Woodland Hills Independent Living, Assisted Living & Memory Care

Inspections

On record

With violations

Visits that cited something

Clean visits

Nothing cited

169

Violations cited

Individual findings

Standards cited

Distinct rules

Complaint visits

Prompted by a complaint

Woodland Hills Independent Living, Assisted Living & Memory Care was inspected 68 times between November 17, 2020 and June 15, 2026 by the Virginia Department of Social Services. 39 of those visits ended with violations cited and 29 with none. Across that history VDSS cited 169 violations under 69 distinct standards. 26 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. 62 of these 68 are still on the state's site; the other 6 have since dropped off it and are reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type

Assisted Living Facility

License type

One Year

License expires

04/10/2026

Administrator

Kennedy Flynn

Licensing inspector

Cynthia Ball

Inspector phone

(540) 309-2968

Approved for

Assisted Living · Non-Ambulatory · Special Care Unit

Inspection History

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

June 15, 2026Inspection0 violations

Inspection dates

06/15/2026

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: 06/15/2026 8:00am until 1:30pm 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 06/11/2026 regarding allegations in the area(s) of: Resident care and related services Number of interviews conducted with residents: 2 Number of resident records reviewed: 2 Number of interviews conducted with staff: 5 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

June 15, 2026Inspection0 violations

Inspection dates

06/15/2026

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 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: 06/15/2026 8:00am until 1:30pm 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 05/14/2026 regarding allegations in the area(s) of: Resident care and related services 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 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

June 15, 2026Complaint survey0 violations

Inspection dates

06/15/2026

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Comments

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 6/15/2026 8:00am until 1:30pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 06/03/2026 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: 22 on safe secure unit The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of interviews conducted with staff: 7 The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

June 15, 2026Complaint survey0 violations

Inspection dates

06/15/2026

Areas reviewed

22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Comments

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

June 15, 2026Complaint survey0 violations

Inspection dates

06/15/2026

Areas reviewed

22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Comments

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 6/15/2026 8:00am until 1:30pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 06/02/2026 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: 22 on safe secure unit The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of interviews conducted with staff: 7 The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

April 27, 2026Inspection0 violations

Inspection dates

04/27/2026

Areas reviewed

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: 04/27/2026 9:15am until 1:30pm 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 03/19/2026 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: 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: 2 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

April 27, 2026Complaint survey0 violations

Inspection dates

04/27/2026

Areas reviewed

22VAC40-73 BUILDINGS AND GROUND

Comments

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 04/27/2026 11am until 1:30pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 04/27/2026 regarding allegations in the area(s) of: Building and Grounds Number of residents present at the facility at the beginning of the inspection: 94 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

March 19, 2026Complaint survey4 violations

Inspection dates

03/19/2026

Areas reviewed

22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Comments

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03/19/2026 9:20am until 5:00pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 03/16/2026 regarding allegations in the area(s) of: Staffing and supervision, Resident care and related services, Emergency Preparedness The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 1 Number of interviews conducted with staff: 12 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: Staffing and supervision, Resident care and related services, Emergency Preparedness A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of these inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations

22VAC40-73-990-A

Based on resident record review, facility policy and procedure review and staff interview, the facility failed to ensure implementation of their written plan for resident emergencies.

Evidence

In an interview with 2 licensing inspectors (LI’s) and staff person 5 conducted on the day of on-site inspection, staff person 5, the RMA on duty on the unit where resident 1 resided, reported that they did not contact the supervisor on duty or complete documentation regarding a fall that resident 1 sustained after dinner on 03/13/2026.
The record for resident 1 does not have documentation of resident 1’s fall on 03/13/2026 until a progress note dated 03/16/2026 at 17:15 (5:15pm) that was authored by staff person 2.
The facility procedures for resident emergencies were requested by the LI for review on 03/19/2026. The following is documentation that is included in the policies that were made available for review. The policy named Falls (policy # 614) has the following documentation listed under B number 6: The Charge Nurse will notify the physician and responsible party and B number 8: A licensed nurse will complete an incident report. The resident will be monitored, evaluated and documented on for three consecutive shifts post fall. This includes the shift when they fell and the two following. Monitor, evaluate and document a fourth note 24 hours after the third consecutive shift note and then again 24 hours after the fourth note. There should be five (5) total notes. In an interview with 2 LI’s and staff person 1 conducted on the day of on-site inspection, staff person 1 stated that the policy for Falls (policy # 614) is part of the facility nursing policies and procedures included in the facility plan for resident emergencies.

Plan of correction

1. The facility reviewed the incident involving Resident #1 and reinforced implementation of the facility’s emergency response and fall management procedures, including required notifications, documentation. 2. An audit of resident emergency and incident documentation was conducted to ensure staff are implementing the facility’s written emergency response policies and procedures appropriately. 3. The Administrator/Nurse/Designee re-educated all staff regarding the facility’s emergency procedures and Falls Policy #614, including requirements for supervisor notification, physician and responsible party notification, incident reporting, resident monitoring, and post-fall documentation. 4. The Administrator/Nurse/Designee will review all falls and emergency incidents weekly for four weeks and monthly thereafter for two months to ensure compliance with the facility’s emergency response plan and policies. Any deficiencies identified will be corrected with additional education and/or disciplinary action implemented as necessary.

22VAC40-73-300-B

Based on resident record review, facility documentation and staff interview, the facility failed to ensure a method of written communication shall be utilized as a means of keeping direct care staff on all shifts informed of significant happenings or problems experienced by residents, including complaints and incidents or injuries related to physical or mental conditions.

Evidence

The facility written communication for keeping direct care informed of significant happenings or problems experienced by residents was requested for review on the day of on-site inspection. The communications report from 03/12/2026 through 03/19/2026 provided for review does not have any documentation to keep direct care staff informed of Resident 1’s fall on 03/13/2026 or of resident 1’s complaints of pain/discomfort on 03/14/2026, 03/15/2026 or 03/16/2026.

Plan of correction

1. The records for Resident #1 were reviewed and updated to include documentation regarding the resident’s fall on 03/13/2026. 2. An audit of communication logs and shift-to-shift reporting documentation was conducted to ensure resident incidents, complaints, injuries, and changes in condition are properly communicated to direct care staff on all shifts. 3. The Administrator/Registered Nurse/Designee re-educated all direct care staff, medication aides, and supervisors regarding documentation and communication requirements for resident incidents, complaints, injuries, and changes in condition. 4. The Administrator/Registered Nurse/Designee will review communication logs and shift reports weekly for four weeks and monthly thereafter for two months to ensure ongoing compliance. Any deficiencies identified will be corrected immediately with additional education provided as needed.

22VAC40-73-450-F

Based on resident record review, the facility failed to ensure that individualized service plans (ISPs) were updated as needed for a change in residents condition.

Evidence

The record for resident 2 has documentation of a fall risk rating being completed on 03/04/2026 and 03/08/2026 after resident 2 had sustained a fall. Both fall risk ratings have resident 2 in a high risk for falling category. The ISP dated 02/17/2026 in the record for resident 2 does not include the identified need of monitoring resident 2 as a high risk for falling.

Plan of correction

1. Resident #2’s ISP was updated to include interventions and monitoring related to the resident’s identified high risk for falls. 2. An audit of resident records was conducted to identify residents with changes in condition requiring ISP updates, including fall risk status and other significant clinical changes. 3. The Administrator/Nurse/Designee re-educated nursing staff and interdisciplinary team members regarding requirements for timely ISP updates following changes in resident condition, assessments, incidents, or identified risks. 4. The Administrator/ Nurse/Designee will conduct weekly audits of five resident ISPs for four weeks and monthly thereafter for two months to verify ISPs are updated timely and accurately following changes in condition. Any discrepancies identified will be corrected and additional education provided as needed.

22VAC40-73-470-F

Based on resident record review, facility documentation and staff interviews, the facility failed to ensure that medical attention from a licensed health care professional was secured when a resident suffered a serious accident, injury, illness, or medical condition, or there was reason to suspect that such has occurred. The circumstances involved and the medical attention received or refused shall be documented in the resident's record. The date and time of occurrence, as well as the personnel involved, shall be included in the documentation.

Evidence

The licensing inspector (LI) received a self-reported incident via email from staff person 1 at 7:06pm on 03/16/2026 that resident 1 reported experiencing discomfort and staff evaluated resident to determine appropriate next steps. Due to resident 1’s complaints of pain, further medical evaluation was initiated. Imaging was ordered and completed on-site at the facility of resident 1’s left hip, femur, pelvis and knee. Results from the x-ray indicated a hip fracture.
In an interview conducted on the day of on-site inspection by 2 licensing inspectors (LI’s) and staff person 6, staff person 6 reported that resident 1 had been complaining of pain and not wanting to get out of bed on Saturday 03/14/2026 and again on Sunday 03/15/2026, which was when staff person 6 stated that they found out about resident 1 falling on 03/13/2026.
In an interview conducted on the day of on-site inspection by 2 LI’s and staff person 12, staff person 12 reported that on Friday 03/13/2026 as they were collecting plates from dinner, they saw resident 1 slip onto the floor from their wheelchair, landing on his knees. Staff person 12 stated that they went to get staff person 5, who was the RMA on the floor, obtained resident 1’s vitals and then they got resident 1 up from the floor and sat him back into his wheelchair. Staff person 12 noted that resident 1 was not complaining of pain at the time of the incident. Staff person 12 stated that when they returned to work in the AM on Sunday 03/15/2026 they went in to assist staff person 6 with getting resident 1 up for the day and observed resident 1 to be complaining of pain and grimaced when they sat him in his wheelchair and that he wanted to go back to bed. Staff person 12 repoerted that staff person 6 mentioned that resident 1 had also complained of pain the day before and staff person 12 stated that they mentioned the fall from 03/13/2026 to staff person 6 at that time.
In an interview with 2 LI’s and staff person 5 conducted on the day of on-site inspection, staff person 5 reported that they had been notified by staff person 12 that resident 1 was on the floor. Staff person 5 stated that they helped staff person 12 get resident 1 up of the floor and back into their wheelchair. Staff person 5 reported that resident 1 was not complaining at the time and that they did not document the fall or contact the supervisor on duty to report the incident.
During interviews conducted on the day of on-site inspection by 2 licensing inspectors (LIs) and several additional staff, it was reported that resident 1 was complaining of pain/discomfort on Saturday 03/14/2026 and Sunday 03/15/2026.
Documentation by staff person 3 dated 03/14/2026 at 22:49 (10:49pm) in progress notes for resident 1 has that “resident was not feeling good during this day. vitals had been taken, communication fax completed. complaint pain in his right leg. resident been monitored during this shift”.
Documentation by staff person 4 dated 03/15/2026 at 20:48 (9:48pm) in progress notes for resident 1 has documentation of “Note text: new orders received per collateral witness 1, PA: x-ray to left knee, left hip, left femur and pelvis. DX: C/O pain, Norco Tablet 5-325mg 1 tab po every 6 hours PRN for pain x14 days, Tylenol 650mg 1 tablet Q6 hours prn for pain, Voltaren Gel 1% apply to left knee/thigh topically two times a day for pain”.

Plan of correction

1. Resident #1 was evaluated by a licensed healthcare professional and transferred to the emergency room for further treatment and management following identification of the hip fracture. 2. A review was conducted of incident reports, progress notes, and emergency response documentation for current residents to ensure timely notification, assessment, medical follow-up, and documentation requirements are completed appropriately. 3. The Administrator/Nurse/Designee re-educated all direct care staff, medication aides, and nursing staff regarding immediate reporting requirements for falls, complaints of pain, injuries, changes in condition, securing prompt medical evaluation, supervisor notification, and documentation standards. 4. The Administrator/Nurse/Designee will audit resident incidents and falls weekly for four weeks and monthly thereafter for two months to ensure timely medical evaluation, proper notification, and complete documentation in accordance with regulations and facility policy. Any identified concerns will be corrected immediately with additional education and/or disciplinary action as appropriate.

March 19, 2026Inspection2 violations

Inspection dates

03/19/2026

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: 03/19/2026 9:20am until 5:00pm 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 03/16/2026 regarding allegations in the area(s) of: Resident care and related services The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of these inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations

22VAC40-73-680-N

Based on resident record review and staff interview, the facility failed to ensure stat-drug boxes may only be used when the drug is removed from the stat-drug box and administered by a nurse, pharmacist, or prescriber licensed to administered medications and registered medication aides are not permitted to either remove or administer medications from the stat-drug box.

Evidence

A progress note in the record for resident 1 written by staff person 1 at 2:04PM on 03/15/2026 states that per staff report resident has had increased verbal behaviors and exit seeking, notified Collateral 1 and new orders obtained for the following: Benadryl 50MG STAT and Geodon 20MG STAT. Interview with staff person 2 during on-site inspection on 03/19/2026 revealed that she came to the facility on 03/15/2026 and removed Benadryl 50MG and Geodon 20MG from the facility’s stat-drug box to administer to resident 1; however, staff person 2 revealed that resident 1 was asleep and staff person 2 revealed to the two licensing inspectors (LIs) that they did not administer these two medications to resident 1. Staff person 2 revealed that they placed the aforementioned medications in the medication cart for medication administration staff to administer to the resident once the resident was awake.
The March 2026 medication administration record (MAR) for resident 1 contains staff person 3’s initials as administering Geodon Oral Capsule 20MG STAT for outburst, verbal aggression towards others, exit at 2:56PM on 03/15/2026 and staff person 4’s initials as administering Benadryl 25MG give 2 tablets by mouth STAT for outburst, verbal aggression towards others, exit seeking – give two tablets to equal 50MG at 9:45PM on 03/15/2026. Staff person 2 confirmed this is accurate.

Plan of correction

Correction: • Re-education was provided to licensed nursing staff member and regarding stat-drug box procedures, emphasizing that medications removed from the stat-drug box must be administered immediately by authorized licensed personnel only. • Staff were instructed that registered medication aides are not permitted to remove medications from the stat-drug box under any circumstance. • The facility reinforced that stat medications must be administered at the time of removal or, if the resident is unavailable, returned and re-dispensed per policy by licensed staff. • The Director of Nursing reviewed the incident with involved staff and reinforced correct regulatory and facility procedures. Monitoring: • The Director of Nursing or designee will conduct weekly audits of all stat-drug box usage logs, MARs, and incident reports for 4 weeks. • Any discrepancies between stat-drug box removal and administration will be investigated immediately and corrected. Responsible Party: Executive Director/Director of Clinical Services or Designee Completion Date: May 12, 2026

22VAC40-73-680-D

Based on resident record review and staff interview, the facility failed to ensure medications shall be administered in accordance with the physician’s or other prescriber’s instructions.

Evidence

A progress note in the record for resident 1 written by staff person 5 at 1:58PM on 03/13/2026 states that resident 1 was not in the building at this time. A progress note in the record for resident 1 written by staff person 5 at 2:47PM on 03/13/2026 states that resident 1 is a new resident, very confused, lots of redirection, participated during activity-music, and continue to monitor resident. Resident 1’s March 2026 medication administration record (MAR) contains a “9” for the following medications: Atorvastatin Calcium 80MG at 6:00PM on 03/13/2026, 03/14/2026, and 03/15/2026; Isosorbide Mononitrate ER 30MG and Lisinopril 10MG at 9:00AM on 03/14/2026 and 03/15/2026; Proscar 5MG at 5:00PM on 03/13/2026, 03/14/2026, and 03/15/2026; Quetiapine Fumarate 25MG (give 0.5 tablet by mouth at bedtime) at 8:00PM on 03/13/2026 and 03/14/2026; and Eliquis 5MG and Metoprolol Tartrate 25MG at 8:00PM on 03/13/2026 and 03/14/2026 and at 8:00AM on 03/14/2026 and 03/15/2026. Interview with staff person 6 revealed that “9” on the resident’s March 2026 MAR indicates that resident 1 was not administered the aforementioned medications. During an interview with staff person 2 during the on-site inspection on 03/19/2026, staff person 2 informed two licensing inspectors (LIs) that resident 1’s family brought in the resident’s medications upon his arrival to the facility on 03/13/2026; however, the medications were not placed in the medication cart that resident 1’s medications would have been administered from and staff person 2 confirmed the resident was not administered the aforementioned medications.
A progress note in the record for resident 1 written by staff person 1 at 2:04PM on 03/15/2026 states that per staff report resident has had increased verbal behaviors and exit seeking, notified Collateral 1 and new orders obtained for Ativan 1MG STAT. Resident 1’s March 2026 MAR does not contain staff initials or documentation that Ativan 1MG – give 1mg by mouth STAT for outburst, verbal aggression towards others, exit seeking was administered to resident 1 on 03/15/2026. Staff person 2 informed two LIs that this medication was not available in the facility’s stat-drug box and therefore resident 1 was not administered STAT Ativan 1MG on 03/15/2026.

Plan of correction

Correction: • Resident #1’s medication regimen was reviewed, reconciled, and ensured to be fully available for administration per physician orders. • STAT medication protocols were reviewed, and emergency medications were obtained and stocked appropriately, including Ativan. • Employee was re-educated on medication administration requirements, STAT medication procedures, and MAR documentation standards. Monitoring: • The Director of Nursing or designee will conduct weekly MAR and medication availability audits for 4 weeks. • Any missed medications or documentation discrepancies will be corrected, with follow-up staff education provided as needed. Responsible Party: Executive Director/Director of Clinical Services or Designee Completion Date: May 12, 2026

March 9, 2026Complaint survey2 violations

Inspection dates

03/09/2026, 04/27/2026

Areas reviewed

Comments

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03/09/2026 8:30am until 11:00am and 04/27/2026 9:15am until 1:30pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 03/03/2026 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: 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: 1 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. However, violation(s) not related to the complaint but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations

22VAC40-73-680-D

Based on resident record review, the facility failed to ensure that medications were administered in accordance with physician instructions.

Evidence

The record for resident 1 has a signed physician order dated 01/31/2026 for Morphine Concentrate 20mg/ml, 0.25ml every 8 hours scheduled for pain. The January and February 2026 medication administration records (MARs) for resident 1 have documentation from 01/31/2026 through 02/07/2026, that the Morphine was administered at 0900 (9am), 1500 (3pm) and 2100 (9pm), which is not the scheduled 8 hours as written in the physician order.

Plan of correction

The record for Resident #1 was reviewed and the medication administration schedule for Morphine Concentrate 20 mg/ml was Reviewed. The Administrator/Designee re-educated licensed nurses and medication aides regarding proper medication scheduling, physician order transcription, and administration requirements to ensure medications are administered in accordance with physician orders. Any identified discrepancies will be corrected.

22VAC40-73-650-E

Based on resident record review, the facility failed to ensure that all signed physician orders were contained in resident records.

Evidence

The January and February 2026 medication administration record (MAR) for resident 1 has documentation of the prescribed medication Memantine HCL 2mg/ml, 2.5ml by mouth two times a day for dementia. The record for resident 1 did not contain the signed physician order this medication.

Plan of correction

The record for Resident #1 was reviewed and updated to include the signed physician order for Memantine HCL 2 mg/ml, 2.5 ml by mouth two times daily for dementia. The Administrator/Designee re-educated licensed nurses, medication aides, and medical records staff regarding requirements for obtaining, verifying, and maintaining signed physician orders in resident records prior to medication administration. Any identified discrepancies will be corrected.

March 9, 2026Inspection10 violations

Inspection dates

03/09/2026

Areas reviewed

22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY32.1- (37) REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2- (1) GENERAL PROVISIONS63.2- (16) PROTECTION OF ADULTS AND REPORTING63.2- (17) LICENSURE AND REGISTRATION PROCEDURES63.2- (18) FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS

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: 03/09/2026 8:30am until 6:00pm 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: 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: 7 Number of staff records reviewed: 3 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 5 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of these inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations

22VAC40-73-650-E

Based on resident record review and staff interview, the facility failed to ensure that physician’s written orders or notation of physician’s oral orders were maintained in resident records.

Evidence

The record for resident 2 contains a signed physician’s order, dated 02/05/2026, for upper back wound: stage 2 - cleanse with wound cleanser, pat dry, apply Xerofoam and cover with Mepilex every other day and as needed for soilage/dislodgement. The record for resident 2 contains an additional signed physician’s order, dated 03/03/2026, that contains documentation for the facility to update wound care orders for resident 2 per home health.
Interview with staff person 2 revealed that the wound care order has changed from every other day to Monday, Wednesday and Friday; however, staff person 2 informed the licensing inspector (LI) that the physician’s order changing resident 2’s wound care was not available at the facility during the on-site inspection.

Plan of correction

Correction: 1. The updated wound care order for Resident 2 has been obtained and placed in the resident’s record. The MAR and care plan have been updated to reflect the new schedule (Monday, Wednesday, Friday). Monitoring: • All available charts with wound care orders will have their orders audited to ensure proper documentation, correct frequency, and alignment with the care plan and MAR. • All new or updated wound care orders will be verified and placed in the resident record before implementation. • Any discrepancies found during audits will be corrected immediately and documented. Responsible Party: Executive Director/Director of Clinical Services or Designee

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

The UAI dated 10/06/2025 in the record for resident 5 has documentation under behavior pattern that the resident is wandering/passive less than weekly, but the type of inappropriate behavior box is blank on the UAI.

Plan of correction

Correction: 1. The UAI for Resident 5 has been reviewed and updated to accurately complete the “type of inappropriate behavior” section. Monitoring: • All available charts for residents’ UAIs will been audited to ensure all required sections, including behavior patterns, are fully completed. 10% weekly audit for 90 days. • All new private pay UAIs will be reviewed and verified for completeness prior to finalization. • Any discrepancies identified during audits will be corrected immediately and documented. Responsible Party: Executive Director/Director of Clinical services or designee

22VAC40-73-950-E

Based on review of facility documentation and staff interviews, the facility failed to ensure that a semi-annual review of the facility emergency preparedness and response plan was documented by signing and dating with all residents.

Evidence

The documentation of a semi-annual review of the facility emergency preparedness and response plan with all residents was requested for review on 03/09/2026, the day of on-site inspection. In an interview with staff person 1 on the day of on-site inspection, staff person 1 explained that they did not have documentation of a review of the facility emergency preparedness and response plan with residents.

Plan of correction

Correction: 1. All residents have now completed the semi-annual review of the facility emergency preparedness and response plan. Documentation has been signed and dated for each resident. Monitoring: • Leadership will audit all available records to ensure semi-annual emergency preparedness reviews are completed, signed, and dated. • All new residents will have the emergency preparedness review completed and documented upon admission and every six months thereafter. • Any discrepancies will be corrected immediately and documented. Responsible Party: Executive Director/Director of Clinical Services or Designee

22VAC40-73-650-A

Based on resident record review and staff interview, the facility failed to ensure that no medication, dietary supplement, diet, medical procedure, or treatment was started, changed, or discontinued without a valid order form a physician or other prescriber.

Evidence

The report of resident physical examination for resident 4, dated 01/09/2026, contains documentation on page 3 of 5 for PRN (as needed) Nitroglycerin; however, the February and March 2026 medication administration records (MARs) do not contain documentation that the resident has as needed Nitroglycerin available.
Interview with staff person 3 revealed that they were unsure of the exact order that was written on the resident physical examination for as needed Nitroglycerin; therefore, they did not send the order to the pharmacy. During the on-site inspection, staff person 3 was unable to locate any additional physician’s orders for the as needed Nitroglycerin.

Plan of correction

Correction: 1. The PRN Nitroglycerin order has been clarified with the resident’s physician and updated to reflect appropriate wording for RMA administration. The order has been submitted to the pharmacy and MARs updated accordingly. Monitoring: • All available charts’ MARs will be audited to ensure all PRN medications are documented accurately, include correct RMA administration wording, and are available for use. • All new PRN medication orders will be verified for accuracy, clarity for RMA administration, and availability prior to implementation. • Any discrepancies found during audits will be corrected immediately and documented. Responsible Party: Executive Director/Director of Clinical Services or Designee

22VAC40-73-680-D

Based on resident 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

The record for resident 1 contains a signed physician’s order, dated 12/17/2025, for Glucagon (rDNA) Injection Kit 1MG inject 1 mg subcutaneously every 15 minutes as needed for hypoglycemia for blood sugar less than 70 and Glucose Oral Tablet Chewable (Dextrose) give 2 tablets by mouth as needed for hypoglycemia for blood sugar less than 70. The March 2026 medication administration record (MAR) for resident 1 contains documentation by staff person 4 on 03/04/2026 at 11:00AM that the resident’s blood sugar was 61; however, there is no documentation on the MAR that the resident was administered either of the aforementioned as needed medications. Interview with staff person 3 confirmed this is accurate.
The record for resident 5 has documentation of a signed physician order dated 03/05/2026 to discontinue the residents prescribed medications Abilify 2mg daily and to start Abilify 5mg daily. During observations of the morning medication pass conducted on 03/09/2026, staff person 5 explained to the licensing inspector (LI) that the Abilify 5mg has not been received from the pharmacy and was not administered to resident 5 on the day of on-site inspection. A bubble pack containing Abilify 2mg tablets for resident 5 were observed to still be on the medication cart. A review of the March 2026 MAR for resident 5 has staff person 5’s initials for administering the Abilify 5mg at 9am on 03/07/2026 and 03/08/2026. In an interview with staff person 5 in the presence of staff person 2 on the day of on-site inspection, staff person 5 explained that they gave Abilify 2mg to resident 5 on 03/07/2026 and 03/08/2026.

Plan of correction

Correction: 1. Resident 1’s PRN hypoglycemia medications have been verified as available on the MAR, and MAR updated to reflect proper administration. 2. Resident 5’s Abilify 5 mg order has been received from the pharmacy, and MAR updated to reflect correct medication and dose. Monitoring: • New or changed medication orders will be verified for pharmacy delivery and MAR accuracy prior to administration. • 1:1 education was provided to the accountable team members to prevent future practice • Any discrepancies will be corrected immediately and documented. Responsible Party: Executive Director/Director of Clinical Services or Designee

22VAC40-73-450-F

Based on resident record review and staff interview, the facility failed to ensure individualized service plans (ISPs) were reviewed and updated at least once every 12 months and as needed for a significant change of a resident’s condition.

Evidence

The record for resident 3 has documentation on a Morse Fall-Senior Living form dated 01/09/2026 that the resident is a high risk for falls. The ISP dated 01/09/2026 does not include the identified need for high fall risk. The ISP also has documentation that resident 3 has an identified need for oxygen but the record for resident 3 does not have an order for oxygen use. Staff person 2 and 3 confirmed the ISP is incorrect.
The record for resident 4 contains a Durable Do Not Resuscitate Order (DNR), dated 12/09/2025; however, the ISP in the record for resident 4, signed by staff person 3 on 02/06/2026 and resident 4’s family on 02/13/2026, contains documentation that the resident is a full code and Cardiopulmonary Resuscitation (CPR) is to be initiated for the resident. Staff person 3 confirmed the ISP is incorrect.
The record for resident 5 has documentation on a Morse Fall-Senior Living form dated 10/06/2025 that the resident is a moderate risk for falls. The ISP dated 10/06/2026 does not include the identified need for moderate fall risk.
The record for resident 6 has documentation on a Morse Fall-Senior Living form dated 02/17/2026 that the resident is a high risk for falls. The ISP dated 02/24/2026 does not include the identified need for high fall risk. The record for resident 6 also has a signed Do not Resuscitate (DNR) order dated 01/02/2025. The ISP is inconsistent as it has documentation that resident 6 is a full code. Staff person 2 and 3 confirmed the ISP is incorrect.
The uniform assessment instrument (UAI) in the record for resident 7, dated 01/31/2026, contains documentation that the resident requires mechanical and human help physical assistance with walking and stairclimbing; however, the ISP in the record for resident 7, dated 02/18/2026, does not include the aforementioned information regarding walking and stairclimbing. Staff person 3 confirmed the UAI is correct, and the information should have been included on the resident’s ISP.

Plan of correction

Correction: 1. ISPs for Residents 3, 4, 5, 6, and 7 have been updated to accurately reflect: a. Fall risk levels b. DNR or code status c. Physical assistance needs as documented on UAIs and assessments Monitoring: • Internal Quality Assurance measures will be reinforced to ensure ISPs reflect resident needs as it relates to chronic care needs.. • Any discrepancies identified during audits will be corrected immediately and documented. Responsible Party: Executive Director/Director of Clinical Services or Designee

22VAC40-73-380-A

Based on resident record review, the facility failed to ensure that all required information was included on resident personal/social data sheets.

Evidence

Resident 3’s report of resident physical examination, dated 01/02/2026, has documentation that the resident is allergic to Cephalexin however, the allergy section on the resident-personal/social data sheet in the record for resident 3 is blank.
Resident 4’s report of resident physical examination, dated 01/09/2026, and a physician’s note, dated 03/02/2026, both contain documentation that the resident has an allergy to cipro and ferric derisomaltose; however, the resident-personal/social data sheet in the record for resident 4 contains documentation that the resident does not have any allergies.

Plan of correction

Correction: 1. The allergy sections for Residents 3 and 4 have been updated to accurately reflect documented allergies. 2. Nursing staff educated on verifying and documenting resident allergies consistently across all records. Monitoring: • All new admissions’ personal/social data sheets will be verified for accuracy before the resident moves in. • Any discrepancies found during audits will be corrected immediately and documented. Responsible Party: Executive Director/Director of Clinical Services or Designee

22VAC40-73-680-K

Based on resident record review and staff interview, the facility failed to ensure that the use of PRN (as needed) medications is prohibited, unless one or more of the following conditions exist: the resident is capable of determining when the medication is needed, licensed health care professionals administer PRN medication, or medication aides administer PRN medication when the facility has obtained from the resident’s physician or other prescriber a detailed medication order that shall include symptoms that indicate the use of the medication, exact dosage, the exact time frames the medication is to be given in a 24-hour period, and directions as what to do if symptoms persist.

Evidence

The record for resident 4 contains an assessment of serious cognitive impairment, dated 01/09/2026, that states the resident has a serious cognitive impairment due to a primary diagnosis of dementia. Resident 4 resides in the facility’s safe, secure unit.
The record for resident 4 contains a signed physician’s order, dated 02/16/2026, for Geodon Oral Capsule 20MG – give 20MG by mouth every 12 hours as needed for agitation, max dose of 40MG in 24 hours and a signed physician’s order, dated 02/25/2026, for Lorazepam 1MG – give 1MG by mouth every 12 hours as needed for anxiety/agitation.
The February 2026 and March 2026 medication administration records (MARs) for resident 4 indicates that Geodon 20MG wasadministered to the resident by a registered medication aide (RMA) on 02/17/2026, 02/25/2026, and 03/06/2026 and Lorazepam 1MG was administered to the resident by a RMA on 02/27/2026, 03/06/2026 and 03/07/2026; however the physician’s orders do not include symptoms that indicate the use of the medication. Staff persons 1 and 2 revealed that resident 4 is unable to determine when this medication is needed.

Plan of correction

Correction: 1. Physician orders for Geodon and Lorazepam have been clarified and updated to include explicit symptom-based instructions for PRN administration. Orders now specify: a. Symptoms that indicate use b. Exact dosage and frequency within 24 hours c. Instructions for actions if symptoms persist 2. MARs have been updated to reflect the revised orders. Monitoring: • All new PRN orders for cognitively impaired residents will be verified for complete symptom-based instructions prior to administration. • Any discrepancies will be corrected immediately and documented. Responsible Party: Executive Director/Director of Clinical Services or Designee

22VAC40-73-1090-A

Based on resident record review, the facility failed to ensure that prior to admission to a safe, secure environment, all residents were assessed as having a serious cognitive impairment (SCI) due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare.

Evidence

Resident 4 was admitted to the facility’s safe, secure unit on 02/06/2026. The assessment of serious cognitive impairment form (ASCI) for resident 4, dated 01/09/2026, indicates that resident 4 is able to recognize danger or protect their own safety and welfare.

Plan of correction

Correction: 1. Resident 4’s assessment has been reviewed and updated to accurately reflect cognitive status prior to admission to the safe, secure unit. Monitoring: • Leadership will audit all available charts admissions to the safe, secure unit to ensure ASCI forms are completed accurately prior to admission. 10% audit per week 90 days. • Any discrepancies identified during audits will be corrected immediately and documented. Responsible Party: Executive Director/Director of Clinical Services or Designee

22VAC40-73-860-I

Based on observations of the facility physical plant, the facility failed to ensure that cleaning supplies were stored in a locked area.

Evidence

A bottle of Clorox Multi Surface Cleaner was observed in an unlocked cabinet by the elevator on the second floor near room 211 at 8:27am on the day of on-site inspection.
The door to the third-floor wellness room was noted to be opened at 9:18am on the day of on-site inspection and the room was unattended by staff. A container of Sani Cloths was observed sitting on the counter by the printer. The door to the med prep room was also observed to be unlocked and the room contained a bottle of EBOC Enzymatic Bio Odor sitting on the counter and a bottle of Misty Heavy Duty Glass Cleaner in an unlocked cabinet in the room.
At 9:27am on the day of on-site inspection an unlocked cabinet at the bar located on the first floor was observed to contain a can of Pro Easy Off and a bottle of Anytime Cleaner and polish. The open area beside the dishwasher at the bar contained a bottle of Double Bubble Liquid Enzyme and a bottle of Clean up Disinfectant.

Plan of correction

Correction: 1. All cleaning and chemical products have been removed from unsecured areas and placed in locked cabinets or designated secure storage locations. 2. Human Resources corrective action has been implemented for staff found non-compliant with safe storage procedures, including documentation in employee files. Monitoring: • Any unsecured products identified during rounds will be immediately secured and documented. • Random weekly audits will be conducted for one month to ensure continued compliance. Responsible Party: Executive Director/Director of Clinical Services or Designee

March 9, 2026Complaint survey0 violations

Inspection dates

03/09/2026

Areas reviewed

22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Comments

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03/09/2026 2:30pm until 5:00pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 03/09/2026 regarding allegations in the area(s) of: Staffing, Resident care and related services, Building and grounds. 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 interviews conducted with staff: 7 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

March 9, 2026Inspection0 violations

Inspection dates

03/09/2026

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: 03/09/2026 8:30am until 12:30pm 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 03/07/2026 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: 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: 2 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

March 9, 2026Inspection0 violations

Inspection dates

03/09/2026

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Comments

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03/09/2026 8:30am until 1:40pm 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 02/24/2026 regarding allegations in the area(s) of: Resident care and related services and additional requirements for facilities that care for residents with serious cognitive impairments 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 interviews conducted with residents: 1 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

February 12, 2026Complaint survey1 violation

Inspection dates

02/12/2026

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 02/12/2026 8:30am until 4:00pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 01/09/2026 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: 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: 1 Number of interviews conducted with residents: 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 some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: Resident care and related services A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations

22VAC40-73-680-C

Based on resident record review, facility documentation and staff interview, the facility failed to ensure that resident medications were administered not earlier than one hour before and not later than one hour after the facilities standard dosing schedule.

Evidence

The November 2025 medication administration record (MAR) for resident 1 has the medications Magnesium Chloride 64mg tablet, Risperidone 0.5mg tablet, Carvedilol 6.25mg tablet and Eliquis 5mg tablet for scheduled administration at 1700 (5pm) and the medications Atorvastatin Calcium 20mg tablet and Lisinopril 20mg tablet for scheduled administration at 2100 (9pm).
A self-reported incident dated 11/24/2025 has documentation that the 5pm and 9pm medications for resident 1 were administered together at 7pm. In an interview with 2 licensing inspectors (LIs) and staff persons 1 and 2 on the day of on-site inspection, it was explained that staff person 3 had administered resident 1’s 5pm and 9pm medications together at 7pm on 11/22/2025.

Plan of correction

POC = The facility will ensure that all medications are administered in accordance with physician orders and at the scheduled times identified on the MAR unless otherwise directed by a licensed prescriber. To be Corrected: 3.24.26 Action Items: 1. ED/RCD/designee will conduct an immediate medication administration review with Staff Person #3 to address the medication timing error that occurred on 11/22/2025 and reinforce expectations regarding adherence to scheduled administration times. 2. RCD/designee will complete a 100% audit of current MARs and the last 30 days of medication administration records to ensure medications are being administered according to physician orders and scheduled times. Any discrepancies identified will be addressed immediately. 3. All medication aides and licensed staff will receive re-education on medication administration policies, including proper timing parameters, documentation requirements, and procedures for handling missed or delayed medications. Staff will sign acknowledgment of training. 4. The facility will implement a medication administration refresher in-service focused specifically on time-critical medications and proper spacing of scheduled medication passes to prevent combining scheduled doses unless ordered. 5. ED/RCD/designee will conduct weekly medication administration audits for 4 weeks to ensure ongoing compliance. Any identified concerns will result in immediate corrective counseling and follow-up monitoring.

February 12, 2026Inspection2 violations

Inspection dates

02/12/2026

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 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: 02/12/2026 8:30am until 3:40pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 01/13/2026 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: 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 interviews conducted with residents: 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 some, but not all of the self-report; 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 self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of these inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations

22VAC40-73-700-2

Based on observations of the facility physical plant, the facility failed to post “No Smoking-Oxygen in Use Signs” in rooms where oxygen is in use.

Evidence

At approximately 9:16am on the day of on-site inspection 2 licensing inspectors (LIs) observed an oxygen concentrator and a oxygen tank in room 238. The room did have a No Smoking-Oxygen in Use sign.
At approximately 10:05am on the day of on-site inspection 2 LIs observed an oxygen concentrator in room 211. The room did have a No Smoking-Oxygen in Use sign.

Plan of correction

POC = The facility will ensure that “No Smoking–Oxygen in Use” signage is properly posted in all resident rooms where oxygen equipment is present, in accordance with life safety and regulatory requirements. To be Corrected: 3.24.26 1. Immediate Corrective Action: Upon identification during the on-site inspection, appropriate “No Smoking–Oxygen in Use” signage was immediately posted in Room 211. Room 238 was confirmed to have proper signage at the time of observation. 2. Audit of Oxygen Rooms: ED/DCS/designee will conduct an immediate 100% audit of all resident rooms to identify any rooms with oxygen in use and verify appropriate signage is posted. Any missing signage will be corrected immediately. 3. Education: All nursing staff, maintenance personnel, and housekeeping staff will receive re-education on oxygen safety requirements, including signage placement and monitoring responsibilities. Staff will sign acknowledgment of training. 4. Ongoing Monitoring: ED/DCS/designee will conduct weekly environmental rounds for 4 weeks to verify compliance with oxygen signage requirements. Monitoring will then transition to monthly safety rounds to ensure continued compliance. Any identified concerns will be corrected immediately.

22VAC40-73-650-C

Based on resident record review, the facility failed to ensure that physician orders were reviewed and signed by a physician or other prescriber within 14 days.

Evidence

The record for resident has a physician order dated 01/13/2026 for “No intervention for left tibia fracture d/t minimal discomfort and family not wanting her sent back to hospital. Pain manage & WC provided”. The order was not signed by the physician/prescriber until 02/12/2026.

Plan of correction

POC = The facility will ensure that all physician orders are signed and authenticated by the physician/prescriber in a timely manner in accordance with regulatory requirements. To be Corrected: 3.24.26 Action Items: 1. Immediate Corrective Action: The physician order dated 01/13/2026 was reviewed and confirmed as signed by the physician on 02/12/2026. The record has been updated to reflect the authenticated order. 2. Audit of Physician Orders: RCD/designee will conduct a 100% audit of all physician orders written within the last 30 days to ensure all orders have been properly signed and dated by the physician/prescriber. Any unsigned orders identified will be forwarded to the physician immediately for signature. 3. Process Improvement: The facility will implement a tracking system to monitor newly received physician orders weekly to ensure signatures are obtained within the required timeframe. 4. Staff Re-education: All licensed nurses and administrative staff responsible for record management will receive re-education regarding requirements for physician order authentication, including timeframes and follow-up procedures for unsigned orders. Staff will sign acknowledgment of training.

February 12, 2026Inspection1 violation

Inspection dates

02/12/2026

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 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: 02/12/2026 8:30am until 3:45pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 01/24/2026 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: 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 interviews conducted with residents: 4 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 some, but not all of the self-report; 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 self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of these inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations

22VAC40-73-450-F

Based on resident record review, the facility failed to ensure that individualized service plans (ISPs) were updated as needed for a change in resident condition.

Evidence

The uniform assessment instrument (UAI) dated 09/25/2025 in the record for resident 1 has that the resident is assessed as abusive, aggressive, disruptive less than weekly with documentation that resident 1 is physically, verbally, abusive, aggressive and disruptive. The ISP dated 09/25/2025 in the record for resident 1 does not include documentation for the identified need for monitoring for physically, verbally, abusive, aggressive and disruptive behaviors.

Plan of correction

POC = The ISP will be reviewed and updated to ensure all identified needs in the UAI, including behavioral concerns, are accurately incorporated with appropriate monitoring and intervention strategies. To be Corrected: 3.24.26 Action Items: 1. ED/DCS/designee will immediately review and update Resident #1’s ISP to include monitoring and interventions for physically, verbally abusive, aggressive, and disruptive behaviors as identified in the UAI dated 09/25/2025. 2. ED/DCS/designee will conduct a 100% audit of all current resident UAIs and corresponding ISPs to ensure identified needs, including behavioral concerns, are reflected accurately in each ISP. Any discrepancies will be corrected at the time of audit. 3. Licensed nurses and staff responsible for completion of UAIs and ISPs will receive re-education on regulatory requirements to ensure alignment between assessments and service plans, with emphasis on documentation of behavioral monitoring and interventions. 4. ED/designee will conduct bi-weekly audits of newly completed UAIs and ISPs for 90 days to ensure continued compliance. Any identified concerns will be addressed immediately through corrective action and follow-up education as needed.

February 12, 2026Inspection1 violation

Inspection dates

02/12/2026

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: 02/12/2026 08:30 am – 03:36 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 11/21/2025 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: 93 Number of resident records reviewed: 2 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the self-report; 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 self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of these inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Cynthia Beckner-Ball, Licensing Inspector at (540) 309-2968 by email at Cynthia.ball@dss.virginia.gov.

Violations

22VAC40-73-560-E

Based on resident record review and staff interview, the facility failed to ensure that resident records shall be kept current.

Evidence

On 02/12/2026, the date of the on-site inspection, the record for resident 2 did not contain documentation or outcomes for an incident that was reported to the licensing inspector (LIs) on 11/21/2025. In an interview with staff person 1 and two LI’s conducted on the day of on-site inspection, staff person 1 acknowledged that there was no documentation of the incident that was reported on 11/21/2025 in the record for resident 2.

Plan of correction

POC = The facility will ensure that all incidents are thoroughly documented in the resident’s record, including a description of the incident, investigative findings, outcomes, and any follow-up actions taken, in accordance with regulatory requirements. To be Corrected: 3.24.26 1. Immediate Corrective Action:ED/DCS/designee will immediately complete a late entry for Resident #2 regarding the 11/21/2025 incident. The documentation will include a detailed description of the incident, investigative steps taken, findings, outcomes, notifications made, and any corrective measures implemented. 2. DCS/designee will conduct a 100% audit of all incident reports from the past 30 days to ensure each reported incident is fully documented in the corresponding resident record, including outcomes and follow-up actions. Any missing documentation will be completed immediately. 3. Staff Re-education:All administrative and clinical staff will receive re-education on incident documentation requirements 4. Ongoing Monitoring:ED/RCD/designee will conduct weekly audits of all reportable incidents for 4 weeks to ensure proper documentation is completed in the resident record. Any discrepancies identified will result in immediate corrective counseling and retraining as necessary.

February 12, 2026Complaint survey0 violations

Inspection dates

02/12/2026

Areas reviewed

22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 02/12/2026 8:30am until 4pm 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 02/12/2026 regarding allegations in the area(s) of: Personal 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: 1 Number of staff records reviewed: 3 Number of interviews conducted with residents: 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 did not support the allegation of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

February 12, 2026Inspection0 violations

Inspection dates

02/12/2026

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 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: 02/12/2026 8:30am until 3:53pm 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 02/10/2026 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: 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: 5 Number of interviews conducted with residents: 5 Number of interviews conducted with staff: 5 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

February 12, 2026Inspection0 violations

Inspection dates

02/12/2026

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

February 12, 2026Inspection0 violations

Inspection dates

02/12/2026

Areas reviewed

22VAC40-73 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: 02/12/2026 8:30am until 3:36pm 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 11/22/2026 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: 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 interviews conducted with residents: 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 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

October 14, 2025Inspection1 violation

Inspection dates

10/14/2025

Areas reviewed

22VAC40-73 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: 10/14/2025 9:05am until 1:15pm 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 09/24/2025 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: 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: 4 Number of interviews conducted with residents: 3 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations

22VAC40-73-70-A

Based on resident record review and staff interviews, the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident.

Evidence

The record for resident 1 contains a progress note written by staff person 2, dated 08/29/2025, that resident 1 was sitting in the day room area after dinner when resident 2 went to sit next to resident 1. Resident 2 tried to reposition themselves and their hand touched resident 1’s hand and resident 1 became upset and hit resident 2 two times on their left upper arm. Resident 2 was then moved to a different area away from resident 1 when resident 3 came and sat down beside resident 1. Resident 1 hit resident 3 two times on their left arm. Interview with staff person 2 revealed the aforementioned incidents occurred on 08/28/2025.
The record for resident 1 contains a progress note written by staff person 2, dated 10/05/2025, that resident 1 was taken to the day room prior to breakfast in her wheelchair and she fell asleep. Another resident (resident 4) was seated next to resident 1 and resident 4 did not like that resident 1 was asleep and began to yell at resident 1 to wake up. Staff person 2 documented that since resident 1 did not wake up, resident 4 smacked resident 1 and then resident 1 grabbed resident 4’s arm to keep resident 4 from hitting her again and it caused a small skin tear on resident 4’s right arm.
Interview with staff persons 1 and 2 revealed that as of on-site inspection on 10/14/2025, the aforementioned incidents had not been reported to the regional licensing office.

Plan of correction

Executive Director and Director of Clinical Services will connect daily when a reportable event occurs to ensure details are communicated timely to the regional licensing o¿ce. To be Corrected: 11.1.2025 Action Items: 1.ED and Director of Clinical Services will review the 24hour shift report routinely to identify reportable incidents. 2.All sta¿ will be educated on notifying ED and Director of Clinical Services on reportable incidents and communication expectations 24 hours a day. 3.Resident #1 report was submitted to the regional licensing o¿ce.

October 14, 2025Inspection0 violations

Inspection dates

10/14/2025

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

October 14, 2025Inspection0 violations

Inspection dates

10/14/2025

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

October 14, 2025Inspection0 violations

Inspection dates

10/14/2025

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

October 14, 2025Complaint survey0 violations

Inspection dates

10/14/2025

Areas reviewed

22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/14/2025 9:05am until 1:15pm 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 09/22/2025 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: 91 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of interviews conducted with residents: 5 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

September 18, 2025Inspection3 violations

Inspection dates

09/18/2025

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: 09/18/2025 12:00pm until 2:30pm 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 09/15/2025 regarding allegations in the area(s) of: Resident care and related services Number of resident records reviewed: 2 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. However, violation(s) not related to the self-report but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations

22VAC40-73-680-I

Based on resident record review, the facility failed to ensure that all required information was documented on resident medication administration records (MARs).

Evidence

The September 2025 MAR for resident 1 has documentation of a physician order dated 08/30/2025 for Seroquel 12.5mg my mouth at bedtime as needed for severe agitation only. The MAR for resident 1 has documentation that the Seroquel 12.5mg was administered on 09/10/2025 at 4:22pm but does not have documentation of the effectiveness of the medication.

Plan of correction

1. Staff education provided regarding follow-up documentation of medication effectiveness after administration. 2. Routine review of the Medication Administration Record will be conducted to ensure compliance with documentation requirements.

22VAC40-73-680-D

Based on resident record review, the facility failed to ensure that medications were administered in accordance with physician instructions.

Evidence

The record for resident 1 has documentation of a signed physician order dated 08/30/2025 for Seroquel 12.5mg my mouth at bedtime as needed for severe agitation only. The September 2025 medication administration record (MAR) for resident 1 has documentation that the Seroquel 12.5mg was administered on 09/08/2025 at 3:20pm, 09/10/2025 at 4:22pm, 09/14/2025 at 4:11pm and on 09/16/2025 at 4:59pm, of which these times are not at bedtime.

Plan of correction

1. Facility obtained updated orders from the physician regarding administration time for the medication. 2. Staff were educated on proper medication administration procedures and the importance of following physician instructions. 3. Resident medical record was updated to reflect the corrected medication orders and administration times.

22VAC40-73-440-D

Based on resident record review, the facility failed to ensure that a uniform assessment instrument (UAI) was completed as required.

Evidence

The record for resident 1 has documentation in progress notes of the resident having aggressive/agitated behaviors on 08/29/2025, 08/30/2025, 09/14/2025 and 09/16/2025. The UAI in the record for resident has documentation that resident 1’s behavior pattern is wandering/passive and does not assess the residents aggressive/agitated behaviors.

Plan of correction

1. Executive Director and Director of Clinical Services will audit current UAIs to ensure they reflect residents’ current care needs and behaviors. 2. Education will be provided to the Director of Clinical Services, and Assistant Director of Clinical services regarding regulatory requirements for updating UAIs following changes in resident status. 3. Documentation audits will be conducted monthly to ensure updated assessments are placed in the medical record in a timely manner.

June 17, 2025Complaint survey1 violation

Inspection dates

06/17/2025

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/17/2025 8:40am until 3:30pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 06/04/2025 regarding allegations in the area(s) of: Administration and administrative services and resident care and related services Number of residents present at the facility at the beginning of the inspection: 88 Number of resident records reviewed: 2 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation; area(s) of non-compliance with standard(s) or law were: Administration and administrative services A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations

22VAC40-73-70-A

Based on resident record review, facility documentation and staff interview, 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

The record for resident 1 has documentation in progress notes dated 05/23/2025 at 15:10 that resident 1 was involved in a resident-to-resident altercation in which resident 1 fell and was sent to the local hospital via 911 for evaluation. The regional licensing office did not receive a report of this incident until an email was received by the licensing inspector on 05/27/2025, 4 days after the incident occurred.

Plan of correction

Executive Director and Director of Clinical Services will connect daily when a reportable event occurs to ensure details are communicated timely to the regional licensing office. To be Corrected: 8.31.25 Action Items: 1. ED and Director of Clinical Services will review the 24hour shift report routinely to identify reportable incidents. 2. All staff will be educated on notifying ED and Director of Clinical Services on reportable incidents and communication expectations 24 hours a day. 3. Resident report was submitted to the regional licensing office

June 17, 2025Inspection2 violations

Inspection dates

06/17/2025

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: 06/17/2025 8:40am until 3:30pm 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 05/26/2025 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: 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 interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the self-report; 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 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations

22VAC40-73-440-D

Based on resident record review, the facility failed to ensure that private pay uniform assessment instruments (UAI) were competed as required.

Evidence

The record for resident 1 has documentation in progress notes of the resident displaying wandering and agitated behaviors on 05/06/2025, 05/25/2025 requiring 911/local police to be called, and on 05/27/2025. The UAI dated 06/23/2024 in the record for resident 1 is inconsistent as it has documentation that resident 1’s behavior pattern is appropriate.

Plan of correction

Director of Clinical Services or designee will audit active resident records to ensure a current completed UAI is present and accurate. To be Corrected: 8.31.25 Action Items: 1.Director of Clinical Services or designee will complete community audit to identify outdated or inaccurate UAIs. 2.All identified UAIs will be corrected/completed by certified team member. 3.Resident #1 chart will be corrected.

22VAC40-73-450-E

Based on resident record review, the facility failed to ensure that an individualized service plan (ISP) was signed and dated by the person who developed the plan and by the resident or their legal representative.

Evidence

The ISP in the record for resident 1 with the date initiated on 06/27/2024 does not have documentation of a signature/date by the person who developed the plan or a signature/date of the resident or their legal representative.

Plan of correction

Director of Clinical Services or designee will audit active resident records to ensure a current completed ISP is signed by the individual who completed it and the resident legal representative and placed on the record. To be Corrected: 8.31.25 Action Items: ACTION ITEMS: 1.DCS and ED will review all charts for comprehensive ISPs for signature of individual who completed ISP and resident and/or RP 2.Resident #1 chart will be corrected. 3. Follow up on report findings for resolution.

June 17, 2025Inspection1 violation

Inspection dates

06/17/2025

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Comments

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/17/2025 8:40am until 3:30pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 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: 7 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations

22VAC40-73-1180-B

Based on observations of the facility physical plant, the facility failed to ensure that when there are indications that ordinary materials or objects may be harmful to a resident, these materials or objects shall be inaccessible to the resident except under staff supervision.

Evidence

A can of Febreze was observed sitting out on the bathroom sink in room 236 at 8:58am on the day of on-site inspection.
A hair-dryer was observed sitting out on the bathroom sink in room 226 at 9am on the day of on-site inspection.

Plan of correction

Routine rounds will be conducted by designee to ensure that harmful materials or objects are not accessible to residents without staff supervision. To be Corrected: 8.31.25 Action Items: 1.ED/EVS/DCS/designee will conduct routine rounds on safe secure unit and secure any materials or objects that may be harmful to residents. 2.All staff will be educated in consistent monitoring practices to ensure such materials or objects are not made accessible to residents without staff supervision.

June 17, 2025Inspection1 violation

Inspection dates

06/17/2025

Areas reviewed

22VAC40-73 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: 06/17/2025 8:40am until 3:30pm 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 06/10/2025 regarding allegations in the area(s) of: Administration and administrative services and resident care and related services Number of residents present at the facility at the beginning of the inspection: 88 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of interviews conducted with residents: 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 some, but not all of the self-report; area(s) of non-compliance with standard(s) or law were: Administration and administrative services A violation notice was 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations

22VAC40-73-70-A

Based on resident 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

Progress notes in the record for resident 1 has documentation on 06/07/2025 at 14:00 that resident 1 stated while she was in the beauty shop yesterday her right lower leg was hit, she does not remember if it was during a transfer or if while she was in the chair but now she is having bad leg pain in the right lower leg that kept her up most of the night. Progress notes dated 06/07/2025 at 18:41 have documentation that resident 1 was complaining of pain in right lower extremity and that resident 1 was sent to the local ER for evaluation.
A report of this incident was not received by the licensing inspector until an email was received on 06/10/2025 in regard to resident 1 returning from the hospital on 06/09/2025 with a diagnosis of Costochondral Separation (CS) of a rib, which is believed to be an old injury and a right lower extremity fracture.

Plan of correction

Executive Director and Director of Clinical Services will connect daily when a reportable event occurs to ensure details are communicated timely to the regional licensing office. To be Corrected: 8.31.25 Action Items: 1.ED and Director of Clinical Services will review the 24hour shift report routinely to identify reportable incidents. 2.All staff will be educated on notifying ED and Director of Clinical Services on reportable incidents and communication expectations 24 hours a day. 3.Resident #1 report was submitted to the regional licensing office.

June 17, 2025Inspection2 violations

Inspection dates

06/17/2025

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: 06/17/2025 8:40am until 3:30pm 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 05/21/2025 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: 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 interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the self-report; 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 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations

22VAC40-73-440-D

Based on resident record review, the facility failed to ensure that private pay uniform assessment instruments (UAI) were competed as required.

Evidence

The record for resident 1 has an assessment of serious cognitive/mental impairment form dated and signed by the residents physician on 05/06/2025 that has documentation that the resident has a serious cognitive impairment due to a primary diagnosis of dementia and has agitation at times. The UAI dated 05/05/2025 in the record for resident 1 is inconsistent as it has documentation that resident 1’s behavior pattern is appropriate and that the resident is alert and oriented.

Plan of correction

22VAC40-73-450-F

Based on resident record review, the facility failed to ensure that an individualized service plan (ISP) was updated as needed for a change in a residents condition.

Evidence

The record for resident 1 has an assessment of serious cognitive/mental impairment form dated and signed by the residents physician on 05/06/2025 that has documentation that the resident has a serious cognitive impairment due to a primary diagnosis of dementia and has agitation at times. Documentation in progress notes in the record for resident 1 has documentation of the resident displaying agitated/aggressive behaviors on 05/19/2025, 05/20/2025, 05/29/2025 and 06/01/2025. The ISP signed on 05/07/2025 in the record for resident 1 does not have documentation of the identified need or services to be provided for resident 1’s behaviors.

Plan of correction

DCS, ADCS, and/or designee will audit active residents ISPs to ensure that comprehensive ISPs display the resident-identified needs. To be Corrected: 8.31.25 Action Items: 1.DCS and/or designee will review all resident UAI/ISP for accuracy in psychosocial status and behaviors for accuracy. 2.Result findings will be reviewed and updated as needed for accuracy. 3.Resident #1 chart will be reviewed and corrected to reflect current needs.

June 17, 2025Complaint survey1 violation

Inspection dates

06/17/2025

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/17/2025 8:40am until 3:30pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A Complaint was received by VDSS Division of Licensing on 05/14/2025 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: 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 interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. However, violation(s) not related to the complaint but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations

22VAC40-73-480-E

Based on resident record review and staff interview, the facility failed to ensure that physician’s or other prescriber's orders, services provided, evaluations of progress, and other pertinent information regarding rehabilitative services were recorded in the resident's record.

Evidence

The record for resident 1 has documentation in progress notes dated 05/15/2025 at 14:52 of a new physician order for an urgent ortho consult for radial neck fracture that was scheduled for 05/19/2025 at 8:20am and that resident 1’s daughter will be providing transport. The record for resident 1 does not have documentation of the physician notes from this visit to include any services provided, evaluations or progress, or any pertinent information of any rehabilitative services to be provided. Interview with staff person 2 on the day of on-site inspection expressed that resident 1 had gone to the ortho appointment on 05/19/2025 but that the facility had not obtained any appointment notes as of the day of inspection.

Plan of correction

DCS, ADCS, and/or designee will document pertinent information in resident records regarding orders, services, evaluations of progress, and other pertinent information regarding rehabilitative services. To be Corrected: 8.31.25 Action Items: 1.Charge nurse or designee will notate in clinical record on receipt of orders, services, evaluations, and other pertinent information regarding resident care. 2.Chart reviews will be conducted routinely to ensure adherence. 3.Resident #1 chart will be reviewed and corrected to reflect current needs.

June 17, 2025Complaint survey2 violations

Inspection dates

06/17/2025

Areas reviewed

22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/17/2025 8:40am until 3:30pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A Complaint was received by VDSS Division of Licensing on 06/09/2025 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: 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: 13 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations

22VAC40-73-680-C

Based on observation during morning medication administration, facility medication management plan review, resident record review, and staff interview, the facility failed to ensure that medications shall be administered not earlier than one hour before and no 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

The facility’s medication management plan, provided during on-site inspection on 06/17/2025, states that the community should commence medication administration, assistance or observation within sixty (60) minutes before the designated times of administration and sixty (60) minutes after the designated times of administration.
During observation of morning medication administration during on-site inspection on 06/17/2025 by staff person 1 to resident 1, the licensing inspector (LI) observed the staff person administer the resident’s 8:00AM medications at 9:04am. Resident 1 resides on the memory care unit of the facility.
At approximately 9:15am staff person 2, who was administering medications for residents residing on the 2nd floor of the facility, expressed to the LI that she still had not administered 8:00AM medications to residents 2, 3, 4, 5, 6 and 7.
At approximately 9:30 am staff person 3, who was administering medications for residents residing on the 3rd floor of the facility, expressed to the LI that they still had 8:00am medications to administer for resident 8.
At approximately 10:15am the LI observed that staff person 3 still had 9:00am medications to administer for residents 9, 10, 11 and 12.

Plan of correction

Medication administration times will be reviewed for accuracy and execution. Noted concerns will be addressed for compliance. To be Corrected: 8.31.25 Action Items: 1. DCS/Charge Nurse/Designee will review medication administration times to physicians orders to ensure compliance. Adjustments will be made as needed to gain compliance. 2. Medication administration audit report will be reviewed routinely for late medication administration. Entries will be rectified. 3. Charge nurses will be trained on utilization of clinical dashboard to identify late entries during current shift and rectify. 4. Medication management plan will be reviewed for accuracy and updated as needed. 5. Follow up on report findings for resolution.

22VAC40-73-640-A

Based on resident record review and staff interview, the facility failed to implement their medication management plan (MMP) 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

The facility’s MMP, provided during on-site inspection on 06/17/2025, states that only authorized Community staff may reorder medications from the pharmacy. The community staff should review all on-demand medications daily and re-order when a 5-day supply of the medication is remaining. Emergency refills must be called to the pharmacy. The community should indicate the date and time the medication is needed.
The June 2025 medication administration record (MAR) for resident 13 has documentation of a number nine (9) at 8am from 06/14/2025 through 06/17/2025 for the prescribed medication Rosuvastatin Calcium 40mg daily. The legend on the MAR indicates that the “9” means other/ see progress notes. Progress notes for this medication has documentation that a new script is needed and that the medication has been ordered/waiting for medication from pharmacy.
Interview with staff person 2 on the day of on-site inspection expressed that the medication is not available in the facility to administer to resident 13.

Plan of correction

Director of Clinical Services and/or designee to complete daily audit of administration compliance, Director of Clinical Services to provide medication management plan in-service for RMAs and LPNs- to be monitored by Director of Clinical Services and ED. To be Corrected: 8.31.25 Action Items: 1. DCS and ADCS will be educated on medication management plan. 2. DCS and ADCS will provide education on medication management plan to all LPNs and RMAs. 3. DCS AND ADCS will complete daily medication administration audit report review to assure compliance with medication management plan. 4. Follow up on report finding for resolution.

March 12, 2025Inspection2 violations

Inspection dates

03/12/2025

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: 03/12/2025 9:00am until 1:00pm 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 regarding allegations in the area(s) of: Resident care and related services Number of residents present at the facility at the beginning of the inspection: 86 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 some, but not all of the self-report; 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 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. 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations

22VAC40-73-680-D

Based on observation of the medication cart, staff interview and resident record review, the facility failed to ensure medications shall be administered in accordance with the physician’s or other prescriber’s instructions.

Evidence

The record for resident 1 contains a report of resident physical examination signed by a physician, dated 11/08/2024, that indicates the resident is prescribed Bupropion XL (generic for Wellbutrin) 300MG once daily for depression. The record also has documentation that the resident had a visit with Collateral 1 on 01/24/2025 and that Collateral 1 increased Bupropion XL to 450MG daily for mood (take one 300MG tablet along with 150MG tablet).
There is a psychopharmacologist medication treatment plan, signed and dated by a physician on 02/10/2025, for Bupropion ER 300MG once daily for depression, which is the most recent signed physician order for this medication in the record for resident 1 as confirmed by staff persons 1 and 2 during an interview with both LI’s on 03 12 2025.
The February and March 2025 medication administration record (MAR) for resident 1 contains documentation that the resident was administered Bupropion HCL ER (XL) 450MG at 9:00AM daily from 02/01/2025 through 03/11/2025 with exception to an omission on 03/07/2025.
At approximately 12:55PM on 03/12/2025, staff person 3 showed the two licensing inspectors (LIs) and staff person 2 a container of Bupropion XL 300MG and a container of Bupropion XL 150MG and each label states to take one tablet every day. Staff person 3 stated that the resident receives one tablet of each medication once daily in the mornings which equals the 450mg dose.

Plan of correction

POC= DCS, ADCS, and/or designee will audit all MAR to ensure accuracy to most current signed POS. To be Corrected: 5/30/2025 Action Items: 1. LPNs and RMAs will be in-serviced on medication management plan 2. Medication administration audit report will be reviewed routinely for missed entries; identified missed entries will be rectified. 3. Charge nurses will be trained on utilization of clinical dashboard to identify missed entries during current shift and rectify. 4. Follow up on report finding for resolution.

22VAC40-73-450-F

Based on facility documentation, resident record review, and staff interview, 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

The licensing inspector (LI) received a self-reported incident via email on 12/02/204 that there was an incident that occurred with resident 1 in the facility on 12/01/2024 that prompted the resident to be sent out for a medical evaluation due to the resident having suicide ideations. The incident report included that the facility’s follow-up actions, or care would be q2 checks to monitor resident.
The February and March 2025 medication administration records (MARs) for resident 1 contain documentation that staff are providing 2 hour checks every shift on the resident for monitoring. Interview with staff person 1 confirmed that the 2 hour checks every shift were prompted due to the 12/01/2024 incident. Also, staff person 1 informed the licensing inspectors (LIs) that resident 1 is now receiving services from a psychiatrist.
The ISP in the record for resident 1, signed and dated by staff person 1 and a family member of the resident on 11/22/2024, does not include that the resident is to receive q2 checks and that the resident is receiving services from a psychiatrist. Interview with staff person 1 confirmed that the resident’s ISP was not updated to include this information.

Plan of correction

POC= DCS and/or designee will review all charts to ensure that significant changes have been addressed in individualized services plans. To be Corrected: 5/30/2025 Action Items: 1. Resident 1 ISP will be corrected. 2. DCS and ED will review all ISP to ensure proper identification of needs and services.

March 12, 2025Inspection0 violations

Inspection dates

03/12/2025

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

A self-reported incident was received by VDSS Division of Licensing on regarding allegations in the area(s) of: Resident care and related services Number of residents present at the facility at the beginning of the inspection: 86 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

March 11, 2025Complaint survey3 violations

Inspection dates

03/11/2025

Areas reviewed

22VAC40-73 GENERAL PROVISIONS22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03/11/2025 9am until 5pm 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 02/25/2025 regarding allegations in the area(s) of: Staffing and supervision, resident care and related services Number of residents present at the facility at the beginning of the inspection: 86 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 16 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations

22VAC40-73-680-D

Based on resident record review and staff interview, the facility failed to ensure that medications were administered in accordance with physician instructions.

Evidence

The record for resident 16 has documentation of a physician order dated 02/20/2025 for B12 1000mcg IM daily for 7 days then weekly for 6 weeks for Vitamin B12 deficiency.
The February 2025 medication administration record (MAR) for resident 16 does not have documentation of this medication being administered on 02/22/2025 and 02/24/2025. In an interview with both LI’s and staff person 3 conducted on 03/11/2025, staff person 3 expressed that they were aware of the missed doses on 02/22/2025 and 02/24/2025 and obtained new physician orders on 02/24/2025 to extend the medication to complete the 7-day course that was originally ordered.

Plan of correction

POC= Orders containing a stop date will be reviewed for best practice entry into E.H.R. to ensure course completion of the medication order. Doses that can not be administered will be communicated to the physician in real time to rectify barriers to administration. To be Corrected: 5/30/2025 Action Items: 1.DCS/Charge nurse will review orders to ensure order entry utilization of ‘duration of administration’. 2.DCS and/or designee will educate staff entering orders to utilize ‘duration of administration’ for orders with short term stop dates. 3.Charge nurse will communicate barriers to medication administration to the DCS in a timely manner to ensure MD notification.

22VAC40-73-680-C

Evidence

The facility’s medication management plan, provided during on-site inspection on 03/11/2025, states that the standard administration time for once a day/daily medication on the first and second floors is 8:00AM and on the third floor is 9am.
During observation of morning medication administration during on-site inspection on 03/11/2025 by staff person 1 to resident 1, the licensing inspector (LI) observed the staff person administer the resident’s 8:00AM medications at 9:31AM. Resident 1 resides on the first floor of the facility.
At approximately 9:35AM staff person 1 expressed to the LI that she still had not administered 8:00AM medications to residents 2, 3, 4, 5, 6, and 7 who reside on the first floor of the facility. At approximately 9:55AM, staff person 1 expressed to the LI that she still had not administered 8:00AM medications to residents 4, 6 and 7 who reside on the first floor of the facility.
At approximately 10:30AM staff person 2 expressed to the LI that she still had not administered 9:00AM medications to residents 8, 9, 10, 11, 12, 13, 14 and 15 who reside on the third floor of the facility.

Plan of correction

POC= Medication administration times will be reviewed for accuracy and execution. Noted concerns will be addressed for compliance. To be Corrected: 6/1/2025 Action Items: 1.DCS/Charge Nurse/Designee will review medication administration times to physicians orders to ensure compliance. Adjustments will be made as needed to gain compliance. 2.Medication administration audit report will be reviewed routinely for late medication administration. Entries will be rectified. 3.Charge nurses will be trained on utilization of clinical dashboard to identify late entries during current shift and rectify. 4.Follow up on report finding for resolution.

22VAC40-73-50-A

Based on review of the facility disclosure statement, the facility failed to ensure that information was disclosed accurately in the disclosure statement.

Evidence

The facility disclosure statement has documentation that the number of staff providing direct care per shift is 12 for the 7am to 3pm shift, 12 for the 3pm to 11pm shift and 7 for the 11pm to 7am shift.
The facility daily staffing sheets from 02/23/2025 through 03/10/2025 has documentation that the number of staff providing direct care per shift is 7 for the 7am to 3pm shift, 7 for the 3pm to 11pm shift and 4 for the 11pm to 7am shift. In an interview with 2 licensing inspectors (LI’s) and staff person 3 conducted on the day of inspection, staff person 3 expressed that the daily staffing sheets were correct.

Plan of correction

POC= Disclosure statement will be updated to accurately reflect the direct care staff in the community per shift. To be Corrected: 5/1/25 Action Items: 1. Disclosure statement will be reviewed by ED/BOM and updated to accurately reflect staffing for resident census.

March 11, 2025Inspection18 violations

Inspection dates

03/11/2025, 03/12/2025

Areas reviewed

22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY32.1 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

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: 03/11/2025 9am until 5pm and 03/12/2025 9am until 2pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 86 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 11 Number of staff records reviewed: 6 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 6 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations

22VAC40-73-1180-B

Based on observations during a walk-through of the facility’s safe secure environment, the facility failed to ensure when there are indications that ordinary materials or objects may be harmful to a resident, these materials or objects shall be inaccessible to the resident except under staff supervision.

Evidence

At approximately 10:42am during on-site inspection conducted on 03/11/2025, two licensing inspectors (LIs) observed room 236 on the facility safe, secure unit to be unlocked. The room contained a bucket of paint, a container of drywall plaster/mud and the air condition cover was noted to be off and electrical wires were exposed.
At approximately 10:46AM during on-site inspection on 03/11/2025, two licensing inspectors (LIs) and staff persons 3 and 4 observed a bottle of Gain Febreze Air Mist sitting on the windowsill in the bedroom in resident 2’s room.

Plan of correction

POC= Routine rounds will be conducted by designee to ensure that harmful materials or objects are not accessible to residents without staff supervision. To be Corrected: 6/1/2025 Action Items: 1.ED/EVS/DCS/designee will conduct routine rounds on safe secure unit and secure any materials or objects that may be harmful to residents. 2.All staff will be educated in consistent monitoring practices to ensure such materials or objects are not made accessible to residents without staff supervision.

22VAC40-73-660-B

Based on resident record review, resident interview, staff interview and observation, the facility failed to ensure 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

The UAI for resident 1, dated 04/05/2024, indicates that the resident requires their medications to be administered/monitored by a lay person – registered medication aide, licensed practical nurse, or a registered nurse. At approximately 9:30AM during on-site inspection on 03/11/2025, the licensing inspector (LI) and staff person 1 observed a container of Voltaren Arthritis Pain diclofenac sodium 1% NSAID arthritis pain reliver topical gel sitting on the resident’s bathroom sink. During an interview with the resident, the LI and staff person 1, the resident stated that she uses the Voltaren topical gel on her neck because she has neck pain. The record for resident 1 does not contain a physician’s order that the resident may have and self-administer Voltaren topical gel. Interview with staff person 5 confirmed this is accurate.
The UAI for resident 8, dated 11/25/2024, indicates that the resident requires their medications to be administered/monitored by a lay person – registered medication aide or licensed practical nurse. At approximately 10:38am during on-site inspection on 03/11/2025, 2 LI’s and staff persons 3 and 4 observed a plastic cup sitting out on the dresser in resident 8’s room. The cup was labeled “Halls Drops” and contained numerous cough drops in the cup. Resident 8 resides on the facility safe, secure unit.
The UAI for resident 7, dated 09/12/2024, indicates that the resident requires their medications to be administered/monitored by a lay person – registered medication aide or licensed practical nurse. At approximately 10:40am during on-site inspection on 03/11/2025, 2 LI’s and staff persons 3 and 4 observed a Equate Honey Lemon Cough Drops bag containing numerous cough drops sitting out on the bed side table in resident 7’s room. Resident 7 resides on the facility safe, secure unit.

Plan of correction

POC= DCS/ED/Designee will conduct routine audits of residents identified as self-medication administration to ensure compliance with securing medications in apartment. Additional apartment audit will be conducted to ensure medications are not available at bedside for residents identified as needing medication administration support on the UAI. To be Corrected: 6/1/2025 Action Items: 1.DCS/ED/Designee will educate staff on proper practices for securing medications in the apartment. 2.DCS/ED/Designee will routinely conduct audits to ensure adherence to proper practices to secure medications in apartments. 3.ED will formally communicate with residents and families regarding community practices for securing medications at the bedside.

22VAC40-73-930-D

Based on resident record review and staff interview, for each resident with an inability to use the signaling device, in addition to any other services, the facility failed to ensure once the resident has gone to bed each evening until the resident has arisen each morning, at a minimum, direct care staff shall make rounds no less than every two hours, except that rounds may be made on a different frequency if requested by the resident and agreed to by the facility and the facility shall document the rounds that were made, which shall include the name of the resident, the date and time of the rounds, and the staff member who made the rounds and the documentation shall be retained for two years.

Evidence

During an interview with staff person 5 and 2 licensing inspectors (LI) during on-site inspection on 03/12/2025, staff person 5 stated that residents 4 and 8 require rounding due to the resident’s inability to use the signaling device. The ISP for resident 4, dated and signed by staff person 5 on 03/18/2024 and the ISP for resident 8, dated signed by staff person 5 on 12/10/2024 do not include that the residents require rounding. Interview with staff person 5 confirmed that the ISP’s in the records for residents 4 and 8 were the most current and does not include this information.

Plan of correction

POC= DCS/Designee will ensure all resident care rounding is completed and documented as ordered. Documentation compliance will be routinely monitored to ensure care is received. To be Corrected: 6/1/2025 Action Items: 1. DCS/Designee will audit all resident records that require rounding due to inability to use call device to ensure records identify the need for safety checks and rounding at least every 2 hours or as specified by RP. 2. DCS/Designee will routinely review documentation of rounding to ensure compliance and address concerns accordingly.

22VAC40-90-40-F

Based on staff record review and staff interview, the facility failed to ensure that a criminal history record report issued by the State Police was not accepted by the facility if the report is dated more than 90 days prior to the date of employment.

Evidence

The record for staff person 6, hired at the facility on 05/28/2024, has documentation of a criminal history record being completed on 06/06/2023, which is past 90 days from the date of this employees employment with the facility. In an interview with staff person 9 conducted on 03/12/2025, it was determined that there were no additional criminal history records for review for staff person 6.

Plan of correction

POC= All future hires will have a criminal history record report issued by the State Police prior to start of hire. To be Corrected: 4/1/2025 Action Items: 1. HR/ED/Designee will audit all current files to ensure compliance. Concerns identified will be addressed to resolve. 2. All future hires will have a criminal history record report reviewed by ED and HR to ensure report is dated within 90 days of hire. New reports will be requested as needed.

22VAC40-73-660-A-1

Based on observation and staff interview, the facility failed to ensure a medicine cabinet, container, or compartment that is used for storage of medications and dietary supplements prescribed for residents when such medications and dietary supplements are administered by the facility shall be locked.

Evidence

At approximately 9:52AM during on-site inspection on 03/11/2025, two licensing inspectors (LIs) observed that the first-floor medication cart was sitting unlocked and unattended. At approximately 9:55AM, staff person 1, the assigned medication staff person for the first-floor medication cart, was observed coming out of a resident’s room and acknowledged that she had left the medication cart unlocked and unattended.

Plan of correction

POC= Staff person 1 will receive education on proper storage and securing of medication(s) and medication cart when not attended. Random checks will be completed and documented to ensure continued compliance. To be Corrected: 4/1/2025 Action Items: 1. DCS will provide documented education to staff person 1 regarding safe storage of medications. 2. DCS will randomly audit staff person 1 for continued compliance and document results of audit.

22VAC40-73-560-E

Based on resident record review and staff interview, the facility failed to ensure all resident records shall be kept current and retained at the facility.

Evidence

record for resident 2 contains a physician’s order, dated 03/04/2025, to cleanse wound to BIL great toes with wound cleanser, pat dry apply bacitracin, cover with primapore dressing, may use equivalent products. During an interview with staff person 5, staff person 5 stated that Collateral 1 is the entity that would be providing the wound care but the record for resident 2 did not contain any documentation from Collateral 1 of the wound care being provided. Interview with staff person 5 revealed that there was no documentation at the facility to provide to the licensing inspector (LI) that Collateral 1 has provided any wound care to resident 2.

Plan of correction

POC= DCS/ designee will ensure all resident records will be kept current and retained at the facility if care services are being shared with a third-party provider at the community level. To be Corrected: 6/1/2025 Action Items: 1. DCS/designee will hold routine meetings with third-party vendor services. 2. DCS/designee will ensure that third-party vendor service records are made available on-site. 3. DCS/designee will identify the location of records in the ISP of all residents receiving services. 4. Follow up on report finding for resolution.

22VAC40-73-320-A

Based on resident record review, the facility failed to ensure all required information was included on residents physical examination reports.

Evidence

The physical examination report dated 09/17/2024 in the record for resident 7, admitted to the facility safe, secure unit on 09/20/2024, is incomplete as it does not have documentation as to whether the resident is capable of administering their own medications. The physical examination also has documentation that the resident is ambulatory (physically and mentally capable of evacuating the building in an emergency) which makes it unclear as to the residents placement in a safe, secure unit for residents with serious cognitive impairments.

Plan of correction

POC=All resident records will be reviewed for completeness and accuracy. To be Corrected: 6/1/2025 Action Items: ACTION ITEMS: 1. Resident #7 record will be updated for clarity. 2. ED/DCS/Designee will review all current residents to ensure all required information is included on physical examination reports. 3. Follow up on report findings for resolution. 4. New resident physical examination reports will be reviewed for completion and accuracy prior to physical possession.

22VAC40-73-280-A

Based on resident record review and staff interview, the assisted living facility failed to ensure to have staff adequate in knowledge, skills, and abilities and sufficient in numbers to provide services to attain and maintain the physical, mental, and psychosocial well-being of each resident as determined by resident assessments and individualized service plans, and to ensure compliance with this chapter.

Evidence

The record for resident 1 contains a signed physician’s order, start date 02/18/2025, to cleanse sacrum pressure wound w/ NSS, pat and apply Hydrocellular Foam dressing every 3 days and PRN (as needed) for dislodgement every 24 hours as needed for dislodgement and every evening shift every 3 days for pressure area and the order state date was 02/18/2025.
The February and March 2025 treatment administration records (TARs) for the resident contain documentation that the resident is receiving this treatment during the evening shift. Interview with staff person 5 revealed that a licensed health care professional must provide the aforementioned treatment to the resident.
The February 2025 TAR for resident 1 contains the initials of staff person 11 and the number 9 during the evening on 02/24/2025. Staff person 5 revealed that the number 9 on the TAR means that the resident did not receive the treatment. staff person 11 also stated that staff person 11 is not a licensed health care professional. Staff person 5 reviewed the schedule for the evening shift of 02/24/2025 and revealed that the licensing health care professional that was supposed to work during this shift called out; therefore, there was no licensing health care professional in the facility on the evening shift to provide the ordered treatment to resident 1.

Plan of correction

POC-ED/DCS will routinely review census and resident acuity to ensure to have staff adequate in knowledge, skills, and abilities and sufficient in numbers to provide services to attain and maintain the physical, mental, and psychosocial well-being of each resident as determined by resident assessments and individualized service plans. To be Corrected: 6/1/2025 Action Items: 1. ED/DCS will review census, acuity, and staffing daily during routine meetings 2. Ed/DCS will hold a weekly review of census assessment review for accuracy and projected staffing needs. 3. Third party vendor services will be secured to support resident care needs as deemed appropriate. 3. Follow up on all report/meeting findings for resolution.

22VAC40-73-450-F

Based on resident record review and staff interview, 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

The record for resident 4 contains a Durable Do Not Resuscitate Order dated 10/31/2024. The ISP for resident 4, signed by staff person 5 on 03/18/2024 and resident 4’s family member on 03/19/2024, does not include that the resident has a Durable Do Not Resuscitate Order. Interview with staff person 5 confirmed that the resident’s ISP has not been updated to reflect the resident’s Do Not Resuscitate Order. The same ISP for resident 4 contains documentation that the resident is receiving physical therapy, date initiated 03/07/2024, and speech language pathology, dated initiated 10/03/2022; however, interview with staff person 4 revealed to the licensing inspector (LI) that the resident stopped receiving physical therapy on 02/21/2025 and speech language pathology on 05/09/2024.
The record for resident 7 has documentation on a report of resident physical examination dated and signed by the physician on 09/17/2024 that resident 7 has a do not resuscitate order (DNR). The ISP, dated and signed by staff person 5 on 09/26/2024 does not include that the resident has a DNR order.

Plan of correction

POC=DCS, ADCS, and/or designee will audit active residents ISPs to ensure that comprehensive ISPs display the resident-identified needs. To be Corrected: 6/1/2025 Action Items: 1. DCS/Designee will review all current resident ISPs to ensure code status is properly reflected. 2. DCS/Designee will review all current resident ISPs to ensure 3rd party vendor services are properly reflected. 3. Corrected ISPs will be signed and placed on the resident chart. 4. Routine meetings will be held with 3rd party vendors to ensure ISPs are properly maintained. 5. Individual residents ISPs will be updated with a change in code status at the time the status changes.

22VAC40-73-650-B

Based on resident record review and staff interview, the facility failed to ensure physician or other prescriber orders, both written and oral, for administration of all prescription and over-the-counter medications and dietary supplements shall include the name of the resident, the date of the order, the name of the drug, route, dosage, strength, how often medications is to be given, and identify the diagnosis, condition, or specific indications for administering each drug.

Evidence

The record for resident 2 contains a physician’s order, dated 03/04/2025, to cleanse wound to BIL great toes with wound cleanser, pat dry apply bacitracin, cover with primapore dressing, may use equivalent products. The order does not include how often the resident is supposed to receive the treatment and does not include the diagnosis, condition, or specific indications for administering the medication.

Plan of correction

POC= Resident 2 record will be reviewed and incomplete order will be clarified to include name of the resident, the date of the order, the name of the drug, route, dosage, strength, how often medications is to be given, and identify the diagnosis, condition, or specific indications for administering each drug. To be Corrected: 4/1/2025 Action Items: 1.DCS will connect with the prescribing physician to obtain order clarification. 2.DCS will provide education to the prescribing physician to reduce recurrence of incomplete orders

22VAC40-73-1090-A

Based on resident record review, the facility failed to ensure that prior to admission to a safe, secure environment, a resident was assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare.

Evidence

The record for resident 7, admitted to the facility safe, secure unit on 09/20/2024 has documentation of an assessment of serious cognitive impairment completed by a physician dated 09/17/2024. The assessment has documentation that resident 7 does not have a serious cognitive impairment due to a primary psychiatric diagnosis of dementia, which makes it unclear if resident 7 is appropriate for placement in a safe, secure unit.

Plan of correction

POC= All residents admitted to the safe secure environment will have an assessment that accurately reflects the residents need due to having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare. To be Corrected: 6/1/2025 Action Items: 1.Resident #7 chart will be corrected by DCS and physician. 2.DCS/Designee will audit all current residents chart to ensure resident was assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare. Corrections will be made as needed. 3.DCS/designee will ensure residents are assessed prior to moving into a safe secure unit to have the proper assessment completed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician.

22VAC40-73-640-A

Based on resident record review, staff interview and medication management plan review, the facility failed to ensure to implement its medication management plan.

Evidence

The facility’s medication management plan provided during on-site inspection states that the facility’s methods to ensure 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 are that only authorized community staff may reorder medications from the pharmacy, the community staff should review all on-demand medications daily and re-order when a 5 day supply of the medication is remaining, emergency refills must be called to the pharmacy, and the community should indicate the date and time the medication is needed. The record for resident 1 contains a physician’s order, dated 07/15/2024, for certavite senior tablet multiple vitamins with minerals give 1 tablet by mouth one time a day for supplement. The March 2025 medication administration record (MAR) for the resident indicates that this medication is given to the resident daily at 8:00AM. During observation of the morning medication administration during on-site inspection on 03/11/2025, staff person 1 informed the licensing inspector (LI) that this medication was not available to administer to the resident and the March 2025 MAR for this medication on 03/11/2025 at 8:00AM contains the staff person’s initials and the number 9 that indicates the medication was not administered to the resident.
The facility’s medication management plan states that its methods to prevent the use of outdated, damaged, or contaminated medications are that the community should ensure that medications and biologicals have an expiration date on the label, have not been retained longer than recommended by manufacturer or supplier guidelines, and once any drug or biological package is opened, the community should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. During an audit of the medication cart on the facility safe, secure unit, two licensing inspectors (LIs) and staff person 1 observed that the Lantus Solostar insulin pen and the Aspart Insulin pen (generic for Novolog) for resident 2 did not contain an open date or expiration date and observed that the pens had already been used based on the location of the plunger inside of the pen. The March 2025 medication administration record (MAR) for resident 2 contains documentation that the resident has been administered both insulins during the month. During Interviews with staff persons 1, 3, 4, and 5 and two LIs, all staff persons acknowledged that these insulin pens have an expiration date once taken out of the refrigerator and opened and that the facility’s method is to write the date on the pen the date that it is first used.

Plan of correction

POC= DCS/ designee to complete routine audit of administration compliance. DCS to provide medication management plan in-service for RMAs and LPNs- to be monitored by DCS and ED. To be Corrected: 6/1/2025 Action Items: 1.LPNs and RMAs will be in-serviced on medication management plan and monitoring practices. 2.DCS and ADCS will be in-serviced on order listing report. 3.Order listing report reviewed in daily department head meeting and stand up for review of new orders. 4.DCS and ADCS will be in-serviced on medication/treatment administration audit and reports. 5.Medication/treatment administration audit report will be reviewed daily for missed entries identified missed entries will be rectified. 6.Charge nurses will be trained on utilization of clinical dashboard to identify missed entries during current shift and rectify. 7.DCS and ADCS will complete daily medication administration audit report review to assure compliance with medication management plan. 8.Follow up on report finding for resolution.

22VAC40-73-1140-B

Based on staff record review and staff interview, the facility failed to ensure within four months of the starting date of employment in the safe, secure environment, direct care staff shall attend at least 10 hours of training in cognitive impairment.

Evidence

Staff person 7 was hired on 08/05/2024. Interview with staff person 5 revealed that staff person 7 has worked in the facility’s safe, secure environment since their date of hire.
The record for staff person 7 contains documentation of this staff person only completing 5.5 hours of cognitive impairment training within four months of their date of hire.
Interview with staff person 9 confirmed this is accurate.

Plan of correction

POC= HR/ED/Designee will monitor all active staff members continuing education during the first four months of hire to ensure at least 10 hours of training on cognitive impairment have been completed. To be Corrected: 6/1/2025 Action Items: 1.HR/ED/Designee will audit all current staff records and rectify training hours for cognitive impairment as needed. 2.HR/DCS/Designee routinely review new hire team member training to ensure all new hires receive required cognitive impairment training within form months of hire.

22VAC40-73-325-B

Based on resident record review, the facility failed to ensure that a fall risk rating was completed at least annually for resident who meet the criteria for assisted living care.

Evidence

The uniform assessment instrument (UAI) dated 06/12/2024 in the record for resident 5 has documentation that the resident is assessed as assisted living level of care. The record for resident 5 has documentation that the last fall risk rating completed for this resident was dated 09/29/2023. In an interview on 03/12/2025 with staff person 5, staff person 5 expressed that this was correct and no subsequent fall risk ratings were available for review.

Plan of correction

POC=Annual fall risk assessments will be routinely scheduled in the EHR for timely completion. To be Corrected: 6/1/25 Action Items: 1. Resident #5 annual fall risk rating will be completed by the DCS. 2. All resident records will be audited by DCS for completion of annual fall risk ratings. 3. DCS will schedule an annual fall risk rating review for all current residents going forward to align with annual UAI assessments. 4. Follow up on report finding for resolution.

22VAC40-73-680-D

Based on resident record review, staff record review, staff interview and morning medication administration observation, the facility failed to ensure medications shall be administered in accordance with the physician’s or other prescriber’s instructions.

Evidence

The record for resident 1 contains a physician’s order, dated 02/04/2025, for lactase tablet 0.5MG give 1 tablet by mouth before meals for possiblelactose intolerance. During the morning medication administration during on-site inspection on 03/11/2025, the licensing inspector (LI) observed staff person 1 place this medication in the cup for resident 1 along with the resident’s other 8:00AM morning medications. The LI asked staff person 1 if the resident had eaten breakfast and the staff person stated that the resident had already eaten breakfast. The staff person then proceeded to administer the resident this medication at 9:31AM.
The February 2025 medication administration record (MAR) for resident 10 indicates that Gabapentin 100MG is scheduled for the resident daily at 8:00AM and 1:00PM and Gabapentin 300MG is scheduled for the resident daily at 6:00PM. The record for staff person 7 contains a medication error report, dated 02/03/2025, that on 02/03/2025 at 9:00AM staff person 7 gave resident 10 a 300MG Gabapentin capsule instead of a 100MG Gabapentin capsule per the physician’s order.

Plan of correction

POC= DCS/Designee will educate all staff on medication management plan regarding following physician instructions when administering medications. To be Corrected: 6/1/2025 Action Items: 1. DCS/Designee will hold staff education sessions to educate LPNs and RMAs on medication administration regarding following specialized instructions. Attendance will be documented. 2. DCS/Designee will conduct random medication pass audits to ensure compliance is maintained. Audits will be documented and provided education noted.

22VAC40-73-270-1

Based on staff record review and staff interview, the facility failed to ensure that direct care staff shall be trained in methods of dealing with residents who have a history of aggressive behavior or of dangerously agitated states prior to being involved in the care of such residents.

Evidence

Staff person 7 was hired on 08/05/2024. Interview with staff person 5 revealed that the facility does have residents in care who do have aggressive behaviors.
The record for staff person 7 contains documentation that they did not complete aggressive behavior training conducted by staff person 5 until 09/12/2024; however, staff person 7 had already been working in the facility providing direct care to residents prior to receiving aggressive behavior training.
Interview with staff person 9 confirmed this is accurate.

Plan of correction

POC= DCS, HR and/or designee ensure all staff receive in-person aggressive behavior training on hire and annually thereafter. To be Corrected: 6/1/2025 Action Items: 1. DCS/HR/Designee will audit all current staff records to ensure compliance. 2. DCS/HR/Designee will secure/provide aggressive behavior training to staff in need. 3. DCS/HR/Designee will ensure aggressive behavior training is conducted within first 30 days of hire and annually thereafter.

22VAC40-73-350-B

Based on resident 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 or in fact stays longer than three days.

Evidence

The record for resident 7, admitted to the facility on 09/20/2024, has documentation that a sex offender screening was not completed until10/28/2024.

Plan of correction

POC= CRD, ED, BOM and/or designee will audit all current records to assure compliance. All new residents will have a sex offender screening completed prior to admission to the community. To be Corrected: 6/1/25 Action Items: 1. CRD, ED and BOM will review all resident records for completed sex offender screenings. 2. BOM will upload all resident records to share drive. 3. BOM will send ED link to records with the check off form for review and approval. 4. ED will upload check off form to share drive once approved. 5. Follow up on report findings for resolution.

22VAC40-73-100-C-2

Based on observations of the facility medication carts, the facility failed to implement their infection control policy in regard to blood glucose monitors.

Evidence

At approximately 11:14am during on-site inspection conducted on 03/11/2025, the medication cart located on the facility safe, secure unit was observed to contain a blood glucose monitor in an open box that was not labeled with any information as to who the monitor belonged to.
The licensing inspector requested the facility infection control policy for review. The policy named “Nursing Policies & Procedures Manual, General Care, Blood Glucose Test” has documentation under number 8. that “each resident should have his/her own glucometer labeled with their full name and apartment number”.

Plan of correction

POC=DCS/designee will educate all RMAs and LPNs on the infection control policy related to blood glucose monitors/monitoring. Random observation audits will be conducted to enforce policy and procedure adherence. To be Corrected: 6/1/25 Action Items: 1. DCS/Designee will provide review of the glucose monitoring policy to all RMAs and LPNs which will be documented on in-service education logs. 2. Random observations will be conducted to ensure adherence with 1:1 education during observations as needed to reinforce education. 3. Follow up on report findings for resolution.

March 11, 2025Inspection1 violation

Inspection dates

03/11/2025

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: 03/11/2025 8:40am until 12:30pm 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 regarding allegations in the area(s) of: Resident care and related services Number of residents present at the facility at the beginning of the inspection: 86 Number of resident records reviewed: 1 Number of staff records reviewed: 2 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations

22VAC40-73-680-B

Based on facility documentation, resident records and staff interviews, the facility failed to ensure that medications were removed from the pharmacy container, or the container shall be opened, by a staff person licensed, registered, or acting as a medication aide on a provisional basis as specified in 22VAC40-73-670 and administered to the resident by the same staff person.

Evidence

A facility incident report has documentation that on 12/26/2024 staff person 1, who is a registered medication aide, crushed medications and placed them apple sauce for resident 1 and attempted to administer the medications but resident 1 refused. Staff person 1 then handed the prepared medications to staff person 2, who is not a registered medication aide, to administer them to resident 1 while they were feeding the resident breakfast.
In an interview conducted on 03/11/2025 with 2 licensing inspectors and staff person 2, staff person 2 explained that they were sitting at the dining room table with resident 1 feeding them breakfast when staff person 1 approached them and handed a plastic cup with crushed medications in apple sauce to staff person 2 and asked staff person 2 to give them to resident 1. Staff person 2 expressed that they did give the mixture that was in the plastic cup to resident 1.

Plan of correction

POC= DCS, ADCS, and/or designee will educate all clinical team members to assure medication management compliance with properly administering medications by qualified staff. Staff will receive education on the medication management plan for continued compliance. To be Corrected: 5/30/2025 Action Items: 1. DCS will provide education on medication management plan to all LPNs and RMAs. 2. DCS and/or designee will complete random medication pass observations to ensure compliance to MMP and the 5 rights of medication administration 3. LPN, RMA, CNA will be educated on scope of practice and proper delegation within scope

March 11, 2025Complaint survey0 violations

Inspection dates

03/11/2025

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03/11/2025 9:00am until 1:30pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 02/25/2025 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: 86 Number of resident records reviewed: 1 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

March 11, 2025Inspection0 violations

Inspection dates

03/11/2025

Areas reviewed

22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Comments

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03/11/2025 9:00am until 1:00pm 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 regarding allegations in the area(s) of: ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Number of residents present at the facility at the beginning of the inspection: 86 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

March 11, 2025Inspection0 violations

Inspection dates

03/11/2025

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: 03/11/2025 9:00am until 1:00pm 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 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: 86 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of staff 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 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

March 6, 2024Inspection11 violations

Inspection dates

03/06/2024

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 PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY32.1 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

Type of inspection: Renewal Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03/06/2024 8:30am until 5:30pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 66 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: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 4 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations

22VAC40-73-640-A

Based on observations of the morning medication pass and review of the facility medication management plan, the facility failed to ensure implementation of the medication management plan regarding the crushing of mediations.

Evidence

At 8:53am on 03/06/2024 the LI observed the morning medication pass on the facility memory care unit and noted that staff person 1 crushed the 9am medications for resident 7, which included the medication Metoprolol 25mg ER (extended release).
A review of the facility medication management plan noted that the plan has documentation that a pharmacy policy and procedure manual used by the facility is available to all wellness staff on-site for reference and review. The pharmacy policy and procedure manual has documentation on page 48 under 2.7 that The community staff may crush oral medications only in accordance with applicable law, pharmacy guidelines and/or community policy. See Appendix 11: Oral Dosage Forms That Should Not Be Crushed. Appendix 11 on page 104 has documentation that extended-release medications are a oral dosage form that should not be crushed.

Plan of correction

DCS, ADCS, and/or designee to complete daily audit of administration compliance, DCS to provide medication management plan in-service for RMAs and LPNs- to be monitored by DCS and ED. To be Corrected: 5/6/2024 Action Items: 1. DCS and ADCS will be educated on medication management plan. 2. DCS and ADCS will provide education on medication management plan to all LPNs and RMAs. 3. DCS AND ADCS will complete daily medication administration audit report review to assure compliance with medication management plan. 4. Follow up on report finding for resolution.

22VAC40-73-680-K

Based on resident record review, the facility failed to ensure that a detailed medication order that included symptoms to indicate the use of a PRN medication was obtained when medication aides administer PRN medications to residents.

Evidence

The record for resident 3 has a physician order dated 01/29/2024 for Ativan 0.5mg, give 1 tablet by mouth every 8 hours as needed for anxiety. The order does not include symptoms to indicate the use of the medication when medication aides administer the medication.
The uniform assessment instrument (UAI) dated 08/15/2024 has documentation that resident 3 is dependent with medication administration and is disorient to all spheres some of the time. Interview with staff person 4 conducted on 03/06/2024 expressed that this is correct and that resident 3 would not be able to ask for the PRN Ativan medication.
The February and March 2024 medication administration record (MAR) has staff person 6’s initials for administering the PRN Ativan on 02/01/2024 and 03/03/2024. The February 2024 MAR has staff person 1’s initials for administering the PRN Ativan on 02/05/2024. Staff persons 1 and 6 are both noted to be registered medication aides.

Plan of correction

DCS, ADCS, and/or designee will audit all PRN medications for specific symptoms. Any necessitating an assessment, we will contact doctor to rewrite orders with specific symptoms. To be Corrected: 5/6/2024 Action Items: 1. DCS and ADCS will be educated on medication management plan. 2. LPNs and LPNs will be in-serviced on medication management plan and monitoring practices. 3. DCS and ADCS will be in-serviced on order listing report. 4. Order listing report reviewed in daily department head meeting and stand up for review of new orders. 5. DCS and ADCS will be in-serviced on medication/treatment administration audit and reports. 6. Medication/treatment administration audit report will be reviewed daily for missed entries identified missed entries will be rectified. 7. Charge nurses will be trained on utilization of clinical dashboard to identify missed entries during current shift and rectify. 8. DCS and ADCS will complete daily medication administration audit report review to assure compliance with medication management plan. 9. Follow up on report finding for resolution.

22VAC40-73-450-E

Based on resident record review, the facility failed to ensure that individualized service plans (ISP) were signed and dated by the person who developed the plan and by the resident of their legal representative.

Evidence

The ISP dated 02/07/2024 in the record for resident 3 does not have documentation of the resident or their legal representative’s signature. A note on the ISP has documentation that “copy sent via email to RP on 02/02/2024” but the email was unable to be located on the day of inspection to verify if and who the ISP was sent to.
The ISP in the computer record for resident 5 has documentation that the ISP was updated on 01/30/2024 for Falls and Hospice care. The ISP also has documentation of an update on 02/06/2024 for A DNR. The ISP does not have documentation of the signature of the person who updated the ISP or the resident or their legal representative.

Plan of correction

DCS, ADCS and/or designee will review all charts for comprehensive ISPs for signature of individual who completed ISP and resident and/or RP To be Corrected: 5/6/2024 Action Items: ACTION ITEMS: 1. Resident 3 and resident 5 ISPs will be corrected. 2. DCS and ED will review all charts for comprehensive ISPs for signature of individual who completed ISP and resident and/or RP. 3. Follow up on report findings for resolution.

22VAC40-73-680-B

Based on observations of the facility medication carts, the facility failed to ensure that medications remained in the pharmacy issued container with the prescription label or direction label attached until administered to residents.

Evidence

The LI conducted an audit of the medication cart located on the facility memory care unit on 03/06/2024 and observed in the second drawer a plastic cup labeled with “222” with a clear liquid inside, a plastic cup labeled with “223” with a clear liquid inside, a plastic cup with a clear liquid and a powder substance on the bottom of the cup and a plastic measured medicine cup with a pink cream substance. In an interview conducted on 03/06/2024 with staff person 1 in the presence of staff person 3, staff person 1 expressed that the 2 cups labeled with room numbers contained Miralax with water for residents 5 and 7, the cup with the powder substance contained a crushed Potassium pill and water for resident 11 and the plastic measured medicine cup contained Calmoseptine Cream for resident 2. The medications were not in the pharmacy issued containers with the prescription label attached.

Plan of correction

DCS, ADCS, and/or designee will audit all medication carts to assure medication management compliance with dating, storing, signing, and discarding medications per the medication management plan. Staff will receive education on the medication management plan for continued compliance. To be Corrected: 5/6/2024 Action Items: 1. DCS and ADCS will be educated on medication management plan. 2. DCS and ADCS will provide education on medication management plan to all LPNs and RMAs. 3. DCS AND ADCS will complete daily medication administration audit report review to assure compliance with medication management plan. 4. Follow up on report finding for resolution.

22VAC40-73-380-A

Based on resident record review, the facility failed to ensure that required personal and social information was obtained for residents prior to or at the time of admission.

Evidence

The record for resident 1, admitted to the facility on 02/06/2024, does not have documentation that a personal and social data form was completed to include all required information prior to or at the time of admission. Interview with staff person 4 on 03/06/2024 expressed that this is correct and that a personal and social data form has not been completed.

Plan of correction

CRD/ED/BOM and/or designee will audit all current records to assure compliance. All new residents will have personal and social information completed and entered uploaded to share drive prior to admission to the community. To be Corrected: 5/6/2024 Action Items: 1. Resident 1’s personal and social data sheet will be added to resident records. 2. CRD, ED and BOM will review all resident records for completed Personal and Social Data sheets. 3. Follow up on report findings for resolution.

22VAC40-73-440-A

Based on resident record review, the facility failed to ensure that uniform assessment instruments (UAI) were completed as required.

Evidence

The UAI dated 01/22/2024 in the record for resident 1 is checked that the resident has wandering/passive behaviors and is disoriented to some spheres all of the time but the boxes indicating the type of inappropriate behaviors or spheres affected are blank.
The record for resident 2 has documentation that the last Annual UAI that was completed for this resident was dated 11/08/2022. In an interview with staff person 4 on 03/06/2024, staff person 4 expressed that this was correct and no subsequent UAI’s have been completed.
The UAI dated 11/13/2023 in the record for resident 5 is checked that the resident has aggressive, abusive disruptive behaviors but the box indicating the type of inappropriate behaviors is blank.

Plan of correction

DCS, ADCS and/or designee will audit active resident records to ensure a current completed UAI is present and accurate-to be monitored by DCS and ED. To be Corrected: 5/6/2024 Action Items: 1. Resident 1, 2 and 5’s charts will be corrected. 2. DCS and ADCS will review all charts for accurate and completed UAIs. 3. Corrected UAIs will be signed and placed on chart within 24 hours of corrections made. 4. Follow up on report findings for resolution.

22VAC40-73-450-D

Based on a review of resident records, the facility failed to ensure that all coordinated services provided by hospice and by the facility were included on the residents individualized service plans (ISPs).

Evidence

The ISP dated 02/07/2024 in the record for resident 4 has documentation dated 09/02/2023 that the resident is receiving Hospice care but does not address any coordinated services between the facility and hospice or any hospice services that are being provided.
The record for resident 5 has documentation that the resident was admitted to hospice services on 11/29/2023. The ISP in the computer record for resident 5 has documentation dated 01/30/2023 that resident 5 is receiving Hospice care but does not address any coordinated services between the facility and hospice or any hospice services that are being provided.

Plan of correction

DCS, ADCS, and/or designee will audit active resident medical records receiving Hospice Services to ensure that comprehensive ISPs display the resident-identified needs are met via wellness team and hospice team To be Corrected: 5/6/2024 Action Items: 1. DCS, ADSCS and ED will review all charts for comprehensive ISP’s utilizing hospice services. 2. DCS will meet with each hospice provider and amend the ISP to reflect the services provided by hospice to the resident. 3. Corrected ISPs will be signed and placed on chart within 24 hour of changes made. 4. Follow up on report findings for resolution.

22VAC40-73-560-E

Based on resident record reviews, the facility failed to ensure that resident records were kept current.

Evidence

The record for resident 6, admitted on 09/14/2023, did not contain documentation of written acknowledgement of the resident receiving a facility disclosure statement or signed acknowledgement of the resident receiving an orientation to the facility.

Plan of correction

ED, BOM and/or designee will review all resident records to ensure all include signed disclosure statement and orientation acknowledgment. To be Corrected: 5/6/2024 Action Items: 1. ED, BOM and/or designee will meet with resident 6 to review and sign the community disclosure statement and orientation acknowledgement. 2. All resident records will be audited for correct disclosure statements and orientation acknowledgments. 3. BOM and ED will upload resident records to share drive. 4. Follow up on report finding for resolution.

22VAC40-73-350-B

Based on resident record reviews, the facility failed to ascertain prior to admission whether a resident was a registered sex offender.

Evidence

The record for resident 5, admitted to the facility on 11/20/2023, has documentation that a sex offender screening was not completed until 12/21/2023.
The record for resident 6, admitted to the facility on 09/14/2023, has documentation that a sex offender screening was not completed until 10/18/2023.

Plan of correction

CRD, ED, BOM and/or designee will audit all current records to assure compliance. All new residents will have a sex offender screening completed prior to admission to the community. To be Corrected: 5/6/2024 Action Items: 1. CRD, ED and BOM will review all resident records for completed sex offender screenings. 2. BOM will upload all resident records to share drive. 3. BOM will send ED link to records with the check off form for review and approval. 4. ED will upload check off form to share drive once approved. 3. Follow up on report findings for resolution.

22VAC40-73-560-F

Based on observations and staff interviews, the facility failed to ensure that all records were made available for inspection by the department’s representative.

Evidence

On 03/06/2024 at 8:59am the LI supplied staff person 5 with a list of resident records that were being requested for review. This list included the record for resident 7.
Several additional verbal requests for the medical record for resident 7 were made by the LI to staff persons 3, 4 and 5 in the presence of the Licensing Administrator (LA) between 10:30am and 5:00pm on 03/06/2024. During the on-site exit interview conducted at 5:25pm on 03/06/2024 the LI expressed to staff person 3 in the presence of the LA that the record for resident 7 was not produced/made available on the day of inspection. Staff person 3 expressed that they had been unable to locate the medical record for resident 7.

Plan of correction

DCS, ADCS, and/or designee will audit all medical charts to ensure all are kept in their designated areas. To be Corrected: 5/6/2024 Action Items: 1. Resident 7 medical chart will be audited and stored in the designated area. 2. DCS and ED will audit all medical charts to ensure all are in designated areas. 3. Follow up on report finding for resolution.

22VAC40-73-950-E

Based on resident record and facility documentation review, the facility failed to ensure that a review of the facility emergency preparedness and response plan was completed semi-annually with residents.

Evidence

The semi-annual review of the facility emergency preparedness and response plan that was completed with staff on 01/16/2024 does not have documentation that the review was completed with residents. No other documentation was available for review on 03/06/2024 to show that a semi-annual review has been completed with residents.

Plan of correction

ED, ESD and/or designee will review all emergency preparedness and response plans monthly at Resident Council meetings. ED will include a copy to all families and residents via weekly email correspondence. To be Corrected: 5/6/2024 Action Items: 1. ED, ESD and/or designee will review emergency preparedness and response with all residents monthly at Resident Council meeting. 2. ED will include the emergency preparedness and response plan in all weekly email correspondence with families and residents. 3. ED will keep all sign in sheets from resident council meetings in binder in ED office.

September 11, 2023Inspection1 violation

Inspection dates

09/11/2023

Areas reviewed

Comments

Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/11/2023 9:00am until 1:00pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed:5 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations

22VAC40-73-720-A

Based on resident record review and staff interview, the facility failed to ensure that Do Not Resuscitate Orders (DNR) for withholding cardiopulmonary resuscitation from a resident in the event of cardiac or respiratory arrest may only be carried out when the facility has a valid written order that has been issued by the resident’s attending physician.

Evidence

The history and physical dated 07/24/2023 in the record for resident 6 has documentation that the resident is a DNR and to please include Virginia EMS durable DNR Form. During the on-site inspection conducted on 09/11/2023, the record for resident 6 did not contain a written durable DNR form order signed by a physician. Interview with staff 6 confirmed this was accurate.

Plan of correction

The DCS, ADCS, or designee will audit the community to identify all residents requiring a DNR order. All identified residents will have a DNR order written, signed, and placed if absent on audit.

September 11, 2023Complaint survey0 violations

Inspection dates

09/11/2023

Areas reviewed

22VAC40-73 BUILDINGS AND GROUND

Comments

Type of inspection: Complaint Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/11/2023 9:00am until 1:00pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on (date) regarding allegations in the area(s) of: Building and grounds The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the (allegation(s)/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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

June 21, 2023Inspection1 violation

Inspection dates

06/21/2023

Areas reviewed

22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/21/2023 1:15pm until 2:15pm 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 06/17/2023 regarding allegations in the area(s) of: Resident care and related services Number of residents present at the facility at the beginning of the inspection: 78 Number of interviews conducted with residents: 4 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations

22VAC40-73-130-A

Based on facility documentation and staff interviews, the facility failed to ensure that All staff who are mandated reporters under § 63.2-1606 of the Code of Virginia reported suspected abuse, neglect, or exploitation of residents in accordance with that section.

Evidence

A facility self-reported incident was received on 06/17/2023 by the LI. The report has documentation of alleged verbal abuse from a staff person to residents 1 through 5 and that the staff person has been suspended pending investigation.
Interviews were conducted by both LI’s with staff persons 5 and 6 on 06/21/2023. Staff person 5 expressed that a report of suspected abuse had not been completed/sent to the local Adult Protective Services (APS).

Plan of correction

Full investigation completed. Associated team members were terminated. All associated team members were reported to the VA Board of Licensure Community staff training was reinforced as it relates to Mandated reporting/Misappropriation /Abuse/neglect. Community leadership training was reinforced regarding DSS standards and § 63.2-1606 Code of Virginia . APS report was filed on 6/21/23.

June 15, 2023Complaint survey1 violation

Inspection dates

06/15/2023, 06/21/2023

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND

Comments

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/15/2023 8:30am until 11:30am and 06/21/2023 1:15pm until 2:15pm 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 06/07/2023 regarding allegations in the area(s) of: Resident care and related serives, resident accommodations and building and grounds. Number of residents present at the facility at the beginning of the inspection: 78 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of interviews conducted with residents: 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 allegation of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations

22VAC40-73-860-G

Based on observations made of the facility physical plant, the facility failed to maintain hot water temperatures between 105’F and 120”F at taps available to residents.

Evidence

The hot water coming from the sinks/showers in the following rooms were noted by both LI’s and staff person 1 to be below 105’F during and on-site visit conducted on 06/15/2023; Room 213-92.5’F, Room 217- 75.7’F, Room 229- 75.6’F, Room 232-98’F, Room 234-73.4’F, Room 235-76.8’F, Room 313-98.1,F and the hand washing sink in the kitchen was 100.3’F.
Interview conducted by both LI’s with staff person 1, who expressed that the facility currently has a boiler (boiler-1) that is inoperable and problems with the boiler pump and that repairs have been scheduled.

Plan of correction

The Community had identified and was working with Valley Boiler at the time of inspection. The facility has two boiler systems on site. Due to air in the system, the circulating pump of boiler (1) had its impeller broken inside of the pump housing, rendering the pump ineffective. On 6/17/23 the expansion tank was replaced, both circulation pumps were rebuilt. Water temperatures are routinely checked for quality assurance as part of our preventative maintenance program with escalation of inadequate temperature to the Executive Director and Environmental Service Director.

February 15, 2023Inspection22 violations

Inspection dates

02/15/2023, 02/16/2023

Areas reviewed

22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY32.1 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

Type of inspection: Renewal Dates of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 02/15/2023 9am until 6:45pm and 02/16/2023 1pm until 3:30pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 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: 14 Number of staff records reviewed: 5 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 5 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations

22VAC40-73-860-I

Based an observation during a tour of the facility physical plant, the facility failed to ensure cleaning supplies and other hazardous materials were stored in a locked area.

Evidence

At approximately 9:28AM during an on-site inspection on 02/15/2023, one licensing inspector (LI) noted that the door to the spa and salon on the first floor was unlocked, the lights were turned off and there were no staff present in the room. To the left of the entrance was a shelf with multiple containers of hair products such as Luxe unlimited in control hairspray which contained a warning to keep out of reach of children. A room within the spa and salon contained a bottle of Cosmedix pure enzymes exfoliating mask which contained a warning to keep out of reach of children. On the counter in the spa and salon there was a spray bottle of Zep high-output chemical spray and the cabinets beside the counter contained a bottle of Hydrogen Peroxide and a bottle of Barbicide which both contained warnings to keep out of the reach of children.
The following items that contained a warning to keep out of reach of children were noted by the LI in the facility’s safe, secure unit between 10:17AM through 10:28AM: a container of Barbasol in room 221 and in room 231 and two containers of Biotene dry mouth oral rinse in resident 12’s room.
One LI noted a small plastic cup of an unknown pink paste/cream in room 226, in the facilities safe, secure unit on the bedside table.
At approximately 10:40AM, two LIs noted a container of Sure Immersion cleaning tablets located in the drawer beside the coffee machine in the Shenandoah room that contained a warning to keep out of reach of children.
At approximately 3:57PM, two LIs along with staff 7 noted the following items in the unlocked cabinet under the bathroom sink in resident 1’s room, in the facilities safe, secure unit: Lysol disinfectant spray, Clorox disinfectant wipes, Witch Hazel astringent, a container of laundry detergent, a spray bottle of Lysol cleaner and a container of Clorox toilet bowl cleaner.

Plan of correction

EVS to provide in-service with all housekeeping/maintenance on proper storage of cleaning supplies and hazardous materials. EVS or EVS assistant will monitor cleaning supplies and hazardous materials daily.

22VAC40-73-250-D

Based on staff record review, the facility failed to ensure that a screening for tuberculosis was completed on or within seven days prior to the first day of work at the facility.

Evidence

The record for staff 5, hired on 01/10/2023, has a Virginia Department of Health TB Risk Assessment form that is not signed or dated by the individual who completed the form. The form also indicates that staff 4 had a tuberculin skin test on 08/25/2023, which is past the seven days prior to the first day of work for this employee.

Plan of correction

BOM will audit all active employee files and obtain current TB evaluations as needed by 4/15/23 and annually thereafter

22VAC40-73-450-C

Based on resident record review and staff interview, the facility failed to ensure individualized service plans (ISPs) were completed as required.

Evidence

The uniform assessment instrument (UAI) for resident 1, dated 09/14/2022, indicates that the resident is disoriented some spheres, all the time to time and place. The resident’s ISP, with an initiated date of 03/24/2022, indicates that the resident is disoriented; however, the ISP does not indicate that the resident is disoriented all the time to time and place. Also, the record for resident 1 contains a physician’s order, dated 10/04/2022, that a no concentrated sweets, dysphagia texture thin consistency diet is to be prepared and served to the resident; however, this information is not included on the resident’s ISP.
The UAI for resident 4, dated 06/10/2022, indicates that the resident is disoriented some of the time and the spheres affected are person, place, and time. The resident’s ISP, dated 06/16/2022, indicates that the resident is disorientated; however, the ISP does not indicate that the resident is disoriented some of the time to person, place, and time.
The UAI dated 09/12/2022 in the record for resident 5 has documentation that the resident requires physical assistance with wheeling. The ISP dated 05/05/2022 in the record for resident 5 does not address this identified need.
The record for resident 11 has a physician order dated 01/31/2023 for home health evaluation for lower extremity venous stasis dermatitis. Documentation in progress notes dated 02/13/2023 express that home health visited this morning related to resident wound care. The ISP dated 11/03/2022 in the record for resident 11 does not address these identified needs.

Plan of correction

DCS, DICSE, OR DESIGNEE WILL AUDIT ACTIVE RESIDENT MEDICAL RECORDS TO ENSURE THAT COMPRESIVE ISPS DISPLAY THE RESIDENT IDENTIFIED NEEDS

22VAC40-73-350-B

Based on resident record review and staff interview, the facility failed to ascertain prior to admission whether a potential resident is a registered sex offender.

Evidence

The record for resident 9, admitted 11/12/2022, did not contain the results of a registered sex offender search during on-site inspection. Interview with staff 7 confirmed this was accurate.

Plan of correction

CRD/ED/BOM/designee will audit all current records to assure compliance. All new residents will have a sex offender screening completed prior to admission to the community.

22VAC40-73-325-B

Based on resident record review and staff interview, the facility failed to ensure the fall risk rating for a resident was updated after a fall.

Evidence

Facility progress note, dated 02/01/2023, indicated that the resident was being seen by a physician on 02/01/2023 due to wrist pain from a fall that occurred on 01/27/2023. The most recent fall risk rating for the resident on day of inspection was dated 12/06/2022. Interview with staff 7 confirmed this was accurate.
A Nursing Fax Communication Form in the record for resident 5 has documentation that the resident was observed on the floor on 01/02/2023. The most recent fall risk rating for resident 5 on the day of inspection was dated 05/05/2022.

Plan of correction

DCS, ADCS, or designee will utilize internal auditing processes to assure a fall risk rating assessment is completed after a fall per regulations and community policy.

22VAC40-73-720-A

Evidence

Resident 9 was admitted to the facility on 11/12/2022. The resident’s social data form and the resident’s individualized service plan (ISP), dated 11/11/2022, both indicated that the resident has a DNR order. During the on-site inspection on 02/15/2023, the record for resident 9 did not contain a written DNR order signed by a physician. Interview with staff 7 confirmed this was accurate.

Plan of correction

DCS/ADCS/DESIGNEE WILL AUDIT ALL CURRENT RESIDENT FILES TO ASSURE DNR ORDERS ARE IN PLACE AS REQUIRED FOR COMPLIANCE. EACH CHART WILL BE REVIEWED ROUTINELY FOR SUSTAINED COMPLIANCE

22VAC40-73-220-B

Based on observation, resident record review and staff and collateral interview, the facility failed to ensure all requirements were met when private duty personnel, who are not employees of a licensed home care organization, provide direct care or companion services to a resident in an assisted living facility.

Evidence

During an on-site inspection on 02/15/2023, one licensing inspector (LI) observed Collateral witness 1 in resident 4’s room. When the LI questioned Collateral witness 1 of her relation to resident 4, Collateral witness 1 stated that she performs direct care services for the resident that includes bathing, toileting, dressing and transferring along with anything else the resident may require hands-on assistance with and is at the facility on Tuesday, Wednesday, and Saturday. Collateral witness 1 also indicated that Collateral witness 2 is at the facility on Monday, Thursday and Friday for the resident and performs the same direct care staff duties for resident 4.
Collateral witness 1 stated that she and Collateral witness 2 are not employed by a licensed home care organization but are employed by resident 4’s family.
During interview with staff 7 it was revealed that the facility has not maintained documentation to ensure that Collateral witness 1 and 2 are qualified for the types of direct care or companion services they are responsible for providing to the resident and there are no criminal history record reports for Collateral 1 and 2.

Plan of correction

HR/ED/designee will audit all active residents with private duty personnel to assure all required documents are on file to satisfy requirements. Going forward required documents will be obtained prior to the start of care.

22VAC40-73-1140-B

Based on staff record review, the facility failed to ensure a direct care staff person attended at least 10 hours of training in cognitive impairment training within four months of the starting date of employment in the safe, secure environment.

Evidence

Interview with staff 7 revealed that staff 3 works in the facility’s safe, secure environment and one licensing inspector (LI) also observed staff 3 working in the safe, secure environment on the date of inspection. The record for Staff 3, date of hire 10/25/2021, contained documentation that staff 3 had only attended 5.5. hours of cognitive impairment training from 10/25/2021 through 02/25/2022.

Plan of correction

BOM/HR/designee will audit all current employee files for compliance. At orientation, BOM or designee to assign/schedule cognitive training to be completed for each new direct care staff that will take place within 4 months of start date.

22VAC40-73-550-G

Based on resident record review and staff interview, the facility failed to ensure the rights and responsibilities of residents in assisted living facilities were reviewed annually with each resident or their legal representative or responsible individual.

Evidence

The record for resident 1 has documentation that the last annual review of resident rights conducted with this resident was dated 01/21/2022. Interview with staff 7 confirmed this was accurate.
The record for resident 10, admitted on 04/23/2020, did not contain documentation of an annual review of resident rights with this resident. Interview with staff 7 confirmed this was accurate.
The record for resident 11 has documentation that the last annual review of resident rights conducted with this resident was dated 01/28/2022. Interview with staff 7 confirmed this was accurate.

Plan of correction

BOM/ED WILL AUDIT ALL RESIDENT RECORDS TO ASSURE RESIDENT RIGHTS ARE REVIEWED AND SIGNED ANNUALLY.

22VAC40-73-440-D

Based on resident record review, the facility failed to ensure that private pay uniform assessment instruments (UAIs) were completed as required.

Evidence

The UAI dated 03/16/2022 in the record for resident 3 has documentation that the residents behavior is Abusive/ Aggressive/ Disruptive weekly or more but does not have documentation of the type of inappropriate behavior for this resident.
The UAI for resident 5, dated 09/12/2022, indicated that the resident’s medication are administered/monitored by professional nursing staff; however, the facility also employees registered medication aides which are considered laypersons and not licensed professional nursing staff.
The UAI for resident 11, dated 11/03/2022, indicated that the resident’s medication are administered/monitored by professional nursing staff; however, the facility also employees registered medication aides which are considered laypersons and not licensed professional nursing staff.

Plan of correction

DCS, DICSE, OR DESIGNEE WILL AUDIT ACTIVE RESIDENT MEDICAL RECORDS TO ENSURE THAT A CURRENT COMPLETED UAI IS PRESENT AND ACCURATE- TO BE MONITORED BY DCS AND DICSE

22VAC40-73-640-A

Based on observations of the facility medication carts, the facility failed to ensure implementation of their medication management plan in regards to methods to prevent the use of outdated, damaged or contaminated medications and methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes.

Evidence

The third floor medication cart contained a Novolin R Flex Pen Insulin with an open date of 12/29/2022 for resident 14. Manufacturer instructions are to discard this medication 28 days after opening. The facility policy 800A Medication Management & Services has documentation that “The Community should ensure that medications and biologicals: have not been retained longer than recommended by manufacturer or supplier guidelines”.
The facility Controlled Narcotic Counts Sheets were missing signatures for the following shifts: 02/15/2023 on the first floor medication cart for the 7 to 3 on coming shift, 02/03/2023 on the second and third floor medication carts for the 11 to 7 going off shift. The facility policy 800A Medication Management & Services has documentation that “The community should ensure that the incoming and outgoing nurse or designees count all controlled medications at least once per shift and document the results on the “Controlled Drug Count Verification/Shift Count Sheet”.

Plan of correction

DCS, DCISE, and/or designee will audit all medication carts to assure medication management compliance with dating, storing, signing, and discarding medications per the medication management plan. Staff will receive education on the medication management plan for continued compliance.

22VAC40-73-270-1

Based on staff record review and staff interview, the facility failed to ensure that aggressive behavior training contained all required components.

Evidence

The record for staff 2, 3 and 4 has documentation that aggressive behavior training for these individuals was computer based Relias training only. The documentation of the training did not include any demonstration and/or practical experience in self-protection or the name of the qualified health professional who provided the training. Interview with staff 7 confirmed that the aggressive behavior training staff 2, 3 and 4 had received did not contain the required demonstration portion.

Plan of correction

In person aggressive training will be offered/completed by staff annually to meet demonstration requirements

22VAC40-73-680-K

Based on resident record review, the facility failed to ensure that the use of PRN (as-needed) medications is prohibited, unless one or more of the following conditions exist: the resident is capable of determining when the medication is needed; licensed health care professionals administer PRN medication; or if medication aides administer PRN medication, the resident’s physician or other prescriber’s order shall include symptoms that indicate the use of the medication, exact dosage, the exact time frames the medication is to be given in a 24-hour period, and directions as to what to do if symptoms persist.

Evidence

The record for resident 4 contains a physician’s order for Systane Solution eye drops one drop in both eyes every 1 hour as needed for dry eyes 1-2 drops in affected eye as needed. The order does not include the exact dosage, the exact time frames the medication is to be given in a 24-hour period, directions as to what to do if symptoms persist. The facility does have registered medication aides (RMAs) that administer PRN medications.

Plan of correction

The DCS or designee will audit all community medication orders for clarity, appropriateness to standards, and completeness. Staff education will be provided related to the scope of practice and medication management plan.

22VAC40-73-410-A

Based on resident record review and staff interview, the facility failed to ensure upon admission to provide an orientation for a new resident and their legal representatives, that includes emergency response procedures, mealtimes, and the use of the call system.

Evidence

The record for resident 9, admitted 11/12/2022, did not contain signed and dated acknowledgment by the resident, or the resident’s legal representative as appropriate, that resident 9 had received the required orientation upon admission. Interview with staff 7 confirmed this was accurate.

Plan of correction

CRD or designee will complete resident orientation for residents 6 and 7 by 4/30/23. The CRD or designee will audit active resident files for the completed resident orientation forms by 4/30/23

22VAC40-73-450-H

Based on resident record review and staff interview, the facility failed to ensure that the care and services specified in the individualized service plan (ISP) are provided to each resident.

Evidence

The ISP for resident 1, updated 11/08/2022, includes documentation that the resident is frequently incontinent and for direct care staff to check the resident every two hours when awake and to offer assistance to the resident to the bathroom when the resident is able. During on-site inspection the licensing inspectors (LIs) requested documentation to show that resident 1’s identified need for two hour checks is being conducted by staff; however, the documentation provided on the day of inspection by staff 7 does not include documentation that staff have performed checks on the resident every two hours from 01/17/2023 through 02/15/2023.
The ISP for resident 6, updated 11/03/2022, includes documentation that staff are to check on the resident every 2-3 hours for incontinence and to encourage and assist the resident to the bathroom to prevent incontinence. During on-site inspection the LIs requested documentation to show that resident 6’s identified need for 2 to 3 hour checks is being conducted by staff; however, the documentation provided on the day of inspection by staff 7 does not include documentation that staff have performed checks on the resident every 2 to 3 hours from 01/17/2023 through 02/15/2023.
The ISP for resident 8, with a review date of 03/29/2022, incudes documentation that staff are to check on the resident every 2-3 hours in apartment when awake to offer any needed assistance, ensure resident’s apartment is free of fall and trip hazards when checking on the resident, and keep personal items within close reach of the resident. During on-site inspection the LIs requested documentation to show that resident identified need for 2 to 3 hour checks is being conducted by staff; however, the documentation provided on the day of inspection by staff 7 does not include documentation that staff have performed checks on the resident every 2 to 3 hours from 01/17/2023 through 02/15/2023.

Plan of correction

DCS, DICSE, OR DESIGNEE WILL AUDIT ACTIVE RESIDENT ISP TO ENSURE THAT COMPREHENSIVE ISPS DISPLAY THE RESIDENT-IDENTIFIED NEEDS. ALL IDENTIFIED NEEDS WILL CONTAIN SUPPORTING DOCUMENTATION TO MEET COMPLIANCE STANDARDS

22VAC40-73-120-A

Based on staff record review, the facility failed to ensure that staff orientation and training was completed within the first seven working days of employment.

Evidence

The record for staff 6, hired on 01/25/2023, has a community orientation form that was signed by staff 6 on 01/25/2023. The training areas for employee orientation listed on the form did not contain the trainer’s initials or the date the training was completed.

Plan of correction

HR/ED/designee will review all current staff records for compliance. All new hired staff will have training completed within the first 7 days of employment. New hire orientation records will be signed as completed by a second team member.

22VAC40-73-930-D

Based on resident record review, the facility failed to ensure to document the rounds that were made for each resident with an inability to use the signaling device.

Evidence

The individualized service plan (ISP), dated 06/10/2022, for resident 4 contained documentation that resident 4 is unable to utilize his pendent (call bell) and that staff are to perform safety rounds approximately every two hours for safety and support. During on-site inspection the licensing inspectors (LIs) requested rounding logs for resident 4; however, the documentation provided during on-site inspection from 01/17/2023 through 02/15/2023 for resident 4 did not include documentation that staff had performed safety rounds on the resident every two hours.
The ISP, dated 11/30/2022, for resident 3 contained documentation that staff are to make frequent wellness checks every 2-3 hours as resident does not always use pendant (call bell) or ask for help. During on-site inspection the LI’s requested rounding logs for resident 3; however, the documentation provided during on-site inspection from 01/17/2023 through 02/15/2023 for resident 3 did not include documentation that staff had performed wellness checks on the resident every 2-3 hours.

Plan of correction

22VAC40-73-250-C

Based on staff record review and staff interview, the facility failed to ensure verification that a staff person has received a copy of his current job description.

Evidence

Staff 4 is a registered medication aide (RMA) at the facility. The record for staff 4 did not contain verification that she has received a copy of a RMA job description. Interview with staff 7 confirmed this is accurate.

Plan of correction

HR or the designee will audit all current employee files for compliance and correct them accordingly. All employees will receive and sign a job description prior to start of employment/during orientation.

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 a resident’s medication review were documented in the resident’s record.

Evidence

The most recent medication review for resident 6, conducted on 11/01/2022 and 11/02/2022, contained a recommendation for a physician to consider attempting a gradual dose reduction of Lorazepam to 0.5MG every 12 hours as needed due to the resident being a fall risk and to evaluate this medication as contributing to the resident being a fall risk.
Resident 6 receives hospice services and on 11/15/2022 the facility’s physician acknowledged the recommendation; however, the physician did not make a determination of the recommendation and noted for the recommendation to be deferred to hospice.
During on-site inspection, interview with staff 7 and 9 revealed that the recommendation had not been sent to the hospice agency that provides services to resident 6.

Plan of correction

DCS/ADCS/DESIGNEE WILL FOLLOW UP ON ALL MD/IDT RECOMMENDATIONS TO ASSURE DOCUMENTATION IS COMPLETED AS REQUIRED TO ACHIEVE COMPLIANCE.

22VAC40-73-100-C-2

Based on observations of the facility medication carts, the facility failed to ensure implementation of their infection control policy in regards to blood glucose monitoring practices.

Evidence

A plastic bag with resident 13’s name was observed in the third floor medication cart. A glucometer was noted in the bag that did not contain a residents name. The facility policy 608 Blood Glucose Test has documentation under # 8 that “Each resident should have his/her own glucometer clearly labeled with their full name and apartment number”.

Plan of correction

The DCS, ADCS, or designee will audit the community to identify all BS monitoring devices and label each per CDC recommendations and provide clinical education based on CDC recommendations and facility IC policy.

22VAC40-73-680-M

Based on observation during medication cart audit, resident record review and staff interview, the facility failed to ensure medication ordered for as needed (PRN) administration was available at the facility.

Evidence

The record for resident 7 contained a physician’s order for Tylenol 325MG give two tablets every six hours as needed for pain. During audit of the facility’s safe, secure medication cart, the PRN medication could not be located. Staff 10 verified that the aforementioned PRN was not available for the resident.

Plan of correction

DCS, ADCS, or designee will audit all community medication orders for medication availability and non-use. Medications will be ordered/discontinued as appropriate.

22VAC40-73-450-D

Based on resident record review, the facility failed to ensure that hospice services were included in individualized service plans (ISPs).

Evidence

The record for resident 5 has documentation in progress notes that the resident is receiving hospice services. The ISP dated 05/05/2022 in the record for resident 5 does not include what services hospice is providing.

Plan of correction

DCS, DICSE, OR DESIGNEE WILL AUDIT ACTIVE RESIDENT MEDICAL RECORDS TO ENSURE THAT COMPREHENSIVE ISPS DISPLAY THE RESIDENT-IDENTIFIED NEEDS

February 15, 2023Complaint survey0 violations

Inspection dates

02/15/2023, 02/16/2023

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Comments

Type of inspection: Complaint Dates of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 02/15/2023 9am until 6:45pm and 02/16/2023 1pm until 3pm 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 12/29/2022 regarding allegations in the areas of: Resident care and related services and staffing. 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: 5 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

December 7, 2022Complaint survey2 violations

Inspection dates

12/07/2022

Areas reviewed

22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 EMERGENCY PREPAREDNESS

Comments

Type of inspection: Complaint Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/07/2023 9:30am until 12:30pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 11/28/2022 regarding allegations in the area of resident care and related services and emergency preparedness. Number of residents present at the facility at the beginning of the inspection: 86 Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: Emergency Preparedness A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations

22VAC40-73-990-A

Based on facility policy review and staff interview, the facility failed to ensure implementation of their written plan for resident emergencies.

Evidence

A facility incident report dated 11/02/2022 was received in regards to resident 1. The incident report has documentation that on 11/01/2022 resident 1 was being driven to a follow-up appointment. While making a turn at an intersection, the van driver heard a thud and looked back through the rear view mirror and saw resident 1 lying on the floor of the van. The incident report also has documentation that resident 1 complained of neck pain but no other injuries and upon arriving to the appointment, the van driver discovered a head laceration.
In an interview with staff 1 conducted on 12/07/2022 it was expressed that staff 1 was transporting resident 1, who was in a wheelchair, on the facility van to a doctor’s appointment. Staff 1 explained that while making a left turn at an intersection he heard a thud and looked back through the rear mirror and saw resident 1 lying on the floor of the van. Staff 1 indicated that he immediately pulled over into a parking lot, assessed resident 1 and noted that resident 1 was holding his neck and complaining of pain. Staff person 1 explained that he assisted resident 1 off the floor of the van and back into his wheelchair and they proceeded on to resident 1’s doctor’s appointment. Staff 1 explained that during resident 1’s doctor’s appointment the physician advised that resident 1 needed to be evaluated at the local emergency room.
A hospital discharge summary dated 11/03/2022 has documentation that resident 1 was diagnosed with a closed non-displaced odontoid fracture with type II morphology, laceration of scalp and injury of head.
Facility procedures for resident emergencies was requested by the LI for review on 12/07/2022. The following is documentation that is included in the policies that were made available for review. The policy named First Aid (policy # 502) has the following documentation listed under number 4 on the page “If the situation warrants, the local emergency rescue personal will be notified for immediate transport to an emergency medical center”. The policy named Fractures (policy # 503) has the following documentation listed under number 1 on the page “Any resident suspected of sustaining a possible fracture will be transported to the emergency room by emergency transport”. The policy named Head Injuries (policy # 504) has the following documentation listed under number 2 on the page “Do not move the resident and tell the resident not to move until EMS arrives”. The policy named Community Van Emergency (policy # 603) has the following documentation listed under number 2.a. on the page “ If a serious injury has occurred or if police need to be notified, the van driver should immediately call 911”.

Plan of correction

1.Education will be provided by the Executive Director, Activities Director, and Director of Nursing to the van driver(s) on what to do during any outing in the community van for emergency. It is the responsibility of the Activities Director to ensure that the van driver understands and manages all emergency procedures in case of any accident or breakdown. 11/2022 and 2/28/2023. 2.In case of emergency, and if possible, the van driver should pull off the road to a safe area. 3.The van driver should assess the nature and scope of the problem. Safety of residents is the priority. a. If a serious injury has occurred or if police need to be notified, the van driver should immediately call 911. b. As soon as the situation is stable, the van drivers should notify the Executive Director, Activities Director, or Manager on Duty (MOD). c. If necessary, the van driver should evacuate the van or take the residents to a safe place until help arrives. d. If a minor injury has occurred, the van drivers should notify nursing.

22VAC40-73-990-B

Based on review of facility documentation, the facility failed to ensure that the facility procedures for resident emergencies were reviewed with all staff at least every six months.

Evidence

A review of facility documentation indicates that the last review of facility procedures for resident emergencies was completed with staff 1 on 02/24/2022. A Skills Competency Validation Record has documentation that on 11/10/2022 staff 1 received refresher training in emergency preparedness but does not document that the employee had a review of facility procedures for resident emergencies.

Plan of correction

The Executive Director and Director of Nursing or designee will ensure the Resident Emergency Review 6 steps listed below shall be reviewed by all staff at the community every 6 months and during general orientation. Education was provided 11/2022, 1/25/2023, The education will be provided by 2/28/2023. 1. Procedures for handling medical emergencies, including identifying the staff person responsible for (i) calling the rescue squad, ambulance service, resident's physician, or Poison Control Center; and (ii) providing first aid and CPR, when indicated. 2. Procedures for handling mental health emergencies such as, but not limited to, catastrophic reaction or the need for a temporary detention order. 3. Procedures for making pertinent medical information and history available to the rescue squad and hospital, including a copy of the current medication administration record and advance directives. 4. Procedures to be followed in the event that a resident is missing, including (i) involvement of facility staff, appropriate law enforcement agency, and others as needed; (ii) areas to be searched; (iii) expectations upon locating the resident; and (iv) documentation of the event. 5. Procedures for notifying the resident's family, legal representative, designated contact person, and any responsible social agency. 6. Procedures for notifying the regional licensing office as specified in 22 VAC 40-73-70.

November 21, 2022Complaint survey2 violations

Inspection dates

11/21/2022

Areas reviewed

22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS

Comments

Type of inspection: Complaint Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/21/2022 9:00am until 5:00pm 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 10/28/2022 regarding allegations in the area(s) of: Resident care and related services, staffing, physical plant and emergency preparedness. Number of residents present at the facility at the beginning of the inspection: 96 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: Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: Resident care and emergency preparedness. A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations

22VAC40-73-950-E

Based on a review of facility documentation, the facility failed to ensure that a review of the facility emergency preparedness and response plan was completed semi-annually with all residents.

Evidence

The facility emergency preparedness plan reviews completed on 01/25/2022 and 09/29/2022 show documentation of staff initials for receiving the review but did not contain documentation to reflect that these reviews were conducted with residents.

Plan of correction

Executive Director, Director of Clinical Services, and Environmental Service Director will ensure that a review of emergency preparedness is conducted with residents semi-annually.

22VAC40-73-450-H

Based on resident record review and resident and staff interivews, the facility failed to ensure that services listed on individualized service plans (ISP) were provided.

Evidence

The ISP dated 03/30/2022 in the record for resident 1 has documentation that the resident requires assistance with bathing. During an onsite inspection conducted on 11/21/2022 it was expressed by resident 1 during an interview that they had spoken with staff person 2 about help with their shower but no staff ever showed up to help. Resident 1 explained that they took their shower this morning without any assistance.

Plan of correction

Resident1 plan of care document showed the specific time of day on the scheduling details. The plan of care document schedule was updated to reflect the shift and days of the week. Resident 1 Individualized Service Plan was updated 12/2/2022.

November 21, 2022Inspection10 violations

Inspection dates

11/21/2022

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS

Comments

Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/21/2022 9:00am until 5:00pm 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: 96 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 interviews conducted with residents: 3 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 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations

22VAC40-73-610-D

Based on observation, resident record review and staff interviews, the facility failed to ensure when a diet is prescribed for a resident by his physician or other prescriber, it is served according to the physician’s or other prescriber’s order.

Evidence

The record for resident 1 contained a physician’s order, dated 09/20/2022, for fluid restriction of 1500ML per day. During observations made of the facility’s kitchen, two licensing inspectors (LIs) noted that the kitchen’s special diet listing did not contain documentation of resident 1’s order for fluid restriction of 1500ML per day. Kitchen staff present during the observation indicated to the LIs that the posted special diet listing are the special diets that they are aware of and that are served to the residents.

Plan of correction

The Director of Clinical Services and/or designee will audit diets to ensure all orders are appropriate and being followed. Dietary orders will be reviewed daily between clinical leadership and dining leadership, through QA tools, and weekly reports.

22VAC40-73-680-E

Based on resident record review, the facility failed to ensure medical treatments ordered by a physician or other prescriber were provided according to his instructions and documented.

Evidence

The record for resident 1 contained a physician’s order, dated 09/20/2022, for Oxygen at 2L/min via nasal cannula. The November 2022 medication administration record (MAR) for the resident included documentation for the aforementioned oxygen order; however, the MAR does not include any staff initials to show that the oxygen is being provided according to the physician’s instructions.
The November 2022 TAR for resident 2 does not have staff initials for the elevation of bilateral lower extremities while seated and in bed every shift on the evening shift of 11/08/2022, and the night shifts of 11/12/2022, 11/13/2022 and 11/17/2022.

Plan of correction

The Director of Clinical Services and/or designee will provide medication management plan in-services for all RMAs and LPNs and complete daily audits of medication administration compliance.

22VAC40-73-450-C

Based on resident record review, the facility failed to ensure that identified needs were addressed on individualized service plans (ISPs).

Evidence

The record for resident 3 contained a physician’s order, dated 10/04/2022, for a no concentrated sweets diet – dysphagia texture, thin consistency. The ISP for the resident with a review date of 11/08/2022, does not include the aforementioned special diet for the resident.
The uniform assessment instrument (UAI) for resident 5, dated 04/07/2022, indicated that the resident is disoriented, some spheres some of the time to time, place, and situation; however, the ISP for the resident, dated 04/07/2022, does not include the aforementioned information.
Resident 7 is receiving skilled home health services for wound treatment. The ISP for the resident with a review date of 11/09/2022, indicates that the wound will be treated per physician orders and per home health; however, the ISP does not indicate the name of the home health company that is providing the service.

Plan of correction

The Director of Clinical Services or designee will audit active resident records to ensure the ISPs are comprehensive and address identified needs.

22VAC40-73-860-I

Based on observation during a tour of the facility’s physical plant, the facility failed to ensure that cleaning supplies were stored in a locked area.

Evidence

At approximately 9:26AM during on-site inspection, the door to the janitor closet by the facility’s dining room was noted by one licensing inspector (LI) to be unlocked. The closet contained a bottle of Zep professional lemongrass carpet extraction solution concentrate, a spray bottle of Stanley Steamer spot remover and a spray bottle of Goo Gone.

Plan of correction

The Environmental Services Director will conduct an in-service with all departmental staff on proper storage of cleaning supplies and hazardous materials. Supply storage areas will be monitored daily for compliance.

22VAC40-73-680-D

Based on review of medication administration records (MARs) treatment administration records (TARs) resident records and staff interview, the facility failed to ensure medications were administered in accordance with the physician’s or other prescriber’s instructions and consistent with the standards of practice outlined in the current medication aide curriculum approved by the Virginia Board of Nursing.

Evidence

The record for resident 7 contained a physician’s order, dated 10/04/2022, for Atenolol 25MG give 12.5MG by mouth one time a day and to hold the aforementioned medication if the systolic blood pressure (top number of blood pressure) is less than 90 or pulse is less than 60. The November 2022 MAR for resident 7 contained documentation that the medication was held on 11/07/2022 at 8:00AM; however, the resident’s blood pressure was 143/40 and the resident’s pulse was 62 therefore the medication should have been administered to the resident. Also, the November 2022 MAR for the resident contained documentation that the medication was not administered on 11/19/2022 at 8:00AM due to the resident sleeping. The physician’s order does not indicate that the medication can he held if the resident is asleep.
Page 8 of the current medication aide curriculum has documentation of “Medication Aides are not trained to perform wound care or dressing changes, as this is considered a skilled treatment and not a medication.” The record for resident 7 contained a physician’s order, dated 11/08/2022, for “cleanse with wound cleanser and gauze or soap and water. Apply calcium alginate, cover with foam and adhesive.” The November 2022 TAR for resident 7 contained the initials of staff 4 on 11/11/022 and 11/14/2022 and the initials of staff 6 on 11/17/2022 and 11/18/2022, as the staff that performed the wound treatment. Staff 4 and 6 are registered medication aides and not licensed health care professionals (LHCP). Interview with staff 4 revealed that only a LHCP performs the wound treatment and that she, a registered medication aide (RMA), will document that it has been completed by the LHCP. There is no documentation on resident 7’s TAR of the initials of the LCHP that preformed this treatment.

Plan of correction

The Director of Clinical Services and/or designee will audit all community medication orders for clarity, appropriateness to standards, and completeness. Staff education to be provided related to the scope of practice and medication management.

22VAC40-73-680-K

Based on resident record review, the facility failed to ensure that physician’s or other prescriber’s orders contained all required components when medication aides administer as needed (PRN) medications.

Evidence

Resident 5 resides in the facility’s safe, secure unit. The uniform assessment instrument (UAI) for resident 5, dated 04/07/2022, indicates that the resident’s medications are administered/monitored by a lay person; either a LPN or RMA.
The record for resident 5 included a physician’s order, dated 10/04/2022, for Acetaminophen 650MG every four hours as needed for pain 1-4. The aforementioned order does not include symptoms that indicate the use of the medication and directions as to what to do if symptoms persist.

Plan of correction

The Director of Clinical Services and/or designee will audit all community medication orders for clarity, appropriateness to standards, and completeness. The order for resident 5 will be clarified.

22VAC40-73-640-A

Based on observation during medication cart audit and document review, the facility failed to implement portions of its medication management plan.

Evidence

The facility’s medication management plan indicates that the community should ensure that medications and biologicals should have an expiration date on the label, have not been retained longer than recommended by manufacturer or supplier guidelines and once any drug or biological package is opened, the Community should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications.
The facility’s safe, secure unit medication cart contained two opened bottles of liquid Lorazepam for resident 11 which were not refrigerated. The first bottle of liquid Lorazepam contained documentation that it was opened by staff on 06/06/2022 and the most recent dose had been administered to the resident on 09/27/2202. The second bottle of liquid Lorazepam contained documentation that it was opened by staff on 09/13/2022 and the most recent dose had been administered to the resident on 11/19/2022.
The manufacturer’s guidelines for liquid Lorazepam indicate the following: “Store original dropper bottle in the refrigerator at 36 degrees Fahrenheit to 46 degrees Fahrenheit. If kept in the refrigerator, date when opened and discard 90 days after opening. If refrigeration is not possible, manufacturer data on file supports storage at room temperature up to 77 degrees Fahrenheit for 30 days”.

Plan of correction

The Director of Clinical Services and/or designee will audit all community medication carts to assure medication management compliance with dating, storing, and discarding medication per the medication plan. Staff will receive education on the medication management plan for continued compliance.

22VAC40-73-560-F

Based on observation during a tour of the facility’s physical plant, the licensee failed to ensure that all records were treated confidentially and that information was only made available when needed for the care of residents.

Evidence

At approximately 10:28AM, two licensing inspector (LIs) observed four postings on the outside of the door of residents 13 and 14.One of the postings indicated that either one or both residents have “Clostridium spp., C. difficile” (C. diff) and information regarding precautions that individuals need to take prior to entering the residents’ room.

Plan of correction

The Director of Clinical Services or designee will ensure appropriate signage is used for isolation precaution notification not to include diagnoses. Noted signage was removed at the time of inspection.

22VAC40-73-680-M

Based on observations of the facility medication carts and review of medication administration records (MARs) the facility failed to ensure that all medications for PRN use were available, properly labeled and stored at the facility.

Evidence

The November 2022 Mar for resident 10 has a physician order dated 01/19/2021 for Calmoseptine Ointment, apply to gluteal crease as needed for redness to gluteal crease. The medication was noted to not be available in the facility on the day of inspection.

Plan of correction

The Director of Clinical Services and/or designee will audit all community medication orders for medication availability and non-use. Medications will be ordered/discontinued as appropriate

22VAC40-73-100-C-2

Based on observation during medication cart audit and document review, the facility failed to ensure blood glucose monitoring practices that are consistent with the Centers for Disease Control and Prevention (CDC) recommendations were implemented.

Evidence

The CDC recommends that whenever possible, blood glucose meters should be assigned to an individual person and not be shared; however, the infection control policy provided to the licensing inspectors (LIs) during the on-site inspection did not include information regarding each individual resident having their own blood glucose meter assigned to them.
During an audit of the Wellness One medication cart, two LIs observed that neither glucometer contained a name for residents 11 and 12.

Plan of correction

The Director of Clinical Services or designee will audit the community to identify all blood glucose monitoring devices and label each per CDC recommendations and provide clinical team education on CDC recommendations

August 19, 2022Complaint survey1 violation

Inspection dates

08/19/2022

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

Type of inspection: Complaint Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 08/19/2022 9:00am until 2:00pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 08/10/2022 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: 86 Number of resident records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were issued. 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations

22VAC40-73-680-E

Based on a review of resident records and interviews with staff, the facility failed to ensure that medical procedures or treatments ordered by a physician or other prescriber was provided according to instructions and documented.

Evidence

The progress notes for resident 1 has documentation dated 08/06/2022 at 7:55 that “resident noted with skin tear to right upper arm, area cleansed with normal saline and dpd applied. Dr. to evaluate and updated order”.
A nursing fax communication form dated 08/06/2022 in the record for resident 1 has “skin tear noted to right upper arm, area cleansed with normal saline xeroform applied, covered with non-adherent dssg, held in place by tubi-grip. This nursing fax communication form was noted and signed by the physician on 08/09/20222 with orders to continue with above treatment and monitor.
A facility incident report form was received on 08/11/2022 in regards to resident 1. The incident report has documentation “received communication of skin tear on 08/11/2022. Skin tear assessed by director of clinical services. Dressing noted in place at time of assessment”.
Interviews with staff persons 2 and 3 expressed that they were both made aware of the skin tear on resident 1’s right upper arm on 08/11/2022. Per staff persons 2 and 3, contact was made with resident 1’s physician and treatment orders were confirmed.
The August 2022 medication administration record (MAR) for resident 1 has documentation that a daily treatment for the skin tear to the resident’s right upper arm was not started until 08/11/2022. The August 2022 MAR also does not have staff initials for the treatment being completed on 08/16/2022 and 08/17/2022.

Plan of correction

Provide medication management plan in-service for all RMAs and LPNs. Director of Clinical Services (DCS), Director of Clinical Inspiritas and Engagement (DCISE), or designee to complete daily audit of medication administration compliance. To be monitored by DCS, DCISE, or designee.

August 19, 2022Inspection8 violations

Inspection dates

08/19/2022

Areas reviewed

Comments

Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 08/19/2022 9:00am til 2:00pm Number of residents present at the facility at the beginning of the inspection: 86 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of interviews conducted with staff: 6 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations

22VAC40-73-660-A-6

Based on observations made of the facility medication carts, the facility failed to ensure that medications requiring refrigeration were refrigerated.

Evidence

The wellness cart on the first floor contained a bottle of Lorazepam liquid in the dart for resident 2. Manufacturer instructions on the box indicate to store at cold temperature, refrigerate at 36’ to 46’ F.

Plan of correction

All medication carts will be audited by designee to ensure medications are stored properly. Training will be completed to RMA and LPNs on proper storage.

22VAC40-73-680-D

Based on resident record review and staff interview, the facility failed to ensure medications were administered in accordance with the physician’s or other prescriber’s instructions.

Evidence

The record for resident 1 contained a physician’s order, dated 03/15/2022, for Ricola cough drops as needed every six hours for cough and congestion. Interview with staff persons 1 and 3 revealed that the resident has the aforementioned cough drops in her room; however, the physician’s order does not indicate that resident 1 can self-administer the cough drops.
The record for resident 1 contained a physician’s order, dated 08/09/2022, for Ibuprofen 600mg every 8 hours for gout for five days. The August 2022 medication administration record (MAR) for resident 1 contained documentation that the resident was not administered the aforementioned medication on 08/10/2022 through 08/14/2022 at “0000” hours because the resident was asleep. The physician’s order does not indicate that the medication may be held due to the resident sleeping. Also, during on-site inspection on 08/19/2022, it was observed by two licensing inspectors and staff person 4 that the blister card for the Ibuprofen 600mg still contained four Ibuprofen 600mg tablets even though the medication had ended.

Plan of correction

The Director of Clinical Services (DCS), Director of Clinical Inspiritas and Engagement (DCISE), or designee will provide education to the RMA(s) on administering medications in accordance with physician or other prescriber’s instructions. DCS or designee to provide in-service to all RMAs and LPNs regarding administering medications in accordance with physician instructions. – To be monitored by DCS or designee.

22VAC40-73-640-A

Based on observations made during a medication cart audit, resident record reviews, document review and staff interviews, the facility failed to implement their medication management plan.

Evidence

During a medication cart audit on 08/19/2022 and an interview with staff person 4, it was revealed that the facility did not have resident 1’s scheduled Ferrous Sulfate 325MG or resident 2’s scheduled Sertraline 25MG. The facility’s medication management plan states the following: “The Community staff should review all on-demand medications daily and re-order when a 5-day supply of the medication is remaining.”
The Controlled Narcotic Count Sheets on the memory care unit and the wellness first floor medication carts were noted to be missing staff signatures for the coming on and going off narcotic counts. The facility’s medication management plan states the following “ The community should ensure that the incoming and outgoing nurse or designee count all controlled medications at least once per shift and document the results on the controlled drug count verification/shift count sheet”.

Plan of correction

The Director of Clinical Services (DCS), Director of Clinical Inspiritas and Engagement (DCISE), or designee to complete daily audit of medication administration compliance. DCS to provide medication management plan in-service for LPNs and RMAs. - To be monitored by DCS and Executive Director (ED)

22VAC40-73-450-C

Based on a review of resident records, the facility failed to ensure all identified needs were addressed on individualized service plans (ISPs).

Evidence

The record for resident 1 contained a physician’s order, dated 03/10/2022, for “fluid restriction 1500ml/day”. The ISP for resident 1, dated 11/18/2021, did not indicate this identified need.

Plan of correction

The Director of Clinical Services (DCS), Director of Clinical Inspiritas and Engagement (DCISE), or designee will audit active resident medical records to ensure that the comprehensive ISPs display the residents identified needs.

22VAC40-73-860-I

Based on observations made during a tour of the facility physical plant, the facility failed to ensure that cleaning supplies were stored in a locked area.

Evidence

The door leading to the back service area was noted by the LI and staff person 2 to be propped open on the day of inspection. A spray bottle with a yellow liquid was noted sitting out on a table in the unlocked staff break room. Clorox Clean-Up spray, Shine Up Furniture Polish, Clorox Urine Remover and Granite and Stone Cleaner was noted sitting out in the unlocked laundry room.

Plan of correction

Environmental Service Director (EVS), Housekeeping Assistants, Maintenance Assistant, or designee will provide in-service with housekeeping/maintenance, and departments on proper storage of cleaning supplies and hazardous materials. EVS, Maintenance assistant, or designee will monitor cleaning supplies and hazardous materials daily. To be monitored by EVS and Executive Director (ED)

22VAC40-73-680-E

Based on a review of resident records and staff interview, the facility failed to ensure medical treatments ordered by a physician or other prescriber were provided according to his instructions and documented.

Evidence

The record for resident 1 contained a physician’s order, dated 03/20/2022, for Oxygen at 2L/min via nasal cannula. The record for the resident did not contain documentation that staff monitor resident 1’s Oxygen usage. Interviews with staff persons 1 and 3 revealed that the resident self-administers her Oxygen; however, the physician’s order does not indicate that resident 1 can self-administer Oxygen.
The record for resident 2 contained a physician’s order, dated 12/31/2021, for Calmoseptine Ointment apply every shift. The August 2022 treatment administration record (TAR) for resident 2 contained documentation of multiple shifts that did not include documentation that Calmoseptine Ointment had been applied to the resident.
The record for resident 3 contained physician’s orders, dated 07/20/2021, 02/24/2022, and 03/20/2022, for staff to continue to monitor area on left face for changes (increased size, scaly, bleeding or complaints). The record for resident 3 did not contain documentation that staff have been monitoring the aforementioned physician’s order. Interviews with staff person 1 and 3 indicated this is accurate and that there was no order to discontinue the monitoring of the area on the left side of resident 3’s face.

Plan of correction

The Director of Clinical Services (DCS), Director of Clinical Inspiritas and Engagement (DCISE), or designee will provide medication management plan in-service for all RMAs and LPNs. DCS, DCISE, or designee to complete daily audit of medication administration or treatment administration compliance. – To be monitored by DCS, DCISE, or designee

22VAC40-73-610-D

Based on a review of resident records, observations, and staff interview, the facility failed to ensure when a diet is prescribed for a resident by his physician or other prescriber, it is served according to the physician’s or other prescriber’s order.

Evidence

The record for resident 1 contained a physician’s order, dated 03/10/2022, for fluid restriction of 1500ML per day. During observations made of the facility’s kitchen, one licensing inspector observed that the kitchen’s special diet listing did not contain documentation of resident 1’s order for fluid restriction of 1500ML per day. Interview with staff person 6 revealed that he was not aware of the aforementioned fluid restriction physician’s order for resident 1. Interviews with staff persons 1 and 3 indicated that resident 1’s fluid intake was not being recorded to ensure that the facility was only offering 1500ml of fluids daily to the resident between medication passes, dietary and activities.

Plan of correction

Diets will be audited by the Director of Clinical Services (DCS), Director of Clinical Inspiritas and Engagement (DCISE), or designee and ensure all orders are being followed. Dietary team will be given updates with any order change.

22VAC40-73-680-M

Based on observations made during a medication cart audit and staff interview, the facility failed to ensure medication ordered for PRN (as needed) use were available at the facility.

Evidence

The record for resident 1 contained a physician’s order, dated 08/09/2022, for Tylenol 650mg every 8 hours as needed for pain. Interview with staff person 4 revealed the medication was not available at the facility during on-site inspection.
The record for resident 1 contained a physician’s order, dated 12/31/2021, for Hydromorphone give 0.5ml every four hours as needed for pain or shortness of breath and Calcium Carbonate give 1000ML every six hours as needed for heartburn. Interview with staff person 4 revealed the medication was not available at the facility during on-site inspection.
The record for resident 3 contained a physician’s order, dated 03/20/2022, for Bio freeze apply to chest topically as needed for chest swelling with pain. Interview with staff person 4 revealed the medication was not available at the facility during on-site inspection.

Plan of correction

The Director of Clinical Services (DCS), Director of Clinical Inspiritas and Engagement (DCISE), or designee will provide medication management plan in-service for all RMAs and LPNs. DCS and DCISE to complete daily audit of medication administration compliance.

August 19, 2022Inspection2 violations

Inspection dates

08/19/2022

Areas reviewed

22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Comments

Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 08/19/2022 9:00am until 2:00pm 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 regarding allegations in the area of: Resident care and related services. Number of residents present at the facility at the beginning of the inspection: 87 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 did not support the self-report of non-compliance with standard(s) or law. However, violation(s) not related to the self-report but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations

22VAC40-73-450-E

Based on a review of resident records, the facility failed to ensure that individualized service plans (ISP) were signed and dated by the individual who completed the plan and by the resident or their legal representative.

Evidence

The ISP with a target date list as 04/19/2023 in the record for resident 1 did not contain the signature of the individual who completed the plan, the date that the ISP was developed or the signature of the resident or their legal representative.

Plan of correction

The Director of Clinical Services (DCS), Director of Clinical Inspiritas and Engagement (DCISE), or designee will audit active resident records to ensure that the comprehensive individualized service plans (ISPs)display the required signatures. – To be monitored by DCS, DCISE

22VAC40-73-440-D

Based on a review of resident records, the facility failed to ensure that uniform assessment instruments (UAI) were completed as required.

Evidence

The UAI dated 03/29/2022 in the record for resident 1 has the box checked under behavior pattern that the resident is wandering/passive weekly or more. The box on the UAI for documentation of type of inappropriate behavior is blank and does not list resident 1’s specific behavior patterns.

Plan of correction

The Director of Clinical Services (DCS), Director of Clinical Inspiritas and Engagement (DCISE), or designee will conduct a full audit on active residents’ uniform assessment instruments (UAIs) for completeness and accuracy. –To be monitored by DCS, DCISE

February 22, 2022Inspection22 violations

Inspection dates

02/22/2022

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

Technical assistance

A phone conversation was conducted with the facility Administrator on 03/23/2022 to discuss the difference between standards 22VAC40-73-1100-A (approval for place from resident, family, POA, etc.) and standard 22VAC40-73-1110-A ( Administrator approval for placement in a safe, secure unit) to gain better understanding of the regulations.

Comments

The LI for Woodland Hills conducted an on site renewal study at the facility from 8:45am until 5:30pm on 02/22/2022 in conjunction with another LI and noted 92 residents to be in care. A tour of the facility physical plant was conducted and the morning medication pass was observed. Resident and staff records as well as other forms of facility documentation were reviewed and interviews were conducted with residents and staff. The morning and mid day meals and the morning activity were observed. An exit interview was conducted with the Administrator and other management personal on the date of inspection, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. Information gathered during the inspection determined non-compliances with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations

22VAC40-73-440-D

Based on a review of resident records, the facility failed to ensure that uniform assessment instruments (UAIs) were completed as required by 22VAC30-110.

Evidence

The UAI dated 04/15/2021 in the record for resident 1 does not have the signature of the person who completed the assessment or the administrator or their designee.
The UAI dated 09/22/2021 in the record for resident 2 does not have the signature of the person who completed the assessment or the administrator or their designee.
The UAI dated 03/12/2021 in the record for resident 3 has documentation that medication administration is provided by professional nursing staff. The facility employees registered medication aids, who are considered laypersons, that administer medications to residents residing in the facility.
The UAI dated 02/15/2022 in the record for resident 8 has documentation that medication administration is provided by professional nursing staff. The facility employees registered medication aids, who are considered laypersons, that administer medications to residents residing in the facility.
The UAI dated 12/02/2021 in the record for resident 9 has documentation that medication administration is provided by professional nursing staff. The facility employees registered medication aids, who are considered laypersons, that administer medications to residents residing in the facility.
The UAI for resident 7 dated 1/25/2022 shows this resident needs to have medication administered by professional nursing staff and mechanical help only with wheeling. Interviews with facility staff reveal that medications need to be administered by registered medication aides (lay persons) and the resident needs physical assistance with wheeling at times.
The UAI date 5/6/2021 for resident 5 shows this person is able to provide self-care for urinary incontinence and the ISP dated 5/6/2021 shows that staff takes care of this need. The same UAI shows resident 5 is independent in mobility and the same ISP shows that staff provides supervision.

Plan of correction

– A full audit on UAIs will be conducted by DCS, DCISE or designee for completeness and accuracy. – 5/31/22 – To be monitored by DCS, DCISE

22VAC40-73-640-A

Based on resident record review and the facility medication management plan, the facility failed to implement its medication management plan to ensure that prescription medications and over-the-counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages.

Evidence

The facility’s medication management plan states: “Methods to ensure that each resident’s prescription medication and any over-the-counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages Only authorized Community staff may reorder medications from the Pharmacy. The Community staff should review all on-demand medications daily and re-order when a 5-day supply of the medication is remaining. Emergency refills must be called to the Pharmacy. The community should indicate the date and time the medication is needed.”
The record for resident 4 has an order signed on 11/2/2021 for Ferrous Sulfate Tablet 325 (65 Fe) one tablet orally every 48 hours. The February 2022 MAR has documentation that it was not given on 2/22/2022. It was ordered from the pharmacy by staff 1 and documented that the reason it was not given was “waiting pharmacy”.
The Progress Notes and MAR for resident 5 show that Triamterene HCTZ Tablet 37.5 -25 mg was not given on: 2/5/2022, 2/7/2022, 2/9/2022 through 2/14/2022, and 2/16/2022 through 2/21/2022 because they were waiting for the pharmacy. The MAR shows it is to be administered daily. The Progress Notes and MAR for resident 5 show that Lexapro Tablet 10 mg was not given because of “waiting on pharmacy.” The MAR shows it should be given daily.
The record for resident 6 has an order signed on 1/6/2022 for Rivastigmine Tartrate Capsule 3 mg, give 3 mg by mouth three times a day. The February 2022 MAR has documentation that it was not given beginning at 8 am 2/16/2022 through 1 pm on 2/21/2022. It was documented as given on 2/21/2022 at 6 pm, and not given 2/22/2022 at 8 am. The progress notes indicate that all instances of not giving the medication are because of waiting for either the pharmacy of the family to bring it to the facility.
The Progress Notes for resident 7 documents that the following medications were not given: Fluoxetine HCI Capsule 20 mg was not given on 1/21/2022 because “medication was not available daughter contacted”; Levothyroxine Sodium Capsule 75 mcg was not given on 2/10/2022 because “Awaiting daughter to bring this medication”; Prevagen Extra Strength Capsule 20 mg was not given on 2/22/2022 because “unavailable dtr. notified”.

Plan of correction

DCS, DCISE and/or designee to complete daily audit of medication administration compliance. DCS to provide medication management plan in-service for LPNs and RMAs. – 4/30/22 - To be monitored by DCS and ED

22VAC40-73-620-A

Based on a review of facility documentation, the facility failed to ensure that an oversight of special diets was conducted at least every six months.

Evidence

The last oversight for special diets completed for the facility has documentation that is was completed on 06/25/2021.

Plan of correction

Dietician oversight was conducted on 2/28/22 and will continue to provide oversight quarterly. – 3/31/22 – To be monitored by ED and DCS

22VAC40-73-870-A

Based on observations made of the facility physical plant, the facility failed to keep the interior of the building clean.

Evidence

The dining room floor in the facility's safe secure unit was noted to be sticky on the day of inspection and dried food was noted lying on the floor. Staff person 5 expressed that the floor was sticky when they came to mop it.

Plan of correction

ED and EVS and/or designee to perform regular checks on cleanliness of floors to ensure the building is being kept clean. – 5/31/22 – To be monitored by ED and EVS

22VAC40-73-250-D

Based on a review of staff records, the facility failed to ensure that a staff person completed an annual TB evaluation.

Evidence

The record for staff 1, hired on 10/16/2020, lacks documentation to support that an annual TB evaluation was completed. A screening for tuberculosis for staff person 1 was provided to the LI by email on 03/02/2022. This screening has documentation that staff person 1 completed a screening for tuberculosis on 02/08/2021, which would have required an annual screening for tuberculosis to have been completed by 02/08/2022 for this employee.

Plan of correction

BOM will audit all active employee files and obtain current TB evaluations as needed by 3/31/22 and annually thereafter. – To be monitored by BOM and ED

22VAC40-73-860-I

Based on observations of the facility physical plant, the facility failed store cleaning supplies in a locked area.

Evidence

The door lock on the door labeled Janitor's Closet next to the dining room was noted to be inoperable on the day of inspection. The closet contained Zep Industrial Solution Extraction Cleaner on the shelf.

Plan of correction

The Janitor’s closet door lock was fixed on day of inspection. EVS to provide in-service with all housekeeping/maintenance on proper storage of cleaning supplies and hazardous materials. EVS or EVS assistant will monitor cleaning supplies and hazardous materials daily. – 4/30/22 – To be monitored by EVS and ED

22VAC40-73-990-B

Based on a review of staff records and facility documentation, the facility failed to ensure that a review for procedures for resident emergencies was completed at least every six months.

Evidence

Facility documentation dated 01/25/2022 has that missing resident emergencies were reviewed but the facility does not have documentation that a review for all resident emergencies policies required by this regulation were completed within the past six months.

Plan of correction

– EVS to conduct in-service on procedures for resident emergencies by 4/30/22 and every six months after that. – 4/30/22 – To be monitored by EVS and ED

22VAC40-73-680-E

Based on a review of resident records and medication and treatment administration records (MARs/TARs), the facility failed to ensure that all medical procedures or treatments were documented.

Evidence

The February 2022 TAR for resident 3 does not have staff initials for the application of the prescribed ointment Calmoseptine to the resident buttocks on the day shift on 02/01/2022 and on the night shift on 02/07/2022 and 02/15/2022.
The MAR/TAR for resident 7 has documentation of daily weights for Congestive heart failure, beginning 12/18/2021. There is no documentation on the MAR to support that this was done on 2/6/2022.
The MAR/TAR for resident 4 does not have staff initials for the administrations of the prescribed medication Lidocaine Patch 4 % in the am on 2/4/2022.

Plan of correction

DCS to provide medication management plan in-service for all RMAs and LPNs. DCS and DCISE to complete daily audit of medication administration compliance. – 4/30/22 – To be monitored by DCS, DCISE

22VAC40-73-450-F

Based on a review of resident records, the facility failed to ensure that individualized service plans (ISPs) were updated as needed for a significant change in a resident condition.

Evidence

The record for resident 3 has documentation of the resident falling 9 times between 05/09/2021 and 02/13/2022. The record also has a physician order for oxygen 2 litters a minute via nasal cannula for 26 hours a day. The ISP dated 03/12/2021 in the record for resident 3 has not been updated to reflect the residents needs for monitoring for fall prevention or for the use of oxygen.
The record for resident 9 has a physician order for TED hose on the am and off in the PM. Progress notes for January and February 2022 in the record for resident 9 has documentation that the resident frequently refuses to wear the TED hose. The record also has a Do Not Resuscitate (DNR) order signed by the resident physician on 11/11/2021. The ISP dated 12/02/2021 in the record for resident 9 has not been updated to reflect these identified needs.
The physical exam for resident 7 shows this person is allergic to Macrobid, Penicillin, and Codeine and the allergies to these medications are not addressed on the ISPs dated 12/17/2021 or 1/27/2022.
The uniform assessment instrument (UAI) dated 12/13/2021 for resident 6 shows this resident requires mechanical and human help with mechanical assistance when climbing stairs. This is not addressed on the ISP updated on 12/15/2021. The same UAI shows this resident is disoriented to time and situation all of the time, and the same ISP addresses confusion to location instead.

Plan of correction

A complete review of all resident ISPs will be conducted to ensure they are updated as needed for significant changes in resident conditions. – 5/31/22 – To be monitored by ED, DCS, DCISE

22VAC40-73-950-A

Based on a review of facility policy and procedures, the facility to document annual contact with the local emergency coordinator to determine local disaster risks, communitywide plans to address different disasters and emergency situations, and assistance, if any, that the local emergency management office will provide to the facility in an emergency.

Evidence

During a review of the facility emergency preparedness and response plan it was noted that there was no documentation of annual contact with the local emergency coordinator to determine local disaster risks, communitywide plans to address different disasters and emergency situations, and assistance, if any, that the local emergency management office will provide to the facility in an emergency. An interview with staff person 2 expressed that the facility does not documentation of an annual review.

Plan of correction

ED and EVS will work to ensure a local emergency coordinator makes annual contact with the facility for emergency preparedness assistance. – 5/31/22 – To be monitored by EVS and ED

22VAC40-73-450-E

Based on a review of resident records, the facility failed to ensure that individualized service plans (ISPs) were signed and dated by the licensee, administrator, or his designee, (the person who has developed the plan), and by the resident or his legal representative.

Evidence

The ISP's in the records for resident 1 and 2 do not contain the date that the plans were developed, the signature of the person who completed the plans or the signature of the residents or their legal representatives.
The ISP dated 12/02/2021 in the record for resident 9 does not have the signature of the resident of their legal representative.
The ISP dated 12/15/2021 for resident 6 does not have the signatures of the person who completed the plan or the signature of the residents or their legal representatives.

Plan of correction

Signatures for residents 1,2, 6 and 9 ISPs will be obtained by 4/30/22. The DCS or designee will audit active resident records to ensure that the comprehensive ISPs display the required signatures by 5/31/22. – To be monitored by DCS, DCISE

22VAC40-90-40-B

Based on staff record review, the facility failed to obtain the results of a Virginia State Police Criminal Records check within 30 days of beginning work for a new staff person.

Evidence

The record for Staff person 4, hired on 1/12/2022 did not contain a Virginia State Police Criminal Records check as of the day of the inspection.

Plan of correction

Criminal record check on Staff 4 was obtained day of inspection. BOM will audit remaining active team member files to ensure compliance for the remaining team members by 5/31/22 – To be monitored by BOM and ED

22VAC40-73-410-A

Based on a review of resident records, the facility failed to document that new residents had orientation to the facility.

Evidence

The record for resident 6, admitted on 12/13/2021, lacks documentation of acknowledgment of having received an orientation to the facility.
The record for resident 7, admitted on 10/31/2021, lacks documentation of acknowledgement of having received an orientation to the facility. Documentation provided to the LI via email on 03/02/2022 has that resident 7 signed for acknowledgement of receiving an orientation to the facility on 11/09/2021 and not upon admission per this regulations requirements.

Plan of correction

LED or designee will complete resident orientation for residents 6 and 7 by 4/30/22. The LED or designee will audit active resident files for the completed resident orientation forms by 4/30/22. – 4/30/22 – To be monitored by LED

22VAC40-73-210-B

Based on a review of staff records, the facility failed to ensure that a staff person had at least 18 hours of training annually.

Evidence

Staff 3 began work on 3/30/2019. The record for staff 3 shows that in the employment year beginning 9/30/2020 and ending 9/29/2021, only 14.5 hours of annual training was obtained.

Plan of correction

Staff 3 will complete annual training hours by 3/31/22. All staff records will be audited by BOM to make sure they have the proper amount of training annually by 5/31/22. – 5/31/22 – To be monitored by BOM and ED

22VAC40-73-210-D

Based on a review of staff records, the facility failed to ensure that a registered medication aide had required continuing education required by the Virginia Board of Nursing.

Evidence

The record for staff 3, who began work on 9/30/2019 and is a Registered Medication Aide, has no documentation to support the required four hours of refresher training annually for Registered Medication Aides has been completed.

Plan of correction

Staff 3 will complete RMA annual refresher training by 3/31/22. All RMA records will be audited by BOM for required hours of annual refresher training by 5/31/22. – 5/31/22 – To be monitored by BOM and ED

22VAC40-73-950-E

Based on a review of staff records and facility documentation, the facility failed to ensure that a semi-annual review of the emergency preparedness and response plan was conducted with all residents and all staff.

Evidence

Documentation of the facility semi-annual review of their emergency preparedness and response plan with residents and staff was requested for review on the day of inspection. Per an interview with staff person 2 on the day of inspection this documentation was unavailable for review.

Plan of correction

– EVS to conduct emergency preparedness in-service with staff and residents by 4/30/22 and semi-annually after that. – 4/30/22 – To be monitored by EVS and ED

22VAC40-73-440-A

Based on resident records review, the facility failed to obtain a uniform assessment instrument (UAI) prior to admission.

Evidence

The record for resident 7 shows the move in date was 10/31/2021. The earliest UAI in the record is dated 11/5/2021.
The move in record, Resident Personal/Social Data sheet, and the individualized service plan both show that resident 6 moved in on 12/10/2021. The UAI was done on 12/13/2021.

Plan of correction

Clinical UAIs will be completed by certified personnel, signed by ED/designee, and placed in health record prior to admission – 5/31/22 – To be monitored by ED, DCS, DCISE

22VAC40-73-320-A

Based on a review of resident records, the facility failed to ensure physical examinations contained all required information.

Evidence

The physical examination dated 09/20/2021 in the record for resident 8 is incomplete as it does not have documentation as to whether the resident can self administer their own medications.
The physical examination dated 10/20/2021 in the record for Resident 7 has documentation that the resident has allergies to Macrobid, Penicillin, and Codeine but it does not include what the allergic reactions are.

Plan of correction

DCS or DICSE will conduct audit of all resident physical assessments to ensure completion compliance by 4/30/22. Future physical assessments will be audited for completion prior to resident move-in or return. – 4/30/22 – To be monitored by DCS/ DCISE

22VAC40-73-680-D

Based on observation and resident record review, the facility failed to administer medications in accordance with physician instructions.

Evidence

Resident 4 has an order signed on 11/2/2021 for Vitamin D3 (cholecalciferol) 1000 unit, give three (3) tablet by mouth one time a day, which is reflected on the medication administration record (MAR). The LI observed that the resident was given three 25 mcg tablets instead.

Plan of correction

Education was provided to the RMA on administering medications in accordance with physician instructions. DCS to provide in-service to all RMAs and LPNs regarding administering medications in accordance with physician instructions. – 4/30/22 – To be monitored by DCS

22VAC40-73-1140-B

Based on staff record review and interview, the facility failed to ensure that direct care staff who work in the safe, secure unit had at least 10 hours of training in cognitive impairments within four months of starting work.

Evidence

In an interview at 3:42 pm, staff person 7 stated that staff 1 and 3 both work in the safe, secure unit.
The record for staff person 1, hired on 10/16/2020, does not have documentation to support that this employee received any hours of training in cognitive impairments within the first 4 months of employment. The record has documentation that only 9 of the 10 required hours of training in serious cognitive impairments has been completed by this employee as of the date of this inspection.
The record for staff person 3, hired on 09/30/2019, has documentation that only 7.75 hours of training in serious cognitive impairments was completed within this employees first 4 months of employment.

Plan of correction

– ED or BOM to schedule cognitive training for staff persons 1 and 3 immediately. At orientation, BOM or designee to assign/schedule cognitive training to be completed for each new direct care staff. – 5/31/22 – To be monitored by ED, BOM, DCS, DCISE

22VAC40-73-660-B

Based on observations of the facility physical plant, the facility failed to ensure that residents who are capable of self administering their medications based on their uniform assessment instrument (UAI), kept their medications in an out of sight place in their rooms.

Evidence

Residents 1 and 2 were noted to reside in the same room. Resident 1's UAI dated 04/15/2021 has documentation that the resident is capable of self administering their own medications. Resident 2's UAI dated 09/22/2021 has documentation that the resident requires assistance with medication administration. Resident 1's medications were observed sitting out on the counter by the kitchen sink on the day of inspection.

Plan of correction

Resident one had medications moved to an out of sight secure location day of survey. DCS, ED and/or designees will perform audit of all residents that self-administer medication for appropriate storage– 4/30/22 – To be monitored by DCS and ED

22VAC40-73-260-A

Based on a review of staff records, the facility failed to ensure that direct care staff obtained first aid training within 60 days of employment and to ensure that staff maintained certification in first aid.

Evidence

The file for staff person 3, hired on 9/30/2019, has documentation that their certification expired in December 2021. An updated first aid certification was not documented in the staff persons record

Plan of correction

BOM and/or designee to audit first aid certifications monthly for expiring certifications. Schedule classes as needed to provide appropriate training. – 5/31/22 – To be monitored by BOM and ED

December 20, 2021Complaint survey9 violations

Inspection dates

12/20/2021

Areas reviewed

Comments

The LI for Woodland Hills conducted an on-site complaint investigation on 12/20/2021 in conjunction with another LI. A tour of the facility special care unit was conducted and interviews were held with staff. Resident records as well as other forms of facility documentation were reviewed. An exit interview was conducted with the facility Administrator and the opportunity was given for additional documentation to be provided. The evidence gathered during the investigation supported the allegations of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.

Violations

22VAC40-73-450-E

Based on resident record review, the facility failed to ensure the individualized service plan (ISP) was signed and dated by the by the licensee, administrator, or his designee, (i.e., the person who has developed the plan) or the resident or his legal representative.

Evidence

The ISP in the record for resident 1 does not have a signature of the person who completed the plan, the date the plan was completed or signature of the resident or their legal representative.
The ISP dated 06/10/2021 in the record for resident 2 does not contain the signature of the resident or his legal representative.

Plan of correction

The DCS or designee will contact the resident and/or POA and the comprehensive ISP for Resident 1 and 2 will be reviewed with the resident and family and a signature obtained by 3/11/22. The DCS or designee will audit weekly resident ISPs to ensure that the ISP displays a resident or family signature until 3/31/22. – 3/31/22 – To be monitored by DCS

22VAC40-73-680-B

Based on observation, the facility failed to ensure that medications remained in the pharmacy issued container, with the prescription label or direction label attached, until administered to the resident.

Evidence

At approximately 10:21AM during on-site complaint inspection, the door to room 215, which is located in the facility’s safe, secure unit, was found to be unlocked by one licensing inspector (LI). The LI observed a small clear, plastic medication cup on the floor of the room that contained a pink paste that was labeled with resident 3’s name.

Plan of correction

– Appeal - Director of Clinical Services will review medication administration passes to ensure that all medications remain in pharmacy dispensed containers. A training of all LPNs and RMAs will be conducted using our medication management plan. – 3/18/22 – To be monitored by DCS, DICSE

22VAC40-73-450-F

Based on resident record review and staff interview, the facility failed to review and update the individualized service plan (ISP) as the condition of a resident changes.

Evidence

The record for resident 1 has documentation of the resident falling/found on the floor on 09/25/2021, 10/20/2021, 10/26/2021, 11/30/2021 and 12/09/2021. The ISP in the record for resident 1 does not have documentation of any additional needs for monitoring or fall prevention since 01/29/2021.
The facility had documentation, fall risk ratings and incident reports, that showed resident 2 had nine falls between 09/16/2021 through 12/12/2021. The fall risk ratings for resident 2 during this time period also indicate that the resident is a high fall risk. The ISP for the resident, dated 06/10/2021, does not indicate that the resident is a high fall risk.

Plan of correction

– ISPs for Residents 1 and 2 will be updated to address fall prevention. This will be completed by 3/11/22. DCS and ED will monitor ISPs for accuracy during weekly meetings. ISP will be updated with significant change on resident by DCS/DICSE/designee. – 2/11/22 – To be monitored by DCS and ED

22VAC40-73-325-B

Based on resident record review, the facility failed to ensure that the fall risk rating was reviewed and updated after a fall for residents who meet the criteria for assisted living care.

Evidence

The uniform assessment instrument (UAI), dated 06/04/2021 for resident 2 has them assessed as assisted living level of care. The record for resident 2 contained an incident note from nursing, dated 10/11/2021, that stated “Note Text: Resident found sitting in bathroom floor. Alert with no complaints of pain, dizziness, or LOC. Skin tear noted on LFA. Cleansed with NS, steri-strips applied and covered with Kling. Resident cleansed, brief changed, dressed and shaved. Sitting in recliner with no complaints. DON spoke with spouse.” The record for resident 2 did not contain a fall risk rating for this fall.

Plan of correction

Resident 2 file will be audited by DCS or designee to ensure compliance with fall risk ratings by 3/11/22. The DCS or designee will conduct weekly audits on fall risk ratings. – 3/31/22 – To be monitored by DCS

22VAC40-73-700-2

Based on observation, the facility failed to post “No Smoking-Oxygen in Use” signs when oxygen therapy is provided.

Evidence

Resident 4’s room contained an oxygen concentrator and one oxygen portable tank. The room did not contain a “No Smoking-Oxygen in Use” sign.

Plan of correction

Oxygen signs were ordered and placed on Resident 4’s room door on 2/28/22. All rooms belonging to residents using oxygen have been checked to make sure proper signage is displayed. EVS will continue to monitor rooms for proper signage. – 2/28/22 – To be monitored by EVS and ED

22VAC40-73-440-D

Based on resident record review, the facility failed to ensure for private pay individuals the uniform assessment instrument (UAI) was completed as required by 22VAC30-110.

Evidence

The UAI dated 01/29/2021 in the record for resident 1 does not contain the signature of the person who completed the assessment or the Administrator or designee.
The UAI dated 06/04/2021 in the record for resident 2 does not contain the signature of the administrator or designee.

Plan of correction

The DCS or designee will correct the UAI for Resident 1 and 2 by 3/11/22. The DCS or designee will audit active resident records to ensure that the UAI displays the appropriate documentation by 4/30/22. – 4/30/22 – To be monitored by DCS

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

At approximately 9:45AM during on-site complaint inspection, the door to the laundry room in the facility’s safe, secure unit was found by two licensing inspectors (LIs) to be propped open with a small towel. A container of sprayway glass cleaner, ecolab home-style laundry detergent packs and a plastic water bottle with a blue substance were noted to be located in the laundry room.

Plan of correction

Storage room door was adjusted to latch and lock. EVS to provide in-service with all housekeeping/maintenance staff of proper storage of cleaning supplies and hazardous materials. EVS or EVS assistant will monitor cleaning supplies and hazardous materials daily. – 3/18/22 – To be monitored by ED and EVS

22VAC40-73-1130-C

Based on a review of facility staffing sheets and employee schedule, the facility failed to ensure that at least 3 direct care staff members were awake and on duty in the special care unit when 23 to 32 residents were present.

Evidence

The facility special care unit was noted to have a census of 25 on the day of inspection. The facility daily staff staffing sheets has documentation of only 2 direct care staff members working on the special care unit on the 11pm to 7am shift on 10/06/2021, 10/07/2021, 10/09/2021, 12/03/2021, 12/07/2021, and 12/18/2021. Interviews with staff person 1 expressed that the special care unit census was been between 23 and 32 residents during these shifts, which would require a minimum of 3 direct care staff on duty on the special care unit..

Plan of correction

Executive Director to review schedule daily to ensure appropriate number of staff are on schedule to meet DSS requirements. DCS, DICSE, or designee BOM to ensure staff are available based on secure unit staffing regulation and acuity of residents. – 3/18/22 – To be monitored by ED, DCS, DICSE, BOM

22VAC40-73-280-A

Based on resident record review, the assisted living facility failed to ensure staff adequate in knowledge, skills, and abilities and sufficient in numbers to provide services to attain and maintain the physical, mental, and psychosocial well-being of each resident as determined by resident assessments and individualized service plans (ISPs).

Evidence

The facility had an incident report for resident 2, dated 10/23/2021 at 10:00PM, which showed “CNA observed resident on floor during rounds. Resident assessed, 911 called for assistance in lifting resident safely back to bed.” The facility daily staffing sheet has documentation of 3 direct care staff members schedule for the facility memory care unit, where resident 2 resides.

Plan of correction

November 4, 2021Inspection1 violation

Inspection dates

11/04/2021

Areas reviewed

22VAC40-73 GENERAL PROVISIONS22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

A non-mandated self-report inspection was initiated on 11/04/2021 and concluded on 12/09/2021. A self-reported incident was received by the department regarding allegations in the areas of resident care and related services. The Administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the Administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the self-report of non-compliance with standards or law, and violations cited can be found on the violation notice.

Violations

22VAC40-73-450-F

Based on a review of resident records, the facility failed to ensure that individualized service plans (ISPs) were updated to address all identified needs.

Evidence

The record for resident 1 admitted to the facility on 11/05/2019 has documentation on a history and physical exam completed 10/30/2019 that resident 1 has a diagnosis of depression and that they take medication for this diagnosis. A physician progress noted dated 10/28/2021 has documentation that resident 1 was seen for anxiety with depression and had expressed suicidal ideations with the physician during the visit. A referral for a geriatric psychiatry evaluation was documented on the progress note dated 10/28/2021. The ISP dated 10/19/2021 in the record for resident 1 does not address the identified need for monitoring for signs of increased symptoms or suicidal ideations related to residents 1's diagnosis of depression.

Plan of correction

A 100% review of all resident's diagnosis will be conducted to identify anyone with needs for monitoring for signs of increased symptoms or suicidal ideations related to a diagnosis of depression. Individualized service plans will be updated accordingly to outline treatment plan and monitoring. This will be completed by January 15, 2022. Wellness Director and Executive Director will monitor ISP's for accuracy.

September 28, 2021Complaint survey0 violations

Inspection dates

09/28/2021

Areas reviewed

22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDING AND GROUNDS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity

Comments

A non-mandated complaint inspection was initiated on 09/28/2021 and concluded on 10/04/2021. A complaint was received by the department regarding allegations in the areas of resident care and related services, staffing and building and grounds. The Administrator was contacted by telephone to conduct the investigation. The licensing inspector provided a list of documentation required to complete the investigation. The licensing inspector conducted an on-site observation at the facility on 09/28/2021. The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law.

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

September 8, 2021Inspection1 violation

Inspection dates

09/08/2021

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

A non-mandated inspection was initiated on 09/08/2021 and concluded on 09/16/2021. A self-reported incident was received by the department regarding allegations in the areas of resident rights. The Administrator was contacted by telephone to conduct the investigation. The evidence gathered during the investigation supported the self-report of non-compliance with standards or law, and violations cited can be found on the violation notice.

Violations

22VAC40-73-550-C

Based on staff interviews and a review of facility documentation, the facility failed to ensure that a resident of the assisted living facility had the rights and responsibilities as provided in § 63.2-1808 of the Code of Virginia and this chapter.

Evidence

An incident was self-reported by the facility on 09/08/2021. On 09/07/2021 staff person 2 received a complaint in regards to staff person 1 taking inappropriate videos of resident 1, who resides in the facility safe, secure unit, and uploading the videos to a social media platform (snap chat). In a phone interview with staff person 2 on 09/09/2021, staff person 2 explained that they had reviewed the videos that were uploaded to snap chat. Staff person 2 expressed that the videos shows resident 1 sitting in a facility bathroom, which violates resident 1's rights to be free of degrading or demeaning acts against them and to be treated with dignity. Staff person 1 was suspended on 09/07/2021 and terminated from employment with the facility on 09/10/2021.

Plan of correction

Staff person 1 terminated from employment on 9/10/2021 effective immediately. ED & BOM All staff retrained on RUI/Woodland Hills Social Media Policy. Signatures obtained from staff. ED & Department Heads Resident Rights training to be scheduled for staff at Woodland Hills. ED and/or designee

August 9, 2021Inspection1 violation

Inspection dates

Aug. 9, 2021

Areas reviewed

Comments

A non-mandated monitoring inspection was initiated on 8/9/2021 and concluded on 8/10/2021. The Administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the Administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation supported non-compliance with standards or law, and violations were issued.

Violations

22VAC40-73-1140-B

Based on a review of staff training records, the facility failed to ensure that direct care staff attended at least 10 hours of training in cognitive impairments within the first four months of employment.

Evidence

The training record for staff person 1, hired on 2/10/2021, does not have documentation of any training in cognitive impairments within the first four months of employment for this employee.
The training record for staff person 3, hired on 3/4/2021, has documentation of only 1 hour of training in cognitive impairments completed within the first four months of employment for this employee.

Plan of correction

Staff person 1 completed the dementia training hours on 7/27/21. Staff person 3 was asked to finish the training or be taken off the schedule. Staff 3 turned in resignation on 7/27/21, effective immediately. This staff member is no longer employed at Woodland Hills. All new, caregiver hires working on safe, secure unit will be assigned 10 hours dementia training on Relias to be completed within first 4 months of hire. Report to be pulled and audited weekly by BOM, ED and/or designee.

August 7, 2021Inspection0 violations

Inspection dates

08/07/2021

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity

Comments

A non-mandated inspection was initiated on 08/07/2021 and concluded on 08/23/2021. A self-reported incident was received by the department regarding allegations in the areas of resident care and related services. The Administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the Administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law.

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

July 23, 2021Inspection0 violations

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

A non-mandated self-report inspection was initiated on 07/23/2021 and concluded on 08/17/2021. A self-reported incident) was received by the department regarding allegations in the areas of resident care and related services. The Administrator was contacted by telephone to conduct the investigation. The licensing inspector notified the Administrator of a list of documentation required to complete the investigation. The evidence gathered during the investigation did not support the (allegation(s)/self-report) of non-compliance with standards or law.

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

March 23, 2021Inspection12 violations

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

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 3/23/2021 and concluded on 3/25/2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 79. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 4 resident records, 4 staff records, health care oversight, staff schedules, fire and health department inspections, fire drill logs, dietician oversight and new employee sworn disclosure and criminal records submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliances with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations

22VAC40-73-1110-A

Based on a review of resident records, the facility failed to ensure that written determination and justification was provided by the licensee, administrator or designee prior to place to a special care unit.

Evidence

The record for resident 2, admitted to the facility special care unit on 1/29/21, did not contain written determination and justification prior to the residents placement in a special care unit.

Plan of correction

Required form for SCU placement in use form for all admissions to SCU. ED and/or designee to ensure appropriate placement form used for each new admission placement form used for each new admission.

22VAC40-73-1140-B

Based on a review of staff records, the facility failed to ensure that direct care staff attended at least 10 hours of training in cognitive impairments within four months of thier start date of employment.

Evidence

The record for staff person 2, hired on 10/16/20, did not contain any documentation of training for residents with cognitive impairments. In an interview with staff person 6 it was expressed that this employee does work at times on the facility safe secure unit with residents who has cognitive impairments.

Plan of correction

BOM or ED to schedule cognitive training for staff person 2 to begin immediately upon return from leave. At orientation, BOM or designee to assign/schedule cognitive training to be completed over following 4 months for each new direct care staff.

22VAC40-73-260-A

Based on a review of staff records, the facility failed to ensure that all direct care staff maintained certification in first aid.

Evidence

The record for staff person 4, hired on 10/17/19, did not contain a current first aid certification card from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. A notation was made on staff person 4's relias training record for first aid on 10/21/19 but the notation did not include the entity that provided the training or the time frame that the certification was valid for.

Plan of correction

BOM and/or designee to audit certifications monthly for expiring certifications. Schedule classes as needed to provide appropriate training .

22VAC40-73-270-1

Based on a review of staff records, the facility failed to ensure that direct care staff received training in methods of dealing with residents who have a history of aggressive behavior or of dangerously agitated states prior to being involved in the care of such residents. This training shall include, at a minimum, information, demonstration, and practical experience in self-protection and in the prevention and de-escalation of aggressive behavior.

Evidence

The record for staff person 2, hired on 10/16/20, did not contain documentation that this employee has received training in methods of dealing with residents who have a history of aggressive behavior or of dangerously agitated states prior to being involved in the care of such residents. In an interview with staff person 6 it was expressed that this employee works at times on the facility safe secure unit where resident 2, whos record has documentation of aggressive behavior on at least one occasion, resides.
The record for staff person 3 has documentation on their relias training record of receiving aggressive behavior training on 10/15/19 and 4/17/20. The training record does not include a written description of the content of this training to also include any demonstration and practical experience provided or a notation of the qualified health professional who provided the training.
The record for staff person 4 has documentation on their relias training record of receiving aggressive behavior training on 10/10/19 and 4/17/20. The training record does not include a written description of the content of this training to also include any demonstration and practical experience provided or a notation of the qualified health professional who provided the training.

Plan of correction

WD to conduct Behavior Training with all direct care staff. Training will be conducted as part of orientation for all new direct care staff.

22VAC40-73-280-A

Based on a review of resident records and staffing daily assignment sheets, the facility failed to ensure that staffing was sufficient in numbers to provide services to attain and maintain the physical, mental, and psychosocial well-being of each resident.

Evidence

The record for resident 2, who resides in the facility safe secure unit, has documentation on his individualized service plan ( ISP) of the resident requiring assistance of 2 staff for transfers and toileting assistance every 2 to 3 hours for bladder incontinence. Progress notes in resident 2's record has documentation on 2/1/21 of the resident requiring assistance of 4 staff for transferring and on 2/6/21 requiring assistance of 3 staff for transferring. The progress notes also has documentation during the 11 to 7 shift on 2/6/21, 3/1/21, 3/17/21 and 3/18/21 of the resident falling and EMS being called for assistance to get the resident up from the floor and assist in putting him back to bed. Daily staffing assignment sheets has documentation that only 2 direct care staff were present on the safe secure unit for 14 shifts between 3/2/21 and 3/21/21. During these shifts that only 2 direct care staff were present and were providing care for resident 2's transfer needs no other direct care staff were scheduled to be on the unit to assist in the care needs care for resident 2s transfer needs, no other direct care staff were scheduled to be on the unit to assist in the care needs of other residents.

Plan of correction

Continue to schedule daily number of staff to meet DSS requirements. WD, AWD or designee BOM to continue recruitment efforts to ensure ample staff available.

22VAC40-73-325-B

Based on a review of resident records, the facility failed to ensure that fall risk ratings were completed annually.

Evidence

The record for resident 3, who was assessed as assisted living level of care on their most recent uniform assessment instrument (UAI) dated 2/17/21, has documentation that the last fall risk rating completed for this resident was dated 1/28/20.

Plan of correction

Resident 3 Fall risk rating updated at time of inspection. WD, AWD, and/or designee to complete full audit of fall risk ratings. WD to create system to track Fall Risk rating needs.

22VAC40-73-440-D

Based on a review of resident records, the facility failed to ensure that private pay uniform assessment instruments (UAIs) were competed as required.

Evidence

The UAI dated 1/29/21 in the record for resident 2 has documentation that the residents medications are administered/monitored by professional nursing staff. It was noted that the UAI should indicate that medications are administered/monitored by lay persons as registered medication aides administer medications to this resident.
The UAI dated 9/16/20 in the record for resident 4 has documentation that the residents medications are administered/monitored by professional nursing staff. It was noted that the UAI should indicate that medications are administered/monitored by lay persons as registered medication aides administer medications to this resident.

Plan of correction

UAI for residents 2 & 4 updated at time of inspection. Full audit on all UAIs. WD, AWD, and/or designee

22VAC40-73-450-C

Based on a review of resident records, the facility to ensure that all identified needs were addressed on residents individualized service plans (ISPs).

Evidence

The record for resident 1 has documentation that the resident has a Do Not Resuscitate (DNR) order. The comprehensive ISP dated 11/6/20 does not address this identified need.
The comprehensive ISP dated 1/29/21 in the record for resident 2 has documentation of the resident being a fall risk. The residents record has documentation of the resident falling 7 times since 1/29/21 but the ISP does not reflect any additional measures put in place to prevent/reduce further falls, including the identified need for a bed alarm ordered on 1/30/31 and the identified need for a bed side commode ordered on 1/29/21. The record for resident 2 also has a physician order for physical and occupational therapy services dated 2/2/21 but this identified need is not addressed on the ISP.
The fall risk rating completed on 1/28/20 in the record for resident 3 has indicates that the resident is a high risk for falls. The comprehensive ISP dated 2/17/21 does not address this identified need.
The fall risk rating completed on 2/2/21 in the record for resident 4 has indicates that the resident is a high risk for falls. The comprehensive ISP dated 9/16/20 does not address this identified need. Also the progress notes for resident 4 has documentation that the resident has been receiving Home Health Therapy services and will be transitioning to facility in house therapy. The ISP does not address the identified need for this residents therapy services.

Plan of correction

ISP for resident 1 updated at time of inspection to reflect all identified needs are addressed. WD, AWD, ED to complete full audit on all current ISPs. Begin weekly audit on 5 resident ISPs completed by WD, AWD and/or designee.

22VAC40-73-450-D

Based on review of resident record, the facility failed to ensure that the services provided by both, the assisted living facility and the licensed hospice organization, were included on the individualized service plan (ISP).

Evidence

The record for resident 1 shows the resident is receiving hospice services. The comprehensive ISP for resident 1, dated 11/6/20, indicates the resident is receiving hospice services, but does not include the services provided by the hospice organization.
The record for resident has documentation that the resident is receiving Hospices services since 9/17/20. The comprehensive ISP dated 9/16/20 doe not address any Hospice services being provided to the resident.

Plan of correction

ISP for resident 1 updated at time of inspection to include hospice services. WD, AWD, ED to complete full audit on resident's ISPs currently receiving hospice services. Begin weekly audit on 5 resident ISPs completed by WD, AWD and/or designee.

22VAC40-73-640-A

Based on a review of resident records and the facility medication management plan, the facility failed to follow their medication management plan in regards to methods for verifying that orders have been accurately transcribed to medication administration records (MARs) within 24 hours of receipt of a new order.

Evidence

The facility medication management plan has documentation that the wellness director of community designee will review new orders transcribed into PCC within 24 hours of a new or change in order. If any order was noted to be transcribed inaccurately, verify order and correct documentation. The record for resident 3 has a physician order dated 2/16/21 to encourage the resident to take PO fluids. This physician order was not transcribed on the Residents March 2021 medication administration record.

Plan of correction

Order for resident 3 transcribed to the residents MAR on date of inspection. WD, AWD, and/or designee to complete ongoing audit for orders to be transcribed to the MAR. WD to provide Medication management plan in-service for LPNs and RMAs.

22VAC40-73-650-A

Based on a review of resident records, the facility failed to ensure that no medication was changed without a valid order from a physician.

Evidence

The record for resident 1 has documentation of a physician order dated 11/3/2020 for the resident to be NPO for diet, texture and consistency, no food or fluids by mouth. The record also has physician orders dated 11/7/2020 for Ativan 0.5 mg 1 tablet by mouth every 6 hours as needed and Oxycodone 5mg, 1 tablet by mouth every 4 hours as needed. No clarification was received to change the original order dated 11/3/20 that the resident is to be NPO and take nothing by mouth.

Plan of correction

Order for resident 1 clarified with physician and record updated. WD to provide education to Charge Nurses regarding order clarification. WD, AWD, and/or designee to begin weekly chart audits to ensure orders are correct.

22VAC40-73-680-I

Based on a review or resident medication administration records (MARs), the facility failed to ensure that all required documentation was present on resident MARs.

Evidence

The March 2021 MAR for resident 1 does not have staff initials for the administration of the medication Carbidopa/Levodopa 25/100mg at 1pm on 3/7/2, Jevity tube feedings at 1pm on 3/7/21 and 5am on 3/14/21 and tube flushes at 1pm on 3/7/21 and 5am on 3/14/21.
The March 2021 MAR for resident 2 does not have staff initials for the administration of Buspirone 10mg at 2pm on 3/1/21or Voltaran Gel at 9pm on 3/6/21 and 3/11/21.
The March 2021 MAR for resident 3 does not have staff initials for the administration of Fosamax 70mg at 630am on 3/17/21.

Plan of correction

WD to provide Medication management plan in-service for LPNs and RMAs. WD and AWD to check dashboard daily for alerts.

March 5, 2021Complaint survey1 violation

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES

Comments

This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A complaint inspection was initiated on 3/5/2021 and concluded on 3/16/2021. A complaint was received by the department regarding allegations in the areas of Infection Control Policies and Procedures. The Administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the Administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the allegation of non-compliance with standards or law, and violations were issued.

Violations

22VAC40-73-40-A

Based on a review of staff records and facility documentation, the licensee failed to ensure compliance with relevant state law, with other relevant regulations and the facility's own policies and procedures.

Evidence

The records for staff persons 5 and 7 were reviewed on 3/16/2021 and did not contain documentation of written certifications required under code section 16VAC25-220- Emergency Temporary Standard Infectious Prevention: SARS- CoV-2 Virus that Causes COVID-19.

Plan of correction

All staff members to receive emergency temp. standard training if not previously trained. Initial orientation of new hires to include emergency temporary standard infectious prevention training.

March 5, 2021Complaint survey0 violations

Areas reviewed

22VAC40-73 GENERAL PROVISIONS22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity

Comments

This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A complaint inspection was initiated on 0/3/2021 and concluded on 3/16/2021. A complaint was received by the department regarding allegations in the areas of resident care and related services, building and grounds, staffing and supervision and safe secure units. The Administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the Administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law.

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

November 17, 2020Complaint survey0 violations

Inspection dates

Nov. 17, 2020

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES

Comments

This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A complaint inspection was initiated on 11/17/2020and concluded on 12/4/2020. A complaint was received by the department regarding allegations in the areas of 22VAC40-73-100. The Administrator was contacted and interviewed by telephone to conduct the investigation. The evidence gathered during the investigation did not support the non-compliance with standards or law.

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.