Administrator discussed the risk assessment ratings for the violations for this inspection. Please complete the “plan of correction” and “date to be corrected” for each violation cited on the violation notice and returned it to the office. You will need to specify how the deficient practice will be or has been corrected. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s).
Violations
22VAC40-73-450-F
Based on resident record review and staff interview, it was determined that the facility failed to update an Individualized Service Plan (ISP) annually as required.
Evidence
  1. Resident B had no current documentation on the ISP of an annual review. The last ISP was dated April 9, 2022.
Plan of correction
All resident records will be audited by the Administrator. All ISPs will be current in the record as required.
August 28, 2023Complaint survey2 violations
Inspection dates
Aug. 28, 2023
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Technical assistance
1. Highly recommend maintaining a copy of paper MARs as back up to the electronic system. 2. No shifts should be covered solely by agency staff not familiar with the building or the residents. 3. Request copies of the current registration of any medication aides sent from agency. 4. All agency staff should participate in a shortened version of orientation to include emergency procedures.
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: 8/15-8/28/23 A self-report then complaint with additional concerns was received by VDSS Division of Licensing on 8/27/23 and 8/13/23 respectively regarding allegations in the areas failure to provide medication as prescribed and failure to have oversight by a qualified person. The complaint involved the review of medication administration reports, interviews with family, staff and administration as well as collateral parties. Violations were identified related to the complaints and self-report and can be found in the violation portion of this report. All three aspects of the complaint were found to be valid. The evidence gathered during the investigation supported the allegation and self-report of non-compliance with standard(s) or law, and violation(s) were issued. The licensee can 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. An exit meeting was conducted to review the inspection findings. 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 Sharon DeBoever, Licensing Inspector at (540) 292-5930 or by email at sharon.deboever@dss.virginia.gov
Violations
22VAC40-73-150-B
The facility failed to name an otherwise qualified person to be the administrator during the absence of the newly named administrator. The Vice president of operations who is otherwise qualified did come to the building after five days to assist in administration.
Plan of correction
Plan of correction forthcoming
22VAC40-73-680-C
On 8/12/23 morning medication for all residents at the facility was administered outside the one hour after parameter due to the lack of a medication aide and the medication aide from the previous shift refusing to stay. This was verified by the resident care coordinator, additional staff, residents, family members and vice president of operations. on 8/27/28 morning medication was not given to any of the residents as per the vice president of operations due to agency staff not being able to log into the computer system and the agency rather than facility administration directing the medication aide not to administer any medication since it was now 9:25am and administration time was 8am.
Plan of correction
Plan of correction forthcoming
March 16, 2023Inspection0 violations
Inspection dates
03/16/2023
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS
Technical assistance
1. Ensure the specific fruit served at each meal is listed on the posted menu instead of just writing “fruit/fruit parfait.” 2. Recommended a form be created that includes all of the required information to be reviewed by the dietician, then have the dietician sign and date the form at the end of each review to certify the requirements for the review were met. Attach this form to the dietician’s summary report and keep all information on file.
Comments
Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 3/16/2023 from approximately 12:10 pm to 2:10 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 26 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: selected sections of 4 + 1 contract staff Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 4 Observations by licensing inspector: Lunch meal, afternoon activity Additional Comments/Discussion: A monitoring inspection was conducted as a follow-up to the renewal inspection. Reviewed criminal record reports for all staff hired since the last inspection. 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Janice Knight, Licensing Inspector at (540) 430-9258 or by email at janice.knight@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
January 30, 2023Inspection10 violations
Inspection dates
01/30/2023, 01/31/2023
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Technical assistance
1. Ensure timeframes required by the standards are followed and that information is obtained/completed within those timeframes. 2. Recommended the monthly resident council meetings be included on the activities calendar. 3. Review of the fire, emergency preparedness and infection control plans and renewal of the limited liability insurance are due by the end of March 2023. 4. Food consumption logs need to be completed after each meal and not at the end of the shift. 5. Ensure all policies are current and send all changed/updated policies to this inspector for review.
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: 1/30/2023 from approximately 7:00 am to 10:00 am, 12:00 noon to 7:00 pm and 1/31/2023 from approximately 7:10 am to 6:50 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: 27 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 4 + selected sections of 2 additional staff records Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 5 + 1 collateral Observations by licensing inspector: Meals, medication administration, medications, medication carts, emergency food supply, first aid kit, staffing, communication logs, food consumption logs, postings, etc. Additional Comments/Discussion: A preliminary review of all non-compliance was conducted at the end of each day of the inspection. The administrator was given an opportunity to ask questions and to provide any missing documentation at those times. 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 Janice Knight, Licensing Inspector at (540) 430-9258 or by email at janice.knight@dss.virginia.gov
Violations
22VAC40-73-250-D
Based upon documentation and an interview, the facility failed to ensure one of five tuberculin (TB) skin tests/assessments was completed within seven days of hire.
Evidence
  1. Staff 5 (hired 10/1/2022) had an initial TB skin test completed on 10/4/2022.
  2. On 1/31/2023, the LI interviewed the administrator who stated this TB test was the only test on file for staff 5.
Plan of correction
The administrator will maintain a log as a monitoring tool to document the TB screening of each new employee hired to ensure that the test is performed on or within seven days prior to the first day of work. The administrator will ensure the TB test has been read and is negative prior to the employee’s start date.
22VAC40-73-260-C
Based upon observations, documentation and an interview, the facility failed to ensure the FA and CPR posted list was kept current.
Evidence
  1. On 1/30/2023, during the facility tour, the LI observed the posted list of staff with FA/CPR. The date at the bottom indicated the list was last updated on 8/23/2022.
  2. On 1/30/2023, the LI interviewed the administrator who stated the FA/CPR list had not been updated since she had been the administrator.
  3. Of the five staff records reviewed, staff 5 had completed FA/CPR and was not on the posted list for staff with current FA/CPR certifications.
Plan of correction
An updated FA/CPR list was posted on the day of inspection. The administrator updated the FA/CPR employee list and will update the list each time an employee is hired who has current certification, when a new employee obtains certification and when an employee who has certification leaves. The administrator will update the list with each change of staff and will ensure the posted list remains current at all times.
22VAC40-73-260-A
Based upon documentation and an interview, the facility failed to ensure one of five staff completed first aid (FA) within 60 days of hire.
Evidence
  1. Staff 1 (hired 9/30/2022) did not have documentation on file for completion of FA training.
  2. On 1/31/2023, the LI interviewed the administrator who stated staff 1 had not completed FA training.
  3. On 1/31/2023, the LI interviewed staff 1 who stated she had completed the training at another facility, however, it expired.
Plan of correction
The administrator will complete a 100% staff chart audit to ensure compliance. Administrator will develop a spreadsheet that includes employee’s expiration dates of cardiopulmonary resuscitation (CPR) and FA. Administrator will audit the spreadsheet monthly to ensure employees are scheduled for the class at least one month prior to the expiration dates in order to ensure continued compliance
22VAC40-73-980-H
Based upon observations and an interview, the facility failed to ensure at least a 96-hour supply of emergency food was available with 48 hours being on site.
Evidence
  1. On 1/30/2023, the LI observed the food storage area, refrigerators and freezers and there was no canned/frozen/fresh fruit, canned/frozen/fresh vegetables and no canned/frozen precooked meats on site to serve in case of an emergency.
  2. On 1/30/2023, the LI interviewed staff 7 who stated they did not have any emergency food on site.
Plan of correction
The administrator and dietary staff will work together to ensure a 96-hour supply of emergency food is on hand at all times. The administrator and dietary staff will log monthly food checks to ensure a 96-hour supply of food is on hand. The administrator will be responsible for compliance with this standard.
22VAC40-73-640-A
Based upon documentation, the facility failed to implement the facility medication management plan by not ensuring medications were ordered and available to avoid missed doses for two of two resident medication administration records (MARs) reviewed.
Evidence
  1. Page 160 6.a and b. of the facility medication management plan states, “A notebook shall be maintained to assure accurate and timely communication with the pharmacy regarding new orders, refills, and medication discrepancies/concerns, etc. Pharmacy communications will be logged with initials, date and time to avoid duplication. Evening and night shifts should log requests for refills, and other non-emergency communications that will then be called into the pharmacy by the oncoming day shift med aide. Therefore, day shift med aide will check the pharmacy communication notebook each morning at the start of shift. If a medication is not available at the scheduled time of administration, the pharmacy will be notified, an entry will be made in the pharmacy communication notebook, and the supervisor will be notified. Charting “med not available” on the MAR alone, does not fulfill this requirement.”
  2. Page 162, 8.b and c. of the facility medication management plan states, “All medication staff are responsible for monitoring the need for refills. It shall be the responsibility of the night shift medication aide or nurse to check all medications to include PRN medications and private pharmacy medications twice a week to see if refills are needed.”
  3. Resident 1 had as needed (PRN) physician’s orders signed on 1/17/2023 for Biofreeze and Nystatin Powder and on 1/3/2023 for Refresh Tears.
  4. On 1/30/2023, the LI and staff 1 conducted a medication cart audit and these medications were not in the cart or available on site.
  5. Resident 2 had a renewed physician’s order signed 1/11/2023 for Pantoprazole, one 180mg tablet twice a day.
  6. The MAR for resident 2 was initialed and circled on 1/7/2023, 1/13/2023 - 1/15/2023, 1/18/2023, 1/21/2023 – 1/25/2023, 1/27/2023 – 1/29/2023 for 7:00 am and 4:00 pm; 1/10/2023, 1/11/2023, 1/16/2023, 1/19/2023, 1/20/2023 and 1/26/2023 for 4:00 pm; and 1/30/2023 for 7:00 am. The notes for not administering the medication stated, “Physically unable to take.”
  7. On 1/30/2023, the LI interviewed staff 1 and the administrator and both stated the medication was not administered as it was not available on site and the only suitable option to select on the MAR was “Physically unable to take.”.
  8. Resident 2 had a physician’s order signed 10/26/2022 for Senna Lax two 8.6mg tablets at bedtime.
  9. The MAR was circled and initialed on 1/19/2023 – 1/22/2023, 1/24/2023 – 1/25/2023 and 1/27/2023. The notes indicated, “Physically unable to take.”
  10. On 1/30/2023, the LI and the administrator conducted a check of the medication cart and the card for the Senna Lax for resident 2 was found in the bottom drawer of the cart with the PRN medications.
  11. Resident 2 had PRN orders signed on 12/20/2022 for Azelastine nasal spray and Benzonatate for cough.
  12. During the medication cart audit the PRN Azelastine and Benzonatate for resident 2 were not in the cart or available on site.
Plan of correction
Signed orders were obtained and sent to the licensing inspector. Pantoprazole was received from pharmacy and is now being administered per order signed 2/5/2023. The administrator and wellness coordinator will conduct monthly medication cart audits to ensure all medications are available. Night shift registered medication aide (RMA) will also do a medication cart audit on the monthly change over cycle to ensure all medications are available. The administrator will keep log of all medication cart audits and the staff that performed them. The administrator will actively monitor these medication cart audits to ensure all medications are available and to ensure compliance with this standard.
22VAC40-73-620-A
Based upon documentation and an interview, the facility failed to ensure the dietary oversight was completed every six months.
Evidence
  1. The last dietary oversight on file was documented as completed 6/23/2022.
  2. On 1/23/2023, the LI interviewed the administrator who stated the previous dietitian cancelled the contract in August of 2022 and no dietary oversights had been completed since 6/23/2022.
Plan of correction
The administrator and corporate team will ensure we have contracts and dietary oversights completed every six months. Corporate sent new dietary contract on 1/31/2023. Dietician came out on 2/9/2023 and completed the dietary oversight. The administrator will ensure a dietary oversight is completed for all special diets every six months. The administrator will review the dietician’s report and ensure it meets all requirements of this standard. If the contract is cancelled at any time, a new contract will be obtained in a timely manner to ensure continued compliance with this standard.
22VAC40-73-610-C
Based upon documentation, observations and interviews, the facility failed to ensure the meals met the United States Department of Agriculture’s (USDA) food guidance system.
Evidence
  1. On 1/30/2023, the licensing inspector (LI) observed the breakfast and lunch meals and a glass of orange juice for breakfast was the only fruit observed being provided to the residents.
  2. The posted menu for the week of 1/30/2023 to 2/5/2023 listed the following fruits: orange juice served for breakfast every day, fruit cocktail at lunch on 2/2/2023, and peaches at dinner on 2/5/2023. The menu listed only two servings of vegetables on 1/30/2023 and 2/4/2023.
  3. On 1/30/2023, the LI interviewed the cook who stated they had no fruit to serve as none had been ordered.
  4. On 1/30/2023, the LI checked the area where food was stored and there were no cans of fruit on the shelves, cabinets or in the refrigerators.
Plan of correction
The administrator will work with dietary staff to ensure the menus meet the USDA food guidance system. The administrator and dietary staff will ensure two servings of fruit and three servings of vegetables are being served daily, along with the other recommended servings for the other food groups. The administrator will review the menu the week prior to posting to ensure compliance. The administrator will be responsible for monitoring the menus and meals for compliance with this standard.
22VAC40-73-520-I
Based upon observations and an interview, the facility failed to ensure a written schedule of activities was posted.
Evidence
  1. On 1/30/2023, the LI conducted a tour of the facility and an activities calendar was not observed posted on any bulletin board or anywhere in the facility.
  2. On 1/30/2023, the LI interviewed the administrator who stated since the activities staff left she had not created or posted an activities calendar.
Plan of correction
The administrator created an activities schedule and posted it. The administrator will ensure the activities schedule is posted and up to date. Once the activities director starts, she will take over the responsibility of creating the activities schedule and keeping the posted activities schedule up to date. The administrator will conduct at least weekly checks and will be responsible for ensuring compliance with this standard.
22VAC40-73-520-E
Based upon observations and interviews, the facility failed to ensure at least 14 hours of activities were held each week with no less than one hour each day.
Evidence
  1. On 1/30/2023, the LI did not observe any activities occurring throughout the day.
  2. On 1/30/2023, the LI interviewed residents 3 and 6 and staff 3. All three stated they have activities two to three times a week now.
Plan of correction
The administrator delegated the morning (6:00 am to 2:00 pm) direct care staff to conduct one hour of activities daily at 10:00 am. The 2:00 pm to 10:00 pm direct care staff will conduct one hour of activities daily at 3:00 pm until an activities director is hired. An activities director was hired on 2/15/2023 and will start work on 3/1/2023. Administrator and direct care staff will ensure 14 hours of activities are being done each week.
22VAC40-73-40-B-3
Based upon documentation and an interview, the facility failed to ensure one of fourteen staff had a criminal record report (CRR) completed within 30 days of hire.
Evidence
  1. Staff 5 (hired 10/1/2022) had a CRR dated as completed 1/30/2023.
  2. On 1/31/2023, the LI interviewed the administrator who stated staff 5 started working on 10/15/2022 and the CRR had not been completed until 1/30/2023.
Plan of correction
The administrator obtained all missing CRRs. The administrator will ensure all CRR paperwork is completed, checked and immediately mailed at the time when the pre-hire paperwork is completed, prior to starting work. The administrator will be responsible to ensure all CRRs are obtained prior to hire and no later than within 30 days of hire to ensure compliance with this standard.
January 30, 2023Complaint survey0 violations
Inspection dates
01/30/2023
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 1/30/2023 from approximately 6:45 am to 7:00 am and 10:00 am to 12:00 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 1/18/2023 regarding allegations in the area of: Administrative and Administrative Services Number of residents present at the facility at the beginning of the inspection: 27 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: N/A Number of staff records reviewed: N/A Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 4 Observations by licensing inspector: Tour of the facility and observations of infection control practices by staff on both first and third shifts. Additional Comments/Discussion: Interviews were conducted with both residents and staff along with observations of infection control practices. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Janice Knight, Licensing Inspector at (540) 430-9258 or by email at janice.knight@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
June 27, 2022Inspection2 violations
Inspection dates
06/27/2022
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS
Technical assistance
Reminded administrator and wellness nurse to carefully review the medication administration record along with the physicians’ orders immediately upon admission (or prior to if possible) to ensure all information is included and is accurate and complete.
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: 6/27/2022 from approximately 11:45 am to 3:00 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 9 (only selected sections) Number of staff records reviewed: 0 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 4 Additional Comments/Discussion: Reviewed selected sections of four medication administration records, physician’s orders and medications. 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 Janice Knight, Licensing Inspector at (540) 430-9258 or by email at Janice.knight@dss.virginia.gov
Violations
22VAC40-73-70-B
Based upon documentation and an interview, the facility failed to ensure a stage 2 wound was reported to the licensing office.
Evidence
  1. Resident 4 (admitted 6/14/2022) had an admission progress documented by staff 1 on 6/14/2022 which stated, “Resident is currently bed bound and has a stage II pressure sore on her coccyx. Also on upper right thigh.”
  2. The major incident report was submitted to this licensing inspector (LI) by the administrator during this inspection on 6/27/2022.
  3. On 6/27/2022, the LI interviewed the administrator and she stated she meant to send this report and knew she was supposed to but just had not completed it.
Plan of correction
1. Facility reported incident (FRI) for Resident 4 was completed and submitted on 06/27/2022. All new admissions within the past 60 days were reviewed by the administrator on 06/28/2022 and found to be in compliance with the standard. 2. Training will be provided to all staff at next staff meeting scheduled for 07/07/2022. The district nurse will review documentation of all new admissions and report any major incident to the administrator immediately. 3. The administrator is responsible for the implementation and monitoring of this corrective action. 4. This corrective action will be fully implemented by July 7, 2022.
22VAC40-73-680-I
Based upon documentation, observations and interviews, the facility failed to ensure all medications administered to one of four residents were documented on the medication administration record (MAR).
Evidence
  1. Resident 4 (admitted 6/14/2022) had signed physician’s orders dated 6/9/2022 for as needed oxygen and Aspercreme.
  2. On 6/27/2022, the LI interviewed resident 4 and observed oxygen in use; however, resident 4 stated she has never needed the Aspercreme or asked for it.
  3. The June 2022 MAR for resident 4 did not list the oxygen or the Aspercreme.
Plan of correction
1. The district nurse contacted the pharmacy to add orders for oxygen and Aspercreme to the MAR. Administrator reviewed MAR on 06/29/2022 and confirms that both were added on 06/27/2022. 2. The district nurse and wellness coordinator met with administrator on 06/28/2022 and will complete a full review of all MARs to ensure compliance with the physicians’ orders. The third shift RMA will be tasked with performing weekly audits of the MAR and report any areas of noncompliance with the district nurse immediately. 3. The district nurse is responsible for the implementation and monitoring of this corrective action. 4. This corrective action will be fully implemented by July 15, 2022
May 9, 2022Inspection9 violations
Inspection dates
05/09/2022, 05/10/2022
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 PREPAREDNESS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Technical assistance
Standards/Information reviewed with the administrator in training: 1. Recommended cart and medication audits be conducted on a weekly basis to ensure medications and treatments are on site and being administered as ordered and that documentation is accurate and complete - this includes the controlled medication count. 2. Recommended nurse conduct medication administration observations at least twice a month to ensure proper protocols are being followed. 3. Reviewed standard 650 which requires each medication order to have a specific diagnosis, condition or specific indications for administering (especially if an as needed/PRN medication), name of the drug, specific dose, strength, route and how often it is to be given. Stating for anxiety is not sufficient. Also, when a cream is ordered the order must indicate where that cream is to be administered and what it is to be administered for. Ensure orders are specific prior to filing and ensure all information is included on the medication administration record. 4. Recommended a more frequent system of checks be implemented with the medication administration records, physicians' orders, resident and staff records, food consumption logs, fire drills and training. 5. Notify inspector once the new walkie-talkies are received. 6. New administrator in training must complete the medication aide class. Send this certificate immediately upon completion.
Comments
Type of inspection: Monitoring Dates of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 5/9/2022 from approximately 8:15 am to 5:35 pm and 5/10/2022 from approximately 7:54 am to 4:50 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: 24 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 and selected sections of three additional resident records Number of staff records reviewed: 5 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: Medication administration observations were completed with one registered medication aide for two residents for a total of 17 medication administration observations. The April and May medication administration records, physicians' orders and medications were all reviewed. All required postings were observed and the medication cart was checked. 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 violations 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 violations 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 Janice Knight, Licensing Inspector at (540) 430-9258 or by email at Janice.knight@dss.virginia.gov
Violations
22VAC40-73-450-F
Based upon documentation and an interview, the facility failed to ensure four of the six individualized service plans (ISPs) reviewed included all needs and services provided.
Evidence
  1. The updated ISPs for the following residents did not include all assessed needs and services provided:
  2. On 5/10/2022, the LI interviewed the administrator and nurse and both stated resident 3 required two person assistance; however, the ISP (updated 3/15/2022) for resident 3 did not include the need for two-person assistance. Resident 3 was also receiving wound care by hospice; however, this need was also not listed on the ISP.
  3. The uniform assessment instrument (UAI) completed 3/15/2022 for resident 4 indicated resident needed assistance with medication administration; however, the ISP (updated 3/15/2022) did not include this need. The resident also had a physician's order (signed 4/22/2022) to self-administer a gel nasal spray which also was not listed on the ISP.
  4. Resident 5 had a physician's order (signed 4/4/2022) for half rail on one side of bed to assist with transferring and positioning. The UAI (completed 3/22/2022) for resident 5 indicated resident needed mechanical assistance with transferring; however, the ISP (updated 3/22/2022) for resident 5 did not include the half rail for assistance with transferring and positioning and also did not include disorientation to time.
  5. Resident 6 had a physician's order (signed 4/14/2022) for half rails to assist with transferring and positioning. The UAI (completed 3/15/2022) indicated resident 6 needed mechanical assistance with bathing, transferring, walking, wheeling and mobility; however, the ISP (completed 3/15/2022) did not include these needs.
Plan of correction
1. RDON will review and make all necessary corrections to the ISP for residents 3, 4, 5 and 6. RDON will review the UAIs and ISPs for all active residents to ensure accuracy of the service plan and update as needed. 2. AA and Wellness Coordinator (WC) will complete ISP training providing the community with 3 employees trained in this area. Staff meeting scheduled for 05/19/2022 will include an agenda topic to remind all staff of the importance to report any resident change in condition immediately to their supervisor so that the UAI/ISP can be updated in a timely manner. 3. The RDON will be responsible for the monitoring of this preventative measure and will report any areas of ongoing noncompliance to the AA. 4. This corrective action will be fully implemented by June 30, 2022.
22VAC40-73-290-A
Based upon documentation and an interview, the facility failed to ensure a work schedule was maintained that included all substitutions and changes.
Evidence
  1. The staff schedule for April 2022 did not indicate substitutions for the 6:00 am to 2:00 pm shift on 4/1, 4/4, 4/5, 4/12, 4/20; for the 10:00 pm to 6:00 am shift on 4/23, 4/24 and 4/28.
  2. The May 2022 schedule did not indicate substitutions for the 6:00 am to 2:00 pm shift on 5/2 through 5/5; 10:00 pm to 6:00 am shift on 5/1 and 5/2.
  3. On 5/9/2022, the licensing inspector (LI) interviewed the administrator who stated the changes were not added to the staff schedule.
Plan of correction
1. Acting Administrator (AA) and Regional Director of Nursing (RDON) reviewed 22VAC40-73-290 to review all elements of compliance. April and May staffing calendar was reviewed by both AA and RDON and updated to indicate substitutions for the dates and shifts indicated on the violation notice. 2. Beginning 05/13/2022, RDON will report weekly to AA all schedule changes and substitutions for the previous week and AA will update and maintain an accurate and complete schedule to be kept in the compliance binder. 3. RDON and AA are responsible for the implementation and monitoring of this corrective action. 4. This corrective action will be fully implemented by May 16, 2022.
22VAC40-73-990-C
Based upon record reviews and an interview, the facility failed to ensure resident emergency procedures were reviewed with all staff at least once every six months.
Evidence
  1. The only documented review on file for resident emergencies was completed on 2/17/2022.
  2. On 5/10/2022, the LI interviewed the administrator who stated the training on 2/17/2022 was the only training she could find for resident emergencies in the past year.
Plan of correction
1. Interim Administrator (IM), Wency Chapnkem, identified this area of noncompliance in February and provided training on February 17, 2022. 2. AA to create a list of all training due dates to be reviewed monthly and scheduled in a timely manner to ensure compliance with this standard. Staff will be required to sign off on the training and a copy of this form will be kept in the compliance binder in AA's office. 3. AA is responsible for the implementation and monitoring of this corrective action. 4. This corrective action will be fully implemented by May 27, 2022.
22VAC40-73-410-A
Based upon record reviews and an interview, the facility failed to ensure four of the six resident records reviewed had signed documentation by the resident that resident orientation was completed.
Evidence
  1. Residents 1, 5 and 6 had no documentation of orientation completion and the resident orientation form was not on file.
  2. Resident 2 had resident orientation form on file and completed; however, the family member instead of the resident had signed the form.
  3. On 5/9/2022, the LI interviewed the administrator who stated the resident orientation forms were not in the residents' records and the family member instead of the resident had signed the form for resident 2.
Plan of correction
1. AA and RDON met on 05/13/2022 and discussed the possibility that the missing resident orientations may have been thinned last month and placed in storage. AA to pull the thinned charts to see if this is the case. If not, RDON will meet with residents to review the resident orientation form and collect signature. AA met with resident 2 to review her orientation and obtain signature on 05/09/2022. All active resident charts will be reviewed for compliance. 2. Upon admission, the AA, RDON or charge person will review the orientation form and obtain signature from the resident. The RDON will review the orientation form for accuracy and file in the resident folder. AA is creating a quality assurance form to routinely review records for accuracy and this element will be added to the form. 3. The RDON will be responsible for the monitoring of this preventative measure and will report any areas of ongoing noncompliance to the AA. 4. This corrective action will be fully implemented by June 10, 2022
22VAC40-73-650-B
Based upon documentation and an interview, the facility failed to ensure one of two residents' physicians' orders reviewed included a diagnosis for each medication.
Evidence
  1. The physician's orders (signed 4/15/2022) for resident 2 did not include a diagnosis for twelve of thirteen medications.
  2. On 5/9/2022, the LI interviewed the nurse on duty who stated the physician had not indicated a diagnosis on the orders and the facility had not requested the diagnoses for the medications.
Plan of correction
1. RDON contacted physician on 05/10/2022 to obtain diagnosis for the 12 medications identified for resident 2. RDON will conduct a review of the physician orders for all active residents to ensure compliance with this standard. 2. AA will review the physician orders for all new admissions to ensure compliance with this standard prior to admission. RDON will provide a second review upon admission to the community. 3. RDON and AA are responsible for the implementation and monitoring of this corrective action. 4. This corrective action will be fully implemented by June 30, 2022.
22VAC40-73-640-D
Based upon observation and interviews, the facility failed to ensure at least one pharmacy reference book, drug guide or medication handbook for nurses was readily accessible.
Evidence
  1. On 5/10/2022, the LI conducted a medication cart audit and requested staff 2 show her the drug reference book. Staff 2 stated the book was supposed to be in the medication cart; however, upon checking the cart there was no book found. Staff 2 and the administrator also checked the record/medication room and neither could find a drug reference book.
Plan of correction
1. AA contacted pharmacy on 05/09/2022 and two drug reference books were delivered that evening. One will be kept in the medication cart and the other is in the AA's office. Staff meeting scheduled for 05/19/2022 will include an agenda topic to remind RMA’s that this is a required element in the medication cart and RDON should be notified immediately if it is found to be missing. 2. WC and RDON will include this element as part of their scheduled audits of the medication cart. 3. WC and RDON are responsible for the implementation and monitoring of this corrective action and will report any areas of ongoing noncompliance to the AA. 4. This corrective action will be fully implemented by May 19, 2022.
22VAC40-73-970-A
Based upon documentation, the facility failed to ensure fire drills were conducted each shift in a quarter.
Evidence
  1. The fire drill forms indicated fire drills on the 6:00 am to 2:00 pm shift were held 3/24/2021, 6/24/2021, 12/27/2021, 1/13/2022 and 4/26/2022.
  2. The fire drill forms indicated fire drills on the 2:00 pm to 10:00 pm shift were held 4/29/2021, 5/26/2021, 7/28/2021, 8/31/2021, 9/22/2021, 10/29/2021, 11/15/2021 and 2/14/2022.
  3. The fire drill forms indicated fire drills on the 10:00 pm to 6:00 am shift were held 2/26/2021 and 3/25/2022.
Plan of correction
1. AA was made aware of this issue in January 2022 by MD and corrective action was taken at that time. January fire drill was performed on first shift, February on second shift, March on third shift and April on first shift. The fire drill for May is scheduled for second shift during week of 05/23/2022. 2. No new measures are warranted at this time as corrective action was implemented in January 2022 and records indicate that we are in compliance since that time. 3. MD is responsible for the implementation and monitoring of this corrective action and will report any areas of ongoing noncompliance to the AA. 4. This corrective action will be fully implemented by May 16, 2022.
22VAC40-73-860-G
Based upon observations and interviews, the facility failed to ensure the hot water temperature remained between 105 to 120 degrees Fahrenheit (F).
Evidence
  1. On 5/9/2022, the LI conducted interviews with residents 1 and 2 and both residents stated the water temperature was fine, that it gets hot but they can adjust it.
  2. On 5/9/2022, the LI tested the hot water temperature in the bathroom sink of room N-8 and the temperature reached 124.9 degrees F.
Plan of correction
1. On 05/09/2022, AA contacted Maintenance Director (MD) to check the water temperature and adjust accordingly. Maintenance schedule indicates that April 2022 reading was 110 degrees. MD reported on 05/10/2022 that he took two readings (one in the back of the building and one in the front) measuring 117 and 119 degrees. Temperature was turned down 2 degrees and reads 114 and 116 degrees on 05/13/2022. 2. Weekly readings to be obtained by MD for the next month. If all readings remain below 120, then community will return to monthly temperature measurements. 3. MD is responsible for the implementation and monitoring of this corrective action and will report any areas of ongoing noncompliance to the AA. 4. This corrective action will be fully implemented by May 16, 2022.
22VAC40-73-680-E
Based upon observations, documentation and an interview, the facility failed to ensure one of two residents' treatments were administered as ordered.
Evidence
  1. On 5/9/2022, the LI conducted medication administration observations with staff 2 for resident 2. During the medication pass, staff 2 stated she could not find the Triamcinolone Acetonide cream for resident 2 in the medication or treatment cart and she stated, "It was almost empty yesterday so staff must have thrown it away." Staff 2 did not apply the cream to resident 2.
  2. Resident 2 (admitted 4/24/2022) had a physician's order (signed 4/14/2022) for Triamcinolone Acetonide topical cream apply a thin layer twice a day to affected area.
  3. The April and May MAR listed "Triamcinolone Acetonide 0.1% crm jar, apply a thin layer to the affected area(s) 2 times daily starting 4/25/2022." The times listed were 9:00 am and 4:00 pm.
  4. The April medication administration record (MAR) was initialed and circled for 4:00 pm on 4/26/2022; 9:00 am and 4:00 pm on 4/27/2022 and 4/28/2022; 9:00 am on 4/29/2022 and 4/30/2022. The omission notes listed were: "Physically unable to take. Not here from pharmacy yet. Not on the cart. Waiting for medication."
  5. On 5/9/2022, the LI interviewed the nurse on duty who stated the cream was not on site but had been ordered and would be delivered in the evening.
Plan of correction
1. On 05/09/2022, the treatment was ordered and delivered by the pharmacy that evening. MARs was reviewed by AA and RMA on duty on 05/13/2022 and confirmed that resident has been receiving treatment as ordered. 2. Wellness Coordinator will be conducting weekly audits of the medication administration records to ensure proper administration of both medications and treatments. RDON will be notified immediately of any noncompliance. RDON will review medication cart every other week for compliance. AA is scheduled to begin RMA training on 07/11/2022. 3. Wellness Coordinator, RDON and AA are responsible for the implementation and monitoring of this corrective action. 4. This corrective action will be fully implemented by May 16, 2022.
March 14, 2022Inspection0 violations
Inspection dates
03/14/2022
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION
Technical assistance
Discussed and recommended including the first aid and cardiopulmonary resuscitation certification on the staff schedule.
Comments
An unannounced monitoring inspection was conducted on 3/14/2022 from approximately 9:44 am to 12:05 pm to follow up on previous violations related to staff training. Eleven staff records and all staff schedules (since the last inspection) were reviewed. Staff interviews were also conducted. Based upon documentation as well as interviews, there were no violations as a result of this inspection.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
February 18, 2022Complaint survey0 violations
Inspection dates
02/18/2022
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDING AND GROUNDS
Comments
The licensing inspector for Royal Care at Birch Ridge conducted an unannounced complaint inspection in response to a complaint that was received by the licensing office on 2/16/2022. Interviews were conducted with residents and staff relating to the allegation of exploitation and neglect. The information gathered during the investigation does not support the allegation, so the complaint is determined to be "not valid." There are no violations resulting from this complaint investigation. If you have any questions, contact your licensing inspector at (540) 430-9258.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
January 31, 2022Complaint survey4 violations
Inspection dates
01/31/2022, 02/01/2022
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Technical assistance
Licensing inspector conducted a condensed review of most of the standards and answered questions of the assistant administrator. Reminded assistant administrator that a copy of the direct care/nurses aide, etc. certificate must be on file even if they have the registered medication aide certificate. Both qualifications must be on file in each staff record.
Comments
The licensing inspector conducted an unannounced complaint inspection in response to a complaint that was received by the licensing office on 1/10/2022. Interviews were conducted with residents and staff related to allegations of insufficient resident care and staff not having the required training. Staff records and schedules were reviewed. The information gathered during the investigation supports the allegation of staff not having the required training, so the complaint is valid. The investigation, however, did not support the allegation of insufficient resident care. Please complete the columns for "description of action to be taken" and "date to be corrected" for each violation cited on the violation notice, and then return a signed and dated copy to the licensing office within 10 calendar days of receipt. If you have any questions, contact your licensing inspector at (540) 430-9258.
Violations
22VAC40-73-260-A
Based upon record reviews and interviews, the facility failed to ensure nine of 18 staff had current first aid certification.
Evidence
  1. The following staff had no documentation of first aid training on file: 1 (hired 10/26/2021), 2 (hired 7/26/2021), 3 (hired 10/29/2021), 4 (9/15/2021), 5 (hired 11/10/2021), 8 (hired 5/22/2021), 9 (hired 8/21/2021, 16 (hired 2/11/2021) and 17 (hired 11/5/2021).
  2. On 1/31/2022, the LI interviewed the AA who stated she could not find first aid certifications on these staff.
  3. On 2/4/2022, the LI interviewed staff 4 who stated she had first aid training; however, it expired in January.
  4. According to the staff schedules, on the following days there were no staff on duty with first aid certification: 12/4/2021, 12/5/2021, 12/8/2021, 12/10/2021, 12/16/2021, 12/21/2021, 12/30/2021, 1/1/2022, 1/2/2022, 1/6/2022, 1/10/2022, 1/11/2022, 1/12/2022, 1/19/2022, 1/22/2022, 1/23/2022 and 1/28/2022 on the 6:00 am to 2:00 pm shift; 12/2/2021, 12/7/2021, 12/11/2021, 12/12/2021, 12/24/2021, 1/8/2022, 1/12/2022, 1/13/2022, 1/19/2022, 1/22/2022, 1/23/2022 and 1/28/2022 for the 2:00 pm to 10:00 pm shift; 12/6/2021, 12/7/2021, 12/10/2021, 12/13/2021, 12/14/2021, 12/16/2021, 12/17/2021, 12/20/2021, 12/21/2021, 12/24/2021, 12/27/2021, 12/28/2021, 1/3/2022, 1/4/2022, 1/5/2022, 1/7/2022, 1/8/2022, 1/9/2022 through 1/13/2022, 1/15/2022 through 1/18/2022, 1/20/2022, 1/24/2022 and 1/27/2022 on the 10:00 pm to 6:00 am shift.
Plan of correction
The ED to conduct 100% audit on all current staff records to ensure first aid certification is obtained prior to employment. The ED will schedule first aid trainings for staff who need initial certification and/or recertification. The first aid training is scheduled for February 8, 2022. The AA will monitor new hires and enroll those without certification into a class within 30 days of hire date. The ED will develop a system to ensure that first aid certifications are current and that re-certifications are obtained prior to expiration. The AA will create an excel spreadsheet to document the expiration date for first aid certification, this spreadsheet will also be shared with the WC on a quarterly basis. The AA and WC will review this spreadsheet quarterly to identify all employees in need of recertification. The AA and WC will perform audits on at least 25% of employee files quarterly to verify compliance with this corrective action. The ED will be responsible for implementing and monitoring the corrective action.
22VAC40-73-260-B
Based upon record reviews and interviews, the facility failed to ensure at least one staff person on duty had current certification in cardiopulmonary resuscitation (CPR).
Evidence
  1. The following staff did not have certification in CPR: 2, 3, 4, 5, 6, 7, 8, 9, 12, 14, 15, 16, and 17.
  2. According to the staff schedules for December 2021 and January 2022, on the following dates there were no staff with current certification in CPR: 1/1/2022, 1/2/2022, 1/22/2022, 1/23/2022, 1/28/2022 on the 6:00 am to 2:00 pm shift; 12/2/2021, 12/7/2021, 12/11/2021, 12/12/2021, 12/26/2021, 1/8/2022, 1/12/2022, 1/13/2022, 1/19/2022, 1/22/2022, 1/23/2022 and 1/28/2022 on the 2:00 pm to 10:00 pm shift; 12/6/2021, 12/7/2021, 12/10/2021, 12/13/2021, 12/14/2021, 12/16/2021, 12/17/2021, 12/20/2021, 12/21/2021, 12/24/2021, 12/27/2021, 12/28/2021, 1/3/2022, 1/5/2022, 1/7/2022, 1/9/2022 through 1/13/2022, 1/17/2022 1/18/2022, 1/20/2022, 1/24/2022 and 1/27/2022 on the 10:00 pm to 6:00 am shift.
  3. On 1/31/2022, the licensing inspector (LI) interviewed the assistant administrator (AA) who confirmed there were no staff on duty during these times that had current certification in CPR.
Plan of correction
The executive director (ED) and AA will conduct 100% audit on all current staff records to identify employees in need of initial certification or recertification. The AA will schedule CPR training for staff to obtain initial certification or re-certification. The AA will develop a system to ensure that CPR certifications are current and that re-certifications are obtained prior to expiration. The AA will create a spreadsheet with CPR expiration dates and share with the wellness coordinator (WC) on a monthly basis. The WC will be responsible for notifying staff when certification needs to be renewed and the AA will schedule renewal classes. The WC will be responsible for ensuring that at least one CPR certified staff member is always on duty. CPR certified staff will be identified on the monthly schedule with an asterisk to indicate current certification. The ED and AA will perform audits on at least 25% of the employee files quarterly to verify compliance with this corrective action. The AA will also review the staffing calendar with the WC monthly to ensure compliance. The AA and ED will be responsible for implementing and monitoring the corrective action.
22VAC40-73-120-A
Based upon documentation and interviews, the facility failed to ensure 13 of 18 staff completed or had documentation of completion of orientation within the first seven working days of employment.
Evidence
  1. The following staff had no documentation of orientation completion in their staff records: Staff 1 (hired 10/26/2021), 3 (hired 10/29/2021), 4 (hired 9/15/2021), 5 (hired 11/10/2021), 6 (hired 11/22/2021), 7 (hired 12/1/2021), 11 (hired 12/21/2021), 12 (hired 11/30/2021), 13 (hired 10/26/2021), 14 (hired 11/19/2021), 15 (hired 10/20/2021), 16 (hired 2/11/2021) and 18 (hired 2/1/2021).
  2. On 1/31/2022, the LI interviewed staff 8 and 10 and both stated they were oriented to the floor; however, they were not oriented to the policies.
  3. On 2/1/2022, the LI interviewed staff 18 who stated, "Staff were oriented but paperwork was not done as time was spent working the floor."
  4. On 2/1/2022, the AA stated the documentation of orientation completion for the staff was not in the staff records and could not be found.
  5. On 2/4/2022, the LI conducted a telephone interview with staff 4 who stated she was oriented to all of the areas required; however, there was no documentation of the orientation on file.
Plan of correction
The ED and AA to conduct 100% audit on all current staff to ensure all orientation documentation is completed. AA and WC will ensure all staff complete the orientation process, including knowledge of assisted living facility (ALF) policies, as evidenced by completion of all elements on the model orientation form, initials of instructor and signature of employee, that orientation has been completed. The AA will notify the WC of any new hire. The WC will be responsible for conducting the orientation process and report to the AA any employee who has not completed the orientation process within the seven day timeframe. Any employee who fails to complete the orientation process by day seven will be pulled from the schedule until such time that orientation is complete. The AA and WC will perform audits on at least 25% of employee files quarterly to verify compliance with this corrective action. The ED will be responsible for implementing and monitoring the corrective action.
22VAC40-73-200-C
Based upon documentation and an interview, the facility failed to ensure one of 18 staff records reviewed had documentation of completion of direct care aide (DCA) training within 60 days of hire.
Evidence
  1. Staff 9 (hired 8/21/2021) had no documentation of direct care aide training completion or any other direct care certification training on file.
  2. On 2/4/2022, the LI interviewed staff 9 who stated, "I was in line to complete the class but with the administrative changes I never was able to get into a class as I didn't know when they were available."
Plan of correction
The ED to conduct 100% audit on all staff records to ensure direct care aide (DCA) training was completed within 60 days of hire. The ED will enroll staff 9 in the DCA program. The WC will be responsible to enroll new hires without certification into the DCA program within 30 days of date of hire and report to the ED when the class has been scheduled. Any staff who has failed to complete the DCA program within 60 days of hire will be removed from the schedule until the class is completed. The AA and WC will perform an audit on 25% of employee files quarterly to verify compliance with DCA training. The ED will be responsible for implementing and monitoring the corrective action.
January 31, 2022Complaint survey0 violations
Inspection dates
01/31/2022
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 BUILDING AND GROUNDS
Comments
The licensing inspector for Royal Care at Birch ridge conducted an unannounced complaint inspection in response to a complaint that was received by the licensing office on 12/28/2021. Interviews were conducted with residents and staff relating to the allegation of staff conduct and broken equipment. The information gathered during the investigation does not support the allegations, so the complaint is determined to be "not valid." There are no violations resulting from this complaint investigation. If you have any questions, contact your licensing inspector at (540) 430-9258.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
November 1, 2021Inspection0 violations
Inspection dates
11/01/2021, 11/02/2021, 11/03/2021
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Technical assistance
Ensure staff are completing frequent audits of the medication/treatment administration records to ensure proper medication administration protocols and documentation (such as as needed medications, etc.) continue to be followed.
Comments
A non-mandated monitoring inspection was initiated on 11/1/2021 and concluded on 11/3/2021. A follow up inspection was conducted as a result of a medication administration violation from a previous self-reported investigation. The acting administrator was contacted by telephone to conduct the inspection. The licensing inspector emailed the acting administrator a list of documentation required to complete the inspection. The licensing inspector conducted a virtual inspection on 11/1/2021 and 11/3/2021. The information gathered during the inspection determined no violations with applicable standards or law from the previous inspection. No violations were issue.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
September 22, 2021Inspection1 violation
Inspection dates
09/22/2021, 09/23/2021
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Technical assistance
Conduct regular in-services on the importance of ensuring the five rights of medication administration and always completing one resident's medication administration before moving on to the next. Also, conduct regular medication administration observations with all staff who administer medications and document the observations in the staff records.
Comments
A non-mandated self-report inspection was initiated on 9/22/2021 and concluded on 9/23/2021. A self-report was received by the department regarding allegations in the area of resident care and related services. 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 a violation was issued. Any violations related to the self-report can be found on the violation notice.
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 9/5/2021 stated on 9/4/2021 at 5:06 pm, staff 1 administered resident 1 the scheduled 4:00 pm medications along with Buspirone 10mg, Eliquis 2.6mg, Gabapentin 100mg, Metoprolol Tartrate 25mg and Senna Docusate 8.6-50, which were for resident 2.
  2. The signed physician's orders for resident 1 for 4:00 pm included Cyclopentolate 1% eye drops, Ipratropium 0.06% nasal spray, Vitamin C, Warfarin Sodium 2mg and Warfarin Sodium 3mg. 3.The September medication administration record (MAR) for resident 1 listed the 4:00 pm medications as Cyclopentolate eye drops, Ipratropium 0.06% nasal spray, Vitamin C, Warfarin Sodium 2mg and Warfarin Sodium 3mg.
  3. The September MAR for resident 2 listed the 4:00 pm medications as Buspirone 10mg, Eliquis 2.5mg, Gabapentin 100mg, Metroprolol Tartrate 25mg and Senna Docusate 8.6-50.
  4. On 9/23/2021, the licensing inspector (LI) interviewed staff 1 who stated she prepared the medications for resident 2 and then resident 1 came and she set the medication cup for resident 2 aside and pulled the medications for resident 1. She stated she then mistakenly placed resident 1's medications into the cup that had the medications already prepared for resident 2 and administered them all to resident 1. 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."
  5. Page 8, letter E of the current medication aide curriculum states, "Meidcation aides may not pre-pour medications for anyone (self included).
Plan of correction
1. Registered medication aide (RMA) will complete med refresher training class by 10/18/2021. 2. Wellness coordinator will conduct weekly observation of medication pass by RMA and complete a performance sheet, for a duration of 60 days. 3. RMA will review with wellness coordinator the company med plan policy by 10/18/2021. 4. A monthly performance assessment will be conducted by executive director and wellness coordinator following 60 days, for a time period of four months. 5. Wellness coordinator will conduct a meeting with all RMAs to review company med plan policy by 10/18/2021. 6. Wellness coordinator will conduct a quarterly medication observations pass with all RMAs.
February 11, 2021Inspection4 violations
Inspection dates
Feb. 11, 2021 , Feb. 16, 2021 and Feb. 17, 2021
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS63.2 General Provisions63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS
Technical assistance
Answered questions and discussed the following with the administrator: 1) Recommended having the email registered with the state police include the administrator's title rather than the administrator's name. 2) Ensure each blank of the orientation form is initialed and dated rather than drawing a line through them and only initialing and signing the first blank. 3) Reviewed the leniency issued (due to the COVID-19 pandemic) for first aid training. 4) The written assurance must be signed by the resident or legal representative and a copy kept on file. 5) Recommended an audit be conducted of all resident records to ensure all paperwork is completed and on file. 6) Only check "medications administered by lay persons" on the uniform assessment instrument when medication aides administer medications. Staff were checking this section as well as by licensed professionals since they have a part time nurse. 7) Once the new administrator completes the medication aide training, please forward the documentation to this inspector.
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 2/11/21 and concluded on 2/17/21. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 16. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed two resident and two staff records. activities calendar, menu, staff schedules, fire drills, medication administration records, physicians' orders, medication pharmacy reviews, dietitian's reviews, health care oversights, as well as other documents to ensure documentation was complete. Selected sections of seven resident, six staff and two contract staff records were also reviewed. A virtual inspection and tour were also conducted. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations were documented on the violation notice issued to the facility.
Violations
22VAC40-73-260-A
Based upon record reviews and an interview, the facility failed to ensure one of three staff completed first aid certification within the required timeframe.
Evidence
  1. Staff B (hired 7/18/20) did not have any documentation on file for completion of first aid training.
  2. On 2/17/21, the licensing inspector (LI) interviewed the administrator who stated staff B had not completed first aid training.
Plan of correction
New administrator has been in communication with a trainer and is in the process of scheduling a cardiopulmonary resuscitation (CPR)/first aid class for staff. Staff B will have her certification completed by 3/19/21. New administrator will ensure all new employees obtain their CPR/first aid certification within the first 60 days (and 90 days during the COVID-19 pandemic). New administrator will maintain a tickler file and will check it the first of each month to ensure compliance.
22VAC40-73-310-D
Based upon documentation and an interview, the facility failed to ensure four of the eight resident records reviewed had a signed written assurance on file.
Evidence
  1. The written assurances on file for resident A (admitted 9/28/20) and D (admitted 2/4/21) were not signed by the residents or their legal representatives; resident C (admitted 6/29/20) and I (admitted 6/29/20) did not have a copy of a written assurance on file.
  2. On 2/17/21, the LI interviewed the administrator who stated the written assurances were not completed as required.
Plan of correction
New administrator will audit all resident financial files to ensure a written assurance was given and obtain, if needed, signatures by the resident and/or power of attorney by 3/19/2021. Resident D signed the assurance on 2/17/2021. Resident assurances will be signed by resident A and C by 2/25/2021. New administrator will develop a new resident checklist to include the written assurance and will review the checklist prior to each resident's admission to ensure compliance.
22VAC40-73-350-A
Evidence
  1. On 2/17/21, the LI interviewed the administrator who stated she had not reregistered with the Virginia State Police since she was hired (12/28/20). The email address for the facility registration uses the name of the administrator rather than the position title.
Plan of correction
New administrator is now currently registered to receive such notifications. Upon any change of administrator, the current administrator will notify the facility's director of operations that the new administrator needs to register with the state police to receive the sex offender notifications. The current administrator will copy the licensing inspector on this notification.
22VAC40-73-350-B
Based upon record reviews and an interview, the facility failed to ensure three of the seven resident records reviewed had a sex offender registry check completed prior to admission.
Evidence
  1. There was no sex offender registry check on file for resident E (admitted 9/2/20).
  2. Resident A (admitted 9/28/20) had a sex offender registry checked completed on 11/16/20 and resident F (admitted 9/19/20) had one completed on 9/21/20.
  3. On 2/16/21, the LI interviewed the administrator and she stated the above sex offender checks were not completed prior to the residents' admission.
Plan of correction
New administrator will audit all resident files to ensure all sex offender checks have been completed and if not, obtain for the resident files by 3/19/2021. Resident E's sex offender check was obtained on 2/17/2021. New administrator will develop a new resident checklist to include the sex offender registry and will review the checklist prior to residents admission to ensure compliance.
November 6, 2020Complaint survey0 violations
Inspection dates
Nov. 6, 2020 and Jan. 27, 2021
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS
Comments
This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A complaint inspection was initiated on 11/6/20 and concluded on 1/27/21. A complaint was received by the department on 11/6/20 regarding an allegation in the area of resident care. The administrator was contacted by telephone to conduct the investigation. The evidence gathered during the investigation did not support the allegation of non-compliance with standards or law.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.