Virginia DSS · Assisted Living Facility

Birch Gardens

📍 12 Royal Drive, Staunton, VA, 24401

ID 45360Two Year licenseActive
25
Inspections
On record
18
With violations
Visits that cited something
7
Clean visits
Nothing cited
80
Violations cited
Individual findings
47
Standards cited
Distinct rules
13
Complaint visits
Prompted by a complaint

Birch Gardens was inspected 25 times between February 1, 2021 and February 25, 2026 by the Virginia Department of Social Services. 18 of those visits ended with violations cited and 7 with none. Across that history VDSS cited 80 violations under 47 distinct standards. 13 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. 24 of these 25 are still on the state's site; the other 1 has since dropped off it and is reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type
Assisted Living Facility
License type
Two Year
License expires
02/25/2026
Administrator
Rachel Craig
Licensing inspector
Angela Via
Inspector phone
(540) 682-1739
Approved for
Assisted Living · Non-Ambulatory

Inspection History

25

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

February 25, 2026Inspection10 violations
Inspection dates
02/25/2026
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 25, 2026, from 10:30 a.m. until 4:30 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 37 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 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
22VAC40-73-870-A
Based on direct observation and staff interview, the facility failed to ensure that the interior of the building was maintained in good repair.
Evidence
  1. During the facility tour on 02/25/2026 LI observed approximately 47 gaps in the flooring throughout the hallways leading from resident rooms into the common areas and dining room of the facility posing a risk for possible tripping hazards and resident falls.
  2. Staff 5 acknowledge the presence of gaps in the floor and that the areas could pose a risk for tripping. Staff 5 acknowledged gaps in floor do not meet the standard of maintaining the building in good repair.
  3. During the facility tour on 02/25/2026, LI observed missing cabinet doors and drawer faces in the kitchen.
  4. Staff 5 acknowledge the absence of some of the cabinet doors and drawer faces in the kitchen and confirmed that it does not meet the standard of maintaining the building in good repair.
  5. Photo evidence taken.
Plan of correction
ED and WC are working with maintenance to ensure the flooring is repaired or replaced and does not pose a risk to residents. Maintenance repaired kitchen cabinet and doors. Completed 3/4/2026
22VAC40-73-680-G
Based on direct observation and staff interview, the facility failed to ensure that over-the-counter medications were labeled with the resident's name.
Evidence
  1. During medication cart audit on 02/25/2026, LI found an unlabeled bottle of extra strength Tylenol rapid release 500 mg gel tablets in the medication cart.
  2. During an interview with LI on 02/25/2026, staff 5 confirmed that the Tylenol was unlabeled.
  3. Photo evidence taken.
Plan of correction
ED and WC will ensure all over the counter medications are labeled and dated on arrival, through teachings to RMA's and monthly med cart audits.
22VAC40-73-450-C
Based on resident record review and staff interviews, the facility failed to ensure the comprehensive individualized service plan (ISP) included a written description of what services would be provided to address identified needs, and if applicable, other services, and who would provide them.
Evidence
  1. Comprehensive ISP for resident 4, admit date 03/09/2022, did not include bed rails.
  2. During an interview with LI on 02/25/2026, staff 4 and 5 acknowledged that ISP dated 06/09/2025 in resident 4’s record did not include bedrails.
Plan of correction
ED and WC will ensure ISP include written descriptions of what services will be provided to address identified needs.
22VAC40-73-260-A
Based on staff record review and staff interview, the facility failed to ensure staff completed first aid (FA) certification within 60 days of hire.
Evidence
  1. Staff 1, hire date 09/11/2025, had not completed FA training as of the date of inspection on 02/25/2026, which was not within 60 days of hire.
  2. During an interview with licensing inspector (LI) on 02/25/2026, staff 5 confirmed FA training for staff 1 did not occur within 60 days of employment.
Plan of correction
ED and WC will ensure all staff have first- aid certification within 60 days of hire.
22VAC40-73-350-B
Based on resident record review and staff interview, 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 12/29/2025, contained a registered sex offender search dated 12/30/2025, which was after the day of admission.
  2. During an interview with the LI on 02/25/2026, staff 5 confirmed the registered sex offender search for resident 2 was not completed prior to admission.
Plan of correction
ED and WC will ensure new admissions sex offender registry is completed prior to or on admission.
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.
Evidence
  1. The admission date for resident 1 was 10/04/2025. The date of the face-to-face physical examination for resident 1 was 08/25/2025, which was not within 30 days preceding admission.
  2. Staff 4 and 5 acknowledged that the physical examination report for resident 1 was not completed according to the standard.
Plan of correction
ED and WC will ensure physical examinations are completed within 30 days of time the examination is completed.
22VAC40-73-640-A
Based on resident record review and staff interview, the facility failed to implement a written plan for medication management that addressed procedures for administering medication, including methods to prevent the use of outdated medications.
Evidence
  1. During a medication cart audit on 02/25/2026, LI found calcium with vitamin D3 40 mcg (1600 IU) that expired 08/2023.
  2. During an interview with LI on 02/25/2026, staff 5 confirmed that the calcium with vitamin D3 was expired.
  3. Photo evidence taken.
Plan of correction
ED and WC will ensure expired medications are discarded by providing monthly cart audits.
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 02/25/2026, the LI observed the semiannual review of emergency preparedness with staff only occurred once in 2025.
  3. Staff 5 confirmed the reviewed emergency preparedness and response trainings only occurred once on 06/04/2025 with staff, not twice as required with staff, residents, and volunteers.
Plan of correction
ED and WC will ensure all staff review the emergency preparedness plan twice a year.
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. During medication observation on 02/25/2026, staff 6 administered Systane eye drops to the right eye of resident 8.
  2. The physician’s order and MAR (Medication Administration Record) for resident 8 indicated to administer Systane eye drops to left eye two times a day.
  3. During an interview with LI on 02/25/2026, staff 6 was asked which eye resident 8 should receive the Systane eye drops in. Staff 6 confirmed the left eye. LI asked staff 6 which eye of resident 8 the drop was administered in during the medication pass. Staff 6 confirmed drop was given in right eye instead of left as required by the physician’s order.
Plan of correction
ED and WC will provide training with RMA's on following Dr orders and instructions to ensure medications are being administered properly.
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 02/25/2026, LI requested documentation of practice exercises for resident emergencies.
  2. During document review on 02/25/2026, LI observed the semiannual review of resident emergencies only occurred once in 2025.
  3. Staff 5 confirmed the review of resident emergencies only occurred once on 06/11/2025 with staff, not semi-annually as required.
Plan of correction
ED and WC will ensure every 6 months staff will participate in an exercise for resident emergencies are practiced.
November 6, 2025Complaint survey4 violations
Inspection dates
11/06/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-80 Complaint Investigation
Comments
Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 10/23/2025 regarding allegations in the area(s) of: RESIDENT CARE AND RELATED SERVICES BUILDINGS AND GROUND Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: November 6, 2025, from 11:30 a.m. until 2:15 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: 33 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: 8 Number of interviews conducted with staff: 6 Observations by licensing inspector: Licensing inspector toured facility, including some resident rooms, and interviewed some staff and residents. 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 Angela Via, Licensing Inspector at (540) 682-1739 or by email at Angela.Via@dss.virginia.gov
Violations
22VAC40-73-870-D
Based on direct observation and staff interviews, the facility failed to ensure building was kept free of infestations of insects.
Evidence
  1. A complaint received by the regional licensing office on 10/23/2025 alleged that “gnats through the building were bad”, which included the kitchen area.
  2. During a tour of the facility on 11/06/2025, LI observed several gnats in resident 6 and 7’s shared bathroom on the mirror above the sink.
  3. Photo evidence taken.
  4. Resident 7 stated that gnats were so bad last night at dinner that they were landing in the food. Resident 7 stated the gnats have been in the building approximately a month. Resident 7 had expressed concerns regarding gnats to staff 1 and 3. Resident 7 keeps a fly swatter in room to kill the gnats, and LI observed resident kill two gnats.
  5. Staff 4 and 6 acknowledged seeing gnats throughout the building, including the kitchen.
  6. Staff 3 acknowledged seeing gnats for about a week, especially around sink in beauty shop. Staff 3 stated, “one was in my coffee yesterday”.
  7. Staff 1 acknowledged the presence of gnats in the building and stated that Terminix was coming that day. Staff 1 later confirmed that Terminix did not service the facility on the day of inspection but came out on 11/21/2025.
Plan of correction
ED called Terminix, there is no treatment for gnats. Terminix came on 11/21/2025. Terminix did our routine pest prevention. Terminix recommended sitting out a vinegar and dawn solutions. Due to my Memory Care community that could not be done in most areas. Terminix also recommended cleaning sink, and shower drains with bleach solution. Maintenance, housekeeping, and direct care staff have been working together to keep sink drains and shower drains clean and a bleach solution used weekly. Resident 6 and 7 were able to have the vinegar solution in their bedroom.
22VAC40-73-870-A
Based on direct observation and staff interviews, the facility failed to ensure that the interior of building was maintained in good repair.
Evidence
  1. During the facility tour on 11/6/2025 licensing inspector (LI) observed approximately 19 one-inch gaps between the flooring throughout the main hallway leading into the dining room of the facility posing a risk for possible tripping hazards and resident falls.
  2. Staff 1 acknowledge the presence of gaps in the floor and that the areas could pose a risk for tripping. Staff 1 acknowledged gaps in floor does not meet the standard of maintaining the building in good repair. Photo evidence taken.
Plan of correction
ED has put in work orders with maintenance. Maintenance has started repairing 19 one-inch gaps in the common areas leading to the dining room.
22VAC40-73-870-E
Based on direct observation and staff interview, the facility failed to ensure all furnishings were kept clean and in good repair and not soiled in a manner that presents a health hazard.
Evidence
  1. A complaint received by the regional licensing office on 10/23/2025 alleged that “the rooms of the residents are disgusting- body fluids are stuck in carpets.”
  2. During a tour of the facility on 11/06/2025 with staff 1, LI observed a large, circular stain in the middle of the carpet in room of residents 9 and 10. Staff 1 acknowledged that there was area on the carpet that was discolored but said it was due to frequent cleaning. LI asked staff 1 about appearance and smell of carpet and asked about the possibility of replacing. Staff 1 acknowledged that carpet was soiled and not in good repair and needed to be replaced.
  3. During a tour of the facility on 11/06/2025 with staff 1, LI observed feces on the bathroom wall and trim next to commode, in an unlined trash can, and on the shower floor. Staff 1 acknowledged that these areas were soiled with feces and stated that resident 11 takes herself to the bathroom and “that’s what she does”. Staff 1 acknowledged that housekeeping does not clean well.
  4. Photo evidence taken.
Plan of correction
ED educated direct care staff/RMA’s that resident 11 bathroom and bedroom need checked on rounds as resident 11 does take herself to the bathroom at times. Reviewed job duties of direct care staff that resident care includes making sure if they have an accident staff clean up the resident and their bathroom/bedroom area.
22VAC40-73-870-B
Based on direct observation and staff interviews, the facility failed to ensure that building was free from foul, stale, and musty odors.
Evidence
  1. A complaint received by the regional licensing office on 10/23/2025 alleged that “the rooms of the residents are disgusting and smell like urine.”
  2. During a tour of the facility on 11/06/2025 with staff 1, LI detected a stale, musty smell in the shared apartment of residents 9 and 10. Staff 1 acknowledged that there was a smell but stated “it was how resident 9 smelled.” Neither resident was in the room at the time to which staff 1 indicated “he (resident 9) makes it smell this way.”
  3. During a tour of the facility on 11/06/2025 with staff 1, licensing inspector detected a strong smell of feces in the bedroom and bathroom of resident 11. Staff 1 acknowledged that there was a smell of feces in resident 11’s bedroom and bathroom.
Plan of correction
ED moved resident 9 and 10 into room A5. ED educated direct care staff that if the resident 11 have an accident in their room, as their caregiver its your job to clean up the residents bedroom or bathroom area where the accident occurred. 2-hour rounds are in place to take the residents tot eh bathroom to help cut down on accidents.
August 29, 2025Inspection0 violations
Inspection dates
08/29/2025
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES63.2- (16) PROTECTION OF ADULTS AND REPORTING
Comments
Type of inspection: Monitoring A self-reported incident was received by VDSS Division of Licensing on 7/8/2025 regarding allegations in the area(s) of: 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: 8/29/2025 10:00 a.m. - 10:55 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: 35 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 1 Observations by licensing inspector: The licensing inspector reviewed resident records, incident reports, and facility communication logs. 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 self-report of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jessica Gale, Licensing Inspector at 540-571-0358 or by email at Jessica.Gale@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
June 25, 2025Complaint survey3 violations
Inspection dates
06/25/2025
Areas reviewed
22VAC40-73 BUILDINGS AND GROUND22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 6/24/2025 regarding allegations in the area(s) of: Building and Grounds Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 6/25/2025 2:40 p.m. - 3:15 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: 34 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: The licensing inspector toured the inside and outside of the facility including the kitchen and resident rooms. 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: Building and Grounds 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 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-D
Based on direct observation the facility failed to ensure that any operable window (i.e., a window that may be opened) was effectively screened.
Evidence
  1. During the facility tour on 6/25/2025, two licensing staff observed nine operable windows in the dining room, one operable window in the activity room, and 1 operable window in the common area lobby to be without a screen.
  2. Photo evidence taken.
Plan of correction
Maintenance ordered 7 screens in July. We will order the remaining screens in 8/2025. All windows will have screens by September.
22VAC40-73-870-A
Based on direct observation, the facility failed to ensure that the interior of the building was maintained in good repair and kept clean.
Evidence
  1. During the facility tour on 6/25/2025, two licensing staff observed the main facility kitchen with dark brown liquid and food substance dried and splattered and/or dripped on several of the walls and floors throughout the kitchen.
  2. Three cabinet drawers had been removed and left missing in the kitchen as well as two cabinet doors that had been removed.
  3. Photo evidence taken.
Plan of correction
ED advised housekeeping to mop up any spills after breakfast and lunch. ED reminded direct care staff that they need to sweep the dining room after breakfast, lunch and dinner. To mop up any spills. ED is working with maintenance on fixing the cabinets and drawers in the kitchen.
22VAC40-73-870-E
Based on direct observation the facility failed to ensure all furnishings were kept in good repair and condition.
Evidence
  1. During the facility tour on 6/25/2025, two licensing staff observed four (4) out of 12 rocking chairs on the front porch to have broken pegs or a missing arm rest.
  2. Photo evidence taken.
Plan of correction
Maintenance fixed 2 of the four broken rocking chairs. Two were disposed of.
June 2, 2025Inspection14 violations
Inspection dates
06/02/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY63.2- (1) GENERAL PROVISIONS22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 6/2/2025 from 8:45 a.m. to 3:30 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: 34 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 3 Number of interviews conducted with residents: 5 Number of interviews conducted with staff: 3 Observations by licensing inspector: The Licensing Inspector observed the residents during activities and meals. The Licensing Inspector reviewed the following at the time of inspection: fire drills, emergency drills, resident council reports, pharmacy review, healthcare oversight, menus, activity calendars and dietician report. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jessica Gale, Licensing Inspector at (540) 571-0358 or by email at Jessica.Gale@dss.virginia.gov
Violations
22VAC40-73-680-G
Based on direct observation and staff interview the facility failed to ensure that over the-counter medications were labeled with the resident's name, or in a pharmacy-issued container, until administered.
Evidence
  1. During observation of medication administration, the licensing inspector observed a bottle of Tylenol inside of the original packaging that was missing the top of the package and was not labeled with the resident’s name.
  2. During an interview with staff 6, when asked if the medication was labeled with the resident’s name, staff 6 stated “it was labeled on the top, but someone tore it off.”
  3. Photo evidence taken.
Plan of correction
ED and WC did a cart audit and ensured all OTC medications were dated and labeled. ED and WC educated staff on making sure when medications are brought in that they are labeled and dated
22VAC40-73-990-C
Based on record review and staff interview the facility failed to ensure at least once every six months, all staff on duty on each shift participated in an exercise in which the procedures for resident emergencies are practiced.
Evidence
  1. Upon request the facility did not provide any exercises in which the procedures for resident emergencies were practiced.
  2. During an interview with staff 1, when asked if the procedures for resident emergencies were practiced at least once every six months, staff 1 stated “no.”
Plan of correction
ED and WC will ensure all staff participate in an exercise in which the procedures for resident emergencies are practiced.
22VAC40-73-950-E
Based on record review and staff interview the facility failed to implement an orientation and semi-annual review of the emergency preparedness and response plan for all staff, residents, and volunteers, with emphasis placed on an individual's respective responsibilities.
Evidence
  1. Upon request the facility did not provide a review of the emergency preparedness plan with residents or staff.
  2. During an interview with staff 1, when asked if there was a semi-annual review of the emergency preparedness plan completed with residents and staff, staff 1 stated “no”.
Plan of correction
ED and WC will ensure orientation and semi-annual review of the emergency preparedness and response plan for all staff, residents and volunteers.
22VAC40-73-280-A
Based on record review and staff interview the facility failed to have staff adequate in knowledge, skills, and abilities and sufficient in numbers to provide services to attain and maintain the physical, mental, and psychosocial well-being of each resident as determined by resident assessments and individualized service plans.
Evidence
  1. The facility written staffing plan stated on page 78, number 6, “The staffing matrix will be as listed below: “When Birch Gardens Assisted Living has 32 to 39 residents, they will staff 1 Registered Medication Aide (RMA) and 3 Direct Care Aides (DCA) per shift.”
  2. The facility census on the date of the inspection (6/2/2025) was 34.
  3. The staff Schedule for 5/26/2025 through 6/2/2025 showed that out of 21 shifts, 12 shifts were not staffed according to the written staffing plan, with seven out of seven-night shifts having only one RMA and one DCA scheduled.
  4. During an interview with staff 1, when asked what the facility typically staffed per shift, staff 1 indicated two to three DCA’s and one RMA on first and second shift, and one DCA and one RMA on third shift.
Plan of correction
ED changed page 78 to match the current staffing needs to ensure adequate and sufficient care to our residents.
22VAC40-73-710-C
Based on direct observation, record review, and staff interview, the facility failed to ensure if a restraint was used, that it was imposed in accordance with a physician's written order that specified the condition, circumstances, and duration under which the restraint was to be used.
Evidence
  1. During the facility tour on 6/2/2025 two licensing staff observed a half rail in the upright position on an unoccupied bed in resident 2’s apartment.
  2. Record review for resident 2 (admitted 5/2/2023) included a physical exam and report dated 5/1/2023, with a diagnosis of Vascular Dementia listed and a Uniform Assessment Instrument (UAI) dated 11/6/2024 with orientation listed as disoriented all spheres all of the time.
  3. During an interview with staff 1, when asked if there was a physician’s written order for the use of the bed rail, staff 1 stated “no there’s not”, when asked if resident 2 could remove or lower the rails independently when in use, staff 1 stated “no [they] couldn’t.”
Plan of correction
ED removed the bed rail on 6/2/2025. ED and WC will ensure all residents with bed rails have orders. Are able to describe what the bed rail is used for.
22VAC40-73-870-A
Based on direct observation the facility failed to ensure that the interior and exterior of all buildings were maintained in good repair.
Evidence
  1. During the facility tour on 6/2/2025 two licensing staff observed approximately 19 one-inch gaps between the flooring throughout the main hallway leading into the dining room of the facility posing a risk for possible tripping hazards and resident falls.
  2. Photo evidence taken.
Plan of correction
ED contacted the corporate office about the gaps in the flooring. A plan has been put in place to have the flooring repaired and or replaced by 9/2/205.
22VAC40-73-710-D
Based on record review and staff interview the facility failed to ensure whenever physical restraints were used that the facility assisted the resident with the restraint as often as necessary, but no less than 10 minutes every hour, for hydration, safety, comfort, range of motion, exercise, elimination, and other needs.
Evidence
  1. During the facility tour on 6/2/2025 two licensing staff observed a half rail in the upright position on an unoccupied bed in resident 2’s apartment.
  2. During an interview with staff 1, when asked if resident 2 could remove or lower the rails independently when in use, staff 1 stated “no [they] couldn’t.”
  3. When asked if there was documentation of the assistance with hydration, safety, comfort, range of motion, exercise, elimination, and other needs, no less than every 10 minutes every hour, staff 1 stated “no.”
Plan of correction
ED and WC will ensure restraint training to staff is provided and that the residents have documentation of the assistance with hydration, safety, comfort, range of motion, exercise, elimination, and other needs, no less than every 10 minutes every hour.
22VAC40-73-970-E
Based on record review and staff interview, the facility failed to ensure the record of the required fire and emergency evacuation drills were kept in the facility for two years.
Evidence
  1. Review of the records of the fire and emergency evacuation did not include a record for July of 2024 or May of
  3. Upon request the facility did not provide a record for the fire drills completed in July of 2024 or May of
  5. During an interview with staff 1, when asked if there was a fire drill completed in July of 2024 or May of 2025, staff 1 stated “they were done but I can not find the records.”
Plan of correction
ED, WC and maintenance will ensure all fire drills are performed monthly and documented.
63.2-1720-C-2
Based on record review and staff interview, the facility failed to obtain a criminal history record report on or prior to the 30th day of employment for each employee.
Evidence
  1. Record review of all new hires since the last inspection on 2/16/2024 showed that five of 20 employee criminal history record reports were not completed on or prior to the 30th day of employment.
  2. Upon request the facility could not provide a criminal history record report for five of 20 records reviewed.
  3. During an interview with staff 1, when asked if there were criminal history record reports obtained for the five staff, staff 1 stated “I sent them off but never got them back”.
Plan of correction
ED will ensure all staff background checks are received on or prior to the 30th day of hire.
22VAC40-73-450-C
Based on record review the facility failed to ensure that the comprehensive Individualized Service Plan (ISP) included all assessment needs identified on the Uniform Assessment Instrument (UAI)
Evidence
  1. Resident 2 (admitted 5/2/2023) had a UAI dated 11/6/2024 that indicated orientation as disoriented all spheres, all of the time. The ISP for resident 2 dated 11/6/2024 did not include resident 2’s orientation.
Plan of correction
WC updated ISP to include orientation.
22VAC40-73-260-A
Based on record review, the facility failed to ensure each direct care staff member who did not have current certification in first aid had received certification in first aid within 60 days of employment.
Evidence
  1. Staff 2 hired 11/16/2024 as a direct care aide, did not have a current certification in first aid.
  2. Upon request the facility did not provide a certification in first aid for staff 2.
Plan of correction
Not published by VDSS.
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.
Evidence
  1. During the facility tour on 6/2/2025, two licensing staff observed a white board in the resident hallway dated 6/1/2025 with “RMA” and “aides” written on it but no names listed.
  2. Photo evidence taken.
Plan of correction
RMA will ensure at the beginning of shift the RMA and aides are posted on the board. ED and WC will make sure a up to date schedule is also posted under the board.
22VAC40-73-350-B
Based on record review and staff interview, the facility failed to ascertain, prior to admission, whether a potential resident is a registered sex offender.
Evidence
  1. Resident 3 (admitted 11/11/2024) had a sex offender search completed 12/4/2024.
  2. During an interview with staff 1, when asked If the sex offender search was completed prior to admission staff 1 stated “no it wasn’t”.
Plan of correction
Not published by VDSS.
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 6/2/2025, two licensing staff observed the laundry room door unlocked that contained a spray bottle of unlabeled cleaning solution, a jug of Tide laundry detergent, three spray bottles of Pledge wood oil, two containers of cleaner with bleach, three containers of Lysol toilet bowl cleaner, one spray can of Raid insect spray, one spray bottle of glass cleaner and one gallon jug of bleach.
  2. Photo evidence taken.
Plan of correction
ED, WC and all staff will ensure they hit the lock button on the laundry room door when they exit the door.
May 14, 2025Complaint survey0 violations
Inspection dates
05/14/2025
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 SERVICESARTICLE 1 – SUBJECTIVITY63.2- (1) GENERAL PROVISIONS
Comments
Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 5/14/2025 regarding allegations in the area(s) of: 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: 4/14/2025 11:30 a.m - 2:15 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: 34 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 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, in their rooms and in common areas. 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. 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 Jessica Gale, Licensing Inspector at (540) 571-0358 or by email at Jessica.Gale@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
February 28, 2025Inspection0 violations
Inspection dates
02/28/2025
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES63.2 PROTECTION OF ADULTS AND REPORTING
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 2/28/2025 10:40am-11:45am The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-report was received by VDSS Division of Licensing on 1/29/2025 regarding allegations in the areas of: Personnel, resident care and related services, and protection of adults and reporting. Number of residents present at the facility at the beginning of the inspection: The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 1 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 4 Observations by licensing inspector: The Licensing Inspector observed staff and resident interactions, resident rooms, bathrooms, and common areas. Residents were observed during activities and in common areas. 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 self-report of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jessica Gale, Licensing Inspector at 540-571-0358 or by email at Jessica.gale@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
December 12, 2024Complaint survey4 violations
Inspection dates
12/12/2024
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS63.2 PROTECTION OF ADULTS AND REPORTING22VAC40-80 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: 12/12/2024 2:59pm-5:00pm 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 12/10/2024 regarding allegations in the area(s) of: Resident care and related services, staffing, and reporting. Number of residents present at the facility at the beginning of the inspection: 34 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 4 Observations by licensing inspector: The licensing inspector observed residents in common areas and during meals, staff and resident interactions, 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 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. 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) are reviewed and updated at least once every 12 months and as needed for a significant change of a resident’s condition.
Evidence
  1. The Uniform Assessment Instrument for Resident 1 dated 10/22/2024 indicated resident 1 wanders weekly or more.
  2. The ISP for resident 1 dated 10/22/2024, does not include the residents’ wandering behaviors.
  3. When asked if the wandering behaviors are included on the ISP, staff 6 stated “it is not”.
Plan of correction
WC updated ISP to include behaviors of wandering. WC and ED also updated every residents ISP to include wandering of those residents that wander.
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 wandering from the premises.
Evidence
  1. A complaint was received by the regional licensing office on 12/10/2024 alleging resident 1 had eloped from the facility and fallen and obtained an injury and there was no contact made by the facility with family, the physician, or adult protective services.
  2. An incident report was received by the regional licensing office from the facility reporting the same incident as the complaint.
  3. During an interview with staff 1, Staff 1 confirmed that resident 1 wandered out of the facility and was brough back to the facility by an unknown person who found him outside.
  4. When asked if resident 1 had previous wandering behavior, staff 1 stated “yes”.
Plan of correction
ED and WC educated staff on the importance of doing 2 hour rounds. Also educated staff on the importance of doing activities to keep the residents occupied. ED and WC educated staff on the importance of one staff member staying in the common areas at all times.
22VAC40-73-930-D
Based on record review and staff interview, the facility failed to ensure for each resident with an inability to use the signaling device, the inability is included in the resident's individualized service plan.
Evidence
  1. During an interview with staff 2, when asked if resident 1 was able to use the call bell staff 2 stated “I’ve never known him to use the call bell”.
  2. During an interview with staff 6, when asked if resident 1 was able to use the call bell, staff 6 stated “no, I wouldn’t say so”.
  3. The ISP for resident 1 dated 10/22/2024, does not include the residents’ inability to use a signaling device.
Plan of correction
WC and ED updated all ISP of residents that can not use call bell/signaling device.
22VAC40-73-460-F
Based on record review and staff interview, the facility failed to notify the next of kin, legal representative, designated contact person, or, if applicable, any responsible social agency of any incident of a resident falling or wandering from the premises.
Evidence
  1. During the record review on 12/12/2024, there was no documentation of the notification of the next of kin or adult protective services of the incident.
  2. During an interview with staff 5, staff 5 confirmed that they were the supervisor on duty on the date of the incident, and that the next of kin nor APS was notified of the incident.
Plan of correction
ED and WC educated staff on the importance of notifying family/POA or next of kin. Just like a fall any incident needs to be reported to POA and PCP. ED and WC know to notify APS of any elopement
November 21, 2024Complaint survey7 violations
Inspection dates
11/21/2024
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 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: 11/21/2024 12:26pm – 2:42pm 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 11/21/2024 regarding allegations in the area(s) of: Building and grounds, resident care and related services, and medication administration. Number of residents present at the facility at the beginning of the inspection: 32 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Licensing inspector reviewed resident and staff records including the medication administration record. Residents were observed during mealtime and in common areas. 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 allegation(s) area(s) of non-compliance with standard(s) or law were: 670, 680-D, 870-A A violation notice was 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. 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
22VAC40-73-560-E
Based on direct observation the facility failed to ensure resident records are stored in a locked area.
Evidence
  1. During the building and grounds tour the medication room door was observed propped open containing a bookshelf housing the resident records.
  2. Photo evidence taken.
Plan of correction
THE RMA, WD, ED, DCAAND KITCHEN STAFF WILL KEEP MED ROOM DOOR LOCKED AND CLOSED AT ALL TIMES.
22VAC40-73-260-C
Based on record review and staff interview the facility failed to ensure the listing of all staff who have current certification in first aid or CPR is kept up to date.
Evidence
  1. Staff 1 provided a list of all staff who are current in first aid and CPR which included staff 2 on the list.
  2. The facility did not provide the certification of first aid and CPR for staff 2.
  3. When asked if the list was current, staff 1 stated “I guess not because [staff 2] doesn’t have it”
Plan of correction
THE ED AND WC WILL ENSURE A CURRENT CPR/FIRST AID LIST IN POSTED IN THE COMMUNITY.
22VAC40-73-870-A
Based on direct observation the facility failed to ensure the interior of the building be maintained in good repair and kept clean.
Evidence
  1. A complaint was received by the regional licensing office alleging mold growing on the walls of the facility.
  2. During the building and grounds tour on 11/21/2024 a green and black substance was observed on the interior walls of the closet of apartment 18 as well as several areas of baseboard rotting and separating from the walls.
  3. Photo evidence taken.
Plan of correction
ED WILL WORK WITH MAINTENANCE TO TREAT WALLS AND REPLACE BASEBOARDS.
22VAC40-73-860-I
Based on direct observation the facility failed to ensure hazardous materials are stored in a locked area.
Evidence
  1. During the building and grounds tour the following were observed, a.The medication room door was observed propped open containing a jug of drug disposal on the treatment cart. b. The timeclock room door was left fully open containing a container of Clorox disinfecting wipes on the counter. c. The laundry room door was left cracked open containing a container of Clorox wipes, a spray bottle of resolve, and an unlocked closet containing multiple spray bottles of cleaning solution, and three containers of bleach.
  2. Photo evidence taken.
Plan of correction
THE RMA, WD, ED, DCAAND KITCHEN STAFF WILL KEEP MED ROOM DOOR, TIMECLOCK DOOR, LAUNDRY ROOM AND KITCHEN DOORS LOCKED AND CLOSED AT ALL TIMES.
22VAC40-73-260-A
Based on record review and staff interview, the facility failed to ensure each staff member receive certification in first aid within 60 days of employment.
Evidence
  1. The facility did not provide a first aid certification for staff 2 (hired 7/1/2024).
  2. During an interview on 11/21/2024, when asked if staff 2 had a first aid certification, staff 1 stated “I don’t see it”.
Plan of correction
THE WC AND ED WILL ENSURE EVERYONE HAS FIRST AID WITHIN THE FIRST 60 DAYS OF EMPLOYMENT.
22VAC40-73-670-2
Based on record review and staff interview, the facility failed to ensure staff administering medication are registered with the Virginia Board of Nursing as a medication aide.
Evidence
  1. A complaint was received by regional licensing office on 11/21/2024 alleging an unlicensed individual was administering medications.
  2. The record for Staff 2, hired 07/01/2024, had a letter from the Department of Health Professions to act as a provisional medication aide dated 6/12/2024.
  3. The provisional 120-day period for staff 2 ended 10/10/2024.
  4. Staff 2 was scheduled as the RMA on duty and administered medications on 25 dates including October 11,13,15,16,17,18,20,22,23,24,25,27,29,30, 2024 and November 1,3,4,10,12,13,14,15,17,18 and 20, 2024.
  5. During an interview on 11/21/2024, staff 1 confirmed that staff 2 had ended the provisional eligibility period and was scheduled as the RMA on duty on the dates listed. Staff 1 stated “staff 2 passed the RMA exam on November 1, 2024, but is not showing registered with the Board of Nursing.”
Plan of correction
THE ED AND WC WILL HAVE ALL PROVISONAL LETTERS POSTED AND MONITIOR WHEN THEIR PROVISONAL LETTER IS OVER. ED AND WC WILL NOT ALLOW NO ONE PASS MEDICATIONS ONCE THEIR PROVISONAL LETTER IS OVER UNLESS THE LICENSE IS POSTED ON THE BON WEBSITE.
22VAC40-73-680-D
Based on record review and staff interview the facility failed to administer medications in accordance with the physician's or other prescriber’s instructions.
Evidence
  1. A complaint was received by the regional licensing office on 11/21/2024 alleging that medications are not being administered as ordered by the physician.
  2. Resident 1 had a physician’s order dated 10/22/2024 that states Reduce Novolog to 3 units TID (hold if bs <100.
  3. The October Medication Administration Record (MAR) for resident 1 indicated Novolog, 3 units,were administered to resident 1 on October 24, 27, 28, and 29 when the blood sugar was less than 100.
Plan of correction
Not published by VDSS.
October 15, 2024Complaint survey3 violations
Inspection dates
10/15/2024, 10/16/2024
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES63.2 PROTECTION OF ADULTS AND REPORTING22VAC40-80 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 4:22pm-6:13pm, 10/16/2024 11:06am-12:40pm 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 10/15/2024 regarding allegations in the area(s) of: Resident to Resident physical abuse, incident reporting, reporting suspected abuse. Number of residents present at the facility at the beginning of the inspection: 34 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 0 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 7 Observations by licensing inspector: The licensing inspector toured the facility, observed residents in their apartments, common areas, and during mealtime. 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 allegation; area(s) of non-compliance with standard(s) or law were: 70-A, 130-A, 300-B 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 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
22VAC40-73-130-A
Based on record review and staff interview the facility failed to ensure staff who are mandated reporters under § 63.2-1606 of the Code of Virginia shall report suspected abuse, neglect, or exploitation of residents in accordance with that section.
Evidence
  1. A complaint was received by the regional licensing office on 10/15/2024 regarding an incident between two residents alleging abuse.
  2. Staff 1 confirmed during an interview that there have been several incidents between resident 1 and resident 2.
  3. When asked if Adult Protective Services (APS) had been notified of the alleged abuse, staff 1 stated “no, I thought we had handled it medically”.
Plan of correction
The Executive Director and Wellness Coordinator will educate staff on state reporting and mandated reporters. Staff will know how to report suspected abuse, neglect, or exploitation of residents.
22VAC40-73-70-A
Based on record review the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident.
Evidence
  1. A complaint was received by the regional licensing office on 10/15/2024 regarding an incident between two residents alleging abuse.
  2. Staff 1 confirmed during an interview that there have been several incidents between resident 1 and resident 2.
  3. When asked if the incidents had been reported to the regional licensing office staff 1 stated “no, I didn’t know that I needed to do that”.
Plan of correction
The ED and WC will ensure timely reporting to all agencies required by law.
22VAC40-73-300-B
Based on record review and staff interview, the facility failed to ensure a method of written communication was utilized as a means of keeping direct care staff on all shifts informed of significant happenings or problems experienced by residents, including complaints and incidents or injuries related to physical or mental conditions.
Evidence
  1. During an interview with staff 1, it was confirmed that there have been several incidents between resident 1 (admitted 7/24/2019) and resident 2 (admitted 6/2/2021), Several incidents between resident 1 and resident 3 (admitted 11/2/2023) and one incident between resident 1 and resident 4 (admitted 8/19/2024).
  2. During a review of resident 2’s chart there is no documentation for 4 months, with the last note dated 04/20/2024 and the next note dated 08/03/2024.
  3. When asked if the incidents had been documented to determine the date that the incidents occurred, staff 1 stated “no, we’ve been working on documentation.”
  4. During an interview with staff 3 when asked if the witnessed incidents were documented anywhere, staff 3 stated “no, I just told the RMA face to face what had happened”
Plan of correction
The Executive Director and Wellness Coordinator will ensure staff are charting and written communication between staff is completed in full prior to change of shift.
July 1, 2024Complaint survey3 violations
Inspection dates
07/01/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 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: 07/01/2024, 1:30pm-3:30pm 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 6/23/2024 regarding allegations in the area of resident care. 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 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 allegation(s); area(s) of non-compliance with standard(s) or law were: 22VAC40-73-640-A, 22VAC40-73-680-D, 22VAC40-73-680-H, 22VAC40-73-150-C A violation notice was 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. 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
22VAC40-73-680-H
Based on record review and staff interview, the facility failed to ensure at the time the medication is administered, the facility shall document on a medication administration record (MAR) all medications administered to residents.
Evidence
  1. The June MAR for resident 1 did not contain any documentation of medication administered between the hours of 8am to 12pm on June 25, 2024.
  2. Staff 1 stated an employee from the other facility came over to administer the medications that day and must not have documented medications administered.
Plan of correction
The Administrator will collaborate with the Wellness Coordinator for weekly audits of documentation of medication administration to assure documentation is complete and correct, to be conducted over a four week period of time.
22VAC40-73-70-A
Based on record review and staff interview, the facility failed to report to the regional licensing office within 24 hours of any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident.
Evidence
  1. Resident 1 was hospitalized according to the hospital discharge summary from 6/11/2024-6/14/2024 following an incident that occurred at the facility on 6/11/2024.
  2. Staff 1 stated “I don’t believe it was” when asked if the incident was reported to the licensing office.
Plan of correction
The Executive Director and / or Wellness Coordinator will assure timely reporting to all agencies as required by 22VAC40-73-70-A.
22VAC40-73-640-A
Based on record review and staff interview the facility failed to implement a medication management plan including methods for verifying that medication orders have been accurately transcribed to medication administration records (MARs) within 24 hours of receipt of a new order or change in an order.
Evidence
  1. Resident 1 had physicians orders dated 7/2/2024 to discontinue all medications prior to 7/2/2024.
  2. The July 2024 MAR shows Humalog 100u/ml start date 6/14/21, Lispro insulin Kwikpen 100u/ml start date 6/26/2024,and Touejo 300u/ml start date 6/26/2024, were not stopped until 7/9/2024.
Plan of correction
The Administrator will collaborate with the Wellness Coordinator and representative from Wellness Concepts for implementation of routine Order / MAR reconciliation to assure the MAR is accurate and consistent with provider orders. The Wellness coordinator will verify that all new orders received from providers are accurately reflected on the MAR weekly over a four week period of time.
May 31, 2024Complaint survey0 violations
Inspection dates
05/31/2024
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES63.2 PROTECTION OF ADULTS AND REPORTING
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: 5/31/2024 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 5/31/2024 regarding allegations in the area of resident care. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 4 Observations by licensing inspector: Medication administration, care service documentation, physician communication, meal service, resident records, facility communication. 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 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 , Licensing Inspector at 540-571-0358 or by email at Jessica.gale@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
April 22, 2024Inspection3 violations
Inspection dates
04/22/2024
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 4/22/2024 3:00pm - 4:00pm A self-reported incident was received by VDSS Division of Licensing on 4/19/2024 regarding allegations in the area(s) of Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 32 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 2 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Additional Comments/Discussion: N/A The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. However, violation(s) not related to the self-report 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. 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 resident record review and interviews with staff, the facility failed to update the Individualized Service Plan (ISP) to reflect admission to Hospice Services.
Evidence
  1. Following review of resident records, resident 1 was admitted to hospice services on 3/4/2024. The ISP dated for 7/12/2023 was not updated to reflect the admission to hospice services.
  2. An interview was conducted with Staff 1 who confirmed that the ISP had not been updated to reflect admission to hospice services.
Plan of correction
Not published by VDSS.
22VAC40-73-300-B
Based on record review and staff interviews, the facility failed to utilize written communication to inform all shifts of significant happenings or problems experienced by residents, including complaints and incidents or injuries related to physical or mental conditions.
Evidence
  1. Following an incident that occurred at the facility on 4/19/2024 at 1:00pm, an incident report was received by the Virginia Department of Social Services (VDSS) on 4/19/2024 at 4:49pm stating, following the incident “both residents have been put on 30-minute checks for the next 24 hours.”
  2. Following review of the facility Shift Communication Log dated 4/19/2024 and the resident record for residents 1 and 2, there is no evidence of instruction for or completion of 30-minute checks for resident 1 nor resident 2.
  3. Following an interview with staff 2, staff 2 stated “they didn’t do them”.
Plan of correction
Not published by VDSS.
22VAC40-73-130-A
Based on record review, staff, and collateral contact interviews, the facility failed to report an incident in accordance with the Code of Virginia.
Evidence
  1. An incident occurred at the facility on 4/19/2024 between 2 residents.
  2. Staff 1 was interviewed and stated that a report was not sent to APS until 4/21/2024.
  3. An interview with a collateral contact was conducted and confirmed that the incident report was emailed by the facility to another state agency on 4/21/2024 and then forwarded by that agency to the collateral contact on 4/22/2024.
  4. A record review for staff 1 and staff 2 confirmed receipt and signature of the Virginia Legal Requirements to Report Abuse, signed by staff 1 on 3/11/2024, and staff 2 on 4/15/2024.
Plan of correction
Not published by VDSS.
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 30 Number of records reviewed and interviews conducted- 8 records (staff and resident), 8 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. the Licensing Inspector observed the residents during many activities and meals. The Licensing Inspector reviewed the following at the time of inspection: menus, resident council minutes, activities calendars, pharmacy review, fire drills, dietician report 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-D
Based on resident record review and staff interview, it was determined that the facility failed to have documentation of a coordinated plan of care on the Individualized Service Plan (ISP) between the facility and the Hospice agency.
Evidence
  1. Resident C had no documentation on the ISP dated January 10, 2024 of a coordinated plan of care between the facility and the Hospice agency. Resident D had no documentation on the ISP dated January 1, 2024 of a coordinated plan of care between the facility and the Hospice agency.
Plan of correction
The Administrator and/or nursing staff will audit all records to ensure compliance. The ISPs will reflect a coordinated plan of care between the facility and Hospice as required.
March 16, 2023Inspection0 violations
Inspection dates
03/16/2023
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Technical assistance
Recommended a form be created that includes the requirements for the dietary review and that it be signed and dated by the dietician at each dietary review, then filed with the summary results in order to certify the requirements were met.
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 3/16/2023 from approximately 11:10 am to 12:05 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: 32 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 4 Observations by licensing inspector: lunch meal, resident’s rooms Additional Comments/Discussion: This monitoring inspection was conducted as a follow-up to the previous renewal 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. 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.
January 24, 2023Complaint survey0 violations
Inspection dates
01/24/2023
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 BUILDINGS AND GROUND
Technical assistance
Recommended having a company come in that specializes in assessing for mold to ensure there are no issues.
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: 1/24/2023 from approximately 1:00 pm to 3:30 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 1/24/2023 regarding allegations in the area of: Administration and Administrative Services Number of residents present at the facility at the beginning of the inspection: 32 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: N/A Number of staff records reviewed: N/A Number of interviews conducted with residents: 15 Number of interviews conducted with staff: 4 Observations by licensing inspector: All resident rooms and bathrooms, common areas, laundry room, offices, etc. Additional Comments/Discussion: Administrator stated the licensee spoke with a company and an assessment has been scheduled for February 2023 and a report will be submitted to the licensing inspector regarding the findings. 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.
January 23, 2023Inspection8 violations
Inspection dates
01/23/2023, 01/24/2023
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 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 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
Questions answered and discussions occurred as follows: 1. At least a two-day supply of food and water must be maintained on site at all times, as well as evidence of availability (through a contract, etc.) for an additional two days must be on file. Recommended keeping a four-day supply of food and water on site at all times. 2. Recommended an in-service with all staff regarding the importance of not interrupting the medication aide when medications are being administered. 3. Recommended printing resident’s name next to signature when not legible (training rosters, etc.).
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: 1/23/2023 from approximately 6:50 am to 1:00 pm and 3:00 pm to 6:50 pm, 1/24/2023 from approximately 7:00 am to 1:00 pm and 3:30 pm to 6:20 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: 32 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 + selected sections of 3 additional records Number of staff records reviewed: 4 + 2 contract staff Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 + 1 Collateral Observations by licensing inspector: Meals, medication administration, activities, emergency food and water supplies, postings, first aid kit, staffing. 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
22VAC40-73-700-1
Based upon observations, documentation and an interview, the facility failed to ensure signed completed orders for oxygen were on file for two of three residents and that “No Smoking – Oxygen in Use” signs were posted at three of the three resident rooms where Oxygen was in use.
Evidence
  1. On 1/23/2023, the LI conducted a tour of the facility and observed no oxygen sign posted at any resident door.
  2. On 1/23/2023, the LI interviewed the administrator who stated there were three residents on oxygen and provided a list of their names, which included residents 2, 7 and 8.
  3. The signed oxygen orders for resident 2 did not include the route or the source.
  4. There was no oxygen order on file for resident 7.
Plan of correction
“Oxygen in use - no smoking” signs were posted immediately during survey on each resident’s room door with oxygen. Oxygen Orders were obtained with all required documentation by the wellness Coordinator. Wellness Coordinator to in-service all staff and instruct them to place oxygen signs at the entrance to residents’ rooms when oxygen is in use. Wellness Coordinator to review all orders for oxygen to ensure they have all required components for any new oxygen orders. The administrator or wellness coordinator will ensure 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 1/23/2023, the licensing inspector (LI) observed the breakfast, lunch and dinner meals. A glass of orange juice for breakfast was the only fruit observed being provided to the residents for the three meals.
  2. The posted menu for the week of 1/22/2023 to 1/28/2023 listed fruit being served for lunch on 1/23/2023 and dinner on 1/24/2023 and 1/27/2023. The menu listed only two servings of vegetables on 1/23/2023, 1/26/2023, 1/27/2023 and 1/28/2023. There were no noted substitutions on the posted menu.
  3. On 1/23/2023, the LI interviewed the cook who stated fruit is only served three times a week.
  4. The USDA food guidance system recommends two servings of fruit and three servings of vegetables a day.
Plan of correction
Dietary manager was in-serviced on 2/1/2023 regarding nutritional requirement for all menus to meet the USDA food guidance system. The dietary manager will follow the approved dietician menus for all meals to ensure the proper servings of fruits and vegetables are served each day to the residents. The administrator or designee will review the menu each week prior to posting 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.
  3. On 1/23/2023, the LI interviewed the licensee, collateral 2, who stated he was unaware that the facility did not have a contract with a dietitian and that the dietary oversight had not been completed.
Plan of correction
A dietitian was contracted and completed a bi-annual review of resident diets on 2/9/2023 and contracted for services every 6 months and as needed. The administrator will ensure a visit and that documentation of the dietician’s visit is on file every 6 months. The administrator will ensure compliance with this standard.
22VAC40-73-970-E
Based upon documentation and an interview, the facility failed to ensure fire drills were documented as required.
Evidence
  1. The fire drill form for the drill held on 6/29/2022 at 10:25 did not indicate am or pm.
  2. The fire drill form for the drills held on 10/21/2022 and 1/11/2023 did not include the evacuation time.
  3. The fire drill form for the drill held on 1/11/2023 did not indicate the weather.
  4. On 1/23/2023, the LI interviewed the administrator who checked the forms and stated they did not include the required information.
Plan of correction
A 100 percent audit was completed for all fire drills. The Maintenance Director will conduct a fire drill on each shift quarterly rotating the shifts each month. After completion of the fire drill the maintenance director will then give the monthly fire drill form to the administrator prior to filing to ensure that all required documentation has been completed on the form. The administrator will ensure compliance with this standard.
22VAC40-73-680-I
Based upon documentation and an interview, the facility failed to ensure that all medications administered were documented for one of two residents.
Evidence
  1. The January MAR for resident 4 was blank on 1/9/2023 for the 10:00 pm doses of Clonazepam, Diphenoxylate-Atropine, Eliquis, Gabapentin, Melatonin and Trazadone.
  2. On 1/23/2023, the LI interviewed resident 4 who stated she has never missed her 10:00 pm medications.
Plan of correction
All Registered Medication Aides will be in-serviced on the importance of accurate documentation on the MAR. Each Medication Aide will have one medication pass observed by the wellness coordinator with suggestions made to enhance and ensure compliance with accurate documentation of each medication administered. The Wellness Director or Designee will conduct audits 3 times per week of the MAR to check for accuracy in documentation
22VAC40-73-310-M
Based upon documentation and an interview, the facility failed to ensure three of the three hospice agreements included all required information.
Evidence
  1. The three hospice agreements did not include an acknowledgement that the services provided to each resident by hospice must be reflected on the individualized service plan (ISP).
  2. On 1/24/2023, the LI interviewed the administrator who stated the hospice agreements were not updated to include this information.
Plan of correction
The administrator has completed a full review of all hospice contracts and has met with the corporate legal team to create a new hospice agreement to include all requirements for regulations 310.M on 2/3/2023. This agreement has been sent to all hospice companies for reapproval and signatures. The administrator will ensure compliance with this standard
22VAC40-73-680-E
Based upon observations, documentation and an interview, the facility failed to ensure a treatment was provided for one of two resident records reviewed.
Evidence
  1. Resident 4 had a physician’s order signed 5/18/2022 for Ketoconazole shampoo to be applied to scalp every other day for hair loss.
  2. On 1/23/2023, the LI conducted a medication cart audit with staff and the Ketoconazole shampoo was not observed in the medication or treatment cart. Staff 2 stated the shampoo was probably in the resident’s room.
  3. On 1/23/2023, the LI interviewed resident 4 who stated she did not have the Ketoconazole shampoo and that it had been about six months since she had it as she got a different shampoo that she liked and used.
  4. The January medication administration record (MAR) for resident 4 listed Ketoconazole shampoo every other day and was signed off as being administered on 1/2/2023, 1/4/2023, 1/6/2023, 1/8/2023, 1/10/2023, 1/12/2023, 1/14/2023, 1/16/2023, 1/18/2023, 1/20/2023, 1/22/2023.
Plan of correction
All registered medication aides will be in-serviced on medication administration/treatments and that in-service will include proper documentation to ensure physicians’ orders are being followed as prescribed and recorded on the MAR/treatment administration record (TAR) accurately. The wellness coordinator or designee will review the MAR/TAR 3 times per week to ensure accuracy of documentation and each medication aide will be observed during a medication pass to ensure all treatments are completed according to the physicians’ orders.
22VAC40-73-450-F
Based upon documentation and interviews, the facility failed to ensure four of the five ISPs were updated to include all assessed needs.
Evidence
  1. The uniform assessment instrument (UAI), completed 1/20/2023, indicated resident 1 needed mechanical help (MH) with stairclimbing; however, the ISP completed 11/1/2022, did not specify the type of MH needed.
  2. Resident 2 had a physician’s order signed 4/22/2022 for a wander guard; the UAI, completed 4/23/2022, indicated MH for stairclimbing; however, these needs were not listed on the ISP completed 4/23/2022.
  3. The UAI, completed 10/18/2022 for resident 3, indicated MH was needed for bathing and mobility; however, these needs were not listed on the ISP completed 10/20/2022.
  4. The UAI, completed 11/9/2022 for resident 5, indicated MH was needed for dressing; however, no MH was listed on the ISP completed 11/16/2022.
  5. The UAI, completed 1/1/2023 for resident 6, indicated MH and physical assistance for walking, wheeling, stairclimbing and mobility; however, the ISP completed 1/1/2023 did not include any assistance with walking and wheeling, or MH for stairs and mobility.
  6. On 1/24/2023, the LI interviewed staff 7 who checked the ISPs and UAIs and stated the above needs were not listed on the ISPs.
Plan of correction
The administrator or designee will complete a facility review of all resident ISPs for accuracy and to ensure they are current. The administrator and facility wellness coordinator will review upon completions of all ISPs that they reflect the current needs and services the residents are receiving. The Administrator or designee will review ISPs weekly and update the ISP to reflect any changes that occur. The administrator or designee will ensure compliance with this standard.
January 23, 2023Complaint survey2 violations
Inspection dates
01/23/2023
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND
Technical assistance
When a staff member resigns, the responsibilities must be delegated to other staff and the administrator and licensee must ensure the job duties continue to be completed.
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: 1/23/2023 from approximately 1:00 pm to 3:00 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 1/3/2023 regarding allegations in the areas of: Resident Care and Related Services and Buildings and Grounds Number of residents present at the facility at the beginning of the inspection: 32 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 (only selected sections) Number of staff records reviewed: 0 Number of interviews conducted with residents: 3 + 2 family members Number of interviews conducted with staff: 4 + 1 outside agency staff Observations by licensing inspector: Resident rooms, common areas, dining room, laundry room, activities room, etc. Additional Comments/Discussion: Preliminary findings were reviewed and discussed with the administrator at the end of the inspection. The administrator was given the opportunity to ask questions and present any documentation or other information related to the complaint during that time. 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: Activities and housekeeping 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 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-H
Based upon interviews, the facility failed to ensure resident rooms were deep cleaned every week as stated on the individualized service plans (ISPs) for three of the three resident records reviewed.
Evidence
  1. On 1/23/2023, the LI conducted a tour of the facility and resident room. In resident 1’s room there were disposable cups, torn pieces of paper and other miscellaneous trash under the bed.
  2. On 1/23/2023, the LI interviewed resident 1 who stated her daughter comes and cleans her bathroom.
  3. On 1/23/2023, the LI interviewed resident 2 who stated it had been a while since her room had been cleaned.
  4. On 1/23/2023, the LI interviewed resident 3 and checked his bathroom where there was feces on the toilet seat.
  5. On 1/23/2023, the LI checked resident 4’s room and there were little pieces of paper on the floor.
  6. On 1/23/2023, the LI checked resident 5’s room and there were pieces of paper and tissues all over the floor.
  7. On 1/23/2023, the LI interviewed the administrator who stated the resident rooms were not receiving a deep cleaning every week as the housekeeper had resigned.
  8. On 1/23/2023, the LI interviewed a family member who stated the rooms were not being cleaned and that family members were coming in to clean the rooms and bathrooms.
  9. The individualized service plans for residents 1 (completed 10/20/2022, 2 (completed 3/9/2022) and 3 (completed 3/7/2022) listed housekeeping as. “Staff will clean room and bathroom as needed with a deep clean weekly.”
Plan of correction
All resident rooms were deep cleaned by the housekeeper. The maintenance director will complete checks of all rooms weekly to ensure deep clean was completed for each resident weekly. Once every week the administrator will pick 5 rooms at random to ensure all resident rooms were deep cleaned as per ISP. The maintenance director and administrator will be responsible for compliance with this standard.
22VAC40-73-520-E
Based upon interviews, the facility failed to ensure at least one hour of activities was being held daily with a total of 14 hours each week.
Evidence
  1. On 1/23/2023, the LI interviewed the administrator who stated activities were being held two to three times a week in the morning and afternoon.
  2. On 1/23/2023, the LI interviewed staff 2 who stated activities were being held about every three or four days.
  3. On 1/23/2023, the LI interviewed staff 4 who stated since the activities staff left, he has been helping with activities and they are offered about three times a week.
Plan of correction
A new activities director was hired on 2/5/2023 who was given instruction that at least one hour of activities be completed each day with a total of 14 hours per week. Direct care staff will assist with the daily activities in the event the activities director is unavailable. The administrator will review the schedule weekly to ensure that a minimum one hour of activities will be scheduled for each day and 14 hours per week. The administrator will ensure compliance with this standard.
October 6, 2022Inspection2 violations
Inspection dates
10/06/2022
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Technical assistance
Recommended scheduled II drug count sheets be checked at least weekly and narcotic count processes be observed on a regular basis for all registered medication aides/nurses.
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: 10/6/2022 from approximately 1:45 pm to approximately 2:20 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 9/19/2022 regarding allegations in the areas of: Personnel and Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 30 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: Selected sections of 6 Number of staff records reviewed: Selected sections of 3 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 6 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-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(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
22VAC40-73-660-A-2
Based upon interviews, the facility failed to ensure one scheduled II medication was stored in a double locked area.
Evidence
  1. On 9/17/2022 at 1:00 am, staff 1 administered an as needed (PRN) dose of morphine to resident 1.
  2. On 9/17/2022 at 6:00 pm, staff 2 found an empty box with a pharmacy label for morphine with resident 1’s name on it setting on resident 1’s bedside table.
  3. On 10/4/2022, LI interviewed staff 1 who stated, “I went into her room and gave her the 0.25mg morphine as she asked for it. I gave it to her, put the cap back on the bottle, the syringe in the morphine box and I don’t recall whether I put the morphine in the box or not. I always put the syringe and bottle in the box.”
  4. On 10/11/2022, the LI interviewed staff 3 who stated when she was notified about the empty box found in resident 1’s room she checked the medication carts and the morphine was not located.
Plan of correction
A one hundred percent audit has been conducted of all resident medications scheduled II to ensure they are all stored properly in a double locked area. Each registered medication aide has been in-serviced on the importance of following the protocol for keeping scheduled II medications under double lock. Each medication aide will have one medication pass observed to ensure they are following the process on double locking the scheduled II medications. The wellness director or designee will conduct biweekly audits and observations of the medication cart to ensure that all scheduled II medications are stored properly.
22VAC40-73-640-A
Based upon interviews and documentation, the facility failed to ensure the facility’s medication management plan was implemented.
Evidence
  1. On 9/17/2022 at 1:00 am, staff 1 administered an as needed (PRN) dose of morphine to resident 1.
  2. On 9/17/2022 at 6:00 pm, staff 2 found an empty box with a pharmacy label for morphine with resident 1’s name on it setting on resident 1’s bedside table.
  3. On 9/17/2022, staff 2 took the empty box to staff 3 who checked the medication cart and could not find the bottle of morphine.
  4. On 9/17/2022, staff 3 notified staff 5 who coordinated a search for the medication; however, the medication was not found.
  5. The narcotic count sheet for 9/17/2022 at the 6:00 am shift change was signed off by staff 1 and 5; the narcotic count sheet for the 2:00 pm shift change was signed off by staff 3 and staff 5.
  6. On 10/4/2022, the licensing inspector (LI) interviewed staff 1 who stated, “I did not count the liquid morphine. I always count the pill cards but do not always count the liquids.”
  7. On 10/11/2022, the LI interviewed staff 5 who stated, “I wasn’t told she had been given morphine. I don’t always count if they haven’t been given any – sometimes I do and sometimes I don’t.”
  8. On 10/11/2022, the LI interviewed staff 3 who stated, “I’m not going to lie, staff 5 and I didn’t complete the count that day. We didn’t count all the medications as I got sidetracked and staff 5 went on to do something else.”
  9. The facility’s medication management plan states on page 171 and 172: “All medication maintained within the facility that fall under the DEAs Schedule of II – IV will be: - Locked in the medication cart in a double lock box, the locks of which open with separate keys. - Will be counted by an RMA/nurse from the off going shift and one from the oncoming shift. This procedure will occur at the beginning and end of all shifts in the facility. - Keys to the medication cart will be maintained by the person(s) passing medications and only after a count of controlled substances has occurred will keys be passed to another RMA or nurse for any reason.
Plan of correction
All Registered Medication Aides were in-serviced on the facilities medication management plan. Each medication aide will have one medication pass observed by the wellness director with suggestions made to enhance and ensure compliance with the facilities medication management plan. The wellness director or designee will conduct biweekly audits of the registered medication aide to check for compliance to the medication management plan.
October 6, 2022Complaint survey0 violations
Inspection dates
10/06/2022
Areas reviewed
22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/6/2022 from approximately 12:30 pm to 1:35 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 10/6/2022 regarding allegations in the areas of: Resident accommodations and buildings and grounds. Number of residents present at the facility at the beginning of the inspection: 30 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: Selected section of 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 7 Number of interviews conducted with staff: 3 Observations by licensing inspector: Resident rooms, bathrooms, closets, common areas, hallways and one pet Additional Comments/Discussion: None. An exit meeting will be conducted to review the 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. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact 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.
July 28, 2022Complaint survey3 violations
Inspection dates
07/28/2022
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Technical assistance
Recommended all staff be in-serviced on end of life care and registered medication aides be in-serviced on the use of the electronic medication administration record and what to do if they suspect or see a documentation error.
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: 7/28/2022 from approximately 9:52 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 7/27/2022 regarding allegations in the area of resident care and related services. Number of residents present at the facility at the beginning of the inspection: 35 Number of resident records reviewed: 1 Number of staff records reviewed: 11 (only selected sections) Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 10 Observations by licensing inspector: Staff, resident and family interactions; staff providing care to residents Additional Comments/Discussion: Reviewed medication administration records and signed physician’s orders 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 in the areas of resident care, medication administration documentation and medication administration. 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 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
22VAC40-73-680-D
Based upon documentation and interviews, the facility failed to ensure one resident’s medications were administered according to the physician’s orders. 1. Resident 1 had physician’s orders signed 7/8/2022 for oxycodone concentrate 0.25ml (5mg) by mouth PRN every hour for pain/moaning and Lorazepam Intensol 0.25ml (0.5mg) by mouth PRN every four hours for anxiety. 2. On 7/9/2022 at 2:30 am, staff 8 administered 0.50ml of oxycodone and 0.50ml of lorazepam. 3. Resident 1 had physician’s orders signed 7/8/2022 for Lorazepam Intensol 0.25ml (0.5mg) by mouth every four hours. 4. The MAR for resident 1 listed the administration times for the scheduled Lorazepam as 9:00 am, 1:00 pm, 5:00 pm and 9:00 pm. 5. The MAR for resident 1 had the initials for staff 8 for administering the Lorazepam at 9:00 am on 7/9/2022. 6. On 7/28/2022, the licensing inspector (LI) interviewed staff 8 who stated she “would not have given the lorazepam at 9:00 am as her shift is from 10:00 pm to 6:00 am. 7. The staff schedule for 7/9/2022 indicated staff 3 was the medication aide on duty at 9:00 am on 7/9/2022. 8. On 8/11/2022, the LI interviewed staff 3 who stated she did not administer the 9:00 am dose of Lorazepam as the MAR was already signed off by another staff.
Plan of correction
A one hundred percent audit is being conducted of all residents’ medications to ensure accuracy of administration. Each registered medication aide has been in-serviced on the importance of following the orders provided by the physician for each resident. Each medication aide will have one medication pass observed to ensure they are following the orders as prescribed. The wellness director or designee will conduct biweekly audits and observations of the MARs and medication passes to ensure accuracy.
22VAC40-73-680-I
Based upon documentation, the facility failed to ensure the medication administration record (MAR) for one resident included all required documentation. 1. Resident 1 had physician’s orders signed 7/8/2022 for oxycodone concentrate 0.25ml (5mg) by mouth PRN every hour for pain, moaning and Lorazepam Intensol 0.25ml (0.5mg) by mouth PRN every four hours for anxiety. 2. The narcotic count sheets for resident 1 indicated oxycodone was administered on 7/9/2022 at 4:10 am, 9:00 am and 1:00 pm and lorazepam was administered on 7/9/2022 at 4:10 am and 1:00 pm; however, administration of these PRN medications were not documented on the MAR.
Plan of correction
All registered medication aides were in-serviced on the importance of accurate documentation on the MAR. Each medication aide will have one medication pass observed by the regional director of nursing with suggestions made to enhance and ensure compliance with accurate documentation of each medication administered. The wellness director or designee will conduct biweekly audits of the MARs to check for accuracy in documentation.
22VAC40-73-450-H
Based upon documentation and interviews, the facility failed to ensure the care and services specified in the individualized service plans (ISPs) were provided to one of two resident records reviewed.
Evidence
  1. The ISP (signed as completed on 7/8/2022) for resident 1 listed daily oral care and to swab resident’s mouth as needed.
  2. On 7/28/2022, the licensing inspector (LI) interviewed staff 1, 6, and 11 and all three staff stated they did not provide oral care to the resident or swab her mouth on 7/8/2022 or 7/9/2022 while they were on duty.
  3. There was no mutually agreed upon deviation from the ISP documented in resident 1’s record and according to the legal representative interviewed on 7/27/2022.
Plan of correction
All direct care staff have been in-serviced by the regional director of nursing on following the ISP provided for all residents. Biweekly this compliance will be reviewed and monitored by shadowing the direct care staff team by the wellness coordinator and or designee to ensure accuracy of following the ISP for each resident’s care needs.
May 16, 2022Inspection1 violation
Inspection dates
05/16/2022
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS
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: 5/16/2022 from approximately 10:00 am to 3:45 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: 34 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 (selected sections) Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and the violation was 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 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
22VAC40-73-680-I
Based upon documentation and interviews, the facility failed to ensure all required documentation was included on the medication administration records (MARs) for three of three residents' MARs reviewed.
Evidence
  1. The MAR for resident 1 was blank on 5/4/2022 at 5:00 pm for Timolol eye drops; 5/4/2022 at 4:00 pm, 5/5/2022 and 5/12/2022 at 1:00 pm for Tramadol.
  2. The MAR for resident 2 did not include a diagnosis for Novolog.
  3. The MAR for resident 2 did not include the blood glucose levels and amount of insulin administered on 5/1/2022 at 8:00 am, 12:00 pm and 4:30 pm, 5/5/2022 at 4:30 pm, 5/6/2022 and 5/7/2022 at 8:00 am and 12:00 pm, and 5/13/2022 at 4:30 pm; 5/2/2022, 5/4/2022, 5/6/2022 and 5/7/2022 at 4:30 pm, the amount of insulin administered was not documented.
  4. The MAR for resident 3 was not initialed on 5/9/2022 and 5/12/2022 at 2:00 pm for Furosemide, Albuterol and Potassium.
  5. On 5/16/2022, the licensing inspector (LI) interviewed staff 1 who stated, "The medications were administered and I don't know why my initials don't show up unless I forgot to sign them off."
  6. On 5/16/2022, the LI interviewed residents 1 and 3 and both stated they received their medications and have not missed any.
Plan of correction
A 100 percent audit of the MARs was completed by the regional director of nursing and the executive director on 5/24/2022. On 5/23/2022 all registered medication aides were retrained by the regional director of nursing on proper MAR documentation. The regional director of nursing and/or wellness coordinator will review the medication aide documentation daily for the next 30 days and 3 times a week thereafter to ensure compliance with all requirements for documentation of medication administration and to ensure all documentation is recorded accurately on the MARs.
March 23, 2022Inspection9 violations
Inspection dates
03/23/2022, 03/24/2022
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity63.2 General Provisions63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report
Technical assistance
1. Clarify the individualized service plan versus the plan of care on all hospice agreements. 2. Update the mental health agreement with the correct standards. 3. Do not draw lines through the times on the rounds sheet - each time period must be initialed by the staff who conduct each round. 4. Ensure when you post all menus for the month that the current menu remains on top. 5. Recommended more detail be included in the communication log. 6. Ensure if the source of oxygen is portable tank and concentrator that both are listed on the signed physician's order. 7. Even though the storage cases were labeled, ensure glucometers are also labeled.. 8. Recommended keeping a copy of the training provided with the staff/resident sign in sheet. 9. Discussed providing a copy of the medication administration record versus medication administration list to emergency personnel. 10. Recommended having residents sign on the individualized service plan that they received a copy.
Comments
An unannounced monitoring inspection was conducted on 3/23/2022 from approximately 8:00 am to 4:40 pm and on 3/24/2022 from approximately 8:00 am to 5:10 pm. Upon arrival there were 26 residents in care and one nurse, one registered medication aide and three direct care aides on duty. A tour was immediately conducted of the interior and exterior of the facility. All of the required postings were in place and the facility was clean and free from any foul odors. The posted menu and the activities calendar accurately reflected this inspector's observations with the menu reflecting the one substitution observed. Meals were observed and the special diets reviewed were served according to the physicians' orders. Medication administration observations were completed with three residents. The medication administration records, physicians' orders and medications were reviewed. Individual interviews were conducted with residents, family members, outside agency staff and facility staff. Six resident, two contract staff and four facility staff records were reviewed. Selected sections of seven additional residents and four staff records were also reviewed. The areas of noncompliance included first aid and cardiopulmonary resuscitation posting, staff work schedule, individualized service plans, medication administration, medication reviews, over-the-counter medications, physicians' orders, storage of cleaning supplies and fire drills. Staff answered all questions and obtained all information requested. Thank you for your assistance and cooperation during this inspection.
Violations
22VAC40-73-680-D
Based upon documentation, the facility failed to ensure one medication for one of seven residents was administered in accordance with the physician's order.
Evidence
  1. Resident 5 had a physician's order signed 1/10/2022 for, Novolog Flexpen daily at 7:30 am, 11:30 am and 4:40 pm. Sliding scale150-200 inject two units, 201-250 inject four units, 251-300 inject six units, 301-350 inject eight units, greater than 351 inject 10 units; hold if blood glucose (BG) is less than 150.
  2. Resident 5 had a physician's order signed 1/10/2022 for Basaglar Kwikpen inject 30 units subcutaneously every morning, hold if BG is less than 60.
  3. Resident 5 had a physician's order signed 1/10/2022 to check blood sugar three times daily at 7:30 am, 11:30 am and 4:30 pm.
  4. The medication administration record (MAR) for 2/15/2022 at 5:00 pm for resident 5 indicated staff 11 checked resident's blood sugar and the result was 239.
  5. The MAR for 2/15/2022 at 4:30 pm for Novolog sliding scale was blank for the site and BG level and staff 11's initials were circled. The note on the MAR stated, "Withheld per DR/RN orders."
  6. On 2/16/2022, the administrator reported staff 11 administered 14 units of Basaglar instead of 14 units of Novolog on 2/15/2022 at 5:00pm.
  7. Staff 11 completed a written report on 3/25/2022 which stated "Gave resident wrong insulin."
Plan of correction
Staff member 11 was educated on our policy and procedure for medication administration. Staff also completed a medication refresher course provided by the pharmacy on 2/17/2022. All medication aides will be re-educated on medication administration policy by the regional director of nursing. Wellness coordinator or regional director of nursing will complete a medication oversight quarterly for every medication aide.
22VAC40-73-260-C
Based upon observations, documentation and an interview, the facility failed to ensure the posted list of staff with current certifications in first aid (FA) and cardiopulmonary resuscitation (CPR) was kept current.
Evidence
  1. During a tour of the facility on 3/23/2022, the list of staff with FA/CPR certifications was observed posted in the staff office.
  2. On 3/23/2022, the LI interviewed staff 12 who stated the posted list was not current.
  3. When reviewing the posted list of staff with current FA and CPR along with the list of current staff provided by the administrator, staff 9 and 10 were listed; however, they were no longer employed by the facility.
  4. Staff 5 was not on the posted list; however, was currently employed with both FA and CPR certifications on file.
Plan of correction
The listing of staff who are currently certified in first aid and CPR was updated on 3/24/2022. When a new staff member is hired or a staff member leaves the facility, the wellness director will update the CPR/first aid list. To ensure compliance, the executive director will review the list biweekly for any updates.
22VAC40-73-970-A
Based upon documentation and an interview, the facility failed to ensure fire drills were conducted on each shift every quarter.
Evidence
  1. Fire drill forms completed from 5/20/2021 through 2/14/2022, indicated the only fire drills conducted on the 10:00 pm to 6:00 am shift were completed on 5/20/2021 and 12/27/2021.
  2. On 3/23/2022, the LI interviewed the administrator who stated these were the only fire drills conducted on the 10:00 pm to 6:00 am shift.
Plan of correction
On 3/24/2022, a fire drill was conducted for the 10:00 pm to 6:00 pm shift. The maintenance director will hand in all fire drills to the executive director prior to filing to ensure that the correct shift has been completed for the month and a fire drill is conducted on each shift every quarter.
22VAC40-73-860-I
Based upon observations and an interview, cleaning supplies were left unlocked and unattended.
Evidence
  1. On 3/23/2022 at approximately 9:00 am, the (licensing inspector) LI observed the facility cleaning cart in front of the bulletin board just outside the dining room. Numerous cleaning supplies were left on top of the cart and there were no staff in the area for approximately five minutes.
  2. On 3/23/2022, the LI interviewed staff 8 who stated she was not aware that cleaning supplies had to be kept locked at all times when not in use.
Plan of correction
On March 23, 2022, identified items were immediately removed and placed under lock. All staff were retrained on all shifts on 4/1/2022 regarding the storage of cleaning supplies in a locked cabinet. Regular rounds by the maintenance director and executive director will be conducted and monitoring will be ongoing to ensure all cleaning supplies are locked when unattended.
22VAC40-73-680-G
Based upon observations and an interview, the facility failed to ensure three of 15 over-the-counter medications reviewed for three residents were labeled with the resident's name.
Evidence
  1. On 3/23/2022 the LI, along with the registered medication aide (RMA) on duty, checked the medications administered to resident 4 and three of the medications ( Vitamin D3, aspirin and COQ10) observed were not labeled with the resident's name.
  2. Staff 1, the RMA on duty, also checked the medication bottles and during the interview stated the three medications did not have a resident's name on them.
Plan of correction
The wellness coordinator will ensure that all medications ordered for all residents are properly labeled with complete instructions for administration and labeled with the resident's name. A cart audit was completed by the regional director of nursing on 4/1/2022 to ensure all medications are properly labeled. When a medication comes in for a resident, the medication aide on duty will check the medication against the order and label it with the resident's name if it is not already done.
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 of the assessed needs of the residents.
Evidence
  1. The uniform assessment instrument (UAI), signed as completed on 2/28/2022 for resident 2, indicated mechanical help needed for toileting and mobility and that resident 2 was a high risk for falls; however, these needs were not listed on the ISP completed on 2/28/2022.
  2. A physician's order, signed 1/10/2022 for resident 3 stated, "Premarin Vaginal Crm-Appl apply 0.5gm vaginally on Monday, Wednesday, and Friday for vaginitis. May keep at bedside and self-administer;" however, the ISP indicated staff were to administer medications. 3.The UAI, signed as completed on 10/10/2021 for resident 5, indicated mechanical help and physical assistance needed for bathing; however, no mechanical help was listed.
  3. Resident 5 had an order signed 10/15/2021 for a low/no concentrated sweets diet; however, the ISP completed 10/20/2021 indicated resident was on a regular diet.
  4. The ISP, signed as completed on 8/26/2021, was updated on 3/10/2022 to include wound care; however, the care and services provided by outside agency staff, as well as monitoring techniques and services provided by the facility staff, were not listed.
  5. On 3/24/2022, the LI interviewed staff 12 who checked the ISPs and stated the above needs were not listed.
Plan of correction
The regional director of nursing, in conjunctions with the wellness coordinator, will complete a 100% audit of the UAIs and the ISPs to ensure all areas needing support listed on the UAI are captured on the ISP. A 100% audit will be completed on ISPs by the regional director of nursing and the wellness coordinator to ensure any changes in status are captured on the ISP. The executive director will perform an audit on 25% of residents' ISPs quarterly to verify compliance using a community spreadsheet.
22VAC40-73-650-B
Based upon documentation, the facility failed to ensure all physicians' orders for one of three residents included a diagnosis for each medication.
Evidence
  1. Medication orders for resident 4 were as follows: Miralax and Colace (signed 3/3/2022); Amlodopine, aspirin, Co Q-10, Donepezil, Lisinopril, Lorazepam, Pantoprazole, Rosuvastatin and Vitamin D3 ( all signed 2/28/2022).
  2. None of these orders included a diagnosis.
Plan of correction
The regional director of nursing contacted the resident's physician to get a diagnosis for each medication listed. A 100% audit was conducted by the executive director, regional director of nursing and wellness coordinator to ensure that all residents' medications have a diagnosis. All future physicians' orders will be reviewed by the wellness coordinator or regional director of nursing to ensure all information is present prior to placing in the resident's record or MAR. The wellness coordinator will conduct weekly audits of all physicians' orders and MAR records to prevent future violations.
22VAC40-73-290-A
Based upon documentation and interviews, the facility failed to ensure the staff schedule included who was in charge at any given time.
Evidence
  1. The staff schedule for March 2022 did not indicate the staff person in charge. At the top of the schedule was the statement, "RMA=M=Charge Person when administrator is out." The schedule, however, had no "M" noted anywhere nor did it indicate anywhere on the schedule who was in charge at any given time.
  2. On 3/24/2022, the LI interviewed the nurse and administrator and both stated the staff in charge was not indicated on the staff schedule.
Plan of correction
The staff schedule was updated on 3/24/2022. The wellness director will create the schedule and place a "m" by the staff person in charge indicating they are the charge person for that shift. The executive director will review the schedule prior to posting to ensure each shift has one charge person listed for each day and shift. This schedule will be reviewed daily by the wellness director and executive director to update any changes to the charge person. There will be one person listed in charge on the staff schedule in the absence of the administrator.
22VAC40-73-690-B
Based upon documentation and an interview, the facility failed to ensure a medication review was conducted at least once every six months.
Evidence
  1. Medication reviews were dated as completed by the pharmacy on 4/2020, 10/2020 and 10/2021.
  2. On 3/23/2022, the LI interviewed the administrator who stated the medication review was only conducted once during this past year.
Plan of correction
Executive director contacted the pharmacist on 4/7/2022 to schedule the review of all resident medications. Ongoing the executive director will be responsible for scheduling with the pharmacy biannual visits by the pharmacist to ensure they are conducted and all medications reviewed. The executive director will ensure this completion by reviewing the dates of scheduled times of the med review with the regional director of nursing at the managers meetings monthly
November 16, 2021Complaint survey2 violations
Inspection dates
11/16/2021, 11/17/2021, 11/19/2021, 12/08/2021
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Technical assistance
Ensure all staff receive on-going training on the standards and facility policies regarding resident emergencies and reporting major incidents to the licensing office.
Comments
A non-mandated complaint inspection was initiated on 11/16/2021 and concluded on 12/8/2021. A complaint was received on 11/16/2021 by the department regarding allegations in the areas of administration and administrative services and resident care and related services. The administrator was contacted by telephone regarding the documentation required to complete the investigation. In addition, telephone interviews were conducted. The evidence gathered during the investigation did not support the allegation of non-compliance with staff not obtaining medical care for a resident; however, it did support the allegation of a family member not being notified of an incident. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.
Violations
22VAC40-73-460-F
Based upon documentation and an interview, the facility failed to ensure all required individuals were contacted when a resident fell.
Evidence
  1. A facility incident report form was completed on 9/9/2021 for resident 1 stating, "Staff went to answer call bell found res. on the floor. Res. had a cut above her left eye and was bleeding. Hospice was called, 911 called sent to ER."
  2. The family notification section on the form only listed hospice as being notified.
  3. On 12/8/2021, the LI interviewed the administrator who stated there was no documentation that the family was notified of the incident.
Plan of correction
Administrator and DON will retrain all staff to ensure they contact the family or designated contact person any time a resident incident occurs. The DON will document all incidents as required and ensure all required parties are notified of the incidents. The DON will ensure all notes and notification information is documented in the resident's record to include the date, time, caller and designated contact person who was notified. The administrator will check and sign off on all reports to ensure compliance.
22VAC40-73-70-A
Based upon documentation and an interview, the facility failed to ensure five major incidents that negatively affected the life, health and safety or welfare of a resident were reported to the licensing office within 24 hours.
Evidence
  1. A facility incident report form was completed on 9/9/2021 for resident 1 stating, "Staff went to answer call bell found res. on the floor. Res. had a cut above her left eye and was bleeding. Hospice was called, 911 called sent to ER."
  2. On 11/19/2021, the licensing inspector (LI) interviewed the administrator who stated this incident was not reported to the licensing office and was an oversight.
  3. On 11/19/2021, the administrator sent an electronic message also stating the incident on 9/9/2021 was not reported to the licensing office.
  4. On 11/23/2021, the administrator first notified licensing of incidents where residents were sent to the emergency room on 11/19/2021 (resident 2 and 3), 11/20/2021 (resident 4) and 11/21/2021 (resident 5).
Plan of correction
Administrator and director of nursing (DON) were re-in-serviced on reporting to the regional licensing office within 24 hours any major incident that has negatively affected or threatens the life, health, safety, or welfare of any resident. The administrator and DON will review submitted incident reports daily to ensure compliance with timely submission of incident reports for continued compliance.
February 1, 2021Inspection1 violation
Inspection dates
Feb. 1, 2021 , Feb. 2, 2021 , Feb. 3, 2021 and Feb. 4, 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 PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS
Technical assistance
Answered questions/made recommendations regarding the following: 1) When hospice writes orders for as-needed medications, ensure the symptoms that would warrant the medication administration are documented clearly on the orders as medication aides can not assess mild, moderate, severe pain, etc. 2) Once the updated contract for hospice has been resigned by both parties, send a copy to this inspector for review. 3) Once the fire plan has been updated with the fire official's recommendations, resend a copy along with the updated approval to this inspector. 4) Even when the local emergency coordinator does not make any recommendations for change, keep this information with the facility's emergency plan. 5) Due date of criminal record checks is based upon hire date - not start date. Also recommended staff sign a statement that they may not work alone until the criminal record check has been completed and returned.
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 2/1/21 and concluded on 2/4/21. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 26. The inspector emailed the administrator a list of items required to compete the inspection. The inspector reviewed four resident, one discharge and four staff records. Selected sections of two additional resident, two contract staff and three facility staff records were also reviewed. The activities calendar, menu, staff schedules, administrator schedule, fire drills, dietary/medication/health care oversight reviews, January and February medication administration records, physicians' orders all criminal record checks for current employees hired since the last inspection, as well as other documents, were reviewed to ensure documentation was complete. 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
22VAC40-90-40-B
Based upon documentation and an interview, the facility failed to ensure two of the 12 criminal record checks (CRC) reviewed were completed within 30 days of hire.
Evidence
  1. The CRC for staff H (hired 8/27/20) had a completion date of 10/21/20; staff I (hired 7/14/20 and started 8/1/20) had a completion date of 8/19/20.
  2. On 2/4/21, the LI interviewed the administrator who stated the CRC for staff H was missed and discovered during an audit. He stated he used the start date for staff I instead of the hire date as he thought that was acceptable.
Plan of correction
Administrator and/or designee is to ensure all staff members have a completed criminal history record check in their file prior to hire and starting employment. The administrator will be responsible for compliance with this standard.