Virginia DSS · Assisted Living Facility

Indian River Assisted Living

📍 1012 Justis Street, Chesapeake, VA, 23325

ID 45429One Year licenseActive
26
Inspections
On record
17
With violations
Visits that cited something
9
Clean visits
Nothing cited
75
Violations cited
Individual findings
51
Standards cited
Distinct rules
16
Complaint visits
Prompted by a complaint

Indian River Assisted Living was inspected 26 times between January 27, 2021 and September 29, 2025 by the Virginia Department of Social Services. 17 of those visits ended with violations cited and 9 with none. Across that history VDSS cited 75 violations under 51 distinct standards. 16 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. 23 of these 26 are still on the state's site; the other 3 have since dropped off it and are reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type
Assisted Living Facility
License type
One Year
License expires
02/07/2026
Administrator
Ulku Williams
Licensing inspector
Lanesha Allen
Inspector phone
757-715-1499
Approved for
Assisted Living · Non-Ambulatory

Inspection History

26

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

September 29, 2025Complaint survey2 violations
Inspection dates
09/29/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-80 COMPLAINT INVESTIGATION
Technical assistance
22VAC40-73-650
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: 09/29/2025 from 12:32 p.m. until 2:45 p.m. 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 08/27/2025 regarding allegations in the area(s) of: Staffing And Supervision, Buildings and Ground and Resident Care And Related Services. Number of residents present at the facility at the beginning of the inspection: 87 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:3 Number of interviews conducted with staff: 2 Observations by licensing inspector: An observation of the facility occurred during this onsite, resident interviews and record reviewed during onsite. Staff interviews and medication cart review occurred during onsite. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at Lanesha.allen@dss.virginia.gov
Violations
22VAC40-73-450-E
Based on record review and staff interview during the onsite visit, the facility did not ensure the individualized service plan shall be signed and dated by the licensee, administrator, or his designee, and by the resident or his legal representative.
Evidence
  1. A review of the record for Resident #1, admission date 2/4/22, contained a ISP that was not signed by the resident’s guardian.
  2. Staff #1 confirms the ISP in Resident #1’s record was not signed by the resident’s guardian.
Plan of correction
1. - Facility will ensure care plans are signed by all parties. 2. - Facility will complete %100 audit on the ISPs by RCC / ARCC or designee. 3. - RCC and ARCC will be educated on VA DSS requirements on care plans monthly. 4. - Findings will be submitted to the monthly safety committee for analysis and further actions. 5. - Date of completion: 3/6/2026
22VAC40-73-680-C
Based on observation, and interview, the facility did not ensure Medications shall be administered not earlier than one hour before and not later than one hour after the facility's standard dosing schedule, except those drugs that are ordered for specific times, such as before, after, or with meals.
Evidence
  1. On 09/26/2025, during the medication cart audit for the North Hall cart, medications for Resident #1 were observed dispensed in a cup at 9:48am. According to the physician’s order, the medication administration time is 7:00 am.
  2. Staff #2 was asked why medications were dispensed and still on the cart, Staff #2 states Resident #1 prefers to take her medication after breakfast.
  3. During the exit on 9/26/25, Staff #3 was informed of the medications being on the cart by the licensing inspector, Staff #3 states she was unaware medications were dispensed but still on the cart.
Plan of correction
1. Facility will ensure all RMAs/MedTech and licensed clinical team educated on the medication administration policy and procedures. 2. Facility will ensure that the residents will receive medications per the provider's order. 3. Facility will request a medication review if a resident cannot take medications as per the MD orders. 4. RCC and ARCC will audit MARs daily. 5. Findings will be submitted to the monthly safety committee for analysis and further actions. 6. Date of completion: 3/6/2026
September 18, 2025Complaint survey5 violations
Inspection dates
09/18/2025, 09/29/2025
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-80 COMPLAINT INVESTIGATION
Technical assistance
22VAC40-73-640 22VAC40-73-650
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: 09/18/2025, from 12:16 p.m. until 3:45 p.m. and 09/29/2025 from 8:55 am until 1:08 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Complaints were received by VDSS Division of Licensing on 09/162025, 09/18/2025, 09/22/2025 regarding allegations in the area(s) of: Resident Care And Related Services, Buildings And Ground And Emergency Preparedness. Number of residents present at the facility at the beginning of the inspection: 87 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:1 Number of interviews conducted with staff: 2 Observations by licensing inspector: The following were reviewed: An observation of the facility. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at Lanesha.allen@dss.virginia.gov
Violations
22VAC40-73-450-C
Based on the record review and interview during the onsite inspection on 09/18/25, 09/26/25, and 9/29/25, the facility did not ensure the comprehensive individualized service plan shall be completed within 30 days after admission.
Evidence
  1. During the record review for Resident #1, admission date 4/11/2025, it was determined that the record did not contain a Comprehensive ISP. The preliminary plan was reviewed in the record, dated 4/11/25.
  2. Staff #1 confirms the preliminary plan was present in the resident’s record during the onsite inspection on 9/18/25.
Plan of correction
1. Resident's ISP reviewed and updated. 2. 100% UAI audits will be completed by RCC/designee. 3. Clinical team will be trained on reporting change of status and assessments. 4. Findings will be submitted to the monthly safety committee for analysis and further actions. 5. Date of completion: 3/6/2026
22VAC40-73-440-A
Based on the record review and interview during the onsite inspection on 09/18/25, 09/26/25, and 9/29/25, the facility did not ensure the UAI shall be completed prior to admission, at least annually, and whenever there is a significant change in the resident's condition.
Evidence
  1. A Review of Resident #2s record contained a UAI dated 7/24/24. The facility did not update the UAI annually.
  2. Staff #1 confirms the UAI was not completed at the time of the onsite inspection on 9/18/25.
Plan of correction
1. Resident's UAI and ISP reviewed and updated. 2. 100% UAI and ISP audits will be completed by RCC/designee. 3. Clinical team will be trained on reporting change of status and assessments. 4. Findings will be submitted to the monthly safety committee for analysis and further actions. 5. Date of completion: 3/6/2026
22VAC40-73-550-G
Based on the record review and interview during the onsite inspection on 09/18/25, 09/26/25, and 9/29/25, the facility did not ensure the rights and responsibilities of residents be reviewed annually with each resident or his legal representative;
Evidence
  1. of this review shall be the resident's, his legal representative's or responsible individuals, or staff person's written acknowledgment of having been so informed, which shall include the date of the review and shall be filed in the resident's record. Evidence:
  2. During the record review for Resident #2, the record contained a Resident Rights review dated 1/8/25 that was not signed by the Resident’s Guardian.
  3. Staff #1 confirms the document was not signed by Resident #2s Guardian at the time of inspection on 9/18/25.
Plan of correction
1. Facility will ensure annual review of right and responsibilities of residents. 2. Education on the annual review will be provided to the BOM/Administrator/Assistant Administrator. 3. 100% audit on will be completed on the annual reviews. 4. Findings will be submitted to the monthly safety committee for analysis and further actions. 5. Date of completion: 3/6/2026
22VAC40-73-680-H
Based on a review of the medication administration records and interview during the onsite inspection on 09/18/25, 09/26/25, and 9/29/25, it was determined that the facility did not ensure that that the medication administration record (MAR) includes if the medication was administered or there was an omission.
Evidence
  1. The MAR for Midodrine HCL 5mg tab did not indicate whether the medication was administered, or it was not administered on the following dates: 9/21/25 11:00 pm; 9/25/25 3:00 pm; 9/26/25 3:00 pm. Documentation did not indicate an error or refusal.
  2. The MAR for Midodrine HCL 2.5 mg tab did not indicate whether the medication was administered, or it was not administered on the following dates: 9/21/25 11:00 pm; 9/25/25 3:00 pm; 9/26/25 3:00 pm. Documentation did not indicate an error or refusal.
  3. The MAR for Gabapentin 400 mg capsule did not indicate whether the medication was administered, or it was not administered on the following dates: 9/25/25 12:00 pm
  4. Staff #1 and Staff #2 reviewed MAR and acknowledged the signatures were missing.
Plan of correction
1. MARs were reviewed and omissions were addressed. 2. Clinical team will be trained on medication administration plan and record keeping. 3. RCC/ARCC will audit MARs daily and addressed omissions. 4. Findings will be submitted to the monthly safety committee for analysis and further actions. 5. Date of completion: 3/6/2026
22VAC40-73-325-B
Based on the record review and interview during the onsite inspection on 09/18/25, 09/26/25, and 9/29/25, the facility did not ensure the fall risk rating shall be reviewed and updated under each of the following circumstances: At least annually;
Evidence
  1. A Review of Resident #2’s record contained a fall risk rating dated 2/14/19. The facility did not update the Falls Risk Rating annually.
  2. Staff #1 confirms the Falls Risk Rating was not completed at the time of the onsite inspection on 9/18/25 for Resident #2.
Plan of correction
1. Resident's fall risk rating completed. 2. 100% audit of fall risk binder will be completed by the RCC/designee. 3. RMA/MedTech, RCC, ARCC will be educated on the fall risk assessments and rating and record keeping. 4. Monthly fall risk audits will be completed by the RCC/designee. 5. Findings will be submitted to the monthly safety committee for analysis and further actions. 6. Date of completion: 3/6/2026
September 18, 2025Complaint survey0 violations
Inspection dates
09/18/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-80 COMPLAINT INVESTIGATION
Technical assistance
22VAC40-73-80 22VAC40-73-120
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: 09/18/2025 from 12:16 p.m. until 3:45 p.m. and 09/26/2025 from 8:55 a.m. to 1:50 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 08/27/2025 regarding allegations in the area(s) of: Resident Care And Related Services, Resident Accommodations And Related Provisions, Buildings And Ground, Emergency Preparedness. Number of residents present at the facility at the beginning of the inspection: 87 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: 2 Observations by licensing inspector: The following were reviewed: Resident Records, Resident Interviews and staff interviews occurred during this inspection. A tour of the of the facility and water temperature were checked. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) 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 Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at Lanesha.allen@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
August 5, 2025Complaint survey4 violations
Inspection dates
08/05/2025, 09/18/2025, 09/29/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Technical assistance
22VAC40-73-150 22VAC40-73-900
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: 08/05/2025 from 12:00 p.m. until 2:45 p.m., 09/18/2025 from 12:32 p.m. until 2:00 p.m, 09/29/2025 from 9:00 a.m. until 9:45 a.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 08/05/2025 regarding allegations in the area(s) of: Staffing And Supervision, Admission, Retention And Discharge Of Residents, and Resident Care And Related Services. Number of residents present at the facility at the beginning of the inspection: 87 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:2 Number of interviews conducted with staff: 2 Observations by licensing inspector: The following were reviewed: Resident Records, Resident Interviews, Staff Records and staff interviews occurred during this inspection. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at Lanesha.allen@dss.virginia.gov
Violations
22VAC40-73-450-F
Based on observation, interview and document review on 8/2/25, 9/26/25 and 9/29/25, the facility did not ensure that the Individualized service plan shall be reviewed and updated at least once every 12 months and as needed for a significant change of a resident’s condition.
Evidence
  1. During the record review for Resident #1, the record did not contain an annual ISP. The last plan was dated 7/30/24.
  2. Staff #2 states there was a level of care completed July 2025 and it was determined the facility could not provide the level of care Resident #1 required. Resident #1 was awaiting discharge at the time of the record review on 8/5/25.
Plan of correction
Not published by VDSS.
22VAC40-73-470-G
Based on observation, interview and document review on 8/2/25, 9/26/25 and 9/29/25, the facility did not ensure , the facility did not ensure that if a resident refuses medical attention, the facility shall assess whether it can continue to meet the resident's needs.
Evidence
  1. During the onsite inspection on 8/5/25, a review of Resident #1’s record contained a Physicians Order stating Resident #1 Refused Physician assessment, last seen 3/25/25.
  2. During the onsite inspection on 8/5/25, Staff #2 stated “A Level of Care assessment occurred during July, the resident is awaiting discharge as she needs a higher level of care”.
  3. The MAR for Resident #1 indicates medications were not administered to the resident due to documented refusals in the record: Atorvastatin 20 mg; Benztropine MES 1 mg; Loratadine 10 mg; Midodrine HCL 5 mg; Perphenazine 4 mg; Vitamin B-12 1,000 mcg; Vitamin D2 1.25 mg (50,000 unit); Acetaminophen 500 mg (prn) refused almost the entire month of June 2025, July 2025 and all of the month of August 2025 until she went out of the facility on 08/07/2025 and no evidence the physician or POA were notified of refusals.
Plan of correction
1. Facility will ensure medications be administered in accordance with the Physician's or other prescribers' instructions. 2. Daily audits of MARs will be completed by RCC to ensure medication needs timely. 3. Facility will ensure all RMAs/MedTech and licensed clinical team educated on the medication administration policy and procedures. 4. Findings and education needs will be submitted during the next safety committee for analysis and further actions. 5. Date of completion: 3/6/2026
22VAC40-73-680-E
Based on observation, interview and document review on 8/2/25, 9/26/25 and 9/29/25, the facility did not ensure that medical procedures or treatments ordered by a physician were documented.
Evidence
  1. The record for Resident #1 has a physician order for monthly weights effective 08/04/2024. There were no set perimeters stated in the orders. The June, July and August 2025 medication administration record (MAR) for Resident #1 reveals a highlighted section for the 5th of the month that is blank. The MAR does not have documentation of the results of a weight on 06/05/2025, 07/05/2025 or 08/05/2025 as ordered.
  2. During an interview with Staff #1 and Staff #2 on 09/26/2025, it was revealed the highlighted section means something should be documented there but there is no evidence that any staff did it because the resident keeps refusing.
Plan of correction
Not published by VDSS.
22VAC40-73-640-A
Based on observation, interview and document review on 8/2/25, 9/26/25 and 9/29/25, the facility did not ensure to implement their approved medication management plan.
Evidence
  1. Progress notes dated 1/25/2025 at 6:11 pm – “Resident #1 was in a very negative space today. Though she did take her AM medications, she refused to take her evening meds. The other RMA tried giving meds to her, and yet again she refused. Will reach out to her guardian to make aware of the situation.”
  2. Progress notes dated 2/26/2025 at 3:28 pm – “ Resident #1 refused the lab blood work and UA from homehealth so Dr. Kleiman tried to send her out to the ER to get Tx she refused that her POA was called about this left message. Dr. Klieman states we can’t do anything if she keeps refusing everything until it gets worse unfortunately.”
  3. Progress notes dated 6/20/2025 at 12:01 am – “ Resident #1 slipped in the shower onto the floor, and she did not bump her head. RMA and staff member helped her up off the floor and return her to the room. Resident #1 refused to go to the hospital for further evaluation.”
  4. Progress notes dated 6/20/2025 at 10:58 pm – “ Resident #1 refused her meds and seems to be experiencing anxiety hallucinations.”
  5. Physician orders dated for monthly weight by the 5th. On the June MAR dated 6/05/2025 states Resident #1 refused. On a physician assessment on 03/25/2025 it shows resident’s weight was 129 lbs. The physician documented “Her treatment will be dictated by her symptomatology and lab values.”
  6. Medications were not administered for Resident #1 as follows: Atorvastatin 20 mg; Benztropine MES 1 mg; Loratadine 10 mg; Midodrine HCL 5 mg; Perphenazine 4 mg; Vitamin B-12 1,000 mcg; Vitamin D2 1.25 mg (50,000 unit); Acetaminophen 500 mg (prn) refused almost the entire month of June 2025, July 2025 and all of the month of August 2025 until she went out of the facility on 08/07/2025 and no evidence the physician or POA were notified of refusals.
  7. The med management plan on page 30-31 reads in part the following: “Documentation of Medication Administration B. The facility is to have procedures to ensure that there is a consistent method of documenting why a medication was not administered…The employee is also to be knowledgeable of the facility's policy when a resident refuses medications, i.e., notifying the supervisor or physician. E. Any contact with the prescribing practitioner is documented in the resident's record. The employee needs to be knowledgeable of how to write a note in the residents’ record appropriately, i.e., dates and employee's signature. The employee also must be knowledgeable of the facility's procedures for documenting information that needs to be communicated to other staff or health professionals. This may be in the residents’ record or on some other document used to communicate with staff or health professionals.
Plan of correction
1. Facility will ensure all RMAs/MedTech and licensed clinical team educated on the medication administration policy and procedures. 1. Medication management plan will be available at the nurse's station as a reference. 2. RCC/ARCC will ensure medication administration per the prescriber's order. 3. RCC/ARCC will run weekly audits of 10% percent of the total number of residents. 4. Findings will be submitted to the monthly safety committee for analysis and further actions. 5. Date of completion: 3/6/2026
August 5, 2025Complaint survey1 violation
Inspection dates
08/05/2025, 09/18/2025, 09/29/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-80 COMPLAINT INVESTIGATION
Technical assistance
22VAC40-73-680
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: 08/05/2025 from 12:12 pm. until 2:30 pm, 09/18/2025 from 12:16 pm. until 1:30 pm and 9/29/2025 from 9:00 am until 9:23 am. 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 07/08/2025 regarding allegations in the area(s) of: Reports of abuse, neglect, or exploitation, Resident Care And Related Services. Number of residents present at the facility at the beginning of the inspection: 87 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:2 Number of interviews conducted with staff: 4 Observations by licensing inspector: The following were reviewed: Resident Records, Resident Interviews, Staff Records and staff interviews occurred during this inspection. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at Lanesha.allen@dss.virginia.gov
Violations
22VAC40-73-550-B
Based on record review and interviews conducted, the facility did not ensure that the resident has the right to voice or file grievances, or both, with the facility and to make recommendations for changes in the policies and services of the facility. The residents shall be protected by the licensee or administrator, or both, from any form of coercion, discrimination, threats, or reprisal for having voiced or filed such grievances.
Evidence
  1. Resident #1 made a complaint stating on two separate occasions two staff employed by the facility touched him inappropriately, dates were not specified.
  2. During the onsite investigation on 8/5/25, Resident #1 stated staff #3 hit him on the wrist when he attempted to eat another residents’ breakfast.
  3. During the onsite investigation on 8/5/25, Staff #3 stated during the interview “I tapped food, it had medicine in it”.
  4. Staff #2 was present during the interview; he suspended staff #3 while an internal investigation was conducted. The claim was valid.
  5. During the onsite investigation on 8/5/25, Resident #1 stated staff #4 rubbed her breasts on his shoulders while asking him to be her date for the prom at the facility.
  6. During the onsite investigation on 8/5/25, Staff #4 stated she did ask Resident #1 to attend the prom, but did not touch him inappropriately and did not get in his body space.
  7. Staff #2 was present during the interview; Staff #2 stated an investigation was completed and no evidence of Staff #4 inappropriately touching Resident #1.
Plan of correction
1. Past corrected citation. 2. Internal investigation findings did not support the complaint. No evidence found. 3. The staff completed the Residents Rights and Responsibilities training completed. 4. Facility will continue to ensure that the residents have the right to voice or file grievances, and ensure related policies are followed. 5. Date of competition: 9/29/2025 and ongoing
June 26, 2025Complaint survey2 violations
Inspection dates
06/26/2025
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 BUILDINGS AND GROUND
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/26/2025 from 9:32 a.m. until 10:45 a.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 06/25/2027 regarding allegations in the area(s) of: Buildings And Grounds. Number of residents present at the facility at the beginning of the inspection: 87 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: 2 Observations by licensing inspector: The following were reviewed: An observation of the facility. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at Lanesha.allen@dss.virginia.gov
Violations
22VAC40-73-880-C
22VAC40-73-880-C Based on a complaint and onsite observation, the facility did not ensure to develop and implement a plan to protect residents from heat-related and cold-related illnesses in the event of loss of air-conditioning or heat due to emergency situations or malfunctioning or broken equipment.
Evidence
  1. During an tour of the facility, it was determined that temperatures exceeded 80 degrees. An emergency plan was not in place at the time of inspection.
  2. Staff #1 confirmed the Air Conditioning unit was not working on the North, South and East locations in the building.
  3. Staff #1 reports Atlantic Coast and Heating would be onsite on 07/09/2025 to repair the unit.
Plan of correction
We ordered portable units until the company could get out to make the repairs. One unit was replaced on 7/9/25 as soon as we could get the installation scheduled. One unit was repaired on 7/14/25 and another unit is scheduled to be replaced on 7/18/25.
22VAC40-73-150-A
22VAC40-73-150-A Based on the onsite record review the facility did not ensure that the facility shall have an administrator of record.
Evidence
  1. During an interview with staff #1 on 06/26/2025, staff #1 reported he was waiting to take the test for the assisted living facility administrator license. This is more than 90 days since his appointment as Acting Administrator. The test date was not available during the inspection.
Plan of correction
Staff #1 is scheduled to take the test for the assisted living facility administrator license on 8/4/25 and another administrator is in place until staff #1 takes the test.
June 26, 2025Complaint survey1 violation
Inspection dates
06/26/2025
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/26/2025 from 9:32 a.m. until 10:45 a.m. 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 05/18/2025 regarding allegations in the area(s) of: Personnel and Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 87 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: 2 Observations by licensing inspector: The following were reviewed: An observation of the facility. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at Lanesha.allen@dss.virginia.gov
Violations
22VAC40-73-70-A
Based on a self report received on 5/18/2025, the facility did not ensure that the facility shall report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident.
Evidence
  1. A self report was received on 05/18/2025 of an incident requiring medical attention to resident #1 due to overdose.
  2. A Review of the record included medical documentation that indicates the incident occurred on 04/18/2025, and resident #1 required hospitalization following the incident at the facility.
Plan of correction
A meeting was held with the administrative team and Supervisors on 6/26/25 to discuss the process of reporting incidents. A system has been put in place for incident reports to be emailed within 24 hours and to make sure the follow-up documentation is sent in. Incident report training with staff will be conducted on 7/24/25.
March 25, 2025Complaint survey1 violation
Inspection dates
03/25/2025
Areas reviewed
22VAC40-73 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 GROUND
Technical assistance
22VAC40-73-70. Incident reports 22VAC40-73-550. Resident rights 22VAC40-73-100. Infection control program 22VAC40-73-270. Direct care staff training when aggressive or restrained residents are in care.
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: 03/25/2025 from 11:07 a.m. until 12:15 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: 87 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed:0 Number of interviews conducted with residents:1 Number of interviews conducted with staff: 4 Observations by licensing inspector: The following were reviewed: resident records, medication carts, and observation of the facility. Additional Comments/Discussion: 22VAC40-73-70. Incident reports 22VAC40-73-550. Resident rights 22VAC40-73-100. Infection control program 22VAC40-73-270. Direct care staff training when aggressive or restrained residents are in care. 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 Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at Lanesha.allen@dss.virginia.gov
Violations
22VAC40-73-870-D
Based on the report received from the facility, the facility did not ensure the buildings shall be kept free of infestations of insects and vermin. The grounds shall be kept free of their breeding places.
Evidence
  1. A complaint was received by licensing inspector that the facility has bed bugs and does not provide appropriate PPE for residents and staff.
  2. Staff #1 confirms the presence of bed bugs at the facility. Staff #1 provided to licensing inspector reports received from Pest Control shows treatment to the facility.
Plan of correction
Not published by VDSS.
January 2, 2025Inspection8 violations
Inspection dates
01/02/2025
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 PREPAREDNESS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Technical assistance
22VAC40-73-70. Incident reports 22VAC40-73-550. Resident rights
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: 01/05/2025 from 10:30 a.m. until 5:30 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: 86 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Number of staff records reviewed:4 Number of interviews conducted with residents:2 Number of interviews conducted with staff: 3 Observations by licensing inspector: lunch and an activity were observed. A medication pass observation was completed for 5 residents. The following were reviewed: resident and staff records, medication carts, and water temperatures. Additional Comments/Discussion: 22VAC40-73-70. Incident reports 22VAC40-73-550. Resident rights 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 Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at Lanesha.allen@dss.virginia.gov
Violations
22VAC40-90-40-B
Based on record review, the facility did not ensure to obtain a criminal history record report on or prior to the 30th day of employment for each employee.
Evidence
  1. The following staff records did not have a criminal history record report completed on or prior to the 30th day of employment: Staff #1 (hired 8/12/24), Staff #4 (hired 4/29/24), Staff #5 (hired 2/8/24), Staff #7(hired 3/6/24), Staff #8 (hired 4/16/24), Staff #9 (hired 2/29/24) at the time of inspection on 1/2/2025.
  2. Staff #1 confirmed the Criminal Record Reports were not completed.
Plan of correction
A Log is in place along with a face sheet to be signed off by Administration upon completion of Orientation and prior to Employee first day on the Floor to assure all Backgrounds have been completed. The missing background checks have been completed. Corrected 1/16/25
22VAC40-73-550-G
Based on the review of records and interview, it was determined that the facility did not ensure that the rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each resident or his legal representative or responsible individual as stipulated in subsection H of this section and each staff person.
Evidence
  1. of this review shall be the resident's, his legal representative's or responsible individual's, or staff person's written acknowledgment of having been so informed, which shall include the date of the review and shall be filed in the resident's or staff person's record. Evidence:
  2. The record for resident #3 record did not contain the rights and responsibilities of residents document.
  3. The record for resident #4 record contained the rights and responsibilities of residents document that was dated 6/16/21.
  4. The record for resident #5 record contained the rights and responsibilities of residents document that was dated 12/11/19.
  5. The record for resident #6 record contained the rights and responsibilities of residents document that was dated 9/19/19.
  6. The record for Staff #3 contained the rights and responsibilities of residents document that was dated 1/21/22.
  7. The record for Staff #10 did not contain the rights and responsibilities of residents’ document.
  8. Staff #1 reviewed the records for residents #3, #4, #5, #6, and staff #3 and staff #10 but unable to provide documentation during the onsite inspection that the resident rights and responsibilities were reviewed annually for each of the residents and staff listed.
Plan of correction
The rights and responsibilities documentation are in a Binder in the RCC office, The New Administrator was not aware and RCC was not asked for this item. A copy of the documentation will also be placed in the resident file and employee file.
22VAC40-73-250-D
Based on document reviewed and staff interviewed, the facility failed to ensure a staff person on or within seven days prior to the first day of work at the facility submitted the results of a risk assessment documenting the absence of tuberculosis (TB) in a communicable form as
Evidence
  1. d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence:
  2. Staff #10’s record did not have documentation of the absence of TB in a communicable form on or within seven days prior to the first day of work at the facility.
  3. Staff #1 acknowledged there was no documentation of the absence of TB within the required time prior to the first day of work
Plan of correction
We have made a check list and a log, for all New Hires that will be reviewed by Administration and or HR to make sure the TB Documentation is present, and everything is filed in a timely Manner. New employees will not start working until the TB documentation is checked off. Corrected 1/13/2025
22VAC40-90-30-B
Based on record review, the facility did not ensure the sworn statement or affirmation shall be completed for all applicants for employment.
Evidence
  1. The following staff records did not have a the sworn statement or affirmation completed: Staff #1 (hired 8/12/24), Staff #6 (hired 12/3/24) at the time of inspection on 1/2/2025. 2.Staff #1 confirmed the sworn statement or affirmation were not completed.
Plan of correction
The missing sworn statements were located and have been added to the employee file and a copy will be placed in a binder. All New Hire Packages include the sworn statement. The administration will review the checklist to ensure new staff do not work until this is completed. Corrected 1/9/25
22VAC40-73-350-B
Based on the onsite record review, it was determined that the facility did not ensure that prior to admission, whether a potential resident is a registered sex offender and document in the resident's record that this was ascertained and the date the information was obtained.
Evidence
  1. The record for resident #1 did not include a Sex Offender registry check prior to admission. The Sex Offender check in the record was dated 1/2/2025.
  2. Staff #1 confirmed the registry check in the file was the most current.
Plan of correction
Sex Offender registry checks will be run during the time of Interview and before they get approval to move into the Facility. Administration will sign off all Residents to assure nothing is missing before admission.
22VAC40-73-640-A
Based on observation, a review of the facility’s medication plan and interview, it was determined that the facility did not ensure to have, keep current, and implement a written plan for medication management. The facility's medication plan shall address procedures for administering medication and shall include A plan for proper disposal of medication
Evidence
  1. During the medication cart inspection, Artificial Tears Eye Drops for resident #8 were found with an expiration date of 06/01/24.
  2. Staff #3 confirmed the medication for resident #8 was expired.
Plan of correction
Administration and RCC will be doing a Weekly Audit on all 4 Med Carts to assure no expired Medication and also a log is done to assure. A written plan for medication management was available in our pharmacy notebook. We had a Meeting on Monday the 13th of January with Management to assure they understand where to locate the policies and procedures.
22VAC40-73-980-C
Based on record review, the facility did not ensure that first aid kits be checked at least monthly to ensure that all items are present and items with expiration dates are not past their expiration date.
Evidence
  1. Staff #1 was unable to provide documentation of monthly checks on the first aid kit.
Plan of correction
The administration created a log with a checklist to ensure audits of first aid kits are completed each month. Corrected 1/16/25
22VAC40-73-980-A
Based on observation and interview, it was determined that the center did not ensure that each building of the center shall contain a first aid kit with all required items.
Evidence
  1. The first Aid kit did not contain Blankets, Disposable single-use breathing barriers or shields, Plastic bags; Scissors; Small flashlight and extra batteries; Thermometer; Triangular bandages; during the day of inspection.
  2. Staff #1 confirmed the first aid kit did not contain all required items.
Plan of correction
We have done an Audit of the Correct First Aid Box Located in the RCC Office. We will be doing Monthly Audits along with Pictures to assure it is complete and recorded. The first aid will be kept in a central location for easy access. Corrected 1/9/25
February 28, 2024Complaint survey0 violations
Inspection dates
02/28/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 2/28/2024 from 9:10 am to 9:30 am. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Two complaints were received by VDSS Division of Licensing on 02/07/2024 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: 86 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 interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
January 11, 2024Inspection11 violations
Inspection dates
01/11/2024, 01/12/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Technical assistance
22VAC40-73-50 22VAC40-73-490
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: 1/11/2024 from 8:35 am to 3:00 pm and 1/12/2024 from 5:55 am to 8:20 am. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 85 Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: Lunch and an activity were observed. A medication pass observation was completed for 5 residents. The following were reviewed: resident and staff records, medication carts, and water temperatures. 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Violations
22VAC40-90-40-B
Based on record review, the facility failed to obtain a criminal history record report on or prior to the 30th day of employment for each employee.
Evidence
  1. The following staff did not have a criminal history record report completed on or prior to the 30th day of employment: Staff #6 (hired 6/7/2023) completed 12/7/2023, Staff #7 (hired 6/13/2023) completed 12/8/2023, and Staff #8 (hired 11/1/2023) not completed at the time of inspection on 1/11/2024.
Plan of correction
The Administrator or BOM will conduct a criminal history record through the Virginia State Police for all new hires on their orientation day or prior.
22VAC40-73-550-F
Based on observation, the facility failed to post the rights and responsibilities of residents conspicuously in a public place.
Evidence
  1. During the tour of the facility on 1/11/2024, only page 1 of the rights and responsibilities of residents was posted.
Plan of correction
The complete set of Resident Rights and Responsibilities will be posted by the DSS License and checked weekly to be in compliance.
22VAC40-73-610-B
Based on observation, the facility failed to ensure menus for meals for the current week are dated and posted in an area conspicuous to residents.
Evidence
  1. The facility did not have menus for meals for the current week posted in an area conspicuous to residents.
Plan of correction
Indian River will post the weekly menu outside of the Dining Room.
22VAC40-73-200-D
Based on record review and interview, the facility failed to obtain a copy of the certificate issued or other documentation indicating that the person has met one of the requirements of subsection C of this section, which shall be part of the staff member's record in accordance with 22VAC40-73-250.
Evidence
  1. Staff #3 works at the facility as direct care staff; however, their record did not include a copy of the certificate issued or other documentation indicating that the person has met one of the requirements of subsection C of this section.
  2. Staff #5 acknowledges the facility does not have a current certificate issued or other documentation indicating Staff #3 meets one of the requirements of direct care staff in their records.
Plan of correction
Staff #5's Training School was contacted, and her training was verified by the school and her training was dated. The school would not provide any certifications after-the-fact. All future hires must provide their certification(s) or will not be hired.
22VAC40-73-1070-B
Based upon observation, the facility failed to ensure that ordinary materials or objects that are harmful to resident be inaccessible to the residents except under staff supervision.
Evidence
  1. During a tour of the facility on 1/11/2024, the facility’s maintenance closet adjacent to the dining room were left unlocked. Both rooms contained jars of paint, paint supplies, cleaning supplies, and various maintenance equipment.
Plan of correction
Maintenance Coordinator and Administrator will ensure that the Maintenance closet remains closed and checks will be documented in main log.
22VAC40-73-980-C
Based on record review, the facility failed to ensure first aid kits be checked at least monthly to ensure that all items are present and items with expiration dates are not past their expiration date.
Evidence
  1. Staff #4 was unable to provide documentation of monthly checks on the first aid kit.
Plan of correction
A replacement First Aid Kit checkoff list was put in place and will be checked monthly by the RCC or ARCC. Any expired dates will be replaced.
22VAC40-73-550-G
Based on record review, the facility failed ensure the rights and responsibilities of residents in assisted living facilities be reviewed annually with each resident or his legal representative or responsible individual as stipulated in subsection H of this section.
Evidence
  1. The following residents did not have current documentation of an annual review of resident rights and responsibilities: Resident #3, Resident #4, and Resident #5.
Plan of correction
The Activities Coordinator will review in January the Resident Rights and Responsibilities and follow-up with all Guardians and POAs.
22VAC40-73-640-A
Based on observation and interview, the facility failed to ensure their written plan for medication management includes methods to prevent the use of outdated medications and methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes.
Evidence
  1. The following expired medications were observed in the medication carts at the facility on 1/11/2024: PRN Q-Tussin expired 12/21/2023 for Resident #8, PRN Promethazine expired 10/25/2023 for Resident #12, PRN Acetaminophen 325 mg tablets expired 10/28/2023 for Resident #13, Allopurinol 100 mg tablets expired 3/3/2023 for Resident #14, Aspirin 81 mg tablets expired 8/2022 for Resident #15, Ammonium Lactate lotion expired 10/13/2023 for Resident #16, and Lidocaine Solution expired 9/29/2023 for Resident #17.
  2. While ensuring accurate counts of all controlled substances with Staff #4 on 1/12/2024, it was discovered that the count indicated on the Controlled Drug Record was not consistent with the amount of medication for Resident #20’s Gabapentin 300 mg capsules with 141 noted on the record as available with 143 capsules on the medication cart and Resident #21’s Zolpidem Tartrate 5 mg tablets with 27 noted on the record as available with 26 tablets on the medication cart.
  3. Staff #4 acknowledged the Controlled Drug Record was not consistent with the amount of the two medications identified on the medication cart.
Plan of correction
On a weekly basis, the RCC and ARCC will inspect all 4 medication carts for any expired medication and remove them from the cart. Per policy, the RMA must conduct a narcotic count at the end of their shift and count with a nursing team member to ensure the narcotic count is reconciled. On a weekly basis, the RCC or ARCC will conduct a 2 week inventory report.
22VAC40-73-870-A
Based upon observation, the facility failed to ensure that the interior and exterior of all buildings shall be maintained in good repair and kept clean and free of rubbish.
Evidence
  1. One of the east hall bathrooms has tiles missing.
  2. The west hall bathroom has chipped tiles and paint peeling on the walls.
  3. The wall corner guard of the wall between the south and west hall is unsecure to the wall.
  4. The blinds and dresser in the room of Resident #8 were noted to be broken.
  5. A cracked floor tile was noted in the room of Resident #18.
  6. The emergency exit adjacent from Resident #19’s room was noted to have a blanket covering the bottom of the doorway and cracked floor tiles.
  7. The beauty shop has a grey substance on vent in the ceiling.
Plan of correction
Building and Grounds to be checked weekly by Administrator and Maintenance Coordinator. Any concerns will be addressed, repaired, or replaced. Community will continue to hold our quarterly Safety Committee meetings with continued safety inspections.
22VAC40-73-250-D
Based on record review, the facility failed to ensure each staff person on or within seven days prior to the first day of work at the facility and each household member prior to coming in contact with residents submit the results of a risk assessment, documenting the absence of tuberculosis in a communicable form as
Evidence
  1. d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence:
  2. The TB risk assessment for Staff #2 (hired 11/21/2023) was not completed.
Plan of correction
All new hires will have a negative TB reading or TB screening before their first day of work.
22VAC40-90-40-H
Based on record review, the facility failed ensure any person employed does not have a conviction of any of the barrier crimes.
Evidence
  1. Staff #9 was hired on 06/18/2022. A criminal history record report for Staff #9 was completed on 07/06/2022. The criminal history record report indicates Staff #9 was convicted of two misdemeanor barrier crimes in 1997.
Plan of correction
All criminal history record will be reviewed with the employee's application and Sworn Statement and to ensure compliance with the barrier crime listing. Staff #9 was terminated on 1/22/24.
January 11, 2024Complaint survey0 violations
Inspection dates
01/11/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 1/11/2024 from 8:35 am 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 01/03/2024 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: 85 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 interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
December 11, 2023Complaint survey0 violations
Inspection dates
12/11/2023
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Technical assistance
22VAC40-73-70
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: 12/11/2023. 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 12/06/2023 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: 86 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: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
November 6, 2023Inspection3 violations
Inspection dates
11/06/2023
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES
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: 11/06/2023. 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 10/25/2023 regarding allegations in the area(s) of: Personnel and Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 86 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: 2 Number of interviews conducted with staff: 1 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Violations
22VAC40-73-130-A
Based on interviews and record review, the facility failed to ensure all staff who are mandated reporters under § 63.2-1606 of the Code of Virginia report suspected abuse, neglect, or exploitation of residents in accordance with that section.
Evidence
  1. On 10/25/2023, Resident #1 alleged Staff #1 pushed them onto the floor from their bed.
  2. Staff #2 confirmed Adult Protective Services was not notified of this allegation of abuse.
Plan of correction
Any suspected abuse, neglect or exploitation to be reported by all mandated employees. All employees to conduct Relias module on abuse, neglect and exploitation.
22VAC40-73-280-E
Based on interview, the facility failed to ensure no employee be permitted to work in a position that involves direct contact with a resident until a background check has been received as required in the Regulation for Background Checks for Assisted Living Facilities and Adult Day Care Centers (22VAC40-90), unless such person works under the direct supervision of another employee for whom a background check has been completed in accordance with the requirements of the background check regulation (22VAC40-90).
Evidence
  1. During the inspection on 11/06/2023, Staff #1 works as direct care staff and did not have a completed background check. Resident #1 and Resident #2 stated Staff #1 was not under the direct supervision of another employee at the time an alleged incident on 10/25/2023.
Plan of correction
All new employees will be put through the VA State Police for background checks. Should the background check not be back in a timely manner, the new employee will work under the direct supervision of another employee who has a completed background check.
22VAC40-90-40-B
Based on record review, the facility failed to obtain a criminal history record report on or prior to the 30th day of employment for each employee.
Evidence
  1. Staff #1 (hired 10/03/2023) did not have a completed history record report on 11/06/2023.
Plan of correction
All new hires will be put through the VA State Police to check their criminal history record for barrier crimes upon hire.
October 19, 2023Inspection1 violation
Inspection dates
10/19/2023
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Technical assistance
22VAC40-73-70 22VAC40-73-460
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: 10/19/2023. 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 10/04/2023 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: 83 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 interviews conducted with staff: 1 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Violations
22VAC40-73-450-C
Based on record review, the facility failed ensure resident’s comprehensive individualized service plan include a description of identified needs.
Evidence
  1. Resident #1’s UAI (dated 10/20/2022) indicates the resident requires physical assistance with dressing and toileting and supervision with transferring; Resident #1’s ISP (dated 04/11/2023) does not address these identified needs. Additionally, Resident #1’s ISP also does not address wandering and need for a wanderguard.
Plan of correction
ISP will be updated to reflect all the needed ADLs for resident.
August 3, 2023Complaint survey0 violations
Inspection dates
08/03/2023
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 08/03/2023. 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 08/01/2023 regarding allegations in the area(s) of: Resident Care and Related Services. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 2, 2023Complaint survey0 violations
Inspection dates
05/02/2023
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS
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: 5/2/2023 from 9:45 am to 11:00 am. 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 03/23/2023 regarding allegations in the area(s) of: Part II Administration and Administrative Services and Resident Care and Related Services. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
December 13, 2022Inspection19 violations
Inspection dates
12/13/2022; 12/15/2022; 12/19/2022
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/13/2022 from 8:40 am to 4:25 pm, 12/15/2022 from 10:40 am to 1:00 pm, and 12/19/2022 from 11:22 am to 11:50 am. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 92 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 5 Number of staff records reviewed: 10 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Violations
22VAC40-73-310-D
Based on record review, the facility failed to provide written assurance to a resident or the legal representative documenting that the facility has the appropriate license to meet their care needs prior to admission.
Evidence
  1. There was no evidence of written assurance to Resident #6 or their legal representative documenting that the facility has the appropriate license to meet their care needs prior to admission.
Plan of correction
A written assurance will be received from Resident #6’s guardian and placed in his resident record.
22VAC40-90-40-B
Based on record review, the facility failed to obtain a criminal history record report on or prior to the 30th day of employment for each employee.
Evidence
  1. The following staff did not have a completed criminal history record report in their record: Staff #2 (hired 03/04/2022), Staff #8 (hired 06/16/2022), Staff #9 (hired 09/01/2022), and Staff #10 (hired 06/18/2022).
Plan of correction
Criminal history record will be obtained on or prior to the 30th day of employment for a new hire.
22VAC40-73-410-A
Based on record review, the facility failed to ensure upon admission, the assisted living facility provide an orientation for new residents and their legal representatives, including emergency response procedures, mealtimes, and use of the call system. Acknowledgment of having received the orientation shall be signed and dated by the resident and, as appropriate, his legal representative, and such documentation shall be kept in the resident's record.
Evidence
  1. The following residents did not have evidence of receiving orientation upon admission: Resident #4 (admitted 10/27/2022) and Resident #6 (admitted 01/05/2022).
Plan of correction
On day of admission, the Administrator or RCC will orient new resident to IRAL.
22VAC40-73-210-B
Based on record review, the facility failed to ensure in a facility licensed for both residential and assisted living care, all direct care staff attend at least 18 hours of training annually, except for direct care staff who are licensed health care professionals or certified nurse aides shall attend at least 12 hours of annual training.
Evidence
  1. Staff #3 had a total of 3.75 hours of training from 10/2021-10/2022.
Plan of correction
Administrator & BOM to ensure that staff is completing their mandatory meetings, in-services and Relias. If not completed, staff will be taken off of schedule until completed.
22VAC40-73-50-B
Based on record review, the facility failed to retain written acknowledgment of the receipt of the disclosure by the resident or his legal representative.
Evidence
  1. Upon review of Resident #4 and Resident #6’s record, there was no written acknowledgment of the receipt of the disclosure by the resident or their legal representatives in the resident's record.
Plan of correction
A written acknowledgment of receipt of disclosure will be completed and placed in Resident #4 & Resident #6 each resident’s record.
22VAC40-73-390-A
Based on record review, the facility failed to ensure at or prior to the time of admission, there be a written agreement/acknowledgment of notification dated and signed by the resident or applicant for admission or the appropriate legal representative, and by the licensee or administrator.
Evidence
  1. The facility was unable to provide documentation there was a written agreement/acknowledgment of notification dated and signed by the appropriate legal representative for Resident #6 (admitted 01/05/2022).
Plan of correction
The written agreement will be done on the day of the resident’s admission. Except for JFS guardianship, admission paperwork will be sent to the guardian and signatures will be placed in the new resident’s record.
22VAC40-73-990-C
Based on interview, the facility failed to document staff participation in practice exercises for resident emergencies at least once every six months.
Evidence
  1. The facility could not provide documentation that staff had participated in an exercise in which the procedures for resident emergencies were practiced at least every six months.
Plan of correction
In January and June staff will participate in a practice exercise for resident emergencies including: missing person, hurricane and tornado drills.
22VAC40-73-610-B
Based on observation, the facility failed to ensure menus for meals for the current week are dated and posted in an area conspicuous to residents.
Evidence
  1. During the tour of the facility on 12/13/2022 and 12/15/2022, the posted menu did not indicate the days date.
Plan of correction
A 4-week menu cycle will be posted outside of the Dining Room. Any substitutions will be noted.
22VAC40-73-980-B
Based on observation, the facility failed to ensure a first aid kit on the vehicle that is used to transport residents contain items as identified in the standard.
Evidence
  1. The vehicle first aid kit did not include adhesive tape, antiseptic wipes/ointment, and a first aid instructional manual.
Plan of correction
The van has a new first aid kit with all items mentioned including a first aid instructional manual.
22VAC40-73-890-B
Based upon observation, the facility failed to ensure that all interior and exterior areas be adequately lighted for the safety and comfort of residents and staff.
Evidence
  1. There were three lights out within the dining room of the facility.
Plan of correction
Management staff to conduct daily rounds to check all common areas for light out and any maintenance repairs.
22VAC40-73-1070-B
Based upon observation, the facility failed to ensure that ordinary materials or objects that are harmful to resident be inaccessible to the residents except under staff supervision.
Evidence
  1. During a tour of the facility on 12/13/2022 and 12/15/2022, the facility’s maintenance closet adjacent to the dining room and employee’s closet on the north hall were left unlocked. Both rooms contained jars of paint, paint supplies, cleaning supplies, and various maintenance equipment.
Plan of correction
Hot water tank room will be kept locked and all hazardous and flammable materials were removed.
22VAC40-73-870-A
Based upon observation, the facility failed to ensure that the interior and exterior of all buildings shall be maintained in good repair and kept clean and free of rubbish.
Evidence
  1. The south hall bathroom has tiles missing on the tub, paint peeling on the walls, stains to the ceiling, a light out, and rust noted on fixtures.
  2. The west hall bathroom has tiles missing on the tub, dirt, dust, and rust noted on fixtures. There were also used wet towels on the floor.
Plan of correction
Management staff to patrol campus for trash & daily rounds to note any maintenance concerns.
22VAC40-73-610-E
Based on discussion, the facility failed to attain a copy of a diet manual containing acceptable practices and standards for nutrition to be kept current and readily available to personnel responsible for food preparation.
Evidence
  1. During the tour of the facility on 12/13/2022, Staff #1 confirmed the facility does not have a copy of a diet manual containing acceptable practices and standards for nutrition.
Plan of correction
Will work with Dietician to provide a diet manual.
22VAC40-73-260-C
Based on observation and discussion, the facility failed to ensure a listing of all staff who have current certification in first aid or CPR is posted in the facility.
Evidence
  1. During the tour of the facility on 12/15/2022, Staff #6 acknowledged a listing of all staff who have current certification in first aid or CPR is not posted in the facility.
Plan of correction
Administrator & BOM will post a listing of staff certified in First Aid & CPR and their expiration dates.
22VAC40-73-350-B
Based on record review, the facility failed to ascertain, prior to admission, whether a potential resident was a registered sex offender and failed to document that this was ascertained and the date the information was obtained.
Evidence
  1. The following residents did not have a completed sex offender screening in their record: Resident #4 (admitted 10/27/2022), Resident #5 (admitted 09/14/2022), and Resident #6 (admitted 01/05/2022).
Plan of correction
Sex offender screenings will be redone for Resident #4, Resident #5 and Resident #6. All qualified applicants will be screened for sex offender PRIOR to admission.
22VAC40-73-550-G
Based on record review, the facility failed ensure the rights and responsibilities of residents in assisted living facilities be reviewed annually with each resident or his legal representative or responsible individual as stipulated in subsection H of this section.
Evidence
  1. The following residents did not have current documentation of an annual review of resident rights and responsibilities: Resident #3, Resident #6, Resident #7, and Resident #8.
Plan of correction
The Resident Rights & Responsibilities will be reviewed with new residents and on an annual basis in January and June.
22VAC40-73-250-D
Based on record review, the facility failed to ensure each staff person or household member required to be evaluated annually submit the results of a risk assessment, documenting that the individual is free of tuberculosis in a communicable form as
Evidence
  1. d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence:
  2. The last tuberculosis risk assessment for Staff #4 was completed on 01/28/2021.
Plan of correction
No later than August 1st each year all employees (except new hires) will receive a TB screening by one of our house physicians.
22VAC40-73-860-G
Based on observation, the facility failed to ensure hot water at taps available to residents are maintained within a range of 105°F to 120°F.
Evidence
  1. During the tour of the facility on 12/13/2022, the hot water taps sampled were not within the required range in the following areas: south hall bathroom measured 128°F and east hall bathroom measured 100°F.
Plan of correction
Maintenance Coordinator to check 3 rooms on each wing weekly and adjust the water temps to read between 105F-120F.
22VAC40-90-40-H
Based on record review, the facility failed ensure any person employed does not have a conviction of any of the barrier crimes.
Evidence
  1. Staff #7 was hired on 04/25/2022. A criminal history record report for Staff #7 was completed on 06/21/2022. The criminal history record report indicates Staff #7 was convicted of a felony barrier crime.
Plan of correction
Any person who has a conviction of any of the barrier crimes will be terminated.
August 29, 2022Complaint survey7 violations
Inspection dates
08/29/2022
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUNDARTICLE 2 – SUBJECTIVITY
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 8/29/22 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 8/16/22 regarding allegations in the area(s) of: Part IV. Staffing and supervision; VI. Resident care and related services; Part VIII. Buildings and Grounds Number of residents present at the facility at the beginning of the inspection: 94 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 4 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: Dining room, water temperatures, bathrooms, residents’ rooms, kitchen, medication administration records, and physician’s orders, resident and staff records were all observed reviewed. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. However, violation(s) not related to the complaint(s) but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alyshia Walker, Licensing Inspector at (757)670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Violations
22VAC40-73-870-A
Based upon observation and discussion with staff, the facility failed to ensure that the interior and exterior of all buildings shall be maintained in good repair and kept clean and free of rubbish.
Evidence
  1. In the south bathroom, there were tiles missing on the tub and paint peeling on the walls.
  2. In one of the bathrooms located on the east hall, there were used wet towels and bath cloths on the floor.
  3. In the same bathroom, the floors were slippery and muddy.
Plan of correction
Tiles were replaced in the South Wing Bathroom. Peeling paint will be removed and repainted. Nursing, housekeeping and administration staff to check bathrooms for wet linens and safety.
22VAC40-73-780-B
Based upon observation and discussion with staff, the facility failed to ensure the building shall be free from foul, stale , and musty odors
Evidence
  1. Inspector noticed a strong urine odor located on the south hall of the facility.
Plan of correction
Soiled residents will be changed immediately. Soiled pullups/ diapers to be doubled bagged and placed in dumpster. Housekeeping/Nursing to disinfect room afterwards.
22VAC40-73-40-B-4
Based on observation, the facility failed to ensure certain documents related to the terms of the license were posted on the premises of thelicensed facility, including the most recently issued license and the findings of the most recent inspection of the facility.
Evidence
  1. During the on-site inspection on 8/29/22, the most recent findings from the inspection dated 12/09/2021 were not posted.
Plan of correction
Administrator will ensure that most recent on-site inspection with findings is posted at the entrance with our DSS AL license.
22VAC40-73-610-B
Based upon observation during the facility tour and discussion with staff, the facility failed to post a current menu which included snacks in an area that is conspicuous to residents.
Evidence
  1. On 8/29/22, during the on-site inspection of the facility, the menu posted was for the previous day 8/28/22 and did not list snacks.
  2. Staff#4 acknowledged that the menu was not current and there was no snack listed.
Plan of correction
Facility will maintain and post a 4-week Menu cycle including snacks available and will note any substitutions.
22VAC40-73-890-B
Based upon observation during facility tour and discussion with staff, the facility failed to ensure that all interior and exterior areas shall be adequately lighted for the safety and comfort of residents and staff.
Evidence
  1. There was one blown light bulb located on the south hall and one light blown inside of the bathroom located on the south hall.
  2. On the same hall there were light bulbs that were flickering.
Plan of correction
Administrator and Maintenance Coordinator will make daily rounds and replace any burnt out light bulbs.
22VAC40-73-1180-B
Based upon observation during facility tour and discussion with staff, the facility failed to ensure that ordinary materials or objects that are harmful to resident be inaccessible to the residents except under staff supervision.
Evidence
  1. On August 29, 2022, during an inspection of the facility, bleach was left unattended in dining area.
  2. On this same date, the facility’s maintenance and employee’s room were left unlocked. Both rooms contained jars of paint and paint supplies.
Plan of correction
Kitchen staff in-serviced on sanitizing dining room and securing cleaning products after use. All cleaning products, paint and paint supplies will be stored in locked area.
22VAC40-73-290-B
Based on an inspection of the facility on 8/29/22, the facility failed to ensure the posting of the name of the current on-site person in charge as required.
Evidence
  1. On 8/29/22 the name of the staff person in charge was Staff #1, who was not in the building during the inspection.
Plan of correction
Administrator will post the Weekly Designated Person in Charge in the front entrance.
February 6, 2022Inspection1 violation
Inspection dates
02/06/2022
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS
Comments
A Representative with the Division of Licensing, conducted an unannounced non-mandated complaint inspection. During the inspection the Licensing Inspector interviewed residents, staff and reviewed additional documentation for compliance. There was not enough evidence to support the allegation and the complaint is found to be not valid. Areas of non-compliance were found during the inspection and are contained within this violation notice. Please contact the facility Licensing Inspector, Kimberly Rodriguez at 757-586-4004 or by email at kimberly.rodriguez@dss.virginia.gov for additional questions or concerns.
Violations
22VAC40-73-70-A
Based on resident and staff interviews 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. On 03/09/2022 while interviewing resident #1, resident #1 confirmed that the resident sustained and fall, that caused bruising to face and lower body. Resident #1 confirmed that the resident was transported to the hospital. Evidence #2: While interviewing staff #1, staff #1 confirmed that resident #1 sustained a fall on 12/09/2021, however the Licensing Department did not receive notification until requested on 02/08/2022
Plan of correction
Not published by VDSS.
December 9, 2021Inspection4 violations
Inspection dates
12/09/2021
Areas reviewed
22VAC40-73 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 PREPAREDNESS
Comments
Two Licensing Inspectors with the Division of Licensing, conducted an unannounced, mandated, renewal inspection on 12/09/2021.The Licensing Inspectors reviewed resident and staff records, observed the facility physical plant and reviewed additional facility documentation for compliance. Areas of non-compliance can be found within this violation notice. Please contact the facility Licensing Inspector Kimberly Rodriguez at 757-586-4004 or by email at kimberly.rodriguez@dss.virginia.gov for additional questions or concerns.
Violations
22VAC40-73-440-A
Based on resident record review the facility failed to ensure All residents and applicants to assisted living facilities shall be assessed face to face using the uniform assessment instrument in accordance with Assessment in Assisted Living Facilities (22VAC30-110) at least annually.
Evidence
  1. While reviewing resident record # 2, the Licensing Inspector observed the residents Uniform Assessment Instrument was last completed on 12/08/2020
Plan of correction
Not published by VDSS.
22VAC40-73-870-E
Based on observation of the facility physical plant the facility failed to ensure, all furnishings, fixtures, and equipment shall be kept clean and in good repair and condition.
Evidence
  1. While conducting a tour of the facility physical plant with the facility Administrator the Licensing Inspector the following areas not in good repair as evidenced by photos taken: 1-Broken Floor Tile 2-Broken cabinet door 3-Peeling and cracked cabinets 4- Chipped and peeling wall paint
Plan of correction
Not published by VDSS.
22VAC40-73-320-B
Based on resident record review the facility failed to ensure subsequent tuberculosis evaluation were completed annually.
Evidence
  1. while reviewing resident record #2, the Licensing Inspector observed the residents last evaluation was completed 10/07/2020.
Plan of correction
Not published by VDSS.
22VAC40-73-450-E
Based on resident record review, the facility failed to ensure the individualized service plan shall be signed and dated by the resident or his legal representative.
Evidence
  1. While reviewing resident record # 2, the Licensing Inspector observed the residents individualize service plan dated 12/09/2020 was not signed by the resident or legal representative.
Plan of correction
Not published by VDSS.
December 9, 2021Complaint survey0 violations
Inspection dates
12/09/2021,01/09/2022
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS
Comments
Two Representatives with the Division of Licensing conducted an unannounced non-mandated complaint inspection. The complaint was initiated on 12/09/2021 and ended on 01/09/22. During the inspection representatives interviewed residents and staff, reviewed resident records and additional documents provided by the facility. There was not enough evidence to support the allegation and the complaint is found to be not valid. Please contact the facility Licensing Inspector, Kimberly Rodriguez at 757-586-4004 or by email at kimberly.rodriguez@dss.virginia.gov for additional questions or concerns.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
December 9, 2021Inspection0 violations
Inspection dates
12/09/2021,01/09/2022
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS
Comments
Two Representatives with the Division of Licensing conducted an unannounced non-mandated inspection on 12/09/2021 and concluded on 01/09/2022. The inspection was in reference to a facility self reported incident. The Licensing Inspectors interviewed residents staff, reviewed resident records and reviewed additional documents for compliance. There were no violations cited during the inspection. Please contact the facility Licensing Inspector, Kimberly Rodriguez at 757-586-4004 or by email at kimberly.rodriguez@dss.virginia.gov for additional questions or concerns.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
June 10, 2021Inspection0 violations
Inspection dates
June 10, 2021 , June 11, 2021 and June 14, 2021
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 monitoring inspection was initiated on June 10, 2021 and concluded on June 14, 2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 90. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 2 resident records, home health documentation, and training records submitted by the facility to ensure documentation was complete. Consultation provided regarding individualized service plans and hospital orders. The information gathered during the inspection determined no violations with applicable standards or law. No violations were issued.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
February 4, 2021Inspection3 violations
Inspection dates
Feb. 4, 2021 , Feb. 17, 2021 , Feb. 18, 2021 and Feb. 19, 2021
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-90 The Sworn Statement or Affirmation
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 February 4, 2021 and concluded on February 19, 2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 89. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 7 resident records, 5 staff records, menus, activities calendars, staff calendars, health inspection, fire inspection, and resident council notes submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility. Consultation was provided regarding Healthcare Oversight, Individualized Service Plans containing appropriate contacts, Activity lengths, Schedules, Training Documentation Requirements.
Violations
22VAC40-73-610-B
Based on record review and discussion, the facility failed to ensure menus for meals documented substitutions or additions shall be recorded on the posted menu.
Evidence
  1. The facility failed to specify items served on the menu each day of January and February 2021 for items such as ?Juice of Choice“, ”Beverage of Choice“ ”Cold Cereal or Hot Cereal“, ”Fruit of the Day“, and ”Mixed Vegetables?.
  2. Staff #1 could not provide the menu with documented substitutions and additions recorded on the posted menu.
Plan of correction
Menu will be changed to specify type of drink, fruit etc. Dietician approved menu substitutions will be noted on the posted weekly menus and the daily menu printouts for all residents to review. Daily Menu printouts with noted substitutions will be filed with the weekly menu for record keeping and available upon request.
22VAC40-73-830-E
Based on record review and discussion, the facility failed to provide a written response to the council prior to the next meeting regarding any recommendations made by the council for resolution of problems or concerns.
Evidence
  1. December 2020 and January 2021 Resident Council notes were reviewed. No documentation was provided of a written response to the council for either month.
  2. Staff #1 confirmed there was no documentation of written response to the residents. ith A ti it C
Plan of correction
Reviewed Resident Council regulations with Activity Coordinator. Activity Coordinator revised the council meeting minutes note taking process. Administrator will review the draft of meeting minutes to ensure all written responses, notification method, and date of responses are properly recorded for documentation moving forward. Issues are to be addressed, if possible, within a week of the monthly Resident Council meeting.
22VAC40-90-30-C
Any person making a materially false statement on the sworn statement or affirmation shall be guilty of a Class 1 misdemeanor.
Evidence
  1. The following staff checked “No” on the question, ?Have you ever been convicted of a law violation(s) but excluding offenses committed before your eighteenth birthday that were finally adjudicated in a juvenile court or under a youth offender law??: Staff #2, Staff #3, Staff #4, Staff #5, and Staff #6.
  2. Staff #1 confirmed the aforementioned staff’s sworn statement or affirmation contained materially false statements contradicting the “Criminal History Request Response” received.
Plan of correction
IRAL created a “New Hire Check List” sheet to ensure all Sworn Statements, background checks & applications are properly filled out with the Administrator & BOM during new hire process. All current employee’s Sworn Statements & background checks will be audited for discrepancies. BOM will meet individually with staff who have improperly filled out Sworn Statements. BOM will review the purpose of the form and the consequences of falsifying information on the Sworn Statement. An opportunity to correct each form will be given at this time. During the application/orientation process, Administrator & BOM will ensure each applicant thoroughly reads & answers Sworn Statement truthfully. Each application will now include a Sworn Statement with “Class I Misdemeanor” highlighted to ensure it is properly seen and read by the applicant.
January 27, 2021Complaint survey2 violations
Inspection dates
Jan. 27, 2021 , Jan. 28, 2021 and Jan. 29, 2021
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A complaint inspection was initiated on January 12, 2021 and concluded on January 29, 2021. A complaint was received by the department regarding allegations in the areas of Resident Care and Related Services and health care services being secured timely for residents with respiratory medical conditions. The Administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the Administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the allegation of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice. Consultation provided regarding healthcare oversight, individualized service plan updates, and admission physical requirements. The complaint is not valid.
Violations
22VAC40-73-480-C
Based on record review and discussion, the facility failed to arrange for specialized rehabilitative services by qualified personnel as needed by the resident. Rehabilitative services include physical therapy, occupational therapy, and speech- language pathology services.
Evidence
  1. Resident #1 admitted to the hospital on 12-20-2020 according to “Discharge Summary” that documented, ?Of note, case management reports that this is living facility is not allowing outside home health, but this should be considered when possible“ Disposition: Return to ALF [assisted living facility] recommend home health services.” The Summary was signed by [Hospital Physician #1] on 12-28-2020.
  2. Resident #4 admitted to the hospital on 12-17-2020 according to “Discharge Summary” that documented, ?The patient is temporarily homebound due to weaknes secondary to covid. PT [physical therapy] is needed to regain mob. SN [skilled nursing] is needed to perform diabetes management. OT [occupational therapy] is needed to equipneeds?? This was signed by [Hospital Physician #2] on 12-23-2020.
  3. Rehabilitative services notes were not provided for Resident #1 or Resident #4’s record. Staff #2 stated due to COVID- 19, they were not allowing therapy services in the building at this time until 02-08-2021; however, there was no discontinued order for rehabilitative services that were recommended.
Plan of correction
IRAL will implement a new binder for home health only. An audit will be conducted on all residents who returned from the hospital starting on 12/1/2020. All resident MARs and TARs will be audited for any discharged orders. The home health binder will be audited monthly for all new orders, discharged orders and make sure that any new orders are complete before being faxed to the Pharmacy.
22VAC40-73-650-B
Based on record review and discussion, the facility failed to ensure physician or other prescriber orders identified the diagnosis, condition, or specific indications for administering each drug.
Evidence
  1. Resident #2’s physician’s orders dated 01-08-2021 did not identify the diagnosis for Duloxetine HCL DR 30 mg cap, Isosorbide MN ER 60 MG tablet, Multi-Day Plus Iron, Oxycodone-Apap 5-325, Rosuvastatin Calcium 20 mg tab, and Victoza 18 mg/3 ML Inject P.
  2. Staff #2 confirmed Resident #2’s latest signed orders did not contain all if the required information.
Plan of correction
Going forward, all new orders will be reviewed for completeness including diagnosis. The RCC or ARCC will check off before new order is faxed to the pharmacy.