Virginia DSS · Assisted Living Facility

Charter Senior Living of Newport News

📍 655 Denbigh Boulevard, Newport News, VA, 23608

ID 45781One Year licenseActive
14
Inspections
On record
13
With violations
Visits that cited something
1
Clean visits
Nothing cited
114
Violations cited
Individual findings
66
Standards cited
Distinct rules
6
Complaint visits
Prompted by a complaint

Charter Senior Living of Newport News was inspected 14 times between June 7, 2021 and December 18, 2025 by the Virginia Department of Social Services. 13 of those visits ended with violations cited and 1 with none. Across that history VDSS cited 114 violations under 66 distinct standards. 6 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. 13 of these 14 are still on the state's site; the other 1 has since dropped off it and is reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type
Assisted Living Facility
License type
One Year
License expires
12/30/2026
Administrator
Angel Lawhorn
Licensing inspector
Darunda Flint
Inspector phone
(757) 807-9731
Approved for
Assisted Living · Special Care Unit · Non-Ambulatory

Inspection History

14

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

December 18, 2025Inspection5 violations
Inspection dates
12/18/2025, 12/19/2025
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 IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Number of residents present at the facility at the beginning of the inspection: The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 5 Observations by licensing inspector: Lunch and an activity were observed. A medication pass observation was completed for four residents. The following were reviewed: emergency preparedness, medication review, medication carts, health care oversight, special diets oversights, fire inspection report, health inspection report, and water temperatures were measured. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Darunda Flint, Licensing Inspector at (757) 807-9731 or by email at darunda.a.flint@dss.virginia.gov
Violations
22VAC40-73-610-B
Based on observation and staff interviewed, the facility failed to ensure menus for meals and snacks for the current week was dated and posted in an area conspicuous to residents.
Evidence
  1. The weekly menu was not posted on the safe secure unit.
  2. The daily menu posted did not document the substitution of baked beans and apple streusel cake for the lunch meal observed.
  3. Staff #3 acknowledged that there was no weekly menu posted on the safe secure unit and the substitutions were not documented.
Plan of correction
Plan of Correction: Weekly menus are dated and posted in conspicuous locations on all units, including the safe secure unit. Menu substitutions are documented using a substitution log. The Dining Director or designee will complete weekly menu audits for 30days The Executive Director (ED) or designee will review audit findings during the Quarterly Quality Assurance meeting. Compliant as of 1/25/2026
22VAC40-73-980-A
Based on observation and staff interviewed, the facility failed to ensure the first aid kit included all required items.
Evidence
  1. The first aid kit did not include adhesive tape.
  2. Staff #2 acknowledged the first aid kit did not include the required item.
Plan of correction
Plan of Correction: Adhesive tape was immediately added to the first aid kit to ensure all required items are present. The Health and Wellness Director (HWD) or designee, , will complete and document weekly first aid kit audits for 30 consecutive days. Following the initial 30-day audit period, audits will be conducted monthly and reviewed during the Quality Assurance (QA) meeting by Executive Director To be compliant by 1/20/2026
22VAC40-73-950-F
Based on interview and document review, the facility failed to review the emergency preparedness plan annually or more often as needed, documenting the review by signing and dating the plan, and making necessary plan revisions.
Evidence
  1. Staff #1 could not provide documentation of an annual review of the emergency preparedness and response plan.
Plan of correction
Plan of Correction: The Emergency Preparedness and Response Plan has been reviewed, signed, and dated. The annual review has been added to the facility compliance calendar. The Executive Director (ED) or designee will ensure the plan is reviewed prior to the annual due date.
22VAC40-73-950-A
Based on staff interviewed and documents reviewed, the facility failed to develop a written emergency preparedness and response plan that shall address documentation of initial and annual contact with the local emergency coordinator to determine (i) local disaster risks, (ii) communitywide plans to address different disasters and emergency situations, and (iii) assistance, if any, that the local emergency management office will provide to the facility in an emergency.
Evidence
  1. Staff #1 could not provide annual documentation of emergency preparedness review with a local emergency coordinator.
Plan of correction
Plan of Correction: The facility will initiate documented communication with the local emergency management coordinator via email. Environmental Service Director or designee will document all communication attempts and any information obtained. If documentation cannot be obtained, attempts will be recorded and retained. Emergency coordinator communication will be completed annually and tracked on the compliance calendar. Executive Director to review quarterly in quality assurance. Compliant 1/25/2026
22VAC40-73-550-G
Based on record review and staff interviewed, the facility failed to annually review the rights and responsibilities of residents with each resident, or his legal representative or responsible individual as stipulated in subsection H of this section and each staff person.
Evidence
  1. The record for resident #6 contained an annual review of rights and responsibilities dated 12/12/2023. Resident #6’s date of admit was 12/20/2023.
  2. The record for resident #5 did not contain an annual review of rights and responsibilities. Resident #5’s date of admit was 09/01/2020.
Plan of correction
Plan of Correction: All residents will receive an annual review of rights and responsibilities. Documentation will be maintained in resident records. Life enrichment director , Memory care director or designee to audit monthly for 90 days The Executive Director (ED) will review in quality assurance meeting
May 12, 2025Complaint survey7 violations
Inspection dates
05/12/2025
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 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 IMPAIRMENTS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint An unannounced complaint inspection conducted on 5-12-25. Ar (08:04 a.m./ Dep 15:25 p.m.) The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection A complaint was received by VDSS Division of Licensing on 4-17-25 regarding allegations in the Resident Care and Related Services, Buildings and Grounds and Staffing and Supervision. Number of residents present at the facility at the beginning of the inspection: 47 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Yes Number of resident records reviewed: 6 Number of staff records reviewed: Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 5 Observations by licensing inspector: tour of facility, staffing schedule and medication pass observation, breakfast meal Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were valid. 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 Willie Barnes, Licensing Inspector at 757-439-6815 or by email at willie.barnes@dss.virginia.gov
Violations
22VAC40-73-650-B
Based on document reviewed and staff interviewed, the facility failed to ensure the physician or other prescribers orders, written and oral, for administration of all prescription and over-the-counter medications and dietary supplements shall identify the diagnosis, condition, or specific indications for administering each drug.
Evidence
  1. On 5-12-25, resident #4’s physician’s order dated 5-5-25 did not include the diagnosis for Memantine tablet.
  2. Resident #5’s physician’s order dated 11-22-24 did not include diagnoses for Magnesium Oxide tablet, Ozempic injection, Famotidine tablets and Melatonin tablets.
  3. Staff #1 acknowledged the physician’s orders did not include the diagnosis or specific indications for administering each drug.
Plan of correction
A review of all active medication and supplement orders will be conducted by June 3, 2025. Orders lacking the required diagnosis will be sent to physician for clarification and correction by June 6 , 2025. All medications staff will receive retraining of requirement of orders to include diagnosis and to clarify orders with prescribers when information is missing by June 6, 2025. Monthly audits of physician orders will be conducted for 90 days by Health and Wellness Director or designee. Executive director to review at least quarterly during QA. Complaint by 6/06/2025
22VAC40-73-680-D
Based on observation, document reviewed, and staff interviewed, the facility failed to ensure medications shall be administered in accordance with the physician’s or other prescriber’s instructions.
Evidence
  1. On 5-12-25, during medication pass observation with staff #3, resident #2’s Metamucil Orange Packer order dated 3-25-25 and May 2025 medication administration record (MAR) noted, “take 1 packet by mouth every day in 8 oz of water…”. The staff placed the powder in the cup and then added the water. When inquired if the cup being used was measured or had measuring lines, staff stated no. The inspector checked the information on the cup and noted the bottom of the clear plastic cup noted 9. The cup was determined to be a 9 oz cup.
  2. Staff #3 acknowledged the Metamucil mixture was not added to 8 ounces of fluid per the prescriber’s order.
Plan of correction
All medication staff to be retrained to utilize measuring cups when having to measure medication and how to accurately read and follow prescriber instructions by June 6, 2025. Measuring cups to be available on all medication carts be utilized by medication staff. Daily audits by medication staff to ensure measuring cups on mediation cart for 90 days. Weekly audits to be done be on all medication carts by Health and Wellness Director or designee for 90 days. Executive Director to review quarterly during QA.
22VAC40-73-680-I
Based on document reviewed and staff interviewed, the facility failed to ensure the Medication Administration Record (MAR) included all required information.
Evidence
  1. On 5-2-25, resident #4’s April 2025 and May 2025 MAR did not have diagnosis or specific conditions for Memantine tablet.
  2. Resident #5’s April 2025 and May 2025 MAR did not have diagnosis or specific conditions for Lantus Solostar injection.
  3. Resident #6’s April 2025 and May 2025 did not have diagnosis for Aspercreme Lidocaine 4% Patch.
  4. Staff #1 acknowledged the resident’s MARs did not include diagnosis or specific conditions for the prescribed medications.
Plan of correction
All MARs will be audited for required information by June 3, 2025. Any discrepancies will be notified to the prescriber for clarification by June 6, 2025. All medication staff will be reeducation on MAR required information June 14th Health and Wellness Director or designee will conduct weekly MAR audits for 90 days. Executive Director to review in QA quarterly Compliant as of 6/14/2025
22VAC40-73-640-A
Based on observation and staff interviewed, the facility failed to ensure it did not administer outdated medications and ensure that medications are refilled in a timely manner.
Evidence
  1. On 5-12-25, during the medication pass with staff #3, resident #1 was administered medication that was outdated. The physician’s order dated 5-5-25 and April and May 2025 medication administration record (MAR) noted Budesonide-Formoterol Fumarate 160-4.5mcg HFA inhaler, “discard 90 days after opening and store upright”. The labeled on the box was dated 12-15-24.
  2. Staff #3 acknowledged the medication administered was outdated based on the opened date noted on the label.
  3. Resident #1’s Occsoft lid pad scrub applied twice daily was not available on the following days: 4-28-25 (8 p.m.); 4-29-25 (8 a.m.); 4-30-25 (8 a.m.); 5-1-25 (8 a.m.) and 5-2-25 (8 p.m.).
  4. The facility’s Medication Management Policy No: MED-WI-023, Medication, Non-Availability noted, “staff member(s) providing medication assistance/administration will be responsible for requesting the refill, or communication the refill need to the appropriate staff member, when the medication supply is at the 7-day level.
Plan of correction
All medication management staff will receive retraining on identifying and removing expired medications, medication ordering and refill timelines, proper documentation of missed or delayed doses by June 6, 2025. Weekly audits of medication carts by medication staff to identify expired medications and medications with low remaining qualities. Health and Wellness Director or designee to review audit weekly to verify medications for 90 days to ensure compliance. Executive director to review at least quarterly during QA. Compliant as of 6/14/2025
22VAC40-73-680-K
Based on document reviewed and staff interviewed, the facility failed to ensure the order for PRN (as needed) order included the exact dosage.
Evidence
  1. On 5-12-25, resident #6’s April 2025 and May 2025 medication administration record (MAR) noted for the Polyethylene Glycol (MiraLAX), “mix 1 packet in 4-8 ounces of non-carbonated liquid of choice…”
  2. Staff #1 acknowledged the PRN medication did not document the exact ounces of liquid, and the facility have Registered Medication Aides (RMAs) who administer medications.
Plan of correction
All MARS will be audited of current PRN medication orders for complete orders by June 3, 2025 and be clarified with prescribers for clarification by June 6, 2025. All medication staff to be retrained on PRN orders, how to identify and obtain clarification for incomplete medication orders by June 6, 2025. Monthly PRN audits to be conducted by Health and Wellness Director or designee for 90 days. Executive director to review quarterly during QA Compliant by 6/14/2025
22VAC40-73-680-M
Based on observation, document reviewed, and staff interviewed, the facility failed to ensure medications ordered for PRN (as needed) administration shall be available, properly labeled for the specific resident, and properly stored at the facility.
Evidence
  1. On 5-12-25, resident #2’s physician orders dated 3-25-25 noted resident is prescribed PRN Lidocaine Pain Relief 4% adhesive patch. Staff #3 was not able to locate the patch during the medication pass observation.
  2. Staff #1acknowledged resident #2’s PRN Lidocaine Patch was not available and properly stored at the facility.
Plan of correction
All PRN medications to be audited by June 3, 2025 for availability. Medication staff to be retrained on proper labeling of PRN medications, checking and reordering medications before they run out by June 6, 2025. Weekly audits to be conducted by medication staff for 90 days. Weekly PRN audits to be conducted by Health and Wellness Director or designee to verify medications. Executive director to review in QA quarterly. Complinat by 6/14/2025
22VAC40-73-70-A
Based on document reviewed, resident and staff interviewed, the facility failed to ensure it reported to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident.
Evidence
  1. On 5-12-25, resident # 5 stated receiving roommate’s 2:00 p.m. medications by mistake after the registered medication aide (RMA) brought both residents’ afternoon medications to the room.
  2. Resident #5’s clinical notes, dated 3-16-25 at 5:15 p.m. and 3-16-25 at 5:34 p.m. included notation of this medication mistake, noting, “The resident accidently picked up the wrong medication and swallowed it during the mid-day med Pass”. (sic). Notification to the resident’s physician and poison control noted. The resident’s clinical notes dated 3-16-25 at 5:24 p.m. noted, “physician requested spot checks and vitals to be taken”. Clinical notes dated 3-16-25 at 9:50 p.m. noted, “Resident, complained of stomach discomfort and threw up dinner meal”. The resident’s physician was contacted, and the nurse instructed the staff to provide the resident with fluids. Clinical notes dated 3-17-25 at 12:05 p.m. noted, resident complained to staff, (Registered Medication Aide) of being up most of the night throwing up”. (sic)
  3. A review of resident #5’s roommate’s medication list noted resident #6’s afternoon medication as: Carbidopa/Levodopa ER 50-200 tablet at 2:00 p.m. for Parkinson’s and Entacapone 200 mg tablet at 3:00 p.m. for pain. Resident #5 is not prescribed these medications.
  4. Resident #5’s afternoon medication prescribed was Gabapentin 100 mg tablet.
  5. Staff #1 acknowledged a medication error occurred and the regional licensing office was not notified of this incident.
Plan of correction
The facility has implemented the following corrective measures to ensure compliance moving forward. The facility will report any major incidents within 24 hours. The Health and Wellness Director or designee will be assigned to oversee all incident reviews and ensure timely reporting. Executive Director will follow up daily about any incidents. A weekly audit of incidents will be conducted for 90days to ensure compliance. Executive director to review at least quarterly during QA. Compliant as of 6/14/2025
December 23, 2024Inspection16 violations
Inspection dates
12/23/2024;12/26/2024
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 IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Renewal An unannounced mandated renewal inspection conducted on 12-23-24 with two inspectors from the PLO (Ar 10:32 a.m./Dep 17:50 p.m.). Day 2- one inspector, Ar 09:15/ Dep 15:25 p.m). The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 76 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Yes Number of resident records reviewed: 7 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 9 Observations by licensing inspector: breakfast/lunch meal, medication pass Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov
Violations
22VAC40-73-380-B
Based on record reviewed and staff interviewed, the facility failed to ensure the resident’s personal and social information was kept current.
Evidence
  1. On 12-23-24, resident #1’s DSS social data and mental health determination form noted the resident’s date of admit was 3-26-23. The facility’s face sheet noted resident’s physical move in date as 3-28-23. Staff #4 stated the resident’s physical move in date was 3-28-23.
  2. Resident #3’s DSS social data noted resident’s physical admission date was 10-10-23. The facility’s face sheet and DSS mental health form noted physical move in date as 10-6-23. Staff #4 stated the resident’s physical move-in date was 10-6-23.
  3. Staff #4 acknowledged the aforementioned residents’ social data was not kept current.
Plan of correction
The Health and Wellness Director or designee will audit all Resident Social Information Data Sheets to ensure current information documented by January 24, 2025. The Health and Wellness Director will ensure corrections are made when changes occur to keep current. The Executive Director will review in Quality Assurance Meeting Quarterly. In compliance by January 31, 2025
22VAC40-73-610-B
Based on observation and staff interviewed, the facility failed to ensure the menus for meals and snacks for the current week was dated and posted in an area conspicuous to residents.
Evidence
  1. On 12-23-24, the menu and snacks for the current week was not posted in the facility.
  2. Staff #5 acknowledged the current menu and snacks was not posted.
Plan of correction
The Memory Care Director or designee will ensure menus are posted in conspicuous area for residents daily. The Executive Director or Manager on Duty will check menu posting daily. In compliance as of January 21, 2025
22VAC40-73-680-C
Based on document reviewed, staff interviewed and observation, the facility failed to ensure a resident’s medication was administered not earlier than one hour before and not later than one hour after the facility’s standard dosing schedule.
Evidence
  1. On 12-26-24, during the medication pass observation with staff #8, the following 08:00 a.m. medications for resident #7 were administered at 09:37 a.m.: Biotin, Donepezil, Memantine, Omeprazole, Oyster shell calcium plus D, and Vitamin B-12.
  2. Staff #3 stated the facility had extended dosing hours.
  3. Review of the facility’s medication policy submitted during the initial application did not document extended dosing hours.
  4. Staff #1 acknowledged the aforementioned resident’s medication was not administered within the dosing schedule time.
Plan of correction
The Health and Wellness Director or designee will in-service staff on medication administration and the one hour before or after dosing schedule by January 24, 2025. A daily audit of medication administration times will be conducted by the Health and Wellness Director or designee. Daily discrepancies will be reported to the Executive Director. The Executive Director will review in the Quality Assurance Meeting Quarterly. In compliance as of January 31, 2025
22VAC40-73-660-A
Based on observation, resident and staff interviewed, the facility failed to ensure medications was stored in a manner consistent with current standards of practice.
Evidence
  1. On 12-26-24, resident #1’s individualized service plan (ISP) noted the resident’s medications were self-administered. A check of the storage of resident’s medication observed the medications were not stored in a locked container/area. The resident medications included control medication (Xanax/Alprazolam) which was not in a locked area/container. Resident #1 stated, the medication has always been in that particular drawer, resident pointed to the drawer where the medications were located. The facility’s medication policy (Policy No: MED-001) noted on page 2, Medication Storage, medications “must be stored per regulatory standards”.
  2. Staff #3 acknowledged the aforementioned resident’s medication was not stored according to current standards of practice.
Plan of correction
The Health and Wellness Director or designee will audit all storage areas of residents allowed to Self-Administer medications. All medications will have proper locked storage for medications. The Registered Medication Aide or Licensed Practical Nurse will verify daily these storage areas are locked during the 7-3 shift and 3-11 shift. The Executive Director will review in the Quality Assurance Meeting Quarterly. In compliance by January 31, 2025
22VAC40-73-970-A
Based on staff interviewed and documents reviewed, the facility failed to ensure fire and emergency evacuation drills frequency and participation was in accordance with the current edition of the Virginia Statewide Fire Prevention Code. The drills for each shift in a quarter shall not be conducted in the same month.
Evidence
  1. On 12-26-24, fire drills date was noted as 12-4-24 (9a-4p); 12-6-24 (15:00); 12-12-24 (630a -245p/ 330p); 10-31-24 (16:00- 16:15); 9-27-24 (11:45-12:00 p); 8-13-24 (15:14-15:30) and 7-18-24 (8:08 a- 8:10 a)
  2. The facility did not complete drills for each shift. Staff #1 acknowledged the drills were not completed for each shift in a quarter.
Plan of correction
The Environmental Service Director or designee will conduct every 6 months, on each shift, emergency evacuation drills. The Environmental Service Director or designee will conduct audits of required drills monthly. The Executive Director will review in the Quality Assurance Meeting Quarterly. In compliance as of January 31, 2025
22VAC40-73-450-F
Based on record reviewed and staff interviewed, the facility failed to ensure the resident’s individualized service plan (ISP) included all assessed needs.
Evidence
  1. On 12-23-24, resident #3’s uniformed assessment instrument (UAI) dated 4-10-24 noted resident disoriented sometime to time and place spheres. This need was not documented on the ISP dated 4-10-24.
Plan of correction
The Health and Wellness Director or designee will Audit 100 % of Resident Individualized Service Plans and correct inaccurate information by January 21, 2025. The Health and Wellness Director or designee will conduct weekly audits ongoing. The Executive Director will review in Quality Assurance Meeting Quarterly. In compliance by January 31, 2025
22VAC40-73-860-I
Based on staff interviewed and observation, the facility failed to ensure hazardous materials are in a locked area and not accessible to other residents.
Evidence
  1. On 12-26-24, unsupervised work area with sanding saw, putty knife, an approximately 2 feet of a 2X4 piece of lumber and debris was observed first floor hallway near the bistro and receptionist area.
  2. Staff #4 located the worker responsible for the unsupervised worked area.
Plan of correction
The Environmental Service Director or designee will educate vendors on site to ensure they are aware of the population and all Hazardous materials should be in a locked area when not attended to prevent accessibility by the residents. The Environmental Service Director will monitor each vendor on site in the community. The Executive Director will review in Quality Assurance Meeting Quarterly. In compliance by January 31,2025
22VAC40-73-890-C
Based on staff interviewed and observation, the facility failed to ensure glare was kept to a minimum in rooms used by residents. When necessary to reduce glare, coverings shall be used for windows and lights.
Evidence
  1. On 12-23-24, the overhead light on the first floor near the nurse station, hall 1 and the overhead light near the bistro was observed not having coverings.
  2. Staff #2 acknowledged the overhead lights were not covered to reduce glare.
Plan of correction
The Environmental Service Director or designee will weekly audit lights and coverings to ensure glare is at a minimum . The Environmental Service Director or designee will utilize the Tels system to manage tasks. Any identified areas will be reported immediately to the Executive Director, and corrected. The Executive Director will review in Quality Assurance Meeting Quarterly. In compliance by January 24, 2025
22VAC40-73-550-G
Based on record reviewed and staff interviewed, the facility failed to ensure the resident’s rights and responsibilities was reviewed annual.
Evidence
  1. On 12-26-24, staff #9’s record did not have documentation of annual acknowledgement of resident’s rights and responsibilities. Staff’s date of hire noted as 5-17-23.
  2. Staff #3 and #4 acknowledged the aforementioned staff’s record did not have documentation of annual rights review.
Plan of correction
The Business Office Manager or designee will audit 100% of staff records for signed copies of the Resident’s Rights, and any missing copies to be obtained by January 24, 2025. The Business Office Manager or designee will audit new staff records monthly. The Executive Director will review in Quality Assurance Meeting Quarterly. In compliance by January 31, 2025
22VAC40-73-120-B
Based on record reviewed and staff interviewed, the facility failed to ensure staff orientation included the facility’s organizational structure.
Evidence
  1. On 12-26-24, staff #9’s record did not have documentation of receiving the facility’s organizational structure.
  2. Staff #4 acknowledged the staff’s record did not include documentation acknowledging receipt of the facility’s organization structure.
Plan of correction
The Business Office Manager or designee will audit 100% of staff records for signed copies of the Organizational Chart structure by January 24, 2025. The Business Office Manager or designee will audit new staff records monthly. The Executive Director will review in Quarterly Assurance Meeting Quarterly. In compliance as of January 31, 2025.
22VAC40-73-990-C
Based on document reviewed and staff interviewed, the facility failed to ensure the resident emergency and practice exercise was conducted with all staff currently on duty on each shift.
Evidence
  1. On 12-26-24, the resident emergency- elopement drill conducted on 11-20-24 at 2:20 p.m. and 12-12-24 training conducted on 630a/ 245p and 330p did not include documentation of all staff currently on duty on each shift.
Plan of correction
The Environmental Service Director or Designee will ensure emergency and practice exercises with all staff on duty for each staff every shift and utilizing Tels system. Executive Director to review in Quality Assurance Meeting Quarterly.
22VAC40-73-1080-A
Based on document reviewed and staff interviewed, the facility failed to ensure prior to being admitted or retained in a safe, secure environment, a resident must have a cognitive impairment due to a primary psychiatric diagnosis of dementia and be unable to recognize danger or protect his own safely and welfare.
Evidence
  1. On 12-26-24, resident #6’s assessment of serious cognitive impairment dated 9-20-24 did not indicate that the resident has a serious cognitive impairment. Resident was place in safe, secure unit upon admission on 9-26-24.
  2. Staff #3 acknowledged the aforementioned resident, prior to placement on the secure unit, did not have a diagnosis of serious cognitive impairment by an independent clinical psychologist or physician licensed to practice in the Commonwealth.
Plan of correction
The Health and Wellness Director and or designee will have audited 100% of residents records by 1/21/2025 for cognitive impairment due to primary psychiatric diagnosis of dementia and be unable to recognize danger or protect his own safety and welfare for all residents admitted into the safe and secure environment. The Executive Director will review in the Quality Assurance Meeting Quarterly. In compliance by February 4th 2025
22VAC40-73-700-2
Based on record reviewed, staff interviewed and observation, the facility failed to ensure it posted the “No Smoking-Oxygen in Use” sign in a room where oxygen was in use.
Evidence
  1. On 12-26-24, resident #5’s record noted resident is prescribed oxygen at bedtime. The room did not have a “No Smoking-Oxygen in Use” sign posted.
  2. Staff #2 and #3 acknowledged the aforementioned resident’s room did not have the required “No Smoking-Oxygen in Use” sign where oxygen is in use.
Plan of correction
The Health and Wellness Director or designee will audit 100% of resident’s using oxygen to ensure “No Smoking Oxygen In Use Signs” are clearly posted on the resident’s door by January 14, 2025. The Registered Medication Aid will alert the Health and Wellness Director or designee if any resident using oxygen does not have a posted sign on the resident’s door. The Executive Director will review in the Quality Assurance Meeting Quarterly. In compliance by January 14, 2025.
22VAC40-73-320-A
Based on record and staff interviewed, the facility failed to ensure the physical examination form included all required information.
Evidence
  1. On 12-26-24, resident #6’s physical examination statement documented the resident was considered ambulatory. The resident was admitted to the facility’s safe, secure unit which is non-ambulatory.
  2. Staff #3 acknowledged the aforementioned resident’s physical examination form did not include the correct classification.
Plan of correction
The Health and Wellness Director or designee will audit all Resident Physical Examination records by January 14, 2025. Upon admission, the Health and Wellness Director will review the Resident’s Physical Examination record for correct classification of Ambulatory or Non-Ambulatory. The Executive Director will review in Quality Assurance Meeting Quarterly. In compliance as of February 4, 2025.
22VAC40-73-970-E
Based on documents reviewed and staff interviewed, the facility failed to ensure the record of the required fire and emergency evacuation drills included all required information.
Evidence
  1. On 12-26-24, the fire drills conducted on 12-12-24, 12-6-24, 12-4-24, 11-20-24 did not include the method used for notification of the drill, the number of residents participating; any special conditions simulated, the time it took to complete the drill, weather conditions and if any problems were encountered.
  2. The fire drills conducted on 10-31-24, 9-27-24; 8-13-24 and 7-18-24 did not include the method used for notification of the drill and any special conditions simulated.
  3. Staff #1 acknowledged the fire and evacuation drills conducted did not include all required information.
Plan of correction
The Environmental Service Director or designee will conduct fire drills and ensure all required information is listed per state regulations. The Environmental Service Director or designee will conduct audits of required drills monthly. The Executive Director will review in the Quality Assurance Meeting Quarterly. In compliance as of January 31, 2025
22VAC40-73-870-A
Based on observation and staff interviewed, the facility failed to ensure the interior of the building was maintained in good repair.
Evidence
  1. On 12-23-24, during a tour of the facility with staff #2, room #108’s wall was observed to have dark scuffed marks and paint tearing along the entrance walls and closet door to the room.
  2. Staff #2 acknowledged the room’s wall was in need of repair.
Plan of correction
The Environmental Service Director or designee will weekly audit the building and grounds to ensure the interior of building and grounds are in good repair. Any unacceptable areas will be reported immediately to Executive Director, and corrected. The Executive Director will review in Quality Assurance Meeting Quarterly. In compliance by February 14, 2025
September 10, 2024Complaint survey2 violations
Inspection dates
09/10/2024 09/23/2024;11/21/2024
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint An onsite complaint inspection was conducted on 9-10-24 (Ar 6:08 p.m/ Dep 9:30 p.m.); 9-23-24 (Ar 12:10 p.m./ Dep 12:55 p.m.) and 11-21-24 (Ar 09:10 a.m./Dep 14:55 p.m.) The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 9-10-24 regarding allegations in the area of resident care and related services-medication disposal. Number of residents present at the facility at the beginning of the inspection: 82 on 9-23-24 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 5 Number of staff records reviewed: 3 Number of interviews conducted with residents: Number of interviews conducted with staff: 5 Observations by licensing inspector: medication in dumpster behind dining facility Additional Comments/Discussion: 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 (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov
Violations
22VAC40-73-40-A
Based on document reviewed and staff interviewed, the facility failed to ensure the licensee was in compliance with all regulations for licensed assisted living facilities and terms of the license issued by the department, with relevant federal, state, and local laws; with other relevant regulations; and with the facilities own policies and procedures.
Evidence
  1. On 9-10-24, the inspectors observed medications in the dumpster located behind the facility’s dining room. Staff #2 and #3 retrieved three large black trash bags from the dumpster. The contents of the bags consisted of over two-hundred sixty-four (264) bubble packets, bottles and containers of medications for forty-seven (47) residents including from pills, creams, inhalers, ear drops, patches, eyedrops, cough syrups, antidiarrheal, ointment, etc. that had not been destroyed per the facility’s medication management policy. The date of the medications ranged from 2-28-24 to 8-15-24. (See Photos)
  2. The facility’s “Department Medication Management Policy No: MED-001, Medication Administration, Effective 9/2017-Revised 10/2021”, section “Discontinued Medication” noted medication staff will: “…remove the discontinued medication from the medication storage cart/cabinet and store in the designated secure area for drugs awaiting return/destruction. Unless otherwise prohibited under applicable state laws, non-controlled medications supplied in sealed containers may be returned, if unopened, to the issuing pharmacy. Medication destruction will be conducted per applicable state law. Two medication staff members (at least 1 licensed nurse must be present) will destroy all controlled medications. The Health and Wellness Director and/or designee will be responsible for destroying non-narcotic medications…Medication destruction will be recorded in the resident’s record/file and on a destruction log sheet, as required by state law”.
  3. Staff #1 acknowledged staff #2’s last day at the facility was 09-11-2024. Staff #3’s record included documentation of further personnel action.
Plan of correction
Corrective Action(s): The facility updated and educated on the Medication Destruction/Permanent Discontinuance policy in 11/2024. An initial training session for med techs and nurses occurred on 11/17/2024. Documentation of this training is available in their personnel files. Inservice Log is attached to this POC. Systemic Change(s): The Medication Destruction/Permanent Discontinuance Policy (attached to this POC) outlines the proper procedures for the disposal and destruction of unused, expired, or discontinued medications to ensure safety and compliance with regulations. Newly hired staff who are qualified to administer medications will receive training on this policy from the Health and Wellness Director or designee during the facility's job specific onboarding. In addition, the policy will be uploaded into Relias, our learning management software, and auto-assigned to new Med Techs and Nurses to track and verify completion. The Health and Wellness Director or designee is responsible for reviewing and signing all clinical orientation checklists, acknowledging training on the policy and procedures and the completion of clinical orientation. Monitoring: The Executive Director will review job onboarding checklists for new Med Techs and Nurses x 180 days to verify they are complete and training has occurred. If compliant, will move to quarterly audits of new employee files as part of the Quality Assurance Meetings. This audit will be ongoing as part of the Quality Assurance Meetings and will include Med Techs and Nurses among the other associates. The facility has developed and implemented an audit tool designed to verify the proper disposal and destruction of medication as it occurs, with a weekly review by the Health and Wellness Director. This will occur for next 60 days. If in compliance, will discontinue audit tool. Initial training on this tool for all current staff qualified to administer medications occurred on 2/26/2025. Documentation of the training will be available in their personnel files. Inservice Log is attached to this POC.
22VAC40-73-640-A
Based on document reviewed and staff interviewed, the facility failed to ensure it had, kept current, a implemented a written plan for proper disposal of medication.
Evidence
  1. On 9-10-24 during a complaint inspection regarding the improper disposal of medication, a request for a copy of the facility’s medication disposal policy was requested from staff #2 and #3. The facility’s, “Department Medication Management Policy No: MED-014, Medication Drug Disposal” policy was provided to the inspectors.
  2. On 9-25-24, staff #1 confirmed in an email that the medication disposal policy received was in fact the one (1) page document that was sent on 9-10-24.
Plan of correction
Corrective Action(s): The facility updated and educated on the Medication Destruction/Permanent Discontinuance policy in 11/2024. An initial training session for med techs and nurses occurred on 11/17/2024. Documentation of this training is available in their personnel files. Inservice Log is attached to this POC. Systemic Change(s): The Medication Destruction/Permanent Discontinuance Policy (attached to this POC) outlines the proper procedures for the disposal and destruction of unused, expired, or discontinued medications to ensure safety and compliance with regulations. Newly hired staff who are qualified to administer medications will receive training on this policy from the Health and Wellness Director or designee during the facility's job specific onboarding. In addition, the policy will be uploaded into Relias, our learning management software, and auto-assigned to new Med Techs and Nurses to track and verify completion. The Health and Wellness Director or designee is responsible for reviewing and signing all clinical orientation checklists, acknowledging training on the policy and procedures and the completion of clinical orientation. Monitoring: The Executive Director will review job onboarding checklists for new Med Techs and Nurses x 180 days to verify they are complete and training has occurred. If compliant, will move to quarterly audits of new employee files as part of the Quality Assurance Meetings. This audit will be ongoing as part of the Quality Assurance Meetings and will include Med Techs and Nurses among the other associates. The facility has developed and implemented an audit tool designed to verify the proper disposal and destruction of medication as it occurs, with a weekly review by the Health and Wellness Director. This will occur for next 60 days. If in compliance, will discontinue audit tool. Initial training on this tool for all current staff qualified to administer medications occurred on 2/26/2025. Documentation of the training will be available in their personnel files.
August 15, 2024Inspection9 violations
Inspection dates
08/15/2024
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 IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Monitoring An on-site inspection was conducted on 8-15-24. (Ar 07:25 a.m./Dep 18:45 p.m.) The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 81 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Yes 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: 10 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov
Violations
22VAC40-73-870-A
Based on observation and staff interviewed, the facility failed to ensure the interior and exterior of the building was maintained in good repair and kept clean and free of rubbish.
Evidence
  1. On 8-15-24 during a tour, the roof on the rear of the building, the back dock, kitchen area entrance from rear is missing a portion of the fascia. The fascia on the front porch covering area is in need of repair.
  2. The carpet in resident’s room #136 is in need of cleaning. The ceiling tile above the table near the juice bar in the dining area in the safe, secure unit contains a large brown circular spot.
  3. Staff #1 and #7 acknowledged the interior and exterior areas of the facility is in need of repair.
Plan of correction
Weekly audit of building and grounds by Director of Maintenance or Designee utilizing tels. Will notify Executive Director of any items needed to schedule repairs. Audit completion as of 9/20/2024 To be completed with repairs as of 9/30/2024. Director of Maintenance or designee will conduct weekly reviews of TELs and complete tasks required. The Executive Director will review at least quarterly during QA.
22VAC40-90-40-B
Based on record reviewed and staff interviewed, the facility failed to ensure the criminal history record report was obtained on or prior to the 30th day of employment for each employee.
Evidence
  1. On 8-15-24, staff #9’s criminal background check document in the record was dated 1-20-23. The sworn disclosure was dated 7-8-24. The staff’s date of hire noted as 7-1-24, during a discussion with staff #2, it was determined the staff was a new hire and not a transfer staff.
  2. Staff acknowledged; the staff did not have a criminal background check within the required time requirement.
Plan of correction
Audit to be completed as of all employee files to ensure background and sworn statements are in files by 9/20/2024 by Business Office Manager or designee. The Business office Manager will conduct an ongoing audit of minimum 10% staff files every month to ensure background and sworn statements completed prior to 30th day of employment.. Any identified missing report to Executive Director. Executive Director to review at least quarterly in QA.
22VAC40-73-290-B
Based on observation and staff interviewed, the facility failed to ensure the posting for the name of the current on-site person in charge was current.
Evidence
  1. On 8-15-24, the on-site staff person in charge posting was dated 8-13-24.
  2. Staff #4 acknowledged the staff in charge posting was not current.
Plan of correction
Prior to leaving shift 11p-7 am shift med tech or designee will ensure staffing is posted for that day. The manager on duty will check daily. Any day not having staff posted will be reported to Executive Director and will be corrected immediately. Executive Director to review quarterly in QA to be completed by 8/30/2024
22VAC40-73-320-A
Based on record reviewed and staff interviewed, the facility failed to ensure the physical examination was within 30 days of a resident’s admission.
Evidence
  1. On 8-15-24, resident #3’s physical examination date was noted as 11-23-2022. The resident’s date of admit noted as 9-28-24.
  2. Staff #1 acknowledged the resident’s physical examination was not within 30 days of the date of admission.
Plan of correction
Audit of 100% resident records ensuring accurately dated by provider to be completed by 9/20/2024 by health and wellness director or designee. Ongoing monthly audit of minimum 10% resident records. Any identified reported to Executive Director . Identified discrepancies will be sent to the physicians by 10/5/2024 . Executive Director to review in QA quarterly.
22VAC40-80-120-E-2
Based on observation and staff interviewed, the facility failed to ensure the findings of the most recent inspection of the facility was posted.
Evidence
  1. On 8-15-24, the most recent inspection for the facility was not posted. Staff #4 and the inspector search the front area for the document but was not successful in locating the facility last inspection.
  2. Staff #1 and #4 acknowledged the most recent inspection for the facility was not posted.
Plan of correction
Executive Director or designee to ensure most up to date inspection posted. Completed as of 8/27/24. Manager on Duty or designee will audit daily as part of the daily checklist to ensure compliant. Executive Director will review monthly.
22VAC40-73-250-D
Based on record reviewed and staff interviewed, the facility failed to ensure each staff person on or within seven days prior to the first day of work at the facility submitted the results of a risk assessment, documenting the absence of tuberculosis (TB) in a communicable form as
Evidence
  1. d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence:
  2. On 8-15-24, staff #9’s TB document in the record was dated 7-8-24. The staff’s date of hire was noted as 7-1-24. A discussion was conducted regarding staff’s status, was staff a transfer or a new hire.
  3. Staff #1 and #2 acknowledged the staff’s TB was not within the required timeframe.
Plan of correction
Audit to be conducted by 9/20/2024 of all employee files for tb to be conducted prior to start date by business office manager or designee. Any employee file identified to not have TB will be reported to the Executive Director and in compliance as of September 20th. Will utilize orientation check off to audit 10% employee files monthly. Executive Director to review in QA quarterly
22VAC40-73-450-F
Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) included all assessed needs.
Evidence
  1. On 8-15-24, resident #3’s personal and social data noted resident’s allergy to adhesive tape. This was allergy was not documented on the resident’s ISP dated 9-15-23 and 10-15-23.
  2. Resident #4’s uniformed assessment instrument dated 5-3-24 noted eating/feeding need assessed as mechanical help; this need was not on the ISP dated 5-3-24. Wheeling need assessed as mechanical help/physical assistance; the ISP noted wheeling need as mechanical help. Mobility need assessed as mechanical help/physical assistance; the ISP noted mobility need as mechanical help/ supervision.
  3. Staff #1 and #2 acknowledged the residents ISPs did not include all assessed needs.
Plan of correction
Audit of social data sheets100 % residents to be conducted by 9/20/2024 by health and wellness director or designee. Any missing information to be reported to the Executive Director. All missing information to be corrected by 9/30/2024. The Executive Director will review at least quarterly during QA. Audit of UAI and ISP 100% residents to be conducted by 9/20/2024 by health and wellness director or designee for inaccuracies. Any discrepancy identified will be reported to the Executive Director. Inaccuracy will be corrected and new ISP/UIA will be printed placed in chart by 9/30/204. HWD will review at least 20% of residents UAI/ISPs during weekly CCR meeting. All changes in conditions to be made by health and wellness director or designee ongoing for accuracy. Executive Director to review in QA quarterly
22VAC40-73-50-B
Based on record reviewed and staff interviewed, the facility failed to ensure written acknowledgement of the receipt of the disclosure by the resident or the legal representative was retained in the resident’s record.
Evidence
  1. On 8-15-24, resident #1’s record did not have written acknowledgement of receipt of the facility’s disclosure. The resident’s date of admit was noted as 8-5-24.
  2. Staff #1 acknowledged the resident’s record did not have written acknowledgement of the facility’s disclosure.
Plan of correction
Executive Director or designee will audit 100% of residents records for acknowledgements and disclosures by September 13th and ongoing monthly to ensure completed . In compliance as of September 30th Will utilize move in checklist to ensure completion on going. Executive Director to review in QA quarterly
22VAC40-73-310-D
Based on record reviewed and staff interviewed, the facility failed to ensure the administrator provided written assurance to the resident that the facility had the appropriate license to meet the care needs of the resident at the time of admission. A signed copy by the resident or legal representative shall be kept in the resident’s record.
Evidence
  1. On 8-15-24, resident #1’s record did not include a copy of the signed written assurance document.
  2. Staff #1 acknowledged the resident’s record did not include a signed written assurance.
Plan of correction
Executive Director or designee will audit 100% of residents records for written assurance by September 20th and ongoing monthly to ensure completed . In compliance as of September 30th Will utilize move in checklist to ensure completion on going. Executive Director to review in QA quarterly
May 6, 2024Inspection23 violations
Inspection dates
05/06/2024; 05/07/2024
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 IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-80 THE LICENSING PROCESS
Comments
Type of inspection: Renewal An unannounced on-site renewal inspection was conducted on 5-6-24 (Ar 07:36 a.m./dep 17:46 p.m.) Day 1. The facility census was 81. Day 2 (Ar 08:13/dep 4:50 p.m.). The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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. 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 (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov
Violations
22VAC40-90-40-B
Based on documents reviewed and staff interviewed, the facility failed to ensure that no employee shall be permitted to work in a position that involved direct contact with residents until a background check has been completed, unless the person works under the direct supervision of another employee for whom a background check has been completed in accordance with the requirements of the background check regulation (22VAC40-90)
Evidence
  1. On 5-6-24, staff #10 provided the inspector with the sworn disclosure and background check documentation and list of all new staff since the last inspection.
  2. Staff #10 (CRC- 22)’s record did not have a background check; staff’s date of hire noted as 11-0-23.
  3. Staff #CRC-14, record did not have documentation of a background check; staff’s date of hire noted as 9-6-23.
  4. Staff #1 and #10 acknowledged the staff record did not have documentation of a background check document.
Plan of correction
An audit will be conducted by Business Office Manager by 5/31/2021 ongoing prior to start of employment the background check completed and filed Date to be corrected 6/10/24 and monitor monthly . Report any missing to executive director .
22VAC40-73-990-C
Based on documented provided and staff information, the facility failed to ensure that at least every six months, all staff currently on duty on each shift shall participate in an exercise in which the procedures for resident emergencies in the facility are practiced. This information shall be maintained for at least two years.
Evidence
  1. On 5-6-24, the review of the facility’s resident emergency/emergency preparedness plan was conducted. All staff in the facility is not documented as participating in the required review and/or practice for resident emergency.
  2. Staff #2 and #4 acknowledged the resident emergency review and practice exercise was not completed and /reviewed by all staff in the facility.
Plan of correction
Business office manager or designee to audit all staff files by 5/31/2024. Environmental Service Director or designee will ensure that all staff on each shift shall participate in an exercise in which the procedures for resident emergencies in the facility are practiced at least every 6 months. Completed date of 6/10/24 and ongoing
22VAC40-73-290-A
Based on documents reviewed and staff interviewed, the facility failed to ensure the written work schedule include the names and job classification of all staff working.
Evidence
  1. On 5-6-24, the concierge/activity schedule did not include the staff’s full name nor job classification.
  2. The housekeeping/maintenance schedule provided did not include the staff's full name and job classification.
  3. Staff #1, #2 and #4 acknowledged the staff schedules provided did not include all required information.
Plan of correction
Audit to be conducted by 5/31/2024 by business office manager or designee to ensure that a schedule for each dept with first and last name will also include the job classification for each associate. Date to be corrected 6/10/2024 and monitor ongoing monthly by executive director or designee.
22VAC40-73-310-H
Based on record reviewed and staff interviewed, the facility failed to ensure that it did not admit or retain individual with any prohibited conditions or care needs without supporting documentation.
Evidence
  1. On 5-6-24, resident #9’s May 2024 medication administration record (MAR) noted resident is prescribed Sertraline. The physician’s order dated 4-26-24 noted the Sertraline. The record did not include a treatment plan for this prescribed psychotropic medication.
  2. Resident #13’s May 2024 MAR noted resident is prescribed Trazadone. The physician’s order dated 3-22-24 noted the Trazadone. The record did not include a treatment plan for this prescribed psychotropic medication.
  3. Staff #2 and #3 acknowledged, the residents’ record did not have a treatment plan for these psychotropic medications prior to the inspection on 5-6-24.
Plan of correction
Audit will be conducted by Health and Wellness Director or designee of all residents charts to ensure psychotropic medication treatment plan is UTD by 5/31. Any resident identified needing will be reported to Executive Director . Health and Wellness Director or designee will faxed to Doctor for signature by 06/10/2024. A psychotropic binder will be held in Health and wellness director office and will be reviewed monthly. Reviewed during CCR monthly. Executive Director will review quarterly during QA
22VAC40-73-310-B
Based on record reviewed and staff interviewed, the facility failed to ensure a documented interview between the administrator or a designee responsible for admission and retention decisions, the individual, and the legal representative, if any.
Evidence
  1. On 5-6-24, resident #3’s record did not have documentation of an interview between the administrator and or facility designee.
  2. Staff #2 and #3 acknowledged the resident’s record did not have a documented interview.
Plan of correction
All UAI’s will be documented as interview with administrator prior to admission to facility. All resident charts will be audited by 5/31/2024 by Health and wellness director , resident care coordinator or designee . Date of completed 6/10/2024
22VAC40-73-580-A
Based on document reviewed and staff interviews, the facility failed to ensure that when any portion of the assisted living facility is subject to inspection by the Department of Health, the facility shall be in compliance with those regulations, as
Evidence
  1. d by a subsequent annual inspection from Virginia Department of Health. The report shall be retained at the facility for a period of at least two years. Evidence:
  2. On 5-6-24, the health inspection provided was dated 3-17-23. The facility did not have documentation of contact with the health inspector prior to the health inspection expiring nor after the expiration.
  3. Staff #1 acknowledged; the health inspection had expired. There was no written documentation of contact with the Health Department to obtain an inspection prior to its expiration date.
Plan of correction
All staff files will be audited by 6/05/2024 to ensure license Up to date by business office manager or designee Any staff identified with expired license will be reported to Executive Director . Business office manager or designee will monitor licensure expiration date and prior to the expiration date begin contacting the licensee official to ensure documentation of contact prior to expiration made. At least 10% of the staff files will be audited monthly by business office manager or designee Any missing items will be reported to ED. Completed 6/10/2024 and ongoing monthly review. Executive Director will review at least quarterly during QA
22VAC40-73-410-A
Based on record reviewed and staff interviewed, the facility failed to ensure that upon admission, the assisted living facility shall provide an orientation for new and their legal representative. If needed, the orientation shall be modified as appropriate for residents with cognitive impairments. Acknowledgement shall be signed and dated, and such documentation shall be kept in the resident’s record.
Evidence
  1. On 5-7-24, the orientation document in resident #6’s record was not signed and dated by the resident, who is assigned to the safe, secure unit neither the legal representative. The resident’s date of admit noted as 12-20-23.
  2. Staff #2 acknowledged the orientation document was not signed and dated by the resident neither the resident’s legal representative.
Plan of correction
Audit of all resident files by 5/31/2024 by health and wellness director or designee . Health and Wellness Director or Executive Director will upon move-in the move-in orientation sheet will be signed by resident/POA. Date of compliance will be 6/10/2024
22VAC40-73-680-M
Based on observation and staff interview the facility failed to ensure that medications ordered for PRN administration was available, properly labeled for the specific resident and properly stored at the facility.
Evidence
  1. On 5-6-24, during the medication pass with staff # 6, resident #9’s May 2024 medication administration record (MAR) noted resident was prescribed Bisacodyl suppositories. Staff searched for the items but could not locate the resident’s PRN.
  2. During the medication pass with staff #7, resident #12’s May 2024 MAR noted resident was prescribed Ibuprofen 800 mg and Refresh Tears 0.5%. These items were not available in the facility on 5-6-24.
  3. Staff #7 acknowledged the resident’s PRN medication noted were not available.
Plan of correction
Cart audits will be conducted by 5/31/2024 for all med carts weekly to ensure all meds are on the cart by health and wellness director . Any medication found needed for cart will be reported to Health and Wellness Director and Executive Director to ensure med is ordered. Health and Wellness Director will review audits weekly. Executive Director will review at least quarterly. Completed by 6/10/2024
22VAC40-73-450-E
Based on record reviewed and staff interviewed, the facility failed to ensure that the individualized service plan (ISP) was signed and dated by the licensee, administrator, or his designee, the person who developed the plan and by the resident or the legal representative. These requirements also apply to reviews and updates of the plan.
Evidence
  1. On 5-7-24, resident #6’s record noted resident had a change in condition. The physician completed an assessment for safe secure unit on 3-12-24. The facility and family documented condition change for placement in the safe secure unit on 3-14-24.
  2. The resident’s ISP was last signed and dated 1-13-24.
Plan of correction
Any changes in resident condition will be Reviewed during CCR meeting and noted on UAI/ISP and family will be contacted to document changes by Health and Wellness Director and Resident Care Coordinator date of compliance 6/10/24 and ongoing. Will be reviewed during CCR and Executive Director will review quarterly
22VAC40-73-450-F
Based on record reviewed and staff interviewed, the facility failed to ensure that the reviewed and updated individualized service plan (ISP) included all needs.
Evidence
  1. On 5-6-24, resident #2’s ISP dated 5-3-24 did not include the name of the coordinated dialysis facility where resident receive services, when or frequency of attendance and what to do when resident refuses attendance.
  2. Staff #2 and #3 acknowledged the resident’s ISP did not include all information for dialysis services.
Plan of correction
Health and Wellness Director or designee will audit Any resident receiving dialysis services charts. Any missing documentation will be reported to Executive Director and Health and wellness director or designee will include all information needed and plan for refusals will be documented date of compliance 6/10/2024 All charts will be audited by Health and Wellness Director or designee to identify orientation forms missing. Any Orientation form missing will be reported to Executive Director and Health and Wellness Director or designee will have signed and dated by resident or legal representative health and wellness director or designee will monitor ongoing. Executive director will review audits quarterly during QA
22VAC40-73-380-B
Based on record reviewed and staff interviewed, the facility failed to ensure the resident personal and social information was kept updated.
Evidence
  1. On 5-7-24, resident #4’s personal and social information document, the admission date and advance directive information section were blank.
  2. Staff #2 and #3 acknowledged, the aforementioned resident’s social data was not updated.
Plan of correction
Audit will be conducted by Health and wellness director or designee to ensure social data sheet are completed by 5/31/2024. Any resident Identified will be reported to Executive Director. Health and Wellness Director or designee will report to family and have filled out completely. Upon admission, social data sheet will be reviewed by Health and Wellness Director, Resident Care Coordinator, and Executive Director to ensure all information is complete as part of the move in process. Date of compliance 6/10/2024 and ongoing . Executive Director will review at least quarterly during QA
22VAC40-73-960-B
Based on observation and staff interviewed, the facility failed to ensure that the fire and emergency evacuation drawing posted in the facility included all required information.
Evidence
  1. On 5-6-24, during a tour with staff #4, the fire and evacuation drawing observed on the first floor did not include the assembly areas, telephones and/or area of refuge. The postings on the second floor also did not include this information.
  2. Staff #4 acknowledged the fire and emergency evacuation posting did not include all required information.
Plan of correction
Fire and evacuation drawing audit by Environmental service director or designee and corrected to include all information per regulation by 5/31/2024. Date of corrected 6/10/2024 by Environmental Service Director or designee . Executive director will review at least quarterly during qa
22VAC40-73-450-C
Based on record reviewed and staff interviewed, the facility failed to ensure the resident’s individualized service plan (ISP) included all assessed needs.
Evidence
  1. On 5-7-24, resident #4’s record noted resident as a fall risk. The facility’s fall risk evaluation document noted a score of 14 (moderate risk) on 7-30-23. The facility’s fall risk evaluation noted a score of 16 (moderate risk) on 3-9-24. This assessment was not documented on the resident’s ISP dated 7-12-23.
  2. Staff #3 acknowledged the resident’s ISP did not include the fall risk assessment.
Plan of correction
All fall risk will be audited and reviewed by 5/31/2024 by health and wellness director or designee to ensure correct calculation. All fall risk greater than 12 will be correct risk is on ISP. Health and wellness director or designee will provide All LPNs will fall risk eval completion training by_6/10/2024 .Fall risk will be reviewed by Health and Wellness Director and Resident Care Coordinator after each fall. Executive Director will review quarterly during QA
22VAC40-73-260-C
Based on document reviewed and staff interviewed, the facility failed to ensure that the listing of all staff who have current certification in first aid or CPR was kept updated.
Evidence
  1. On 5-7-24, the first aid/CPR posting for the facility did not include all nursing department staff who are first aid or CPR certified.
  2. Staff #2 acknowledged the first aid/CPR posting did not include all required staff and not updated.
Plan of correction
All CPR certified staff will be audited by health and wellness director or designee and be posted by 5/31/2024 and reviewed monthly by HWD and RCC. Executive Director will review during QA at least quarterly
22VAC40-73-250-D
Based on record reviewed and staff interviewed, the facility failed to ensure that the health information required by these standards was maintained at the facility and included in the staff record for each staff person.
Evidence
  1. On 5-7-24, staff #1’s record did not have documentation of the results of a risk assessment documenting the absence of tuberculosis (TB) in a communicable form. Staff’s date of hire was noted as 4-16-24.
  2. Staff #6’s record did not have documentation of a current TB assessment. Staff’s date of hire noted as 6-25-07.
  3. Staff #1, #2 and #3 acknowledged the staff’s record did not have documentation of a current TB assessment.
Plan of correction
Business Office Manager or Designee will audit all staff files ensure prior to start date tb completed and ensure annually completed. Date to be completed 6/10/2024. Upon new hire business office manager or designee to ensure that tb completed and monthly audits to be conducted by business office manager or designee. Executive director to review monthly
22VAC40-73-870-A
Based on observation and staff interviewed, the facility failed to ensure that the interior of all buildings shall be maintained in good condition.
Evidence
  1. On 5-7-24, the ceiling in the dining area near the window in the safe, secure room was observed to have a large brownish colored circle on the tile. The ceiling in the common area in the safe, secure unit was observed to have large and small areas of a brownish colored circles on the ceiling tiles. Staff #8 stated that the circles are from water leakage, but the source is unknown.
  2. Staff #8 acknowledged that there were brownish colored circle areas on the ceiling tiles in areas of the safe, secure unit.
Plan of correction
Environmental Service Director or Designee will ensure that the interior shall be maintained in good condition .Audit will be completed by 5/31/2024 Environmental service director , designee or executive director. To continue audit monthly by environmental service director or designee. Any issue present to be reported to the Executive Director for any repairs necessary or designee. Date to be corrected 6/10/2024
22VAC40-73-210-E
Based on record reviewed and staff interviewed, the facility failed to ensure that staff had training relevant to the population in care.
Evidence
  1. On 5-7-24, staff #6 and #7’s training record did not have documentation of oxygen training. The facility currently has a resident who is prescribed oxygen via nasal cannula continuously.
  2. Staff #2 acknowledged the staff’s record did not have documentation of oxygen training
Plan of correction
Audit of staff files will be conducted by 5/31/2024 by business office manager or designee Any staff identified without trainings requires will be reported to Executive Director Any additional 3rd party entities (ie oxygen, catheter) will have training for direct care staff within 30 days of the resident start of care. Completion date 6/10/2024. Health and wellness director or designee will monitor quarterly
22VAC40-73-950-E
Based on documents reviewed and staff interviewed, the facility failed to ensure that all staff, residents, and volunteers review the facility’s emergency preparedness plan initially and semi-annually. The review shall be documented by signing and dating.
Evidence
  1. On 5-6-24, the emergency preparedness plan for the facility is not being reviewed and signed and dated by all staff on all shifts.
  2. Staff #2 and #4 acknowledged the facility’s emergency plan is not being reviewed with all staff on all shifts.
Plan of correction
Audit to be completed regarding training by business office manager or designee by 5/31/2024 Environmental Service Director or designee will ensure that emergency preparedness is reviewed, signed and dated by all staff on all shifts semiannually. Corrected date 6/10/2024 and ongoing
22VAC40-73-260-A
Based on record reviewed and staff interviewed, the facility failed to ensure that staff maintained current certification in adult first aid.
Evidence
  1. On 5-7-24, staff #7’s First aid and CPR certification was expired as of 3-14-24. Staff’s date of hire noted as 2-21-24.
  2. Staff #2 and #3 acknowledged the staff’s first aid certification was not current.
Plan of correction
All staff files to be audited for first aid/cpr 5/31/2024 completion and expiration by 5/31/2024. Audit to be completed by health care director or designee. Any staff files identified without first aide/cpr will be reported to Executive D. First aide/CPR classes for all staff to be completed by 6/30/2024 and certificates to be held in binder in HWD office and will be reviewed monthly. Executive Director will review at least quarterly during QA
22VAC40-73-680-I
Based on record reviewed and staff interviewed, the facility failed to ensure the facility’ medication administration record (MAR) included all required information.
Evidence
  1. On 5-6-24, during the medication observation pass with staff #7, resident # 11’s May 2024 MAR did not have a diagnosis, condition, or specific indications for the medication, Gemtesa being administered.
  2. Resident #13’ s May 2024 MAR did not have diagnosis or condition for medications, Norvasc, Aspirin, Chlorthalidone, Trazadone, and Spironolactone.
  3. Staff #7 acknowledged the medications did not have a diagnosis on the May 2024 MAR on 5-6-24.
Plan of correction
An audit will be conducted of all residents MARs to ensure all medications have diagnosis by 5/31/2024 by health and wellness director or designee . Any medications identified without dx will be reported to ED and physician to get dx if needed. All MARs will be reviewed for diagnosis monthly during cart audits by 5/31/2024 Reviewed and completed by 6/10/2024. Executive Director will review quarterly during QA
22VAC40-73-960-C
Based on observation and staff interviewed, the facility failed to ensure the emergency numbers are posted.
Evidence
  1. On 5-7-24, the inspector inquired of staff #7 where the emergency numbers and/or Poison Control Center number was located. Staff search for the number at the first-floor nurses’ station near the resident’s record room; but could not find the Poison Control Center telephone number.
  2. Staff on the second-floor nurses’ station- was asked where the emergency telephone numbers, poison control number was located. Staff #13 searched for the numbers but were not able to locate the emergency and Poison Control Center number.
  3. Staff # 2 and #3 acknowledged the emergency numbers, Poison Control Center number is not available near the telephones in the facility.
Plan of correction
Health and Wellness Director or designee will ensure that emergency numbers are posted. Audit of all nursing stations conducted by 5/31 by health and wellness director or designee. Date to be corrected 6/10/2024. Executive director to review at qa
22VAC40-73-660-A-7
Based on observations and staff interviewed, the facility failed to ensure medical supply and equipment was appropriately labeled.
Evidence
  1. On 5-6-24, the glucometer for resident #14, was not labeled. Staff #6 acknowledged the glucometer was not labeled.
  2. On 5-7-24, the glucometer for resident #4 was not labeled. Staff #11 acknowledged the glucometer was not labeled.
Plan of correction
A med cart audit will be conducted by Health and Wellness Director or Designee to ensure all glucometers are labeled properly. Any glucometers not labeled properly will be reported to Health and Wellness Director and Executive Director . All glucometers will be labeled with resident’s name upon admission. Cart audits will be conducted weekly by 5/31/2024 to ensure labeling of glucometers. Audits will be Reviewed weekly and as needed by HWD and Resident Care Coordinator and completed by 5/31/2024. Executive Director will review audits quarterly
22VAC40-73-640-D
Based on observations and staff interviews, the facility failed to ensure that it readily accessible at least one pharmacy reference book, drug guide, or medication handbook for nurses that is no more than two years old as reference materials for staff who administer medication.
Evidence
  1. On 5-6-24, staff #7 was asked where the facility’s drug book was kept. The book was located on the nurse’s station. The drug reference book was for year 2019.
  2. On 5-7-24, staff #11 was asked where the facility’s drug book was kept. Staff obtain a book dated year 2019 from top of the medication cart.
  3. Staff #7 and #11 acknowledged the drug reference book 2019 was more than two years old.
Plan of correction
All Carts will be audited for drug book by Health and Wellness Director or Designee by 5/21/24. An up-to-date drug book will be placed on med cart and will be audited yearly for expiration. Any drug book older than 2 years will be removed and discarded. . Completed by 5/31/2024
April 3, 2024Complaint survey2 violations
Inspection dates
04/03/2024
Areas reviewed
22VAC40-73 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 IMPAIRMENTS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint An unannounced complaint inspection conducted on 04-03-24 (AR 13:05 p.m./dep 17:45 p.m.) The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 2-13-24 regarding allegations in the areas of resident care and related services. Number of residents present at the facility at the beginning of the inspection: 86 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: Number of interviews conducted with residents: Number of interviews conducted with staff: 3 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. 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 Willie Barnes, Licensing Inspector at 757-439-6815 or by email at willie.barnes@dss.virginia.gov
Violations
22VAC40-73-1140-A
interviewed, the facility failed to ensure prior to admitting a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia to a safe, secure environment, the licensee, administrator, or designee shall determine whether placement in the special care unit is appropriate. The determination and justification for the decision shall be in writing and shall be retained in the resident’s file.
Evidence
  1. On 04-03-24, resident #3’s record did not include documentation of the licensee, administrator, designee’s justification for placement on the safe, secure unit. Resident admitted to the facility’s safe, secure unit was noted as 3-11-24.
  2. Staff #1 and #2 acknowledged the resident’s assessment document for placement on the safe, secure unit by the licensee, administrator or designee was not documented and in the record.
Plan of correction
The Administrator or designee will write a statement to satisfy the regulation of appropriate placement in a special care unit. The determination and justification will be placed in the resident’s file. Completed on 4.09.2024/ on-going.
22VAC40-73-310-H
Based on record reviewed and staff interviewed, the facility failed to ensure it did not admit or retain individuals with any of the prohibitive conditions or care needs without supporting documentation.
Evidence
  1. On 4-3-24 resident #2’s record documented resident prescribed Seroquel, Belsomra and Melatonin psychotropic medications on 3-20-24. The psychotropic treatment document did not include the date and signature of the prescriber.
  2. Staff #1 and #2 acknowledged the psychotropic treatment plan in resident #2’s record did not include the date and signature of the prescriber.
Plan of correction
The Resident Care Coordinator or Health and Wellness Director will review all paperwork, prior to admission, to ensure all physician signatures and dates are present. If a signature is needed, the RCC or HWD will contact the physician’s office to have corrected. Completed on 4.09.2024/ on-going.
August 31, 2023Complaint survey1 violation
Inspection dates
08/31/2023 09/20/2023
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint An on-site complaint inspection conducted on 8-31-23, completed following monitoring 1:30 p.m. to 16:20 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 8-30-23 regarding allegations in the resident care- medication-adl care (bathing-dressing). Number of residents present at the facility at the beginning of the inspection: 73 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 4 Observations by licensing inspector: care staff and residents Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation 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 (willie Barnes), Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov
Violations
22VAC40-73-450-F
Based on record reviewed and staff interviewed, the facility failed to ensure the annual individualized service plan (ISP) included all assessed needs.
Evidence
  1. On 8-31-23 during a complaint inspection, resident #1’s uniform assessment instrument dated 7-19-23 documented transferring assessed as performed by others. The individualized service plan (ISP) dated 11-4-22 documented transferring as mechanical help/physical assistance. Hospice services contract noted services included skilled nursing, social worker, aide and chaplain. These hospice services were not documented on the ISP. Resident assessed as disoriented some spheres, some time to time and place. The ISP did not document the how resident would be redirected.
Plan of correction
Not published by VDSS.
August 31, 2023Inspection3 violations
Inspection dates
08/31/2023, 09/05/2023
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Monitoring An on-site IPOC Monitoring Inspection was conducted on 8-31-23 (AR: 09:40/ Dep 16:20 p.m.) The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The final exit meeting will be scheduled. 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 (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov
Violations
22VAC40-73-250-C
Based record reviewed and staff interviewed, the facility failed to ensure an employee record included documentation of a sworn disclosure statement.
Evidence
  1. On 8-31-23, staff #5’s record did not include documentation of a sworn disclosure statement.
  2. Staff #1 and #4 acknowledged the staff’s record did not include a sworn disclosure statement.
Plan of correction
Not published by VDSS.
22VAC40-73-320-A
Licensee/provider did not provide POC by due date Based on record reviewed and staff interviewed, the facility failed to ensure the resident’s physical examination document included all required information.
Evidence
  1. On 8-31-23, resident #2’s physical examination document dated 8-24-23 did not include the resident’s height, weight, and blood pressure.
  2. Staff #2 and #3 acknowledged the resident’s physical examination document did not include all required information.
Plan of correction
Not published by VDSS.
22VAC40-73-450-A
Based on record reviewed and staff interviewed, the facility failed to ensure the preliminary plan of care included all assessed needs.
Evidence
  1. On 8-31-23, resident #2’s uniformed assessment instrument (UAI) dated 8-16-23 noted dressing need assessed as mechanical help/physical assistance. The preliminary plan of care noted dressing services received as physical assistance.
  2. Staff #2 and #3 acknowledged the resident’s assessed need was not what was documented on the service plan for services provided.
Plan of correction
Not published by VDSS.
June 5, 2023Inspection14 violations
Inspection dates
:06/05/2023,06/07/2023,06/09/2023,06/21/2023
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 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Renewal An on-site Renewal Inspection conducted on 6-5-23 (Ar 08:30/dep 5:10), 6-7-23 (08:54/ dep 5:15) and 6-9-23 (09:53/ dep 1:25). The census on 6-5-23 was 81. A medication pass observation was conducted, activity on the safe, secure unit- observed. Staff and resident interviews conducted. An exit meeting was conducted all three days with the administrator and staff. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov
Violations
22VAC40-73-450-F
Based on record reviewed and staff interviewed, the facility failed to ensure individualized service plan (ISP) shall be reviewed and updated at least once every 12 months and as needed for a significant change of a resident’s condition.
Evidence
  1. On 6-5-23, resident #2’s ISP dated 5-21-23 did not include documentation of resident’s physical therapy services. The record included a signed order dated 5-1-23 to continue home health services. Interview with resident on 6-5-23, resident stated receiving physical therapy services to help gain strength to walk. Resident’s date of admit noted as 7-28-21.
  2. Resident #5’s record noted resident receiving podiatry services, documents in record dated 2-5-23 and 5-15-23. The ISP dated 5-13-23 did not include this service. Resident’s date of admit noted as 12-22-16.
  3. Resident #7’s record noted resident receiving wound care services for foot ulcer not on ISP dated 11-4-22. Resident’s date of admit noted as 1-23-22.
Plan of correction
Records will be audited to verify residents have a UAI that is consistent with the ISP and accurately identifies the care needs of the resident and/or any assistance they need. Audit to be completed by HWD and RCC with a completion date of 08/04/2023. ISPs will be in compliance with regulation 22VAC40-73-450-F by 8/4/2023. Moving forward, residents will have preliminary ISP completed prior to admission. Comprehensive ISP to be completed within 30 days of admission, annually and with significant change. UAI to be reviewed and updated upon changes to comprehensive ISP. Chart audits will be completed monthly by ED, HWD or company designee to verify ongoing compliance.
22VAC40-73-380-B
Based on record reviewed and staff interviewed, the facility failed to the resident’s personal and social information document was kept current.
Evidence
  1. On 6-5-23, resident #3’s admitting physical examination dated 3-27-23 documented resident’s allergy to Brimonidine and lactose intolerant. The allergy section of the personal and social data form is blank. The admit date section is also blank.
  2. Resident #4’s admit date, vocation and organ donation section of the personal and social data form are blank.
  3. Resident #5’s mental health and substance abuse information on the personal and social data form are blank.
Plan of correction
Upon move in, resident Social Data sheet will be updated digitally and printed out from electronic record. System in place as of 07/01/2023. Existing resident social data sheets will be updated, printed and updated in physical chart with a completion date of 08/04/2023. This sheet will be used as the new Social Data Sheet moving forward.
22VAC40-73-450-C
Based on record reviewed and staff interviewed, the facility failed the comprehensive individualized service plan (ISP) included all assessed needs.
Evidence
  1. On 6-5-23, resident #1’s admitting physical examination document dated 9-22-22 noted physical therapy, occupational therapy and skilled home health nurse. The resident’s ISP dated 9-22-22 and 4-19-23 did not documented services. Resident’s date of admit noted as 9-27-22.
  2. Resident #3’s record noted resident receiving podiatry services, document dated 4-28-23. The ISP dated 5-13-23 did not include this service. Resident’s date of admit noted as 4-27-23.
Plan of correction
Records will be audited to verify residents have a UAI that is consistent with the ISP and accurately identifies the care needs of the resident and/or any assistance they need. Audit to be completed by HWD and RCC with a completion date of 08/04/2023. ISPs will be in compliance with regulation 22VAC40-73-450-C by 8/4/2023. Moving forward, residents will have preliminary ISP completed prior to admission. Comprehensive ISP to be completed within 30 days of admission, annually and with significant change. UAI to be reviewed and updated upon changes to comprehensive ISP. Chart audits will be completed monthly by ED, HWD or company designee to verify ongoing compliance.
22VAC40-73-680-I
Based on observation and staff interviewed, the facility failed to ensure that the facility’s medication administration record (MAR) included all information.
Evidence
  1. On 6-5-23, during the medication pass observation with staff #7, resident #1’s June 2023 MAR did not include diagnosis for Memantine and Liquifilm Tears.
  2. Staff #7 acknowledged the aforementioned medications on the June 2023’s MAR for resident #1 did not have a diagnosis.
Plan of correction
Team members who administer medication will receive training on passing their medications and what to do in the event of a hole in the MAR. HWD and RCC will supervise all training for staff. Training to be completed by 08/04/2023.
22VAC40-73-350-B
Based on record reviewed and staff interviewed, the facility failed to ensure it ascertained, 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 and shall document in the resident’s record that this was ascertained and the date the information was obtained for one of ten records.
Evidence
  1. On 6-5-23, resident #4’s record did not include documentation of a sex offender report. The resident’s date of admission was documented as 3-28-23.
Plan of correction
Potential residents touring the community will be checked for sex offender. Sales Director or designee will perform sex offender checks prior to admission into the community. All residents charts will be audited for compliance with sex offender checks. System in place as of 07/01/2023. Completion of audit to be completed by 08/04/2023.
22VAC40-73-260-C
Based on observation and staff interviewed, the facility failed to ensure a listing of all staff who have current first aid or CPR was posted in the facility so that the information is readily available to all staff at all times. The posting should also be kept up to date.
Evidence
  1. On 6-7-23 following a check of the first aid kit, staff #10, the staff listed as the person in charge, was asked where the facility’s listing of staff with first aid and CPR was posted. The listing was not posted and not current. Staff #10’s name was not on the list that was provided later during the day.
Plan of correction
All first aide kits will be audited monthly by Nursing team to ensure all required product is available in the kit. System in place and started as of 07/01/2023.
22VAC40-73-580-B
Based on record reviewed and staff interviewed, the facility failed to ensure a written agreement to the effect of the resident having meals routinely consumed in resident’s room was signed and dated by both the resident and the license or administrator and filed in the resident’s record.
Evidence
  1. 0n 6-5-23 during interview with resident #2, the resident stated consuming all meals in room. Resident #2’s individualized service plan (ISP) dated 5-21-23 did not document resident’s eating all meals in the resident’s room.
  2. A copy of the written agreement to consume all meals in room was not in effect, signed and dated by both the resident and the licensee or administrator and filed in the resident #2’s record.
  3. Resident’s record noted an order for Ensure or Boost for protein intake and has a diagnosis of dementia.
Plan of correction
Written agreement will be made with any residents routinely consuming meals in their room. This will also be noted on resident’s care plan and ISP. Completion date to be 08/04/2023
22VAC40-73-210-B
Based on record reviewed and staff interviewed, the facility failed to all direct care staff attend at least 18 hours of training annually.
Evidence
  1. On 6-9-23, staff #7’s training record documented 16.25 hours of annual training.
Plan of correction
Staff records to be reviewed weekly for compliance with annual training. Review of all current records for compliance will be conducted. Completion date to be 08/04/2023
22VAC40-73-310-D
Based on record reviewed and staff interviewed, the facility failed to ensure prior to admission that it provided written assurance to the resident that the facility has the appropriate license to meet the care needs at the time of admission. A signed copy of the document shall be kept in the resident’s record.
Evidence
  1. On 6-5-23, resident #1’s record did not include signed documentation of written assurance information provided to the resident and or legal representative prior to the admission date 9-27-22.
Plan of correction
Written assurance will be reviewed during move in process of all residents. Residents entering the facility will have one to coincide with their UAI. System in place as of 07/01/2023
22VAC40-90-40-B
Based on the employee record review and staff interviewed, the facility failed to ensure the criminal history record report was obtained on or prior to the 30th day of employment for each employee.
Evidence
  1. On 6-7-23, the review of the new hires list highlighted fifty-nine staff members. Nine of the currently employed staff’s CRC document noted “being processed” from 10-17-22 to 5-31-23. Sixteen employees did not have CRCs from 11-2-22 to 5-31-23.
Plan of correction
BOM to conduct review of all team members’ state background checks to ensure that the final copy received from the state is in their chart and not stored digitally. All records will be maintained physically instead of digitally moving forward. Completion date to be 08/04/2023
22VAC40-73-320-A
Based on record reviewed and staff interviewed, the facility failed to ensure the results of a risk assessment documenting the absence of tuberculosis (TB) in a communicable form as
Evidence
  1. d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it was conducted for one of ten resident records reviewed. Evidence:
  2. On 6-5-23, resident #1’s record did not include documentation of an initial TB results prior to the documented 9-27-22 admission date.
Plan of correction
As part of the admission process, initial TB will be verified prior to resident move in. System in place and started as of 07/01/2023.
22VAC40-73-310-H
Based on record reviewed and staff interviewed, the facility failed to ensure it did not admit or retain individuals with any of the prohibitive conditions or care needs without supporting documentation for five of ten records reviewed.
Evidence
  1. On 6-5-23, resident #1’s record included a physician’s order dated 4-11-23 for Celexa. The record did not include a treatment plan for this prescribed psychotropic medication.
  2. Resident #6 record included a physician’s order dated 3-13-23 for Buspar. The record did not include a treatment plan for this prescribed psychotropic medication.
  3. Resident #7’s record included a physician’s order dated 5-11-23 for Ativan and Haloperidol. The record did not include a treatment plan for these prescribed psychotropic medications.
  4. On 6-7-23, resident #8’s record included documentation of Buspar. The record did not include a treatment plan for this prescribed psychotropic medication.
  5. Resident #9’s record included documentation of Zyprexa. The record did not include a treatment plan for this prescribed psychotropic medication.
Plan of correction
HWD and RCC to conduct review of residents on psychotropic medications. Team will coordinate with doctor for treatment plan for residents on psychotropic medications. Completion date to be 08/04/2023.
22VAC40-73-980-C
Based on observation and staff interviewed, the facility failed to ensure the first aid kits were checked at least monthly to ensure that all items are present and items with expiration dates are not past their expiration date.
Evidence
  1. On 6-7-23 during a check of the facility’s first aid kits with staff #6, #10 and #11, the first aid kits were missing the following items: (a) adhesive tape (Flourish); (b) assorted band aids (Hall 1 nurse’s station); (c) blanket (Flourish); (d) assorted roller gauze (Vehicle); (e) plastic bags (Flourish); (f) scissors (Hall 1); (g) flashlight (Vehicle) extra batteries (Hall 1); (h) thermometer (Hall 1 and Vehicle) and (i) Tweezers (Vehicle).
Plan of correction
All first aide kits will be audited monthly by Nursing team to ensure all required product is available in the kit. Team will also ensure all product in the kit is not expired. System in place and started as of 07/01/2023.
22VAC40-73-210-F
Based on record reviewed and staff interviewed, the facility failed to ensure at least two of the required hours of training shall focus on infection control and prevention. When adults with mental impairments reside in the facility, at least four of the required hours shall focus on topics related to the resident’s mental impairment.
Evidence
  1. On 6-9-23, staff #3’s training document noted .75 hours of infection control and prevention training. Staff #7’s document noted .50 hours of infection control and prevention training.
Plan of correction
Infection control hours for all staff has been increased to state minimum of 2 hours per employee. Completion date to be 08/04/2023
March 21, 2023Complaint survey6 violations
Inspection dates
03/21/2023,03/24/2023,03/26/2023,04/18/2023
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND
Comments
Type of inspection: Complaint An unannounced complaint inspection conducted on 03/21/22 (ar 9:42 a.m./dep 5:20 p.m.) The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 03-9-23 regarding allegations in the areas of resident care and related services, buildings and grounds. Number of residents present at the facility at the beginning of the inspection: 85 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. On 3-24-23 Number of resident records reviewed: 5Number of staff records reviewed: 0 Number of interviews conducted with residents:4 Number of interviews conducted with staff: 7 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations area(s) of non-compliance with standard(s) or law were valid. 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 Willie Barnes, Licensing Inspector at 757-439-6815 or by email at willie.barnes@dss.virginia.gov
Violations
22VAC40-73-440-H
Based on record reviewed and staff interviewed, the facility failed to ensure that an annual reassessment or reassessment due to a significant change in the resident’s condition, using the UAI, shall be utilized to determine whether a resident’s need can continue to be met by the facility and whether continued placement in the facility is in the best interest of the resident.
Evidence
  1. On 3-24-23, resident #3’s record did not include a uniform assessment instrument (UAI). The resident’s date of admission was documented as 8-30-19.
Plan of correction
Records will be audited to verify residents have a UAI that complies with regulation 22VAC40-73-400. Audit to be completed by HWD and RCC with a completion date of 04/25/2023. UAI’s will be in compliance with regulation 22VAC40-73-400 by 6/1/2023. Moving forward, residents will have UAI completed prior to admission, annually and with significant change. Chart audits will be completed monthly by ED, HWD or company designee to verify ongoing compliance.
22VAC40-73-220-B
Based on record reviewed, staff, resident and collateral interviews, the facility failed to ensure it had the required documents when a private duty personnel who are not employees of a licensed home care organization provide direct care or companion services to residents in the assisted living facility.
Evidence
  1. On 3-24-23, CL-1 was providing activities of daily living to resident #2. During conversation with the resident and CL-1, it was determined that CL-1 was hired by the family to provide services to resident #2. CL-1 stated not having any credentials as direct care staff (personal aide, direct care nor nurse’s aide training).
  2. On 3-24-23, staff #1 stated not having documentation of the requirements for CL-1 as a private sitter/companion caregiver for resident #1, no criminal record check, no orientation and no tuberculosis (TB) documentation.
Plan of correction
Care personnel hired by the family will go through community orientation, criminal background check, and TB test prior to providing care within the community. There are no other care personnel hired by the family in the community. Going forward, all third party personnel hired by family will abide by the regulations listed in state regulation 22VAC40-73-220.
22VAC40-73-870-A
Based on observation and staff interviewed, the facility failed to ensure that the interior of the building was maintained in good repair and kept clean and free of rubbish.
Evidence
  1. On 3-24-23, the carpet in resident #5’s room was stained in various areas. According to the resident and staff #1, the stains near the window/air conditioner is water stains. There were also dark stains of various sizes near the bed and in the middle of the floor.
Plan of correction
Carpet has been scheduled for replacement due to overall condition. Scheduled to be replaced by 5/5/2023.
22VAC40-73-450-C
Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) included all required information for one of five residents.
Evidence
  1. On 3-21-23, resident #1’s uniform assessment instrument (UAI) dated 2-3-23 documented bathing need as mechanical help/physical assistance (mh/pa); transferring need- mh; stairclimbing need- mh. The individualized service plan dated 2-6-23 did not document what mechanical help (mh) was needed. Wandering behavior documented greater than weekly and disoriented time and place spheres all the time. The ISP did not document what services to be provided. Stairclimbing documented as not performed, this assessed need not documented on the ISP. Toileting need documented mh/pa; the ISP did not document what mh and what physical assistance to be provided. The ISP did not include the identified need date and expected outcome time frame. The resident’s date of admit was noted 2-6-23.
Plan of correction
Records will be audited to verify residents have a UAI that is consistent with the ISP and accurately identifies the care needs of the resident and/or any assistance they need. Audit to be completed by HWD and RCC with a completion date of 04/25/2023. ISPs will be in compliance with regulation 22VAC40-73-450-C by 6/1/2023. Moving forward, residents will have preliminary ISP completed prior to admission. Comprehensive ISP to be completed within 30 days of admission, annually and with significant change. UAI to be reviewed and updated upon changes to comprehensive ISP. Chart audits will be completed monthly by ED, HWD or company designee to verify ongoing compliance.
22VAC40-73-70-A
Based on observation, interviews and record reviewed, the facility failed to ensure that it reported to the regional licensing office within 24 hours any major incident that has negatively affected or threatens the life, health, and safety, or welfare of any resident.
Evidence
  1. On 3-21-23, when speaking with resident #3, the inspector observed a laceration to the left side of the resident’s head and bruising noted on left side of the resident’s face. Resident #3 stated falling and being sent to the emergency room for care. A check for this incident to the licensing office determined no report was received. A review of resident’s clinical notes noted incident on 2-6-23, out to emergency room (ER), cellulitis diagnosis and 1-24-23, fall out of bed, out to ER, laceration to right ear.
  2. A complaint report to the office stated, resident #1 had a broken neck and had previously had a broken leg. The resident did not have a broken leg. The office did receive an incident report on the afternoon on 3-9-23 with reporting an incident for resident #1 on 3-8-23 at 08:00. This report was received after the complaint allegation received on the morning of 3-9-23.
  3. The facility did not report the incident reports within the 24-hour reporting period.
Plan of correction
Facility shall report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident. All future incidents will be reported to the licensing office as soon as possible upon notification and to not exceed 24 hours.
22VAC40-73-450-F
Based on record reviewed and staff interviewed, the facility failed to ensure the updated individualized service plan (ISP) included all resident’s need for three residents.
Evidence
  1. On 3-21-23, resident #2’s ISP dated 11-4-22 did not include documentation of the resident’s sitter/companion/ caregiver who provides care on Monday, Tuesday, Wednesday and Thursday. The resident’s date of admit noted as 1-23-22.
  2. On 3-24-23, resident #4’s ISP dated 12-15-22 did not include resident’s podiatry services, date of last service was 1-31-23. Wheeling need assessed as not performed, this need was not on the ISP.
  3. On 3-24-23, resident #3’s record did not include an ISP. The resident’s date of admit was noted 8-30-19.
Plan of correction
Records will be audited to verify residents have a UAI that is consistent with the ISP and accurately identifies the care needs of the resident and/or any assistance they need. Audit to be completed by HWD and RCC with a completion date of 04/25/2023. ISPs will be in compliance with regulation 22VAC40-73-450-F by 6/1/2023. Moving forward, residents will have preliminary ISP completed prior to admission. Comprehensive ISP to be completed within 30 days of admission, annually and with significant change. UAI to be reviewed and updated upon changes to comprehensive ISP. Chart audits will be completed monthly by ED, HWD or company designee to verify ongoing compliance.
December 15, 2022Complaint survey19 violations
Inspection dates
Dec. 15, 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 BUILDINGS AND GROUND22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUSCOGNITIVE IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES
Comments
Type of inspection: Complaint An unannounced complaint inspection conducted on 10-14-22 (ar 10:50 a.m./dep 3:00 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 9-13-22 regarding allegations in the areas of resident care and related services, buildings and grounds, staffing and food/nutrition. Number of residents present at the facility at the beginning of the inspection: 82 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. On 10-14-22 Number of resident records reviewed: 4 Number of staff records reviewed: 5 Number of interviews conducted with residents:0 Number of interviews conducted with staff: Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations area(s) of non-compliance with standard(s) or law were valid. 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 Willie Barnes, Licensing Inspector at 757-439-6815 or by email at willie.barnes@dss.virginia.gov
Violations
22VAC40-73-450-F
Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) was reviewed and updated at least once every 12 months and as needed for a significant change of a resident’s condition for two of four records reviewed.
Evidence
  1. On 10-18-22, resident #1’s ISP was not updated to include the resident’s change in condition, resident admission/discharge from hospice services.
  2. Resident #3, ISP in record was last dated 2-29-20.
  3. Staff acknowledged the residents’ ISPs were not updated at least once every 12 months or when there was a significant change in the resident’s condition.
Plan of correction
HWD and RCC will conduct audit of residents at the community. ISPs will be current and up to date. Required signatures or attempt to obtain signatures due to scheduling conflicts will be noted. HWD and RCC to complete by 01/15/2023,
22VAC40-73-450-E
Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) was signed and dated by the licensee, administrator, or his designee (the person who had developed the plan), and the resident or his legal representative. These requirements shall also apply to reviews and updates of the plan.
Evidence
  1. On 10-18-22, resident #1’s ISP dated 7-15-22 was not signed by the resident and/or legal representative.
  2. Resident #4’s ISP not signed and dated by the developer and not signed by the resident/le al representative.
  3. Staff acknowledged the residents’ ISPs were not signed and dated.
Plan of correction
HWD and RCC will conduct audit of residents at the community. ISPs will be current and up to date. Required signatures or attempt to obtain signatures due to scheduling conflicts will be noted. HWD and RCC to complete by 01/15/2023.
22VAC40-73-870-A
Based on observation and staff interviewed, the facility failed to ensure the interior of the interior of the building was maintained in good repair and kept clean and free of rubbish.
Evidence
  1. On 10-14-22 during a tour of the facility for a compliant inspection of the building having a hole in the ceiling and water leaks, repair of the ceiling on the second floor was observed being completed. Staff #1 staff the ceiling was being repaired due to water damage.
  2. Staff acknowledged the ceiling in the building needed repair and was being fixed.
Plan of correction
Charter leadership has hired a vender to diagnose the roof of the building. Maintenance team has been replacing stained ceiling tiles where patch work had been done on the roof and the leak is no longer present. Vender recommends routine maintenance at this time and patching of any areas of the roof that have damage. Roof in good condition according to vender. Patches will be patched as problems arise. Diagnosis of roof was completed on 12/15/2022. Maintenance to clear off any remaining debris and perform routine maintenance on existing roof per recommendations of vender’s report. Ceiling tiles to be replaced by 01/15/2023.
22VAC40-73-870-D
Based on documents and staff interviewed, the facility failed to ensure the building was kept free of infestations of insects and vermin.
Evidence
  1. On 10-14-22 during a complaint inspection regarding bedbugs in the facility, staff #1 acknowledged the facility did have an issue with bedbugs.
  2. On 10-18-22, pest control invoices provided documented treatment for bedbugs were completed on 9-8-22 and 5-27-22.
  3. Staff acknowledged the facility was being treated for bed bugs.
Plan of correction
Maintenance team to monitor complaints of bugs in the community and address all concerns promptly. Team members will be training on how to properly put in work orders and report pest issues promptly to the maintenance team. Training to be completed by 01/31/2023.
22VAC40-73-120-A
Based on record reviewed and staff interviewed, the facility failed to ensure a staff’s record included documentation of orientation and training required within the first seven working days of employment.
Evidence
  1. On 10-14-22 staff #9’s record did not include documentation of orientation and training. Staff’s date of hire documented as 9-6-22.
  2. Staff #1 acknowledged the staff’s record did not include documentation of required orientation and training.
Plan of correction
Team members will obtain orientation and training required prior to their 7th day of employment. BOM to monitor all new hires first month of employment to ensure team members are obtaining the training required by ALF regulations. Audit of existing team members will be conducted by 01/31/2023
22VAC40-73-680-I
Based on record reviewed and staff interviewed, the facility failed to ensure the medication administration record (MAR) for three of four records reviewed included all requirements.
Evidence
  1. On 10-18-22 during a complaint inspection regarding medications, resident #’1’s September 2022 MAR did not include the initials of direct care staff administering the medications on 9-3-22 (Seroquel). August 2022 MAR did not include initials on 8-29-22 and 8-30-22 (Seroquel); 8-30-22 and 8-31-22 (Clonidine) and 8-29-22, 8-30-22 and 8-31-22 (Senokot).
  2. Resident #3’s September 2022 MAR did not include initials on 9-8-22 (Seroquel and Nitrofuran) and 9-25-22 and 9-29-22 (Vitamin D3). August 2022 MAR did not include initials for Oscal, Nitrofuran, Seroquel and Levothyroxine. July 2022 MAR did not include initials for Aspirin, Synthroid, Seroquel and Macrobid.
  3. Resident #4’s September 2022 MAR did not include initials for Aricept, Namenda, Mefformin, Soft Gel-Omega 3, Seroquel, Zocor, Lisinopril and Glipizide.
  4. On 10-18-22 staff #2 acknowledged the residents’ MARs did not include the initials of the direct care staff administering the medications.
Plan of correction
Team members who administer medication will receive training on passing their medications and what to do in the event of a hole in the MAR. Charter has also upgraded their MARs to EMAR which will be completely up and running by 01/01/2023. HWD and RCC will supervise all training for staff.
22VAC40-73-325-B
Based on record reviewed and staff interviewed, the facility failed to ensure a fall risk rating was completed after a fall for resident.
Evidence
  1. On 10-28-22, resident #1, record documented falls on the following dates with no fall risk rating: 2-20-22, 4-14-22, 4-16-22, 5-27-22 and 7-29-22. The fall risk ratings in the record were dated 2-4-20 and 5-22-20.
  2. Staff #1 acknowledged the resident’s record did not include a fall risk rating following each fall as required.
Plan of correction
HWD and RCC will review all falls during morning meeting. Falls will be followed up by HWD and RCC in morning meeting with management team. Fall risk rating will be updated after each reported fall by RCC and HWD. Audit of current resident charts will be conducted for compliance by 01/15/2023.
22VAC40-73-350-B
Based on record reviewed and staff interviewed, the facility failed to ensure it ascertained, 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 and shall document in the resident’s record that this was ascertained and the date the information was obtained for one of four records.
Evidence
  1. On 10-18-22, resident #2’s record did not include documentation of a sex offender report. The resident’s date of admission was documented as 5-30-22.
  2. Staff acknowledged the resident’s record did not include documentation of a sex offender report.
Plan of correction
Potential residents touring the community will be checked for sex offender. Sales Director or designee will perform sex offender checks prior to admission into the community. All residents charts will be audited for compliance with sex offender checks. Audit to be completed by 12/31/2022.
22VAC40-73-300-B
Based on document reviewed, record reviewed and staff interviewed, the facility failed to ensure documentation of significant happenings or problems experienced by residents, including complaints or incidents or injuries related to physical or mental conditions were documented in the facility’s communication book.
Evidence
  1. On 10-18-22, during a complaint inspection regarding a physical injury, the facility’s communication book did not include documentation of resident #4’s 911 transport to a local hospital. The resident’s record documented on 7-16-22, resident sent out for left shoulder pain. The record did not document the resident’s return or result of the emergency room visit.
  2. Resident #1’s record documented resident sent out to the emergency room following 911 call on 8-26-22 and returned on 8-31. The communication book did not document this incident.
  3. On 10-18-22 staff #2 acknowledged the resident’s record did not include follow-up documentation of the ER visit. The facility’s communication book also did not include documentation of this incident.
Plan of correction
Facility communication book to be reviewed by HWD and RCC frequently and ensure proper documentation is in both the chart and the communication book. Management will retrain staff on proper documentation and where to put information. Training to be completed by 01/15/2023
22VAC40-73-640-A
Based on record reviewed and staff interviewed, the facility failed to follow its medication management plan to ensure resident’s prescription medications and any over-the-counter drugs and supplements ordered are filled and refilled in a timely manner to avoid missed dosages for one of four resident’s record reviewed.
Evidence
  1. On 10-18-22, during a complaint inspection regarding medications, resident #3’s July 2022 medication administration record (MAR) documented resident’s medication was not available to administer: Seroquel not available 7-6-22 thru 7-10-22 and Macrobid not available 7-1 thru 7-10-22. The resident’s nursing notes did not document medication not being available.
  2. Staff acknowledged the resident’s record noted resident’s medication not available to administer.
Plan of correction
Team members with the credentials to pass medication will be trained on reordering low medication and inform HWD and RCC of any medication that is not present at the community. Team member will document appropriately when medication is unavailable. HWD and RCC to perform training to team members with the credentials to pass medication. Training for team to be completed by 01/31/2023.
22VAC40-73-450-C
Based on record reviewed and staff interviewed, the facility failed to ensure the comprehensive individualized service plan (ISP) was completed within 30 days after admission and included all required assessed needs for four of four records.
Evidence
  1. On 10-18-22, resident #2’s record did not include a preliminary service plan and a 30-day comprehensive plan was not in the record. The resident’s UAI was dated 5-13-22 and the date of admission was documented as 5-30-22.
  2. Resident #3’s ISP was dated 2-29-20 with a review end date of Feb 2021. The resident’s date of admission was documented as 2-11-21 (2-26-18).
  3. Resident #4’s ISP dated 5-4-22 and provided by staff #11 did not include the need date and expected outcome time frame.
  4. Resident #1’s ISP dated 7-15-22 did not include the need date and expected outcome time frame.
  5. Staff acknowledged the residents’ record did not include an ISP, updated ISP and required ISP information.
Plan of correction
Residents’ preliminary ISP will be completed with admission to community. Resident will be observed for 30 days after admission and an ISP will be developed based on the resident’s first 30 days at the community. ISP will be presented to the resident and/or family for review and signature. ISP to be updated on change of condition and/or annual review. Attempts to obtain signatures will be noted if parties are unavailable timely. Audit to be completed by 01/31/2023
22VAC40-73-1140-B
Based on record reviewed and staff interviewed, 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
  1. On 10-14-22 during a complaint inspection regarding staff training, staff #4’s record did not have documentation of the required 10 hours of cognitive training within 4 months of employment. Staff’s record documented 6 hours of cognitive training (the document did not have a date). The staff’s date of employment was dated as 3-31-21.
  2. The staff acknowledged the staff’s record did not have documentation of the required hours of cognitive training.
Plan of correction
BOM to monitor staff training of team members in the community and ensure that the team member is provided training in compliance with state regulations. Team members training will be audited for compliance by BOM by 01/31/2023.
22VAC40-73-450-D
Based on record reviewed and staff interviewed, the facility failed to ensure when hospice care is provided to a resident, the assisted living facility and the licensed hospice organization shall communicate and establish an agreed upon coordinated plan of care for the resident. The services provided by each shall be included on the individualized service plan (ISP).
Evidence
  1. On 10-18-22, resident #1’s record included documentation on 2-7-22 from a licensed hospice organization recertification for services. The record also documented hospice services discontinued August 2022. The ISP dated 7-15-22 did not include hospice services.
  2. Staff acknowledged the resident’s ISP did not document hospice services.
Plan of correction
Hospice service provided to residents at community will be noted in care plan. Team will establish frequent meetings with hospice providers providing care to our residents. HWD and RCC to coordinate with hospice. Audit of existing care plans with hospice involvement will be audited and corrected by 01/31/2023.
22VAC40-73-410-A
Based on record reviewed and staff interviewed, the facility failed to ensure upon admission, orientation for a new resident and their legal representative was provided and documentation of such was kept in the record of one of four records reviewed.
Evidence
  1. On 10-18-22, resident #2’s record did not include documentation of orientation to the facility upon admission or following admission. The resident’s date of admission was documented as 5-30-22.
  2. Staff acknowledged the resident’s record did not include documentation of orientation to the facility.
Plan of correction
New residents admitted to the community will be given a proper orientation to the community. ED or designee will ensure orientation is completed on day of admission. Current residents charts will be audited for compliance by 01/31/2023.
22VAC40-73-1140-A
Based on record reviewed and staff interviewed, the facility failed to ensure prior to admitting a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia to a safe, secure environment, the licensee, administrator, or designee shall determine whether placement in the special care unit is appropriate. The determination and justification for the decision shall be in writing and shall be retained in the resident’s file.
Evidence
  1. On 10-18-22, resident #4’s record did not include documentation of the licensee, administrator, designee’s justification for placement on the safe, secure unit. The record also did not include documentation of the resident’s six-month assessment for continued placement in the safe, secure unit. The resident’s date of admission was documented as 4-6-22
  2. Staff acknowledged the resident’s assessment documents for placement on the safe, secure unit by the licensee, administrator or designee was not in the resident’s record.
Plan of correction
Residents residing in the secured unit will be evaluated prior to admission, 6 months within their first year and yearly per state regulations. HWD and RCC to complete audit of existing residents by 01/15/2023.
22VAC40-73-310-H
Based on record reviewed and staff interviewed, the facility failed to ensure it did not admit or retain individuals with any of the prohibitive conditions or care needs without supporting documentation.
Evidence
  1. On 10-18-22 resident #3’s record documented resident prescribed Lexapro and Seroquel psychotropic medications. The record did not include a treatment plan for these psychotropic medications.
  2. Staff #1 acknowledged the resident’s record did not include a treatment plan for prescribed psychotropic medications.
Plan of correction
HWD and RCC to conduct full audit of residents on psychotropic medications. Team will ensure treatment plan is in place for residents with those medications. Audit to be completed by 01/15/2023.
22VAC40-73-50-B
Based on record reviewed and staff interviewed, the facility failed to ensure written acknowledgement of the receipt of the disclosure by the resident or legal representative was retained in the record of one of four records reviewed.
Evidence
  1. On 10-18-22 resident #2’s record did not include a disclosure nor written receipt of the disclosure. The resident’s date of admission documented as 5-30-22.
  2. Staff #1 acknowledged the resident’s record did not include written receipt of the disclosure nor a copy of the disclosure.
Plan of correction
A full audit of resident files will be conducted to ensure resident’s files contain a signed acknowledgement of receipt. Any resident missing the disclosure in the audit will be presented to the resident or POA for review and signature. BOM to audit files of residents by 12/31/2022 and obtain signatures of missing resident’s disclosures by 01/31/2023
22VAC40-73-440-H
Based on record reviewed and staff interviewed, the facility failed to ensure an annual reassessment and reassessment due to a significant change in the resident’s condition, using the uniform assessment instrument (UAI) was utilized to determine whether a resident’s need can continue to be met by the facility and whether continued placement in the facility was in the best interest of the resident for two of four resident’s record.
Evidence
  1. On 10-18-22, resident #1’s record did not include an updated/reassessed annual UAI. The UAI in the record was dated 1-24-20 and 3-4-20. The resident’s record documented resident received hospice services; (hospice recertification documentation dated 2-7-22 and a discharge documentation dated August 2022). The resident’s date of admit to the facility was documented 2-4-20.
  2. Resident #’s UAI in the record was dated 5-24-29 and 5-29-20. The resident’s dates of admit to the facility were documented 2-11-21 (2-26-18).
  3. Staff acknowledged the residents’ record did not include an update/annual reassessment using the UAI document to determine condition change and continued placement.
Plan of correction
RCC and HWD will conduct full audit of residents at the community for updated UAI. Audit to be completed and UAIs will be current by 1/15/2023
22VAC40-90-40-B
Based on the employee record review and staff interviewed, the facility failed to ensure the criminal history record report was obtained on or prior to the 30th day of employment for each employee. 1. On 10-14-22, staff #7’s record did not have documentation of a criminal background record check (CRC). The staff’s date of hire was documented as 11-29-21. 2. Staff acknowledged the aforementioned staff’s record did not have documentation of a criminal background record check.
Plan of correction
BOM to monitor staff training of team members in the community and ensure that the team member is provided training in compliance with state regulations. Team members training will be audited for compliance by BOM by 01/31/2023.
March 29, 2022Inspection7 violations
Inspection dates
03/29/2022
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDING AND GROUNDS
Comments
A Representative with the Division of Licensing conducted an unannounced, mandated renewal inspection on 03/29/2022 and concluded on 03/29/2022. At the point of entrance the facility Administrator was available and on-site. The Licensing Inspector reviewed 4 staff records and 7 resident records, toured the facility physical plant and reviewed additional facility documentation for compliance. Please contact the facility Licensing Inspector Kimberly Rodriguez, at 757-586-4004 or by email at kimberly.rodriguez@dss.virginia.gov for additional questions or concerns.
Violations
22VAC40-73-450-C
The facility failed to ensure the comprehensive individualized service plan shall be completed within 30 days after admission.
Evidence
  1. On 03/29/2022 while reviewing resident record #4, resident #4's record contained an individualized service plan dated 05/25/2021 and read at the top, " Initial ISP". Resident #4's record did not contain a comprehensive service plan nor did the facility provide additional documentation.
Plan of correction
Not published by VDSS.
22VAC40-73-250-D
Based on staff record review the facility failed to ensure each staff person on or within seven days prior to the first day of work at the facility and each household member prior to coming in contact with residents shall submit the results of a risk assessment, documenting the absence of tuberculosis in a communicable form as
Evidence
  1. d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: On 03/29/2022 while reviewing staff record #2 with a date of hire of 3-14-2022 record did not contain a risk assessment nor did the facility provide any additional documentation.
Plan of correction
Not published by VDSS.
22VAC40-73-940-A
Based on facility record review the facility failed to ensure an assisted living facility shall comply with the Virginia Statewide Fire Prevention Code (13VAC5-51) as determined by at least an annual inspection by the appropriate fire official. Reports of the inspections shall be retained at the facility for at least two years.
Evidence
  1. While meeting with the facility Administrator on 03/29/2021, the Administrator was not able to provide the facility fire inspection.
Plan of correction
Not published by VDSS.
22VAC40-73-440-A
Based on resident record review the facility failed to ensure all residents of and applicants to assisted living facilities shall be assessed face to face using the uniform assessment instrument in accordance with Assessment in Assisted Living Facilities (22VAC30-110, at least annually.
Evidence
  1. While reviewing resident record #5, on 03/29/2022 the Licensing inspector observed the last uniform assessment in the resident record was dated 12/20/2019. The facility did not provide additional documentation.
Plan of correction
Not published by VDSS.
22VAC40-73-550-G
Based on staff record review the facility failed to ensure the rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each staff person.
Evidence
  1. of this review shall be the resident's, his legal representative's or responsible individual's, or staff person's written acknowledgment of having been so informed, which shall include the date of the review and shall be filed in the resident's or staff person's record. Evidence: While reviewing staff record #3 on 03/29/2022, staff record #3 hired on 02/10/2020 did not contain a review of resident rights, nor did the facility provide any additional documentation.
Plan of correction
Not published by VDSS.
22VAC40-73-325-B
Based on resident record review the facility failed to ensure the fall risk rating shall be reviewed and updated annually.
Evidence
  1. While reviewing resident record #3 on 03/29/2022, the residents last fall risk assessment was completed on 09-14-2019.
Plan of correction
Not published by VDSS.
22VAC40-73-450-F
Based on resident record review, the facility failed to ensure Individualized service plans shall be reviewed and updated at least once every 12 months and as needed for a significant change of a resident’s condition. The review and update shall be performed by a staff person with the qualifications specified in subsection B of this section and in conjunction with the resident and, as appropriate, with the resident's family, legal representative, direct care staff, case manager, health care providers, qualified mental health professionals, or other persons.
Evidence
  1. While reviewing resident record #1 on 03/29/2022, the Licensing Inspector observed that resident #1's Individualized service plan expired on 3/10/2021.
Plan of correction
Not published by VDSS.
June 7, 2021Inspection0 violations
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 EMERGENCY PREPAREDNESS
Comments
This inspection was conducted by Licensing Staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A monitoring inspection was initiated on 06/07/2021 and concluded on 06/07/2021. The director or in-charge person was contacted by telephone to initiate the inspection. The Inspector reviewed 4 resident records and 4 staff records submitted by the facility to ensure documentation was complete. The information gathered during the inspection determined no violations with applicable standards or law. No violations were issued.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.