Virginia DSS · Assisted Living Facility

The Harmony Collection at Roanoke Assisted Living

📍 4402 Pheasant Ridge Road, Roanoke, VA, 24014

ID 45622One Year licenseActive
61
Inspections
On record
34
With violations
Visits that cited something
27
Clean visits
Nothing cited
125
Violations cited
Individual findings
48
Standards cited
Distinct rules
35
Complaint visits
Prompted by a complaint

The Harmony Collection at Roanoke Assisted Living was inspected 61 times between January 28, 2021 and June 16, 2026 by the Virginia Department of Social Services. 34 of those visits ended with violations cited and 27 with none. Across that history VDSS cited 125 violations under 48 distinct standards. 35 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. 60 of these 61 are still on the state's site; the other 1 has since dropped off it and is reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type
Assisted Living Facility
License type
One Year
License expires
03/02/2027
Administrator
Jenny Nicely
Licensing inspector
Holly Copeland
Inspector phone
(540) 309-5982
Approved for
Non-Ambulatory · Assisted Living

Inspection History

61

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

June 16, 2026Complaint survey2 violations
Inspection dates
06/16/2026
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint 65937 Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/16/2026 from 10:00 AM to 01:00 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 04/28/2026 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: 65 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: N/A Number of interviews conducted with residents: N/A Number of interviews conducted with staff: 2 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A 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(s) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of these inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem-solving conference. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
22VAC40-73-440-A
Based on record review and staff interview, the facility failed to ensure that all residents of and applicants to assisted living facilities shall be assessed face to face using the uniform assessment instrument (UAI). The UAI shall be completed prior to admission, at least annually, and whenever there is a significant change in the resident’s condition.
Evidence
  1. During the on-site follow-up investigation on 06/16/2026, the record for resident 1 contained documentation which indicated an admission date of 03/01/2026.
  2. The record for resident 1 contained a private pay UAI that was completed on 04/16/2026.
  3. An interview with staff 1 and staff 2 on the date of follow-up investigation was unsuccessful at locating a UAI that was completed prior to resident 1’s admission.
Plan of correction
UAI has been completed for Resident 1. Executive Director(ED) and Healthcare Director(HCD) was in-serviced by RDO regarding the expectations of ISP’s. ED/HCD will complete audit of ISP’s to ensure compliance by 6.30.26. Any updates needed will be addressed immediately. HCD will ensure completion of ISP’s upon move in to ensure compliance.
22VAC40-73-450-C
Based on record review and staff interview, the facility failed to ensure that the comprehensive individualized service plan (ISP) shall be completed within 30 days after admission.
Evidence
  1. During the on-site follow-up investigation on 06/16/2026, the record for resident 1 contained documentation which indicated an admission date of 03/01/2026.
  2. The record for resident 1 contained a comprehensive ISP that was completed on 04/30/2026.
  3. An interview with staff 1 and staff 2 on the date of follow-up investigation was unsuccessful at locating an ISP that was completed within 30 days after resident 1’s admission.
Plan of correction
UAI has been completed for Resident 1. Executive Director (ED) and Healthcare Director (HCD) was in-serviced by RDO regarding the expectations of ISP’s. ED/HCD will complete audit of ISP’s to ensure compliance by 6.30.26. Any updates needed will be addressed immediately. HCD will ensure completion of ISP’s upon move in to ensure compliance.
March 23, 2026Complaint survey4 violations
Inspection dates
03/23/2026
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint 65409 Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03/23/2026 from 10:30 AM to 11:45 AM 06/16/2026 from 10:00 AM to 01:00 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 03/09/2026 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: 65 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: N/A Number of interviews conducted with residents: N/A Number of interviews conducted with staff: 2 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. However, violation(s) not related to the complaint(s) but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. 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 Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
22VAC40-73-450-C
Based on record review and staff interview, the facility failed to ensure that the comprehensive individualized service plan (ISP) shall include all required components based on various sources, including the uniform assessment instrument (UAI).
Evidence
  1. During the on-site follow-up investigation on 03/23/2026, the record for resident 1 contained a private pay UAI, dated 11/13/2025, which indicated that the resident required the assistance of an RN, LPN, or RMA to administer medications.
  2. A review of the ISP in the record for resident 1, dated 12/15/2025 and updated 01/06/2026, did not address any potential need for medication administration assistance.
  3. An interview with staff 1 and staff 2 during the follow-up investigation on 06/16/2026 confirmed that resident 1 did require the assistance of an RN, LPN, or RMA to administer medications; however, the interview was unsuccessful at locating an ISP where the need for medication administration was addressed.
Plan of correction
Res 1 UAI updated to capture care. Executive Director (ED) and Healthcare Director (HCD) was in-serviced by RDO regarding the expectations of ISP’s. ED/HCD will complete audit of ISP’s to ensure compliance by 6.30.26. Any updates needed will be addressed immediately. HCD will ensure completion of ISP’s upon move in to ensure compliance.
22VAC40-73-450-E
Based on record review and staff interview, the facility failed to ensure that the individualized service plan (ISP) shall be signed and dated by the resident or his legal representative.
Evidence
  1. During the on-site follow-up investigation on 03/23/2026, the record for resident 1 contained an ISP, dated 12/15/2025 and updated 01/06/2026, that was not signed by the resident or legal representative.
  2. An interview with staff 1 and staff 2 during the 06/16/2026 follow-up investigation was unsuccessful at locating an ISP with the resident’s signature (or signature of a legal representative).
Plan of correction
Res 1 UAI updated to capture signatures. Executive Director (ED) and Healthcare Director (HCD) was in-serviced by RDO regarding the expectations of ISP’s. ED/HCD will complete audit of ISP’s to ensure compliance by 6.30.26. Any updates needed will be addressed immediately. HCD will ensure completion of ISP’s upon move in to ensure compliance.
22VAC40-73-325-B
Based on record review and staff interview, the facility failed to ensure that the fall risk rating shall be reviewed and updated after a fall.
Evidence
  1. During the on-site follow-up investigation on 06/16/2026, the record for resident 1 contained staff progress notes which indicated that the resident was observed on the floor at approximately 03:00 AM on 11/18/2025. The resident denied pain and was assisted up and to the bathroom to take a shower by staff 3.
  2. The progress notes for resident 1, dated 03/08/2026, also indicated that the resident had an unwitnessed fall based on footage from cameras in the resident’s room. The progress notes indicated that resident 1 was transported to the emergency department of the local hospital because of the fall. A review of documentation provided by collateral 1 on 03/16/2026 clarified that the fall occurred on the evening of 03/07/2026.
  3. The record for resident 1 contained a fall risk rating, dated 11/13/2025, which indicated that the resident was a low risk for falls. The record also contained a fall risk rating, dated 07/13/2025, which indicated a high risk for falls.
  4. An interview with staff 1 and staff 2 on the date of the follow-up investigation was unsuccessful at locating any fall risk rating updates for the falls that were documented on 11/18/2025 and 03/07/2026.
Plan of correction
Healthcare Director (HCD) reviewed the fall risk of resident 1 and updated the fall risk assessment. Community has reviewed the practice of ensuring fall risk assessments post fall are completed. Executive Director in-serviced nursing team regarding standards of updating fall risk assessments after a resident fall. HCD will update resident assessments, post fall, to ensure compliance, as needed and ongoing.
22VAC40-73-440-D
Based on record review and staff interview, the facility failed to ensure that for private pay individuals, the uniform assessment instrument (UAI) is completed as required.
Evidence
  1. During the on-site follow-up investigation on 03/23/2026, the record for resident 1 contained a private pay UAI, dated 11/13/2025. The UAI was signed by staff 4 as the person who completed the assessment (assessor). The UAI also indicates that if the assessor is a facility employee, then the administrator or designee must signify approval by signing under the assessor; however, this area of the form was not signed by the administrator or designee.
  2. An interview with staff 1 and staff 2 during the follow-up investigation on 06/16/2026 was unsuccessful at locating a private pay UAI for resident 1 that was also signed by the administrator or designee.
Plan of correction
Res 1 UAI updated to capture documentation. Executive Director (ED) and Healthcare Director (HCD) was in-serviced by RDO regarding the expectations of UAI’s. ED/HCD will complete audit of UAI’s to ensure compliance by 6.30.26. Any updates needed will be addressed immediately. HCD will ensure completion of UAI’s upon move in to ensure compliance.
February 25, 2026Complaint survey3 violations
Inspection dates
02/25/2026
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint 64920 Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 02/25/2026 from 11:00 AM to 03:30 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 01/20/2026 regarding allegations in the area(s) of: RESIDENT CARE AND RELATED SERVICES; RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS BUILDINGS AND GROUNDS Number of residents present at the facility at the beginning of the inspection: 65 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: N/A Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: Observed lunchtime meal in dining room Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. However, violation(s) not related to the complaint(s) but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. 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 Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
22VAC40-73-660-A-1
Based on observation, the facility failed to ensure that the medication storage area shall be locked.
Evidence
  1. During the on-site inspection, at approximately 02:25 PM, LI observed that the medication cart outside of the nurses’ station on the first floor was unlocked and unattended.
  2. The LI stood with the cart for approximately a minute, but no staff appeared; therefore, LI locked the cart and went to notify staff 1 that the cart was observed unlocked and unattended.
Plan of correction
Healthcare Director in-serviced clinical team regarding the med storage area expectations and the importance of it remaining locked when unattended. HCD/designee will train medication aides in regard to locking medication storage areas upon hire and as needed to ensure compliance. HCD/designee to complete rounds weekly to verify medication storage area remains locked when unattended.
22VAC40-73-440-D
Based on record review and staff interview, the facility failed to ensure that for private pay individuals, the uniform assessment instrument (UAI) is completed as required.
Evidence
  1. During the on-site inspection, the record for resident 1 contained a private pay UAI, completed 02/10/2026, that was incomplete in addressing the resident’s abilities when toileting and wheeling.
  2. An interview with staff 1 on the date of inspection was unsuccessful in locating a UAI where toileting and wheeling had been addressed for resident 1.
Plan of correction
UAI updated to address these items for Resident #1. Healthcare Director/designee will complete the UAI and ISPs for accuracy, upon move in, and as needed to ensure compliance. HCD/designee will audit all resident records for accuracy and update UAI’s as applicable. Executive Director/designee will audit UAIs monthly for completion.
22VAC40-73-450-E
Based on record review and staff interview, the facility failed to ensure that the individualized service plan (ISP) shall be signed and dated by the resident, his legal representative, or other responsible party.
Evidence
  1. During the on-site inspection, the record for resident 1 contained an ISP, completed on 12/15/2025 and updated on 12/18/2025; however, the ISP was not signed by the resident/legal representative/responsible party.
  2. An interview with staff 1 on the date of inspection was unsuccessful in locating an ISP that was signed by the resident/legal representative/responsible party.
Plan of correction
ISP will be signed by Resident #1/POA. Healthcare Director and Executive Director will obtain signatures on ISPs upon move in and as applicable to ensure completion. HCD/designee will audit files monthly to ensure signatures are obtained.
February 25, 2026Complaint survey0 violations
Inspection dates
02/25/2026
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint 65260 Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 02/25/2026 from 11:00 AM to 03:30 PM 03/23/2026 from 10:30 AM to 11:45 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 02/04/2026 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: 65 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 11 Number of staff records reviewed: N/A Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
February 25, 2026Complaint survey0 violations
Inspection dates
02/25/2026
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint 65003 Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 02/25/2026 from 11:00 AM to 03:30 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 01/29/2026 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: 65 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: N/A Number of interviews conducted with residents: N/A Number of interviews conducted with staff: 1 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s)of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
January 8, 2026Complaint survey0 violations
Inspection dates
01/08/2026
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint 64592 Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 01/08/2026 from 10:45 AM to 01:15 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 12/08/2025 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: 77 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: N/A Number of interviews conducted with residents: N/A Number of interviews conducted with staff: 2 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
December 16, 2025Inspection9 violations
Inspection dates
12/16/2025
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 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
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: 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: 10 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 5 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A 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 is 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 Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
22VAC40-73-680-I
Based on resident record review and staff interviews, the facility failed to ensure that all required information was documented on medication administration records (MARs).
Evidence
  1. The December 2025 MAR for resident 4 contained documentation of staff 3’s initials on 12/08/2025 for the administration of the following treatments: 1.) Bacitracin and dry dressing daily to toes, 2.) Cleanse wound daily with saline dress wound with Betadine moist to dry dressing and cover with bordered foam dressing, 3.) Cleanse post lower right leg with wound cleaner. Pat dry, apply Xeroform and BFD, change 2x a week-HH to preform and provide, 4.) Treatment Lt Lateral Foot, cleanse with wound cleaner, pat dry, apply alginate to wound bed, cover with BFD for 2 X week-HH to perform/provide.
  2. In an interview with staff 3 on the day of on-site inspection, staff 3 revealed to LI that she did not perform those treatments, but she was unsure of how to document this on the MAR. Staff 3 indicated that home health staff have always performed those treatments.
Plan of correction
Not published by VDSS.
22VAC40-73-560-E
Based on resident record review, the facility failed to ensure that resident records were kept current.
Evidence
  1. The record for resident 4 contained documentation that the resident is receiving skilled nursing treatments from a Home Health agency 1 time a week for treatments to the resident’s left lateral foot.
  2. As of the day of the on-site inspection, the record for resident 4 did not have documentation of the skilled nursing notes for the completion of this treatment since 12/03/2025.
Plan of correction
Not published by VDSS.
22VAC40-73-650-E
Based on resident record review and staff interviews, the facility failed to ensure that physician orders were maintained in resident records.
Evidence
  1. The December 2025 medication administration record (MAR) for resident 4 contained documentation of treatment orders for: 1.) BACITRACIN and dry dressing to toes, 2.) Cleanse wound daily with saline, dress wound with BETADINE moist to dry dressing and cover with bordered foam dressing, 3.) Apply BETADINE and cover with border gauze daily for right heel wound, 4). Cleanse post lower right leg with wound cleaner. Pat dry, apply XEROFORM and BFD, change 2x a week - HH to perform and provide, 5.) Treatment left shoulder, cleanse wound/blister with normal saline, pat dry and apply XEROFORM, cover with foam-bordered dressing to be changed twice weekly until healed. - Medi Home Hospice, 6.) Treatment Lt Lateral Foot, cleanse with wound cleaner, pat dry, apply ALGINATE to wound bed, cover with BFD for 2x per week - HH to perform/provide.
  2. In an interview with staff 4 and staff 5 on the day of on-site inspection, it was explained that these areas have healed.
  3. The record for resident 4 did not contain physician orders to discontinue these treatments.
Plan of correction
Not published by VDSS.
22VAC40-73-450-F
Based on resident record review and staff interviews, the facility failed to ensure that individualized service plans (ISPs) were reviewed/updated as needed for a change in resident condition.
Evidence
  1. The uniform assessment instrument (UAI) in the record for resident 1, dated 11/04/2025, contained documentation that the resident requires mechanical assistance with toileting, transferring, walking, mobility, and wheeling is not performed.
  2. The ISP for resident 1, dated 12/15/2025, was inconsistent as it contained documentation that resident 1 does not require assistance with toileting, transferring, and mobility; and the walking and wheeling functions are not identified on the ISP.
  3. In an interview with staff 4 and staff 5 on the day of on-site inspection, it was explained that resident 1’s UAI was correct and that resident 1 does require mechanical assistance with toileting, transferring, walking and mobility and that resident 1 also uses a wheelchair.
  4. The UAI for resident 2, dated 11/04/2025, indicated that the resident requires mechanical assistance only with walking and mobility and requires mechanical and physical assistance for stairclimbing.
  5. The ISP for resident 2, dated 12/15/2025, indicated that the resident is independent in mobility and the ISP does not address resident 2’s need for assistance, per the UAI, for walking and stairclimbing.
  6. An interview with staff 4 and staff 5 on the date of inspection revealed that the UAI for resident 2 was the most accurate because the resident requires only mechanical assistance for walking and mobility, and mechanical and physical assistance for stairclimbing.
Plan of correction
Not published by VDSS.
22VAC40-73-640-A
Based on observation and staff interview, the facility failed to implement portions of its medication management plan, specifically regarding its methods to prevent the use of outdated, damaged, or contaminated medications.
Evidence
  1. According to the website for the LANTUS SOLOSTAR pen, after the first use of the LANTUS SOLOSTAR pen, it must be thrown away after 28 days, even if it still has insulin in it.
  2. During the on-site renewal inspection on 12/16/2025, LI performed an audit of the 1st floor medication cart with staff 3. That cart contained a LANTUS SOLOSTAR INSULIN INJECTION pen belonging to resident 12. An observation of the pen’s contents and plunger placement indicated that the pen has been used for administration; however, there was no open date written on the pen to ensure that staff are not using an expired pen. That cart also contained a LANTUS SOLOSTAR INSULIN INJECTION pen belonging to resident 8. An observation of the pen’s contents and plunger placement indicated that the pen has been used for administration; however, there was no open date written on the pen to ensure that staff are not using an expired pen.
  3. Point 11 of the facility’s most current medication management plan at the time of renewal, dated 02/2018, indicated that nurses and RMAs are responsible for ensuring that all medications, including over the counter, supplements, and or samples are in the original packaging, undamaged, and used within the appropriate date of use or expiration.
  4. An interview with staff 3 confirmed that neither pen contained an open or expiration date to ensure that staff are not using expired insulin pens.
Plan of correction
Not published by VDSS.
22VAC40-73-860-I
Based on observation of the facility’s physical plant, the facility failed to store cleaning supplies in a locked area.
Evidence
  1. At approximately 8:30am on the day of on-site inspection, the laundry room across from room 123 was noted to be unlocked.
  2. The door to the Mechanical Room inside of the laundry room was also noted to be unlocked and a can of Resolve Pet Expert Foam Carpet Cleaner and a bottle of Method All-Purpose Cleaner were observed sitting in a black tray on the floor in the room.
Plan of correction
Not published by VDSS.
22VAC40-73-260-A
Based on record review and staff interview, the facility failed to ensure that each direct care staff member shall maintain current first aid certification; each direct care staff member who does not have current certification in first aid shall receive certification within 60 days of employment.
Evidence
  1. During the on-site renewal inspection on 12/16/2025, the record for staff 3, hired 09/19/2025, contained documentation of current CPR certification; however, there was no documentation to verify current first aid certification for staff 3.
  2. An interview with staff 6 revealed that staff 3 only has CPR certification.
Plan of correction
Not published by VDSS.
22VAC40-90-30-B
Based on record review and staff interview, the facility failed to ensure that the sworn statement shall be completed for all applicants for employment.
Evidence
  1. The record for staff 7 indicated a hire date of 09/19/2025; however, the sworn disclosure statement in the record for staff 7 was signed on 10/11/2025, after staff 7 was hired.
  2. An interview with staff 6 revealed that the hire date and the sworn disclosure statement date for staff 7 are accurate.
Plan of correction
Not published by VDSS.
22VAC40-73-680-B
Based on observation and staff interview, the facility failed to ensure that medications shall remain in the pharmacy issued container, with the prescription label or direction label attached, until administered to the resident.
Evidence
  1. During the on-site renewal inspection on 12/16/2025, LI performed an audit of the 2nd floor medication cart with staff 1. That cart contained a LANTUS SOLOSTAR INSULIN INJECTION pen with resident 11’s name written on the cap; however, there was no pharmacy label attached to the pen. An observation of the pen’s contents and plunger placement indicated that the pen has been used for administration. That cart also contained a LANTUS SOLOSTAR INSULIN INJECTION pen with resident 6’s name written on a piece of medical tape which was wrapped around the pen; however, there was no pharmacy label attached to the pen. An observation of the pen’s contents and plunger placement indicated that the pen has been used for administration.
  2. An interview with staff 1 confirmed that there are no pharmacy labels attached to those pens.
Plan of correction
Not published by VDSS.
October 23, 2025Complaint survey1 violation
Inspection dates
10/23/2025; 01/08/2026
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint 63624 Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/23/2025 from 08:30 AM to 03:15 PM 01/08/2025 from 10:45 AM to 01:15 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 09/01/2025 regarding allegations in the area(s) of: Staffing and Supervision Resident Care and Related Services Resident Accommodations and Related Provisions Number of residents present at the facility at the beginning of the inspection: 77 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: N/A Number of staff records reviewed: N/A Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. However, violation(s) not related to the complaint(s) but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
22VAC40-73-680-B
Based on observation and staff interview, the facility failed to ensure that medications shall remain in the pharmacy issued container, with the prescription label or direction label attached, until administered to the resident.
Evidence
  1. During a walk-through of the facility on the date of follow-up inspection, on 10/23/2025, at 09:15 AM, LI observed a small round brown pill with a marking of “W2” that was laying on the floor outside of room 113.
  2. An interview with staff 1 acknowledged that LI found the pill loose on the floor outside of room 113, and staff 1 revealed that the pill was likely SENNOSIDES 8.6 MG which was consistent with an online search made by LI
Plan of correction
An audit was completed all of the medications. Was determined that there were no medications missing from the cart. Undetermined where pill came from. Moving forward staff will observe common areas for loose pills as they move about.
October 23, 2025Complaint survey0 violations
Inspection dates
10/23/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint 64134 Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/23/2025 from 08:30 AM to 03:15 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 10/08/2025 regarding allegations in the area(s) of: Resident care and related services Additional requirements for facilities that care for adults with serious cognitive impairments (staffing) Number of residents present at the facility at the beginning of the inspection: 77 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: N/A Number of interviews conducted with staff: 2 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
October 23, 2025Complaint survey0 violations
Inspection dates
10/23/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Complaint 63581 Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/23/2025 from 08:30 AM to 03:15 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Use this statement only if the inspection is related to a complaint or self-reported incident: A complaint was received by VDSS Division of Licensing on 08/27/2025 regarding allegations in the area(s) of: Resident care and related services Number of residents present at the facility at the beginning of the inspection: 77 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: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. Use the following last two statements on every Inspection Summary: For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
October 23, 2025Inspection0 violations
Inspection dates
10/23/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/23/2025 from 08:30 AM to 03:15 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 10/16/2025 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: 77 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: N/A Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A 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. Use the following last two statements on every Inspection Summary: For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
September 10, 2025Inspection2 violations
Inspection dates
09/10/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 08/12/2025 from 10:15 AM to 04:00 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 08/12/2025 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: 73 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: N/A Number of interviews conducted with residents: N/A Number of interviews conducted with staff: 2 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A 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 Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
22VAC40-73-680-D
Based on record review and staff interview, the facility failed to ensure that medications are administered according to physician’s or other prescriber’s orders.
Evidence
  1. On 08/12/2025, LI received a self-reported incident from staff 1 indicating that resident 1 did not receive her scheduled dose of METFORMIN during a morning medication pass but did receive all her other scheduled medications at that time. The report added that on the date of the incident, the METFORMIN was unavailable and was not given as a result, and by the time it was located, it was too late to be administered.
  2. During the on-site follow-up on 09/10/2025, the record for resident 1 contained a uniform assessment instrument (UAI), dated 05/13/2025, and an individualized service plan (ISP), dated 08/06/2025, both of which indicate that resident 1 requires the assistance of a lay person, such as a registered medication aide (RMA) or a nurse, to administer her medications.
  3. The August 2025 medication administration record (MAR) for resident 1 indicates that on 08/11/2025, at 08:00 AM, the following medications were not administered due to “awaiting pharmacy delivery”: ACETAMINOPHEN 325 MG TABLET Take 2 tablets = 650 MG by mouth 2 times a day for pain – Not to exceed 3 GMS daily (3,000 MG) @ 8 AM & 8 PM (written 05/04/2025) LABETALOL HCL 200 MG TABLET Take one tablet by mouth 2 times a day for HEART/HTN @ 8 AM & 8 PM (written 04/19/2025) METFORMIN HCL 1,000 MG TABLET Take one tablet by mouth 2 times a day for DM @ 8 AM & 8 PM (written 04/21/2025), and OXYBUTYNIN 5 MG TABLET Take one tablet by mouth every day for bladder spasms @ 8 AM (written 04/19/2025)
  4. The most recent medication list at the time of the self-report was signed on 05/19/2025 and included the above medications.
  5. On 09/30/2025, an interview with staff 2 revealed that the Aug 2025 MAR for resident 1 was correct on 08/11/2025 at 08:00 AM and the above medications were not administered at that time.
Plan of correction
Medication will be administered in accordance with physician's orders moving forward. Registered Medication Aides received additional training on medication administration. Medication audits and observations are occurring weekly to ensure any issues are addressed in a timely fashion.
22VAC40-73-640-A
Based on record review and staff interview, the facility failed to implement portions of its medication management plan specifically regarding its 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, as well as its methods to ensure that issues and observations related to medication administration are routinely communicated to the prescribing physician or other prescriber.
Evidence
  1. The facility’s most recently provided medication management plan, last revised 02/2018, point #12 indicates that nurses and RMAs shall be responsible for the timely ordering and re-ordering of medications so that there are no missed doses or interruptions in medications being administered.
  2. On 08/12/2025, LI received a self-reported incident from staff 1 indicating that resident 1 did not receive her scheduled dose of METFORMIN during a morning medication pass. The Aug 2025 MAR for resident 1 revealed that ACETAMINOPHEN 325 MG TABLET, LABETALOL HCL 200 MG TABLET, METFORMIN HCL 1,000 MG TABLET, and OXYBUTYNIN 5 MG TABLET were not administered on 08/11/2025 at 08:00 AM due to “awaiting pharmacy delivery”. On 09/30/2025, a phone interview with staff 2 revealed that the Aug 2025 MAR for resident 1 was correct on 08/11/2025 at 08:00 AM and those medications were not in the facility to administer at that time.
  3. The facility’s most recently provided medication management plan, last revised 02/2018, point #13 indicates that if a medication is not available to administer for any reason, the nurse/RMA will contact the physician to inform of when the medication will be made available and seek further instruction. The physician instructions will be documented on the e-MAR.
  4. During the on-site follow-up on 09/10/2025, the record for resident 1 did not contain documentation which indicated that resident 1’s physician was notified of the missed medication administration.
  5. Follow-up correspondence with staff 3 on 10/01/2025 revealed that no documentation has been found to indicate that resident 1’s physician was notified of the missed medication administration.
Plan of correction
Medication will be administered in accordance with the medication management plan moving forward. Registered Medication Aides received additional training on medication administration. Medication audits and observations are occurring weekly to ensure any issues are addressed in a timely fashion.
September 10, 2025Inspection4 violations
Inspection dates
09/10/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/10/2025 from 10:15 AM to 04:00 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 08/18/2025 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: 73 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: N/A Number of interviews conducted with residents: N/A Number of interviews conducted with staff: 2 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A 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 Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
22VAC40-73-450-F
Based on record review and staff interview, the facility failed to ensure that the individualized service plan (ISP) shall be reviewed and updated as needed for a significant change of a resident’s condition.
Evidence
  1. On 08/18/2025, LI received a self-reported incident that the facility had administered medications to resident 1 that belonged to resident 2. In addition, a telephone interview with collateral 1 and a review of collateral 1’s charting notes on 10/03/2025 indicated that resident 1 had been administered his own scheduled evening medications on 08/18/2025 but also received several 09:00 PM medications that belonged to resident 2 on that date.
  2. On 09/12/2025, a review of the ISP for resident 1, dated 05/13/2025, indicated that resident 1 can self-administer medications/does not require assistance with medication; however, based on the self-reported incident, staff interview, and collateral interview, resident 1 was no longer capable of self-administering medications at the time of the medication error.
Plan of correction
Not published by VDSS.
22VAC40-73-450-D
Based on record review and staff interview, 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 individualized service plan.
Evidence
  1. During the on-site follow-up on 09/10/2025, LI interviewed staff 2 who indicated that resident 1 had been receiving hospice services; however, a hospice plan of care could not be located in the record for resident 1 nor in the facility.
  2. A review of facility charting notes for resident 1 revealed that he had been admitted to hospice on 08/15/2025.
  3. The most current individualized service plan (ISP) for resident 1, dated 05/13/2025, did not contain documentation to indicate that resident 1 had been receiving hospice services.
Plan of correction
Not published by VDSS.
22VAC40-73-440-D
Based on record review and staff interview, the facility failed to ensure that the uniform assessment instrument (UAI) was completed as required.
Evidence
  1. On 09/12/2025, LI received a copy of the most current UAI for resident 1, dated 07/23/2025, from staff 2.
  2. The UAI indicated that medication administration is performed by “professional nursing staff” instead of by “lay person”, as required for facilities who employ registered medication aides.
Plan of correction
Not published by VDSS.
22VAC40-73-680-D
Based on record review, staff interview, and collateral interview, the facility failed to ensure that medications were administered in accordance with physician’s or other prescriber’s instructions.
Evidence
  1. On 08/18/2025, LI received a self-reported incident from staff 1 which indicated that resident 1 had received medications belonging to resident 2 at around 05:15 PM on the same date. The incident report added that the executive director (ED) contacted the nurse practitioner (NP), the medication staff member contacted resident 1’s power of attorney (POA) and took vitals, and resident 1 will be monitored for signs and symptoms of any changes in condition.
  2. During the on-site follow-up to the self-report on 09/10/2025, the facility’s charting notes/progress notes confirmed that the medication error had occurred on 08/18/2025. The charting notes also indicated that collateral 1 was notified about the medication error involving resident 1, and collateral 1 was given a list of medications that resident 1 had been given. Collateral 1 consulted with their physician and provided guidance that the facility take resident 1’s blood pressure at the time of notification and again in ½ hour, but there should not be any side effects other than sleepiness.
  3. An interview with staff 2 during the on-site follow-up on 09/10/2025 revealed that the actual medications that resident 1 received in error were not found to be documented in the record for resident 1 nor elsewhere in the facility.
  4. A telephone interview with collateral 1 and a review of collateral 1’s charting notes on 10/03/2025 revealed that resident 1 received his own scheduled evening medications on 08/18/2025 but also received the following 09:00 PM medications that belonged to resident 2 on that date: BALSALAZIDE DISODIUM 750 MG CP Take one capsule by mouth 2 times a day (for ulcerative colitis) BENZONATATE 100 MG CAP Take one capsule by mouth 2 times a day (for chronic cough) MELATONIN 5 MG TAB Take 1 tablet by mouth at bedtime (for sleep) MEMANTINE HCL 10 MG TAB Take 1 tablet by mouth 2 times a day (for memory) MIRTAZAPINE 30 MG TAB Take 1 tablet by mouth at bedtime (for mood/sleep) SIMVASTATIN 40 MG TAB Take ½ tablet = 20 MG by mouth at bedtime (for vascular disease) Collateral 1’s charting notes also indicated that the hospice physician recommended moving the resident closer to the nurses’ station and keeping a close eye on him due to having received multiple sleep medications and to monitor the resident’s blood pressure and increased risk of falls.
Plan of correction
Not published by VDSS.
September 10, 2025Complaint survey2 violations
Inspection dates
09/10/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint 63496 Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/10/2025 from 10:15 AM to 04:00 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 08/20/2025 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: 73 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: N/A Number of interviews conducted with residents: N/A Number of interviews conducted with staff: 1 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. However, violation(s) not related to the complaint(s) but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov. Should you have any questions, please contact Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
22VAC40-73-450-F
Based on record review and staff interview, the facility failed to ensure that individualized service plans were reviewed and updated as needed for a change of a resident’s condition.
Evidence
  1. During the on-site follow-up inspection on 09/10/2025, the facility provided weekly wound care and home health provider notes from 01/08/2025 to 09/09/2025 that wound dressing changes and treatment were being provided to resident 1 for a wound on her left heel. During that time, most of the wound care notes indicate that wound healing had been impacted by the patient’s lack of adherence to the treatment plan, and that proper elevation is essential to healing the current problem and preventing new ones. The 09/09/2025 wound care notes indicate that home health will perform weekly (and as needed) wound dressing changes and wound care treatment will continue on Tuesdays for a total of two dressing changes per week.
  2. An interview with staff 1 on the date of inspection revealed that the ISP was the most current at that time, and staff 1 acknowledged that the ISP had not been updated to include that wound care and home health services were being received by resident 1.
Plan of correction
SP for resident has been updated to include the resident's need for wound care services which were being provided according to physician's orders. Weekly review of special care services is being conducted to identify any change in services to be included on the ISP for residents.
22VAC40-73-450-C
Based on observation and staff interview, the facility failed to ensure that the comprehensive individualized service plan (ISP) shall include a description of identified needs and date identified based on the uniform assessment instrument (UAI); admission physical examination; interview with the resident; fall risk rating; assessment of psychological, behavioral, and emotional functioning; and other sources.
Evidence
  1. The uniform assessment instrument (UAI) for resident 1, dated 11/08/2024, indicates that for bathing, the resident requires mechanical and human physical assistance.
  2. The ISP for resident 1, dated 11/08/2024, indicates for bathing that the resident requires mechanical and human help via physical assistance with bathing; however, the same ISP indicates that the resident can bathe without physical assistance but may require reminding or standby assistance.
  3. The uniform assessment instrument (UAI) for resident 1, dated 11/08/2024, indicates that for toileting, the resident requires mechanical and human physical assistance.
  4. The ISP for resident 1, dated 11/08/2024, indicates for toileting that the resident requires mechanical and human physical assistance with toileting; however, the same ISP also indicates that the resident requires standby assistance for toileting tasks. An interview with staff 1 on the date of inspection revealed that the UAI and ISP were the most current at that time and that the information from the UAI was the most accurate.
Plan of correction
UAI & ISP for resident has been updated to include the resident's assessed needs. Weekly review of UAI & ISP's is being conducted to identify any discrepencies and ensure the documents remain current for each resident.
September 10, 2025Inspection0 violations
Inspection dates
09/10/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 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: 09/10/2025 from 10:15 AM to 04:00 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 09/10/2025 regarding allegations in the area(s) of: Resident care and related services; Emergency preparedness Number of residents present at the facility at the beginning of the inspection: 73 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: N/A Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A 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 Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
September 10, 2025Inspection0 violations
Inspection dates
09/10/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring – Self-report Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/10/2025 from 10:15 AM to 04:00 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 08/18/2025 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: 73 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: N/A Number of interviews conducted with residents: N/A Number of interviews conducted with staff: 1 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A 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 Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
September 10, 2025Complaint survey0 violations
Inspection dates
09/10/2025
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint 63540 Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/10/2025 from 10:15 AM to 04:00 PM A complaint was received by VDSS Division of Licensing on 08/25/2025 regarding allegations in the area(s) of: Personnel Number of residents present at the facility at the beginning of the inspection: 73 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: N/A Number of staff records reviewed: N/A Number of interviews conducted with residents: N/A Number of interviews conducted with staff: 1 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
September 10, 2025Complaint survey0 violations
Inspection dates
09/10/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint 63505 Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/10/2025 from 10:15 AM to 04:00 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A (complaint/self-reported incident) was received by VDSS Division of Licensing on (08/21/2025) 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: 73 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: N/A Number of interviews conducted with residents: N/A Number of interviews conducted with staff: 1 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A 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. 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 Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
August 11, 2025Inspection2 violations
Inspection dates
08/11/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 08/11/2025 from 10:00 AM to 12:00 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 08/06/2025 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: 73 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: N/A Number of interviews conducted with residents: N/A Number of interviews conducted with staff: 2 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A 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 Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
22VAC40-73-640-A
Based on record review and staff interview, the facility failed to implement portions of its medication management plan, specifically regarding its methods to ensure that each resident’s prescription medications are filled in a timely manner to avoid missed dosages; and methods for verifying that medication orders have been accurately transcribed to medication administration records (MARs) within 24 hours of receipt of a new order or change in an order.
Evidence
  1. The facility’s most current medication management plan, dated 02/2018, points 12 and 14, indicate that nurses and RMAs shall be responsible for the timely ordering and re-ordering of medications so that there are no missed doses or interruptions in the medications being administered, new medications will be started within 24 hours of receipt of the Rx from the physician or prescriber, and new orders received shall be transcribed within 24 hours to the e-MAR and reviewed by a licensed nurse or designee.
  2. On 08/06/2025, LI received a self-reported incident from staff 1 which indicated that resident 1 was sent to the emergency department due to an unresponsive episode. The self-report also stated that the medication list that was sent with resident 1 (to the hospital) did not include her ELIQUIS, and as a result, resident 1’s responsible party called (the facility) to inquire about that medication. The self-report reveals that a subsequent review of the medication administration record (MAR) and physician order summary (POS) indicated that ELIQUIS should have been available to resident 1.
  3. Email correspondence with staff 1 on 08/06/2025 revealed that ELIQUIS was not in the facility on that date, and the MAR did not show it was being administered. Staff 1 indicated that after further investigation, the physician’s order for ELIQUIS was found to be written on 07/09/2025, and it was supposed to start on 07/10/2025. Per staff 1, the pharmacy had put the order on the physician’s order summary (POS), but the medication went into pending status and was not approved until 08/02/2025.
  4. The facility’s most current medication management plan, dated 02/2018, point 13, indicates that if a medication is not available to administer for any reason, the nurse/RMA will contact the physician to inform of when the medication will be made available and seek further instruction. The physician instructions will be documented on the e-MAR.
  5. An interview with staff 1 and staff 2 during the on-site follow-up on 08/11/2025 revealed that resident 1 had been prescribed ELIQUIS, but that medication was never in the facility from the resident’s date of admission on 06/21/2025, until the date that resident 1 was transported to the hospital on 08/02/2025.
  6. Per a phone call between staff 2 and collateral 1 during the on-site follow-up, a search would be performed for medication delivery forms for resident 1’s ELIQUIS during June, July, and August 2025; however, as of the date of the violation notice, neither the pharmacy nor the facility were able to provide verification that resident 1’s ELIQUIS had ever been delivered to the facility.
  7. During the on-site follow-up to the self-report on 08/11/2025, the record for resident 1 did not contain documentation that the resident’s physician was notified of the absence of ELIQUIS from the facility nor did it contain documentation that the physician was notified that resident 1 had not received ELIQUIS.
Plan of correction
Not published by VDSS.
22VAC40-73-680-D
Based on record review and staff interviews, the facility failed to ensure that medications shall be administered in accordance with the physician’s or other prescriber’s instructions.
Evidence
  1. On 08/06/2025, LI received a self-reported incident from staff 1 which indicated that resident 1 was sent to the emergency department due to an unresponsive episode. The self-report also stated that the medication list that was sent with resident 1 (to the hospital) did not include her ELIQUIS, and as a result, resident 1’s responsible party called (the facility) to inquire about that medication. The self-report reveals that a subsequent review of the medication administration record (MAR) and physician order summary (POS) indicated that ELIQUIS should have been available to resident 1.
  2. Email correspondence with staff 1 on 08/06/2025 revealed that ELIQUIS was not in the facility on that date, and the MAR did not show it was being administered. Staff 1 indicated that after further investigation, the physician’s order for ELIQUIS was found to be written on 07/09/25, and it was supposed to start on 07/10/25. The pharmacy had put the order on the physician’s order summary (POS), but the medication went into pending status and was not approved until 08/02/25.
  3. Additional email correspondence with staff 1 on 08/06/2025 clarified that the resident was transported to the hospital on 08/03/25, the resident passed away on 08/05/2025, and the report was received by the Licensing Inspector (LI) on 08/06/2025.
  4. During the on-site follow-up inspection on 08/11/2025, the record for resident 1 indicated that the resident was admitted to the facility on 06/21/2025, but the resident’s information was not added to ACCUFLO (e-MAR system) until 07/09/2025.
  5. The resident’s REPORT OF RESIDENT PHYSICAL EXAMINATION, dated 06/18/2025, indicated that, in addition to other medications, the resident had been prescribed ELIQUIS 2.5 MG TAB – 1 TAB BY MOUTH (PO) TWICE DAILY (BID) for a diagnosis of atrial fibrillation (AFIB).
  6. The uniform assessment instrument (UAI) for resident 1, dated 07/11/2025, and the individualized service plan (ISP) for resident 1, dated 07/12/2025, indicated that the resident required the assistance of a lay person (RMA/nurse) for the administration of medications.
  7. The record for resident 1 also contained an internal incident report, dated 08/02/2025, that the resident was found by medication staff during that morning’s medication pass leaning over, breathing heavily, and was unresponsive, so the resident was transported to the hospital.
  8. The June 2025 MAR for resident 1 did not contain any medications, nor documentation that any medications had been administered.
  9. The July 2025 MAR for resident 1 did not contain the ELIQUIS 2.5 MG TAB that was prescribed per the medication list included with the REPORT OF RESIDENT PHYSICAL EXAMINATION, dated 06/18/2025.
  10. The August 2025 MAR for resident 1 did contain the ELIQUIS 2.5 MG TAB – TAKE ONE TABLET BY MOUTH 2 TIMES A DAY FOR AFIB, with an effective date of 07/09/2025; however, the August 2025 MAR indicated that the ELIQUIS was never administered in August up until when the resident was hospitalized on 08/02/2025.
  11. An interview with staff 1 and staff 2 during the on-site follow-up on 08/11/2025 revealed that resident 1 had been prescribed ELIQUIS, but that medication was never in the facility from the resident’s date of admission on 06/21/2025, until the date that resident 1 was transported to the hospital on 08/02/2025.
  12. Per a phone call between staff 2 and collateral 1 during the on-site follow-up on 08/11/2025, a search would be performed for medication delivery forms for resident 1’s ELIQUIS during June, July, and August 2025; however, as of the date of the violation notice, neither the pharmacy nor the facility were able to provide verification that resident 1’s ELIQUIS had ever been delivered to the facility.
Plan of correction
Not published by VDSS.
August 11, 2025Complaint survey0 violations
Inspection dates
08/11/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint 63366 Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 08/11/2025 from 10:00 AM to 12:30 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 08/08/2025 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: 77 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: 1 Number of interviews conducted with staff: 4 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
July 17, 2025Complaint survey5 violations
Inspection dates
07/17/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint 62965 Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/17/2025 from 10:15 AM to 03:00 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 07/02/2025 regarding allegations in the area(s) of: Resident Care and Related Services Buildings and Grounds -------------------------------------------------------------------------------------- Number of residents present at the facility at the beginning of the inspection: 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: 2 Number of interviews conducted with staff: 4 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A 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 Buildings and Grounds A violation notice was issued; any violation(s) not related to the complaint(s) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
22VAC40-73-450-F
Based on observation and staff interview, the facility failed to ensure that individualized service plans (ISPs) shall be reviewed and updated, as needed, for a significant change of a resident’s condition.
Evidence
  1. During the on-site inspection, the record for resident 2 contained an ISP dated 01/09/2025, and the facility’s HSE VA Assessment, which generates the electronic ISP, was also completed on 01/09/2025.
  2. The ISP and the HSE VA Assessment indicated that the resident requires minimal assistance with transferring and/or positioning, with verbal prompts/cues but no hands-on assistance is needed.
  3. On the date of inspection, LI observed resident 2 in her unit, and resident 2 was lying on her bed, head elevated but leaning over, with the lower half of her body turned in the opposite direction toward her wheelchair. Resident 2 informed LI that she had experienced an episode of emesis and was unable to get up from her current position without physical assistance. As a result, LI made contact with staff 4 in the hallway and advised staff 4 that resident 2 needed assistance getting up from her bed and needed assistance to be cleaned up. Staff 4 and another direct care staff member followed LI to resident 2’s unit and both staff members assisted the resident with sitting up in bed and were assisting with cleaning up the resident when LI was exiting that unit.
  4. The ISP and the HSE VA Assessment, completed 01/09/2025, indicate that resident 2 does not require assistance with meal consumption and that meals will be provided in dining areas; however, while LI was in the unit belonging to resident 2, a dining services staff member entered and left to-go containers of food on the resident’s kitchen counter.
  5. An interview with the dining services staff member revealed that they drop off resident 2’s food on her counter for her to eat whenever she prefers, instead of her eating in the dining room. Then, housekeeping and direct care staff dispose of her food containers when she is finished.
  6. On resident 2’s kitchen counter, LI observed two large Styrofoam containers, one containing a sandwich and the other containing fruit and yogurt. Also on the counter was a cup of pie and a cup of soup, and two cups of tea. The food observed appeared consistent with that day’s breakfast and lunch options.
  7. While LI was in the unit belonging to resident 2 on the date of inspection, she was unable to access her food due to not being able to get out of bed without physical assistance of staff, and her meals were not provided in the dining room as per the ISP and the HSE VA Assessment.
Plan of correction
Resident ISPs will be reviewed by HCD or designee monthly for change in resident condition. ISPs will be monitored to ensure they match the resident’s current condition.
22VAC40-73-450-D
Based on record review and staff interview, the facility failed to ensure that when hospice care is provided to a resident, the services provided by each shall be included in the individualized service plan (ISP).
Evidence
  1. During the on-site inspection, the record for resident 2 contained a hospice plan of care which indicated that ongoing hospice services began on 12/09/2024.
  2. The record for resident 2 contained an ISP, dated 01/09/2025, which did not indicate that hospice services have been provided since 12/09/2024.
  3. The facility’s HSE VA Assessment, which generates the electronic ISP, completed on 01/09/2025, also did not indicate that hospice services have been provided since 12/09/2024.
Plan of correction
A 100% chart audit of Hospice resident ISPs will be reviewed to ensure additional services are indicated as applicable. This will be completed by the HCD or designee.
22VAC40-73-440-B
Based on record review and staff interview, the facility failed to ensure that an assisted living facility staff person, who has successfully completed state- approved training on the uniform assessment instrument (UAI) and level of care criteria for either public or private pay assessments, may complete the private pay UAI, provided the administrator or the administrator's designated representative has successfully completed such training and approves and then signs the completed UAI.
Evidence
  1. On the date of inspection, LI did not locate the UAI in the record for resident 2. Staff 1 informed LI that once the UAI is located, she would email it.
  2. On 07/24/2025, staff 1 emailed LI a document titled “HSE VA Assessment Results” which contained the components of the UAI and ISP but in a different format.
  3. Upon review, LI observed that staff 5 had completed the HSE VA Assessment on 01/09/2025; however, that Assessment, which includes completed UAI components, was not signed by staff 1 or a designated representative.
Plan of correction
HCD or designee will audit for complete UAI monthly to ensure complete UAI is present for each resident. Nurses will receive education nurses that are responsible for completing the UAI to ensure it is accurate, complete, signed and placed in chart.
22VAC40-73-660-A-1
Based on observation and staff interview, the facility failed to ensure that when medications and dietary supplements of residents are administered by the facility, that storage area shall be locked.
Evidence
  1. During a walk-through of the facility on the date of inspection, LI observed that the 3rd floor medication cart was left unlocked and unattended next to the unsupervised 3rd floor nurse’s station at 11:59 AM; therefore, LI waited at the cart to see if a medication staff member was working on that floor.
  2. After approximately one to two minutes, staff 2 returned to the 3rd floor medication cart and observed LI waiting. Staff 2 observed that the cart had been left unlocked.
  3. Staff 2 confirmed to LI that she had been working from this medication cart and had walked away, leaving it unlocked, while administering medication.
Plan of correction
HCD will educate all RMA/LPNs on the importance of safety and ensuring medications are locked. Additionally, The HCD or designee will conduct random audits once a month.
22VAC40-73-870-E
Based on observation and interviews, the facility failed to ensure that all furnishings, fixtures, and equipment, including furniture, window coverings, sinks, toilets, bathtubs, and showers shall be kept clean and in good repair and condition, except that furnishings and equipment owned by a resident shall be, at minimum, in safe condition and not soiled in a manner that presents a health hazard.
Evidence
  1. During the on-site complaint follow-up on the date of inspection, LI performed a walk-through of each floor of the facility.
  2. At 11:07 AM, LI entered unit 113 and then entered its bathroom. At that time, LI observed that the toilet presented in an unsanitary soiled condition with multiple brown stains on the toilet seat and a brown ring around the inside of the toilet bowl.
  3. At 11:12 AM, LI entered unit 203 and observed that its carpet had numerous stains, and there were broken potato chips at the foot of the bed and between the bed and the wall. The kitchen floor in unit 203 also had a trail of an unknown debris from the door to the carpet.
  4. At 11:26 AM, LI entered unit 314 and observed numerous recyclable materials and empty containers which appeared cluttered throughout the unit, some of which were restricting access to its kitchen and part of its living room area.
  5. At 11:32 AM, in the same unit (314), this LI observed seven male urinal containers, each containing yellow liquid, on the bedroom floor. An interview with staff 3, who was cleaning the bathroom in the unit at the time, revealed that unit 314 appears in this condition often which makes it difficult for housekeeping staff to clean the unit.
  6. At 12:05 PM, LI entered unit 103 and observed that its carpet had numerous areas of stains of unknown origin. A housekeeping staff member was in unit 103 at that time and was starting to shampoo the stains on the carpet. The housekeeping staff member indicated that the stained areas come back soon after the carpet is shampooed even though housekeeping staff clean them frequently
Plan of correction
Director of Maintenance (housekeeping) will complete rounds to ensure appropriate cleanliness is maintained throughout the community. The ED and Maintenance Director will round daily to ensure compliance and cleanliness.
July 17, 2025Complaint survey0 violations
Inspection dates
07/17/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint # 62966 Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/17/2025 from 10:15 AM to 03:00 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 07/02/2025 regarding allegations in the area(s) of: Resident care and related services Buildings and Grounds Number of residents present at the facility at the beginning of the inspection: 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: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
July 17, 2025Complaint survey0 violations
Inspection dates
07/17/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint # 62865 Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/17/2025 from 10:15 AM to 03:00 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 06/04/2025 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: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the (allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
July 17, 2025Complaint survey0 violations
Inspection dates
07/17/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint # 62679 Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/17/2025 from 10:15 AM to 03:00 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 06/04/2025 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: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the (allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
July 17, 2025Complaint survey0 violations
Inspection dates
07/17/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint # 62520 Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/17/2025 from 10:15 AM to 03:00 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 05/20/2025 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: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the (allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
July 17, 2025Complaint survey0 violations
Inspection dates
07/17/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Complaint # 62450 Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/17/2025 from 10:15 AM to 05:00 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 05/12/2025 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: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
April 10, 2025Inspection0 violations
Inspection dates
04/10/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 04/10/2025 from 09:00 AM to 02:00 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: 16 Number of staff records reviewed: 11 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Holly Copeland, Licensing Inspector at (540) 309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
April 10, 2025Inspection0 violations
Inspection dates
04/10/2025
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 04/10/2025 from 09:00 AM to 02:00 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: 9 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 4 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
January 23, 2025Inspection1 violation
Inspection dates
01/23/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 01/23/2025 from 02:00 PM to 03:15 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 12/31/2024 regarding allegations in the area(s) of: Resident care and related services. Number of residents present at the facility at the beginning of the inspection: 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: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A 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 Holly Copeland, Licensing Inspector at (540)-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
22VAC40-73-680-D
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: 01/23/2025 from 02:00 PM to 03:15 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 12/31/2024 regarding allegations in the area(s) of: Resident care and related services. Number of residents present at the facility at the beginning of the inspection: 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: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The
Evidence
  1. 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 Holly Copeland, Licensing Inspector at (540)-309-5982 or by email at holly.copeland@dss.virginia.gov
Plan of correction
Medications will be administered according to the MAR. An ongoing audit of 10% of the MAR will be conducted monthly by the HCD.
January 23, 2025Inspection2 violations
Inspection dates
01/23/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 01/23/2025 from 02:00 PM to 03:15 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 12/08/2024 regarding allegations in the area(s) of: Resident care and related services. Number of residents present at the facility at the beginning of the inspection: 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: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: N/A Additional Comments/Discussion: Both residents were no longer at the facility. 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 Holly Copeland, Licensing Inspector at (540)-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
22VAC40-73-680-I
Based on record review and staff documentation, the facility failed to ensure that the medication administration record (MAR) included any medication errors or omissions.
Evidence
  1. On 12/08/2024, LI received a self-reported incident from staff 1 which indicated that resident 1 did not receive her scheduled 0600 dose of SYNTHROID 25 MCG on 12/8; however, that medication was given to resident 2 in error.
  2. The record for resident 1 contained physician’s orders, signed 12/08/2024, for LEVOTHYROXINE (SYNTHROID) 25 MCG TABLET – TAKE 1 TABLET BY MOUTH EVERY DAY FOR HYPOTHYROIDISM.
  3. Staff 2’s progress notes for resident 1, dated 12/08/2024 at 12:32 PM, confirmed that resident 1 did not receive her scheduled dose of SYNTHROID 25 MCG at 0600 (on that date) as it was given to resident 2 in error. The same progress notes at that time also indicate that per resident 1’s prescribing physician, since the omitted (SYNTHROID) medication needed to be administered on an empty stomach, it was acceptable that she should not receive a late dose of that medication on 12/08.
  4. The December 2024 MAR for resident 1 indicated that on 12/08/2024 at 0600, staff 3 had administered LEVOTHYROXINE 25 MCG TABLET (SYNTHROID) to resident 1; however, the same December 2024 MAR did not contain any updates to clarify that resident 1’s LEVOTHYROXINE 25 MCG TABLET (SYNTHROID) had actually been omitted.
Plan of correction
Medication errors will be documented on the MAR as appropriate. An audit of 10% of the MAR will be conducted monthly by the HCD.
22VAC40-73-680-D
Based on record review and staff documentation, the facility failed to ensure that medications are administered according to physician’s or other prescriber’s instructions.
Evidence
  1. On 12/08/2024, LI received a self-reported incident from staff 1 which indicated that resident 1 did not receive her scheduled 0600 dose of SYNTHROID 25 MCG on 12/08; however, that medication was given to resident 2 in error.
  2. On 01/23/2025, during the LI’s on-site follow up to the self-report, an interview with staff 2 confirmed the events in the self-report. During the same on-site follow up, the record for resident 1 contained a physician’s orders list, signed 12/08/2024, which contained the orders for 0600 AM administration of LEVOTHYROXINE (SYNTHROID) 25 MCG TABLET – TAKE 1 TABLET BY MOUTH EVERY DAY FOR HYPOTHYROIDISM. Alternately, the record for resident 2 contained a physician’s orders list, signed 12/08/2024, that confirmed that resident 2 did not have orders for LEVOTHYROXINE (SYNTHROID).
  3. Progress notes by staff 2 for resident 1, dated 12/08/2024 at 12:32 PM, confirmed that resident 1 did not receive her scheduled dose of SYNTHROID 25 MCG at 0600 (on that date) as it was given to resident 2 in error. In addition, progress notes by staff 2 for resident 2, dated 12/08/2024 at 11:54 AM, indicated that resident 2 had received, in error, the SYNTHROID 25 MCG at 0600 that belonged to resident 1 on 12/08.
Plan of correction
Medications will be administered according to the MAR. An ongoing audit of 10% of the MAR will be conducted monthly by the HCD.
January 23, 2025Inspection0 violations
Inspection dates
01/23/2025
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 01/23/2025 from 02:00 PM to 03:15 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 10/18/2024 regarding allegations in the area(s) of: Personnel; 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: N/A Number of staff records reviewed: 1 Number of interviews conducted with residents: N/A Number of interviews conducted with staff: 1 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A 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 Holly Copeland, Licensing Inspector at (540)-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
December 3, 2024Inspection16 violations
Inspection dates
12/03/2024
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 PREPAREDNESS22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/03/2024 from 08:25 AM to 05:00 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
22VAC40-73-325-B
Based on record review and staff interview, the facility failed to ensure that the fall risk rating shall be reviewed and updated after a fall.
Evidence
  1. The record for resident 3 contains a most recent fall risk rating form, dated 01/01/2024. Alternately, staff progress notes discuss that resident 3 had fallen on the following dates during the current licensure period: 07/03/2024, 08/11/2024, 08/15/2024, 10/15/2024, 10/17/2024, and 11/20/2024.
  2. An interview with staff 4 and staff 6 could not locate any subsequent fall risk ratings after the fall risk rating dated 01/01/2024, found in the record for resident 3 on the date of inspection.
Plan of correction
What Has Been Done to Correct? This cannot be corrected as it occurred in the past. How Will Recurrence Be Prevented? Each fall with injury will be accompanied with a fall risk rating, in the future. An audit of the charts will be conducted each month, for the next three months. The audit will focus on falls with injuries and fall risk assessments. Person Responsible: HCD or designee Due Date: 1/1/25
22VAC40-73-680-I
Based on record review and staff interview, the facility failed to ensure that the medication administration record (MAR) shall include the date and time given and the initials of direct care staff administering the medication.
Evidence
  1. On the date of inspection, collateral 1 observed staff 2 during a medication pass at 09:22 AM. At that time, resident 10 received the following PRN medications: CLONAZEPAM 0.5 MG TAB TAKE ONE-HALF TABLET 0.25 MG BY MOUTH 2 TIMES A DAY AS NEEDED FOR ANXIETY/PANIC. METHOCARBAMOL 500 MG TAB TAKE 1 TABLET BY MOUTH FOUR TIMES A DAY AS NEEDED FOR MUSCLE SPASMS. After those two medications were administered, resident 10 had to leave for an appointment, and the resident did not receive the remaining 09:00 AM medications at that time: ATORVASTATIN 40 MG TAB TAKE ONE TABLET BY MOUTH EVERY DAY FOR HYPERLIPIDEMIA. CYCLOSPORINE 0.05% EYE EMULSION INSTILL 1 DROP INTO BOTH EYES 2 TIMES A DAY FOR DRY EYES. DICLOFENAC SODIUM 1% GEL APPLY 4 GRAMS TO AFFECTED AREA FOUR TIMES A DAY FOR PAIN. FUROSEMIDE 20 MG TAB TAKE ONE TABLET BY MOUTH EVERY DAY FOR EDEMA. IPRATROPIUM 0.03% SPRAY INSTILL 2 SPRAYS INTO EACH NOSTRIL 3 TIMES A DAY FOR ALLERGIES. LISINOPRIL 10 MG TAB TAKE ONE TABLET BY MOUTH EVERY DAY FOR HYPERTENSION. PANTOPRAZOLE SODIUM 40 MG TAB TAKE ONE TABLET BY MOUTH 2 TIMES A DAY FOR GERD. POLYETHYLENE GLYCOL 3350 POWDER MIX 17 GRAMS IN 8 OUNCES OF LIQUID AND DRINK BY MOUTH EVERY DAY. POTASSIUM CL ER 10 MEQ TAB TAKE ONE TABLET BY MOUTH EVERY DAY FOR SUPPLEMENT. SODIUM CHLORIDE 1 GM TAB TAKE ONE TABLET BY MOUTH EVERY DAY FOR SUPPLEMENT. SYMPROIC 0.2 MG TAB TAKE ONE TABLET BY MOUTH EVERY DAY FOR SPINAL STENOSIS.
  2. During a later review of the December 2024 MAR for resident 10 on the date of inspection, it indicated that resident 10 was on a leave of absence (LOA) for the 09:00 AM medications that were not received.
  3. Alternately, in an interview with staff 2 it was revealed to LI, collateral 1, and staff 4 that staff 2 did administer those remaining medications to resident 10 once she returned from her doctor appointment around 10:00 AM; however, staff 2 failed to update the MAR for resident 10 to reflect that the medications had been administered.
Plan of correction
What Has Been Done to Correct? This cannot be corrected as it occurred in the past How Will Recurrence Be Prevented? RMAs will received additional training on medication administration “refresher course”. Additionally, Harmony will be implementing additional oversight forms to assist with medication administration and RMA competency as an organization early in 2025. Person Responsible: HCD or designee Due Date: 2/1/25
22VAC40-90-30-B
Based on record review and staff interview, the facility failed to ensure that the sworn disclosure statement or affirmation shall be completed for all applicants for employment.
Evidence
  1. The record for staff 10 contained a hire date of 10/08/2024; however, the record did not contain a sworn disclosure statement or affirmation.
  2. An interview with staff 7 confirmed that a sworn disclosure statement or affirmation was not completed by staff 10.
Plan of correction
What Has Been Done to Correct? This cannot be corrected as it occurred in the past. How Will Recurrence Be Prevented? New hire files now have a new filing checklist system to ensure each section is finished before the record is considered complete. Person Responsible: Director of HR or designee Due Date: 12/15/24
22VAC40-73-380-A
Based on record review and staff interview, the facility failed to ensure that certain personal and social information shall be obtained on a person prior to or at the time of admission to an assisted living facility.
Evidence
  1. The record for resident 1, admitted 11/24/2024, contained a RESIDENT PERSONAL/SOCIAL DATA sheet that was incomplete in the following areas: Current behavioral and social functioning; Strengths; and Problems.
  2. The record for resident 3, admitted 03/01/2023, contained a RESIDENT PERSONAL/SOCIAL DATA sheet that was incomplete in the following areas: Current behavioral and social functioning; Strengths; and Problems.
  3. Upon reviewing other areas of the records for resident 1 and resident 3, LI could not locate that the missing information was identified elsewhere.
  4. An interview with staff 4, staff 5, and staff 7 did not result in locating documentation where these areas were addressed for resident 1 and resident 3.
Plan of correction
What Has Been Done to Correct? This cannot be corrected as it occurred in the past. How Will Recurrence Be Prevented? A checklist of information necessary for the initial chart will be developed and used for all new admissions. Person Responsible: ED or designee Due Date: 12/31/24
22VAC40-73-120-A
Based on record review and staff interview, the facility failed to ensure that a staff person shall receive the required new staff orientation and initial training within the first seven working days of employment.
Evidence
  1. The record for staff 3, date of hire 10/08/2024, contained the form RECORD OF INITIAL ALF STAFF TRAINING which indicated that the first day of work for staff 3 was on 10/08/2024; however, the form itself was not completed, and the record for staff 3 did not contain documentation to confirm that staff 3 received the orientation and initial training in all required components.
  2. An interview with staff 7 confirmed that there is no documentation to confirm that staff 3 has received the orientation and initial training as required.
Plan of correction
What Has Been Done to Correct? This cannot be corrected as it occurred in the past. How Will Recurrence Be Prevented? Orientation will occur prior to each staff member being placed in their department. Person Responsible: Director of HR or designee Due Date: 12/15/24
22VAC40-73-660-B
Based on observation during a tour of the building, resident record review and staff interview, the facility failed to ensure that a resident may be permitted to keep his own medication in an out-of-sight place in his room if the uniform assessment instrument (UAI) has indicated that the resident is capable of self-administering medication.
Evidence
  1. During the morning medication administration to resident 6 by staff 2, collateral 1 and staff 2 observed a bottle of REFRESH TEARS lubricant eye drops and a bottle of SYSTANE lubricant eye drops on the resident’s nightstand. Collateral 1 and staff 2 also observed a container of ASPERCREAM ARTHRITIS PAIN and a container of NEOSPORIN on a table located in resident 6’s living room in front of the kitchen counter.
  2. The UAI for resident 6, dated 01/09/2024, indicates that the resident requires the help of a registered medication aide (RMA), licensed practical nurse (LPN), or registered nurse (RN) for medication administration. The record for resident 6 does not contain any orders for the aforementioned medications that were observed in the resident’s room.
  3. Collateral 1’s interview with staff 4 confirmed that resident 6 is not capable of self-administering medications and confirmed there are no orders that the resident can self-administer the medications that were found in resident 6’s room.
  4. At approximately 09:58 AM, collateral 1 noted that resident 7’s room was unlocked and unoccupied. Upon entry, collateral 1 observed a container of TRIAMCINOLONE ACETONIDE CREAM 0.1% on the resident’s nightstand and a container of VOLTAREN ARTHRITIS PAIN RELIEVER in the windowsill beside the resident’s bed.
  5. The UAI in the record for resident 7, dated 11/30/2024, contains documentation that the resident requires the help of a registered medication aide (RMA), licensed practical nurse (LPN), or registered nurse (RN) for medication administration. The record for resident 7 does not contain any orders for the aforementioned medications that were observed in the resident’s room.
  6. An interview between collateral 1 and staff 4 revealed that resident 7 requires assistance with medication administration and that the resident is not capable of self-administering medications. The same interview with staff 4 confirmed that there are no orders that the resident can self-administer the medications that were found in the resident’s room.
  7. The record for resident 4 contains a signed physician’s order, dated 09/25/2024, for PREPARATION H CREAM - APPLY FOR AFFECTED AREA TWO TIMES A DAY FOR HEMORRHOIDS AT 8:00AM and 8:00PM.
  8. The November and December 2024 medication administration records (MARs) for resident 4 contain documentation by staff 8 that the resident self-administered this medication at 08:00 PM on 11/09/2024 and 12/01/2024.
  9. Alternately, the UAI for resident 4, dated 10/31/2024, indicates that the resident requires medications to be administered by an RN, LPN, and/or RMA and the physician’s order does not indicate that the resident can self-administer this medication.
  10. Interview with staff person 4 confirmed that resident 4 is unable to self-administer this medication.
Plan of correction
What Has Been Done to Correct? Resident #6 had the medication removed from the room on 12/3/24 How Will Recurrence Be Prevented? A letter went out from the ED, 12/16/24, reminding all residents to keep their medications behind a locked door. Evening shift will complete rounds looking for violations of 660-B each evening, for those residents who are designated capable of self-administering medication. Person Responsible: HCD or designee Due Date: 1/1/25
22VAC40-73-250-D
Based on record review and staff interview, the facility failed to ensure that 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 by Virginia Department of Health or a form consistent with it. EVIDENCE:
  2. The record for staff 3, date of hire 10/08/2024, did not contain the results of a TB risk assessment.
  3. An interview with staff 7 confirmed that a TB risk assessment does not exist for staff 3.
Plan of correction
What Has Been Done to Correct? This cannot be corrected as it is in the past. How Will Recurrence Be Prevented? Each new staff member’s file will have evidence of this document moving forward. A new checklist has been established to ensure necessary documents are not missed. Person Responsible: Director of HR or designee Due Date: 12/15/24
22VAC40-73-690-G
Based on resident record review and staff interview, the facility failed to ensure that the action taken in response to the recommendations noted in the facility’s medication review shall be documented in the residents’ records.
Evidence
  1. The record for resident 4 contains a recommendation by collateral 2 on the form NOTE TO ATTENDING PHYSICIAN/PRESCRIBER, dated 02/14/2024, that the resident is on insulin therapy, but the current POS (physician’s order list) does not list an order for GLUCOSE gel or a GLUCAGON Hypokit for use during a potential hypoglycemic episode and to please consider if these medications should be added to resident’s orders for emergency use. The same form contains a section for the resident’s physician/prescriber’s response to either agree, disagree (please provide clinical rationale for disagreement), or other and a section for the physician or prescriber to date and sign the document, all of which are blank. The form also contains a written notation that this recommendation was faxed to the physician on 08/27/2024, even though the recommendation was dated 02/14/2024.
  2. A phone interview with staff 4 on 12/05/2024 revealed that the NOTE TO ATTENDING PHYSICIAN/PRESCRIBER form was from the facility’s 02/14/2024 medication review, and when collateral 2 came to the facility to conduct the August 2024 medication review, the facility had no documented follow-up to collateral 2’s 02/14/2024 GLUCOSE gel or GLUCAGON Hypokit recommendation for resident 4. Staff 4 further revealed to collateral 1 during the interview that she was instructed by collateral 2 to send that 02/14/2024 recommendation for resident 4 to the resident’s physician during the August 2024 medication review, and that’s why the form contains a written notation that it was faxed on 08/27/2024.
  3. The record for resident 6 contains a MEDICATION REGIMEN REVIEW document, dated 08/15/2024, with a recommendation made by collateral 2 for the resident’s physician to evaluate resident 6’s APAP and ASA dose; however, the record for resident 6 does not contain documentation that this recommendation was sent to the resident’s physician (or prescriber), nor what action was taken in response to the recommendation.
  4. An interview with staff 4 revealed that she could not locate any documentation that collateral 2’s recommendation for resident 6 was sent to the resident’s physician or prescriber for consideration.
Plan of correction
What Has Been Done to Correct? An order was obtained for glucose gel for emergency use. How Will Recurrence Be Prevented? Each resident on service for diabetic management will be reviewed for corresponding emergency use of glucose gel or glucagon for emergency use. An audit of the charts will be conducted each month, for the next three months. The audit will focus on residents with diabetes. Person Responsible: HCD or designee Due Date: 1/1/25
22VAC40-73-680-M
Based on resident record review and staff interview, the facility failed to ensure medications ordered for PRN (as needed) administration shall be available, properly labeled for the specific resident, and properly stored at the facility.
Evidence
  1. The record for resident 4 contains a signed physician’s order, dated 11/22/2024, for ALBUTEROL SULFATE HFA INHALATION AEROSOL SOLUTION INHALE TWO PUFFS ORALLY EVERY SIX HOURS AS NEEDED FOR SOB.
  2. During the on-site inspection on 12/03/2024, an interview with staff 4 revealed to collateral 1 that this medication was not available at the facility for resident 4.
Plan of correction
What Has Been Done to Correct? The medication was obtained for resident #4. How Will Recurrence Be Prevented? Cart audits will take place every night, on night shift with a signature sheet to be turned in to the HCD. Additionally, Once a week for the next three months an additional audit of the carts will be conducted to ensure compliance/oversight. Person Responsible: HCD or designee Due Date: 1/1/25
22VAC40-73-550-G
Based on record review and staff interview, the facility failed to ensure that the rights and responsibilities of residents in assisted living facilities shall be reviewed annually, once every 12 months, with each resident or responsible party and each staff person, and
Evidence
  1. of this review shall be a written acknowledgment by the resident or representative and each staff person and be filed in the respective record. EVIDENCE:
  2. The record for staff 1, date of hire 11/15/2021, did not contain documentation to confirm that a resident rights review was completed for 2024.
  3. The record for staff 2, date of hire 09/16/2023, did not contain documentation to confirm that a resident rights review was completed for 2024.
  4. An interview with staff 5 and staff 7 confirmed that there is no documentation to support that staff 1 and staff 2 have received annual resident rights training during their annual timeframe in 2024.
  5. The record for resident 4, admitted to the facility on 02/22/2023, contains documentation that the most recent resident rights review for the resident was completed on the date of inspection, which is not within the annual timeframe based on the date of admission.
  6. Interview with staff 5 during the on-site inspection revealed that she was unable to locate any additional resident rights review for resident 4 that was completed within the annual timeframe based on admission.
Plan of correction
What Has Been Done to Correct? This cannot be corrected, as it occurred in the past. How Will Recurrence Be Prevented? -Residents: A 100% chart audit will be conducted by 12/31/24. Anyone missing a current Resident Rights Review will be so informed. Moving forward, November is designated as Resident Rights Review month. In that month all residents will have their rights reviewed with them. -Staff: Resident Rights was the topic at the All Staff meeting in December. Resident Rights will be a topic of discussion at All Staff at least quarterly moving forward. Person Responsible: HR/ED or designee Due Date: 12/15/24
22VAC40-73-490-A-2
Based on record review and staff interview, for a facility with residents who meet the assisted living level of care, the facility failed to ensure that, if the facility employs a licensed health care professional (LHCP) who is on-site on a full-time basis, a LHCP practicing within the scope of his profession, shall provide health care oversight at least every six months, or more often if needed.
Evidence
  1. During the on-site renewal inspection on 12/03/2024, LI noted that the most recent health care oversight provided for record review was dated 04/18/2024.
  2. Staff 4 is a licensed health care professional who is employed on-site on a full-time basis; therefore, the facility shall receive health care oversight at least every six months, or more often if needed.
  3. During an interview on the date of inspection, staff 4 acknowledged that the most recent health care oversight should have been completed in October 2024; however, staff 4 revealed that each building receives a completed health care oversight review by a LHCP from a different building on campus, but the LHCP never completed the health care oversight for this facility.
  4. An interview with staff 4, 5, and 6 revealed that the 04/18/2024 health care oversight is the most current that is completed for this facility.
Plan of correction
What Has Been Done to Correct? The Healthcare Oversight is scheduled to be completed on 1/1/25. How Will Recurrence Be Prevented? The 2025 schedule for Healthcare Oversight has been placed on the calendar and pre-arranged. Person Responsible: HCD or designee. Due Date: January and quarterly thereafter.
22VAC40-73-720-A
Based on record review and staff interview, the facility failed to ensure that Do Not Resuscitate (DNR) Orders for withholding cardiopulmonary resuscitation (CPR) from a resident in the event of a cardiac or respiratory arrest are included in the individualized service plan (ISP).
Evidence
  1. The record for resident 1 contained a DNR that is signed by the resident and physician, dated 11/23/2024; however, the ISP for resident 1, dated 11/23/2024, states that the resident’s full code will be honored, and CPR initiated.
  2. The record for resident 5 contained a DNR that is signed by the resident and physician, dated 04/26/2024; however, the ISP for resident 5, dated 12/03/2024, states only that the resident’s code status will be honored, but the ISP does not indicate that the resident has a DNR.
  3. An interview with staff 4, staff 5, and staff 6 confirmed that the DNR in the record for resident 1 and resident 5 are active, and there are no alternate ISPs which correctly identify the DNR status of those two residents.
Plan of correction
What Has Been Done to Correct? Resident #1: The ISP has been updated Resident #5: The ISP has been updated How Will Recurrence Be Prevented? An audit of the ISPs will be conducted each month, for the next three months. The audit will focus on matching DNR and ISP documentation. Person Responsible: HCD or designee Due Date: 1/1/25
22VAC40-73-640-A
Based on record review and staff interviews, the facility failed to implement portions of its medication management plan (MMP) regarding methods to prevent the use of outdated, damaged, or contaminated medications; 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; methods to ensure accurate counts of all controlled substances whenever assigned medication staff changes; and methods for monitoring medication administration and the effective use of the MARs for documentation.
Evidence
  1. The facility’s current MMP (implemented and revised 02/2018) provided by the facility on the date of inspection, indicates that nurses and RMA’s are responsible for ensuring that all medications, including over-the-counter, supplements and samples are in the original packaging, undamaged and used within the appropriate date of use, or expiration, and that the Healthcare Coordinator or designee will periodically audit the medications to ensure that all medications meet the standards stated herein. The MMP also includes a section, EMAR Medication Assistance Plan, and states on page 8 of this document the following: 7) Opened multiple-dose vials, containers and topical irrigation solutions are to be handled as follows: a. General Rule – all must be initialed and dated when opened, all Multi-Dose Vials (MDV) shall be considered out-of-date (expired) and should be removed from use and placed in a designated area for disposal after 30 days from the date opened or as specified in the community’s polices or manufacturers recommendations; b. Exception: Due to the package size and cost containment, some medications are exempt from the general rule. i.e. (immunizations, vitamin B12, and insulin). These drugs are to be disposed of within the time period specified by the manufacturer; c. Refer to Drug Reference(s) or contact vendor pharmacy when unclear of drug disposal dates. 2. Collateral 1’s interview with staff 4 revealed that medications such as insulin and eye drops are to be dated once they are opened because some of these medications, per manufacturer instructions, expire within a certain period once they are opened and used.
  2. During an audit of the third-floor medication cart, collateral 1 observed an open bottle of BRIMONIDINE 0.2% eye drops for resident 8 that did not contain the date the eye drops were opened on the bottle nor on the orange container that the eye drops were stored in.
  3. During an audit of the same medication cart, collateral 1 observed an open container of LUMIGAN 0.01% eye drops for resident 8 with documentation on the bottle, and on the orange container that the eye drops were stored in, that the eye drops were opened on 10/12 with an expiration date of 11/12. Both bottles of eye drops contained documentation to discard the eye drops after 28 days. Staff 2 also observed that the two bottles of eye drops for resident 8 were in the cart for use past the documented expiration date. 5. During an audit of the same medication cart, collateral 1 observed an open bottle of TIMOLOL MALEATE 0.5% eye drops for resident 9 that did not contain the date the eye drops were opened on the bottle nor on the orange container that the eye drops were stored in. The bottle of eye drops for resident 9 was also observed by staff 2 as having no documented open date. (Due to the limited space allowed by the DSS computer licensing system, the remainder of the violation is on a separate document and available upon request.)
Plan of correction
What Has Been Done to Correct? The medications were removed from the cart and discarded on 12/3/24. How Will Recurrence Be Prevented? Cart audits will take place every night, on night shift with a signature sheet to be turned in to the HCD. Additionally, Once a week for the next three months an additional audit of the carts will be conducted to ensure compliance/oversight. Person Responsible: HCD or designee Due Date: 1/1/25
22VAC40-73-450-F
Based on resident record review and a review of the dietary postings, the facility failed to ensure individualized service plans (ISPs) shall be reviewed and updated as needed for a significant change of a resident’s condition.
Evidence
  1. The record for resident 5 contains a signed physician’s order sheet with a statement on the bottom left corner “Report Run: 10/18/2024 4:02:13PM” for October 2024 and an additional signed physician’s order sheet, dated 11/04/2024, that indicates that the resident is on a mechanical soft diet.
  2. The facility’s kitchen did have a posting that resident 5 is to receive a mechanical soft diet; however, the ISP for resident 5, with updates on 08/20/2024, 10/31/2024, and 11/30/2024, indicates that the resident is on a regular diet (identified on 08/20/2024) and that the resident will maintain compliance with diet as ordered. The ISP does not contain updated documentation that the resident is to receive a mechanical soft diet.
  3. The record for resident 6 contains a signed PHYSICIAN’S DIET ORDER REQUEST sheet, dated 12/06/2023, for the resident to receive a regular house diet with mechanical soft consistency and then a signed physician’s diet order request sheet, dated 05/06/2024, for the resident to receive a mechanical soft (dysphagia level 3) diet.
  4. The record for resident 6 also contains documentation of nutritional reviews, dated 02/16/2024, 05/07/2024, 08/09/2024 and 11/08/2024, that the resident is to be receiving a mechanical soft diet and to continue with this diet order.
  5. The facility’s kitchen has posted that the resident is to receive a mechanical soft diet; however, the ISP for resident 6, with updates on 01/09/2024 and 12/30/2024, identifies on 01/09/2024 that the resident is on a regular diet and that the resident will maintain compliance with diet as ordered. The ISP does not contain updated documentation that the resident is to receive a mechanical soft diet.
Plan of correction
What Has Been Done to Correct? The diet for resident # 5 matches on order and ISP The diet for resident # 6 matches on order and ISP How Will Recurrence Be Prevented? Each resident will have a diet that will match their order (if applicable) and their ISP. An audit of the charts will be conducted each month, for the next three months. The audit will focus on diet order and matching ISP reference. Person Responsible: HCD or designee Due Date: 1/1/25
22VAC40-73-450-E
Based on resident record review and staff interview, the facility failed to ensure the individualized service plan (ISP) shall be signed and dated by the resident or his legal representative.
Evidence
  1. On the date of inspection, the ISP for resident 5, with updates on 08/20/2024 and 10/31/2024, had not been signed and dated by the resident or the legal representative.
  2. Interview with staff person 4 confirmed this is accurate.
  3. On the date of inspection, the ISP for resident 6, with updates on 01/09/2024 and 12/03/2024, had not been signed and dated by the resident or the legal rep.
  4. Interview with staff person 4 confirmed that there are no alternate current ISPs for resident 5 and resident 6 that were signed by the resident or legal rep.
Plan of correction
What Has Been Done to Correct? Resident #5 has signed the ISP. How Will Recurrence Be Prevented? Each resident or their representative will be invited to sign the ISP. An audit of the charts will be conducted each month, for the next three months. The audit will focus on signature on ISPs. Person Responsible: HCD or designee Due Date: 1/1/25
22VAC40-73-210-B
Based on record review and staff interview, in a facility licensed for both residential and assisted living care, all direct care staff shall attend at least 18 hours of training annually, with an exception that direct care staff who are licensed healthcare professionals or certified nurse aides shall attend at least 12 hours of annual training.
Evidence
  1. The record for staff 1, date of hire 11/15/2021, indicated that staff 1 is not a licensed healthcare professional nor a certified nurse aide; therefore, staff 1 requires 18 hours of annual training. The record for staff 1 contained documentation of 16.25 hours of annual training during the most recent training year, based on date of hire.
  2. The record for staff 2, date of hire 09/16/2023, indicated that staff 2 is not a licensed healthcare professional nor a certified nurse aide; therefore, staff 2 requires 18 hours of annual training. The record for staff 2 contained documentation of 16.75 hours of annual training during the most recent training year, based on date of hire.
  3. An interview with staff 7 could not produce documentation of the additional training hours required for staff 1 and staff 2 during the most recent training year.
Plan of correction
What Has Been Done to Correct? The staff member #2 no longer works at this community. How Will Recurrence Be Prevented? Training hours are tracked through our HR department and are aggressively being monitored for compliance. Person Responsible: HR Director or designee. Due Date: 12.15.24
October 3, 2024Complaint survey2 violations
Inspection dates
10/03/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint 60506 Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/03/2024 from 10:15 AM to 03:30 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 09/14/2024 regarding allegations in the area(s) of: Resident care and related services. Number of residents present at the facility at the beginning of the inspection: 93 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. However, violation(s) not related to the complaint(s) but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
22VAC40-73-450-C
Based on record review and staff interview, the facility failed to ensure that the comprehensive individualized service plan (ISP) shall include all required components, specifically regarding the description of identified needs and date identified, a written description of what services will be provided to address identified needs, who will provide them, when the services will be provided, and expected outcome and time frame for expected outcome.
Evidence
  1. The record for resident 1 contained physician’s orders, signed 09/16/2024, for the resident to receive wound care treatment twice weekly. The wound care Start of Care progress notes, dated 09/13/2024, indicate a target date of 11/11/2024 for meeting therapy goals.
  2. The ISP for resident 1, dated 09/20/2024, does not indicate that this resident will be receiving wound care treatment by a specific provider twice weekly with an anticipated completion date of 11/11/2024.
  3. Interview with staff 1 and staff 2 could not produce an ISP that had been updated with this need and services.
Plan of correction
The ISP for the resident will be corrected by 11/30/24. ISPs will be reviewed for all residents in-house by 12/31/24.
22VAC40-73-720-A
Based on record review and staff interview, the facility failed to ensure that a Do Not Resuscitate (DNR) Order is signed by the resident’s attending physician.
Evidence
  1. The record for resident 1 contains a Durable DNR Order form, dated 07/13/2024, that is signed by the resident; however, there is no signature by the resident’s attending physician.
  2. Interview with staff 1 and staff 2 could not produce a DNR form for resident 1 that was signed by a physician.
Plan of correction
The DNR will be signed the attending physician by 11/30/24. A DNR audit will be performed on all resident charts by 12/31/24.
October 3, 2024Complaint survey1 violation
Inspection dates
10/03/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint # 60502 Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/03/2024 from 10:15 AM to 03:30 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 08/27/2024 regarding allegations in the area(s) of: Resident care and related services. Number of residents present at the facility at the beginning of the inspection: 93 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation(s) of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint(s) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
22VAC40-73-680-D
Based on record review and staff interview, the facility failed to ensure that medications shall be administered in accordance with the physician’s or other prescriber’s instructions.
Evidence
  1. The REPORT OF RESIDENT PHYSICAL EXAMINATION form for resident 1, signed 08/20/2024, contains authorization for administration of the following medication: ENOXAPARIN SODIUM INJECTION SOLUTION PREFILLED SYRINGE 40 MG/0.4 ML “Inject 0.4 ml subcutaneously one time a day for DVT PROPHYLAXIS”.
  2. The August 2024 medication administration record (MAR) for resident 1 indicates from 08/22 – 08/25, the ENOXAPARIN SODIUM INJECTION SOLUTION PREFILLED SYRINGE 40 MG/0.4 ML was not administered at 08:00 AM, despite being indicated to administer at 08:00 AM on those dates. The MAR exception notes for those dates indicates that a nurse is to administer that medication.
  3. An interview with staff 1 and email correspondence with staff 2 and 3 revealed that a nurse did not administer the ENOXAPARIN SODIUM INJECTION SOLUTION PREFILLED SYRINGE 40 MG/0.4 ML on those dates, adding that this medication did not come to the facility with the resident during that time and it was ultimately discontinued on 08/26.
Plan of correction
Medications will be administered according to the MAR as of 11/4/24. An ongoing audit of 10% of the MAR will be conducted monthly by the HCD with an expected outcome of 95% compliance rate beginning 11/15/24.
October 3, 2024Complaint survey4 violations
Inspection dates
10/03/2024
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint # 60328 Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/03/2024 from 10:15 AM until 03:30 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 07/26/2024 regarding allegations in the area(s) of: Personnel, resident care and related services, buildings and grounds. Number of residents present at the facility at the beginning of the inspection: 93 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 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: N/A Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. However, violation(s) not related to the complaint(s) but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
22VAC40-73-450-C
Based on record review and staff interview, the facility failed to ensure that the comprehensive individualized service plan (ISP) shall include all required components, specifically regarding services provided, a written description of what services will be provided to address identified needs, who will provide them, when the services will be provided, and expected outcome and time frame for expected outcome.
Evidence
  1. The record for resident 1 contained signed physician’s orders, dated 07/01/2024, regarding wound care treatment services “Pt to be seen 1-2x weekly for placement of Cellular and Tissue-Based Products (CTP’s), and follow up Care”. This resident’s record also contains signed orders, dated 08/02/2024, that the particular wound care treatment provider will “see patient 1-2 x weekly for assessment of I heel wound and Apply collagen and cover with bordered foam... Cleanse wound, dry, pack w collagen and cover with Bordered Foam 1-2x weekly and prn”.
  2. The ISP for resident 1, dated 10/03/2024, indicates that the resident has an overall skin condition, wound, or skin issue, and that a nurse or outside service provider will provide services in the resident’s apartment; however, this ISP does not specify the current service provider, nor when the service will be provided, nor the expected outcome and time frame for expected outcome.
  3. The same ISP for this resident also contains a section for CODE STATUS, identified on 07/05/2024, which does not contain information as to whether the resident is a full code or has a Do Not Resuscitate (DNR) order.
  4. Interview with staff 1 and staff 2 could not produce an ISP that had been updated with the need for wound services, nor an updated ISP with a completed CODE STATUS.
Plan of correction
Not published by VDSS.
22VAC40-73-480-E
Based on record review and staff interview, the facility failed to ensure that services provided, evaluations of progress, and other pertinent information regarding rehabilitative services shall be recorded in the resident’s record.
Evidence
  1. The record for resident 1 contained signed physician’s orders, dated 07/01/2024, regarding wound care treatment services “Pt to be seen 1-2x weekly for placement of Cellular and Tissue-Based Products (CTP’s), and follow up Care”. This resident’s record also contains signed orders, dated 08/02/2024, that the wound care treatment provider will “see patient 1-2 x weekly for assessment of I heel wound and Apply collagen and cover with bordered foam... Cleanse wound, dry, pack w collagen and cover with Bordered Foam 1-2x weekly and prn”.
  2. The record for resident 1 contained wound care progress notes for the following dates: 07/02, 07/11, 07/18, 07/25, 08/01, 08/08, 08/15, 08/22, 08/26, 08/29, 09/03, 09/12, and 10/02. The progress notes dated 09/12 state that the provider will follow up in 1 week; however, there are no other progress notes from that date until 10/02.
  3. Interview with staff 1 and staff 2 revealed that the resident is still receiving wound care treatment, as of the date of inspection on 10/03; however, the progress notes for provider visits between 09/12 and 10/02 have not been filed in the record.
Plan of correction
The wound care notes for this resident will be obtained. An audit for partner notes will be conducted monthly for residents with wounds. 10% of charts will be targeted starting 12/1/24 with an expected outcome of 95% compliance rate.
22VAC40-73-660-B
Based on observation during a tour of the building, record review, and staff interview, the facility failed to ensure that a resident may be permitted to keep his own medication in an out-of-sight place and in his room if the UAI (uniform assessment instrument) has indicated that the resident is capable of self-administering medication.
Evidence
  1. During a walk-through of the facility, while seeking random residents to interview, the LI noted that room 122, belonging to resident 2, was unlocked and unoccupied. Upon entry, LI observed that there were bottles of TUMS, VOLTAREN, and SYSTANE eye drops, as well as a blister pack of IMODIUM sitting out on a table in that room.
  2. The UAI for resident 2, dated 07/26/2024, indicates that the resident requires the help of a registered nurse, licensed practical nurse, or registered medication aide for medication administration.
  3. The report of physical examination for resident 2, dated 04/15/2024, indicates that the resident is not capable of self-administering medication. In addition, the same report of physical examination did not contain signed orders for the four medications that were found in the room.
  4. An interview with staff 1 and staff 2 confirmed that resident 2 is not capable of self-administering medications, nor are there any orders in resident 2’s record for the four medications that were found in the resident’s room.
Plan of correction
Over the counter medications were removed from the residents room on the date of the survey. The medications were given to the power of attorney and explained to the resident. Further, on 11/10/24 a letter explaining the importance of this rule was sent out to the whole of Harmony Collection.
22VAC40-73-860-I
Based on observation, the facility failed to ensure that cleaning supplies and other hazardous materials were stored in a locked area.
Evidence
  1. While performing a walk-through of the facility on the date of inspection, on 10/03/2024, a bottle of SYSCO bleach was found sitting on the floor in the unlocked mechanical room that is located off of the unlocked 1st floor laundry room.
Plan of correction
Not published by VDSS.
October 3, 2024Inspection2 violations
Inspection dates
10/03/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/03/2024 from 10:15 AM to 03:30 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 08/22/2024 regarding allegations in the area(s) of: Resident care and related services. Number of residents present at the facility at the beginning of the inspection: 93 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 4 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A 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 Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
22VAC40-73-680-D
Based on record review and staff correspondence, the facility failed to ensure that medications are administered according to physician’s or other prescriber’s orders.
Evidence
  1. The record for resident 1 contains physician’s orders, signed 08/01/2024, which order the morning administration of LEVOTHYROXINE 112 MCG TAB, (generic for SYNTHROID) “TAKE 1 TABLET BY MOUTH ONCE DAILY FOR HYPOTHYROIDISM”.
  2. On 08/22/2024, LI received a facility reported incident (FRI) from staff 6 which indicated that resident 1 had stated that she did not receive her dose of SYNTHROID on 08/21 and 08/22. The FRI adds that the e-MAR for those dates contains documentation as if that medication was administered on those dates; however, a visual inspection of the medication card revealed that the SYNTHROID tablets for 08/21 and 08/22 were still present in the card.
  3. This LI confirmed that despite the SYNTHROID pills being found in the pill card for 08/21 and 08/22, the August 2024 medication administration record (MAR) for resident 1 does indicate that SYNTHROID was administered on the morning of 08/21, by staff 1 and on the morning of 08/22, by staff 2.
  4. In addition, the record for resident 1 contains physician’s orders, signed 08/01/2024, which order the PRN (as-needed) administration of CLONIDINE HCL 0.1 MG TABLET, “TAKE 1 TABLET BY MOUTH EVERY 12 HOURS AS NEEDED FOR SBP > OR = 180”. Those orders also indicate for medication staff to “CHECK BLOOD PRESSURE TWICE A DAY PER CLONIDINE ORDER” to be performed around 09:00 AM and 09:00 PM.
  5. The August 2024 MAR for resident 1 indicates that at 09:00 AM on 08/22, this resident had a SBP (systolic blood pressure) reading of 180, as documented by staff 3; however, this MAR does not indicate that CLONIDINE HCL 0.1 MG was administered, per signed physician’s orders to administer with a SBP of greater than or equal to 180. The same MAR also indicates that at 09:00 PM on 08/23, this resident had a SBP reading of 227, as documented by staff 4; however, this MAR does not indicate that the CLONIDINE HCL 0.1 MG was administered, per signed physician’s orders.
  6. The record for resident 2 contains physician’s orders, signed 02/02/2024, which order the morning administration of LEVOTHYROXINE 25 MCG TAB, (generic for SYNTHROID) “TAKE 1 TABLET BY MOUTH EVERY MORNING at 6:30 AM FOR THYROID”.
  7. On 08/22/2024, LI received a facility reported incident (FRI) from staff 6 which indicated that resident 2 did not receive her dose of SYNTHROID at 0600 on 08/22. The FRI adds that the medication staff member, staff 2, documented on the MAR that SYNTHROID 25 MCG TAB was not administered on 08/22 because it was not found in the drawer; however, staff 5 indicated that the SYNTHROID pill card was found on the cart with resident 2’s other medications.
  8. In addition, the record for resident 2 contains physician’s orders, signed 02/02/2024, which order PANTOPRAZOLE SOD DR 40 MG TABLET, “TAKE 1 TABLET BY MOUTH EVERY MORNING BEFORE BREAKFAST FOR GERD”. The Aug 2024 MAR for resident 2 contains the same instructions as ordered for PANTOPRAZOLE; however, it was being administered at 12:00 PM instead of before breakfast, as per the signed orders. (Due to the limited space allowed by the DSS computer licensing system, the remainder of the violation is on a separate document and available upon request.)
Plan of correction
Medications will be administered according to the MAR as of 11/4/24. An ongoing audit of 10% of the MAR will be conducted monthly by the HCD with an expected outcome of 95% compliance rate beginning 11/15/24.
22VAC40-73-680-I
Based on record review and staff correspondence, the facility failed to ensure that the medication administration record (MAR) shall include documentation of any medication errors or omissions.
Evidence
  1. Facility incident reports, dated 08/22/2024, indicate that resident 1 and resident 4 did not receive their prescribed doses of SYNTHROID on 08/21 and/or 08/22, and that resident 3 incorrectly received SYNTHROID on 08/22.
  2. Upon review of the Aug 2024 MARs for resident 1, resident 3, and resident 4, documentation of those medication errors/omissions was not found.
Plan of correction
Medication errors will be documented on the MAR as of 11/4/24. An audit of 10% of the MAR will be conducted monthly by the HCD with an expected outcome of 95% compliance rate beginning 12/1/24.
October 3, 2024Inspection0 violations
Inspection dates
10/03/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/03/2024 from 10:15 AM until 03:30 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 09/09/2024 regarding allegations in the area(s) of: Resident care and related services Number of residents present at the facility at the beginning of the inspection: 93 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A 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 Holly Copeland, Licensing Inspector at (540) 309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
October 3, 2024Complaint survey0 violations
Inspection dates
10/03/2024
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint 60504 Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/03/2024 from 10:15 AM until 03:30 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 09/04/2024 regarding allegations in the area(s) of: Personnel Number of residents present at the facility at the beginning of the inspection: 93 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Holly Copeland, Licensing Inspector at (540) 309-5982 or by email at holly.copeland@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
October 3, 2024Complaint survey0 violations
Inspection dates
10/03/2024
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint 60503 Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/03/2024 from 10:15 AM until 03:30 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 09/03/2024 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: 93 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 20 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Holly Copeland, Licensing Inspector at (540) 309-5982 or by email at holly.copeland@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
July 23, 2024Complaint survey5 violations
Inspection dates
07/23/2024
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint 59983 Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/23/2024 from 10:00 AM until 12:00 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 07/18/2024 regarding allegations in the area(s) of: Resident care and related services. Number of residents present at the facility at the beginning of the inspection: 91 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation(s) of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint(s)but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
22VAC40-73-440-A
Based on record review and staff interview, the facility failed to ensure that the uniform assessment instrument (UAI) is completed prior to admission, at least annually, and whenever there is a significant change in the resident’s condition.
Evidence
  1. During the on-site complaint follow up on 07/23/2024, the record for resident 1 contained a UAI that was last completed on 10/05/2022.
  2. Upon being given an opportunity to locate, staff 1 and 2 revealed that a more current UAI for resident 1 did not exist.
Plan of correction
The UAI for resident 1 was updated. A 10% random chart audit will be conducted each month for the next three months to determine compliance. The ED will be responsible to ensure successful implementation of the plan of correction.
22VAC40-73-450-F
Based on record review and staff interview, the facility failed to ensure that individualized service plans (ISPs) shall be reviewed and updated at least once every 12 months and as needed for a significant change of a resident’s condition.
Evidence
  1. During the on-site complaint follow up on 07/23/2024, the record for resident 1 contained an ISP that was last completed on 10/03/2022.
  2. Upon being given an opportunity to locate, staff 1 and 2 revealed that a more current ISP for resident 1 did not exist.
Plan of correction
The ISP for resident 1 was updated. A 10% random chart audit will be conducted each month for the next three months to determine compliance. The ED will be responsible to ensure successful implementation of the plan of correction.
22VAC40-73-680-E
Based on record review and staff interview, the facility failed to ensure that medical procedures or treatments ordered by a physician or other prescriber shall be provided according to his instructions and documented.
Evidence
  1. During the on-site complaint follow up on 07/23/2024, the record for resident 1 contained signed orders, dated 05/02/2024, for resident 1 to “wear her brace at all times only removing for hygiene purposes. There is to be no therapy on her right wrist until further evaluation.”
  2. An interview with resident 1 and her responsible party on 07/23 revealed that family had obtained the brace for her wrist on 05/02 and brought it to the facility with the signed physician’s orders to be applied, as ordered, on the same day. The interview further revealed that staff 5 had taken the brace and placed it in the bottom drawer of the 3rd floor medication cart on that same day. The responsible party added that it wasn’t until 05/11 that resident 1 was seen wearing the brace, over a week after it was brought to the facility.
  3. The May 2024 MARs for resident 1 indicate that the brace was not added to the MAR until 05/09, and there is no documentation that the brace was placed on the resident until the 7 AM – 3 PM shift on 05/11. After that time, the May 2024 MAR exception notes for resident 1 state “Brace Not on Rsd” on 05/11 during the 3 PM – 11 PM shift, and the exception notes on the following dates say that the “patient refused medication” when the brace should have already been on her arm: 05/17, 05/20, 05/21, 05/22, 05/23, 05/25, 05/26, 05/29.
  4. An interview with staff 1 and staff 2 on the date of follow up indicated that there is no documentation which supports that the brace was removed for hygiene purposes and was re-applied or an attempt was made to reapply it on those exception dates.
Plan of correction
No correction can be made as this happened in the past. The staff have been educated as to the importance of updating the medical record. HCD is responsible to ensure successful implementation of the plan of correction.
22VAC40-73-300-B
Based on record review and staff interview, the facility failed to ensure that the method of communication to keep direct care staff informed on all shifts of significant happenings or problems experienced by residents, including complaints and incidents or injuries related to physical or mental conditions, shall be included in the records of the involved residents.
Evidence
  1. During the on-site complaint follow up on 07/23/2024, the record for resident 1 contained documentation from a local hospital’s Emergency Department (ED) that the resident was transported by local EMS from the ALF to the hospital on 04/18 with abdominal issues and to be retested for a UTI due to increased confusion; however, the facility’s staff progress notes do not contain documentation that the resident was transported to this local ED with complaints of abdominal issues and increased confusion.
  2. Upon being given an opportunity to locate, staff 1 and 2 revealed that this specific documentation for resident 1 did not exist.
Plan of correction
Staff have been instructed to communicate all incidents of significant happenings or problems by the end of each shift via progress notes per resident. A 10% random chart audit will be conducted each month for the next three months to determine compliance. HCD will be responsible to ensure successful implementation of the plan of correction.
22VAC40-73-325-B
Based on record review and staff interview, the facility failed to ensure that the fall risk rating shall be reviewed and updated at least annually; when the condition of a resident changes; and after a fall.
Evidence
  1. On 04/05/2024, LI received an incident report from staff 3 which reported that resident 1 had a fall with injury on the same date and was transported to the local hospital for medical evaluation, and results revealed a right wrist fracture and a urinary tract infection. Staff progress notes by staff 4, dated 04/06/2024, confirm the information from the self-report.
  2. Progress notes by staff 4, dated 04/09/2024, indicate that staff 4 had responded to resident 1’s call for assistance on that same date and discovered that resident 1 had fallen earlier that day and had a skin tear to the right elbow. This LI has no documentation that the 04/09 fall had been self-reported by the facility.
  3. During the on-site complaint follow up on 07/23/2024, LI requested to review all fall risk ratings on file for resident 1. The fall risk ratings that were provided by staff 1 and staff 2 were dated 04/09/2024, 01/01/2024, and 10/03/2022. Staff 1 and staff 2 indicated that there was no documentation of a fall risk rating update for resident 1’s 04/05/2024 fall.
Plan of correction
The fall risk has been updated for resident 1. Staff has been educated as to the importance of updating the fall risk rating. HCD is responsible to ensure successful implementation of the plan of correction.
July 2, 2024Inspection3 violations
Inspection dates
07/02/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/02/2024 from 10:45 AM to 01:00 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 06/28/2024 regarding allegations in the area(s) of: Resident care and related services. Number of residents present at the facility at the beginning of the inspection: 90 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A 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 Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
22VAC40-73-680-I
Based on record review and staff interview, the facility failed to ensure that the medication administration record (MAR) shall contain all required components, including any medication errors or omissions.
Evidence
  1. The written self-report, dated 06/28/2024, indicates that resident 1 did not receive her 08:00 PM dose of TYLENOL, BUSPIRONE, CARVEDILOL, and TRAZODONE on 06/25, and when staff 2 was reviewing the dashboard near the end of her shift, that staff member realized that resident 1’s medications were not given at 08:00 PM. When staff 2 went to resident 1’s room to administer the medications, resident 1 was already asleep and “did not wake” to take her medications.
  2. During LI’s on-site follow up on 07/02, staff 1 provided a printout of a text message conversation with staff 2, from 06/26/2024, in which staff 2 admits that resident 1 did not receive her nighttime medications the night before because staff 2 had forgotten to give them to resident 1 at the scheduled time and upon remembering that they had not been given it was after 11:00 PM, so staff 2 did not want to go in and wake up resident 1.
  3. The June 2024 medication administration record (MAR) for resident 1 indicates that the ACETAMINOPHEN 325 MG, BUSPIRONE HCL 10 MG, CARVEDILOL 6.25 MG, and TRAZODONE 50 MG tabs were not given by staff 2 on 06/25 at 08:00 PM and contains exception notes of PATIENT REFUSED MEDICATION.
  4. Alternately, per LI’s interview with staff 1, staff 2 had confessed in a text message that she had forgotten to give the medications to resident 1 at 08:00 PM on 06/25 and did not want to wake up the resident, so resident 1 had not actually refused her medication, instead the medication was omitted by staff 2.
Plan of correction
An in-service was held on 6/28/24 to re-educate all clinical staff on the importance of following the MAR and making proper notifications. A medication refresher course was held on 7.9.24 for all clinical staff. Clinical Specialist, Healthcare Director or designee will ensure a 10% audit of the MAR will be completed each day looking for omissions and pharmacy errors.
22VAC40-73-680-J
Based on record review and staff interview, the facility ailed to ensure that in the event of an adverse drug reaction or a medication error, the following applies: Action shall be taken as directed by a physician, pharmacist, or a poison control center; the resident’s physician of record and family member shall be notified as soon as possible; and medication administration staff shall document actions taken in the resident’s record.
Evidence
  1. On 06/28/2024, LI received a written self-report from staff 1 which reported the discovery of a medication omission by staff 2 for resident 1’s scheduled 08:00 PM medications on 06/25/2024.
  2. The written self-report, dated 06/28/2024, indicates that resident 1 did not receive her 08:00 PM dose of TYLENOL, BUSPIRONE, CARVEDILOL, and TRAZODONE on 06/25, and when staff 2 was reviewing the dashboard near the end of her shift, that staff member realized that resident 1’s medications were not given at 08:00 PM. When staff 2 went to resident 1’s room to administer the medications, resident 1 was already asleep and did not wake to take her medications.
  3. The same written self-report indicates that for actions taken in response to the medication error/omission incident, the facility re-educated employee on the RMA curriculum & DSS guidelines, and personnel action was issued.
  4. During LI’s on-site follow up on 07/02, staff 1 indicated that there were no progress notes or other documentation that could verify that resident 1’s physician was notified of the medication error/omission, nor any documentation of guidance received as a result of the medication error/omission.
Plan of correction
An in-service was held on 6/28/24 to re-educate all clinical staff on the importance of following the MAR and making proper notifications. Clinical Specialist, Healthcare Director or designee will ensure a 10% audit of the MAR will be completed each day looking for omissions and pharmacy errors.
22VAC40-73-680-D
Based on record review and staff interview, the facility failed to ensure that medications are administered in accordance with physician’s or other prescriber’s orders.
Evidence
  1. On 06/28/2024, LI received a written self-report from staff 1 which reported the discovery of a medication omission by staff 2 for resident 1’s scheduled 08:00 PM medications on 06/25/2024.
  2. The written self-report, dated 06/28/2024, indicates that resident 1 did not receive her 08:00 PM dose of TYLENOL, BUSPIRONE, CARVEDILOL, and TRAZODONE on 06/25, and when staff 2 was reviewing the dashboard near the end of her shift, that staff member realized that resident 1’s medications were not given at 08:00 PM. When staff 2 went to resident 1’s room to administer the medications, resident 1 was already asleep and “did not wake” to take her medications.
  3. While LI was in the facility for follow up on 07/02/2024, a most current signed medication list was located for resident 1, dated 04/15/2024, which includes the following medications: BUSPIRONE HCL 10 MG QID for Anxiety; CARVEDILOL 6.25 MG BID for HTN; TRAZODONE 50 MG QHS for Insomnia; and TYLENOL 325 MG BID for Pain.
  4. Also, during LI’s on-site follow up on 07/02, staff 1 provided a printout of a text message conversation with staff 2, from 06/26/2024, in which staff 2 admits that resident 1 did not receive her nighttime medications the night before because staff 2 had forgotten to give them to resident 1 at the scheduled time and upon remembering that they had not been given it was after 11:00 PM, so staff 2 did not want to go in and wake up resident 1.
  5. The June 2024 medication administration record (MAR) for resident 1 indicates that the ACETAMINOPHEN 325 MG, BUSPIRONE HCL 10 MG, CARVEDILOL 6.25 MG, and TRAZODONE 50 MG tabs were not given by staff 2 on 06/25 at 08:00 PM and contains exception notes of PATIENT REFUSED MEDICATION.
  6. Alternately, per LI’s interview with staff 1, staff 2 had confessed in a text message that she had forgotten to give the medications to resident 1 at 08:00 PM on 06/25 and did not want to wake up the resident, so resident 1 had not actually refused her medication, instead the medication was omitted by staff 2.
Plan of correction
An in-service was held on 6/28/24 to re-educate all clinical staff on the importance of following the MAR and making proper notifications. A medication refresher course was held on 7.9.24 for all clinical staff. The Clinical Specialist, Healthcare Director or designee will ensure a 10% audit of the MAR will be completed each day looking for omissions and pharmacy errors.
July 2, 2024Complaint survey2 violations
Inspection dates
07/02/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint # 59806 Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/02/2024 from 10:45 AM until 01:00 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 06/28/2024 regarding allegations in the area(s) of: Resident care and related services. Number of residents present at the facility at the beginning of the inspection: 90 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: N/A Number of interviews conducted with staff: 1 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation(s) of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint(s) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
22VAC40-73-680-I
Based on record review and staff interview, the facility failed to ensure that the medication administration record (MAR) shall contain all required components, including any medication errors or omissions.
Evidence
  1. At 08:39 AM on 06/28/2024, LI received a complaint that resident 1 was transported to a local emergency department (ED) as a result of medication staff finding her with blood on her pillow and altered mental status that morning.
  2. The hospital ED provider notes from 10:17 AM on 06/28/2024 indicate that the resident presented to the emergency room complaining of reported seizure; the onset of symptoms was unknown; and EMS advised that patient apparently missed her nighttime medications including her seizure medicine, LACOSAMIDE. The same notes also indicate that her presenting condition was attributed to medication non-compliance.
  3. At 11:44 AM on 06/28, LI received notification that the physician on duty at the local ED had confirmed with the ALF by phone that staff 1 did not give resident 1 her anti-seizure medication (LACOSAMIDE 150 MG) at 09:00 PM on 06/27, despite staff 1 having indicated on the MAR that the LACOSAMIDE 150 MG was given to resident 1 at 09:00 PM on 06/27.
  4. On 06/28/2024 at approximately 09:23 PM, LI received an incident report from staff 2 which confirmed the events involving resident 1 that were reported to LI in the morning on that same date. The incident also notes that during the facility’s internal investigation of the incident, staff 2 and staff 3 found that the 09:00 PM dose of LACOSAMIDE was omitted on 06/27/2024 by staff 1; however, the MAR was signed by staff 1 to show that the medication was administered along with any other medications due at 09:00 PM. The internal investigation also revealed that the separate controlled drug count sheet was not signed off for the 09:00 PM dose of LACOSAMIDE for 06/27 and that dose was still in the medication card.
  5. Interview between LI and staff 2 on 07/02/2024 verified that staff 1 falsified MAR documentation of administering LACOSAMIDE 150 MG at 09:00 PM on 06/27 when it was not actually administered.
Plan of correction
Staff 1 has been removed from employment at Harmony 7.3.24. Staff 1 has been reported to the BON. Medication refresher course has taken place 7.9.24 for current staff. Healthcare Director or designee will complete a 10% audit of the MAR each day looking for omissions and pharmacy errors.
22VAC40-73-680-D
Based on record review and staff interview, the facility failed to ensure that medications are administered in accordance with physician’s or other prescriber’s instructions.
Evidence
  1. At 08:39 AM on 06/28/2024, LI received a complaint that resident 1 was transported to a local emergency department (ED) as a result of medication staff finding her with blood on her pillow and altered mental status that morning.
  2. Hospital visit documentation indicates that resident 1 displayed seizure activity in the emergency department at approximately 09:57 AM on 06/28. The same documentation contains the following physician statement at 10:14 AM: “Was in provider area when nursing around the corner informed of patient in status epilepticus. Unsure of exact time of start of seizure, but when I came around corner 2 EMS personnel had patient on L side. Nursing requested abortive medications. Ativan 2 mg ordered verbally. Turned NC O2 up from 0.5 LPM to 6 LPM, obtained portable suction and EMS personnel suctioned patient while Ativan administered. Seizure broke. Would estimate total time I witnessed between 1-2 minutes but unclear of exact time of start of seizure.” The same physician notes later state that “patient is supposed to be on Lacosamide 150 MG BID but unclear per son whether she had gotten any last night or this morning but he suspects that she may not have had either.”
  3. The hospital ED provider notes from 10:17 AM on 06/28/2024 indicate that the resident presented to the emergency room complaining of reported seizure; the onset of symptoms was unknown; and EMS advised that patient apparently missed her nighttime dose of her seizure medicine, LACOSAMIDE 150 MG. The same notes also indicate that resident 1’s presenting condition was attributed to medication non-compliance.
  4. At 11:44 AM on 06/28, LI received notification that the physician on duty at the local ED had confirmed with the ALF by phone that staff 1 did not give resident 1 her anti-seizure medication (LACOSAMIDE 150 MG) at 09:00 PM on 06/27, despite staff 1 having indicated on the MAR that the LACOSAMIDE 150 MG was given to resident 1 at 09:00 PM on 06/27. (See attached page for additional evidence)
Plan of correction
Staff 1 has been removed from employment. Staff 1 has been reported to the BON. Medication refresher course has taken place 7.9.24 for current staff. Healthcare Director or designee will complete a 10% audit of the MAR each day looking for omissions and pharmacy errors.
June 11, 2024Inspection2 violations
Inspection dates
06/11/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/11/2024 from 11:00 AM until 02:00 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 05/28/2024 regarding allegations in the area(s) of: Resident care and related services. Number of residents present at the facility at the beginning of the inspection: 90 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: N/A Additional Comments/Discussion: N/A 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 Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
22VAC40-73-680-D
Based on record review and staff interview, the facility failed to ensure that medications are administered according to physician’s or other prescriber’s orders.
Evidence
  1. On 05/28/2024, LI was notified by staff 1 of a medication error over the weekend prior, which was discovered through a medication administration audit. On 06/02/2024, LI received a follow up written report from staff 1 which indicated that an audit discovered that on 05/25/2024, the morning dose of Lacosamide for resident 1 was omitted (not given). The report also indicated that resident 1’s physician and daughter were notified and that there were no negative reactions observed as a result of the missed dose.
  2. The record for resident 1 contained signed orders for LACOSAMIDE 150 MG TAB - Take 1 tab by mouth twice daily for seizures, effective 04/09/2024.
  3. The May 2024 medication administration record (MAR) for resident 1 indicated that on 05/25/2024, the medication LACOSAMIDE 150 MG TAB was not administered at 08:00 AM with a reason noted by staff 2 of “patient unable to take medication”.
  4. An interview with staff 1 revealed that when staff 2 was questioned about the missed dose on the morning of 05/25, staff 2 admitted that resident 1 was physically able to take the medication, but staff 2 could not find the LACOSAMIDE 150 MG TAB for resident 1 in the medication cart at the 08:00 AM medication pass. Staff 2 had later been notified that this medication is kept in the narcotics box.
Plan of correction
Staff 2 has been removed from employment at Harmony 7-3-24. Staff 2 has been reported to the BON. Medication refresher course has taken place 7-9-24 for current staff. Healthcare Director or designee will be responsible to ensure that a 10% audit of the MAR will be completed each day looking for omissions and pharmacy errors.
22VAC40-73-680-I
Based on record review and staff interview, the facility failed to ensure that the medication administration record (MAR) contained all required information, specifically documentation of any medication errors or omissions.
Evidence
  1. The May 2024 MAR for resident 1 indicated that on 05/25/2024, the medication LACOSAMIDE 150 MG TAB was not administered at 08:00 AM with a reason noted by staff 2 of “patient unable to take medication”.
  2. An interview with staff 1 revealed that when staff 2 was questioned about the missed dose on the morning of 05/25, staff 2 admitted that resident 1 was physically able to take the medication, but staff 2 could not find the LACOSAMIDE 150 MG TAB for resident 1 in the medication cart at the 08:00 AM medication pass. Staff 2 had later been notified that this medication is kept in the narcotics box; however, the May 2024 MAR was never updated with an accurate reason to reflect the reason for medication omission that was made by staff 2.
Plan of correction
Staff 2 has been removed from employment at Harmony 7-3-24. Staff 2 has been reported to the BON. Medication refresher course has taken place 7-9-24 for current staff. Healthcare Director or designee will ensure that a 10% audit of the MAR will be completed each day looking for omissions and pharmacy errors.
June 11, 2024Inspection2 violations
Inspection dates
06/11/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/11/2024 from 11:00 AM until 02:00 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 05/14/2024 regarding allegations in the area(s) of: Resident care and related services. Number of residents present at the facility at the beginning of the inspection: 90 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: N/A Additional Comments/Discussion: N/A 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 Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
22VAC40-73-680-D
Based on record review and staff interview, the facility failed to ensure that medications are administered according to physician or other prescriber’s orders.
Evidence
  1. The record for resident 1 indicated that the resident was initially admitted to the assisted living facility (ALF) on 10/23/2022. The record also contained skilled nursing facility (SNF) discharge documentation which indicates that resident 1 had been admitted to a SNF on 04/03/2024 and was to be discharged back to the ALF around 05/03/2024.
  2. On 05/14/2024, LI received a facility reported incident (FRI), dated 05/14/2024, which indicated that resident 1 was not administered the following medications by the ALF for four days due to pharmacy error and failure to send the medication following receipt of a new history and physical: Aripiprazole 2mg, 1 tab PO QD for mood; Aspirin 81mg, 1 tab PO QD for heart health; Plavix 75mg, 1 tab PO QD for Stroke Prevention; Pantoprazole Sodium DR 20mg, 1 tab PO QD for GERD; Rosuvastatin -Calcium 10mg, 1 tab PO QD for cholesterol.
  3. An interview with staff 2, which occurred on 06/11/2024, revealed that resident 1 returned to the assisted living facility from the skilled nursing facility on the afternoon of 05/10/2024. Staff 2 clarified that the reported missed doses of medication occurred between resident 1’s return to the ALF date of 05/10/2024 and the date of the facility’s report to LI on 05/14/2024.
  4. The REPORT OF RESIDENT PHYSICAL EXAMINATION (H&P) completed prior to resident 1’s readmission to the ALF, signed 04/30/2024, contained orders for the following medications to be administered ongoing at that time: Rosuvastatin Calcium Oral Tablet 10mg, 1 tab by mouth one time a day for hyperlipidemia; Clopidogrel Bisulfate Oral Tablet 75mg, 1 tab by mouth one time a day related to atherosclerosis of coronary artery bypass grafts unspecified, with unspecified angina pectoris. Pantoprazole Sodium Oral Tablet Delayed Release 20mg, 1 tab by mouth one time a day for GERD; Midodrine HCl Oral Tablet 5mg, 1 tab by mouth three times a day for orthostatic hypotension; Aspirin EC Low Dose Oral Tablet Delayed Release 81mg, 1 tab by mouth one time a day for prophylaxis; Loperamide HCl Oral Tablet 2 mg, 1 tab by mouth as needed for diarrhea daily as needed (PRN); Acetaminophen Extra Strength Oral Tablet 500mg, 1 tab by mouth every 6 hours as needed for pain (PRN). (See attached page for remainder of evidence)
Plan of correction
Medication refresher course has taken place 7-9-24 for current staff. Healthcare Director or designee will be responsible for a 10% audit of the MAR will be completed each day looking for omissions and pharmacy errors.
22VAC40-73-680-E
Based on record review and staff interview, the facility failed to ensure that medical procedures or treatments ordered by a physician or other prescriber shall be provided according to his instructions and documented.
Evidence
  1. Based on the updated H&P, signed on 04/30, resident 1 had current orders for the following treatments: Budesonide 0.5 MG/2 ML suspension, Inhale 1 vial through nebulizer every 12 hours for shortness of breath; Ipratropium Albuterol Inhalation Solution 0.5-2.5 (3) mg/mL, Inhale 3 mL orally every 6 hours as needed for wheezing.
  2. The May 2024 MAR for resident 1 indicated that the scheduled Budesonide 0.5 mg/2 mL suspension was not administered on the following dates and times: 05/11 at 08:00 AM; 05/12 at 08:00 AM and 08:00 PM; and 05/13 and 05/14 at 08:00 AM, all indicating the dose was missed due to waiting on pharmacy.
Plan of correction
Medication refresher course has taken place 7-9-24 for current staff. Healthcare Director or designee will be responsible for a 10% audit of the MAR will be completed each day looking for omissions and pharmacy errors.
June 11, 2024Inspection0 violations
Inspection dates
06/11/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/11/2024 from 11:00 AM until 02:00 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 04/22/2024 regarding allegations in the area(s) of: Resident care and related services. Number of residents present at the facility at the beginning of the inspection: 90 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: N/A Additional Comments/Discussion: N/A 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 Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
June 11, 2024Complaint survey1 violation
Inspection dates
06/11/2024
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint 59633 Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/11/2024 from 11:00 AM until 02:00 PM. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 05/20/2024 regarding allegations in the area(s) of: Personnel. Number of residents present at the facility at the beginning of the inspection: 90 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: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation(s) of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint(s) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
22VAC40-73-140-E
Based on record review and staff interview, the facility failed to ensure that for a facility licensed for both residential and assisted living care, the administrator shall be licensed as an assisted living facility administrator or nursing home administrator by the Virginia Board of Long-Term Care Administrators pursuant to Chapter 31 (§ 54.1-3100 et seq.) of Title 54.1 of the Code of Virginia.
Evidence
  1. The current license for this facility, effective 03/03/2024 through 03/02/2025, allows for the facility to operate to provide residential and assisted living levels of care.
  2. On 04/16/2024, LI received an email from staff 2 reporting that staff 1 will serve as the administrator on record at the assisted living building, effective on that date. The email also included the Virginia ALF Administrator (ALF-A) license number for staff 1.
  3. During the night of 05/20/2024, LI received an anonymous report that staff 1 has been working under an expired license. On 05/21/2024, LI received a separate anonymous report of the same information.
  4. On 05/21/2024, LI searched the Virginia Department of Health Professions license lookup webpage with the license number that was provided for staff 1. The results of the search revealed that staff 1’s ALF-A license had expired on 03/31/2024.
  5. Separate discussions with staff 1 and staff 3 on 05/21/2024 confirmed that staff 1’s license had expired on 03/31/2024 and was still expired on 05/21.
Plan of correction
The Harmony Collection at Roanoke separated employment with staff 1 on 5/21/2024. A licensed assisted living administrator was appointed to cover the facility and this information was communicated to the Licensing Inspector on same day. The Human Resources Department conducted an audit of all licensed personnel to ensure that all licenses are current. Audits will be conducted on a regular basis to ensure that the licensed personnel have current licensure in their respective positions.
April 16, 2024Inspection2 violations
Inspection dates
04/16/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 04/16/2024 from 10:00 AM until 01:00 PM 05/15/2024 from 11:00 AM until 01:00 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(s) of: Resident care and related services. Number of residents present at the facility at the beginning of the inspection: 93 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A 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 Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
22VAC40-73-640-A
Based on record review and staff interview, the facility failed to implement portions of its medication management plan specifically regarding 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.
Evidence
  1. The facility’s medication management plan, revised 02/2018, point 12 states “nurses and RMA’s shall be responsible for the timely ordering, and re-ordering of medications so that there are no missed doses or interruptions in the medications being administered”. Point 13 of the medication management plan states “if a medication is not available to administer for any reason, the nurse/RMA will contact the physician to inform of when the medication will be made available and seek further instruction. The physician instructions will be documented on the (E)MAR”.
  2. The March MAR for resident 1 contains orders for LORAZEPAM 0.5 MG TABLET (effective 02/20/2024) to “Take 1 tablet by mouth every night for anxiety”. The same MAR indicates that the LORAZEPAM 0.5 MG TAB for resident 1 was not given on 03/27, 03/28, 03/30, and 03/31. The March MAR says this is due to waiting on pharmacy.
  3. Per interviews with staff 1 and staff 2 on 04/16, the LORAZEPAM was received at the facility late on 3/27 and was stocked on the 3rd floor cart on 3/28, but it was not given until the evening of 3/29 before it disappeared, and doses were missed on 3/30 and 3/31 before staff 1 and staff 2 were notified.
  4. The March MAR for resident 1 does not indicate that the resident’s physician was contacted about the outage, nor did it contain any further instructions that were provided by the physician for that time period as per the facility’s medication management plan point 13.
Plan of correction
Not published by VDSS.
22VAC40-73-680-D
Based on record review and staff interview, the facility failed to ensure that medications shall be administered in accordance with the physicians or other prescriber’s instructions.
Evidence
  1. On 04/04/2024, LI received a written incident report from staff 2 regarding a discovery on 03/31/2024 of a missing narcotic card containing 29 LORAZEPAM 0.5 MG tabs for resident 1.
  2. The March MAR for resident 1 contains orders for LORAZEPAM 0.5 MG TABLET (effective 02/20/2024) to “Take 1 tablet by mouth every night for anxiety”. The same MAR indicates that the LORAZEPAM 0.5 MG TAB for resident 1 was not given on 03/27, 03/28, 03/30, and 03/31. The March MAR says this is due to waiting on pharmacy. Per interviews with staff 1 and staff 2 on 04/16, the LORAZEPAM was received at the facility late on 3/27 and was stocked on the 3rd floor cart on 3/28, but it was not given until the evening of 3/29 before it disappeared, and doses were missed on 3/30 and 3/31 before staff 1 and staff 2 were notified.
Plan of correction
Not published by VDSS.
April 16, 2024Complaint survey4 violations
Inspection dates
04/16/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint 59244 Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 04/16/2024 from 10:00 AM until 01:00 PM 05/15/2024 from 11:00 AM until 01:00 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 04/15/2024 regarding allegations in the area(s) of: Resident care and related services. Number of residents present at the facility at the beginning of the inspection: 93 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation(s) of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint(s) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
22VAC40-73-640-A
Based on record review and staff interview, the facility failed to implement a portion of its medication management plan, specifically regarding methods to ensure that medications are filled and refilled in a timely manner to avoid missed doses.
Evidence
  1. The medication management plan for the facility, with a revised date of 02/2018, section 5. (g.) states that “RMAs will complete and document a medication cart audit for their medication carts weekly.” Section 12 states that “nurses and RMAs shall be responsible for the timely ordering and re-ordering of medications so that there are no missed doses or interruptions in the medications being delivered”.
  2. The record for resident 1 contains signed physician’s orders for CHOLESTYRAMINE LIGHT PACKET, effective 02/28/2023, to MIX 1 PACK IN 4-6 OUNCES OF WATER AND DRINK ONCE DAILY FOR CHOLESTEROL.
  3. The April 2024 MAR for resident 1 indicates that the CHOLESTYRAMINE LIGHT PACKET was not given on 04/09, 04/10, 04/12, 04/15, and 04/16 due to awaiting pharmacy delivery.
  4. Progress notes by staff 4 on 04/12/2024 for resident 1 indicate that the resident did not receive her CHOLESTYRAMINE LIGHT supplement packet due to it not being on the cart and staff 4 accidentally clicked (on the MAR) as administered on 04/12 instead of not administered. The same progress note also acknowledges that the family provides the medication, per Express Care.
  5. Progress notes by staff 4 on 04/15/2024 for resident 1 indicate that a voicemail was left on the resident’s responsible party’s phone by two staff members at 09:24 AM to let her know that the resident has ran out of her Cholesterol packets, seven days after the CHOLESTYRAMINE was first noted to be out.
Plan of correction
Not published by VDSS.
22VAC40-73-130-A
Based on record review and staff interview, the facility failed to ensure that staff who are mandated reporters under § 63.2-1606 of the Code of Virginia shall report suspected abuse, neglect, or exploitation of residents in accordance with that section.
Evidence
  1. The Code of Virginia § 63.2-1606-A #1 states that any person licensed, certified, or registered by health regulatory boards shall make suspected abuse, neglect, or exploitation reports to the local department or the adult protective services hotline.
  2. The record for staff 5 reveals that this individual is a licensed healthcare professional.
  3. Progress notes that were entered by staff 5, on 01/18/2024, indicate that staff was notified that resident 1 was going to the front desk and making accusations that money was being stolen from her by her responsible party and that she needed a ride to the bank. The progress notes also indicate that resident 1 has had this behavior in the past and as a result, her responsible party was notified, and the resident was “settled and at lunch”.
  4. Interview with staff 1 revealed that there is no confirmation that staff 5 reported to adult protective services the concerns presented by resident 1 of possible financial exploitation.
Plan of correction
Not published by VDSS.
22VAC40-73-680-D
Based on record review and staff interview, the facility failed to ensure that medications are administered according to physician’s or other prescriber’s orders.
Evidence
  1. The record for resident 1 contained signed physician’s orders for LIDOCAINE 5% PATCH, effective 03/09/2024, to APPLY 1 PATCH TO AFFECTED HIP DAILY FOR PAIN. 12 HOURS ON, 12 HOURS OFF.
  2. On 04/14/2024 at 04:58 PM, LI received photo evidence of resident 1 wearing two patches at the same time, one was located above her right-side waistline (to the side on her lower back) and the other was located below her right-side waistline (in the gluteal region).
  3. Interview with staff 3 revealed that she was aware that resident 1 was discovered with two patches on recently and said that sometimes resident 1 wants her patch placed on her lower back and it’s possible that the medication staff member who applied the second patch did not see the first patch because it was underneath her clothes, below her waistline, not on her hip as prescribed.
Plan of correction
Not published by VDSS.
22VAC40-73-450-F
Based on record review and staff interview, the facility failed to ensure that individualized service plans (ISPs) shall be reviewed and updated at least once every 12 months and as needed for a significant change in a resident’s condition.
Evidence
  1. The progress notes for resident 1, dated 03/31/2022, reference her care plan being completed in conjunction with her responsible party; however, the record for resident 1 does not contain this care plan or ISP, nor does it contain any ISP.
  2. Interviews with staff 1 and staff 3 revealed that they cannot locate any ISP for resident 1.
Plan of correction
Not published by VDSS.
April 16, 2024Complaint survey1 violation
Inspection dates
04/16/2024
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint 59127 Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 04/16/2024 from 10:00 AM until 01:00 PM 05/15/2024 from 11:00 AM until 01:00 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 03/20/2024 regarding allegations in the area(s) of: Resident care and related services and Staffing and Supervision. Number of residents present at the facility at the beginning of the inspection: 93 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A 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(s) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
22VAC40-73-640-A
Based on record review and staff interview, the facility failed to implement a portion of its medication management plan, specifically regarding the methods to ensure accurate counts of controlled substances whenever assigned medication staff changes.
Evidence
  1. The facility’s medication management plan, revised 02/2018, states “narcotics and other controlled substances will be counted shift to shift between the on-coming and off-going medication staff. Direct care staff to staff hand off of the keys to the medication carts will take place after a correct inventory has been documented.”
  2. The Controlled Medication Count Record for March 2024 for the 2nd floor medication cart contains the following statement: “Signing below acknowledges that you have counted the controlled drugs on hand and have found that the quantities of each medication counted agrees with the quantity stated on the Controlled Drug Administration Record. Medication cart is not to be accepted with an inaccurate narc count or missed meds.”
  3. On March 1 through March 23, 2024, and March 27, 28, and 29, the controlled medication count record for the 2nd floor medication cart was not signed as counted by the off-going 11p – 7a medication staff with the oncoming 7a – 3p medication staff.
  4. On March 1 through March 22, 2024, and March 26, 27, and 28, the controlled medication count record for the 2nd floor medication cart was not signed as counted by the oncoming 11p – 7a med staff with the off-going 3p – 11p medication staff.
  5. On March 30, the controlled medication count record for the 2nd floor medication cart was not signed as counted by the oncoming 7a – 3p medication staff with the off-going 11p – 7a medication staff; was not signed as counted by the off-going 7a- 3p med staff; not signed as counted by the oncoming 3p – 11p med staff; and not signed as counted by the off-going 3p – 11p med staff with the oncoming 11p – 7a medication staff.
  6. On March 31, the controlled medication count record for the 2nd floor medication cart was not signed as counted by the oncoming 3p – 11p med staff with the off-going 7a – 3p medication staff, and the record was not signed as counted by the off-going 3p – 11p med staff with the oncoming 11p – 7a medication staff.
  7. An interview with staff 3 and staff 1 revealed that based on the content of the controlled medication count record for the 2nd floor medication cart, it could not be confirmed that staff counted the narcotic medications together at shift change, as indicated in their medication management plan.
Plan of correction
Not published by VDSS.
April 16, 2024Complaint survey0 violations
Inspection dates
04/16/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint 59126 Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 04/16/2024 from 10:00 AM until 01:00 PM 05/15/2024 from 11:00 AM until 1:00 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 03/20/2024 regarding allegations in the area(s) of: Resident care and related services. Number of residents present at the facility at the beginning of the inspection: 93 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 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: N/A Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
March 11, 2024Complaint survey3 violations
Inspection dates
03/11/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint # 59014 Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03/11/2024 from 09:15 AM to 12:45 PM 03/14/2024 from 11:30 PM to 12:30 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 03/08/2024 regarding allegations in the area(s) of: Resident care and related services. Number of residents present at the facility at the beginning of the inspection: 93 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: N/A Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation(s) of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint(s) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
22VAC40-73-680-D
Based on record review, staff documentation, and hospital documentation, the facility failed to ensure that medications shall be administered in accordance with the physician’s or other prescriber’s instructions.
Evidence
  1. A medication list for resident 1, signed 09/27/2023, contains orders for LACOSAMIDE 150 MG TABLET – TAKE 1 TABLET BY MOUTH TWICE DAILY FOR SEIZURES. A subsequent psychoactive medication review form, signed 01/12/2024, indicated to continue the current drug regimen indefinitely.
  2. The March 2024 medication administration record indicates that resident 1 did not receive the medication LACOSAMIDE 150 MG TABLET – TAKE 1 TABLET BY MOUTH TWICE DAILY FOR SEIZURES (at 09:00 AM & 09:00 PM) beginning at 09:00 AM on 03/03/2024 until resident 1 was hospitalized on the morning of 03/08/2024. The MAR exception notes for those dates and times that the medication was missed indicated that the missed doses were due to waiting on the pharmacy.
  3. On 03/08/2024, staff progress notes for resident 1 indicate that resident 1 had missed six days of VIMPAT 150 MG (LACOSAMIDE 150 MG) for seizures. On the same date, progress notes for resident 1 indicate that resident 1 was observed to have seizure activity at approximately 09:00 AM and her POA/responsible party was notified. As a result, the resident was sent to the hospital by way of EMS for evaluation.
  4. Per hospital Emergency Department notes on 03/08/2024 at 10:49 AM, EMS informed ED staff that resident 1 had a seizure the night before and had not had seizure medications since 03/02. Hospital ED notes clarify that resident 1 had not been on the seizure medication due to being unable to contact primary care. Hospital ED notes indicate that resident 1 also had a seizure when EMS arrived at the facility which lasted about one minute. The ED notes also indicate that the POA/responsible party stated that neurology takes care of her seizure medication, and the POA/responsible party was able to contact them quickly.
  5. Per the same hospital ED notes, dated 03/08/2024 at 11:42 AM, the attending nurse was made aware by staff of the patient’s possible seizure activity and the nurse responded to the patient’s bedside. The hospital ED notes further state that the patient appeared to be seizing, jaw clamped, snoring and oxygen saturation dropped to the 70s, but patient stopped seizing on her own without medication intervention at that time.
  6. Per the hospital after visit summary, dated 03/08/2024, instructions indicated for the patient to return to the ED if multiple seizures occur within 24 hours when not on normal seizure medications.
Plan of correction
All RMAs will be put through the RMA refresher course within 30 days. RMAs to receive in-service training to be conducted on 04/25 & 04/26. RMA refresher training will be completed by 06/01/2024.
22VAC40-73-70-A
Based on record review and staff documentation, the facility failed to ensure that each facility shall report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident.
Evidence
  1. On 03/08/2024, staff progress notes for resident 1 indicate that resident 1 had missed the prior six days of VIMPAT 150 MG (LACOSAMIDE 150 MG) for seizures. On the same date, progress notes for resident 1 indicate that resident 1 was observed to have seizure activity at approximately 09:00 AM and her POA/responsible party was notified. As a result, the resident was sent to the hospital by way of EMS for evaluation.
  2. On 03/11/2024, LI responded to the facility to investigate this full event due to receiving a complaint; however, this incident was never reported to the LI by the facility even though it was documented by staff 1 on 03/08/2024.
Plan of correction
All staff receiving Reportable training on 04/25 & 04/26. All Managers provided Reportable Grid on 04/19/2024 from Campus ED.
22VAC40-73-450-H
Based on record review and staff documentation, the facility failed to ensure that services specified in the individualized service plan (ISP) are provided to each resident.
Evidence
  1. The ISP for resident 1, dated 09/06/2023, states that medication will be given to the resident per M.D. orders and assessed for side effects.
  2. The same ISP also indicates that staff will alert POA/responsible party, the ISP includes name and phone number, if this resident refuses the LACOSAMIDE medication or if the medication is not given for any reason with the goal of maintaining medication and to ensure safe administration.
  3. The March 2024 medication administration record indicates that resident 1 did not receive the medication LACOSAMIDE 150 MG TABLET – TAKE 1 TABLET BY MOUTH TWICE DAILY FOR SEIZURES (at 09:00 AM & 09:00 PM). According to this MAR, missed doses began at 09:00 AM on 03/03/2024 until resident 1 was hospitalized on the morning of 03/08/2024. The MAR exception notes for those missed dates and times indicated that staff were waiting on the pharmacy for the medication.
  4. Progress notes on 03/08/2024 state that resident 1 was observed to have seizure activity at approximately 09:00 AM and her POA/responsible party was notified. As a result, the resident was sent to the hospital by way of EMS for evaluation. Progress notes also indicate on the same day, that the resident’s POA/responsible party contacted the resident’s neurologist, and the new LACOSAMIDE 150 MG TAB prescription was sent to the pharmacy.
  5. Progress notes have no indication prior to the 03/08/2024 seizure and hospitalization that the resident’s POA/responsible party had been notified that the LACOSAMIDE 150 MG TAB medication had run out. An interview with the resident’s POA/responsible party also confirmed that she had not been notified that resident 1 had missed her LACOSAMIDE 150 MG TAB medication from the morning of 03/03/2024 through the morning of 03/08/2024.
Plan of correction
All ISPs & UAIs for every resident will be reviewed, updated, etc within 60 days which allows time for HCD to complete as well as HCD & Campus ED to sit with families. ISPs & UAIs will be completed on all new admits by the day of move in so care plan is completed and shared with team members for all new residents.
March 11, 2024Complaint survey4 violations
Inspection dates
03/11/2024; 03/14/2024
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint # 59013 Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03/11/2024 from 09:15 AM to 12:45 PM 03/14/2024 from 11:45 AM to 12:45 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 03/08/2024 regarding allegations in the area(s) of: Resident care and related services and Staffing and Supervision. Number of residents present at the facility at the beginning of the inspection: 93 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: N/A Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A 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(s) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
22VAC40-73-680-D
Based on record review and staff interview, the facility failed to ensure that medications were administered according to physician’s orders.
Evidence
  1. The record for resident 1 contained signed physician’s orders, dated 08/08/2023, which included the following blood pressure medications: AMLODIPINE BESYLATE 5 MG TAB, take 1 tablet by mouth every day for hypertension; ATENOLOL 25 MG TAB, take 1 tablet by mouth every day for hypertension.
  2. The record for resident 1 also contained signed physician’s orders, dated 02/12/2024, which stated to stop AMLODIPINE, STOP ATENOLOL, and START NEBIVOLOL 5 MG. The order further notes that the physician ordered for the AMLODIPINE and ATENOLOL to continue until the NEBIVOLOL 5 MG gets repackaged and sent to the facility, and the order was faxed to the pharmacy on 02/27/2024.
  3. Interview with staff 4 on 03/14/2024 revealed that she was working on the 2nd floor medication cart on the morning of 03/05/2024. Staff 4 recalled to LI that she gave two blood pressure medications to resident 1 on the morning of 03/05/2024, one of which was the new blood pressure medication for resident 1 called NEBIVOLOL 5 MG, and the other was a blood pressure medication that had been discontinued; however, staff 4 cannot remember which discontinued BP medication that she had given.
Plan of correction
RMA’s will be in-serviced on cart audits and the procedure on new and discontinued medications, as well as proper medication administration practices.
22VAC40-73-680-I
Based on record review and staff interview, the facility failed to ensure that the medication administration record (MAR) shall include any medication errors or omissions.
Evidence
  1. The electronic record for resident 1 contained an incident report, completed by staff 3, about a medication error that occurred. The report stated that resident 1 was given a discontinued blood pressure medication on 03/05/2024 on the 7 AM – 3 PM shift. The report further stated that resident 1 was given 2-hour blood pressure checks which had been within normal limits, and the resident’s power of attorney and primary care physician (PCP) were notified.
  2. Interview with staff 4 on 03/14/2024 revealed that she was working on the 2nd floor medication cart on 03/05/2024. Staff 4 recalled to LI that she gave two blood pressure medications to resident 1 on the morning of 03/05/2024, one of which was the new blood pressure medication for resident 1 called NEBIVOLOL 5 MG, and the other was a blood pressure medication that had been discontinued; however, staff 4 cannot remember which discontinued BP medication that she had given.
  3. The March 2024 MAR for resident 1 indicates that at 09:00 AM on 03/05/2024, the date of the medication error, that only the NEBIVOLOL 5 MG TAB was given to resident 1 for hypertension despite the admission of staff 4 that a discontinued blood pressure medication was also given at 09:00 AM on that date.
  4. Interviews with staff 1 and staff 3 revealed that the medication error was not documented on the March 2024 MAR nor in any notes supplemental to the MAR.
Plan of correction
RMA’s will be in-serviced on proper documentation and reporting to ED and Healthcare Director. Staff will be in-serviced on proper policy and procedures as it pertains to this incident.
22VAC40-73-70-A
Based on record review, the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident.
Evidence
  1. The electronic record for resident 1 contained an incident report which was completed by staff 3 about a medication error that occurred. The report stated that resident 1 was given a discontinued blood pressure medication on 03/05/2024 on the 7 AM – 3 PM shift. The report further stated that resident 1 was given 2-hour blood pressure checks which had been within normal limits, and the resident’s power of attorney and primary care physician (PCP) were notified.
  2. The regional licensing office, and this LI, were not made aware of the medication error until the complaint was received on 03/08/2024.
Plan of correction
Staff will be in-serviced on the proper reporting of incidents to the ED and HCD, as Acting ED was not aware of this incident at the time of occurrence. All staff will be in-serviced on reportables.
22VAC40-73-450-F
Based on record review and staff interview, the facility failed to ensure that the individualized service plan (ISP) was updated at least annually.
Evidence
  1. During the on-site investigation on 03/11/2024, the record for resident 1 contained an ISP which was dated 08/12/2022.
  2. Interviews with staff 1 and staff 2 revealed that a 2023 ISP for resident 1 could not be found.
Plan of correction
Clinical Specialist will audit resident ISP’s to ensure compliance and will ensure all ISP’s are up to date and accurate.
February 6, 2024Inspection3 violations
Inspection dates
02/06/2024
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 PREPAREDNESS22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 02/06/2024 from 08:45 AM until 03:45 PM 02/08/2024 from 09:00 AM until 01:30 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
22VAC40-73-260-A
Based on record review and staff interview, the facility failed to ensure that each direct care staff member who does not have current certification in first aid shall receive certification in first aid within 60 days of employment.
Evidence
  1. The record for staff 3, hired 09/19/2023, contained current basic life support (BLS) certification from American Red Cross; however, a review of the content for the American Red Cross BLS course revealed that this course does not include first aid training.
  2. An interview with staff 6 during the inspection revealed that no first aid certification could be found for staff 3.
Plan of correction
Not published by VDSS.
22VAC40-73-680-D
Based on record review, the facility failed to ensure that medications shall be administered in accordance with physician’s or other prescriber’s instructions.
Evidence
  1. The record for resident 7 contained a signed medication list, dated 12/26/2023, for TAFLUPROST 0.0015% EYE DROP – INSTILL 1 DROP INTO RIGHT EYE ONCE DAILY FOR GLAUCOMA. While performing an audit of medication cart 1 on the date of inspection, staff 1 revealed to LI that the TAFLUPROST eye drops were not in the cart because they were waiting on pharmacy delivery. A review of the February 2024 MAR for resident 7 indicated that the TAFLUPROST 0.0015% EYE DROP was not administered to resident 7 on 02/01 and on 02/03-02/08/2024 due to waiting for the pharmacy.
  2. An interview with staff 6 revealed that the TAFLUPROST EYE DROP was being stored in the medication refrigerator at the facility, per manufacturer’s instructions, and staff 6 provided LI visual confirmation that the eye drops were in the refrigerator on the date of inspection. Staff 1 was unaware that the TAFLUPROST EYE DROP was being stored in the refrigerator.
  3. The record for resident 8 contained signed physician’s orders, effective 10/10/2023, for blood pressure and heart rate checks twice daily and to NOTIFY PROVIDER IF SBP > 170 or DBP >100.
  4. The January 2024 MAR for resident 8 indicated the following: On 01/08/2024 on the 3-11 shift, the blood pressure reading was 177/100. On 01/09/2024 on the 7-3 shift, the blood pressure reading was 178/88. On 01/11/2024 on the 3-11 shift, the blood pressure reading was 200/91. On 01/12/2024 on the 3-11 shift, the blood pressure reading was 235/91. On 01/28/2024 on the 7-3 shift, the blood pressure reading was 240/103.
  5. In addition, the February 2024 MAR for resident 8 indicated the following: On 02/03/2024 on the 3-11 shift, the blood pressure reading was 178/68. On 02/05/2024 on the 3-11 shift, the blood pressure reading was 178/82.
  6. Neither the record nor the progress notes for resident 8 contained documentation that the physician was notified of the blood pressure readings on 01/08, 01/09, 01/11, 01/12, 01/28, 02/03, and 02/05/2024 per the prescribed orders.
  7. The record for resident 8 contained a medication list, signed 12/26/2023, for GABAPENTIN CV 100 MG CAPSULE – TAKE ONE CAPSULE BY MOUTH 2 TIMES A DAY FOR NEUROPATHY; however, the January 2024 MAR for resident 8 indicated that this medication was scheduled and/or given 3 times a day from 01/11/2024 through 01/31/2024. Staff 6 provided a signed physician’s order, effective 01/27/2024, which indicated to give GABAPENTIN 100 MG 3 times a day, but staff 6 was unable to provide signed orders for GABAPENTIN CV 100 MG to be scheduled and/or given 3 times a day from 01/11/2024 until 01/26/2024.
  8. The record for resident 10 contained signed physician’s orders for sliding scale insulin effective 09/19/2023. The order indicates: NOVOLOG FLEX PEN 100U/ML INJECT SUBCUTANEOUSLY 3 TIMES A DAY BEFORE MEALS PER SSI: 201-250 = 6U; 251-300 = 8U; 301-350 = 10U; 351-400 = 12U.
  9. The January 2024 MAR for resident 10 indicated the following: On 01/01/2024 at 05:00 PM, the blood sugar (BS) reading was 228 and that 8U of insulin were given. On 01/12/2024 at 08:00 AM, the BS reading for resident 10 was 206 and no insulin was given. On 01/19/2024 at 12:00 PM, the BS reading for resident 10 was 255 and 6U were given.
  10. Based on the prescribed sliding scale, on 01/01/2024 at 05:00 PM, resident 10 should have received 6U. On 01/12/2024 at 08:00 AM, resident 10 should have received 6U. On 01/19/2024 at 12:00 PM, resident 10 should have received 8U.
  11. The February 2024 MAR for resident 10 indicated that on 02/06/2024 at 08:00 AM, the BS reading for resident 10 was 261 and 6U were given; however, based on the prescribed sliding scale, resident 10 should have received 8U on 02/06/2024 at 08:00 AM.
Plan of correction
Not published by VDSS.
22VAC40-73-450-C
Based on record review and staff interview, the facility failed to ensure that the individualized service plan (ISP) contained a description of identified needs based on services being received.
Evidence
  1. The record for resident 9 contained physical therapy (PT) service notes which indicated that the resident has been receiving PT services since 09/05/2023; however, the ISP for resident 9, dated 09/18/2023, does not contain any updates to reflect the PT services being provided to resident 9.
  2. Staff 6 was unable to locate a more current ISP for resident 9 which contained PT services.
Plan of correction
Not published by VDSS.
September 7, 2023Complaint survey2 violations
Inspection dates
09/07/2023
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint 58007 Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/07/2023 from 09:00 AM until 12:00 PM and 11/03/2023 from 11:00 AM until 12:30 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 09/05/2023 regarding allegations in the area(s) of: Administration and Administrative Services; Resident care and related services. Number of residents present at the facility at the beginning of the inspection: 83 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: N/A Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A 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(s) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
22VAC40-73-640-A
Based on record review and staff interview, the facility failed to implement a portion of its medication management plan, specifically regarding its methods for monitoring medication administration and the effective use of MARs for documentation, and methods to ensure accurate counts of all controlled substances.
Evidence
  1. The facility’s medication management plan (MMP), effective 02/2018, section titled Narcotics and Preventing Drug Diversion, indicates that that when a routine dose of a controlled substance is administered, it is documented on the medication administration record (MAR) and is also documented on the Resident Narcotic Medication Control Record.
  2. Per interview with staff 3 on 11/03/2023, resident 1’s LACOSAMIDE 100 MG TAB was retrieved from the locked controlled medication box on the medication cart and was administered as ordered on 09/02/2023 at the 09:00 AM dose; however, the corresponding Controlled Drug Record for the LACOSAMIDE 100 MG TAB for resident 1 does not contain an entry that it was administered on 09/02/2023 at 09:00 AM.
  3. An interview with staff 2 and staff 4 confirmed, per their medication management policy, if a controlled medication is given, it must be documented on the corresponding Controlled Drug Record. Staff 2 and staff 4 acknowledged staff 3’s admission of administering the LACOSAMIDE 100 MG TAB for resident 1 on 09/02/2023 at 09:00 AM; however, staff 2 and staff 4 verified that it was not documented on the corresponding Controlled Drug Record.
  4. The facility’s medication management plan (MMP), effective 02/2018, section titled Medication/Treatment Errors indicates that a medication error may be defined by several actions, one of which includes medication being given but not signed for. The section also indicates that when any medication errors occur, the Healthcare Coordinator should be notified immediately verbally and in the daily log, and to subsequently follow all instructions provided by the Healthcare Coordinator which may include, but are not limited to, the appropriate documentation in the EMAR/MAR and clinical record.
  5. Interview with staff 3 on 11/03/2023 revealed that after administering the LACOSAMIDE 100 MG TAB medication to resident 1, she did not notify the Healthcare Coordinator that she made an error inputting the administration in the EMAR system nor was it documented in the daily log.
  6. Interviews with staff 2 and staff 4 on 11/03/2023 revealed that they had been unaware of staff 3’s input error on the EMAR for resident 1, so they were unable to ensure that the appropriate documentation was contained in the EMAR and clinical record for resident 1.
Plan of correction
Re-educated RMAs on the medication management policy. Specifically, titled Narcotics and Preventing Drug Diversion.
22VAC40-73-680-I
Based on record review and staff interview, the facility failed to ensure that the medication administration record (MAR) shall include the date and time given and initials of direct care staff administering a medication.
Evidence
  1. The physician’s orders for resident 1 and the September 2023 MAR for resident 1 indicate that the resident was taking the medication LACOSAMIDE 100 MG TABLET “TAKE 1 TABLET BY MOUTH EVERY 12 HOURS FOR SEIZURES: 09:00 AM and 09:00 PM”. The September 2023 MAR also indicates that the LACOSAMIDE 100 MG TABLET was not administered on 09/02/2023 at 09:00 AM due to “AWAITING DELIVERY FROM PHARMACY”.
  2. An interview with staff 3 on 11/03/2023 revealed that the LACOSAMIDE 100 MG TAB was administered on 09/02/2023 at 09:00 AM; however, staff 3 stated that it was marked incorrectly on the MAR. Staff 3 clarified that at the 09:00 AM medication pass on 09/02, she could not find the LACOSAMIDE 100 MG TAB on the medication cart; therefore, she entered NOT ADMINISTERED on the MAR and noted “AWAITING DELIVERY FROM PHARMACY”. Shortly after, staff 3 found the medication stored in the controlled medication drawer of the cart and then administered the LACOSAMIDE 100 MG TAB to resident 1.
  3. Staff 3 admitted to LI that she had not notified the clinical staff member in charge about the incorrect entry on the MAR so that it could be updated to contain the date and time given and staff 3’s initials.
Plan of correction
Re-educated RMAs on the medication management policy. Thus, ensuring medications are properly documented for on the MARS.
July 11, 2023Complaint survey0 violations
Inspection dates
07/11/2023
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint # 57641 Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/11/2023 from 12:15 PM until 01:30 PM A complaint was received by VDSS Division of Licensing on 06/27/2023 regarding allegations in the area(s) of: Resident care, laundry services, and monthly menu. Number of residents present at the facility at the beginning of the inspection: 94 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
February 7, 2023Inspection16 violations
Inspection dates
02/07/2023
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 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 02/07/2023 from 09:00 AM to 05:00 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
22VAC40-73-320-A
Based on resident record review, the facility failed to ensure the physical examination and report by an independent physician for a resident within the 30 days preceding admission contained all required components.
Evidence
  1. Resident 3 was admitted to the facility on 01/07/2023.
  2. The report of resident physical examination for the resident, dated 12/22/2022, was lacking the following information: weight, blood pressure, whether the resident is capable of self-administering medication and the results of a risk assessment documenting the absence of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it.
Plan of correction
Not published by VDSS.
22VAC40-73-650-E
Based on resident record review, the facility failed to ensure that physician's or other prescriber's signed written order or a dated notation of the physician's or other prescriber's oral order were retained in resident records.
Evidence
  1. The February 2023 medication administration record (MAR) for resident 9 contained documentation of a physician’s order for: Diclofenac Sodium 1%- Gel Voltaren 1% Gel, apply 2 gm topically 3 times a day, in the morning, at noon and at bedtime to painful joints; however, an order for the application of this medication to be routinely administered three times a day was not in the record for resident 9 at the time of the record review.
  2. Staff 8 contacted the pharmacy, and a copy of the order was faxed to the facility on the date of inspection at 3:28 PM.
  3. The Diclofenac Sodium 1%- Gel Voltaren 1% Gel was also observed at resident 9’s bedside during the morning medication pass on the day of inspection.
  4. Interview with resident 9 expressed that she applies the gel herself when she needs it; however, collateral 2 could not locate a physician’s order in the record for resident 9 to keep at bedside and to self-administer.
Plan of correction
Not published by VDSS.
22VAC40-73-700-1
Based on record review, the facility failed to ensure that when oxygen therapy is provided, the physician’s or other prescriber’s order shall include all required components.
Evidence
  1. The signed oxygen therapy physician’s orders for resident 6, dated 10/29/2022, did not specify the oxygen source nor the delivery device.
  2. The updated signed oxygen therapy orders for resident 6, dated 01/10/2023, did not specify the oxygen source nor the delivery device.
Plan of correction
Not published by VDSS.
22VAC40-73-680-D
Based on resident record and medication administration record (MAR) review, the facility failed to ensure that medications were administered in accordance with physician instructions.
Evidence
  1. The record for resident 12 has a physician’s order dated 06/08/2022 stating “Please check blood pressure prior to administering hypertensive medication, hold if BP is below 120/80”.
  2. The January 2023 MAR has a physician order for Lisinopril 20 MG, take ½ tablet (10 MG) by mouth once daily for hypertension, hold if blood pressure is less than 120/80.
  3. The January 2023 MAR for resident 12 has documentation of the resident’s blood pressure being 113/72 at 08:00 AM on 01/17/2023, 108/62 at 08:00 AM on 01/19/2023 and 107/64 at 08:00 AM on 01/20/2023; however, staff initials are present for administering the prescribed Lisinopril 10 MG on these dates when resident 12’s blood pressure was outside of parameters to be administered.
  4. The record for resident 12 has a physician order dated 01/31/2023 to “Please check BP daily. If systolic is below 120 please hold medication and/or if diastolic is below 80 please hold medication (Lisinopril)”.
  5. The February 2023 MAR for resident 12 has documentation of the resident’s blood pressure being 132/72 at 08:00 AM on 02/01/2023; however, staff initials are present for administering the prescribed Lisinopril 10mg on this date when resident 12’s blood pressure was outside of parameters to be administered.
  6. The record for resident 3 contained a signed physician’s order, with a timestamp of 01/05/2023 09:33 AM, that Warfarin 6 MG is to be administered to the resident at 5:00 PM daily.
  7. The January 2023 medication administration record (MAR) for resident 3 contains documentation that the aforementioned medication had been administered to the resident at 07:00 PM daily starting on 01/10/2023; however, during the on-site inspection, the record for resident 3 did not contain a physician’s order that Warfarin 6 MG should be administered at 7:00PM instead of 5:00 PM.
Plan of correction
Not published by VDSS.
22VAC40-73-260-A
Based on staff record review, the facility failed to ensure each direct care staff member has current certification in adult first aid.
Evidence
  1. The record for staff 2 contained documentation that the staff person received certification in child/infant CPR AED and adult CPR AED on 04/13/2021; however, the certification did not include certification in adult first aid. This was also noted by staff 7.
Plan of correction
Not published by VDSS.
22VAC40-73-870-A
Based on observations of the facility physical plant, the facility failed to maintain the interior of the building in good repair.
Evidence
  1. The hallway outside of room 301 was noted to have a soft or spongy area in the center of the flooring. The spongy area caused the floor to be sunken in that spot.
  2. This area was observed by collaterals 1 and 2 and by staff 7.
Plan of correction
Not published by VDSS.
22VAC40-73-680-C
Based on record review and observation, the facility failed to ensure that medications shall be administered not earlier than one hour before and not later than one hour after the facility’s standard dosing schedule, except those drugs that are ordered for specific times, such as before, after, or with meals.
Evidence
  1. On the date of inspection, LI observed staff 2 administer the following medications to resident 7 between 09:30 AM and 10:00 AM: Amlodipine Besylate 5 mg tab, Atorvastatin 20 mg tab, Duloxetine HCL Dr 60 mg cap, Atenolol 25 mg tab, Furosemide 40 mg tab, Losartan Potassium 100 mg, Vitamin B12 1000 mcg tab, Memantine HCL 5 mg tab, and Potassium CL ER 10 meq tab. Alternately, on the date of inspection, the record for resident 7 contained the most recently signed summary of physician’s orders, effective 12/2022, which indicate that those medications are ordered for 08:00 AM.
  2. The record for resident 10 contained a physician’s order, dated 01/20/2023, that the following medications are to be administered to the resident at 07:00 AM daily: Pantoprazole 40 MG, Loratadine 10 MG, Culturelle, Venlafaxine 75 MG, Therems-M Tablet, Levetiracetam 1,000 MG, and Metoprolol Tartrate 25 MG. Alternately, during the on-site inspection on 02/08/2022, collateral 1 observed staff 2 administer the 07:00 AM medications to resident 10 at 09:16 AM.
Plan of correction
Not published by VDSS.
22VAC40-73-350-B
Based on 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 than three days and shall document in the resident’s record that this was ascertained and the date the information was obtained.
Evidence
  1. The record for resident 6, date of admission 10/31/2022, contained a sex offender check which was dated 12/08/2022.
  2. Interview with staff 7 revealed that there were no other sex offender checks found for this resident.
  3. Resident 3 was admitted to the facility on 01/07/2023; however, the registered sex offender search in the record for resident 3 was dated 01/09/2023.
  4. Staff 8 confirmed that the resident’s date of admission was 01/07/2023.
Plan of correction
Not published by VDSS.
22VAC40-73-720-A
Based on resident record review, the facility failed to ensure that a written Do Not Resuscitate (DNR) order was included in an individualized service plan (ISP).
Evidence
  1. The record for resident 4 has documentation of a signed DNR order dated 12/08/2019.
  2. The ISP dated 05/02/2022 for resident 4 states that the resident’s code status will be “honored, code status verified and code status personalized” but the ISP does not include that resident 4 has a signed DNR order.
Plan of correction
Not published by VDSS.
22VAC40-73-440-D
Based on resident record review, the facility failed to ensure that private pay uniform assessment instruments (UAI) were completed as required.
Evidence
  1. The UAI dated 05/02/2022 in the record for resident 4 was noted to be incomplete on the day of inspection as the area for assistance with eating/feeding was blank and did not assess what type of assistance, if any, the resident needs with eating/feeding.
Plan of correction
Not published by VDSS.
22VAC40-73-320-B
Based on resident record review, the facility failed to ensure that a risk assessment for tuberculosis was completed annually for each resident.
Evidence
  1. The record for resident 4 contained documentation that the last assessment for tuberculosis was completed on 10/26/2021.
  2. The record for resident 8 contained documentation that the last assessment for tuberculosis was faxed to the facility on 01/05/2022; however, the form did not contain the signature of the physician nor the date that the form was completed.
Plan of correction
Not published by VDSS.
22VAC40-73-860-I
Based on observations of the facility physical plant, the facility failed to ensure cleaning supplies were stored in a locked area.
Evidence
  1. A can of Lysol Disinfectant Spray was observed by collaterals 1 and 2 and by staff 7 to be sitting out on the desk in the hallway across from room 126.
  2. A bottle of Reliable Carpet Pro X-Tractor was observed by collaterals 1 and 2 and by staff 7 to be sitting on the floor under the sink in the unlocked laundry room across from room 327.
Plan of correction
Not published by VDSS.
22VAC40-73-450-E
Based on resident record review, the facility failed to ensure the individualized service plan (ISP) for a resident was signed and dated by the resident or his legal representative.
Evidence
  1. The ISP for resident 2, with a subsequent review date of 12/14/2022, was not signed and dated by the resident or the resident’s legal representative.
Plan of correction
Not published by VDSS.
22VAC40-73-250-C
Based on record review, the facility failed to ensure that documentation of certain personal and social data is to be maintained on staff and shall be included in the staff records.
Evidence
  1. Staff 5 administers medications to residents; however, the record for staff 5 did not contain verification of current registration as medication aide.
  2. The record for staff 2 lacked verification that staff 2 had received a copy of their current job description as a registered medication aide (RMA).
Plan of correction
Not published by VDSS.
22VAC40-90-40-B
Based on record review, the facility failed to ensure that the criminal history record check is obtained on or prior to the 30th day of employment for each employee.
Evidence
  1. Staff 6 was hired on 05/24/2022; however, the criminal history record check was not completed until 12/28/2022.
  2. Staff 3 was hired on 10/04/2022; however, the results of a criminal record history were not obtained by the facility until 12/30/2022.
Plan of correction
Not published by VDSS.
22VAC40-73-450-D
Based on record review, the facility failed to ensure that when hospice care is provided to a resident, the services provided shall be included on the individualized service plan.
Evidence
  1. The ISP for resident 5, dated 10/26/2022, does not indicate that resident 5 has been receiving hospice services since 12/13/2022.
Plan of correction
Not published by VDSS.
July 8, 2022Inspection0 violations
Inspection dates
07/08/2022
Areas reviewed
22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS
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: 7/8/2022, 2:38 pm to 5:48 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: 74 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 interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Susan Mallory, Licensing Inspector at (540) 309-3043 or by email at susan.mallory@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 10, 2022Complaint survey0 violations
Inspection dates
05/10/2022
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Complaint 55451 Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 5/10/2022, 10:10am to 1:35pm. 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 4/7/2022 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: 67 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 interviews conducted with residents: 10 Number of interviews conducted with staff: 3 Observations by licensing inspector: Resident rooms were checked, an activity was observed, the activity calendar was reviewed. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. 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 Susan Mallory, Licensing Inspector at (540) 309-3043 or by email at susan.mallory@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 10, 2022Inspection4 violations
Inspection dates
05/10/2022
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 5/10/2022, 10:10 am to 1:35 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 2/11/2022 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: 67 Number of resident records reviewed: 1 Number of interviews conducted with staff: 2 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 Susan Mallory, Licensing Inspector at (540) 309-3043 or by email at susan.mallory@dss.virginia.gov
Violations
22VAC40-73-680-D
Based on resident record review and staff interviews, the facility failed to administer a medication in accordance with a prescriber’s order.
Evidence
  1. The facility reported on 2/11/2022 in an incident report that Xarelto had not been administered to resident 1 because it was not in the facility until 1/20/2022. The order in the record for resident 1 was signed on 12/31/2021.
  2. Interviews with staff 1 and 2 show that they discovered on 1/20/2022 that the Xarelto for resident 1 was never in the facility.
Plan of correction
What Has Been Done to Correct? Med discontinued as reported. How Will Recurrence Be Prevented? Process for orders, med processing, and administration streamlined; Training completed with all med-techs and nurses; 4-Hr refresher completed; Complete audit of orders in chart matched to meds on cart and MAR completed by Express Care Pharmacy. Person Responsible: HCD; Regional Clinical support
22VAC40-73-70-A
Based on documentation review, the facility failed to report an incident that threatens the health of a resident within 24 hours.
Evidence
  1. On 2/11/2022 the facility sent an incident report concerning an incident discovered on 1/20/2022 with resident 1.
  2. The incident report stated, “Order on file for Xarelto following neuro visit at UVA and paperwork returned by daughter. Med list faxed to pharmacy and Xarelto added to MAR as of 12/31. Med to begin on 1/1. MAR shows med was given as ordered, however medication in question was not present in the community until January 20 … .”
Plan of correction
What Has Been Done to Correct? Self-Report completed How Will Recurrence Be Prevented? Incidents meeting standard to be reported to DSS Licensing will be reported within 24 hours of occurrence. Person Responsible: ED, HCD and/or designee
22VAC40-73-650-C
Based on resident record review, the facility failed to obtain an order signed by a physician or other prescriber within 14 days of an oral order to discontinue a medication.
Evidence
  1. An oral order dated 1/27/2022 to discontinue Xarelto for resident 1 was not signed on the day of inspection, 5/10/2022. The facility later submitted the order signed on 5/12/2022.
Plan of correction
What Has Been Done to Correct? Order was reviewed by physician and signed. How Will Recurrence Be Prevented? Verbal orders to be placed in physician binder for signature directly following verbal order given. Person Responsible: Charge nurse, HCD, and/or designee
22VAC40-73-680-I
Based on resident record review, the facility failed to correctly document a medication record (MAR).
Evidence
  1. The MAR for December 2021 shows that Xarelto was administered to resident 1 on 12/31/2021.
  2. The MAR for January 2022 shows that Xarelto was administered to Resident 1 on 1/1/2022 through 1/19/2022.
  3. Interviews with staff 1 and 2 reveal that they discovered on 1/20/2022 that the Xarelto for resident 1 was not in the facility on 12/31/2021 and 1/1/2022 through 1/19/2022.
Plan of correction
What Has Been Done to Correct? Training completed with all med-techs and nurses; 4-hr refresher completed; full audit completed by Express Care pharmacy How Will Recurrence Be Prevented? Weekly review of MAR system (accuflo) and audit of cart Person Responsible: Charge nurse, HCD, ED and/or designee
January 6, 2022Inspection8 violations
Inspection dates
01/06/2022
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity32.1 Reported by persons other than physicians63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Comments
On 1/6/2022 two inspectors conducted an on-site annual monitoring inspection from 8:20 am through 3:05 pm. Nine resident records and three staff records were reviewed. A medication pass was observed and a physical plant tour was done. An exit interview was conducted the day of the inspection, on-site.
Violations
22VAC40-73-450-C
Based on resident record review, the facility failed to show a service on an individualized service plan (ISP).
Evidence
  1. The ISP for resident 1 dated 11/19/2021 shows "resident to bathe with staff assist" but does not describe what type of assistance is to be given by staff.
Plan of correction
What Has Been Done to Correct? ISP for resident 1 updated with details including type of assistance bathing. How Will Recurrence Be Prevented? ISPs will be reviewed by HCD and ED before presenting to resident/family for signatures. Person Responsible: HCD, ED
22VAC40-73-350-B
Based on resident record review, the facility failed to document in a resident record that a sex offender screening had been done.
Evidence
  1. The record for resident 1, admitted on 11/19/2021, lacked documentation to show that a sex offender screening had been done.
Plan of correction
What Has Been Done to Correct? Sex Offender Screening conducted and is now on file for Resident 1. How Will Recurrence Be Prevented? BOM, ED and/or designee to run name of potential resident prior to lease signing. Audit file for completion. Person Responsible: BOM, ED and/or designee
22VAC40-73-450-E
Based on resident record review, the facility failed to obtain required signature(s) on an individualized service plan (ISP)
Evidence
  1. The ISP for resident 1 lacks signatures from the resident or the resident's representative.
Plan of correction
What Has Been Done to Correct? Signature was obtained on Resident 1’s ISP. How Will Recurrence Be Prevented? HCD, ED and/or designee will review and obtain signatures from resident and/or family upon completion of ISP. File audits to be completed for compliance. Person Responsible: HCD, ED and/or designee
22VAC40-73-450-F
Based on resident record review, the facility failed to update a resident's individualized service plan.
Evidence
  1. The ISP for resident 2 shows the "dates of expected outcome" are 10/31/2021. This was noted on 1/6/2022.
  2. The ISP for resident 8 shows the dates of expected outcomes are 9/4/2021. This was noted on 1/6/2022.
Plan of correction
What Has Been Done to Correct? ISP for Resident 2 and 8 updated. Signatures obtained. How Will Recurrence Be Prevented? ISPs will be completed upon admission, annually or with significant changes. File audits to be completed for compliance. Person Responsible: HCD, ED and/or designee
22VAC40-73-50-B
Based on resident record review, the facility failed to retain written acknowledgement of the receipt of the disclosure by the resident or his legal representative in the resident's record.
Evidence
  1. The record for resident 1 lacked written acknowledgment of the receipt of the disclosure by the resident or his legal representative.
Plan of correction
What Has Been Done to Correct? Resident 1 received disclosure statement and signed the acknowledgement. How Will Recurrence Be Prevented? Disclosure statement is in the process of the pre-admit/lease signing process with ED or designee. Audit file for completion. Person Responsible: DSM, ED, BOM
22VAC40-73-440-A
Based on resident record review and interviews, the facility failed to complete complete uniform assessment instruments (UAI) in accordance with Assessment in Assisted Living Facilities (22VAC30-110).
Evidence
  1. The UAI for resident 4, dated 4/18/2021, shows conflicting information: the resident both needs no help walking, and that walking is not performed. Interviews with staff 1 and 5 indicate that "is not performed" is incorrect.
  2. The UAI for resident 5, dated 9/30/2021, shows conflicting information: wheeling is assessed as both mechanical help only and "is not performed". Interview with staff 1 indicate that "is not performed" is incorrect.
  3. The UAI for resident 2, dated 11/10/2021, shows conflicting information: both walking and stairclimbing the resident both needs mechanical help only, and that the activities are "not performed". Interview with staff 5 shows that "is not performed" is incorrect.
Plan of correction
What Has Been Done to Correct? UAI’s for residents 4, 5 and 2 have been corrected in accordance with Assessment in ALF. How Will Recurrence Be Prevented? Education workshop scheduled for staff members in community completing UAIs. All completed UAIs reviewed by HCD and ED. Person Responsible: HCD, ED, BOM
22VAC40-73-210-B
Based on staff record review, the facility failed to ensure that direct care staff had at least 18 hours of annual training.
Evidence
  1. Staff 3 began work on 2/10/2020, and the record documents that 14 hours of training was completed by 2/9/2021. Staff 3 does not meet an exception to the 18 hour requirement.
Plan of correction
What Has Been Done to Correct? Required training for staff #3 is scheduled. How Will Recurrence Be Prevented? Reminders sent to staff about courses due in Relias Person Responsible: BOM, ED, all department heads and supervisors
22VAC40-73-1030-B
Based on staff record review, the facility failed to provide required staff training concerning residents with serious cognitive impairments within four months of starting employment.
Evidence
  1. Staff 2 began work on 8/4/2021, and there is no documentation to support that she had 4 hours of required training for a mixed population. A mixed population has both regular assisted living level of care residents and residents with serious cognitive impairments, but don't have a safe, secure environment) training. The physical examination for resident 6, done on 5/25/2021, shows that resident 6 in non-ambulatory by reason of mental impairment and is not capable of self-preservation without the assistance of another person, and a diagnosis of dementia. This was noted on 1/3/2022.
Plan of correction
What Has Been Done to Correct? Dementia classes added to Relias online learning and completed by staff #2. How Will Recurrence Be Prevented? Classes added to Relias upon hire with due date no more than four months after hire date. Person Responsible: BOM, ED, and/or designee
January 28, 2021Inspection1 violation
Inspection dates
Jan. 28, 2021 and Feb. 4, 2021
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity32.1 Reported by persons other than physicians63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Technical assistance
The medication management plan was reviewed and approved.
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 1/28/2021 and concluded on 2/4/2021. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 44. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed three resident records, three staff records, medication management plan, background checks on all new staff, staff schedules, reports from the health and fire departments 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.
Violations
22VAC40-73-700-1
Based on resident record review, the facility failed to have a complete order for oxygen for a resident.
Evidence
  1. The order for oxygen for resident 1 lacked information regarding the delivery device.
Plan of correction
An order was obtained from the resident's physician which included the delivery devise and all other required information. The Healthcare Director or her designee will review all orders for oxygen received from physicians to ensure that the order is complete with all required information.