Dominion Village at Williamsburg — Virginia Inspection Report

Inspections

On record

With violations

Visits that cited something

Clean visits

Nothing cited

Violations cited

Individual findings

Standards cited

Distinct rules

Complaint visits

Prompted by a complaint

Dominion Village at Williamsburg was inspected 15 times between April 13, 2021 and June 5, 2025 by the Virginia Department of Social Services. 14 of those visits ended with violations cited and 1 with none. Across that history VDSS cited 64 violations under 38 distinct standards. 5 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. 14 of these 15 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

06/30/2026

Administrator

Tabitha Gleesing

Licensing inspector

Alyshia Walker

Inspector phone

(757) 670-0504

Approved for

Assisted Living · Special Care Unit · Non-Ambulatory

Inspection History

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

June 5, 2025Inspection6 violations

Inspection dates

06/05/2025

Areas reviewed

22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE

Comments

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 6/5/2025 8:27 am- 2:35 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 33 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed:3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the 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. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov

Violations

22VAC40-73-450-A

Based on record review, the facility failed to ensure on or within seven days prior to the day of admission, a preliminary plan of care be developed to address the basic needs of the resident that adequately protects his health, safety, and welfare. The preliminary plan shall be signed and dated by the licensee, administrator, or his designee and by the resident or his legal representative.

Evidence

The resident records for Resident # 1 (D.O.A. 10/26/2024) and Resident # 2 (D.O.A. 5/7/2025) did not contain preliminary ISPs.
The preliminary ISP for Resident # 4 did not contain a POA signature.
Staff #1 acknowledged the resident records did not contain preliminary ISPs.

Plan of correction

The Health and Wellness Director or designee is responsible for ensuring that a preliminary plan of care is completed for each new resident within the required timeframe. The Health and Wellness Director or designee will ensure that a preliminary plan of care is written on or within seven days of admission for every resident. This plan will address the resident’s basic needs and be signed by the appropriate parties. The Executive Director will review each new admission to verify that a preliminary plan of care is in place on or within seven days of admission. The Executive Director will include a review of all new admissions and their preliminary care plans during the monthly Quality Assurance (QA) meetings with the Health and Wellness Director.

22VAC40-73-310-H

Based on record reviewed and staff interviewed, the facility failed to ensure in accordance with 63.2-1805 D Code of Virginia, it did not admit or retain individuals with any prohibitive conditions without required documentation.

Evidence

Resident # 3 has been prescribed Quetiapine 20 mg. The resident’s record did not contain a psychotropic treatment plan for the medication.

Plan of correction

The Health and Wellness Director or designee is responsible for ensuring that all psychotropic medications prescribed to residents are supported by a treatment plan signed by the prescriber. A treatment plan for Quetiapine 20mg was obtained on [Insert Date] and placed in the resident’s medical record. The Health and Wellness Director or designee will audit all prescribed psychotropic medications to ensure there is a treatment plan in place. The Health and Wellness Director or designee will audit all new psychotropic medication orders monthly to ensure that a signed treatment plan is in place for each medication. The Executive Director will review the results of the monthly psychotropic medication audits during the Quality Assurance (QA) Meeting with the Health and Wellness Director to ensure continued compliance.

22VAC40-73-450-F

Based on resident record review the facility failed to have the ISP signed and dated by the licensee, administrator, or designee and by the resident or his legal representative.

Evidence

The ISP for Resident # 1 dated 4/26/2025, did not contain a resident or legal representative signature.

Plan of correction

The Health and Wellness Director or designee is responsible for ensuring that all ISPs are signed and dated by the resident or their legal representative. The Health and Wellness Director or designee will ensure that every ISP is reviewed for completeness, including the required resident or legal representative signature, before finalization. The Executive Director will audit all ISPs to ensure they have the resident or legal representatives signature. The Executive Director will conduct a monthly review of all newly developed or updated ISPs during the Quality Assurance (QA) Meeting with the Health and Wellness Director. Any ISPs missing the required signature will be flagged, and appropriate steps will be taken to obtain the signature promptly.

22VAC40-73-940-A

Based on the record review the facility failed to ensure an assisted living facility shall comply with the Virginia Statewide Fire Prevention Code (13VAC5-51) as determine by at least an annual inspection by the appropriate fire official.

Evidence

The facility’s last recorded annual fire inspection was 1/9/2024.
Staff #1 acknowledged the facility’s last annual fire inspection was 1/9/2024.

Plan of correction

The Environmental Services Director will be responsible for ensuring ongoing compliance with fire safety standards and maintaining documentation of inspections. The Executive Director will schedule and confirm the completion of the annual fire inspection with the local Fire Marshall. This will be documented and retained on-site for a minimum of two years. The Executive Director will review the status of fire inspections during monthly Quality Assurance (QA) meetings with the Environmental Services Director. Copies of all fire inspection reports will be stored in a designated compliance binder

22VAC40-73-610-B

Based on observation and interview, facility failed to ensure menus for meals and snacks for the current week shall be dated and posted in an area conspicuous to residents and any substitutions or additions shall be recorded on the posted menu.

Evidence

During the inspection of the facility with Staff #1 on 6/5/2025 there was no menu posted.
Staff # 1 acknowledged the menu was not posted.

Plan of correction

The Director of Dining Services or designee is responsible for ensuring that menus for meals and snacks are dated and posted weekly in a location that is clearly visible to residents. The Director of Dining Services or designee will ensure that the weekly menu is posted and dated by the start of each week. Any substitutions or additions will be clearly recorded on the posted menu. The Executive Director or designee will review the posted menu and any changes weekly to ensure compliance with the regulation.

22VAC40-73-260-A

Based on a review of staff records, the facility failed to ensure each direct care staff member who does not have current certification in first aid as specified in subdivision 1 of this subsection shall receive certification in first aid within 60 days of employment.

Evidence

The employee file for Staff # 2 (D.O.H. 12/2/2024) did not contain verification of First Aid certification.
Staff #1 acknowledged Staff # 2 did not have First Aid certification.

Plan of correction

The Business Office Manager will be responsible for tracking and scheduling First Aid training for all new and current staff. Upon hiring, the Business Office Manager will schedule all new team members for First Aid training within 60 days of employment if they do not already have current certification. The Business Office Manager will conduct a comprehensive review of all staff files to verify current First Aid certification status. Any staff member found without valid certification will be immediately scheduled for training. The Executive Director will meet monthly with the Business Office Manager during the Quality Assurance (QA) Meeting to review any expiring or expired First Aid certificates and ensure timely recertification. A centralized log of all staff First Aid certifications, including expiration dates, will be maintained and updated monthly. This log will be available for inspection and used to proactively manage compliance.

June 5, 2025Inspection1 violation

Inspection dates

06/05/2025

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 6/5/2025 8:35 am- 2:30 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incidents was received by VDSS Division of Licensing on 5/2/2025 and 5/13/2025 regarding allegations in the area(s) of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 37 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia Walker@dss.virginia.gov

Violations

22VAC40-73-40-A

Based on review of facility documentation, the licensee failed to ensure compliance with all regulations for licensed assisted living facilities and terms of the license issued by the department; with relevant federal, state, and local laws; with other relevant regulations; and with the facility's own policies and procedures.

Evidence

The Division of Licensing received a self-report on 5/2/25 regarding a Resident # 1 who requires placement in a safe, secure, unit who was able elope through the emergency door. The resident’s observation notes stated the door’s alarm was not on and that is the reason the resident managed to go through without staff noticing.
The Division of Licensing received a self-report on 5/13/25 regarding a Resident #2 who requires placement in a safe, secure, unit who was able to elope through the emergency door. This resident was able to elope from the building twice on 5/12/25. The resident’s observation notes stated at one point the resident was able to enter a staff member’s car where he refused to exit.

Plan of correction

Health and Wellness Director and/or Memory Care Director and/or Designee will hold mandatory staff training on missing resident procedures. Beginning, 5.15.2025 the Health and Wellness Director and/or Memory Care Director and/or Designee will audit staff members response to facility door alarms and initial resident search expectations when door alarms are activated. Audits will be conducted once per week for the initial 4 weeks. Thereafter, audits will be conducted once every 3 months. The Health and Wellness Director and/or Designee will communicate changes to the community’s direct care staff to encourage activity engagement to prevent further exit seeking. Any issues will be reported to the Executive Director and discussed at quarterly Quality Assurance meeting.

June 3, 2025Complaint survey4 violations

Inspection dates

06/03/2025

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION

Comments

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 6/3/2025 2:30 pm- 4:15 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 5/29/2025 regarding allegations in the area(s) of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 30 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 2 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. However, violation(s) not related to the complaint(s) but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia Walker@dss.virginia.gov

Violations

22VAC40-73-450-A

The Health and Wellness Director (HWD) or designee will verify that every Preliminary Individualized Service Plan is signed and dated by the resident or their legal representative prior to finalization. The Health and Wellness Director (HWD) or designee will review each ISP for completeness, including confirmation that the required signature and date are present before the plan is approved or implemented. The Executive Director (ED) will audit all ISPs to ensure the required resident or legal representative signature has been obtained. The Executive Director (ED) will conduct a monthly review of all newly developed or updated ISPs during the Quality Assurance (QA) meeting with the Health and Wellness Director (HWD). Any ISP identified as missing a required signature will be immediately flagged, and the Health and Wellness Director (HWD) or designee will take prompt action to obtain the signature from the resident or legal representative. All existing service plans will be audited, and any missing signatures obtained by: February 9, 2026.

Plan of correction

22VAC40-73-440-B

Based on record review, the facility failed to ensure the uniform assessment instrument (UAI) was completed and signed by a qualified assessors and the administrator or the administrator's designated representative has successfully completed such training and approves and then signs the completed UAI.

Evidence

The UAI for Resident # 1 dated 3/15/25 did not contain an administrator or administrator’s representative signature.

Plan of correction

The Health and Wellness Director (HWD) or designee will review all resident Uniform Assessment Instruments to verify that each UAI is complete, accurate, and includes the required signature from the Executive Director and Licensed Healthcare Professional completing the form. The Health and Wellness Director (HWD) or designee will conduct a monthly audit of at least 10% of resident files for a period of six months to ensure continued compliance with signature requirements and documentation standards. The Executive Director (ED) will review audit findings during the monthly Quality Assurance (QA) Meeting and will ensure that any identified UAIs that are out of compliance are corrected promptly. Any UAI found to be missing the required signatures will be immediately flagged, and the HWD or designee will take prompt action to obtain the appropriate signature and update the record. A full audit of all Uniform Assessment Instruments will be completed, and any missing signatures obtained by February 9, 2026.

22VAC40-73-325-B

Based on the record reviewed, the facility failed to ensure that a fall risk assessment was reviewed and updated after a fall.

Evidence

Resident # 1 had documented falls on 5/29/25, 5/22/25, 5/15/25, 5/8/25, and 4/6/25. There was no documentation that the resident’s fall risk assessment was reviewed and updated after each of the falls in the resident’s record.
Staff # 1 acknowledged there was no documentation in the file of Resident # 1 that the fall risk assessment was completed after the above-mentioned falls.

Plan of correction

The Health & Wellness Director (HWD) / Resident Care Coordinator (RCC) or designee will review and update Fall Risk Assessments for all residents. Ongoing, after each fall the Health and Wellness Director (HWD)/Resident Care Coordinator (RCC) will review the Incident Report ensuring that each Fall Risk Assessment is completed following the fall event as required by regulation. The Executive Director (ED) will review resident falls during monthly during the Quality Assurance (QA) Meeting with the Health and Wellness Director (HWD)/Resident Care Coordinator (RCC) to ensure a Fall Risk Assessment was completed after each resident fall. Any fall event found to be missing a required Fall Risk Assessment will be immediately flagged, and corrective action will be taken the same day to complete the assessment and update the resident’s record. A full review and update of all resident Fall Risk Assessments will be completed by: February 9, 2026.

22VAC40-73-450-E

Based on staff interview and review of the resident’s record the facility failed to ensure that each resident’s individualized service plan (ISP) contained a signature and date of the resident or their legal representative.

Evidence

The comprehensive ISP for Resident # 1 (D.O.A. 3/18/25) with a review date of 4/15/25 did not contain a signature of the resident or the resident representative.
Staff # 1 acknowledge the comprehensive ISP for Resident # 1 did not contain a resident or resident representative signature.

Plan of correction

The Health and Wellness Director (HWD) or designee will verify that every Comprehensive Individualized Service Plan is signed and dated by the resident or their legal representative prior to finalization and implementation. The Health and Wellness Director (HWD) or designee will conduct a completeness review of each ISP, confirming that all required elements, including the resident or legal representative signature are present before the plan is approved or implemented. The Executive Director (ED) will audit all Comprehensive ISPs to ensure the required signature has been obtained and properly documented. The Executive Director (ED) will conduct a monthly review of all newly developed or updated Comprehensive ISPs during the Quality Assurance (QA) meeting with the Health and Wellness Director (HWD) to ensure ongoing compliance. Any Comprehensive ISP identified as missing the required signature will be immediately flagged, and the Health and Wellness Director (HWD) or designee will take prompt action to obtain the signature from the resident or legal representative.

February 14, 2025Inspection2 violations

Inspection dates

02/14/2025, 06/09/2025

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 2/14/2025 10:00 am- 1:18 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 2/9/2025 regarding allegations in the area(s) of: Resident Care and Related Services The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents:0 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. However, violation(s) not related to the self-report but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia Walker@dss.virginia.gov

Violations

22VAC40-73-450-C

Based on resident record review, the facility failed to complete a comprehensive Individualized Service Plan (ISP) within 30 days after admission to an assisted living facility including a description of needs as identified by the UAI.

Evidence

The record presented at the time of inspection for Resident #1 (date of admission 10/5/24) did not contain a comprehensive ISP. The ISP in the resident’s file was a preliminary ISP dated 10/5/24.

Plan of correction

The Health and Wellness Director or designee is responsible for ensuring that a Comprehensive Individualized Service Plan is completed for each new resident within the required timeframe. The Health and Wellness Director or designee will ensure that a comprehensive individualized service plan is written within thirty days of admission for every resident. This plan will address the resident’s basic needs and be signed by the appropriate parties. The Executive Director will review each new admission to verify that a comprehensive individualized service plan is in place on or within thirty days of admission. The Executive Director will include a review of all new admissions and their comprehensive individualized service plan during the monthly Quality Assurance (QA) meetings with the Health and Wellness Director.

22VAC40-73-440-B

Based on record review, the facility failed to ensure the uniform assessment instrument (UAI) was completed and signed by one of the following qualified assessors: An assisted living facility staff person who has successfully completed state- approved training on the uniform assessment instrument.

Evidence

The UAI dated 10/16/2024 was not signed by the assessor.

Plan of correction

The Health and Wellness Director or designee is responsible for ensuring that all UAI’s are signed and dated by the assessor. The Health and Wellness Director or designee will ensure that every UAI is reviewed for completeness, including the required assessor signature, before finalization. The Executive Director will audit all UAIs to ensure they have the assessor signature. The Executive Director will conduct a monthly review of all newly developed or updated UAIs during the Quality Assurance (QA) Meeting with the Health and Wellness Director. Any UAIs missing the required signature will be flagged, and appropriate steps will be taken to obtain the signature promptly.

February 14, 2025Complaint survey0 violations

Inspection dates

02/14/2025, 06/04/2025

Areas reviewed

22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-80 COMPLAINT INVESTIGATION

Comments

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 2/14/2025 10:00 am- 1:18 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 2/10/2025 regarding allegations in the area(s) of: Resident Care and Related Services The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

February 14, 2025Complaint survey1 violation

Inspection dates

02/14/2025

Areas reviewed

22VAC40-73 PERSONNEL22VAC40-80 COMPLAINT INVESTIGATION

Comments

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 6/5/2025 8:27 am- 2:30 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 4/11/2025 regarding allegations in the area(s) of: Personnel The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 2 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 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(s) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov

Violations

22VAC40-73-200-C

Based on record review and interview, the facility failed to ensure direct care staff meet one of the requirements in this subsection.

Evidence

Staff # 2 worked at the facility from 10/7/2023 through 6/10/2024. The staff’s record did not contain documentation that this employee has direct care qualifications.
Staff # 1 acknowledged Staff # 2’s record did not contain documentation the employee had direct care staff qualifications.

Plan of correction

The Business Office Manager will be responsible for checking all certified or licensed staff prior to hiring. The Business Office Manager will conduct a comprehensive review of all staff files to verify current licensed and certified staff have a current documentation in file. Any staff member found without valid certification will be immediately scheduled for training. The Executive Director will meet monthly with the Business Office Manager during the Quality Assurance (QA) Meeting to review any new hired staff to go over file to make sure we have proper documents.

February 14, 2025Inspection1 violation

Inspection dates

02/14/2025

Areas reviewed

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

Comments

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 2/14/2025 10:00 am- 1:18 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 11/4/2024 regarding allegations in the area(s) of: Resident Care and Related Services The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: The facility has multiple delayed egress doors. 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 Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov

Violations

22VAC40-73-460-D

Based on record review and staff interview, the facility failed to provide supervision of resident schedules, including attention to specialized needs, such as prevention of falls and wandering from the premises.

Evidence

On 11/4/2024, the Licensing Inspector received a self-report from the facility stating Resident #1 was able to exit the building by pressing the delayed egress door. Staff #2 responded to the door’s alarm and observed the resident outside the door. Staff #2 was able to assist the resident back into the building.

Plan of correction

Health Wellness Director and/or Memory Care Director and/or Designee will hold mandatory staff training on missing resident procedures. Beginning 11.5.2024, the Health Wellness Director and/or Memory Care Director and/or Designee will audit staff members response to facility door alarms and initial resident search expectations when door alarms are activated. Audits will be conducted once per week for the initial 4 weeks. Thereafter, audits will be conducted once every 3 months. Additionally, Health Wellness Director and/or Memory Care Director and/or Designee will hold elopement drills quarterly. Health Wellness Director will adjust the resident’s ISP to include elopement risk factors, interventions that have been put into place, and obtain proper signatures from the resident’s legal representative. The Health Wellness Director and/or Designee will communicate changes to the community’s direct care staff to encourage activity engagement to prevent further exit seeking. Executive Director and Health and Wellness Director will discussed at quarterly Quality Assurance meeting.

July 8, 2024Inspection2 violations

Inspection dates

07/08/2024

Areas reviewed

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

Comments

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7/8/2024 11:00 am- 12:30 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 6/14/2024 and 6/20/2024 regarding allegations in the area(s) of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 30 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: The Licensing Inspector completed a tour of the physical plant that included the building and grounds of the facility. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov

Violations

22VAC40-73-880-C

Based on observations made during the tour of the building, the facility failed to provide air conditioning for all areas used by residents including common areas and the temperature shall not exceed 80 degrees Fahrenheit.

Evidence

On the date of the inspection, 7/8/2024, at 11:34 am was 76 degrees, 78 degrees at 12:23 pm, and 81 degrees at 12:22 pm in the resident dinning room and other resident common areas.

Plan of correction

Not published by VDSS.

22VAC40-73-460-D

Based on staff interview and resident record review, the facility failed to provide supervision of resident schedules and specialized needs of wandering from the facility.

Evidence

Resident #1 was admitted on 3/23/2024 to the facility which is a serious cognitive impairment facility.
Resident #1 has a primary diagnosis of dementia and is unable to recognize danger or protect their own safety and welfare per their physician’s evaluation.
On 5/26/2024, Resident #1 scored a 10 on the Elopement Risk Evaluation which indicated the resident was at greater risk of elopement.
On 6/14/2024, the facility reported Resident #1 exited the front door of the facility at 2:30 am. A CNA saw the resident trying to get back into the building and let the resident in.
On 6/14/2024, Resident #1 scored 18 on the Elopement Risk Evaluation which indicated the resident was at a greater risk of elopement.
On 6/20/2024, the facility reported that Resident #1 was able to exit the facility again.

Plan of correction

Not published by VDSS.

May 29, 2024Inspection8 violations

Inspection dates

05/29/2024

Areas reviewed

Comments

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 5/29/2024 9:39am-3:10 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. However, violation(s) not related to the self-report but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at alyshia.walker@dss.virginia.gov

Violations

22VAC40-73-1110-A

Based on record reviewed and staff interviewed, the facility failed to ensure that prior to admitting a resident within 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

The record for Resident #1 did not contain documented evidence of the licensee, administrator, or designee’s justification for the decision to place the resident in the safe, secure environment.

Plan of correction

1. Health and Wellness Director of designee will conduct audit of all residents records to ensure that all records contain Approval of Placement form and that all forms are completed and signed by September 2024. 2. Any resident files not containing Approval of Placement form or form is incomplete will be reported to the ED 3. HWD or designee will audit at least 10% of residents records monthly to ensure that all current resident records contain required documents 4. Health and Wellness Director/ED will utilize move in check-list with every move in moving forward to ensure that all required documents are completed prior to move-in 5. ED will review audits and move in checklist at least quarterly during QA

22VAC40-73-660-A-1

Based on observation and staff interview, the facility failed to ensure that all medications and dietary supplements were stored in a manner consistent with the current standards of practice.

Evidence

During the on-site inspection on 5/29/2024, Licensing Inspectors observed the door to the medication door being unlocked. Inside the medication room, there were 5 gray bins filled with medication unsecured in the corner of the room.
Staff #3 acknowledged the door to the medication room was not locked and the bins contained medication which was unsecured.

Plan of correction

Not published by VDSS.

22VAC40-80-120-E-1

Based on observations made during the tour of the building, the facility failed to ensure certain documents related to the terms of the license are posted as required on the premises of the facility, including the most recently issued license.

Evidence

During the on-site inspection 5/29/2024 there was no facility license posted in the facility for the licensing inspector to inspect.
Staff #1 acknowledged the license was no posted.

Plan of correction

1. BOM or designee will ensure that Facility license are visible at all times. August 2024 2. Bom or designee will conduct weekly rounds to ensure that license are on the wall and UTD. 3. ED will review quarterly during QA

22VAC40-73-580-A

Based on record review, the facility failed to ensure when any portion of an assisted living facility is subject to inspection by the Virginia Department of Health, the facility shall be in compliance with those regulations, as

Evidence

d by an initial and subsequent annual reports from the Virginia Department of Health. Evidence:
During the on-site inspection the most recent documented health inspection was 1/5/2023.
Staff #1 acknowledged the facility’s health inspection was not current.

Plan of correction

1. Business office Manager or designee will contact Virginia Department of Health to schedule annual Inspection by September 2024. 2. Business office Manager or designee will report need for Annual Inspection to Executive Director 3. Executive Director will review licenses and inspections at least quarterly during the QA

22VAC40-73-450-F

Based on staff interview and review of resident records, the facility failed to update the Individualized Service Plan (ISP) at least once every 12 months and as needed for a significant change of a resident’s condition.

Evidence

The Uniform Assessment Instrument (UAI) for Resident #3 states the resident needs mechanical and human help with toileting however the ISP states the resident only requires mechanical help.

Plan of correction

1. Health and Wellness Director or designee will conduct audit of all resident UAI/ISP to ensure that information is accurate and matches by September 2024 2. Any UAI/ISP identified to not be accurate of match will be reported to ED 3. Health and Wellness Director will audit UIA/ISPs monthly during CCR meeting and correct any needed changes identified 4. Executive Director will review at least quarterly during QA

22VAC40-73-250-D

Based on a review of staff records the facility failed to ensure that each staff person submit the results of a tuberculosis (TB) risk assessment on or within seven days prior to the first day of work at the facility and that each staff person submit the results of a risk assessment annually.

Evidence

The file for Staff #2 (D.O.H. 2/27/2024) did not contain a valid TB risk assessment as the assessment form was not completed by a licensed healthcare provider. The form only had the staff member’s signature.
The file for Staff #3 (D.O.H. 2/8/2019) did not contain a current TB risk assessment. The most recent TB risk assessment form was dated 2/20/2023.

Plan of correction

1. Business Office Manager or Designee will conduct an audit on all personnel files to ensure that all files have required TB risk assessment by September 2024. 2. Any files not containing required TB risk assessment will be reported to Executive Director. 3. Business Office Manager or designee will audit at least 10% of personnel files monthly and report any required items identified missing to Executive Director. 4. Executive Director will review audit at least quarterly during QA

22VAC40-73-970-A

Based on document review and staff interviewed the facility failed to ensure fire and emergency drill frequency and participation shall be in accordance with the current edition of the Virginia Statewide Fire Prevention Code (13VAC5-51). The drills requested for each shift in a quarter shall not be conducted in the same month.

Evidence

On 05/29/2024, the facility provided evidence of fire and emergency evacuation drills for first shift and for second shift. There was no evidence of the facility conducting fire and emergency evacuation drills for the first shift for the first quarter of 2024.
Staff # 1 acknowledged the facility did not have documentation of a fire and emergency evacuation drill being conducted for the first shift for the first quarter of 2024.

Plan of correction

1. Environmental Services Director or designee will conduct an audit of TEL system to determine all required drills are completed by September 2024. 2. Environmental Services Director or designee will review TEL system daily and report any needed drills to Executive Director at stand up meetings 3. Executive Director will review Drill quarterly during QA

22VAC40-73-440-D

Based on resident record review and staff interview, the facility failed to ensure that the Uniform Assessment Instrument (UAI) is completed as required by 22VAC30-110 with the assessment, including functional status.

Evidence

Bathing on the UAI for Resident #3 states the resident needs assistance in bathing but does not indicate the type of assistance the resident needs, that section was blank. The Individualized Service Plan states the resident needs mechanical and human supervision for bathing.

Plan of correction

Not published by VDSS.

March 1, 2024Inspection8 violations

Inspection dates

03/01/2024

Areas reviewed

22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

Type of inspection: Other Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 3/1/2024 11:18 am- 1:36 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 1/5/2024 regarding allegations in the area(s) of: Resident Care and Related Services The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 2 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. However, violation(s) not related to the self-report but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at alyshia.walker@dss.virginia.gov

Violations

22VAC40-73-50-A

Based on record reviewed and staff interviewed, the facility failed to ensure it prepared and provided a statement to the prospective resident and the legal representative, if any, that disclose information about the facility. Written acknowledgement of this form shall be retained in the resident’s record.

Evidence

On 3/1/2024, the resident record for Resident #2 did not have documentation a disclosure statement had been provided.

Plan of correction

1. Business office manager or designee will do an audit of all resident files to ensure they have a signed disclosure statement. Done by September 19, 2024 2. Business office manager or designee will report to Executive Director is they do not have one in the file. 3. Business office manager or designee going forward will follow a check list for new move in to make sure all the paperwork is there. 4. Executive Director will check quarterly.

22VAC40-73-450-E

Based on a review of resident records, the facility failed to ensure the Individualized Service Plan (ISP) shall be signed and dated by the resident or his or her legal representative.

Evidence

The record for Resident # 1 (admit date: 2/28/2022) contained an initial ISP that was not signed or dated.
The record for Resident #2 (admit date: 10/10/2023) contained an ISP with a next review date of 10/13/2024 that was not signed or dated.

Plan of correction

Not published by VDSS.

22VAC40-73-450-C

Based on record reviewed and staff interviewed, the facility failed to ensure the comprehensive individualized service plan (ISP) included all assessed needs.

Evidence

Resident #2’s comprehensive ISP did not include the resident’s physical therapy services.

Plan of correction

1. Health and Wellness Director or designee will conduct audit of all resident UAI/ISP to ensure that information is accurate and matches by (September 2024. 2. Any UAI/ISP identified to not be accurate of match will be reported to ED 3. Health and Wellness Director will audit UIA/ISPs monthly during CCR meeting and correct any needed changes identified 4. Executive Director will review at least quarterly during QA

22VAC40-73-350-B

Based on review of resident records, the facility failed to ascertain, prior to admission, whether a potential resident is a registered sex offender.

Evidence

Resident #1 was admitted on 2/28/2022 and the Sex Offender screening was completed on 10/19/2022.

Plan of correction

1.Business office manager or designee will do an audit of all resident files to ensure they have a Sex Offender screening done prior to move in. Done by September 19,2024. 2.Business office manager or designee will report to Executive Director is they do not have one in the file. 3. Business office manager or designee going forward will follow a check list for new move in to make sure all the paperwork is there. 4. Executive Director will check quarterly.

22VAC40-73-440-B

Based on record review, the facility failed to ensure the uniform assessment instrument (UAI) was completed by one of the following qualified assessors: An assisted living facility staff person who has successfully completed state- approved training on the uniform assessment instrument and level of care criteria for either public or private pay assessments, provided the administrator or the administrator's designated representative has successfully completed such training and approves and then signs the completed UAI.

Evidence

The UAI for Resident #2 dated 11/13/2023 did not contain the administrator’s nor administrator’s designee signature.

Plan of correction

1.Health and Wellness Director or designee will conduct audit of all resident UAI/ISP to ensure that they are signed and dated by September 2024 2. Any UAI/ISP identified to not be signed or dated will be reported to ED 3. Executive Director will review at least quarterly during QA

22VAC40-73-40-B

Based on the employee record review, 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

The staff record provided to the licensing inspector at the time of inspection for Staff #2 did not contain a Virginia State Police Criminal history record report. Staff #2’s date of hire was documented as 9/25/2023.

Plan of correction

1. Business Office Manager or designee will audit all files to make sure they have the state police background check not just a national background report. Done by September 19th 2024. 2.Business office manager will report to Executive Director if any staff do not have a VA state police background check. 3.Executive Director will check quarterly

22VAC40-73-550-G

Based on the review of facility records and staff interviews conducted the facility failed to ensure that the rights and responsibilities of residents in assisted living facilities are reviewed annually with each resident or his legal representative or responsible individual as stipulated in subsection H of this section and each staff person.

Evidence

The most recent review of resident’s rights for Resident #1 was dated 11/6/2022.

Plan of correction

1.Health and Wellness Director or designee will conduct audit of all resident UAI/ISP to ensure that they are signed and dated by September 19, 2024 2. Any UAI/ISP identified to not be signed or dated will be reported to ED 3. Executive Director will review at least quarterly during QA

22VAC40-73-310-H

Evidence

Resident #2 has physician’s orders for Quetiapine Fumarate 50 mg and Lorazepam 1 mg and there were no psychotropic treatment plans in the resident record at the time of the on-site inspection for the medications.

Plan of correction

Not published by VDSS.

June 23, 2023Inspection17 violations

Inspection dates

06/23/2023

Areas reviewed

Violations

22VAC40-73-680-I

Based on documentation review, the facility failed to include all required documentation on the Medication Administration Record (MAR).

Evidence

The June 2023 MAR for resident #7 did not include a diagnosis, condition, or specific indications for administering the following prescribed medications: Metoprolol Succ ER 25 mg, Preservision Areds 2 230-5 mg, Spironolactone 25 mg, Warfarin Sodium 5 mg, Warfarin Sodium 6 mg, and Ocusoft LID Scrub Plus.
The June 2023 MAR for resident #2 did not include a diagnosis, condition, or specific indications for administering the following prescribed medications: Albuterol Sulfate, Lisinopril 2.5 mg, Lorazepam 1 mg, and Amlodipine Besylate 2.5 mg.
The June 2023 MAR for resident #3 did not include a diagnosis, condition, or specific indications for administering the following prescribed medications: Austedo 9 mg, Carb-Levo ER50 mg- 200 mg, Furosemide 20 mg, Memantine HCL F/C 5 mg, and Potassium Chloride 10 meq.

Plan of correction

FNP completed the missing information for Residents #7, #3, and #2. The Health and Wellness Director will ensure all orders have diagnoses and dosage instructions going forward and the accuracy of the MAR will be confirmed.

22VAC40-73-260-A

Based on a review of staff records the facility failed to ensure that each direct care staff member who does not have current certification in first aid shall receive certification in first aid within 60 days of employment.

Evidence

The employee file for Staff #4 (D.O.H) 2/5/2022 did not contain evidence of the staff member having First Aid certification.

Plan of correction

First Aid certification will be completed for each direct care staff member. The Health and Wellness Director will arrange to have all staff certified by the completion date. Staff #4 is no longer employed by Dominion Village at Williamsburg. Employees will be scheduled for first aid training at orientation.

22VAC40-73-980-A

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

On 6/23/23 during a check of the facility’s first aid kits, the first aid in the AL medication room were missing the following items: (a) disposable CPR mask; (b) cold pack; (c) assorted roller gauze; (d) hand cleaner/antiseptic towelette; (e) plastic bags; (f) scissors; (g) flashlight/extra batteries; (h) thermometer and (i) triangular bandages, Tylenol expired 5-2022. The first aid kit on the vehicle were missing the following items: (a) disposable CPR masks; (b) disposable waterproof gloves; (c) no extra batteries and (d) no first aid/CPR manual. The first aid kits did not contain a checklist.

Plan of correction

All missing items have been ordered and will be distributed among the five first aid kits. A checklist is being utilized to ensure all items are present in all first aid kits. The kits will be examined monthly using this checklist. The Environmental Services Director will carry out this responsibility.

22VAC40-73-250-D

Based on staff records reviewed, the facility failed to ensure each staff person member’s tuberculosis (TB) risk assessment be completed annually.

Evidence

The staff records for staff members #2 and #3 did not contain TB risk assessment forms.

Plan of correction

Annual TB Risk Assessments are given to the nurse practitioner every January by the Business Office Manager for completion. Random file audits will be completed monthly by Executive Director. Staff #2 is scheduled to have a TB Risk Assessment done on 8/21/23 but did have a negative TB test before beginning work in January 2023. An audit of all employee files will be conducted to verify TB risk assessments are up to date.

22VAC40-73-1110-B

Based on record reviewed and staff interviewed, the facility failed to ensure a resident was assessed for continued appropriateness for residence on the facility’s special care unit.

Evidence

On 6/23/23, resident # 4 a resident assigned to the facility’s special care unit record was reviewed. The record did not have a current (annual) review of appropriateness for continued stay. The last assessment in the record was conducted 3-5-22. The resident’s admission to the unit was dated 7-23-18.

Plan of correction

The updated assessment was completed on Resident #4 and sent to resident’s daughter for signature. All residents will be assessed annually for continued appropriateness for a special care unit. A reminder will be set up to prompt the Memory Care Director when an assessment is due and the documentation will be filed in the resident’s chart. A review of charts will be completed and any missing assessment will be done.

22VAC40-73-350-B

Based on record review, the facility failed to ascertain, prior to each resident’s admission whether a potential resident is a registered sex offender.

Evidence

The resident record for resident #1 did not contain a Sex Offender Screening.

Plan of correction

Results of a search on the sex offender database are printed and filed in the resident’s file. This responsibility is with the Business Office Manager and will be part of the monthly file audits. A search was conducted on Resident #1 on 07/26/23, a screenshot printed, and the documentation filed in the resident’s file. An audit of all resident files will be completed and any missing sex offender information will be added.

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

On 6/23/23, staff # 2 was asked where the facility’s listing of staff with first aid and CPR was posted. The posted listing was not visible and was not current. Staff # 5 was listed but there was no date for the FA/CPR/AED)/ staff members #6, #7, and # were not listed and these staff members names were posted on the roster outside the med room on 6/23/23.

Plan of correction

An up-to-date list of all staff with current first aid and CPR certification was posted in a prominent location in the facility near the front door on July 3, 2023. It will be updated as necessary by the Business Office Manager and Health and Wellness Director.

22VAC40-73-210-B

Based on staff record review the facility failed to ensure in a facility licensed for both residential and assisted living care, all direct care staff shall attend at least 18 hours of training annually.

Evidence

A review of Staff # 4’s record did not contain the required number of annual training hours.
Staff #10 acknowledged the staff record for Staff #4 did not contain the required amount of annual training.

Plan of correction

An audit of employee training will be completed and the Business Office Manager will report compliance weekly to department heads. Training for all staff will be completed using in-services, and online Relias training. Individual department heads will be responsible for ensuring completion. Staff #4 is no longer employed by Dominion Village at Williamsburg.

22VAC40-73-50-A

Evidence

On 6/23/23, the resident records for residents #1 (2/20/23) and #3 (date of admit 6/2/22) did not have documentation a disclosure statement had been provided.

Plan of correction

A checklist is used with every new admission to ensure disclosure statements are signed upon admission and filed in the resident’s file. This responsibility falls on the Executive Director or designee. Resident #1 and Resident #3 signed disclosure statements on 07/06/2023. A review of all resident filed will be completed and any missing disclosure statements will be signed. Audits will be conducted for the next ten admissions.

22VAC40-73-450-F

Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) shall be reviewed and updated at least once every 12 months and as needed for a significant change of a resident’s condition.

Evidence

On 6/23/23, resident #7’s individualized service plan (ISP) dated 6/5/23 did not include resident’s fluid restriction. Resident returned from hospital stay 4/28/23 to 5/3/23, order for fluid restriction 34-48- ounces of fluid a day. The resident is allergic to coconut and nuts, these items not noted on the ISP. The ISP noted mechanical help for bathing but did not identify the mechanical device. The record included signed orders for eye-drops and creams to be kept at bedside, this information was not on the ISP. The UAI and ISP documented all medication to be administered by layperson and nurse. Resident physical therapy services not on the ISP, services 5/6/23 and discharged 6/1/23.
Resident #2’s, UAI (dated 1/23/23 noted bathing need assessed as mechanical help/supervision. The ISP signed 5/3/23 noted “staff will assist resident with washing entire body including arms, legs, back, hair, feet and perineum”.
Resident # 4’s record did not have documentation of a current ISP. The ISP in the record was signed 3/31/22. The resident’s date of admit noted as 7/23/18.

Plan of correction

1. In the future, it will be detailed on the ISP that the resident is responsible for monitoring their fluid intake and following the physician orders for fluid restriction. Home Health will educate and verify understanding and document it on the ISP as such. All other violations corrected on the ISP. 2. The UAI of Resident #2 was corrected. 3. Resident #4’s ISP was completed and sent to the POA for signature. All ISPs will be updated upon significant changes to residents’ condition.

22VAC40-73-410-A

Based on records reviewed and staff interviewed, the facility failed to ensure upon admission, it would provide an orientation for new residents and their legal representatives.

Evidence

Resident #1 was admitted to the facility on 2/20/2023. There was no documented evidence in the resident record of the resident being provided an orientation to the facility.

Plan of correction

The orientation checklist is being used to ensure residents are given an orientation to the facility. An orientation checklist for Resident #1 was completed on . This responsibility will be carried out by the Executive Director or designee. An audit will be done to verify orientation was completed and any missing documentation will be completed.

22VAC40-73-310-H

Evidence

On 6/23/23, resident # 7’s record documented resident administered Sertraline. The facility’s, “Psychopharmacologic Medication Treatment Plan” form dated 3/27/23 was blank for psychotropic/ psychoactive medications.
Resident # 3’s record did not have documentation of psychotropic treatment plan for the following medication being administered: (a) Lorazepam, (b) Seroquel and (c) Trazadone medications noted on 6-5-23 signed physician orders.

Plan of correction

The Health and Wellness Director is reviewing all orders monthly to ensure all new orders for psychotropic medications have a treatment plan. Resident #7 and Resident #3 both had Psychotropic Medication Treatment Plans completed by Meredith Leary, FNP on 08/16/23. An audit of resident psychotropic medication will be completed and verified that a treatment plan is in place when required.

22VAC40-73-310-D

Based on record reviewed and staff interviewed, the facility failed to ensure prior to admission of a resident, the facility administrator provided written assurance to the resident that the facility has the appropriate license to meet the care needs at the time of admission. Acknowledgement of this document should be signed by the resident and legal representative and kept in the resident’s record.

Evidence

On 6/23/23, the records for residents #1 and # 3 did not have documentation of a signed and dated written assurance from the administrator and signed and dated by the resident and/or legal representative.

Plan of correction

A checklist is used with every new admission to ensure written assurances are signed by the resident or their representative and the Executive Director. Written assurances for Resident #1 and Resident #3 were signed on 7/6/23 by the residents and the Executive Director and were filed in the residents’ records. An audit of all files will be completed and missing written assurances will be corrected.

22VAC40-73-310-B

Based on records reviewed and staff interviewed, the facility failed to ensure a documented interview between the administrator or designee responsible for admission and retention, the individual, and the legal representative, if any was in the record for a resident.

Evidence

Resident 1’s record did not include documentation of an interview.

Plan of correction

An interview between the Health and Wellness Director and the legal representative or resident will be conducted and documentation of such will be filed in the resident’s file. The retention interview was conducted on 06/30/23 for Resident #1 and documentation was filed in his chart. An audit of current charts will be completed and any documentation of interviews will be updated and an interview scheduled, if needed.

22VAC40-73-390-A

Based upon documentation review, the facility failed to ensure at or prior to the time of admission, there shall be a written agreement signed by the resident.

Evidence

Resident #1 was admitted to the facility on 2/20/23 and there was no signed resident agreement in the file presented to the licensing inspection at the time of the inspection.

Plan of correction

All residents, including those who share a room with a spouse, will have their own resident agreement on file. A separate agreement for Resident #1 was signed on 08/16/2023 effective 2/20/23. The Executive Director does all lease signings and will ensure compliance. An audit of current resident files will be completed to verify signed resident agreements.

22VAC40-73-320-A

Based on record reviewed and staff interviewed, the facility failed to ensure within 30 days preceding admission, a person shall have a physical examination by an independent physician.

Evidence

On 6/23/23, resident #3 did not have a physical examination prior to being admitted. The resident’s admit date noted as 6/2/22.

Plan of correction

All new admissions, including transfers from other facilities, will be treated as new admissions including having pre-admission physical completed and documented. This item is included on the new admission checklist and the Health and Wellness Director will ensure its completion and accuracy. An audit of all charts will be completed to verify physical examination has been completed and documented in the resident’s chart.

22VAC40-73-440-H

Based on record reviewed and staff interviewed, the facility failed to ensure annual assessment and reassessment due to significant change in the resident’s condition, using the Uniform Assessment Instrument (UAI), shall be utilized to determine whether a resident’s needs can continue to be met by the facility and whether continued placement in the facility is in the best interest of the resident.

Evidence

On 6/23/23, resident #4’s, record did not have documentation of an updated UAI. The UAI in the record was dated 7/23/2020 and 7/23/2021. The resident’s date of admit noted as 7/23/2018.

Plan of correction

The UAI for Resident #4 was updated and a copy sent to the POA for signature. All residents will have their UAIs updated annually or upon a significant change in condition. A reminder will be set up to prompt the Health and Wellness Director or Memory Care Director when an assessment is due. An audit will be conducted to verify residents with a significant change in condition will have an updated, signed UAI.

June 23, 2023Complaint survey1 violation

Inspection dates

06/23/2023

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATIONNone

Comments

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 6/23/2023 9:52 am- 6:47 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 4/26/2023 regarding allegations in the area(s) of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 39 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation(s) of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint(s) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alyshia E. Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov

Violations

22VAC40-73-640-A

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

Evidence

The facility’s Medication Management Plan states that, “Nurses and RMA’s shall be responsible for the timely ordering, and re-ordering of medications so that there are no missed doses or interruptions in the medications being administered. “ The policy further states, “If a medication is not available to administer for any reason, the nurse/RMA will contact the physician to inform of when the medication will be made available and seek further instruction. The physician’s instructions will be documented on the (E) MAR.”
Resident # 1 has a physician’s order for Warfarin Sodium 6 mg tablet to be administered 1 tablet by mouth weekly every Saturday and Sunday. A review of the June 2023 MAR, notes the medication was not available on 6/3/23, 6/4/23, and 6/10/23.
Resident # 2 has a physician’s order for Albuterol Sulfate to be administered via nebulizer every 12 hours. A review of the June MAR notes the medication was not available to be administered on: 6/16/23 at 9:00 am, 6/16/23 at 9:00 pm, 6/17/23 9:00 am, 6/17/23 9:00 pm, 6/18/23 9:00 am “Refused- however medication was not available”, 6/18/23 9:00 pm, 6/19/23 9:00 am, and 6/22/23 9:00 pm.
Resident # 3 has a physician’s order for Aspirin 81 mg to be taken 1 tablet every day. The April 2023 MAR notes the medication was not available to be administered on 4/14/23, 4/15/23, and 4/19/23.
Resident # 3 has a physician’s order for Atorvastatin Calcium 80 mg, 1 tablet at bedtime. The April 2023 MAR notes the medication was not available to be administered on 4/14/23, 4/18/23, 4/19/23, 4/20/23, 4/21/23, 4/22/23, 4/23/23, 4/24/23, and 4/26/23.
Resident # 3 has a physician’s order for Clonazepam 0.25 mg, 1 tablet three times a day. The April 2023 MAR notes the medication was not available to be administered on 4/14/23 8:00 am, 4/24/23 12:00 pm, 4/24/23 5:00 pm, 4/25/23 8:00 am, 4/25/23 12:00 pm, 4/25/23 5:00 pm, 4/26/23 8:00 am, 4/26/23 12:00 pm, 4/26/23 5:00 pm, 4/27/23 8:00 am, 4/27/23 12:00 pm.
Resident # 3 has a physician’s order for Clopidogrel F/C 75 mg, 1 tablet daily. The April 2023 MAR notes the medication was not available to be administered on 4/14/23, 4/23/23, 4/24/23, 4/25/23, 4/26/23, and 4/27/23.
Resident # 3 has a physician’s order for Ferretts 325 mg, 1 tablet by mouth daily. The April 2023 MAR notes the medication was not available to be administered on 4/14/23, 4/15/23, 4/19/23, 4/20/23, 4/21/23, 4/24/23, 4/25/23, 4/26/23, and 4/27/23.
Staff members #1 and #2 acknowledged the facility’s medication Management Plan was not followed.

Plan of correction

Health and Wellness Director made several attempts via fax, phone, and personal visits to the doctor’s office in order to get prescription refills. The refill prescriptions arrived by fax on April 28, 2023 and were filled by the pharmacy the same day. Every Monday and Thursday the Resident Care Coordinator goes through the medication cart and calls the pharmacy to refill any medications running low. On August 9, 2023 Omnicare gave us access to Omniview which allows the Health and Wellness Director and the Resident Care Coordinator to see which medications will be coming due for refill. This will eliminate last-minute refills and allow the pharmacy time to deliver the medications. As of June, 06, 2023 the resident using FNP who visits our residents weekly to ensure better communication between care staff and medical provider and timely responses to medication requests.

February 8, 2023Complaint survey2 violations

Inspection dates

02/08/2023

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 BUILDINGS AND GROUND22VAC40-80 COMPLAINT INVESTIGATION

Violations

22VAC40-73-550-G

Based on record reviewed and staff interviewed, the facility failed to ensure staff reviewed rights and responsibilities of residents in assisted living facility annually.

Evidence

The record for Staff #3 did not contain documentation the staff reviewed the annual rights and responsibilities of residents in assisted living facility.
Staff #1 acknowledged the staff record did not contain annual resident rights review documentation.

Plan of correction

Not published by VDSS.

22VAC40-73-210-B

Based on staff records reviewed the facility failed to ensure in a facility licensed for both residential and assisted living care, all direct care staff shall attend at least 18 hours of training annually.

Evidence

A review of Staff # 2 and Staff #3’s records did not contain the required number of annual training hours.
Staff #1 acknowledged the staff members records did not contain the required amount of annual training.

Plan of correction

Not published by VDSS.

March 30, 2022Inspection5 violations

Inspection dates

03/30/2022

Areas reviewed

22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDING AND GROUNDS

Comments

A Representative with the Division of Licensing conducted an unannounced mandated renewal inspection on 03/30/2022 from 11:00am to 5:00pm. At the point of entrance the facility Administrator was present and assisted with the inspection. The Licensing Inspector observed the facility physical plant, observed the facility emergency food supply, observed 6 resident and 4 staff records 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

22VAC40-73-660-A-1

Based on observation of the facility physical plant the facility failed to ensure the storage area shall be locked.

Evidence

#1: While observing the facility physical plant with the facility Administrator the Licensing inspector observed, "Silver Centrum Men Plus" in resident #7's apartment. The medication was not locked in a storage unit inside resident #7's apartment.

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

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 staff person's record. Evidence: While reviewing staff record #1 and #2 on 03/30/2022, the Licensing Inspector observed staff records #1 and #2 did not contain a review of resident rights nor was the facility able to provide.

Plan of correction

Not published by VDSS.

22VAC40-73-250-D

Based on staff record review the facility failed to ensure each staff person or household member required to be evaluated shall annually submit the results of a risk assessment, documenting that the individual is free of tuberculosis in a communicable form as

Evidence

d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence : While reviewing staff record #3 on 03/30/2022, staff record #3's last tuberculosis assessment was completed on 02/02/2019.

Plan of correction

Not published by VDSS.

22VAC40-73-870-A

Based on observation of the facility physical plant, the facility failed to ensure the interior and exterior of all buildings shall be maintained in good repair.

Evidence

While observing the facility physical plant with the facility Administrator the following areas were found to not be maintained in good repair: 1- The secure unit memory care gardening area contained broken wood 2- The secure unit carpet was stained 3- the secure unit bottom of the hall walls were scratched and faded 4- The secure unit bottom of sink, doors and toilets were brown and appeared to be rusted

Plan of correction

Not published by VDSS.

22VAC40-73-450-C

Based on resident record review the facility failed to ensure the comprehensive individualized service plan shall include the expected outcome and time frame for expected outcome.

Evidence

While observing resident #4's record on 03/30/2022, resident #4's Individualized Service Plan did not contain outcome and time frame for expected outcome.

Plan of correction

Not published by VDSS.

April 13, 2021Inspection6 violations

Inspection dates

April 13, 2021 and April 14, 2021

Areas reviewed

22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED 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 renewal inspection was initiated on 04/13/2021 and concluded on 04/14/2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census. The inspector emailed the Administrator a list of item required to complete the inspection. The inspector reviewed 3 resident records, 3 staff records, staff schedules , Fire Inspection, Health Department Inspection Report and additional documentation provided by the facility. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations

22VAC40-73-210-B

Based on staff record reviews, the facility failed to ensure In a facility licensed for both residential and assisted living care, all direct care staff shall attend at least 18 hours of training annually.

Evidence

#1: While reviewing staff #2's, hired by the facility on 1-27-2020, the record did not contain any annual training. Evidence: #2 While reviewing staff #3's record hired by the facility on 07-09-2012, the last date of annual training completed was 12-04-2019.

Plan of correction

Not published by VDSS.

22VAC40-73-250-D

Evidence

While reviewing staff record #2 and #3 documentation provided evidenced the last tuberculosis screening was completed on 01/02/2020 and 01/15/2020.

Plan of correction

Not published by VDSS.

22VAC40-73-260-A

Based on record review the facility failed to ensure each direct care staff member who does not have current certification Description: Based on record review the facility failed to ensure each direct care staff member who does not have current certification in first aid as specified in subdivision 1 of this subsection shall receive certification in first aid within 60 days of employment.

Evidence

Staff record #2, hired by the facility on 01-27-2020 as a Direct Care staff did not contain First Aide training.

Plan of correction

Not published by VDSS.

22VAC40-73-450-E

The facility failed to ensure the individualized service plan shall be signed and dated by the resident or his legal representative.

Evidence

While reviewing resident record #1 and #2, documentation provided for the residents individualized service plan, did not contain signatures provided by the resident or legal representative.

Plan of correction

Not published by VDSS.

22VAC40-73-550-G

Based on record review the facility failed to ensure the rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each resident or his legal representative or responsible individual as stipulated in subsection H of this section and each staff person as

Evidence

d of this review shall be the resident's, his legal representative's or responsible individual'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 resident records #1, #2 and #3, all three records did not contain signed resident rights.

Plan of correction

Not published by VDSS.

22VAC40-73-970-A

Based on resident record review the facility failed to ensure fire and emergency evacuation drill frequency and participation shall be in accordance with the current edition of the Virginia Statewide Fire Prevention Code (13VAC5-51).

Evidence

While reviewing the fire and emergency evacuation drills during the quarter of February to April, 2021. The facility did not provide a fire drill for the month of March 2021. In addition the facility did not provide a fire drill all required shifts.

Plan of correction

Not published by VDSS.