Virginia DSS · Assisted Living Facility

Harmony at Harbour View

📍 5871 Harbour View Boulevard, Suffolk, VA, 23435

ID 45465One Year licenseActive
48
Inspections
On record
35
With violations
Visits that cited something
13
Clean visits
Nothing cited
143
Violations cited
Individual findings
75
Standards cited
Distinct rules
28
Complaint visits
Prompted by a complaint

Harmony at Harbour View was inspected 48 times between January 6, 2021 and March 10, 2026 by the Virginia Department of Social Services. 35 of those visits ended with violations cited and 13 with none. Across that history VDSS cited 143 violations under 75 distinct standards. 28 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. 45 of these 48 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
08/15/2026
Administrator
Cristy Hansen
Licensing inspector
Donesia Peoples
Inspector phone
757 353-0430
Approved for
Assisted Living · Special Care Unit · Ambulatory Only · Non-Ambulatory

Inspection History

48

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

March 10, 2026Complaint survey1 violation
Inspection dates
03/10/2026
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 IMPAIRMENTS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 03/10/2026 at 10:45 am to 11:48 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 03/08/2026 regarding allegations in the areas of: Resident Care and Related Services and Buildings and Grounds Number of residents present at the facility at the beginning of the inspection: 81 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 6 Observations by licensing inspector: Residents were observed eating lunch. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations: areas of non-compliance with standard(s) or law were: Building and Grounds A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of these inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-860-G
Based on the observation of the water temperature, and staff interviews the facility failed to ensure hot water at taps available to residents shall be maintained within a range of 105°F to 120°F.
Evidence
  1. During the onsite inspection on 03/10/26 the Licensing Inspector (LI) along with staff #1 measured the hot water temperature in the bathrooms of resident #1, resident #2, and resident #3. The hot water temperature was read as the following: • 78.8°F in the bathroom of resident #1 • 77.0°F in the bathroom of resident #2 • 76.5 °F in the bathroom of resident #3
  2. During an interview on 03/10/26 with resident #2, resident #2 stated the water in the resident’s bathroom has not been hot within the past few days.
  3. During an interview on 03/10/26 with resident #3, resident #3 stated the water in the resident’s bathroom has not been running hot water since the weekend of 03/07/2026.
  4. During an interview on 03/10/26 with staff #1, and staff #2, staff #1 and staff #2 confirmed the facility did not have hot water as of 03/08/26 due to a water pump replacement needed for the facility’s boiler.
Plan of correction
What has Been Done to Correct? The facility promptly initiated corrective action upon identification of the issue with hot water temperatures. Replacement parts for the boiler system were ordered and installed. During the repair process, the technician identified that the twin high-efficiency, constant pressure booster pump system was not functioning properly. The malfunctioning pumps were immediately ordered and replaced upon arrival. Following the completion of all repairs, hot water service was fully restored throughout the community. Water temperature readings were obtained in multiple resident locations and were within the required regulatory range, with documented readings of 107.1°F, 105.4°F, 108.2°F, and 105.8°F. How Will Recurrence Be Prevented? The facility has implemented a comprehensive preventative maintenance program for the boiler and hot water systems, which includes contracted servicing at a minimum of every six months and additional service as needed. In addition, the facility has established routine monitoring procedures to ensure ongoing compliance with hot water temperature regulations. Maintenance Director/designee will check and document water temperatures in resident areas on a weekly basis to confirm temperatures remain within the required range of 105°F to 120°F. Maintenance staff have been educated on promptly identifying and addressing any issues related to hot water systems. Any temperature readings outside of the acceptable range will be reported immediately, and corrective action will be initiated without delay. The Executive Director and/or designee will review temperature logs monthly to ensure compliance and accountability. Person Responsible: Executive Director Due Date: 4.1.2026
March 10, 2026Complaint survey0 violations
Inspection dates
03/10/2026
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 IMPAIRMENTS
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: An unannounced complaint inspection took place on 03/10/2026 at 11:49 am to 1:02 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 03/08/2026 regarding allegations in the area(s) of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 81 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 2 Observations by licensing inspector: Lunch was observed, and an observation of the facility's food supply was completed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the (allegation(s)/self-report) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
February 19, 2026Inspection2 violations
Inspection dates
02/19/2026
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 IMPAIRMENTS
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: An unannounced monitoring inspection took place on 02/19/2026 at 9:37 am to 11:35 am. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 01/30/2026 regarding allegations in the areas of: Resident Care and Related Services and the Safe Secure Environment Number of residents present at the facility at the beginning of the inspection: 64 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed:0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Residents were observed in the facility’s safe secure environment. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of these inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-460-D
Based on the incident report review, record review, and staff interview the facility failed to ensure the facility shall provide supervision of resident schedules, care, and activities, including attention to specialized needs, such as prevention of falls and wandering from the premises.
Evidence
  1. Resident #1’s review of appropriateness of continued residence in special care unit dated 01/01/26 documents the resident has a diagnosis of dementia and is not able to recognize danger or provide for his own safety. Photographic evidence is available.
  2. Resident #1’s Individualized Service Plan (ISP) dated 12/05/25 documents the resident as a fall risk, disoriented with all spheres, some of the time and that the resident requires assistance with wandering weekly or more. Photographic evidence is available.
  3. Resident #1’s incident report dated 01/30/26 documents the following: • The resident was found outside of the community, lying on the ground in the grass. • The resident was identified as a memory care resident of the community. • The resident was assessed with bloody cuts on both hands and a bruise on the right cheek. • The resident was sent to the Emergency Room and was diagnosed with fall with facial contusions, skin tear of right hand, skin tear of right elbow, abrasion of right knee, and effusion of left elbow. Photographic evidence is available.
  4. During an interview on 02/19/26 with staff #2, staff #2 confirmed resident #1 exited the facility’s safe secure unit on 01/30/26 at 7:16 am through an unlocked door that leads to the assisted living facility and then the resident exited the building. Staff #2 confirmed the assisted living facility staff was not aware during the time of 7:16 am to 7:20 am that the resident had exited the building and the concierge staff was notified at 7:20 am that the resident was outside.
Plan of correction
What Has Been Done to Correct? The facility immediately addressed the elopement risk identified for Resident #1. Interim safety measures were implemented, including the installation of audible door alert systems that activate when an individual approaches the designated exit points, allowing staff to respond promptly and prevent unauthorized exits. In addition, the facility engaged Security Technology Group (STG) to evaluate and enhance the security of the memory care unit. The facility is currently collaborating with STG and the City of Suffolk to obtain approval for the installation of magnetic locking (mag lock) systems on designated exit doors. Upon approval, STG will complete installation and ensure proper functionality of the system. Staff were immediately re-educated on resident supervision expectations, particularly for residents identified as at risk for wandering and elopement, and on maintaining awareness of secured unit integrity at all times. How Will Recurrence Be Prevented? All exit points in the memory care unit will be equipped with functioning alarm systems to alert staff of door approach and exit attempts. Upon approval and installation, magnetic locking systems will provide an additional layer of security to prevent unauthorized exits. The facility will conduct safety checks each shift to ensure all doors and alarms are function properly. Any identified issues will be addressed immediately. Staff will receive ongoing training and re-education on supervision requirements, elopement prevention, and the specific needs of residents with dementia, including those identified as fall and wandering risks. Emphasis will be placed on increased vigilance during high-risk times, such as shift changes and early morning hours. Residents identified as at risk for wandering will be closely monitored per their Individualized Service Plans (ISPs), and care plans will be reviewed and updated as needed to reflect appropriate interventions by Healthcare Director/designee. The Executive Director and/or designee will conduct regular audits of incident reports, supervision practices, and safety checks to ensure compliance and accountability. Person Responsible: Executive Director
22VAC40-73-1150-A
Based on the record review and staff interviews the facility failed to ensure doors that lead to unprotected areas shall be monitored or secured through devices that conform to applicable building and fire codes, including door alarms, cameras, constant staff oversight, security bracelets that are part of an alarm system, pressure pads at doorways, delayed egress mechanisms, locking devices, or perimeter fence gates. Residents who reside in safe, secure environments may be prohibited from exiting the facility or the special care unit if applicable building and fire codes are met.
Evidence
  1. Staff #2 sent an email to the Licensing Inspector on 02/02/26 as a follow up to resident #1’s incident report of an elopement that occurred on 01/30/26. The email stated that when a staff member exited the memory care (special care unit) resident #1 was able to walk out shortly afterwards. Photographic evidence is available.
  2. During an interview on 02/19/26 with staff #2, staff #2 confirmed that staff #1 exited the memory care on 01/30/26 at 7:09 am and the doors did not lock after the staff exited the memory care. Resident #1 exited the memory care at 7:16 am through the unlocked exit doors.
  3. Staff #2 stated staff #2 reviewed the facility’s camera footage after the incident on 01/30/26 to confirm staff #1’s and resident #1’s exit times from the memory care. Photographic evidence is available.
  4. During an interview on 02/19/26 with staff #3, staff #3 confirmed at the time of the resident’s exit from the memory care on 01/13/26 at 7:16 am, staff #3 was working on duty in the memory care unit and confirmed the door alarm did not sound and the cameras were not monitored by staff at the time of the resident’s exit
Plan of correction
What Has Been Done to Correct? The facility immediately addressed the elopement risk identified for Resident #1. Interim safety measures were implemented, including the installation of audible door alert systems that activate when an individual approaches the designated exit points, allowing staff to respond promptly and prevent unauthorized exits. In addition, the facility engaged Security Technology Group (STG) to evaluate and enhance the security of the memory care unit. The facility is currently collaborating with STG and the City of Suffolk to obtain approval for the installation of magnetic locking (mag lock) systems on designated exit doors. Upon approval, STG will complete installation and ensure proper functionality of the system. Staff were immediately re-educated on resident supervision expectations, particularly for residents identified as at risk for wandering and elopement, and on maintaining awareness of secured unit integrity at all times. How Will Recurrence Be Prevented? All exit points in the memory care unit will be equipped with functioning alarm systems to alert staff of door approach and exit attempts. Upon approval and installation, magnetic locking systems will provide an additional layer of security to prevent unauthorized exits. The facility will conduct safety checks each shift to ensure all doors and alarms are function properly. Any identified issues will be addressed immediately. Staff will receive ongoing training and re-education on supervision requirements, elopement prevention, and the specific needs of residents with dementia, including those identified as fall and wandering risks. Emphasis will be placed on increased vigilance during high-risk times, such as shift changes and early morning hours. Residents identified as at risk for wandering will be closely monitored per their Individualized Service Plans (ISPs), and care plans will be reviewed and updated as needed to reflect appropriate interventions by Healthcare Director/designee. The Executive Director and/or designee will conduct regular audits of incident reports, supervision practices, and safety checks to ensure compliance and accountability. Person Responsible: Executive Director
December 17, 2025Complaint survey0 violations
Inspection dates
12/17/2025
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 GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 12/17/2025 at 12:04 pm to 3:33 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 12/10/2025 regarding allegations in the areas of: Resident Care and Related Services, and the Safe Secure Environment. Number of residents present at the facility at the beginning of the inspection: 80 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Residents were observed in the safe secure environment. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
December 17, 2025Complaint survey0 violations
Inspection dates
12/17/2025
Areas reviewed
22VAC40-73 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 IMPAIRMENTS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 12/17/2025 at 10:35 am to 12:03 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 11/17/2025 regarding allegations in the areas of: Resident Care and Related Services, and Buildings and Grounds Number of residents present at the facility at the beginning of the inspection: 80 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 1 Observations by licensing inspector: The facility’s elevators and emergency preparedness plan was reviewed. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
October 7, 2025Complaint survey1 violation
Inspection dates
10/07/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 10/07/2025 at 12:16 pm to 5:20 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 09/23/2025 regarding allegations in the areas of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 80 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: 3 Number of interviews conducted with staff: 4 Observations by licensing inspector: Lunch and the facility’s dining areas were observed. The facility’s staffing schedule was reviewed. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: Resident Care and Related Services A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-460-B
Based on the record review and resident interview the facility failed to ensure care provision and service delivery should be resident-centered to the maximum extent possible and include: Prompt response by staff to resident needs as reasonable to the circumstances.
Evidence
  1. Resident #2’s Individualized Service Plan (ISP) identifies the following needs dated 08/18/25: the resident requires mechanical help and human assistance with bathing, dressing, toileting, and transferring. 2.Resident #2’s call pendant logs documents the resident pushed her emergency pendant on the following dates and times: • 9/03/25 at 5:13 am. The response time of staff response to the resident is documented at 6:07 am. • 9/17/25 at 9:48 pm. The response time of staff response to the resident is documented at 10:37 pm. • 9/20/25 at 7:05 am. The response time of staff response to the resident is documented at 8:51 am. • 9/22/25 at 7:04 am. The response time to the resident is documented at 7:48 am.
  2. During an interview on 10/07/25 with resident #2. Resident #2 confirmed pushing her emergency pendant several times in the month of September 2025 and waiting 45 minutes or more for staff to respond to needs for toileting, dressing, and bathing. Resident #2 confirmed on the day of 9/20/25 the resident waited over an hour for staff assistance to get out of her recliner chair and to use the restroom, and because of the wait time the resident soiled her clothing.
  3. During an interview on 10/07/25 with staff #4, staff #4 confirmed the September 2025 emergency pendant logs for resident #2 documented the response time by staff was more than 45 minutes on the dates of 09/03/25, 09/17/25, 09/20/25, and 09/22/25.
Plan of correction
1. Corrective Action for Residents Potentially Affected A facility-wide audit of all resident care plans was conducted to ensure: Documentation of resident participation in care decisions Inclusion of individualized preferences (e.g., daily routines, activity choices, cultural considerations) Clear instructions for staff on prompt response expectations Any missing or outdated information was corrected in collaboration with the resident or their representative. 2. Systemic Changes to Prevent Recurrence All direct care staff to complete mandatory training on: Principles of resident-centered care Communication techniques to involve residents in decision-making Strategies for timely response to resident needs Training completion documented in personnel files. Residents (and/or representatives) will be invited to all care conferences. 3. Monitoring and Quality Assurance HCD or designee will conduct regular rounds and interview residents about satisfaction with participation, personalization, and response times. 4. Responsible Parties Administrator – Oversight of compliance. HCD – Care plan audits, staff education, and resident interviews; and ongoing monitoring and data analysis. 5. Completion Date December 24, 2025
October 7, 2025Complaint survey1 violation
Inspection dates
10/07/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 10/07/2025 at 12:16 pm to 5:20 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 09/10/2025 regarding allegations in the areas of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 80 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: 3 Number of interviews conducted with staff: 4 Observations by licensing inspector: Lunch and the facility’s dining areas were observed. The facility’s staffing schedule was reviewed. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: Resident Care and Related Services A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-680-D
Based on the record review, resident interview, and staff interview the facility failed to ensure medications shall be administered in accordance with the physician's or other prescriber’s instructions.
Evidence
  1. The record for resident #4 contains the following: • A physician order dated 09/05/25 for diclofenac 1% topical gel to apply 2 gram to affected area three times a day, apply to both knees three times a day. • A physician order dated 5/25/22 for Refresh eye drops, 1 drop every bedtime. • A physician note dated 8/26/25 with instructions for Restasis , 1 drop in both eyes twice daily; acetaminophen 1 tablet by mouth twice daily; Ensure 1 bottle by mouth twice daily.
  2. Resident #4’s September 2025 Medication Administration Record (MAR) documents on the days of 09/07/25 and 09/08/25 the resident was not administered the following medications as prescribed: • Ensure scheduled at 5:00pm • Refresh eye drops scheduled at 6:00pm • Restasis eye drops scheduled at 8:00pm • Acetaminophen scheduled at 8:00pm The MAR documents the reason as “see home health notes.”
  3. Upon request and during an interview on 10/07/25 with staff #4, staff #4 was not able to provide home health notes dated 09/07/25 and 09/08/25 for resident #4 nor was staff #4 able to provide documentation of the reason the resident was not administered medications as prescribed on the dates of 09/07/25 and 09/08/25.
Plan of correction
1. Corrective Action Taken for the Affected Resident(s): A full medication administration record (MAR) audit was conducted for all residents over the past 30 days to identify medication errors or discrepancies. For any resident affected by a medication error: The prescriber was notified to include RP if the resident does not have capacity. The resident’s condition was monitored and documented. Corrective action, including follow-up orders, was implemented promptly. An incident report was completed, and the event was logged and reviewed for quality improvement. 2. Systemic Changes to Prevent Recurrence: All Medication Administration Records (MARs) are now being reviewed by the Medication Aide or Health Care Director or Designee to ensure accuracy and compliance with current physician orders. A medication reconciliation process has been implemented: Orders are reviewed and verified upon admission, hospital discharge, and after each provider visit. Any changes to medication orders are sent to the pharmacy and confirmed on delivery. Staff retraining has been completed for all medication aides and licensed nurses on: Proper medication administration techniques, using the Five Rights to Medication Administration. Prescriber orders will be verified and confirmed with provider, prior to administration. Documentation standards and error reporting procedures. 3. Monitoring and Quality Assurance: The Health Care Director or designee will: Conduct weekly MAR audits for all residents for the next 90 days. Observe medication passes randomly to ensure adherence to best practices. Medication errors will be tracked and analyzed monthly using a medication error log. 4. Date of Completion: December 24, 2025
October 7, 2025Complaint survey0 violations
Inspection dates
10/07/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced monitoring inspection took place on 10/07/2025 at 12:15 pm to 5:20 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 09/15/2025 regarding allegations in the areas of: Resident Care and Related Services, The Safe Secure Unit, and Building and Grounds Number of residents present at the facility at the beginning of the inspection: 80 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 4 Observations by licensing inspector: The Safe Secure Unit Exit Doors Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
October 7, 2025Inspection0 violations
Inspection dates
10/07/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
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: An unannounced monitoring inspection took place on 10/07/2025 at 11:05 am to 12:15 pm. 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 09/22/2025 regarding allegations in the areas of: Personnel and Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 80 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 4 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
August 26, 2025Complaint survey0 violations
Inspection dates
08/26/2025
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 08/26/2025 at 1:25 pm to 1:55 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 08/11/2025 regarding allegations in the areas of: Buildings and Grounds Number of residents present at the facility at the beginning of the inspection: 82 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 4 Observations by licensing inspector: Entrance and exit doors were observed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
July 22, 2025Complaint survey3 violations
Inspection dates
07/22/2025, 07/23/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 07/22/2025 at 8:25 am to 5:25 pm and 07/23/2025 at 9:10 am to 3:40 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 7/18/2025 regarding allegations in the areas of: Personnel, Resident Care and Related Services and The Safe Secure Environment. Number of residents present at the facility at the beginning of the inspection: 81 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 5 Observations by licensing inspector: Breakfast was observed and residents were observed in the common areas in the safe secure unit. The facility staffing schedule and round logs were reviewed. Additional Comments/Discussion An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: Personnel and the Safe Secure Unit A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-220-B
Based on review of the facility’s private duty personnel list and staff interview, the facility failed to ensure when private duty personnel who are not employees of a licensed home care organization provide direct care or companion services to residents in an assisted living facility, the requirements listed under subdivisions A 2 through A 6 of this section apply. In addition, before direct care or companion services are initiated, the facility shall ensure compliance with the requirements listed in this subdivision B1 through B3.
Evidence
  1. The facility provided a list of the following residents receiving direct care or companion services from private duty personnel who are not employees of a licensed home care organization: a) Resident #2 b) Resident #3 c) Resident #5
  2. Upon request and during an interview on 07/23/25 with staff #2. Staff #2 was not able to provide the following documentation for the private duty personnel providing care to resident #2, resident #3, and resident #5: a) Documentation in writing on the type and frequency of the services to be delivered to the resident by private duty personnel. b) Evidence of completion of a tuberculosis examination and report. c) Documentation of qualifications for the type of care provided. d) Criminal History report e) Orientation and training on the facilities policy and procedures regarding private duty personnel.
  3. During an interview on 07/23/25 with private duty personnel #1, private duty personnel #1 confirmed providing direct care services to include bathing and dressing once or twice weekly since January 2024 for resident # 2 (admission date 06/01/21). Private duty personnel #1 confirmed not being employed with a licensed home care organization.
Plan of correction
1. Corrective Action Taken for the Affected Resident(s): • A full review was conducted of all residents receiving services from non-agency private duty personnel. • For each case: o Background checks, training records, and qualifications were obtained and reviewed. o Written authorization from the resident or legal representative was secured. o The resident’s Individualized Service Plan (ISP) was updated to reflect private duty involvement. o Facility care staff were briefed on the scope of services being provided. o Any unauthorized or noncompliant personnel were immediately suspended from providing care until full compliance was confirmed. 2. Systemic Changes to Prevent Recurrence: • The facility developed a Private Duty Personnel Onboarding Packet which must be completed before services begin. It includes: o A background and registry check attestation. o Documentation of training and competency verification. o Resident or legal representative consent form. o Statement of care coordination agreement. o Identification badge issuance protocol. • A Private Duty Personnel Review Form is now required to be completed by the Administrator or Designee before approval. • All private duty personnel are logged in a Private Duty Services Roster, with: o Dates of service o Shift times o Services provided • Facility staff are now trained to report any unidentified or unauthorized caregivers to administration immediately. 3. Staff Training • All administrative, admissions, and health services staff have been retrained on: o Regulatory requirements under subdivisions A2-A6 and B1-B3. o How to process and approve private duty personnel. o How to document and coordinate external care services. 4. Monitoring and Quality Assurance: • The Administrator or designee will: o Review all new private duty personnel files prior to service initiation. o Conduct monthly audits of all active private duty caregivers for 90 days. o Confirm compliance with background checks, training, consent, and care logs. • Audit findings and trends will be discussed in monthly QAPI meetings. • Any deficiencies will result in immediate corrective action and retraining.
22VAC40-73-930-D
Based on the record review and staff interview the facility failed to ensure for each resident with an inability to use the signaling device the following shall be met: a minimal frequency of daily rounds to be made; once the resident has gone to bed each evening until the resident has arisen each morning, at a minimum direct care staff shall make rounds no less than every two hours; the facility shall document the rounds that were made, which shall include the name of the resident, the date and time of the rounds, and the staff member who made the rounds.
Evidence
  1. The record for resident #2 contains an Individualized Service Plan (ISP) dated 03/05/25 that documents the following identified need: “Round checks every 2 hours. Resident will be checked on every 2 hours, resident is unable to acclimate to use of call bell.”
  2. The facility’s May, June, and July 2025 round logs did not include documentation 2-hour rounds were completed for resident #2 on the following dates and shifts: a) 05/11/25, 3pm to 11 pm. b) 05/26/25, 11pm to 7am. c) 06/18/25, 11pm to 7am. d) 06/27/25, 11pm to 7am. e) 07/08/25, 11pm to 7am. f) 07/11/25, 3pm to 11pm.
  3. During an interview on 07/23/25 with staff #3, staff #3 confirmed the 2-hour round logs for May, June, and July 2025 were missing documentation of the 2 hour rounds being completed on the following dates and staff #3 was not able to provide documentation the 2 hour rounds were completed on these dates: a) 05/11/25, 3pm to 11 pm. b) 05/26/25, 11pm to 7am. c) 06/18/25, 11pm to 7am. d) 06/27/25, 11pm to 7am. e) 07/08/25, 11pm to 7am. f) 07/11/25, 3pm to 11pm.
Plan of correction
. Corrective Action Taken for the Affected Resident(s): • A list of all residents unable to use the signaling device was immediately complied and verified by the Health Care Director or Designee. • For each affected resident: o A care conference was held to confirm continued inability to use the call system and reassess overnight needs. o Rounds were initiated every two hours overnight and scheduled during the day based on individual needs. o All missing documentation was reviewed, and new forms were initiated for accurate tracking. o Any issues or changes in resident condition due to lack of monitoring were evaluated and addressed immediately. 2. Systemic Changes to Prevent Recurrence: • A new “Resident Rounding Log” has been implemented for all residents unable to use a call system. The form includes: o Resident’s name o Date o Time of each round o Initials or printed name of staff completing the round • A bedtime-to-wake-up rounding schedule is now included in each affected resident’s Individualized Service Plan (ISP). • Direct care staff have been assigned specific rounding responsibilities during each shift and trained on: o How often rounds must be conducted o The importance of documentation o What to observe during rounds (e.g., incontinence care, positioning, safety, comfort) • A “No-Call Capability Resident List” is posted in the Resident Rounding Log. 3. Staff Training: • All direct care staff and supervisory staff were retrained on: o Requirements for rounding on residents unable to use signaling devices. o Documentation standards o Responding to and reporting unmet needs discovered during rounds. 4. Monitoring and Quality Assurance: • The Administrator or designee will: o Conduct random audits of rounding logs (3) times per week for 60 days, then weekly. o Directly observe overnight rounding at least once per month. • Any missed rounds or incomplete documentation will result in: o Immediate correction and o Coaching or progressive disciplinary action as needed • Rounding compliance and trends will be discussed during monthly QAPI meetings to ensure ongoing accountability.
22VAC40-73-220-A
Based on the staff interview the facility failed to ensure when private duty personnel from a licensed home care organizations provide direct care or companion services to residents in an assisted living facility, the following applies as listed under subdivisions A1 through A6 of this section.
Evidence
  1. During an interview on 07/23/25 with staff #2, staff #2 stated resident #4 (admission date 08/06/24) is receiving private duty personnel services from a licensed home care organization.
  2. Upon request on 07/23/25, staff #2 was not able to provide the following documentation for the private duty personnel providing services to resident #4: a) Documentation in writing on the type and frequency of the services to be delivered to the resident by private duty personnel. b) Evidence of completion of a tuberculosis examination and report. c) Orientation and training on the facilities policy and procedures regarding private duty personnel.
Plan of correction
1. Corrective Action Taken for the Affected Resident(s): • All current private duty staff working in the facility were reviewed to: o Verify licensure of their affiliated home care agency. o Obtain and review documentation of criminal background checks and training. o Ensure they were clearly identified while in the facility (e.g., name badge with agency name). • The facility contacted each affected resident (and/or their legal representative) to confirm: o Authorization for private duty services. o Continued appropriateness of care based on their current ISP. 2. Systemic Changes to Prevent Recurrence: • A Private Duty Personnel Verification Form has been developed and is now required for each new private duty caregiver working in the facility, including: o Name and credentials of caregiver o Copy of agency license o Documentation of training and background check o Scope of services to be provided • All private duty personnel must wear visible identification including the name of the home care agency at all times while in the facility. • A Private Duty Services Log has been implemented to: o Track entry and exit times o Log services provided o Ensure coordination with facility care staff • The Health Care Director or Designee will review each resident’s ISP to ensure services provided by private duty personnel are: o Aligned with the facility’s service plan. o Do not duplicate or conflict with care provided by facility staff 3. Staff Training: • All administrative and care management staff have been retrained on: o Regulatory requirements for oversight of private duty personnel (A1-A6). o Documentation standards and communication expectations. o Protocol for reporting concerns about private duty caregivers or agencies. 4. Monitoring and Quality Assurance: • The Administrator or designee will: o Conduct monthly audits of private duty personnel files for 3 months. o Perform random spot checks to ensure private duty staff are appropriately identified and providing care within their scope. • Documentation and compliance results will be reviewed during monthly Quality Assurance and Performance Improvement (QAPI) meetings. • Ongoing tracking will ensure only properly verified private duty staff are authorized to provide services within the facility.
July 22, 2025Inspection10 violations
Inspection dates
07/22/2025, 07/23/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS
Technical assistance
22VAC40-73-270 First Aid/CPR Posting
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: An unannounced renewal inspection took place on 07/22/2025 at 8:25 am to 5:25 pm and 07/23/2025 at 9:10 am to 3:40 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 81 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 7 Observations by licensing inspector: A tour of the facility was conducted to include inside and outside building grounds. Breakfast, lunch, and an activity were observed. A medication pass observation was completed for three residents. The following were reviewed: staffing schedule, emergency preparedness drills, medication carts, first aid kits, fire inspection report, certificate of liability insurance, and a health inspection report. Water temperature was measured, and the call bell system was monitored. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-450-C
Based on the record review and staff interview the facility failed to ensure the comprehensive individualized service plan (ISP) shall include the following: A description of identified needs and date identified based upon the UAI. The expected outcome and timeframe for expected outcome.
Evidence
  1. The record for resident #4 contains an ISP dated 06/27/25. The ISP in the record does not include the following: a) date the needs were identified. b) expected outcome and timeframe for expected outcome.
  2. During an interview on 07/23/25 with staff #4 and staff #5, staff #4 and staff #5 confirmed resident’s #4 ISP did not include the following: a) date the needs were identified. b) expected outcome and timeframe for expected outcome.
Plan of correction
Not published by VDSS.
22VAC40-73-350-B
Based on the record review and staff interview the facility failed to ascertain, prior to admission, whether a potential resident is a registered sex offender if the facility anticipates the potential resident will have a length of stay greater three days or in fact stays longer than three days and shall document in the resident’s record that this was ascertained and the date the information was ascertained.
Evidence
  1. The record for resident #2, admission date of 11/19/24, does not contain documentation a registered sex offender screening was completed prior to the resident’s admission.
  2. During an interview on 07/22/25 with staff #7, staff #7 confirmed the following: a) the facility did not document in resident’s #2 record that a sex offender screening was ascertained prior to the resident’s admission. b) resident’s #2 record did not contain documentation of a sex offender screening completed prior to the resident’s admission.
  3. Upon request of a sex offender screening for resident #2, staff #7 provided a sex offender screening dated as completed on 07/22/2025 for resident #2.
Plan of correction
1. Corrective Action Taken for the Affected Resident(s): • A retrospective review has been initiated for all current residents who were admitted without a documented sex offender registry check. • Any missing verifications will be immediately conducted via the applicable state and national sex offender registries. • The date of verification and outcome will be documented in each affected resident’s record. 2. Systemic Changes to Prevent Recurrence: • A Pre-Admission Screening Checklist has been updated to include a mandatory Sex Offender Registry Check for all prospective residents. • The facility has a “Sex Offender Verification Form”, to be: o Completed prior to admission, o Signed and dated by the administrator or designee • Admission staff have been retrained on: o How to perform sex offender registry checks using state and federal databases, o The importance of documenting the verification date, o The process for recording results in the resident’s file. • No resident will be admitted without completion of this step. 3. Monitoring and Quality Assurance: • The Administrator or designee will review 100% of new admissions to ensure compliance with sex offender verification procedures for the next 90 days. • After 90 days, random audits of minimum of 25% of monthly admissions will be conducted.
22VAC40-73-450-F
Based on the record review and staff interview the facility failed to ensure the individualized service plan (ISP) shall be reviewed and updated at least once every 12 months and as needed for a significant change in the resident’s condition.
Evidence
  1. The record for resident # 3 contains an ISP completed on 06/06/23. The resident’s record does not contain documentation the resident’s ISP was reviewed and updated at least once every 12 months after 06/06/23.
  2. During an interview on 07/22/25 with staff #4, staff #4 confirmed resident’s #3 ISP dated 06/06/23 did not contain documentation the ISP was reviewed and updated at least once every 12 months after 06/06/23.
  3. Upon request on 07/22/25, staff #4 was not able to provide an ISP completed after 06/06/23 for resident #3.
Plan of correction
1. Corrective Action Taken for the Affected Resident(s): • The Administrator and Designee completed a comprehensive audit of all resident records to: o Identify ISPs that were overdue for annual review. o Identify residents who experienced a significant change without corresponding ISP updates. • For each affected resident: o The ISP was reviewed and updated immediately to reflect current care needs. o The resident and, if applicable, their legal representative were involved in the review process. o Updated ISPs were signed, dated, and filed in the resident’s permanent record. 2. Systemic Changes to Prevent Recurrence: • All relevant staff have been retrained on: o Annual ISP review requirements o Criteria for “significant change” in a resident’s condition o Timelines and documentation procedures for updating ISPs 3. Monitoring and Quality Assurance: • The Administrator or designee will: o Monitor Yardi Dashboard daily for ISP dates and completion dates. o 100% chart audit for annual ISP will be completed x 3 months. o Audit 25% of all updated ISPs monthly to verify they were completed timely and accurately. • Any discrepancies will be addressed through immediate staff retraining or corrective documentation.
22VAC40-73-450-E
Based on the record review and staff interview the facility failed to ensure the individualized service plan (ISP) shall be signed and dated by the licensee, administrator, or his designee, (i.e., the person who has developed the plan), and by the resident or his legal representative.
Evidence
  1. The record for resident #4 contains an ISP dated 06/27/25. The ISP is not signed by the licensee, administrator, or his designee, (i.e., the person who has developed the plan), and is not signed and dated by the resident or his legal representative.
  2. During an interview on 07/23/25, with staff #4, staff #4 confirmed resident’s #4 ISP dated 06/27/25 is not signed by staff #4 (the person who developed the plan) and is not signed and dated by the resident or his legal representative.
Plan of correction
1. Corrective Action Taken for the Affected Resident(s): • The Administrator and Designee reviewed all current ISPs to identify deficiencies. • For each affected resident: o The UAI was cross-referenced to ensure all identified needs were accurately captured in the ISP. o Missing elements (need description, dates, outcomes, and timeframes) were immediately added or corrected. o Revised ISPs were reviewed with the resident and, if applicable, their legal representative. o Signed and dated updates were filed in the resident record. 2. Systemic Changes to Prevent Recurrence: • All direct care and assessment staff have been retrained on: o Regulatory requirements for ISP content o How to properly interpret and transfer information from the UAI into the ISP o The importance of clearly defined, person-centered outcomes and realistic timeframes • ISPs will now be reviewed and approved by the Administrator or designee before being finalized and filed. 3. Monitoring and Quality Assurance: • The Administrator or designee will conduct monthly audits of: o All new ISPs o 25% of updated or annual review ISPs • Audits will ensure each ISP includes: o Needs, dates, outcomes, and timeframes linked to the UAI
22VAC40-73-680-D
Based on the record review, medication administration record review (MAR) review, and staff interview, the facility failed to ensure medications shall be administered in accordance with the physician’s or other prescriber’s instructions.
Evidence
  1. The record for resident #1 contains a physician order dated 08/09/24 that includes the following: a) Atorvastatin 20mg, take 1 tablet daily with dinner for hyperlipidemia. b) Metformin ER 500 mg, take 1 tablet daily at dinner for prediabetes.
  2. Resident’s #1 June 2025 MAR documents the resident was not administered the following medications on 06/08/25 scheduled at 5:00 pm: a) Atorvastatin 20mg b) Metformin 500 mg The MAR and the resident’s record did not document the reason why the medication was not administered.
  3. During an interview on 07/23/25 with staff #4 and staff #5, staff #4 and staff #5 reviewed resident’s #1 June 2025 MAR and confirmed the MAR did not contain a reason resident #1 was not administered the following medications on 06/08/25 at 5:00 pm: a) Atorvastatin 20mg b) Metformin 500 mg
Plan of correction
1. Corrective Action Taken for the Affected Resident(s): • A full medication administration record (MAR) audit was conducted for all residents over the past 30 days to identify medication errors or discrepancies. • For any resident affected by a medication error: o The prescriber was notified to include RP if the resident does not have capacity. o The resident’s condition was monitored and documented. o Corrective action, including follow-up orders, was implemented promptly. o An incident report was completed, and the event was logged and reviewed for quality improvement. 2. Systemic Changes to Prevent Recurrence: • All Medication Administration Records (MARs) are now being reviewed by the Medication Aide or Health Care Director or Designee to ensure accuracy and compliance with current physician orders. • A medication reconciliation process has been implemented: o Orders are reviewed and verified upon admission, hospital discharge, and after each provider visit. o Any changes to medication orders are sent to the pharmacy and confirmed on delivery. • Staff retraining has been completed for all medication aides and licensed nurses on: o Proper medication administration techniques, using the Five Rights to Medication Administration. o Prescriber orders will be verified and confirmed with provider, prior to administration. o Documentation standards and error reporting procedures. 3. Monitoring and Quality Assurance: • The Health Care Director or designee will: o Conduct weekly MAR audits for all residents for the next 90 days. o Observe medication passes randomly to ensure adherence to best practices. • Medication errors will be tracked and analyzed monthly using a medication error log.
22VAC40-73-410-A
Based on the record review and staff interview the facility failed to ensure upon admission, the assisted living facility shall 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 record for resident #2, admission date of 11/19/24, did not contain documentation of an acknowledgement of receiving an orientation upon admission.
  2. During an interview on 07/22/25 with staff #7, staff #7 confirmed the record for resident #2 did not contain documentation of the resident or his legal representative acknowledgement of receiving an orientation upon admission.
  3. Upon request on 07/22/25, staff #7 was not able to provide documentation acknowledging resident #2 or his legal representative received an orientation upon admission.
Plan of correction
1. Corrective Action Taken for the Affected Resident(s): • The Administrator conducted an audit of all current resident files to identify any missing orientation acknowledgments. • For residents lacking this documentation, the orientation was immediately provided or reviewed again with the resident and/or legal representative. • A new signed and dated acknowledgment form was obtained and filed in the respective residence records. 2. Systemic Changes to Prevent Recurrence: • The facility has a standardized Resident Orientation Packet that includes: o Written details on emergency response procedures o Meal schedules and dining expectations o Instructions on using the call system • The facility has a standardized “Resident Orientation Acknowledgment Form” that includes: o Signed and dated by the resident and, when applicable, the legal representative at the time of orientation o Completed no later than 24 hours post-admission o Filed in the resident’s permanent record. • The orientation is integrated into the admission process and must be completed before admission is finalized. • All staff responsible for admissions have been retrained on: o The required orientation content, o Timing of the orientation o How to obtain and file the signed acknowledgment form 3. Monitoring and Quality Assurance: • The Administrator or designee will conduct 100% audits of all new resident records to ensure: o Orientation was provided o Signed acknowledgment form is present. • These audits will be performed for the next 90 days. • Afterward, random audits of 25% of monthly admissions will continue.
22VAC40-73-680-M
Based on the record review, the medication cart observation, and staff interview the facility failed to ensure medications ordered for PRN administration shall be available, properly labeled for the specific resident, and properly stored at the facility.
Evidence
  1. The record for resident #1 contains a physician order dated 08/09/24 that includes the following: a) Tramadol, take 0.5mg every 8 hours as needed for degenerative joint disease involving multiple joints. b) Clobetasol, 0.5% use as directed for dry scalp.
  2. During the medication cart observation on 07/23/25, with staff # #2, staff #2 was not able to locate the PRN medications, Tramadol and Clobetasol for resident #1.
  3. During an interview on 07/23/25, with staff #2, staff #2 confirmed the PRN medications, Tramadol and Clobetasol were not onsite at the facility and available for resident #1.
  4. The record for resident #2 contains a physician order dated 06/11/25 for Nitroglycerin 0.4mg tablet, take as needed for pain.
  5. During the medication cart observation on 07/23/25 with staff #8, staff #8 was not able to locate the PRN medication, Nitroglycerin for resident #2.
  6. During an interview on 07/23/25 with staff #8, staff #8 confirmed the PRN medication, Nitroglycerin was not onsite at the facility and available for resident #2.
  7. The record for resident #3 contains a physician order dated 10/01/24 for Antacid Chewable Tablet, take every 8 hours as needed for GERD.
  8. During the medication cart observation on 07/23/25 with staff #3, staff #3 was not able to locate the PRN Antacid Chewable Tablets for resident #3.
  9. During an interview on 07/23/25 with staff #3, staff #3 confirmed the PRN medication, Antacid Chewable tablet was not onsite at the facility and available for resident #3.
Plan of correction
1. Corrective Action Taken for the Affected Resident(s): • A comprehensive medication storage audit was conducted in all medication carts, storage rooms, and resident-specific storage areas. • For each resident whose PRN medication was missing, mislabeled, or improperly stored: o The resident’s prescribing provider and pharmacy were immediately contacted to obtain a correctly labeled replacement or refill. o All corrected medications were logged, verified, and secured properly. o The resident was monitored to ensure no adverse effects resulted from the medication unavailability. 2. Systemic Changes to Prevent Recurrence: • A PRN Medication Management Protocol has been implemented, including: o A weekly audit will be conducted to ensure all ordered PRN medications are on hand and unexpired. o Verification that each PRN medication is labeled and contains appropriate instructions for administration by RMA staff members: Noting signs and symptoms as indicated for prescribed administration. o Confirmation that all PRN medications are stored securely, separate from other residents’ medications, in accordance with best practices and pharmacy law. • Staff retraining has been completed for all licensed and unlicensed personnel who handle medications on: o Proper PRN medication labeling and storage requirements. o Reordering and tracking procedures for low or missing PRN stock o How to log and report unavailable or improperly labeled PRN medications. 3. Monitoring and Quality Assurance: • Weekly PRN medication audits will be conducted for 100% of residents receiving PRN medications for the next 90 days. • Any discrepancies found will be noted in audits as outlined. • Notification of audit results will be reported to the Administrator, with MD contacted immediately for correction. • Quarterly staff competencies will be performed, with reeducation and training completed for immediate correction.
22VAC40-73-310-D
Based on the record review and staff interview the facility failed to ensure upon review of the UAI prior to admission of a resident, the assisted living facility administrator shall provide written assurance to the resident that the facility has the appropriate license to meet his care needs at the time of admission. A copy signed by the resident or his legal representative shall be kept in the resident's record.
Evidence
  1. During the record review on 07/22/25, the record for resident #4 (admission date of 06/06/25) did not contain a written assurance signed by the resident or his legal representative.
  2. During an interview on 07/22/25 with staff #7, staff #7 was not able to provide a written assurance signed by resident #4, and staff #7 confirmed a written assurance signed by resident #4 was not in the resident’s record.
  3. During the onsite inspection completed on 07/23/25, staff # 5 provided a written assurance signed and dated by the resident on 07/23/25.
Plan of correction
1. Corrective Action Taken for the Affected Resident(s): • The facility administrator has completed review of all current resident records to identify any missing written assurances. • Any residents admitted without this documentation will be contact (or their legal representatives), and retroactive written assurance will be issued and signed, with copies placed in their residence records; noting communication of date/times, etc. until received. 2. Systemic Changes to Prevent Recurrence: • A Pre-Admission Checklist has been revised to include the “Written License Assurance” step as a required item prior to finalizing admission. • The administrator (or designee) will complete a “Facility License Assurance Form” for each new resident after reviewing the UAI Plan and before admission. • The form will be signed by both the administrator and the resident or legal representative and filed in the resident’s permanent record. • Admission packets have been updated to include this document and will be used for all future admissions. • Staff responsible for admissions have been retrained on the updated procedure by the Administrator. 3. Monitoring and Quality Assurance: • The Administrator or designee will audit 100% of all new admissions for compliance with the updated procedure for the next 90 days. • Thereafter, monthly random audits (minimum of 25% of new admissions) will be conducted for ongoing compliance.
22VAC40-73-440-A
Based on the record review and staff interview the facility failed to ensure all residents and applicants to assisted living facilities shall be assessed face to face using the uniform assessment instrument (UAI) in accordance with Assessment in Assisted Living Facilities (22VAC30-110). The UAI shall be completed annually.
Evidence
  1. The record for resident # 3 contains a UAI completed on 05/26/24. The resident’s record does not contain a UAI completed annually after 05/26/24.
  2. During an interview on 07/22/25 with staff #4, staff #4 confirmed resident’s #3 record did not have a current UAI and staff #4 was not able to provide a UAI completed annually after 05/26/24.
Plan of correction
1. Corrective Action Taken for the Affected Resident(s): • The Administrator and Designee completed a full audit of all current resident records to identify: o Missing UAI assessments, o Incomplete or outdated assessments, • For all residents with overdue or missing assessments: o A qualified assessor was scheduled to complete or update theUAI. o The completed UAIs were signed and filed in each resident’s record. 2. Systemic Changes to Prevent Recurrence: • A UAI Compliance Plan has been implemented to: o Review the date of admission assessments as scheduled on EHR Dashboard. o Track annual due dates, utilizing the scheduling process in EHR. • A designated staff member (e.g., Health Care Director or Associate Health Care Director) is now responsible for: o Monitoring UAI compliance during routine review. o Scheduling assessments with EHR to provide all upcoming UAI notifications on Dashboard for HCD or designee to monitor. • Admission procedures have been updated to include: o A pre-admission UAI assessment. o Documentation of the assessment in the applicant’s pre-admission record. • Staff have been retrained on: o The UAI completion requirements: Pre-move In, Initial, Move In, Annual, Change in Condition if needed. o Timelines for re-assessment o Proper documentation procedures. 3. Monitoring and Quality Assurance: • The Administrator or designee will: o Conduct monthly audits of all new admissions to verify UAI completion, o Review 10% of current resident records monthly to ensure timely annual reassessments.
22VAC40-73-450-A
Based on the record review and staff interview the facility failed to ensure on or within 7 days prior to the day of admission, a preliminary plan of care shall be developed to address the basic needs of the resident that adequately protects his health, safety, and welfare. Exception: A Preliminary plan of care is not necessary if a comprehensive individualized service plan (ISP) is developed, in conformance with this section, on the day of admission.
Evidence
  1. The record for resident #4, admission date of 06/06/25, did not contain a preliminary plan of care completed on or within 7 days prior to the day of admission nor an ISP completed on the day of admission.
  2. During an interview on 07/23/25 with staff #4, staff #4 confirmed the record for resident #4 did not contain a preliminary plan of care completed on or within 7 days prior to the resident’s day of admission nor an ISP completed on the day of admission.
  3. Upon request on 07/23/25, staff #4 provided an ISP dated as completed on 06/27/25 for resident #4.
Plan of correction
1. Corrective Action Taken for the Affected Resident(s): • The Administrator and Designee audited all recent admissions to identify mission or late preliminary plans of care. • For each resident admitted without a timely plan: o A retrospective plan of care was completed to document basic needs and services provided since admission. o A thorough review of the resident’s current needs was conducted to ensure appropriate care is being delivered. o Any gaps in care were immediately addressed. 2. Systemic Changes to Prevent Recurrence: • The Admission Checklist has been revised to include: o A mandatory Preliminary Plan of Care Completion step required within seven days prior to admission unless a same-day comprehensive ISP is completed. • Admission staff and care planning team members have been retrained on: o The timing and content requirements for both preliminary and comprehensive plans of care, o Proper documentation procedures. • All new admissions are now reviewed by the Administrator or designee to verify that either: o A Pre-Move In plan of care was completed 7 days prior to admission. o An Initial Individual Service Plan has been completed on move into community. An Annual ISP must be completed within 30 days of admission. 3. Monitoring and Quality Assurance: • The Administrator or designee will conduct 100% audits of new admissions over the next 90 days to ensure: o Compliance with timing and content requirements for care plans, o Documentation is complete and filed in resident records. • Following the 90-day period, random audits of 25% of monthly admissions will be performed.
July 15, 2025Complaint survey0 violations
Inspection dates
07/15/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 07/15/2025 at 11:19 am to 12:40 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 07/08/2025 regarding allegations in the areas of: Administration and Administrative Services, Personnel. Staffing and Supervision, and Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 80 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 2 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: Residents observed in the common areas and eating lunch in the dining area. An observation of the facility’s food supply, and PPE supplies was completed. Additional Comments/Discussion: A review of the facility’s staffing schedule was completed. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
July 15, 2025Complaint survey0 violations
Inspection dates
07/15/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 BUILDINGS AND GROUND22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 07/15/2025 at 11:19 am to 12:40 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 07/08/2025 regarding allegations in the areas of: Administration and Administrative Services and Personnel Number of residents present at the facility at the beginning of the inspection: 80 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 2 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: Residents observed in the common areas and eating lunch in the dining area. Additional Comments/Discussion: A review of the facility’s smoking and substance use policy were reviewed. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
July 15, 2025Complaint survey0 violations
Inspection dates
07/15/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 BUILDINGS AND GROUND22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 07/15/2025 at 11:19 am to 12:40 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 07/08/2025 regarding allegations in the areas of: Administration and Administrative Services and Personnel Number of residents present at the facility at the beginning of the inspection: 80 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 2 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Residents were observed in the common areas and eating lunch in the dining area. Additional Comments/Discussion: A review of the facility’s weapons policy was completed. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
July 15, 2025Inspection0 violations
Inspection dates
07/15/2025
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
An unannounced monitoring inspection was conducted. The focus of the inspection was to determine whether the provider had corrected or is in the process of correcting previously cited violations in the areas of standards referenced above. This inspection yielded no violations of applicable laws or regulations.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
June 10, 2025Complaint survey5 violations
Inspection dates
06/10/2025, 06/25/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 06/10/2025 at 9:45 am to 3:40 pm and 06/25/2025 at 1:10 pm to 2:40 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 5/25/2025 regarding allegations in the areas of: Administration and Administrative Services and Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 79 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: 6 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 8 Observations by licensing inspector: Residents observed in the common areas and eating lunch in the dining area. Additional Comments/Discussion: A review of the facility’s policies and procedures were completed. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegations of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-460-B
Personalization of care and services tailored to the resident's circumstances and preferences; and Prompt response by staff to resident needs as reasonable to the circumstances.
Evidence
  1. Resident’s #1 Uniform Assessment Instrument (UAI) and Individualized Service Plan (ISP) dated 09/17/24 documents the resident needs mechanical and human help to include physical assistance in the areas of bathing, toileting, and transferring. 2.Resident’s #1 call pendant logs documents the resident pushed her emergency pendant on 05/11/25 at 1:36 pm. The response time of staff response to the resident is documented at 2:35 pm.
  2. Video footage dated 05/11/25 at 2:34 pm through 2:39 pm shows staff # 6 enter resident’s #1 room. Resident #1 states “I been ringing an hour.” Resident #1 states “I wet my pants already.” Staff #6 states staff # 6 did not hear the call bell ringing but “someone should have came.”
  3. Video footage dated 05/07/25 during the time of 5:29 am through 5:58am includes the following: resident #1 requesting for staff #7 and staff #8 to assist the resident to the bathroom by use of the wheelchair or rollator. Staff #7 and staff #8 did not provide resident #1 with the resident’s wheelchair or rollator as requested by the resident. Resident #1 states her preference to use the toilet and staff #7 informs resident #1 to use her depends instead of the toilet and did not provide physical assistance for resident #1 to go to the bathroom. Resident #1 states her preference to get dressed in the bathroom however staff #7 proceeds to dress resident #1 in the bed.
Plan of correction
1. Corrective Action for Residents Potentially Affected •A facility-wide audit of all resident care plans was conducted to ensure: oDocumentation of resident participation in care decisions oInclusion of individualized preferences (e.g., daily routines, activity choices, cultural considerations) oClear instructions for staff on prompt response expectations • Any missing or outdated information was corrected in collaboration with the resident or their representative. 2. Systemic Changes to Prevent Recurrence •All direct care staff to complete mandatory training on: oPrinciples of resident-centered care oCommunication techniques to involve residents in decision-making oStrategies for timely response to resident needs oTraining completion documented in personnel files. •Residents (and/or representatives) will be invited to all care conferences. 3. Monitoring and Quality Assurance •HCD or designee will conduct regular rounds and interview residents about satisfaction with participation, personalization, and response times. 4. Responsible Parties •Administrator – Oversight of compliance. •HCD – Care plan audits, staff education, and resident interviews; and ongoing monitoring and data analysis. 5. Completion Date •October 15, 2025
22VAC40-73-210-G
Based on the record review and staff interview the facility failed to ensure documentation of the type of training received, the entity that provided the training, number of hours of training, and dates of the training shall be kept by the facility in a manner that allows for identification by individual staff person and is considered part of the staff member’s record.
Evidence
  1. The record for staff #3 (Personal care aide), effective start date for nursing staff 06/26/22, does not contain documentation of the required 18 hours of annual training for direct care staff during the timeframe of 06/26/2023 through 06/26/2024. Staff #3 last documented hours of training in addition to first aid and CPR training is dated as 09/13/23.
  2. Upon request, during an interview with staff # 10 on 06/10/25, staff #10 confirmed the facility did not have documentation or evidence of the required annual training for staff #3.
Plan of correction
1. Corrective Action for Staff Potentially Affected • A facility-wide audit of all staff training records was conducted to ensure every file contains: o Complete training details as required by regulation. • Any missing or incomplete records were corrected immediately in collaboration with the staff member and/or training provider. 2. Systemic Changes to Prevent Recurrence •HR provided in-service training to all department heads and trainers on the updated documentation requirements and timelines. 3. Monitoring and Quality Assurance •BOM will review 10% of staff files monthly to verify training documentation completeness. •Administrator will conduct quarterly audits of the master training log and a random sample of personnel files to ensure compliance. 4. Responsible Parties •Administrator – Oversight of compliance. •BOM – Maintenance of training records, master log, and monthly audits. •Department Heads – Ensuring timely submission of training documentation for their staff. 5. Completion Date •October 15, 2025
22VAC40-73-260-A
Based on the record review and staff interview the facility failed to ensure each direct care staff member shall maintain current certification in first aid.
Evidence
  1. The record for staff # 2, hire date 01/21/2025, did not contain a current certification in first aid.
  2. Upon request, during an interview with staff # 10 on 06/10/25, staff #10 confirmed the facility did not have documentation or evidence of a current certification in first aid for staff # 2.
Plan of correction
1. Corrective Action for Staff/Residents Affected •Immediately upon identification of the deficiency, the Administrator reviewed personnel files to identify all direct care staff whose first aid certification had expired or was missing. •Any staff without current certification were removed from unsupervised direct care duties until proof of current certification was obtained. •Residents under the care of affected staff were reassigned to certified personnel to ensure safety and compliance. 2. Corrective Action to Prevent Recurrence •A master tracking log was created to record each direct care staff member’s first aid certification status, including expiration dates. •The system will generate alerts 60 days prior to expiration to allow time for renewal. •All non-compliant staff were scheduled for and completed an approved first aid certification course within 60 days of deficiency identification. 3. Monitoring and Quality Assurance •The BOM or Designee will review the certification tracking log monthly to ensure all staff remain current. •The Administrator will conduct quarterly audits of personnel files to verify compliance. 4. Responsible Parties •Administrator – Oversight of compliance. •BOM – Maintenance of certification tracking log, scheduling renewals, and file audits. •HC – Verification of compliance before assigning direct care duties. 5. Completion Date •October 15, 2025
22VAC40-73-460-D
Based on video footage of resident interview, and staff interview the facility failed to ensure the facility shall provide supervision of resident schedules, care, and activities, including attention to specialized needs, such as prevention of falls and wandering from the premises.
Evidence
  1. Video footage dated 05/13/25 at 7:13 pm includes resident #1 providing resident’s #1 description of a fall the resident experienced at the facility on 05/12/25 while receiving assistance from facility staff to use the toilet. Resident’s #1 statement in the video includes the following: “I pulled myself up on the bar and I went to sit on the toilet and I slipped and slid down and she tried to pick me up 3 times and I kept falling on the floor and I bent my legs back and that’s how I broke it.”
  2. During an interview on 06/11/25 with staff #3, staff #3 confirmed that on the day of 05/12/25 near the time of 11:40 pm staff #3 responded to resident’s #1 room after receiving a call from staff #1 requesting assistance. Upon staff #3 arrival to resident’s #1 room, staff #3 observed resident #1 on the floor near the toilet in the bathroom and staff #1 standing in the bathroom. Staff #3 assisted staff #1 with lifting resident #1 off the floor and placing resident #1 on the toilet. Staff #3 stated resident #1 was complaining of leg pain and was unable to bear weight and stand up.
  3. An updated incident report sent to the Licensing Inspector (LI) via email on 07/25/25 includes the following update for the incident report dated 05/13/25 for resident #1: “On 6/26, staff # 11 interviewed staff #3 and confirmed the new-found information pertaining to resident #1 being assisted off the floor onto the toilet.”
  4. Resident’s #1 "City of Suffolk Prehospital care report” dated 05/13/25 documents the following: “responded out to the patient 3 hours ago for right leg pain. Patient was found then on the toilet needing assistance getting back to bed. Patient did not want to go back to bed. Patient was lifted from the toilet and placed in the bed.”
  5. Resident’s #1 prehospital report for the 2nd visit on 05/13/25 includes the following: “this visit patient asked to go to the ER for leg pain, stomach pain, and pain all over.” “Patient has bruises on both her right and left knees. Patient right leg is more swollen than the left but it is unknown what her legs normally look like.”
  6. Harbourview Emergency Room Nurse left a voicemail for collateral contact #1 on 05/13/25 stating that resident #1 had a fall at the facility and injured her leg.
  7. During an interview on 05/28/2025 with collateral contact #3, collateral contact #3 stated resident #1 was admitted to the hospital on 05/13/2025 for treatment of a broken femur above the resident’s right knee, the resident received surgery for the broken femur on 05/13/2025 and was hospitalized up until the resident’s death on 05/20/2025.
  8. Resident’s #1 death certificate filed 05/23/25 includes a date of death of 05/20/25 and documents a cause of death as “complications of right femur fracture.”
Plan of correction
1. Corrective Action for Residents Potentially Affected •A facility-wide audit of all residents’ care plans was conducted to ensure: o Accurate documentation of individualized schedules, activities, and supervision needs. o Identification of specialized needs related to fall prevention. •Any missing or outdated information was corrected in collaboration with residents and/or their representatives. 2. Systemic Changes to Prevent Recurrence •The “Resident Supervision and Safety” policies reviewed: o Fall assessments upon admission, quarterly, and after any incident o Documentation of supervision levels in the care plan o Immediate implementation of interventions when risk status changes •All direct care staff completed mandatory in-service training on: o Fall prevention strategies (safe transfers, use of assistive devices, environmental safety) oImportance of adhering to resident schedules and activity plans to reduce risk 3. Monitoring and Quality Assurance •HCD will review all fall reports weekly to identify patterns and implement corrective measures. 4. Responsible Parties •Administrator – Oversight of compliance and policy enforcement •HCD – Risk assessments, care plan updates, staff training coordination, and ongoing monitoring. 5. Completion Date •October 15, 2025
22VAC40-73-40-A
Based on review of the facility’s policy and procedures, and staff interview the facility failed to ensure the licensee shall ensure compliance with all regulations for licensed assisted living facilities and terms of the license issued by the department; with relevant federal, state, and local laws; with other relevant regulations; and with the facility's own policies and procedures.
Evidence
  1. The facility’s “Responding to Medical Emergencies” Policy and Procedure dated 03/2025 documents the following on page 2: “If the resident is on hospice services the licensed nurse/team member will call the hospice provider and notify them of the change in condition. The licensed nurse/team member will follow the directions of the hospice agency. If the situation is emergent (obvious broken bone, uncontrolled bleeding, etc.) and the hospice agency does not respond immediately call 911.”
  2. Resident’s #1 Individualized Service Plan (ISP) dated 09/17/24 documents a start of care date of 04/11/24 for hospice care services.
  3. Resident’s #1 incident report dated 05/13/25 documents 911 emergency personnel were called at 12:05 am due to resident experiencing pain in the leg. Emergency personnel responded and the resident refused to go to the Emergency Room. At 3:34 am resident #1 requested for 911 to be called again due to experiencing pain in the leg and the resident was transported to the hospital by emergency personnel.
  4. During an interview on 06/11/25, with staff #2, staff #2 confirmed staff #2 nor any of the facility staff notified resident’s #1 hospice care agency of the following incidents that occurred on 05/13/25 for resident #1: resident #1 experiencing pain, resident’s initial refusal to go to the emergency room, facility staff contacting 911 emergency personnel, and of the resident’s transport to the emergency room.
  5. During an interview on 06/18/25 with collateral contact #1, collateral contact #1 confirmed the hospice care organization did not receive notification of the following incidents that occurred on 05/13/25 for resident #1: Resident #1 experiencing pain, resident’s initial refusal to go to the emergency room, facility staff contacting 911 emergency personnel, and of the resident’s transport to the emergency room.
Plan of correction
1. Corrective Action for Residents Affected •The facility administrator conducted a facility-wide check to ensure all call bell systems were fully operational. •Any outstanding call bell alerts at the time of discovery were addressed immediately, and residents were assessed to ensure no adverse outcomes occurred. 2. Systemic Changes to Prevent Recurrence •The facility’s “Call Bell Response” policy was reviewed and all direct care staff received mandatory re-training on the updated policy, emphasizing the importance of timely responses for resident safety and dignity. •Training included hands-on drills simulating call bell alerts during various shifts. •Staff signed an acknowledgment form confirming understanding of the policy and consequences for non-compliance. 3. Monitoring and Quality Assurance •HCD, or AHCD, or Designee will review call bell response logs regularly to identify any delays and address them immediately with staff. •The Administrator or designee will conduct weekly audits of call bell system reports to track average response times and identify trends. 4. Responsible Party •Administrator – Overall oversight of compliance and implementation of corrective actions. •HCD – Staff training, monitoring, and enforcement of policy. 5. Completion Date •October 15, 2025
May 20, 2025Inspection1 violation
Inspection dates
05/20/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
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: An unannounced monitoring inspection took place on 05/20/2025 at 9:30 am to 11:55 am. 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 04/22/2025 regarding allegations in the area of: Resident Care and Related Services and the Safe Secure Environment. 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 staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: Residents were observed in the facility’s safe secure environment. The facility’s safe secure unit staffing schedule was completed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-460-D
Based on the record review and staff interview the facility failed to ensure the facility shall provide supervision of resident schedules, care, and activities, including attention to specialized needs, such as prevention of falls and wandering from the premises.
Evidence
  1. Resident’s #1 Individualized Service Plan (ISP) documents the resident requires a secured memory care due to the diagnosis of dementia with serious cognitive impairment.
  2. Resident’s #1 incident report documents the following incident occurred on 04/21/25 at 6:25pm: “Resident #1 followed the evening dining cart out the secured doors.” The resident was outside the facility’s building to include” the safe secure environment for 15 minutes” before returning to the front lobby of the facility.
  3. During an interview on 05/20/25 with staff #1, staff #1 acknowledged on 04/21/25 resident #1 exited the facility’s building to include the safe secure environment, and the resident walked outside the facility building for 15 minutes unsupervised.
  4. During an interview on 05/20/25 with staff #2, staff #2 acknowledged staff #2 was on duty in the safe secure environment on 04/21/25 and the facility staff was not aware resident #1 exited the facility and was outside 15 minutes unsupervised.
Plan of correction
1. Corrective Action Taken for the Affected Resident(s): Immediate assessments were completed for all residents identified as at risk for falls or elopement. Interventions were reviewed and updated, including placement of fall mats, bed/chair alarms, and frequent rounding protocols. Wandering residents were provided with individualized care plans including wander alerts, one-on-one monitoring, and visual cues to reduce confusion. 2. Measures to Identify Other Residents Who May Be at Risk: A facility-wide review was conducted to identify residents with a history or risk of falls or wandering behavior. All residents were reassessed using standardized fall risk and elopement risk tools. Care plans were updated accordingly to reflect individualized interventions. 3. Systemic Changes to Prevent Recurrence: Nursing and care staff will receive in-service training on: Supervision protocols Fall prevention strategies Wandering risk indicators Implementation of individualized care plans A supervision schedule was implemented to ensure staff coverage aligns with residents’ needs and risk levels. An electronic alert system was reviewed and enhanced for real-time alerts for high-risk residents. Environmental modifications (e.g., securing exit doors, signage for reorientation, and improved lighting) were completed to support safety. 4. Monitoring and Quality Assurance: The Health Care Director or designee will audit 10 resident care plans weekly for 8 weeks to verify fall/wandering prevention measures are in place and followed. Weekly audits of incident reports will be conducted to analyze trends and adjust interventions. Monthly Quality Assurance and Performance Improvement (QAPI) meetings will include a review of fall and elopement data to evaluate the effectiveness of interventions and adjust strategies as needed. 5. Date of Completion: July 11, 2025
April 22, 2025Complaint survey2 violations
Inspection dates
04/22/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 04/22/2025 from 12:07 pm to 3:50 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint received by VDSS Division of Licensing on 04/02/25 and 04/14/25 regarding allegations in the area of: Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 76 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 4 Observations by licensing inspector: Review of the facility’s medication carts was completed. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: Resident Care and Related Services A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-680-B
Based on observation and staff interview the facility failed to ensure medications shall remain in the pharmacy issued container, with the prescription label or direction labeled attached, until administered to the resident.
Evidence
  1. During the Licensing Inspector (LI) observation of the medication cart on 04/22/25 with staff #2, the LI observed one clear plastic cup filled with 3 pills located on the top drawer of the cart.
  2. During an interview on 04/22/25 with staff #2, staff #2 acknowledged that staff #2 was assigned to the medication cart, however staff #2 was not able to provide an explanation of who the medications belonged to, who poured the medications in the cup, and how long the medications were in the cup.
Plan of correction
Corrective Action Plan: 1.Re-education of Staff: Conduct mandatory in-service training on medication storage and labeling requirements. 2.Policy Review and Reinforcement: Update and reinforce policies regarding medication handling and ensure strict adherence. 3.Audit and Monitoring: Implement a weekly audit process to ensure all medications are properly labeled and stored. 4.Accountability Measures: Establish accountability measures for staff found non-compliant during audits. 5.Resident Safety Checks: Conduct regular safety checks to confirm medications are in their original containers until administration. Follow-Up and Monitoring: •Weekly audits will be conducted for the next 60 days, with findings documented and reviewed by the management team. •Immediate corrective actions will be enforced upon identification of non-compliance.
22VAC40-73-680-I
Based on the record review and staff interview the facility failed to ensure the Medication Administration Record (MAR) shall include: Any medication errors or omissions.
Evidence
  1. Resident’s #1 progress note dated 04/04/25 documents the following occurred on 03/31/25: Staff #1 signed off on medication at 0911 and eye drops at 0800 and 1000. The resident was out of the building at 0750 and did not receive any medications in the morning. Staff #1 stated staff #1 did not give the medications to the resident because the resident was out of the building.
  2. Resident’s #1 March 2025 MAR did not include omissions on the morning of 03/31/25 for the following scheduled 8:00 am and 9:00 am medications: Eliquis, Refresh Tears eye drops, Amiodarone, Baza Protect Cream, Breo Ellipta, Bumetanide, Quetiapine, and Sertraline.
  3. During an interview on 04/22/25 with staff #4, staff #4 acknowledged staff #1 did not administer resident’s #1 scheduled 8 am and 9 am medications to the resident on 03/31/25 however staff #1 documented on the MAR that the medications were administered.
Plan of correction
Corrective Action Plan: 1.Staff Education: Conduct immediate in-service training on MAR documentation requirements, focusing on the importance of recording all medication errors and omissions. 2.Policy Reinforcement: Review and enforce policies regarding accurate MAR documentation. 3.Audit Implementation: Implement bi-weekly audits of MARs to identify gaps and ensure compliance. 4.Error Reporting Procedures: Establish a clear and mandatory error reporting procedure for all staff. 5.Follow-Up Measures: Management will follow up with staff who fail to document errors or omissions accurately. Follow-Up and Monitoring: •Bi-weekly audits will be performed for 60 days, with findings reported to the management team. •Non-compliance will be addressed immediately through retraining and corrective action plans.
March 31, 2025Complaint survey1 violation
Inspection dates
03/31/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 03/31/2025 from 11:09 am to 1:10 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint received by VDSS Division of Licensing on 03/06/2025 regarding allegations in the area of: Staffing and Supervision, and Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 76 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: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Review of the facility’s staffing schedule was completed. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: Resident Care and Related Services A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-680-H
Based on the record review and staff interview the facility failed to ensure at the time the medication is administered, the facility shall document on a medication administration record (MAR) all medications administered to residents.
Evidence
  1. Resident’s #1 February 2025 Orders Charted Report (administered medication times report) documents a medication administration day and time of 02/13/25 at 10:23 am for the following medications that were scheduled for 02/12/25 at 6:30 pm and 7:00pm: (Hydrocodone, Clonazepam, Donepezil, Melatonin, Mirtazapine, Preservision).
  2. During an interview on 03/31/25 with staff #1, staff #1 acknowledged resident’s #1 medications scheduled for 6:30 pm and 7:30 pm on 02/12/25 were administered on time, however the MAR was not documented until 02/13/25 at 10:23 am.
Plan of correction
What Has Been Done to Correct? RMA’s will be re-educated on appropriate documentation of medication administration. How Will Recurrence Be Prevented? Healthcare Director or Designee will conduct a weekly audit to monitor medication administration documentation times and address any issues with RMA’s as appropriate Person Responsible: Healthcare Director or Designee Due Date: 5/30/2025
January 30, 2025Inspection3 violations
Inspection dates
01/30/2025, 02/28/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-80 THE LICENSE
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: An unannounced monitoring inspection took place on 01/30/2025 at 9:30 am to 4:20 pm and 02/28/2025 at 9:36 am to 3:15 pm. 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 01/29/2025 regarding allegations in the area 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 staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 4 Observations by licensing inspector: Residents were observed in the facility’s safe secure environment. The facility’s staff schedule, and medical emergency plan were reviewed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-930-D
Based on the record review the facility failed to ensure for each resident with an inability to use the signaling device the following shall be met: a minimal frequency of daily rounds to be made; once the resident has gone to bed each evening until the resident has arisen each morning, at a minimum direct care staff shall make rounds no less than every two hours; the facility shall document the rounds that were made, which shall include the name of the resident, the date and time of the rounds, and the staff member who made the rounds.
Evidence
  1. Resident’s #1Individualized Service Plan (ISP) dated 09/15/24 includes the resident requires a secured memory care due to a diagnosis of dementia and identifies a need for round checks every 2 hours. The facility’s round logs did not include documentation 2-hour rounds were completed for resident #1 on the following dates: 01/10/25, 01/12/25, 01/13/25, 01/18/25, 01/20/25, 01/23/25, 01/24/25, 01/25/25, 01/26/25.
  2. During an interview with staff #4 on 01/30/25, staff #4 acknowledged resident’s #1 January round logs did not include documentation 2-hour rounds were completed on the following dates: 01/10/25, 01/12/25, 01/13/25, 01/18/25, 01/20/25, 01/23/25, 01/24/25, 01/25/25, 01/26/25.
Plan of correction
What Has Been Done to Correct? Staff have been re-educated to document the two hour rounds on the log after each round while the resident is in bed. How Will Recurrence Be Prevented? Harmony Square Director will audit the documentation of the rounds each day and address any non-compliance with staff members as appropriate. Person Responsible: Harmony Square Director Due Date: 5/07/2025
22VAC40-73-460-A
Based on the record review and staff interview the facility failed to ensure the facility shall assume general responsibility for the health, safety, and well-being of the residents.
Evidence
  1. Resident’s #1 progress note dated 01/22/25, documents the “resident complained of pain in right leg, no bruises or falls noted”
  2. Staff #1 and staff #2 written statements completed on 01/28/25 documents resident #1 complained of pain in the hip on 01/24/25. Staff #1 noticed the resident limping and walking unbalanced on the day of 01/24/25.
  3. Resident’s #1 progress note dated 01/27/25 documents the “resident was sent to hospital on 01/26/25 at 9pm. Resident was in a lot of pain.”
  4. Resident’s #1 hospital admission paperwork documents a hospital admission from the dates of 01/27/25 to 01/29/25 and includes a hospital treatment list for the following: Fall, closed compression fracture of L3 lumbar vertebra sequela, Closed fracture of left inferior pubic ramus, Closed fracture of multiple ribs of right side, closed fracture sacrum, rib fractures, and trauma.
  5. During an interview on 01/30/25 with staff #4 and staff #5, staff #4 and staff #5 acknowledged staff #1, staff #2, and staff #3 did not notify a licensed health care professional of resident #1 experiencing hip pain nor was the resident assessed by a licensed healthcare professional during the timeframe of 01/22/25 though 01/25/25.
Plan of correction
What Has Been Done to Correct? Implemented the shift to shift communication report. Staff have been re-educated to complete the shift to shift report and notify the Healthcare Director or Harmony Square Director of notable changes in a resident’s condition. How Will Recurrence Be Prevented? Healthcare Director or Harmony Square Director will implement documentation binder for reporting to the licensed healthcare professional. Healthcare Director or Harmony Square Director will review shift to shift communication report, progress notes report and medication administration reports to ensure that the health, safety and well-being of residents is met. Person Responsible: Healthcare Director, Harmony Square Director, Executive Director Due Date: 5/7/2025
22VAC40-73-460-E
Based on the record review the facility failed to ensure the facility shall regularly observe each resident for changes in physical, mental, emotional, and social functioning. Any notable change in a resident’s condition or functioning, including illness, injury, or altered behavior, and any corresponding action taken shall be documented in the resident’s record.
Evidence
  1. The facility provided the following staff statements: (a) A statement dated 01/28/25 from staff #1 that included staff #1 interaction with resident #1 on the day of 01/24/25: “resident had a few complaints about pain in her hip, her bed was broken, family came to fix bed and clean. Noticed limping and unbalanced walking. After getting pain meds (Tylenol) seemed fine, no more complaints.” (b) A statement completed on 01/28/25 written by staff #2 for an interaction that occurred with resident #1 on 01/24/24: “resident was complaining about pain in hip on left side, staff #1 told med tech at the time about said pain. Resident was given Tylenol and throughout the day supervised. Minimal walking was observed.” The record for resident #1 did not contain documentation of the resident’s complaints of hip pain, limping, and unbalanced walking as documented on the written statements completed on 01/28/25.
  2. During an interview on 01/30/25 with staff #4 and staff #5, staff #4 and staff #5 acknowledged resident’s #1 record did not contain documentation of the resident’s complaints of hip pain, limping, and unbalanced walking.
Plan of correction
What Has Been Done to Correct? Implemented the shift to shift communication report. Staff have been re-educated to complete the shift to shift report and notify the Healthcare Director or Harmony Square Director of notable changes in a resident’s condition. How Will Recurrence Be Prevented? Healthcare Director or Harmony Square Director will implement documentation binder for reporting to the licensed healthcare professional. Healthcare Director or Harmony Square Director will review shift to shift communication report, progress notes report and medication administration reports to ensure that the health, safety and well-being of residents is met. Person Responsible: Healthcare Director, Harmony Square Director, Executive Director Due Date: 5/07/2025
January 30, 2025Inspection11 violations
Inspection dates
01/30/2025, 02/28/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-80 THE LICENSE
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: An unannounced monitoring inspection took place on 01/30/2025 at 9:30 am to 4:20 pm and 02/28/2025 at 9:36 am to 3:15 pm. 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 01/13/2025 regarding allegations in the area 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 staff records reviewed: 3 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 7 Observations by licensing inspector: The following were reviewed: staffing schedule, facility’s medical emergency plan, and policy and procedures re: CPR. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-380-B
Based on the record review, the facility failed to ensure the resident’s personal and social information shall be placed in the resident’s record and kept current.
Evidence
  1. On 02/28/2025, resident 1’s personal and social data sheet and face sheet, noted resident 1 has a Do Not Resuscitate Order (DNR). Resident 1’s individualized service plan (ISP) indicates resident 1’s code status as Full Code. Resident 1’s record did not contain a DNR order.
  2. During an interview on 02/28/2025, staff 5 acknowledged the record for resident 1 was not current and stated resident 1 did not have a DNR
Plan of correction
What Has Been Done to Correct? Resident’s data sheet was updated. How Will Recurrence Be Prevented? An audit will be conducted of the personal social data forms for all resident records to ensure they are kept current. Person Responsible: Business Office Manager, Healthcare Director and Executive Director Due Date: 5/30/2025
22VAC40-73-990-B
Based on the record review and staff interview the facility failed to ensure that the procedures in the plan for resident emergencies required in subsection A of this section shall be reviewed by the facility at least every six months with all staff. Documentation of the review shall be signed and dated by each staff person.
Evidence
  1. The record for staff #1, hire date 09/29/23, did not include evidence staff #1 reviewed the facility’s written plan for resident emergencies at least once every six months.
  2. The record for staff #2, hire date 07/07/17, did not include evidence staff #2 reviewed the facility’s written plan for resident emergencies at least once every six months. The most recent plan for resident emergencies in the staff record is dated 07/31/19.
  3. The record for staff #3, hire date 09/06/23, did not include evidence staff #3 reviewed the facility’s written plan for resident emergencies at least once every six months.
  4. During an interview on 01/30/25, Staff 6 and staff 7 acknowledged the facility did not have evidence of staff 1, staff 2, or staff 3 reviewing the facility’s written plan for resident emergencies at least once every six months.
Plan of correction
What Has Been Done to Correct? The resident emergencies procedures have been reviewed and practiced with staff. An audit will be conducted to ensure that all staff attended this session. How Will Recurrence Be Prevented? This review and practice will be conducted at least every six months to maintain compliance. Person Responsible: Executive Director or Healthcare Director Due Date: 5/30/2025
22VAC40-73-260-A
Based on the record review and staff interview the facility failed to ensure each direct care staff member shall maintain current certification in first aid.
Evidence
  1. The record for staff # 3, hire date 09/06/23, did not contain a current certification in first aid. The first aid certification in the record expired 12/2024.
  2. Upon request during an interview with staff 6 on 01/30/25 the facility did not provide documentation of a current certification in first aid for staff 3.
Plan of correction
What Has Been Done to Correct? A first aid course has been scheduled. How Will Recurrence Be Prevented? Business Office Manager will schedule routine CPR and First Aide training to ensure that each staff person receive it prior to expiration of their current certification Person Responsible: Business Office Manager, Executive Director Due Date: 6/30/2025
22VAC40-73-680-C
Based on the record review and staff interview, the facility failed to 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. The facility’s medication management plan, dated 02/2018, provided during the onsite inspection states medications should be given within 1 hour on either side of the specified times.”
  2. Resident’s #1 Order Chart Report for Medication Administration documents the following: 6 of the resident’s scheduled 8 am medications (Furosemide, Eliquis, Metolazone, Potassium, Nebivolol, and Vitamin B-12) and 8 of the resident’s scheduled 9 am medications ( Cetirizine, Coenzyme Softgel, Doxazosin Mesylate Duloxetine, Vitamin D, Alpha lipoic Acid, Finasteride, and Trelegy) were administered to the resident more than one hour after the scheduled times of 8 am and 9am on the following dates: 8/28/24, 09/02/24, 09/03/24, 09/05/24, 09/06/24,09/07/24, 09/09/24, 09/11/24, 09/15/24, 09/16/24, 09/17/24, 09/30/24, 10/05/24,10/07/24, 10/14/24, 10/17/24, 10/21/24, 10/23/24, 10/28/24, 10/29/24, 10/30/24,10/31/24, 11/02/24, 11/03/24, 11/06/24, 11/07/24, 11/10/24, 11/11/24, 11/26/24, 11/29/24, 12/09/24, 12/18/24, 12/28/24, 12/29/24, 12/30/24, 12/31/24, 01/01/25, 01/02/25, 01/03/25, 01/04/25, 01/06/25, 01/08/25, 01/11/25, 01/12/25.
  3. The record for resident 1 contains the following physician order for Furosemide/Lasix: A physician order dated 12/03/24, “change timing of Lasix to 0600 and 1400.”
  4. Resident’s #1 administered medication times report documents the resident did not receive the Lasix/ Furosemide medication as ordered at 0600 and 1400 on the following dates: 12/07/24, scheduled at 6:00 am and administered at 10:03 am. 12/29/24, scheduled at 6:00 am and administered at 11:27 am. 12/31/24, scheduled at 6:00 am and administered at 4:55 am. 01/12/25, scheduled at 2:00 pm and administered at 5:42 pm.
  5. Staff 5 and staff n7 was not able to provide an explanation as to why the medications were not administered on time.
Plan of correction
What Has Been Done to Correct? RMA’s will be re-educated on appropriate documentation of medication administration. How Will Recurrence Be Prevented? Healthcare Director or Designee will conduct a weekly audit to monitor medication administration documentation times and address any issues with RMA’s as appropriate Person Responsible: Healthcare Director or designee Due Date: 5/30/2025
22VAC40-73-450-E
Based on the record review, the facility failed to ensure the individualized service plan (ISP) shall be signed and dated by the licensee, administrator, or his designee, and by the resident or his legal representative.
Evidence
  1. Resident 1’s ISP dated 11/04/24 does not include the signature and date of the resident or the legal representative.
Plan of correction
What Has Been Done to Correct? An audit of ISP’s will be conducted and any missing signatures will be obtained. How Will Recurrence Be Prevented? The Healthcare Director or designee will ensure all signatures are obtained at the time of completion Person Responsible: Healthcare Director or designee Due Date: 5/30/2025
22VAC40-73-870-I
Based on observation and staff interview, the facility failed to ensure elevators, where used, the signed and dated certificate of inspection issued by the local authority shall be
Evidence
  1. of such inspection. Evidence:
  2. The elevator’s certificate of inspection located in the facility, expired 05/31/24. The elevator is accessible by both residents and staff. Staff 7 confirmed the facility is awaiting the certificate of inspection to be issued by the local building official.
Plan of correction
What Has Been Done to Correct? The elevators were inspected in 10/2024. The City of Suffolk has been contacted to produce the current certificate of operation for the elevators How Will Recurrence Be Prevented? The ED or designee will ensure that current certifications are maintained. Person Responsible: ED or designee Due Date: 5/30/2025
22VAC40-73-650-E
Based on the record review and staff interview the facility failed to ensure the resident’s record shall contain the physician’s or other prescriber’s signed written order or a dated notation of the physician’s or other prescriber’s oral order.
Evidence
  1. Resident’s #1 physician report dated 08/22/24 documents recommendation for continued use of CPAP for obstructive sleep apnea and the resident’s ISP dated 11/04/24 documents the resident uses a CPAP/BIPAP.
  2. The resident’s record did not contain a physician order for use of a CPAP for obstructive sleep apnea.
  3. During an interview with staff #1, staff #2, and staff #3, confirmed resident #1 used a CPAP while residing at the facility.
  4. A physician order for use of a CPAP for obstructive sleep apnea for resident #1 was requested, and staff #5 was not able to provide a copy of the physician order.
Plan of correction
What Has Been Done to Correct? Physician’s orders were placed in the resident record. How Will Recurrence Be Prevented? Staff will be re-educated to ensure that all physician’s orders are maintained in the record. An audit will be conducted to ensure physician’s orders are in the resident records Person Responsible: Healthcare Director or designee Due Date: 5/30/2025
22VAC40-73-40-B
Based on observation the facility, the facility failed to ensure that the current license is posted in the facility in a place conspicuous to the residents and the public.
Evidence
  1. During the onsite inspection on 01/30/25 and 02/28/25, the current license was not observed to be posted anywhere in the facility. The license for the previous license period (02/16/24 through 08/15/24) is posted in the facility.
Plan of correction
What Has Been Done to Correct? The current license has been posted. How Will Recurrence Be Prevented? The ED or designee will monitor to ensure the current license remains posted at the AL entrance. Person Responsible: Executive Director or designee Due Date: 4/23/2025
22VAC40-73-250-D
Based on the record review and staff interview, the facility failed to ensure each staff person shall annually submit the results of a risk assessment, documenting that the individual is free 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. The record for staff 1, hire date 09/29/23, did not contain an annual risk assessment for TB.
  3. Upon request, during an interview with staff 6 on 01/30/2025, the facility did not provide documentation of a completed TB risk assessment for staff 1.
Plan of correction
What Has Been Done to Correct? A TB risk assessment was completed for staff person 1. An audit will be conducted to ensure all TB risk assessments are documented in the employee record. How Will Recurrence Be Prevented? Business Office Manager will ensure that all TB risk assessments are completed for employees annually. Person Responsible: Business Office Manager, Executive Director Due Date: 5/30/2025
22VAC40-73-280-B
Based on the record review and staff interview the facility failed to ensure the assisted living facility shall maintain a written plan that specifies the number and type of direct care staff required to meet the day-to-day, routine direct care needs and any identified special needs for the residents in care. This plan shall be directly related to actual resident acuity levels and individualized care needs.
Evidence
  1. The facility’s written plan, provided by staff 7 on 02/28/2025, did not specify the type and number of direct care staff required to meet routine direct care needs, identified special needs for the residents in care and the plan was not based on resident acuity levels and resident’s individualized care needs. During an interview on 02/28/2025, staff 7 acknowledged the written plan did not contain all the required components.
Plan of correction
What Has Been Done to Correct? Written plan for staffing will be updated. How Will Recurrence Be Prevented? Written plan for staffing will be updated based on the needs of the residents in care. Person Responsible: Business Office Manager, Healthcare Director and Executive Director Due Date: 5/30/2025
22VAC40-73-470-F
Based on the record review and staff interview, the facility failed to ensure when the resident suffers serious accident, injury, illness, or medical condition, or there is reason to suspect that such has occurred, medical attention from a licensed health care professional shall be secured immediately. The circumstances involved and the medical attention received or refused shall be documented in the resident’s record in accordance to this section (22VAC40-73-470-F). If a resident refuses medical attention, the resident’s physician shall be notified immediately.
Evidence
  1. The record for resident #1 contains an incident report dated 01/13/25 documents that on 01/12/25 at approximately 10:00pm, the resident was having trouble breathing, but he refused to go to the ER.
  2. Staff 3 stated that when the staff checked on the resident around 12:15 am the resident was found not breathing. Staff started CPR, and the paramedic arrived. Resuscitation efforts were unsuccessful, and the resident was deceased.
  3. The resident’s record did not contain documentation a licensed healthcare professional nor the physician was notified immediately of the resident experiencing trouble with breathing and of the resident’s refusal to go to the ER.
  4. Staff 1 confirmed a licensed healthcare professional nor the physician was not immediately notified of resident’s 1 having difficulty breathing and refusal to go to the ER.
Plan of correction
What Has Been Done to Correct? Staff will be re-educated on resident emergencies procedures and securing medical attention immediately. How Will Recurrence Be Prevented? Healthcare Director will ensure that residents receive medical attention anytime they suffer a serious incident. Person Responsible: ED, Healthcare Director or designee Due Date: 5/30/2025
January 30, 2025Complaint survey0 violations
Inspection dates
01/30/2025
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 PREPAREDNESS
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: An unannounced complaint inspection took place on 01/30/25 at 9:30 am to 4:20 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 01/29/2025 regarding allegations in the areas of: Resident Care and Related Services and Buildings and Grounds Number of residents present at the facility at the beginning of the inspection: 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: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: An observation of heaters and temperatures was checked in resident rooms and the facility’s common areas. Additional Comments/Discussion An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
December 20, 2024Complaint survey2 violations
Inspection dates
12/20/2024
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 IMPAIRMENTS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 12/20/2024 at 9:50 am to 1:45 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 12/13/2024 and 12/19/2024 regarding allegations in the area(s) of: Personnel, Resident Care and Related Services, and the Safe Secure Environment 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: 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: A review of the facility’s medication carts was completed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation’s area(s) of non-compliance with standard(s) or law were: Resident Care and Related Services A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-930-D
Based on the record review the facility failed to ensure for each resident with an inability to use the signaling device the following shall be met: a minimal frequency of daily rounds to be made; once the resident has gone to bed each evening until the resident has arisen each morning, at a minimum direct care staff shall make rounds no less than every two hours; the facility shall document the rounds that were made, which shall include the name of the resident, the date and time of the rounds, and the staff member who made the rounds.
Evidence
  1. Resident’s #1 Individualized Service Plan (ISP) documents the following (a) “resident #1 will be checked on every 2 hours.” (b) “resident requires a secured memory care due to the diagnosis of dementia with serious cognitive impairment.” The facility’s round logs did not include documentation 2-hour rounds were completed for resident #1 during the timeframe of 10 pm to 7am on the dates of of 12/14/24, 12/15/24, 12/17/24, and 12/18/24.
Plan of correction
Not published by VDSS.
22VAC40-73-660-A
Based on observation it was determined that the facility failed to ensure medications shall be stored in a manner consistent with current standards of practice and the storage area shall be locked.
Evidence
  1. During a tour of the facility on 12/20/2024 at 10:06 a.m., the medication cart located on the 3rd Floor was observed to be unlocked and unstaffed.
Plan of correction
Not published by VDSS.
December 10, 2024Complaint survey3 violations
Inspection dates
12/10/2024
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 IMPAIRMENTS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 12/10/2024 from 9:46 am to 12:51 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint received by VDSS Division of Licensing on 12/02/2024 regarding allegations in the area of: Staffing and Supervision, and Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 88 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: Review of the facility’s staffing schedule, call bell logs, and maintenance repair schedule was completed. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-870-I
Based on observation and staff interview the facility failed to ensure elevators, where used, shall be kept in good running condition and shall be inspected at least annually. Elevators shall be inspected in accordance with the Virginia Uniform Statewide Building Code (13VAC5-63). The signed and dated certificate of inspection issued by the local authority shall be
Evidence
  1. of such inspection. Evidence:
  2. The elevator’s certificate of inspection located in the facility, expired 05/31/24. Staff #2 acknowledged the facility is awaiting the certificate of inspection to be issued by the local building official.
Plan of correction
Not published by VDSS.
22VAC40-73-1130-C
During night hours, the following number of direct care staff members shall be awake and on duty at all times in each special care unit and shall be responsible for the care and supervision of the residents: When 23 to 32 residents are present, at least three direct care staff members.
Evidence
  1. The facility’s staff schedule and time record logs dated 11/29/2024, 12/01/24, and 12/03/24 documents 2 staff scheduled and working in the special care unit during the 11pm to 7 am shift. The facility has a documented census of 23 residents for the dates of 11/29/24 through 12/03/24.
Plan of correction
Not published by VDSS.
22VAC40-73-220-B
Based on the staff interview the facility failed to ensure when private duty personnel who are not employees of a licensed home care organization provide direct care or companion services to residents in an assisted living facility, the requirements listed under subdivisions A 2 through A 6 of this section apply. In addition, before direct care or companion services are initiated, the facility shall ensure compliance with the requirements as listed in this subdivision (22VAC40-73-220-B)
Evidence
  1. The facility provided a list of the following residents receiving direct care or companion services from private duty personnel who are not employees of a license home care organization: Resident #3, resident #4, Resident #5, resident #6, resident #7, resident #8. Staff #3 and staff #4 was not able to provide the following documentation for the private duty personnel: (a) A tuberculosis examination and report; (b) Orientation and training provided by the facility; (c) Documentation in writing of information on the type and frequency of the services to be delivered to the resident; (d) Documentation of qualifications; (e) Criminal history report;
  2. During an interview with private duty personnel #1, private duty personnel #1 confirmed providing direct care services to include bathing and dressing for resident #3. Private duty personnel #1 confirmed not being employed with a licensed home care organization. The facility did not have the required items as listed in (22VAC40-73-220-B) for private duty personnel #1.
Plan of correction
Not published by VDSS.
November 15, 2024Inspection0 violations
Inspection dates
11/15/2024
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 PREPAREDNESS
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced monitoring inspection took place on 11/15/24 at 8:30 am to 12:40 pm. 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 11/07/2024 regarding allegations in the area of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 84 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: An observation of the facility’s community bus was completed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
October 29, 2024Complaint survey2 violations
Inspection dates
10/29/2024, 11/15/2024
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 IMPAIRMENTS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 10/29/2024 at 9:33 am to 3:50 pm and 11/15/24 at 8:30 am to 12:40pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint received by VDSS Division of Licensing on 10/17/2024 regarding allegations in the area of: Resident Care and Related Services and Buildings and Grounds Number of residents present at the facility at the beginning of the inspection: 84 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: 5 Number of interviews conducted with staff: 3 Observations by licensing inspector: Observation of lunch, staffing schedule, and the residents heating and cooling system was monitored. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-460-E
Based on the record review the facility failed to ensure the facility shall regularly observe each resident for changes in physical, mental, emotional, and social functioning. Any notable change in a resident’s condition or functioning including illness, injury, or altered behavior, and any corresponding action taken shall be documented in the resident’s record.
Evidence
  1. Resident’s #1 hospital emergency department notes from a visit dated 10/14/24 at 11:57 pm documents the following: “presents with from nursing facility, acute onset at 8 PM of vomiting sweats diarrhea feeling bad;” “patient arrived to ED via suffolk medic # 5 from Harmony House.” “Patient presents with Emesis, Diarrhea, Fatigue;” On 10/15/24 @ 5:51 am, “patient transported by MMT to Harmony at Harbour View.”
  2. The record for resident #1 does not contain documentation the resident was experiencing an illness on 10/14/24, a call to 911 for emergency personnel, and the resident’s transport to the hospital’s emergency department on 10/14/24.
  3. The record for resident #1 does not contain documentation the resident was discharged from the hospital’s emergency department on 10/15/24.
  4. Resident’s #1 hospital discharge summary dated 10/15/24 documents a diagnosis of Gastroenteritis. The resident’s record does not contain documentation of facility staff observing resident for changes in physical, mental, emotional, and social functioning after the residents Emergency department discharge that occurred on 10/15/24.
Plan of correction
The HCD or designee will update resident records in a timely manner with any notable change in condition or functioning and/or admission to a hospital or other healthcare facility
22VAC40-73-470-F
Based on the record review and staff interview the facility failed to ensure when the resident suffers serious accident, injury, illness, or medical condition, or there is reason to suspect that such has occurred, medical attention from a licensed health care professional shall be secured immediately. The circumstances involved and the medical attention received or refused shall be documented in the resident’s record in accordance to this section (22VAC40-73-470-F).
Evidence
  1. Resident’s #1 hospital emergency department notes from a visit dated 10/14/24 at 11:57 pm documents the following: “patient arrived to ED via suffolk medic # 5 from Harmony House.” “Patient presents with Emesis, Diarrhea, Fatigue;” On 10/15/24 @ 5:51 am, “patient transported by MMT to Harmony at Harbour View.”
  2. The record for resident #1 does not contain documentation the facility contacted 911 to transport the resident to the hospital’s emergency department.
  3. The record for resident #1 does not contain documentation resident’s #1 physician, next of kin, designated contact person, and or responsible party was notified of the resident’s illness and visit to the emergency department on 10/14/24.
  4. Staff #2, and staff #3 was unable to provide documentation completed by the facility of resident’s #1 visit to the hospital emergency department on 10/14/24 and the resident’s return on 10/15/24.
Plan of correction
The HCD or designee will ensure documentation of incidents in a timely manner to ensure treatment plan is being followed.
October 29, 2024Complaint survey3 violations
Inspection dates
10/29/2024, 11/15/2024
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 IMPAIRMENTS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 10/29/2024 at 9:33 am to 3:50 pm and 11/15/2024 at 8:30 am to 12:40 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint received by VDSS Division of Licensing on 10/08/24 and 10/28/24 regarding allegations in the area of: Personnel, Staffing and Supervision, and Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 84 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 2 Number of interviews conducted with residents: 5 Number of interviews conducted with staff: 4 Observations by licensing inspector: Observation of breakfast and lunch was completed. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: Personnel, and Resident Care and Related Services. A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-460-B
Based on the video footage, record review, and resident interview the facility failed to ensure care provision and service delivery shall be resident centered to the maximum extent possible and include prompt response by staff to resident needs as reasonable to the circumstances.
Evidence
  1. Review of video footage for resident #1 includes the following: Resident #1 pushed her call pendant for assistance on 10/05/24 at 6:40 am to request assistance to get up to shower and use the restroom. Staff #3 responded at 6:47 am and informed resident #1, the resident would need to wait until 7:00 am to receive assistance from the oncoming shift staff. No staff responded to the resident at 7am. Resident #1 pushed her call pendant again at 7:27 am and staff #2 responded at 8:10 am and informed resident #1, staff #2 would get someone to help the resident. The next staff person responded at 8:20 am to provide assistance to the resident.
  2. Resident’s #1 call bell logs for the month of September, October and November 2024 documents the facility did not promptly respond to the resident’s needs on the following dates and times: 9/05/24 @ 7:11am, wait time (1 hr. and 15 mins.) 10/07/24 @ 7:31 am, wait time (1hr. and 46 mins.) 11/09/24 @ 7:12 am, wait time (1 hr. and 58 mins.) 11/10/24 @ 6:56 am, wait time (1 hr. and 20 mins.) Resident’s #1 UAI and ISP documents the resident needs physical assistance with bathing, and dressing and includes incontinent for bladder with the need for incontinent supplies. During an interview with resident #1, resident #1 stated she uses her call pendant when she needs assistance with dressing, bathing, and when she has experienced bladder incontinence.
Plan of correction
All current CAHV staff will be re-educated prior to their next shift, and not later than 03.01.25 regarding standard expectations for call bell response times, demonstrations to reset call bells and individual resident pendants. Response expectations will be discussed upon hire and as needed based on regular reviews of call bell response time reports. Training will be conducted by Health Care Director, Maintenance Director or designee.
22VAC40-73-210-B
Based on the record review the facility failed to ensure in a facility licensed for both residential and assisted living care, all direct care staff shall attend at least 18 hours of training annually.
Evidence
  1. The record for staff #1, hire date of 8/17/25, contains documentation of 8.75 hours of annual training during the timeframe of 8/17/23 through 11/15/2024.
  2. The record for staff #2, hire date of 10/31/22, contains documentation of 1 hour of annual training during the timeframe of 10/31/23 through 11/15/24.
  3. The record for staff #3, hire date of 8/07/15, does not contain documentation of annual training during the timeframe of 8/07/23 through 11/15/24.
Plan of correction
The Administrator/designee will follow the in-service calendar to ensure that all staff are compliant with the required 18 hours of annual in-service training.
22VAC40-73-990-B
Based on the record review it was determined that the facility failed to ensure the procedures in the plan for resident emergencies required in subsection A of this section shall be reviewed by the facility at least every six months with all staff. Documentation of the review shall be signed and dated by each staff person.
Evidence
  1. The record for staff #1, hire date 8/17/15, did not include evidence staff #1 reviewed the facility’s written plan for resident emergencies at least once every six months.
  2. The record for staff #2, hire date 10/31/22, did not include evidence staff #2 reviewed the facility’s written plan for resident emergencies at least once every six months.
  3. The record for staff #3, hire date 08/07/15, did not include evidence staff #3 reviewed the facility’s written plan for resident emergencies at least once every six months.
Plan of correction
The HCD will ensure this training is completed during orientation. The ED will ensure review is done for all staff at least every six months when fire and safety training is done. The ED will also ensure that at least once every six months all staff currently on duty on each shift will participate in an exercise in which the procedures for resident emergencies are practiced. Documentation of all training will be obtained and kept on file.
October 29, 2024Inspection2 violations
Inspection dates
10/29/2024, 11/15/2024
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 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS
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: An unannounced monitoring inspection took place on 10/29/24 at 9:33 am to 3:50 pm and 11/15/24 at 8:30 am to 12:40 pm. 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 10/24/2024 regarding allegations in the area of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 84 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: An observation of the facility’s community bus was completed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-460-A
Based on the record review and staff interview it was determined that the facility failed to ensure the facility shall assume general responsibility for the health, safety, and well-being of the residents.
Evidence
  1. According to the facility’s incident report on 10/23/24 staff #1 was operating the facility’s bus and “while returning from a lunch outing, resident #1 was thrown from her wheelchair while in transit on the community bus. “ “Resident #1 suffered a laceration to the top upper left portion of her head. Resident #1 was transported to Norfolk General by EMS. Resident #1 is stable with two fractures of her neck.”
  2. During an interview, staff #1, stated that she “stopped on the brakes” to prevent hitting another car who immediately stopped in front of the community bus, and that resident #1 was “thrown from her wheelchair” and “slid” to the front of the bus.” Resident #1 suffered an “injury to her head and was bleeding.”
  3. Staff #1 confirmed resident #1 was not strapped into a seatbelt while being transported on the transport bus prior to the incident and staff #1 did not ensure resident #1 was secured in a seatbelt prior to being transported on the community bus.
Plan of correction
The Executive Director will ensure compliance with all regulations for licensed assisted living facilities and with the facility's own policies and procedures. Executive Director or designee will re-educate all drivers for the community on the policy and procedure (Vehicle Safety Program). The re-education shall include demonstration of how to properly secure seat belts during resident transport.
22VAC40-73-40-A
Based on the record review and staff interview it was determined that the facility failed to ensure the licensee shall ensure compliance with all regulations for licensed assisted living facilities and terms of the licensee issued by the department; with relevant federal, state, and local laws; with other relevant regulations; and with the facilities own policies and procedures.
Evidence
  1. The facility’s Vehicle Safety Program Policy includes the following statements: a) “Motor vehicle reports should be obtained before hiring and, on all drivers, annually.” b) “Drivers are required to sign the vehicle safety program acknowledgement form.” c) “all Drivers are required to complete initial safe driving training.” d) “the Driver and all occupants are required to wear safety belts when operating or driving in a motor vehicle. The Driver is responsible to ensure all passengers are wearing their safety belts.”
  2. The record for staff #1, hire date 08/05/22 does not contain the following as required per the facility’s vehicle safety Program Policy: a) A motor vehicle report completed at hire, and/or an annual motor vehicle report completed prior to the incident on 10/13/24. b) The facility’s vehicle safety program acknowledgement form. c) Documentation of completion of the facility’s “initial safe driver training.”
  3. Staff #1 confirmed resident #1 was not strapped into a seatbelt while being transported on the facility’s community bus as she did not physically assist resident #1 with using and securing the seatbelt.
Plan of correction
The Executive Director will ensure compliance with all regulations for licensed assisted living facilities and with the facility's own policies and procedures. Executive Director or designee will re-educate all drivers for the community on the policy and procedure (Vehicle Safety Program). Motor Vehicle Reports will be accessed immediately for all transport drivers hired at the community. Reports will be accessed and reviewed upon hire and annually thereafter.
October 2, 2024Complaint survey7 violations
Inspection dates
10/02/2024, 10/29/2024
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 IMPAIRMENTS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 10/02/24 at 9:45 am to 2:15 pm and 10/29/24 at 9:33 am to 3:50 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 9/23/2024 regarding allegations in the area(s) of: Personnel, Resident Care and Related Services, and the Safe Secure Environment 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: 2 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 4 Observations by licensing inspector: A review of the facility’s staffing schedule and medication carts was completed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation’s area(s) of non-compliance with standard(s) or law were: Resident Care and Related Services A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-930-D
Based on the record review the facility failed to ensure for each resident with an inability to use the signaling device the following shall be met: a minimal frequency of daily rounds to be made; once the resident has gone to bed each evening until the resident has arisen each morning, at a minimum direct care staff shall make rounds no less than every two hours; the facility shall document the rounds that were made, which shall include the name of the resident, the date and time of the rounds, and the staff member who made the rounds.
Evidence
  1. The record for resident #1 contains an ISP dated 5/28/24 that documents the following: “2-hour rounds monitor for emergencies or other unanticipated needs.” The facility’s round logs did not include documentation 2-hour rounds were completed for resident #1 on the dates of 9/01/24 and 09/06/24.
  2. The record for resident #2, contains an ISP dated 8/19/24 that documents the following: “resident #2 will be checked on every 2 hours” The facility’s round logs did not include documentation 2-hour rounds were completed for resident #1 on the dates of 9/01/24 and 09/06/24.
Plan of correction
Executive Director or designee will perform daily audits of 2 hour round sheets to ensure rounds are being done as scheduled.
22VAC40-73-200-D
Based on the record review the facility failed to ensure the facility shall 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. During the onsite inspection on 10/02/24, the record for staff #2, hire date of 12/28/22, contains personal data information that documents staff #2 is employed as a personal care aide. The facility’s staff roster documents staff #2 as a personal care aide. During the Licensing Inspector review on 10/02/24, the record for staff #2 did not contain a personal care aide certificate or documentation of staff #2 meeting the qualifications as a direct care staff.
  2. During the onsite inspection on 10/02/24, staff #5 reviewed the record for staff #2 and was not able to provide documentation of staff #2 qualifications as a personal care aide or direct care staff.
Plan of correction
The Executive Director or designee will ensure documentation of staff qualifications is on file in staff records. The ED or designee will audit staff records to ensure compliance.
22VAC40-73-250-D
Based on the record review the facility failed to ensure each staff person on or within 7 days prior to the first day of work at the facility prior to coming in contact with residents shall submit the results of a risk assessment documenting the absence of tuberculosis (TB) in a communicable form as
Evidence
  1. d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. The risk assessment shall be no older than 30 days. Evidence:
  2. The record for staff #1, hire date of 8/19/24, did not contain a risk assessment for TB completed on or within 30 days prior to the first day of work.
  3. Staff #5 reviewed the record for staff #1 and was not able to provide documentation of a risk assessment for TB completed on or 30 days prior to staff #1’s first day of work.
Plan of correction
Executive Director or designee will review all staff records for current documentation of TB Assessment Screening.
22VAC40-73-450-E
Based on the record review the facility failed to ensure the individualized service plan (ISP) shall be signed and dated by the licensee, administrator, or his designee, and by the resident or his legal representative.
Evidence
  1. Resident’s #1 ISP dated 5/28/24 does not include the signature and date the resident or the legal representative.
Plan of correction
HCD or designee will ensure all individualized service plans are signed by responsible participants. Will obtain copies of email correspondences to verify ISP forms are sent to responsible participants.
22VAC40-73-210-F
Based on the record review the facility failed to ensure at least two of the required hours of training shall focus on infection control and prevention.
Evidence
  1. The record for staff #2, hire date of 12/28/22, did not contain documentation of completion of at least two hours of training focusing on infection control during the timeframe of 12/28/22 through 10/02/24.
Plan of correction
The Executive Director or designee will ensure that all staff will have 2 hours of infection control with the training year and 1 hour of infection control training will be scheduled at least twice per year.
22VAC40-73-210-B
Based on the record review the facility failed to ensure in a facility licensed for both residential and assisted living care, all direct care staff shall attend at least 18 hours of training annually.
Evidence
  1. The record for staff #2, hire date of 12/28/22, did not contain at least 18 hours of annual training during the timeframe of 12/28/22 through 10/02/24.
  2. The record for staff #2 documented 3 hours of training after the employment date of 12/28/22.
  3. Staff #5 reviewed the record for staff #2 and was not able to provide documentation staff #2 completed at least 18 hours of annual training.
Plan of correction
The Executive Director or designee will ensure that all staff must meet the training requirements to include the number of hours and special training annually.
22VAC40-73-260-A
Based on the record review the facility failed to ensure each direct care staff member who does not have current certification in first aid as specified in subdivision 1 of this subsection shall receive certification in first aid within 60 days of employment.
Evidence
  1. The record for staff #2, hire date of 12/28/22, did not contain documentation of a certification in first aid.
  2. During the onsite inspection on 10/02/24, Staff #5 reviewed the record for staff #2 and was not able to provide documentation of certification in first aid for staff #2.
Plan of correction
The Executive Director or designee will review all staff records to ensure first aid certification documentation is in each staff record
October 2, 2024Inspection1 violation
Inspection dates
10/02/2024
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 IMPAIRMENTS22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS
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: An unannounced monitoring inspection took place on 10/02/24 at 9:45 am to 2:15 pm. 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 09/03/2024 regarding allegations in the area 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: 3 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: An observation of the facility’s dining area was completed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-40-A
Based on the record review the facility failed to ensure the licensee shall ensure compliance with all regulations for licensed assisted living facilities and terms of the licensee issued by the department; with relevant federal, state, and local laws; with other relevant regulations; and with the facilities own policies and procedures.
Evidence
  1. The facility’s policy and procedure for “motorized mobility aids: wheelchairs, carts, and scooters” state the following: “residents using motorized mobility aids need to demonstrate evidence of sufficient skills to follow all safety rules pertaining to motorized mobility aids to operate their device safely. An assessment will be conducted by Rehab personnel to determine physical and mental capability needs to occur upon use, after an incident involving aid, and at least semi-annually.”
  2. Resident #1, admission date of 4/23/24, was admitted to the facility with a motorized wheelchair. The record for resident #1 does not contain the following upon or at admission: an assessment conducted by rehab personnel to determine the resident’s physical and mental ability needs upon the use of the motorized wheelchair and documentation the resident demonstrated sufficient skills to follow all safety rules pertaining to motorized wheelchair.
  3. The facility’s incident report dated 9/02/24 documents the following “resident #1 with mobilized wheelchair rolled into dining room table knocked table over, causing resident #2 to fall.”
  4. The record for resident #3 contains the following progress note dated 9/20/24: resident #1 ran into the table with resident’s #1 motorized wheelchair. Resident’s #1 chair hit resident’s #3 walker into resident’s #3 arm and then the table moved into resident’s #3 arm.
  5. During an interview with staff #1 and staff #2 both staff confirmed that resident #1, did not receive an assessment completed by rehab personnel to determine physical and mental capability needs to occur upon use of the resident’s motorized wheelchair.
Plan of correction
Not published by VDSS.
August 12, 2024Inspection2 violations
Inspection dates
08/12/2024
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 IMPAIRMENTS
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: An unannounced monitoring inspection took place on 8/12/24 at 9:11 am to 3:10 pm. 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 08/07/2024 regarding allegations in the area of: Article 3: Safe, Secure Environment 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: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 5 Observations by licensing inspector: An observation of the safe secure environment was completed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-450-C
Based on the record review the facility failed to ensure the individualized service plan (ISP) shall include A description of identified needs based upon the UAI other sources.
Evidence
  1. The record for resident #1, admission date of 06/02/23 to the facility’s safe secure environment contains the following: an assessment for serious cognitive impairment dated 05/23/23 that documents “a serious cognitive impairment due to dementia and the resident is unable to recognize danger or protect his/her own safety and welfare.” 2.Resident’s # 1 physician notes dated 09/04/23 and 06/27/24 documents a diagnosis of “dementia” and includes the following: “patient requires 24-hour supervision and assistance. Continue supportive care, maintain safety, and fall preventions.” 3.Resident’s #1 ISP dated 5/28/24 does not include an identified need to address the resident’s serious cognitive impairment to include dementia, placement in the safe secure environment, and needs for supervision. 4.Resident’s #1 UAI dated 5/28/24 documents the resident needs human help supervision with toileting. The resident’s needs for supervision with toileting is not included in the resident’s ISP dated 5/28/24.
Plan of correction
The HCD/HSD or designee will ensure that all residents are assessed face to face and a comprehensive ISP is developed to meet the resident's individualized care and service needs. The ISP will be provided to the family for review. The family will be asked to sign and date the document following the review. The Executive Director or designee will conduct a monthly audit of all new resident files to ensure they have a current UAI/ISP. Audits will be conducted for 4 months to monitor for compliance.
22VAC40-73-460-D
Based on the record review and staff interviews the facility failed to ensure the facility shall provide supervision of resident schedules, care, and activities, including attention to specialized needs, such as prevention of falls and wandering from the premises.
Evidence
  1. Resident’s #1 incident report dated 8/07/24 documents the following incident that occurred on 08/07/24 in the safe secure environment: “Resident had an unseen fall, unsure of the time of incident. When 7-3 staff came in, they seen resident in the bathroom on the floor lying in blood. Resident stated that she had been on the floor all night. Resident did suffer head trauma and bleeding. Resident sent to the Norfolk General hospital for evaluation and treatment.”
  2. During an interview, staff #1 reported on the day of 08/07/24 approximately the time of 7:40 am, staff #1 found resident #1 lying on the floor in the resident’s bathroom. Staff #1 observed the following on resident #1: “head and nose bleeding” “dry blood on arm” “resident #1 complained of shoulder pain” “blood on ground and toilet chair.”
  3. The record for resident #1 contains physician notes dated 09/04/23 and 06/27/24 that documents a diagnosis of “dementia” and includes “patient requires 24-hour supervision and assistance. Continue supportive care, maintain safety, and fall preventions.”
  4. Resident’s #1 ISP dated 5/28/24 documents “resident is at a moderate potential risk for falls.”
  5. Resident’s #1 UAI dated 5/28/24 documents the resident needs human help supervision with toileting and bathing.
  6. The facility’s staff schedule documents staff #2, #3, and #4 worked as the onsite direct care staff working in the safe secure environment for the 11pm to 7am shift on 8/06/24 to 8/07/24.
  7. During an interview with staff #2, staff #2 confirmed that they did not observe resident #1 and did not complete round checks for resident #1 during the 11pm to 7am shift on 8/06/24 to 8/07/24.
  8. During an interview with staff #3, staff #3 reported completing an observation on resident #1 once at 3:30 am on 8/07/24 during the 11pm to 7am shift and stated resident was sleeping, but staff #3 did not document this encounter.
  9. During an interview with staff #4, staff #4 confirmed that they did not observe resident #1 and did not complete round checks for resident #1 during the 11pm to 7am shift on 8/06/24 to 8/07/24.
  10. The facility’s round logs for the safe secure environment includes the following statement: “8/6/2024, 08/07/2024, no rounds done.”
Plan of correction
Residents who cannot use the call bell system due to a physical or serious cognitive impairment were placed on a two-hour rounding log 08.12.24. The HCD/HSD will review the rounding log daily to ensure rounds are completed as scheduled. The HCD/HSD will ensure all that all resident UAIs and ISPs reflect the residents’ physical or cognitive impairment and the need for regular rounding. The HCD/HSD will review 5 charts weekly to assure UAIs and ISPs reflect residents’ assessed needs. Audits will continue for 4 months to monitor for compliance.
August 12, 2024Complaint survey2 violations
Inspection dates
08/12/2024
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 IMPAIRMENTS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 8/12/24 at 9:11 am to 3:10 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 8/01/24 regarding allegations in the area(s) of: Staffing and Supervision, 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: 3 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: A review of the facility’s staffing schedule and medication carts was completed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation’s area(s) of non-compliance with standard(s) or law were: Resident Care and Related Services A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-930-D
Based on the record review the facility failed to ensure for each resident with an inability to use the signaling device the following shall be met: once the resident has gone to bed each evening until the resident has arisen each morning, at a minimum direct care staff shall make rounds no less than every two hours; the facility shall document the rounds that were made, which shall include the name of the resident, the date and time of the rounds, and the staff member who made the rounds.
Evidence
  1. The record for resident #2 contains an ISP dated 8/11/24 that documents the following: ‘due to physical or serious cognitive impairment resident cannot utilize call bell system; staff will perform every 2-hour checks from time resident goes to bed to waking up and about any time resident is in room resting as needed.” 2.The facility’s round logs did not include documentation 2-hour rounds were completed for resident #2 on the dates of 8/11/24 to 8/12/24 during the 11pm to 7am shift.
Plan of correction
A new rounding log was implemented. The HSD/ED will schedule training for all direct care staff to review use of the log and reinforce the importance of signing after completing two-hour rounds. The HSD/HCD/Executive Director or designee will audit the log daily to check for accuracy. Audits will continue for 4 months to monitor compliance.
22VAC40-73-450-A
Based on the record review the facility failed to ensure on or within 7 days prior to the day of admission, a preliminary plan of care shall be developed to address the basic needs of the resident that adequately protects his health, safety, and welfare. Exception: A Preliminary plan of care is not necessary if a comprehensive individualized service plan (ISP) is developed, in conformance with this section, on the day of admission.
Evidence
  1. The record for resident #1, admission date of 08/09/24, does not contain a preliminary plan of care completed on or within 7 days of admission or an ISP completed on the day of admission. The ISP in the record for resident #1 is dated as completed on 8/11/24. 2.The record for resident #2, admission date 8/05/24, does not contain a preliminary plan of care completed on or within 7 days of admission or an ISP completed on the day of admission The ISP in the record for resident #2 is dated as completed on 8/11/24.
Plan of correction
The HCD/HSD will ensure that a preliminary plan of care is completed on or within 7 days of admission or that an ISP is completed on the day of admission. The HCD/HSD/ED or designee will review the records of all new admissions prior to move-in to assure compliance.
July 16, 2024Inspection10 violations
Inspection dates
07/16/2024, 07/18/2024
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 REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS
Technical assistance
Written Assurance Personal Data
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: An unannounced renewal inspection took place on 07/16/24 at 8:14 am to 4:18 pm and 07/18/24 at 9:12 am to 4:47 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 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: 10 Number of staff records reviewed: 6 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 4 Observations by licensing inspector: Breakfast and lunch were observed. A medication pass observation was completed for three residents. The following was reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, medication carts, fire inspection report, health inspection report, and a staffing schedule. Water temperature was measured, and the call bell system was monitored. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-870-I
Based on observation and staff interview the facility failed to ensure elevators, where used, shall be kept in good running condition and shall be inspected at least annually. Elevators shall be inspected in accordance with the Virginia Uniform Statewide Building Code (13VAC5-63). The signed and dated certificate of inspection issued by the local authority shall be
Evidence
  1. of such inspection. Evidence:
  2. The elevator’s certificate of inspection located in the facility, expired 05/31/24. Staff #8 confirmed the elevator’s certificate of inspection expired 05/31/24.
Plan of correction
The elevator inspection scheduled to be completed 08.12.24. Future inspections scheduled annually. Maintenance director or designee will be responsible to ensure inspection completed as scheduled through December 31, 2024 to monitor for ongoing compliance.
22VAC40-73-460-E
Based on the record review and staff interview the facility failed to ensure the facility shall regularly observe each resident for changes in physical, mental, emotional, and social functioning. Any notable change in a resident’s condition or functioning, including illness, injury, or altered behavior, and any corresponding action taken shall be documented in the resident’s record.
Evidence
  1. The facility’s communication log dated 07/11/24 for resident #3 states, “fell in bathroom resident has skin tear.” The record for resident #3 and the facility’s communication log did not include documentation of corresponding action taken by the facility to provide first aide for the resident’s skin tears.
  2. During an interview with staff #7, staff #7 acknowledged the facility staff applied a bandage and changed the bandage for the skin tear for resident #3, however the facility did not have documentation of the staff providing first aide to the resident’s skin tear.
  3. The record for resident #3 contains physician orders dated 07/12/24 and 07/17/24 “HHSN (Home Health Skilled Nursing) evaluation and treatment skin tears to right forearm,” however, the physician order dated 07/12/24 includes the wrong last name for the resident. Staff #7 confirmed the physician order dated 07/12/24 included the wrong last name for resident #3 which resulted in a delay of resident #3 receiving home health skilled nursing services for treatment of the skin tears. Staff #7 confirmed the record for resident #3 did not contain documentation of staff observing the resident’s skin tears and or the facility’s staff providing first aide to the skin tears.
Plan of correction
The HCD, and or/designee will partner with outside health care agencies to ensure all wound care and treatments outside of scope of practice is performed in accordance with physician's orders. All home health orders will be reviewed by HCD or designee by 09.15.24. The HCD or designee will review all new home health orders through December 31, 2024 to monitor for ongoing compliance.
22VAC40-73-450-D
Based on the record review the facility failed to ensure when hospice care is provided to a resident, the assisted living facility and the licensed hospice organization shall communicate and establish an agreed upon coordinated plan of care for the resident. The services provided by each shall be included in the ISP.
Evidence
  1. The record for resident #7 contains a hospice care effective date of 04/08/24. The resident’s ISP dated 02/19/24 was not updated and reviewed to include hospice care services provided by the hospice care provider.
Plan of correction
The Community will correct the ISP to include detailed services provided by outside care partners for resident #7. The HCD or designee will review all hospice residents’ ISPs to ensure that services by outside health care partners is included. ISP audit will be completed by 09.15.24. The HCD or designee will continue to monitor all ISP’s monthly. The HCD or designee will review the preliminary ISPs for all new move-ins through December 31, 2024 to monitor for ongoing compliance.
22VAC40-73-450-A
Based on the record review the facility failed to ensure on or within 7 days prior to the day of admission, a preliminary plan of care shall be developed to address the basic needs of the resident that adequately protects his health, safety, and welfare. Exception: A Preliminary plan of care is not necessary if a comprehensive individualized service plan (ISP) is developed, in conformance with this section, on the day of admission.
Evidence
  1. The record for resident #3, admission date of 6/28/24, does not contain a preliminary plan of care completed on or within 7 days of admission or an ISP completed on the day of admission. During an interview with resident #3, resident #3 confirmed their admission date to the facility as 06/28/24.
Plan of correction
Resident Files will be Audited for compliance. Audit will be completed by 09.15.24 The Health Care Director or designee will conduct and complete the preliminary ISP no later than day of admission for all new move-ins. The ED or designee will review the preliminary ISPs for all new move-ins through December 31, 2024 to monitor for ongoing compliance.
22VAC40-73-860-I
Based on the onsite observation, the facility failed to ensure each facility shall store cleaning supplies and other hazardous materials in a locked area.
Evidence
  1. During the onsite observation on 07/18/24 at 9:18 am in the safe, secure unit, the Licensing Inspector (LI) observed Bleach and Comet, and cleaning liquid products located in the unlocked medication room. The medication room was unstaffed during the observation.
Plan of correction
Automatic door closers to be installed by EOD Friday August 9, 2024. Automatic door closers will be installed to automatically close behind the staff to ensure chemical storage areas remain closed and locked. Daily reviews of physical plant will occur to ensure hazardous materials are stored appropriately and all storage spaces are locked. Executive Director or designee will be responsible for daily physical plant review through December 31, 2024 to monitor for ongoing compliance.
22VAC40-73-440-A
Based on the record review the facility failed to ensure the Uniform Assessment Instrument (UAI) shall be completed prior to admission, at least annually, and whenever there is a significant change in the resident’s condition.
Evidence
  1. The record for resident #3, admission date 06/28/24, contains an UAI that documents an assessment date of 07/02/24 and is signed and dated by the assessor on 07/08/24. During an interview with resident #3, resident #3 confirmed their admission date to the facility as 06/28/24.
  2. The record for resident #7 contains a hospice care note that documents the resident was admitted to hospice care effective 04/08/24. The UAI in the resident’s record is dated 01/19/24. The resident’s record does not contain a UAI completed when there was a significant change in the resident’s condition to include hospice care treatment.
Plan of correction
1. Resident #3 UAI will be updated to reflect correct assessment date and current status. Date to be corrected 09.15.24 2. Team members trained to complete the UAI will complete resident’s care and related documentation to monitor for changes that required updates to the UAI/ISP. 3. The Health Care Director or designee will review UAIs and ISPs for accuracy during the Quarterly Clinical Oversight and on an as needed basis. Findings will be reviewed in the Quality Assurance and Performance Improvement meetings. 4. Will be reviewed in QAPI through 12.31.24 to monitor ongoing compliance
22VAC40-73-320-A
Based on the record review the facility failed to ensure within the 30 days preceding admission, a person shall have a physical examination completed by an independent physician.
Evidence
  1. The admission’s record for resident #8, admission date 07/17/24, contains a physical examination that documents an exam date of 05/10/24, however 05/10/24 is more than 30 days prior to the resident’s admission to the facility.
Plan of correction
The history and physical examination for resident 8 was amended by the attending physician in order to reflect the correct examination date. All other history and physical examination forms will be audited to verify they include an examination date that is not more than 30 days prior to the resident’s admission to the community. All new history and physical examination forms will be reviewed by the HCD and/or ED or designee to assure compliance with dating of history and physical exam forms. . The HCD is responsible for ongoing compliance. Will be reviewed in QAPI through 12.31.24 to monitor ongoing compliance.
22VAC40-73-680-E
Based on the record review the facility failed to ensure medical procedures or treatments ordered by a physician or other prescriber shall be provided according to his instructions and documented. The documentation shall be maintained in the resident’s record.
Evidence
  1. The record for resident #2 contains a physician order dated 05/31/24 for “Dermatology consult to eval & treat.” The resident’s record did not contain documentation of completion of a dermatology consultation and/or a dermatology evaluation and treatment.
  2. During the onsite inspection, documentation of a dermatology consultation and evaluation and treatment for resident #2 was requested from staff #7 and was not provided.
Plan of correction
LPNs and RMAs will be re-educated before 09.15.24 on following physician orders per standard 22VAC40-73-(6)- 680-E and the community process and procedure for obtaining new orders. The HCD or designee will audit all new orders to ensure all consult(s) orders with physician completed as ordered. The HCD or designee will educate all LPN’s and RMA’s to complete new order process through December through December 31, 2024 to monitor for ongoing compliance.
22VAC40-73-480-C
Based on the record review the facility failed to ensure facilities shall 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. The record for resident #1 contains a physician order dated 09/26/23 for speech therapy “ST eval & treat recurrent pneumonia.” The resident’s record did not contain documentation of completion of an evaluation and treatment for speech therapy.
  2. During the onsite inspection, documentation of completion of a speech therapy evaluation and treatment for resident #1 was requested from staff #7 and was not provided.
Plan of correction
All charts will be reviewed to ensure compliance by 09.15.24. The Health Care Director or designee will meet with third party providers post treatment to obtain the required documents and care changes. The HCD or designee will review a minimum of 5 charts per month through December 31, 2024 to monitor for ongoing compliance.
22VAC40-73-660-A-1
Based on observation it was determined that the facility failed to ensure medications shall be stored in a manner consistent with current standards of practice and the storage area shall be locked.
Evidence
  1. During a tour of the facility on 07/18/24 at 9:22 am, the Licensing Inspector (LI) observed the medication cart located in the safe secure unit to be unlocked and unstaffed
Plan of correction
All LPN's and Medication Aides will be re-educated on standard procedures for securing the medication cart and promoting safety in medication administration before 09.15.24. The HCD or designee will reeducate as needed to all new staff through December 31, 2024 to monitor for ongoing compliance.
June 11, 2024Inspection5 violations
Inspection dates
06/11/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS
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: An unannounced monitoring inspection took place on 06/11/24 at 9:48 am to 3:25 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 88 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 5 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 4 Observations by licensing inspector: Lunch was observed. The following were reviewed: staffing schedule, emergency preparedness drills, and medication carts. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-200-C
Based on the onsite staff record review it was determined that the facility failed to ensure direct care staff shall meet one of the requirements in this subsection. If the staff does not meet the requirement at the time of employment, he shall successfully meet one of the requirements in this subsection within two months of employment.
Evidence
  1. The record for staff #1, hire date 03/12/24, did not contain documentation of staff #1 meeting one of the direct care staff qualifications.
  2. The record for staff #1 and the facility’s staff record list, documents staff #1 position as a “personal care aide.” Staff # 1’s record did not contain a personal care aide certification.
  3. Staff # 8 was unable to provide documentation to demonstrate staff #1 meets the requirements for direct care staff.
Plan of correction
The business office manager or designee will perform an audit of employee files by 7/1/2024 to validate the certifications of all current employees. The business office manager or designee will collect all required certifications for employees during the hiring process. The ED or designee will validate that new employee files contain all required certifications through 12/31/2024. Date to be corrected: 7/1/2024 (audit); 12/31/2024 (monitoring)
22VAC40-73-250-D
Based on the record review the facility failed to ensure each staff person on or within 7 days prior to the first day of work at the facility prior to coming in contact with residents shall submit the results of a risk assessment documenting the absence of tuberculosis (TB) in a communicable form as
Evidence
  1. d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. The risk assessment shall be no older than 30 days. Evidence:
  2. The record for staff #1, hire date of 3/12/24, did not contain a risk assessment for TB completed on or within 30 days prior to the first day of work.
  3. The record for staff #5, hire date of 3/15/24, did not contain a risk assessment for TB completed on or within 30 days prior to the first day of work.
  4. Staff #8 confirmed the record for staff #1 and staff #5 did not contain a risk assessment for TB completed on or within 30 days prior to the first day of work for staff #1 and staff #5.
Plan of correction
The business office manager or designee will perform an audit of employee files by 7/1/2024 to validate that the required initial TB risk assessment is no more than 30 days prior to the employee’s date of hire. The business office manager or designee will collect required TB risk assessments dated within the required timeframe during the hiring process. The ED or designee will validate that the new employee files contain a properly dated TB risk assessment through 12/31/2024. Date to be corrected: 7/1/2024 (audit); 12/31/2024 (monitoring
22VAC40-73-260-A
Based on the record review and staff interview it was determined that the facility failed to ensure each direct care staff member shall maintain current certification in first aid.
Evidence
  1. The record for staff # 2, hire date 10/29/22, does not contain a current certification in first aid.
  2. The record for staff # 5, hire date 03/15/24, did not contain documentation of a certification in first aid.
  3. Staff #8 acknowledged the records for staff #2 and staff #5 did not contain documentation of a current certification in first aid.
Plan of correction
The business office manager or designee will perform an audit of employee files by 7/1/2024 to validate that proof of required, current first aid and CPR training is present. Employees who are found to not have the required training will receive such training. Training will be repeated as required by the certifying agency/organization. The business office manager or designee will collect proof of required, current first aid and CPR training during the hiring process. The ED or designee will validate that the new employee files contain proof of required, current first aid and CPR training through 12/31/2024. Date to be corrected: 7/1/2024 (audit), 12/31/2024 (monitoring) Next Class scheduled: June 26, 2024 10am and 1pm
22VAC40-73-450-A
Based on the record review the facility failed to ensure on or within 7 days prior to the day of admission, a preliminary plan of care shall be developed to address the basic needs of the resident that adequately protects his health, safety, and welfare. Exception: A Preliminary plan of care is not necessary if a comprehensive individualized service plan (ISP) is developed, in conformance with this section, on the day of admission.
Evidence
  1. The record for resident #1, admission date of 5/20/24 does not contain a preliminary plan of care completed on or within 7 days of admission or an ISP completed on the day of admission.
  2. The record for resident #3, admission date 5/15/24, does not contain a preliminary plan of care completed on or within 7 days of admission or an ISP completed on the day of admission.
  3. Staff #8 confirmed the records for resident #1 and resident #3, did not contain a preliminary plan of care completed on or within 7 days of admission or an ISP completed on the day of admission.
Plan of correction
The Health Care Director or designee will complete and finalize the ISP on the day the resident moves in or within 7 days prior. The HCD will provide ISP training, including the required timeframes for completion to all employees who develop plans of care by 7/1/2024. Date to be corrected: 7/1/2024
22VAC40-73-990-B
Based on the record review it was determined that the facility failed to ensure the procedures in the plan for resident emergencies required in subsection A of this section shall be reviewed by the facility at least every six months with all staff. Documentation of the review shall be signed and dated by each staff person.
Evidence
  1. The record for staff #2, hire date 10/29/22, did not include evidence staff #2 reviewed the facility’s written plan for resident emergencies at least once every six months.
  2. The record for staff #3, hire date 8/17/15, did not include evidence staff #3 reviewed the facility’s written plan for resident emergencies at least once every six months.
  3. The record for staff #4, hire date 4/04/23, did not include evidence staff #4 reviewed the facility’s written plan for resident emergencies at least once every six months.
  4. Staff #8 acknowledged the facility did not have evidence of staff #3, staff #2, staff #3, and staff #4 reviewing the facility’s written plan for resident emergencies at least once every six months.
Plan of correction
The administrator will assure that there is a written plan for medical emergencies in place that includes all requirements as outlined in 22VAC40-73-990. The plan will be reviewed with all employees every six months and documentation of training will be retained at the community. Additionally, every six months all employees on duty will participate in an exercise in which they carry out procedures for responding to medical emergencies based on the plan, and documentation of this training will be retained at the community. A copy of the medical emergency plan will be available in the community for staff, residents, families and legal representatives to review. Date to be corrected: 07.01.24(audit) monitoring 12.31.24
May 7, 2024Complaint survey1 violation
Inspection dates
05/07/2024
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 IMPAIRMENTS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 05/07/2024 from 9:07 am to 4:36 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 3/12/24, 03/13/24, 03/19/24, and 3/20/24 regarding allegations in the area(s) of: Staffing and Supervision and 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: 5 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 safe secure unit, and assisted living unit was completed, and a review of the medication cart. Lunch was observed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation’s area(s) of non-compliance with standard(s) or law were: Resident Care and Related Services A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-460-B
Based on the record review the facility failed to ensure care provision and service delivery shall be resident centered to the maximum extent possible and include prompt response by staff to resident needs as reasonable to the circumstances.
Evidence
  1. Resident’s #1 call bell logs for the month of March, April, and May 2024 documented the facility did not promptly respond to the resident’s pendant alert system on the following dates and times: 03/16/24, wait time (1 hr. and 29 mins.) 03/17/24, wait time (5hrs. and 54 mins.) 03/18/24, wait time (3 hrs. and 27 mins.) 03/20/24, wait time (2 hrs. and 06 mins.) 03/30/24, wait time (1 hr. and 34 mins.) 04/03/24, wait time (1 hr. and 50 mins.) 04/06/24, wait time (1 hr. and 07 mins.) 04/12/24, wait time (2 hrs. and 02 mins.) 04/17/24, wait time (1 hr. and 06 mins.) 04/18/24, wait time (2 hrs. and 46 mins.) 04/20/24, wait time (4 hrs. and 11 mins.) 04/22/24, wait time (2 hrs. and 34 mins.) 05/02/24, wait time (2 hrs. and 08 mins.) 05/04/24, wait time (2 hrs. and 08 mins.) 05/04/24, wait time (6 hrs. and 30 mins.) 05/06/24 wait time (1 hr. and 03 mins.) Resident’s #1 UAI and ISP documents the resident needs physical assistance with bathing, dressing, toileting, transferring, eating/feeding, wheeling and mobility.
  2. An adult protective services investigation for resident #1 documents the following: “the client was never put to bed and was left in the lazy boy all night and was found on the floor by the 7am staff this morning, 03/17/24;” “there is sufficient evidence to show that resident #1 was neglected, resident #1 was found on the floor by morning staff, and documentation provided shows pendant was pushed multiple times on the date of the incident.” Resident’s #1 call bell log documents the resident’s pendant was pushed on the night of 03/16/24 and the morning of 03/17/24 at the following times: 03/16/24 @ 11:15 p.m. 03/17/24 @ 2:13 a.m. 03/17/24 @ 3:09 a.m. 03/17/24 @ 3:18 a.m. 03/17/24 @ 3:48 a.m. 03/17/24 @ 7:57 a.m.
  3. Resident’s #2 call bell logs for the month of March, April, and May 2024 documented the facility did not promptly respond to the resident’s pendant alert system on the following dates and times: 05/05/24, wait time (1 hr. and 4 mins.) Resident’s #2 UAI and ISP documents the resident need physical assistance for bathing, and dressing.
Plan of correction
The ED/ designee will audit call bell response times daily for the next 30 days and monitored on an ongoing basis as a part of the community’s daily stand up meeting. Any response times outside of CAHV standards will be addressed immediately. Findings will be reported to the Health Care Director for follow-up as needed.
May 7, 2024Complaint survey2 violations
Inspection dates
05/07/2024
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 IMPAIRMENTS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 05/07/2024 from 9:07 am to 4:36 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 04/03/24, 04/09/24, 04/17/24, 04/25/24, 04/28/24, and 05/06/24 regarding allegations in the area(s) of: Staffing and Supervision, Resident Care and Related Services, and Buildings and Grounds. 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: 4 Number of staff records reviewed: 0 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: An observation of the safe secure unit, and assisted living unit was completed, and a review of the medication cart. Lunch was observed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation’s area(s) of non-compliance with standard(s) or law were: Resident Care and Related Services A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-930-B
Based on the staff interview the facility failed to ensure in buildings licensed to care for 20 or more residents under one roof, there shall be a signaling device that terminates at a central location that is continuously staffed and permits staff to determine the origin of the signal or is audible and visible in a manner that permits staff to determine the origin of the signal.
Evidence
  1. During an interview with staff #3, staff # 3 confirmed the signaling device was not working in the assisted living facility during the dates of 04/29/2024 to 05/02/2024.
Plan of correction
The signaling device system has been working properly since May 2, 2024. The Maintenance Director completed a pendant check on all resident pendants to ensure they were working properly.
22VAC40-73-680-C
Based on the record review the facility failed to 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. The facility’s medication management plan dated 02/2018 documents “medications should be given within 1 hour on either side of the specified times.” 2.The facility’s “Orders Charted Report” documents resident #1 received their Insulin Aspart 100 units more than 1 hour after the scheduled time of 7:30 am on the following dates and times: 04/24/24 @ 12:38 p.m. 04/27/24 @ 9:40 a.m. 3.The facility’s “Orders Charted Report” documents resident #1 received the following 8:00 am medications more than 1 hour after the scheduled time on the date of 04/24/24 at the time of 12:38 p.m.: Acetaminophen, alprazolam, dicyclomine, fluoxetine, metformin, pregabalin, and promethazine. 4.The facility’s “Orders Charted Report” documents resident #2 received the following 8:00 am and 9:00am medications more than 1 hour after the scheduled time on the date of 04/24/24 at the time of 12:19 p.m.: Eliquis, ensure liquid, amiodarone, breo- ellipta, bumetanide, quetiapine fumarate, and sertraline.
Plan of correction
All RMAs and licensed nurses will be re-educated by the HCD/HSD on the proper procedure for documenting the specific reason a medication was administered late before June 1, 2024. Administration times will be reviewed by the HCD/HSD on a weekly basis to determine if changes to administration times are required for specific residents, or if staff assignments require adjustment to allow them to complete the medication pass in a timely manner. The HCD/HSD will review the medication administration policy with all RMAs and licensed nurses every six months. The Pharmacy Manual will also be reviewed in relation to the procedure for ordering medications. The HCD/HSD will complete a medication pass observation on all medication aides and licensed nurses once every six months, or more often if deemed necessary based on the results of the audit. All RMA’s and licensed nurses will continue to follow Harmony Standards.
May 7, 2024Inspection2 violations
Inspection dates
05/07/2024
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 IMPAIRMENTSARTICLE 1 – SUBJECTIVITY22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced monitoring inspection took place on 05/07/24 from 9:07 am to 4:36 pm. 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 04/03/2024 regarding allegations in the area 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 staff records reviewed: 2 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: An observation of the facility’s medication cart was completed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-680-D
Based on the record review the facility failed to ensure medications shall be administered in accordance with the physician’s or other prescriber’s instructions.
Evidence
  1. The record for resident #1 contains a medication error report that documents on the day of 03/31/24, the resident reported not receiving, Levothyroxine for the am dose and the” resident was given an Keflex that was discharged but still in the resident’s medication cart and slot.”
  2. The record for resident #1 contains the following: a physician order dated 03/13/24 for Levothyroxine, “Take 1 tablet by mouth every day;” a physician order dated 03/01/24 for Keflex “take four times a day for 10 days."
  3. Resident’s #1 medication administration record (MAR) includes a note for the date of 03/31/24 “Levothyroxine, not available, will order, patient unable to make medication.”
  4. During an interview with resident #1, resident #1 confirmed that on the day of 03/31/24, the resident received a dose of Keflex, and the resident did not receive a dose of Levothyroxine as prescribed.
Plan of correction
HCD/designee will provide re-education to RMAs based on the standard training curriculum to include proper documentation of medication administration, resident refusals, medications wasted, medication inventory and counting, dating medications when opened, and dates of expiration. HCD/designee will also provide re-education on physician orders, proper filing of orders within the wellness record, proper turnover and shift change reporting including information relevant to changes in resident medication orders, and the review of all discharge papers by the HCD/designee. New physician orders will be reviewed and signed off by HCD/designee. Medication time adjustments will be made as needed and per resident request.
22VAC40-73-640-A
Based on the onsite observation, record review, and staff interview the facility failed to implement a written plan for medication management to include: methods to ensure that each resident’s prescription medications and any over the counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages, and a plan for proper disposal of medication.
Evidence
  1. The record for resident #1 contains the following physician orders: A physician order dated 02/06/24 for Estradiol “apply pea sized amount around the uretha nightly;” A physician order dated 04/05/24 for Imodium, “take 1 tablet by mouth 3 times a day PRN Diarrhea.” During the medication cart observation, the medications, Estradiol and Imodium, prescribed for resident #1 was not located on the cart.
  2. Staff #1 confirmed resident’s #1 Estradiol and Imodium medications were not located on the facility’s medication carts.
Plan of correction
HCD/designee will ensure disposal of unused, unneeded or expired medications will be mixed in an undesirable substance prior to storing in a non-descript container or securely stored in a sealed container prior to turning them over to a disposal company. HCD/Designee will run report on a monthly basis to review with Primary Care Physician to discontinue PRN’s not used in the last 90 days. HCD/HSD will complete MAR to cart audits quarterly to assure medications ordered are physically present in the community. Initial MAR to cart audit will be complete before June 15, 2024.
March 7, 2024Complaint survey2 violations
Inspection dates
03/07/2024
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 IMPAIRMENTS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 03/07/24 from 9:11 am to 3:25 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 02/15/24 regarding allegations in the area of: Staffing and Supervision, and Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 84 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: 4 Observations by licensing inspector: An observation of the medication storage area was completed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility.
Violations
22VAC40-73-280-B
Based on staff interview it was determined that the facility failed to maintain a written plan that specifies the number of direct care staff required to meet the day-to-day, routine direct care needs and any identified special needs for the residents in care. This plan shall be directly related to actual resident acuity levels and individualized care needs.
Evidence
  1. The facility’s written plan that specifies the number of direct care staff required to meet the day to day, routine direct care needs of the residents in care was requested on 03/07/24 and was not provided.
  2. Staff #3 acknowledged the facility did not have a written plan that specifies the direct care staff required to meet the day to day, routine direct care needs of the residents.
Plan of correction
The appropriate number of direct care staff members will be scheduled for all three shifts. Staff at the community shall meet the requirements per DSS guidelines. HCD or designee will review staffing needs on a weekly basis to ensure adequate staffing. Staffing sheets posted for each shift to allow employee to report to their duty station in a timely manner. HCD or designee shall review the payroll system to ensure ongoing compliance and present findings monthly at QAPI until 06.01.24.
22VAC40-73-680-C
Based on the record review it was determined that the facility failed to 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. The facility’s medication management plan dated 02/2018 documents “medications should be given within 1 hour on either side of the specified times.” 2. Resident’s #1 medication administration record (MAR) for March 2024 documents a scheduled time of 7:00 am to take the medication, Levothyroxine. The facility’s “Orders Charted Report” documents the resident was administered the medication more than one hour after the scheduled time on the following dates and times: 03/02/24 @ 9:48am; 03/03/24 @ 8:26 am; 03/04/24 @ 8:05am; 03/05/24 @ 8:54 am; 03/07/24 @ 9:47 am;
  2. Resident’s #1 medication administration record (MAR) for March 2024 documents a scheduled time of 8:00 am to take the medications, Midodrine, Sertaline, Vitamin B-12, Vitamin D3, and Xarelto. The facility’s “Orders Charted Report” documents the resident was administered the medication more than one hour after the scheduled time on the following dates and times: 03/02/24 @ 9:48 am; 03/07/24 @ 9:47 am.
  3. Resident’s #3 medication administration record (MAR) for March 2024 documents a scheduled time of 8:00am and 6:00 pm to take the medication, Quetiapine Fumarate and a scheduled time of 8:00 am and 8:00pm to take the medications, Carbidopa-Levodopa, Latanoprost eye drops, Oyster Shell Calcium, Preservision, Systane eye drops, and Dorzolamide eye drops. The facility’s “Orders Charted Report” documents the resident was administered the medication more than one hour after the scheduled time on the following dates and times: 03/01/24 @ 10:00 pm, and 10:13 pm; 03/02/24 @ 10:12 am; 8:09pm; 9:43 pm; 03/04/24 @ 9:47 pm;
Plan of correction
All medication aides and licensed nurses will be educated by the HCD/HSD on the procedure for documenting the specific reason a medication was documented as late. This information will be reviewed by the HCD/HSD on a weekly basis to determine if changes need to be made for specific residents, or if the staff assignments need to be revised to complete the medication pass in a timely manner. The HCD/HSD will review the administration of medication policy with all medication aides and licensed nurses every six months. The Pharmacy Manual will also be reviewed in relation to the procedure for ordering medications. The HCD/HSD will complete a medication pass audit on all medication aides and licensed nurses once every six months, or more often if deemed necessary based on the results of the audit.
February 6, 2024Complaint survey10 violations
Inspection dates
02/06/24,02/14/24,03/07/24
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 IMPAIRMENTS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 02/06/24 from 9:21 am to 4:30 pm; 02/14/24 from 9:27 am to 2:00pm; 03/07/24 from 9:11 am to 3:25 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint received by VDSS Division of Licensing on 01/24/2024 regarding allegations in the area of: Personnel, Staffing and Supervision, and Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 84 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 7 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 6 Observations by licensing inspector: Observation of the facility’s medication carts, and medication storage areas were observed. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility.
Violations
22VAC40-73-325-B
Based on a review of documentation it was determined that the facility failed to ensure the fall risk rating should be updated after a fall.
Evidence
  1. Resident #2 had a fall on 09/22/23 while at the facility.
  2. Resident’s #2 record did not include a fall risk rating completed after the resident’s fall on 09/22/23.
Plan of correction
ED, HCD/HSD or designee will ensure fall risk rating has been completed after each fall. Will review all the falls to ensure fall risk completed.
22VAC40-73-40-A
Based on video footage, and documentation gathered during the investigation it was determined that the facility failed to ensure compliance with the facility’s own policies and procedures.
Evidence
  1. During an incident with resident #2 on 10/09/23, staff #4 and staff #9 did not follow the facility’s procedure for resident emergencies for when a resident is unresponsive or unconscious.
  2. The facility’s resident emergency plan includes the following: If a resident is unresponsive or unconscious “once CPR has started, do not stop until EMS are present and take over;” “stay with the resident, if alone use alternate communication systems to call for help (radio, pull cord, resident phone). “
  3. Staff #4 and Staff #9 left resident #2 alone in resident’s #2 room while resident #2 was unresponsive and unconscious.
  4. Staff #4 stopped 3 times while providing CPR to resident #2 and EMS was not present to take over.
Plan of correction
All staff members will be in serviced on Harmony Senior Services policy and procedure related to plan for resident emergencies and Emergency Medical Action Plan
22VAC40-73-260-C
Based on observation it was determined that the facility failed to ensure a listing of all staff who have current certification in first aid or CPR, in conformance with subsections A and B of this section, shall be posted in the facility so that the information is readily available to all staff at all times. The listing must indicate by staff person whether the certification is in first aid or CPR or both and must be kept up to date.
Evidence
  1. During observation on 02/06/24 and 02/14/24, the First Aid and CPR list posted in the facility was dated 01/20/23. The First Aid and CPR posting was not current and kept up to date as it included employees who no longer work at the facility.
Plan of correction
The business office manager or designee will perform an employee audit by 06.01.24 to stay current on the employee’s certifications. The business office manager or designee will audit employee certifications to verify continued compliance.
22VAC40-73-990-B
Based on the record review it was determined that the facility failed to ensure the procedures in the plan for resident emergencies required in subsection A of this section shall be reviewed by the facility at least every six months with all staff. Documentation of the review shall be signed and dated by each staff person.
Evidence
  1. The record for staff #4, hire date 10/29/22, did not include evidence staff #4 reviewed the facility’s written plan for resident emergencies at least once every six months.
  2. The record for staff #5, hire date 10/29/22, did not include evidence staff #5 reviewed the facility’s written plan for resident emergencies at least once every six months.
  3. The record for staff #9, hire date 06/02/19, did not include evidence staff #9 reviewed the facility’s written plan for resident emergencies at least once every six months.
  4. Staff #8 acknowledged the facility did not have evidence of staff #4, staff #5, and staff #9 reviewing the facility’s written plan for resident emergencies at least once every six months.
Plan of correction
The HCD will ensure this training is completed during orientation. The ED will ensure this review is done for all staff at least every six months. This training will be done when fire and safety training is done. The ED will also ensure at least once every six months all staff currently on duty on each shift will participate in an exercise in which the procedures for resident emergencies are practiced. Documentation of all training will be kept on file.
22VAC40-73-860-I
Based on the onsite observation it was determined that the facility failed to ensure each facility shall store cleaning supplies and other hazardous materials in a locked area.
Evidence
  1. During the onsite observation on 02/06/24 at 9:41 am in the safe, secure unit, the Licensing Inspector (LI) observed Clorox and Comet cleaning products located in the unlocked medication room.
  2. The medication room was unstaffed during the observation and was accessible by residents.
Plan of correction
HCD/HSD will ensure that all cleaning supplies are kept secured at all times. All staff members to be in-serviced to lock up all hazardous materials.
22VAC40-73-250-D
Based on the record review it was determined that the facility failed to ensure each staff person on or within 7 days prior to the first day of work at the facility prior to coming in contact with residents shall submit the results of a risk assessment documenting the absence of tuberculosis (TB) in a communicable form as
Evidence
  1. d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. The risk assessment shall be no older than 30 days. Evidence:
  2. The record for staff #7, hire date 07/05/23, did not contain a risk assessment for TB.
  3. The record for staff #10, hire date 04/04/23, did not contain a risk assessment for TB.
  4. Staff #2 risk assessment for TB is dated 02/20/23. The staff record did not contain an annual risk assessment for TB completed after 02/20/23. 4.Staff #4 risk assessment for TB is dated 01/27/23. The staff record did not contain an annual risk assessment for TB completed after 01/27/23. Staff #8
  5. Staff #8 acknowledged the records for staff #7 and staff #10 did not contain a risk assessment for TB.
  6. Staff #8 acknowledged the records for staff #2 and staff #4 did not contain an annual risk assessment for TB.
Plan of correction
Business office Manager or designee will ensure all new staff will not have a TB result older than 30 days from date of hire. BOM or designee will check all employee files for compliance
22VAC40-73-450-C
Based on the record review it was determined that the facility failed to ensure the comprehensive individualized service plan (ISP) shall include the following: A description of identified needs based upon the admission physical examination and other sources.
Evidence
  1. The record for resident #2 contains the following: a “Service/Yardi Points guidelines” form dated 06/20/23 that documents assistance needed with CPAP/BIPAP; a physical examination dated 07/05/23 documents “obstructive sleep apnea w/ CPAP;” a vial of life form dated 07/10/23 documents “Sleep apnea;” a nursing noted dated 09/02/23 documents “CPAP mask was applied to the resident’s face.”
  2. Resident’s #2 ISP dated 07/10/23 did not include the need for a CPAP machine and the diagnosis of Sleep Apnea.
Plan of correction
The HCD or designee will complete UAI/ISP Audit weekly for the next 8-weeks, to monitor compliance for all residents in the community. The Executive Director/Designee will be responsible for directing additional corrective action, based on audit findings.
22VAC40-73-260-A
Based on the record review and staff interview it was determined that the facility failed to ensure each direct care staff member shall maintain current certification in first aid.
Evidence
  1. The record for staff # 4, hire date 10/29/22, contains a first aid certification with an expiration date of 01/2024.
  2. The record for staff # 6, hire date (03/28/23) and last day of work date (11/03/23) did not contain documentation of a certification in first aid.
  3. The record for staff #7, hire date 07/05/23, did not contain documentation of a current certification in first aide.
  4. Staff #8 acknowledged the records for staff #4, staff #6 and staff #7 did not contain documentation of a current certification in first aid.
Plan of correction
All active employee records will be checked for First Aid and CPR certification. Employees that have not received training will receive formal training. Staff will receive training annually. Records will be reviewed by HR or designee monthly.
22VAC40-73-660-A
Based on observation it was determined that the facility failed to ensure medications shall be stored in a manner consistent with current standards of practice and the storage area shall be locked.
Evidence
  1. During a tour of the facility on 02/06/24 at 10:37 a.m., two medication carts located on the 2nd Floor was observed to be unlocked and unstaffed.
  2. During a tour of the facility on 02/06/24 at 10:41 a.m., the medication cart located on the 3rd Floor was observed to be unlocked and unstaffed.
Plan of correction
Director of Health Services/Designee will randomly audit unsecured workstations at the community 1x daily for 8x weeks to ensure compliance. All RMA’s and nurses to be in serviced on Harmony standards and DSS standards to store all medications properly.
22VAC40-73-200-C
Based on the staff record review it was determined that the facility failed to ensure direct care staff shall meet one of the requirements in this subsection. If the staff does not meet the requirement at the time of employment, he shall successfully meet one of the requirements in this subsection within two months of employment.
Evidence
  1. The record for staff #7, hire date 07/05/23, did not contain documentation of staff #7 meeting one of the direct care staff qualifications.
  2. Staff # 8 could not provide documentation to demonstrate the personal care aide training completed by staff #7 was approved by Virginia Department of Medical Assistance Services or Virginia Department of Social Services.
Plan of correction
Business Office Manager, Healthcare Director will have tickler system in place to check licenses monthly to ensure licenses are current. We are checking month prior and reminding employees.
January 3, 2024Complaint survey1 violation
Inspection dates
01/03/2024 & 01/04/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS63.2 GENERAL PROVISIONS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 01/03/24 at 8:08 am to 5:08 pm and 01/04/24 at 8:50 am to 4:50 pm. A complaint was received by VDSS Division of Licensing on 01/02/2024 regarding allegations in the areas of: Staffing and Supervision, and Resident Care and Related Services. 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: 84 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 5 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 4 Observations by licensing inspector: Breakfast was observed. A medication pass observation was completed for four residents. The following were reviewed: staffing schedule, emergency preparedness drills, medication carts, fire inspection report, and a health inspection report. Water temperature was measured, and the call bell system was monitored. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations area(s) of non-compliance with standard(s) or law were: Resident Care and Related Services. A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-680-C
Based on the record review the facility failed to 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. The facility’s medication management plan provided during the onsite inspection and dated 02/2018 documents “medications should be given within 1 hour on either side of the specified times.”
  2. Resident’s #1 medication administration record (MAR) for Jan. 2024 documents scheduled times of 8:00 am for Nuedexta and a Lidocaine Patch to be administered and 9:00 am for the following medications to be administered: Aspirin, Vitamin DC, Metoprolol, Entresto and Omeprazole. On 01/03/24 at 10:40 am during the onsite medication pass observation, the Licensing Inspector (LI) observed staff #5 administer the following medications to resident #1: Nuedexta, Lidocaine Patch, Aspirin, Vitamin DC, Metoprolol, Entresto and Omeprazole.
  3. Resident’s #1 Order Chart Report documents the resident’s medications were administered to the resident more than one hour after the scheduled time on the following dates and times: 01/01/24, Nuedexta, schedule for 8:00 pm, and administered 01/02/24 @ 12:22 am. 01/02/24, Lidocaine Patch scheduled for 8:00 am and administered at 11:02 am; 01/02/24, Nuedexta scheduled for 8:00 am and administered at 11:02 am.
  4. Resident’s #3 Jan. 2024 MAR documents the following medications are scheduled to be administered at 9:00am: Acidophilus, Diltiazem, Divalproex, DOK Soft gel, Eliquis, Finasteride, Fluticasone, Furosemide, Metoprolol, Pantoprazole, Quetiapine, Slow-release Iron, Tamsulosin, and Vitamin D3. Resident’s #3 Order Chart Report documents the resident was administered the above listed medications more than one hour after the scheduled time on 01/03/24 at 11:13 am.
  5. Resident’s #4 Jan. 2024 MAR documents Gabapentin is scheduled to be administered to the resident at 8:00 am. The resident’s order report documents Gabapentin was administered to resident #4 more than one hour after the scheduled time on 01/04/24 @ 10:53 am.
  6. Resident’s #4 MAR documents the following medications are scheduled to be administered @ 9:00 am: Ibuprofen, Acidophilus, Cetirizine, Multivitamins, omeprazole, polyethylene, pravastatin, and vitamin D3. Resident’s #3 Order Chart Report documents the resident was administered the above listed medications more one hour after the scheduled time on 01/04/24 at 10:53 am.
Plan of correction
To prevent recurrence, Health Care Director or Designee will review for timely administrations on daily basis for next 6 weeks and skills observations every six months of all RMAs
January 3, 2024Inspection10 violations
Inspection dates
01/03/2024 & 01/04/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS63.2 GENERAL PROVISIONS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS
Technical assistance
Personal and Social Information
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: An unannounced renewal inspection took place on 01/03/24 at 8:08 am to 5:08 pm and 01/04/24 at 8:50 am to 4:50 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 84 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 5 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 6 Observations by licensing inspector: Breakfast was observed. A medication pass observation was completed for four residents. The following were reviewed: staffing schedule, emergency preparedness drills, medication carts, fire inspection report, and a health inspection report. Water temperature was measured, and the call bell system was monitored. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-210-C
Based on the onsite record review and staff interview the facility failed to ensure training for the first year shall commence no later than 60 days after employment.
Evidence
  1. The record for staff #1, hire date of 08/30/23, did not contain documentation of trainings completed by staff #1. 2.Staff #6 confirmed the record for staff #1 did not contain documentation of completed trainings.
Plan of correction
The administrator and Business office Manager will continue to audit employee training hours for next six weeks. ED will complete random audits to ensure ongoing compliance.
22VAC40-73-440-A
Based on the record review the facility failed to ensure the Uniform Assessment Instrument (UAI) shall be completed prior to admission, at least annually, and whenever there is a significant change in the resident’s condition.
Evidence
  1. The record for resident #1, admission date of 09/15/23, does not contain a UAI completed prior to admission. The UAI in the record is dated 10/17/23. 2.The record for resident #2, admission date of 09/30/22, does not contain a UAI completed prior to admission. The UAI in the record is dated as 10/31/22.
Plan of correction
The assessment process shall be completed prior to accepting residents to determine if they meet the criteria for assisting living at Harmony at Harbour View. Once residents move, assessment are reviewed within 30 days of move in, change of condition and annually. Assessments are completed by HCD or designee.
22VAC40-73-320-A
Based on the record review the facility failed to ensure within the 30 days preceding admission, a person shall have a physical examination by an independent physician. The report of such examination shall be on file at the assisted living facility and shall include the following: results of a risk assessment documenting the absence of TB in a communicable form; the signature of the examining physician.
Evidence
  1. Resident’s #1 physical examination dated 09/01/23 does not include the signature of the examining physician. 2.The record for resident #2, admission date 09/30/22, contains a physical examination dated 10/20/22, and a risk assessment for TB dated 10/28/22. The physical exam and risk assessment for TB is dated as completed after the resident’s admission date. Resident’s #2 personal data and the facility’s record documents the resident’s move in date to the facility as 09/30/22.
  2. The record for resident #7, admission date 07/25/23, contains a risk assessment for TB dated 10/26/23, which is dated as completed after the resident’s admission date. Resident’s #7 personal data and the facility’s record documents the resident’s move in date to the facility as 07/25/23.
Plan of correction
ED or designee to audit charts for significant problems on History and Physicals, and ensure on new admissions, updates or change in status and ongoing.
22VAC40-73-550-G
Based on the staff and resident record review the facility failed to ensure the rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each resident or staff person.
Evidence
  1. of this review shall be the resident’s or staff person’s written acknowledgement 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: 1.The record for staff #3 contains an annual review of resident’s rights and responsibilities dated 09/30/22. During the onsite inspection the facility provided a written acknowledgement of review of the resident’s rights for staff #3 signed and dated 01/03/24, which is dated more than annually after the previous review of 09/30/22. 2.The record for staff #5 contains an annual review of resident’s rights and responsibilities dated 05/06/21. During the onsite inspection the facility provided a written acknowledgement of review of the resident’s rights for staff #5 signed and dated 01/03/24, which is dated more than annually after the previous review of 05/06/21. 3.The record for resident #8 contains an annual review of resident’s rights and responsibilities dated 03/08/22. During the onsite inspection the facility provided a written acknowledgement of review of the resident’s rights for resident #8 signed and dated 01/04/24, which is dated more than annually after the previous review of 03/08/22.
Plan of correction
Resident rights will be reviewed with all residents/staff annually and audited by the LED and BOM to ensure that all rights have been reviewed and signed. ED will complete random audits to ensure ongoing compliance.
22VAC40-73-940-A
Based on the record review and staff interview the assisted living facility failed to comply with the Virginia Statewide Fire Prevention Code (13VAC5-51) as determined by at least an annual inspection by the appropriate fire official. Reports of the inspections shall be retained at the facility for at least two years.
Evidence
  1. The facility’s record contains an annual fire inspection completed on 01/06/22. The facility does not have documentation of an annual fire inspection completed after 01/06/22. Staff # 4 acknowledged the facility’s record of the last fire inspection completed is dated 01/06/22.
Plan of correction
Facility Admin will ensure that the annual fire inspection has been/will be completed in a yearly / timely manner. The facility will keep a record on file.
22VAC40-73-350-B
Based on the record review the facility failed to ascertain, prior to admission, whether a potential resident is a registered sex offender if the facility anticipates the potential resident will have a length of stay greater three days or in fact stays longer than three days and shall document in the resident’s record that this was ascertained and the date the information was ascertained.
Evidence
  1. The record for resident # 1, admission date of 09/15/23, contains a sex offender screening dated 09/26/23. The sex offender screening for resident #1 is dated more than 3 days after the resident’s admission. Resident’s #1 progress notes document the resident’s move in date to the facility as 09/15/23. 2.The record for resident #2, admission date of 09/30/22, contains a sex offender screening dated 10/28/22. The sex offender screening for resident #2 is dated more than 3 days after the resident’s admission. Resident’s #2 personal data and facility’s record documents the resident’s move in date to the facility as 09/30/22. 3.The record for resident #3, admission date of 08/08/23, contain a sex offender screening dated 01/04/24. The sex offender screening for resident #3 is dated more than 3 days after the resident’s admission. Resident’s #3 personal data and facility’s record documents the resident’s move in date to the facility as 08/08/23. 4.The record for resident #7, admission date of 07/25/23, contain a sex offender screening dated 01/04/24. The sex offender screening for resident #3 is dated more than 3 days after the resident’s admission. Resident’s #7 personal data and facility’s record documents the resident’s move in date to the facility as 07/25/23.
Plan of correction
The assisted living facility shall ascertain, prior to admission, whether a potential resident is a registered sex offender if determined the potential resident will have a stay of three days or greater. The Administrator or designee will utilize the state approved sex offender registry database to ascertain this information. The community will create a move in check list that determines required move in documentation and Executive Director and/or designee will review all documentation prior to the resident moving into the community.
22VAC40-73-1090-A
Based on the record review the facility failed to ensure prior to admission to a safe, secure environment, the resident shall have been assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare.
Evidence
  1. The record of Resident #7 contains an assessment of serious cognitive impairment dated 06/26/23 that includes the following documentation: a response of “No” for the question “does this individual named above have a serious cognitive impairment due to a primary psychiatric diagnosis of dementia,” and a note that states “patient does not have diagnosis of dementia but has increased confusion.” The resident’s record contains an approval and placement in the safe secure environment dated 06/26/23.
  2. Resident’s #7 personal and social data includes a move in date to the facility as 07/25/23. Staff #7 confirmed resident’s #7 move in date to the facility’s safe secure environment as 07/25/23.
Plan of correction
Not published by VDSS.
22VAC40-73-980-A
Based on review of the facility’s first aid kit the facility failed to ensure a complete first aid kit shall be on hand in each building at the facility, located in a designated place that is easily accessible to staff but not to residents. Items with expiration dates must not have dates that have already passed. The kit shall include: Gauze pads and roller gauze, waterless hand sanitizer or antiseptic towelettes, triangular bandages, and tweezers.
Evidence
  1. During review of the first aid kit with staff #2 the following items were not included in the first aid kit: roller gauze, waterless hand sanitizer or antiseptic towelettes, triangular bandages, and tweezers.
Plan of correction
The community will ensure that all items in the first aid kit are present and items with expiration dates are not past their expiration date. The community will create a spreadsheet and assign care manager on duty and/or designee to check first aid kit supplies and expiration dates monthly and to notify the Executive Director of any supplies out of compliance
22VAC40-73-450-A
Based on the record review the facility failed to ensure on or within 7 days prior to the day of admission, a preliminary plan of care shall be developed to address the basic needs of the resident that adequately protects his health, safety, and welfare. Exception: A Preliminary plan of care is not necessary if a comprehensive individualized service plan (ISP) is developed, in conformance with this section, on the day of admission.
Evidence
  1. The record for resident #1, admission date of 09/15/23 does not contain a preliminary plan of care completed on or within 7 days of admission. The ISP in the record for resident #1 is dated 10/17/23. 2.The record for resident #2, admission date 09/30/22, does not contain a preliminary plan of care completed on or within 7 days of admission. The ISPs in the record for resident #2 is dated 11/01/22 and 11/12/23.
Plan of correction
A preliminary plan of care must be developed on or 7 days prior to the day of admission. HCD/ED or designee will review all admission paperwork including preliminary plan of care of within 7 days of admission. ED will complete random audits to ensure ongoing compliance.
22VAC40-73-250-D
Based on the record review the facility failed to ensure each staff person on or within 7 days prior to the first day of work at the facility prior to coming in contact with residents shall submit the results of a risk assessment documenting the absence of tuberculosis (TB) in a communicable form as
Evidence
  1. d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. The risk assessment shall be no older than 30 days. Evidence: 1.The record for staff #2, hire date of 11/29/23, did not contain a risk assessment for TB. 2.Staff #6 confirmed the record for staff #2 did not contain a risk assessment for TB. 3.The record for staff #4, hire date of 05/30/23, contains a risk assessment for TB dated 09/15/23, which is after staff’s #4 hire date.
Plan of correction
Business Office Manager or designee will audit records for the next 6 weeks basis to make sure all required items are in the record and current for all employees. ED will complete random audits to ensure ongoing compliance.
January 10, 2023Inspection9 violations
Inspection dates
01/10/2023, 01/12/2023
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS
Technical assistance
Ensure the availability of the emergency food supply does not include expired items.
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: An unannounced renewal inspection took place on 01/10/23 at 8:35 am to 4:45 pm and 01/12/23 at 8:25 am to 3:40 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 84 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 5 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 4 Observations by licensing inspector: A tour of the facility was conducted to include inside and outside building grounds. Breakfast, lunch, and an activity were observed. A medication pass observation was completed for four residents. The following were reviewed: staffing schedule, emergency preparedness drills, medication carts, fire inspection report, and a health inspection report. Water temperature was measured, and the call bell system was monitored. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-450-E
Based on the record review the ISP shall be signed and dated by the licensee, administrator, or his designee, and by the resident or legal representative. These requirements shall also apply to reviews and updates of the plan.
Evidence
  1. The record for resident # 2 contains an ISP updated 11/18/22. The ISP update did not include a signature and date by the licensee, administrator, or his designee, and of the resident or legal representative.
  2. The record for resident # 1 contains an ISP updated 10/11/22, 11/18/22, 12/07/22, and 12/15/22. The ISP updates did not include a signature and date by the licensee, administrator, or his designee, and of the resident or legal representative.
Plan of correction
Healthcare Director, Executive Director will ensure staff and family sign ISP when changes are made to ISP.
22VAC40-73-970-A
Based on the onsite review the facility failed to ensure fire and emergency drill frequency and participation shall be in accordance with the current edition of the Virginia Statewide Fire Prevention Code (13VAC5-51). The drills requested for each shift in a quarter shall be conducted in the same month.
Evidence
  1. The facility provided evidence of fire and emergency evacuation drills dated 03/20/22 and 11/16/22. There was no evidence of the facility conducting fire and emergency evacuation drills on each shift at least quarterly.
  2. Staff # 3 acknowledged the facility did not have documentation of fire and emergency evacuation drills being conducted on each shift at least quarterly.
Plan of correction
Executive Director, Maintenance Director will put into place a monthly training and quarterly training of fire drills, resident emergencies.
22VAC40-73-320-B
Based on the record review the facility failed to ensure a risk assessment for tuberculosis (TB) shall be completed annually on each resident.
Evidence
  1. The record for resident #6, includes a risk assessment for TB dated, 06/27/21 and 01/10/23. There is no evidence in the record of a risk assessment for TB being completed annually in the year of 2022.
Plan of correction
Healthcare Director will check TB screenings monthly to ensure they are up to date.
22VAC40-73-620-A
Based on the onsite review the facility failed to ensure there shall be oversight at least every six months of special diets by a dietitian or nutritionist for each resident who has such a diet.
Evidence
  1. The dietitian oversight report, dated 06/27/22 documented “currently there are no residents on special diets.”
  2. Observation of a posting in the kitchen labeled “Special Diets” documented a list of mechanical soft and pureed diets for a total of 9 residents. The posting was not dated.
Plan of correction
Executive Director, Dining Service Director will ensure dietary oversight report is done and is correct quarterly and ensure special diets are reviewed.
22VAC40-90-40-C
Based on the onsite record review the facility failed to ensure any person required to obtain a criminal history report shall be ineligible for employment if the report contains convictions of barrier crimes.
Evidence
  1. Staff # 4, hired 11/18/22, criminal record report contains convictions for two barrier crimes (18.2-57.2).
Plan of correction
Business Office Manager, Executive Director will review all new hires for barrier crimes and screen all new hires. Employee has been terminated
22VAC40-73-200-C
Based on record review the facility failed to ensure Staff #1 met at least one of the direct care staff requirements listed in 22VAC40-73-200-C.
Evidence
  1. Staff #1, hired 08/17/15, certified nursing aide license (CNA) expired 02/18/22.
  2. During the onsite inspection, Staff #1 was observed providing direct care physical assistance to resident # 6 to include assisting resident to get up from a chair and providing physical support while walking with the resident to the bathroom.
  3. Staff # 3 acknowledged the facility identified staff #1 as direct care staff and was not aware the staff’s CNA license was expired.
Plan of correction
Business Office Manager, Healthcare Director will have tickler system in place to check License monthly to ensure licenses are current. We are checking month prior and reminding employees.
22VAC40-73-990-C
Based on the onsite review the facility failed to ensure at least every six months, all staff currently on duty on each shift shall participate in an exercise in which the procedures for resident emergencies are practiced. Documentation of each exercise shall be maintained in the facility for at least two years.
Evidence
  1. The facility did not provide evidence of staff participation in an exercise in which the procedures for resident emergencies were practiced every 6 months.
  2. Staff #3 acknowledged there is no evidence of documentation within the last two years of the facility practicing procedures for resident emergencies every 6 months.
Plan of correction
Executive Director, Maintenance Director will put in place resident emergency trainings for all staff every 6 month.
22VAC40-73-440-A
Based on the record review the facility failed to complete the Uniform Assessment Instrument (UAI) whenever there is a significant change in the resident’s condition.
Evidence
  1. The record for resident # 2 contains a hospice evaluation and treatment physician order dated 11/17/22. The last completed UAI in the record is dated 09/24/22.
  2. The record for resident #2 contains an Individualized Service Plan (ISP) with an updated dated of 11/18/22 which documents supports needed for Hospice Care.
  3. The record for resident # 1 contains an approval for the safe, secure unit dated 12/07/22. The resident moved from the assisted living unit to the safe, secure unit on 12/07/22.
  4. The record for resident #1 includes an ISP updated 12/07/22 documenting the supports needed for the safe, secure unit. The last UAI in the record is dated 09/05/22.
Plan of correction
Healthcare Director, Executive Director will ensure ISP are updated when care changes or annually.
22VAC40-73-670-1
Based on the record review the facility failed to ensure each staff person who administers medication shall be licensed by the Commonwealth of Virginia to administer medications or be registered with the Virginia Board of Nursing as a medication aide.
Evidence
  1. Staff #1, hired 08/17/15, registered medication aide license expired 08/31/21.
  2. During the medication pass observation, Staff #1 was observed administering medications to resident’s # 4, #6, and #10.
  3. The record for staff #1 does not contain evidence of the staff being licensed by the Commonwealth of Virginia to administer medications.
Plan of correction
Business Office Manager, Healthcare Director will ensure tickler system is in place to ensure license of staff working are current.
December 17, 2021Inspection18 violations
Inspection dates
12/17/2021;12/20/2021
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity32.1 Reported by persons other than physicians63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report
Comments
An unannounced renewal inspection was conducted on 12-17-21 and 12-20-21. The facility census was 81. The administrator was present on both days of the inspection. A medication observation was conducted, staff and resident record reviews conducted, breakfast meal observed on the assisted living and safe, secure unit, first aid kit for facility and vehicles were conducted, resident and staff interviews conducted, emergency supplies reviewed, call bell observed, water temperature conducted and activity on safe, secure unit observed. Violations and technical assistance provided throughout the inspection. An exit interview with the administrator was conducted on both days and the Acknowledgement form was signed by the administrator. Please complete the columns for "description of action to be taken" and "date to be corrected" for each violation cited on the violation notice, and then return a signed and dated copy to the licensing office within 10 calendar days of receipt. You need to be specific with how the deficiencies either have been or will be corrected to bring you into compliance with the Standards. Your plan of correction must contain the following three points: 1. Steps to correct the noncompliance with the standard(s) 2. Measures to prevent the noncompliance from occurring again 3. Person(s) responsible for implementing each step and/or monitoring any preventive measure(s) Please provide your responses in a Word Document, if possible. POC due 1-7-2022
Violations
22VAC40-73-290-A
Based on observation and staff interviewed, the facility failed to ensure the written work schedule included the names and job classifications of all staff working each shift, with an indication of whomever is in charge at any given time.
Evidence
  1. On 12-20-21 a review of the written work scheduled with staff #1 and 2, the nursing staff schedule for December 2021 did not indicate whomever is in charge at any given time. The December 2021”Life Enrichment Employee Schedule” documented staff’s first name only, the sales person schedule did not include job classification and documented staff’s first name only, the December schedule for dietary department documented staff’s first name only and staff job classification was not documented for staff who are servers and the housekeeping schedule for staff #14 and #17 documented first name only.
  2. Staff #1 acknowledged the aforementioned staff schedules did not contain all required information.
Plan of correction
What Has Been Done to Correct? All staff work schedules include staff member’s full name and job classification. Staff member in-charge is posted at the front lobby desk, main 2nd floor nurse’s station, and on the direct care daily assignment sheets. How Will Recurrence Be Prevented? Each department manager/designee will create department staff schedule using the appropriate guidelines. Administrator/Designee will second check each department schedule and maintain file. Person Responsible: Each Department Manager/Designee Due Date: 01/01/22
22VAC40-73-290-B
Based on observation and staff interviewed, the facility failed to ensure it posted the name of the current on-site person in charge, as provided for in the regulation, in a place in the facility that is conspicuous to the residents and to the public.
Evidence
  1. On 12-172-1 upon entering the facility, the posting for the staff person in charge (SIC) was not available. The inspector inquired of staff #14 and #15 who was the staff person in charge. Neither staff was able to provide the information. The inspector went to the second floor and spoke with staff #16. The staff provided a copy of the posted staff assignment sheet which noted the first name of the staff in charge per shift.
  2. Staff #1 acknowledged the staff person in charge posting was not available when the inspector arrive at 8:45 a.m. on 12-16-21. The staff sheet is not posted in an area conspicuous to the residents and to the public.
Plan of correction
What Has Been Done to Correct? Staff member in charge, all three shifts, is posted at the front lobby desk, main 2nd floor nurse’s station, and on the direct care daily assignment sheets. How Will Recurrence Be Prevented? Healthcare Director/Designee will create daily staff member in-charge posting, using the appropriate guidelines. Administrator/Designee will second check and maintain schedule file. Person Responsible: Healthcare Director/Designee and Administrator/Designee Due Date: 01/01/22
22VAC40-73-1140-E
Based on record reviewed and staff interviewed, the facility failed to ensure within the first month of employment, staff, other that the administrator and direct care staff, who will have contact with residents in the special care unit shall complete two hours of training on the nature and needs of residents with cognitive impairments due to dementia.
Evidence
  1. On 12-20-21, during record review with staff #1 and #2, the following non-nursing staff did not have 2 hours of cognitive impairment training within the first month of employment: (a) staff #8, date of hire 10-14-21; staff #10, date of hire 11-10-21 and (c) staff #13, date of hire 1-28-21.
  2. Staff #1 and #2 acknowledged the aforementioned staff did not complete 2 hours of cognitive training within the first month of employment.
Plan of correction
What Has Been Done to Correct? Administrator/Designee will ensure within the first month of employment, non-direct care staff, who will have contact with residents in the special care, unit shall complete two hours of training on the nature and needs of residents with cognitive impairments due to dementia How Will Recurrence Be Prevented? Business Office Manager/Designee will create a new hire checklist to include (2) hours of dementia training for all non-direct care staff. As staff complete, document will be checked-off by both Business Office Manager/Designee and Administrator/Designee. Person Responsible: Business Office Manager/Designee, and/or Healthcare Director/Designee, and/or Administrator/Designee Due Date: 01/14/22
22VAC40-73-870-A
Based on observation and staff interviewed, the facility failed to ensure the building was maintained in good repair and kept clean.
Evidence
  1. On 12-17-21 during a tour of the dining area on the first floor, the vent on the wall near where resident #4’s table is located was observed covered with grayish colored substance.
  2. Staff #2 acknowledged the vent was covered with a greyish colored substance and in need of cleaning.
Plan of correction
What Has Been Done to Correct? Housekeeping staff dusted and cleaned the dining room vent. How Will Recurrence Be Prevented? An alert file will be maintained to ensure weekly monitoring of housekeeping cleaning task are completed. Person Responsible: Maintenance Director/Designee Due Date: 01/04/22
22VAC40-73-320-B
Based on record reviewed and staff interviewed, the facility failed to ensure a risk assessment for tuberculosis (TB) was completed annually on each resident 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. On 12-20-21, during record review with staff #2, resident #8’s record did not include documentation on an annual TB. The last documented TB was dated 10-1-20; resident was admit date documented as 2-28-20.
  3. Staff #2 acknowledged the aforementioned resident’s TB was last dated 10-1-20.
Plan of correction
What Has Been Done to Correct? Resident #8, an up to date TB screening has been obtained. How Will Recurrence Be Prevented? Upon annual assessment, all residents will obtain a TB screening. An audit of the TB risk assessments will be completed for all existing residents. An alert file will be maintained to ensure annual TB screenings are completed. Person Responsible: Healthcare Director/Designee Due Date: 01/04/22; audit completion: 01/14/22
22VAC40-73-450-C
Based on record reviewed and staff interviewed, the facility failed to ensure all assessed needs were addressed on the resident’s individualized service plan (ISP).
Evidence
  1. Resident #1’s record documented on 8-11-21 resident is prescribed Oxygen. This assessed need is not documented on the residents 6-4-21 ISP.
  2. Resident #8’s ISP dated 3-30-31 did not include wound care services documented in the hospice care plan. A review of care plans in the record document wound care services dated as of 6-25-21.
  3. Resident #10’s record documented in the hospice care plan resident’s hearing loss. Staff #2 acknowledged staff needed to speak louder and face resident when having a conversation. This information is not documented on the ISP dated 1-15-21.
  4. Staff #2 acknowledged the aforementioned residents’ ISPs did not document all assessed needs.
Plan of correction
What Has Been Done to Correct? Residents #1, #8, and #10 – ISP’s has been updated. How Will Recurrence Be Prevented? Upon completion of UAI’s for residents, ISP’s will be created that identify needs of residents as indicated on UAI. An alert file will be maintained to ensure annual assessments and/or significant changes that occur are noted and updated on ISP’s. Person Responsible: Healthcare Director/Designee Due Date: 01/10/22
22VAC40-73-260-C
Based on observation and staff interviewed, the facility failed to ensure the first aid and CPR listing posted was kept up to date.
Evidence
  1. The first aid/CPR posting on the second floor and provided for review included dates that were past due for CPR/FA. The list also did not include the names of all staff members.
  2. On 12-17-21 during exit meeting staff #1 and #2 acknowledged the first aid/ CPR posted document was not kept updated.
Plan of correction
.What Has Been Done to Correct? All staff required to have first aid and CPR, will be listed and posted – current posting is up to date. How Will Recurrence Be Prevented? An alert file will be maintained to ensure all appropriate staff are listed and up to date on the first aid and CPR posting. Person Responsible: Business Office Manager/Designee Due Date: 01/12/22
22VAC40-73-960-B
Based on observation and staff interview, the facility failed to ensure the fire and emergency evacuation drawing posted contained all required information.
Evidence
  1. On 12-17-21 during a tour of the facility with staff #6, the evacuation posting on the first floor in the dining area and the first floor in hallway near concierge and administrator’s office and the posting on the second floor near the elevator did not include the telephone locations, fire alarm boxes and fire extinguishers
  2. On 12-17-21 during the exit interview, staff #1 acknowledged the posted emergency evacuation drawings did not include all required information.
Plan of correction
What Has Been Done to Correct? The Maintenance Director/Designee will update all floor plan/drawings to reflect the missing information. How Will Recurrence Be Prevented? Maintenance Director/Designee will make building rounds and check to ensure all floor plans/drawings are reviewed for accuracy. Person Responsible: Maintenance Director/Designee Due Date: 01/14/22
22VAC40-73-680-K
Based on record reviewed and staff interviewed, the facility failed to ensure when medication aides administer the PRN medication, the order from the resident’s physician or other prescriber shall include the exact dosage.
Evidence
  1. On 12-17-21, resident #1’s record included an order for Oxygen to be administered, the 8-11-21 document noted Oxygen 2-4 Liter continuous as needed. Staff was asked if the resident was to received Oxygen as needed or continuously.
  2. Staff #2 acknowledged the order was not clearly written.
Plan of correction
What Has Been Done to Correct? Training completed with medication administration staff to know when to question if MD orders need to be clarified. A copy of the medication policy is also on the med carts. How Will Recurrence Be Prevented? A review of current orders with parameters will be reviewed for compliance. In addition, a med pass review will be conducted with each medication administration staff member. Person Responsible: Healthcare Director/ Designee Due Date: 01/12/22
22VAC40-73-970-E
Based on documents reviewed and staff interviewed, the facility failed to ensure the record of the required fire and emergency evacuation drills included all required information.
Evidence
  1. On 12-17-21, the facility’s fire drill record for 10-25-21 at 2:00 p.m. did not include the number of residents, special conditions simulated and any problems encountered.
  2. The fire drill records for 11-22-21 at 650; 11-22-21 at 4:40 p.m.; 10-26-21 at 7 a.m.; 9-8-21 at 2-330 a.m. and 7-8-21 at 2-330 did not include documentation of the number of residents, the method used for notification of the drill, any special conditions simulated, weather conditions and problems encountered, if any.
  3. Staff #1 and #2 acknowledged the facility fire drills provided for review did not include all of the required information.
Plan of correction
What Has Been Done to Correct? The Maintenance Director/Designee will conduct the required fire and emergency evacuation drills to include required documented information. How Will Recurrence Be Prevented? An alert file will be maintained to ensure required fire and emergency evacuation drills are completed and include required documented information. Person Responsible: Maintenance Director/ Designee and Administrator/Designee Due Date: 01/12/22
22VAC40-73-250-D
Based on record reviewed and staff interviewed, the facility failed to ensure each staff person on or within seven days prior to the first day of work at the facility shall submit the results of a risk assessment, documenting the absence of tuberculosis (TB) in a communicable form as
Evidence
  1. d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence:
  2. On 12-20-21 a review of staff records with staff #1 and #2, the following staff’s record did not have documentation of the absence of tuberculosis (TB) in a communicable form: (a) staff #8, date of hire documented as 10-14-21; (b) staff #9, date of hire documented as 6-2-21 and (c) staff #10, date of hire documented as 11-10-21.
  3. Staff #1 and #2 acknowledged the aforementioned staffs’ record did not included documentation of the absence of TB.
Plan of correction
What Has Been Done to Correct? Staff members #8, #9, and #10 obtained a TB screening. An audit of the TB risk assessments will be completed for all new hires. How Will Recurrence Be Prevented? Upon hire, all new staff members will present a risk assessment. Business Office Manager/Designee will create a new hire checklist to include check-off box for completed TB screening – this checklist will be located in each new staff’s personnel file. Administrator/Designee will be the second checker. Person Responsible: Business Office Manager/ Designee and Administrator/Designee Due Date: 01/04/22; audit completion: 01/14/22
22VAC40-73-1140-B
Based on record reviewed and staff interviewed, the facility failed to ensure within four months of starting date of employment in the safe, secure environment, direct care staff shall attend at least 10 hours of training in cognitive impairments that meets the requirements of subsection 22VAC40-73-1140-C of the regulation.
Evidence
  1. On 12-20-21 during record review with staff #1 and #2, the following staff’s record did not have documentation of 10 hours of cognitive impairment training within the four months of employment: (a) staff #11, no documentation of dementia training following employment, date of hire 8-11-21 and (b) staff #12, documented 6.0 hours of training, date of hire 4-7-21.
  2. Staff #1 and #2 acknowledged the aforementioned staff’s record did not document required hours of cognitive training.
Plan of correction
What Has Been Done to Correct? Administrator/Designee will ensure within four months of starting date of employment in the safe, secure environment, direct care staff shall attend at least 10 hours of training in cognitive impairments. How Will Recurrence Be Prevented? Business Office Manager/Designee will create a new hire checklist to include (10) hours of cognitive impairment training. As staff complete, document will be checked-off by both Business Office Manager/Designee and Administrator/Designee. Person Responsible: Business Office Manager/Designee, and/or Healthcare Director/Designee, and/or Administrator/Designee Due Date: 01/14/22
22VAC40-73-940-A
Based on document reviewed and staff interviewed, the facility failed to ensure it complied with the Virginia Statewide Fire Prevention Code (13 VAC 5-51) as determined by at least an annual inspection by the appropriate fire official.
Evidence
  1. On 12-17-21, a request for the facility’s fire inspection was conducted. The date of the last inspection was dated 1-29-19.
  2. On 12-20-21, the emails attached to the fire drill did not address the fire inspection, all emails were related to suspension of fire drills with staff and resident. Staff #1 was informed that the documentation did not address the facility’s fire inspection.
Plan of correction
What Has Been Done to Correct? Maintenance Director has scheduled annual fire inspection with local Fire Marshall. How Will Recurrence Be Prevented? An alert file will be maintained to ensure annual fire inspections with the local Fire Marshall are completed. Person Responsible: Maintenance Director/Designee Due Date: 01/06/22
22VAC40-73-450-F
Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) shall be reviewed and updated at least once every 12 months and as needed as the condition of the resident changes.
Evidence
  1. On 12-17-21, resident #3’s ISP was last reviewed and updated on 11-16-20. Staff #2 acknowledged resident’s ISP was not updated at least annually.
  2. Resident #4’s ISP dated 5-19-21 was not updated to reflect the resident’s change in condition and outcome for therapy services which ended on 6-11-21.
  3. Staff #2 acknowledged the aforementioned residents’ IPS’ were not updated to reflect the residents’ current status.
Plan of correction
What Has Been Done to Correct? Residents #3 and #4 – ISP’s has been updated. How Will Recurrence Be Prevented? Upon completion of UAI’s for residents, ISP’s will be created that identify needs of residents as indicated on UAI. An alert file will be maintained to ensure annual assessments and/or significant changes that occur are noted and updated on ISP’s. Person Responsible: Healthcare Director/Designee Due Date: 01/07/22
22VAC40-73-860-G
Based on observation and staff interviewed, the facility failed to ensure the hot water at taps available to residents shall be maintained within a range of 105 degrees Fahrenheit (F) to 120 degrees Fahrenheit (F).
Evidence
  1. On 12-17-21 during a tour of the facility with staff #6, the water temperature in the facility’s Sweet Memories (safe, secure unit) in room #H-121 was 125.8 degrees F.
  2. Staff #1 and #6 acknowledged the water temperatures were not maintained within a range of 105 degrees to 120 degrees Fahrenheit.
Plan of correction
What Has Been Done to Correct? Maintenance Director/Designee will make rounds and check water temperatures in resident’s units to ensure water temperatures are at the appropriate temperature. How Will Recurrence Be Prevented? An alert file will be maintained to ensure monitoring of water temperatures are accurate in resident’s units. Person Responsible: Maintenance Director/Designee Due Date: 01/07/22
22VAC40-73-250-C
Based on record reviewed and staff interviewed, the facility failed to ensure the facility had verification that the staff person had received a copy of his current job description .
Evidence
  1. On 12-20-21, staff #8‘s record did not have documentation of having received a copy of his/her job description.
  2. Staff #1 acknowledged the aforementioned record did not have documentation of receiving a copy of the job description.
Plan of correction
What Has Been Done to Correct? Staff #8 has signed a job description. How Will Recurrence Be Prevented? Business Office Manager/Designee will create a new hire checklist to include job description and will check-off as completed for each new staff member’s personnel file. Administrator/Designee will second check each new staff member’s checklist. Person Responsible: Business Office Manager/Designee and Administrator/Designee Due Date: 01/12/22
22VAC40-73-100-C-1
Based on observation and staff interviewed, the facility failed to ensure infection control procedures were implemented.
Evidence
  1. On 12-17-21 during the medication observation check of the medication cart on the second floor with staff #3, the following residents’ glucometer were not labeled: (a) resident #11, (b) resident #12 and (c) resident #13.
  2. During initial exit meeting on 12-17-21 and final on 12-20-21, staff #1 acknowledged the aforementioned residents’ glucometers were not labeled.
Plan of correction
What Has Been Done to Correct? Residents #11, #12, and #13 – each resident’s glucometer machine are labeled with their name on the machine. How Will Recurrence Be Prevented? Upon admission and/or new order, all resident’s glucometer machines will have their name labeled on machine. An alert file will be maintained to ensure all machines are labeled. Person Responsible: Healthcare Director/Designee Due Date: 01/04/22
22VAC40-73-440-H
Based on record reviewed and staff interviewed, the facility failed to ensure an annual reassessment, using the Uniformed Assessment Instrument (UAI), was used to determine whether a resident’s needs can continue to be met by the facility and whether continued placement in the facility is in the best interest of the resident.
Evidence
  1. On 12-17-21, review of resident #3’s record with staff #1, the resident’s UAI was last completed on 10-12-20.
  2. Staff #2 acknowledged the UAI for resident #3 was not updated and not current.
Plan of correction
What Has Been Done to Correct? Resident #3 – UAI has been updated. How Will Recurrence Be Prevented? Upon annual reassessment, UAI’s will be updated to identify needs of residents. An alert file will be maintained to ensure annual assessments and/or significant changes that occur are noted and updated on UAI. Person Responsible: Healthcare Director/Designee Due Date: 01/04/22
July 9, 2021Inspection1 violation
Inspection dates
7/9/2021; 7/20/2021; 8/25/2021; 8/27/2021
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
A non-mandated self-report inspection was initiated on 7-9-21 and concluded on 8-27-21. A self-reported incident was received by the department regarding allegations in the areas of resident care and related services. The administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The licensing inspector conducted an on-site observation at the facility on 8-26-21. The evidence gathered during the investigation supported the self-report of non-compliance with standards or law, and violations were issued. Any violations not related to the self-report but identified during the course of the investigation can be found on the violation notice.
Violations
22VAC40-73-460-D
Based record review and staff interview, the facility failed to ensure it provided supervision of resident schedules, care, and activities, including attention to specialized needs, such as prevention of falls and wandering from the premises.
Evidence
  1. On 7-6-21, the licensing inspector received an initial incident report documenting resident #1 was “located in adjacent neighborhood”.
  2. Resident #1’s individualized service plan (ISP)s dated 5-27-21 and 7-11-21 documented resident’s need for placement on the facility’s safe, secure unit (Memory neighborhood) for “safety and constant supervision”. Resident #1’s ISP date 7-11-21 documented resident’s exit seeking behavior need on 6-1-21. Resident #1’s nurse’s notes also documented resident’s exit seeking behaviors: (a) 5-30-21 note at 9:53 p.m., resident forced emergency door open and exiting building to courtyard; (b) 6-4-21 note at 7:35 p.m., resident attempted to exit unit three times on 7-3; (c) 6-22-21 note at 10:56 a.m., resident still trying to leave community with belongings; (d) 6-23-21 note at 6:13 p.m., resident forced exit door to courtyard open, staff coaxed resident back into building; (e) 6-26-21 note at 6:06 p.m. resident forcibly opened exit door to courtyard and resident coaxed back into building; (f) on 6-29-21 note at 11:06 a.m. resident attempted to open back door into courtyard, resident was coaxed back inside; (g) on 7-2-21 note at 4:22 p.m., resident found in dining room had removed screws from the window frame, was removing the screen to attempt to climb out, resident coaxed back inside and (h) on 7-4-21 note at 8:23 a.m., resident got out the side door and into the courtyard. Resident went out of the gate and left the property.
  3. The local police was called by facility staff to assist in locating resident #1. Local authorities located the resident in the driveway of a residential neighborhood approximately 1.06 miles from the facility. On 8-27-21, collateral interview and police report confirmed the location of the resident at an address in the local community.
  4. Observation of the area confirmed the highway from the facility to the neighborhood is a four lane highway with divided median and a speed limit noted 45 mph at 5:59 a.m.
  5. Interviews with staff #2 and #3 confirmed resident #1 left the facility around 3 or 4:00 a.m. on the morning of July 4, 2021 and was located by local authorities in the community.
  6. On 8-26-21 and 8-27-21, staff #1 acknowledged resident #1 exited the safe, secure unit and was located in a neighborhood in the community.
Plan of correction
What Has Been Done to Correct? Resident #1 was discharged from the community. How Will Recurrence Be Prevented? A review during the assessment process will be completed to identify wandering behavior and implement appropriate interventions. Person Responsible: HCD, or Designee
June 14, 2021Inspection0 violations
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 14, 2021 and concluded on June 14, 2021. The Executive Director was contacted by telephone to initiate the inspection. The Executive Director reported that the current census was 57. The inspector emailed the Executive Director a list of items required to complete the inspection. The inspector reviewed 3 resident records, training logs, and medication observation documentation submitted by the facility to ensure documentation was complete. Consultation provided regarding medication management plan policies. 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.
March 2, 2021Complaint survey4 violations
Inspection dates
March 2, 2021 and March 3, 2021
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity
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 March 2, 2021 and concluded on March 3, 2021. A complaint was received by the department regarding allegations in the areas of Special Care Unit requirements. The Executive Director was contacted by telephone to conduct the investigation. The licensing inspector emailed the Executive Director 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.
Violations
22VAC40-73-1180-B
Based on observation and discussion, the facility failed to ensure ordinary materials that may be harmful to a resident are inaccessible to the resident except under staff supervision.
Evidence
  1. During a virtual tour of the Special Care Unit “Harmony Square” on 03-02-2021, bathrooms in H-111 and H-112 had unlocked drawers with mouthwash, toothpaste, and shampoo.
  2. Staff #1 confirmed Resident #5 has a history of attempting to access materials that may be harmful.
  3. “End of Shift” report notes documented for Resident #5: a. 02-02-21 11 p.m. “ 7 a.m., ”[Resident #5]“ walking hall going into residents rooms during the night”? b. 02-19-21 3 p.m. “ 11 p.m., ”[Resident #5] ?in the dinning room while kitchen staff was cleaning up they came and got us said [Resident #5] was trying to drink the solution that they mop with.?
  4. Staff #1 acknowledged the broken locks in resident bathrooms and aforementioned information.
Plan of correction
What Has Been Done to Correct? A training was completed with the dining team to reiterate safety and the oversite of harmful materials. Locks were repaired in bathrooms where toiletries are stored. Auto locking mechanism installed on kitchen door. How Will Recurrence Be Prevented? Random audits are being completed and results reported to the Executive Director. Person Responsible: ED/Harmony Square Coordinator/Designee
22VAC40-73-450-A
Based on record review and interview, the facility failed to ensure the Individualized Service Plan (ISP) included the resident’s identified need, date identified, and expected outcome date.
Evidence
  1. Resident #1’s current Uniform Assessment Instrument (UAI) dated 11-05-2020 documented need for mechanical assistance with stairclimbing, and mechanical assistance and supervision with mobility. Additionally, fall risk rating dated 10-01-2020 documented resident is a high risk for falls.
  2. Resident #1’s current ISP dated 02-04-2021 did not document the type of mechanical device needed for stairclimbing and mobility, nor a high risk for falls. Additionally, the dates identified and expected outcome dates were not documented for toileting and transferring.
  3. Resident #3’s current UAI dated 04-14-2020 documented need for human help, physical assistance with transferring and stairclimbing.
  4. Resident #3’s current ISP dated 07-07-2030 did not document assistance needed for transferring or stairclimbing.
  5. Staff #1 and staff #2 acknowledged resident #1 and resident #3’s aforementioned needs and dates were not identified on the ISP.
Plan of correction
What Has Been Done to Correct? The UAI and ISP of resident #1 and #3 were corrected. How Will Recurrence Be Prevented? The UAI/ISP will be reviewed for accuracy to ensure the resident’s identified needs are addressed including the date identified and expected outcome date. Person Responsible: ED/Designee
22VAC40-73-570-C
Based on record review and discussion, the facility released information regarding the resident’s personal affairs without the written permission of the resident or his legal representative.
Evidence
  1. Resident #1 went on LOA on 02-07-2021. Resident’s responsible party was given Resident #4’s Acetaminophen 500 mg, Vitamin D3 1,000U, Hyoscyamine .0125mg, and Prochlorperazine 10mg.
  2. Neither Resident #4 or his legal representative gave permission nor was facility aware Resident #1 had Resident #4 medications until later notified.
  3. Staff #1 confirmed during discussion the aforementioned information.
Plan of correction
What Has Been Done to Correct? The healthcare director completed a training on the leave of absence protocol with mediation administration staff regarding verifying all documentation prior to release. How Will Recurrence Be Prevented? Leave of absence documentation will be reviewed for accuracy. Person Responsible: Healthcare Director/Designee
22VAC40-73-640-A
Based on record review and discussion, the facility failed to implement its written plan for medication management ensuring each resident's medications are refilled in a timely manner. The plan was implemented and revised 02/2018.
Evidence
  1. Resident #1’s January 2021 and February 2021 Medication Administration Record (MAR) documented staff did not administer Memantine 28mg on 01-22-2021, and Mirtazapine 30mg on 02-15-2021. The documented reasons Memantine was not administered was “med was order”; and Mirtazapine was “out of meds”.
  2. Resident #2’s February 2021 MAR documented staff did not administer Sertraline 50mg on 02-01-2021, 02-02-2021, or 02-08-2021. The documented reason for Sertraline 50mg not administered was “on order, awaiting pharmacy”.
  3. Resident #3’s January 2021 and February 2021 documented staff did not administer Buspirone 10mg on 01-31-21 or 02-01-2021, and Escitalopram 20mg or Mirtazapine 15mg on 01-31-2021, 02-01-2021, 02-05-21, nor 02-07-21. The documented reason for January 2021 medications was “not available” and “on order” for the February 2021 medications.
  4. Staff #1 and staff #2 acknowledged facility did not implement its plan/policy for medication management to ensure medications were refilled in a timely manner to avoid missed dosages.
Plan of correction
What Has Been Done to Correct? A reconciliation of resident #1, 2, and 3’s mediation was completed to ensure availability of all medications availability of all medications. How Will Recurrence Be Prevented? The health care director completed a training with the medication administration staff on following all directives of the physician order and Harmony medication reordering process. Person Responsible: Healthcare Director/Designee
January 6, 2021Inspection3 violations
Inspection dates
Jan. 6, 2021 , Jan. 8, 2021 , Jan. 11, 2021 and Jan. 12, 2021
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity
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 January 06, 2021 and concluded on January 12, 2021. The Executive Director was contacted by telephone to initiate the inspection. The Executive Director reported that the current census was 52. The inspector emailed the Executive Director a list of items required to complete the inspection. The inspector reviewed 4 resident records, 4 staff records, activities calendars, fire drills, fire and health inspections, menus, staff schedules, healthcare, dietary, and pharmacy oversights 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 special care review, staff training hours, activity hours, healthcare oversight, menus, diagnoses, documentation of medication administration, and fall risk ratings.
Violations
22VAC40-73-1070-B
Based on record review and discussion, the facility failed to ensure that ordinary materials or objects that may be harmful to a resident with a serious cognitive impairment are inaccessible to the resident except under staff supervision.
Evidence
  1. Resident #1’s Individualized Service Plan (ISP) signed on 09/14/2020 documented, ?[Resident #1] needs assistance with wandering and trying to go into other resident’s room??. The need was identified on 02/26/2016.
  2. Staff #1 emailed an incident report on 12/18/2020 regarding Resident #1’s ?possible ingestion of sharp object and abrasion to foot“. The report documented date and time of the incident as ”12/18/2020 at 5:30 a.m.? Resident [#1] observed with a piece of lightbulb in [Resident #1’s] hand and broken lightbulb on the floor. Resident [#1] noted with blood around mouth and on right foot. Broken glass noted on floor bathroom ? Removed piece of glass from resident’s [#1] mouth??
  3. Resident #1 was transported to the hospital on 12/18/2020. “After Visit Summary” dated 12/18/2020 documented, ? Diagnosis: Foreign body ingestion, initial encounter?.
  4. Staff #1 stated during discussion that Resident #1 was able to obtain the light bulb from a bathroom trash can in the Special Care Unit.
Plan of correction
What Has Been Done to Correct? The Administrator completed and audit of all common areas to include the bathroom in the SCU to ensure all articles were removed. How Will Recurrence Be Prevented? A training was completed with the maintenance team to reiterate safety and the immediate removal of discarded articles immediate removal of discarded articles. Person Responsible: The Harmony Square Coordinator/Designee
22VAC40-73-680-D
Based on record review and discussion, the facility failed to ensure medications were administered in accordance with the physician's or other prescriber's instructions.
Evidence
  1. Resident #2’s previous prescriber’s orders dated 06/06/2020 and the current orders 01/05/2021 documented, ? Catapres 0.1mg take one by mouth twice a day for hypertension hold [do not administer] for SBP [systolic blood pressure] less than 160.?
  2. Resident #2 October ? December 2020 medication administration records (MAR) documented Catapres 0.1mg was administered 46 times when the SBP was less than 160 during 10/01/2020 and 12/28/2020. The SBP documented on the MAR ranged between 104 and 158.
  3. Staff #1 confirmed during discussion the prescriber’s orders and acknowledged that the medication was administered when the SBP was less than 160 and not held per the instructions.
Plan of correction
What Has Been Done to Correct? A training was completed with medication staff on following all directives of the physician order. How Will Recurrence Be Prevented? A review of current orders with parameters will be reviewed for compliance. Person Responsible: Healthcare Director/Designee
22VAC40-73-970-E
Based on record review and discussion, the facility failed to ensure a record of the required fire and emergency evacuation drills included the number of residents participating, any special conditions simulated, the time it took to complete the drill, and the weather conditions.
Evidence
  1. October 2020, November 2020 and December 2020 fire and emergency evacuation drills did not include the number of residents who participated, any special conditions simulated, time it took to complete the drill, nor weather conditions.
  2. Staff #1 acknowledged the aforementioned missing items were not recorded for fire and emergency evacuation drills for said times above.
Plan of correction
What Has Been Done to Correct? A review of form with the maintenance director to ensure all blanks are answered on the form. How Will Recurrence Be Prevented? A final review will be completed the form for completion Person Responsible: Executive Director/Designee