Charter Senior Living of 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

Charter Senior Living of Williamsburg was inspected 20 times between January 22, 2021 and June 12, 2026 by the Virginia Department of Social Services. 11 of those visits ended with violations cited and 9 with none. Across that history VDSS cited 55 violations under 38 distinct standards. 7 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. 18 of these 20 are still on the state's site; the other 2 have since dropped off it and are reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type

Assisted Living Facility

License type

One Year

License expires

06/30/2026

Administrator

Kate Lenz

Licensing inspector

Alyshia Walker

Inspector phone

(757) 670-0504

Approved for

Assisted Living · Non-Ambulatory · Special Care Unit

Inspection History

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

June 12, 2026Inspection8 violations

Inspection dates

06/12/2026

Areas reviewed

None22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE 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: 6/12/2026 8:30 am- 5:45 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: 57 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: 24 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 6 Observations by licensing inspector: The Licensing Inspector observed a meal, snack, activities, are medication observations, are some of the areas observed/inspected. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of these inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov

Violations

22VAC40-73-450-F

Based on a review of the resident records, the facility failed to ensure that a resident’s Individualized Service Plan (ISP) be reviewed and updated every 12 months and/or as needed for a significant change in the resident’s condition. The review and update shall be performed by a staff person with the qualifications specified in subsection B of this section and in conjunction with the resident and, as appropriate, with the resident’s family, legal representative, direct care staff, case manager, health care providers, qualified mental health professionals, or other persons.

Evidence

The ISPs for Residents #2, #3, and #4 do not document the date the residents’ needs were identified or the expected outcome dates of the needs.
Resident #2’s ISP (dated 8/12/2025) indicates staff is to provide supervision with transfers, the resident’s UAI (dated 7/28/2025 and 5/6/2026) indicates the resident requires mechanical and physical assistance.
Resident #2’s ISP (dated 8/12/2025) does not indicate the resident is incontinent of bowel, the resident’s UAI (dated 7/28/2025 and 5/6/2026) indicates the resident is incontinent of bowel weekly or more.
Resident #3’s ISP (dated 5/22/2026) indicates the resident is independent in the area of bathing, dressing, toileting, transferring and walking is not documented. The UAI (dated 4/10/2026) indicates the resident requires supervision with bathing, and mechanical help with dressing, toileting, transferring and walking.
The Licensing Inspector obtained copies of all ISPs during the inspection.

Plan of correction

1. Immediate Corrective Actions Taken The ISPs for Residents #2, #3, and #4 were reviewed and updated to ensure service needs, dates identified, expected outcomes, and care needs accurately reflect current assessments and UAIs. 2. Systemic Changes to Prevent Recurrence A new Virginia ISP process has been implemented by the regional corporate team to improve accuracy, consistency, and compliance with ISP documentation requirements. 3. Staff Training and Development The HWD, RCC, and clinical team will receive training on the new Virginia ISP process and documentation requirements on 7/7/2026. 4. Monitoring of Plan of Correction Items Weekly audits of ISPs will be completed through August 31st, 2026. 5. Responsible Parties who will monitor Plan of Correction Items Executive Director Health & Wellness Director

22VAC40-73-250-D

The facility did not ensure that each staff person submits documentation, on or within seven days prior to the first day of work at the facility, the results of a risk assessment documenting the absence of tuberculosis in a communicable form. The documentation must be on the current screening form published by the Virginia Department of Health or a form consistent with it.

Evidence

The TB assessments for staff #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #36, #27, #28, #29, and #30 were not completed by the assessor whose signature appeared on the assessment form.
TB assessments for staff #12, # 20, 21, #22, #23, #7, #25, #26, #27, #28, #29, and #30 were not completed as indicated on the forms (signatures, dates, credentials in appropriate areas).
Staff #2 and Staff #3 acknowledged the individuals whose signatures were on the TB assessment forms did not complete the assessments for the staff members.
The Licensing Inspector obtained photographic evidence of the TB assessment forms during the inspection.

Plan of correction

1. Immediate Corrective Actions Taken Staff records were reviewed and TB screening documentation deficiencies were identified and addressed. Incomplete or improperly completed TB assessments were corrected to ensure compliance. 2. Systemic Changes to Prevent Recurrence A standardized onboarding review process was implemented to ensure all TB screening documentation is completed accurately and included in employee files prior to the first day of work. Moving forward, the Health & Wellness Director, who is an LPN, will complete TB assessments for all new hires. 3. Staff Training and Development The Business Office Director, Health & Wellness Director, and department managers were re-educated on TB screening requirements and documentation standards for new hires. 4. Monitoring of Plan of Correction Items New hire files will be audited weekly for TB screening compliance through July 31st, 2026. 5. Responsible Parties who will monitor Plan of Correction Items Executive Director Business Office Director Health & Wellness Director

22VAC40-73-680-I

Based on record review and review of the Medication Administration Record (MAR), the facility failed to have all items required by the Standards on the MAR specifically the diagnosis, condition, or specific indications for administering the medication or supplement and the effectiveness of the as needed (PRN) medications and the effectiveness of PRN medications.

Evidence

The June 2026 MAR did not document a diagnosis, condition, or specific indications for administering the following medications: Resident #8: acetaminophen 500 mg, Ensure Plus Vanilla, Glycopyrrol 1 mg, risperidone 0350mg; Resident #7: Acetaminophen 325 mg, buspirone 5 mg, vitamin c 250 mg; Resident #1: Buspirone 10 mg, gabapentin 300 mg, and levothyroxine 50 mcg;
There was no documentation on the effectiveness of as needed medication for: Resident #1 (tramadol 50 mg on 6/7/2026)
The Licensing Inspector obtained copies of the residents MARs during the inspection.

Plan of correction

1. Immediate Corrective Actions Taken MARs for Residents #1, #7, and #8 were reviewed and updated to include the required diagnosis, condition, or indication for all identified medications. PRN documentation requirements were reviewed with clinical staff. 2. Systemic Changes to Prevent Recurrence Each prescriber’s order will be reviewed for diagnosis before transmitting it to the pharmacy. If there is not a diagnosis noted on the order, the LPN or Med Tech will contact the prescriber for the diagnosis. At the end of each shift the off going Nurse or Med Tech will review the PRN medications administered for that shift and obtain the outcome if it is within the 1- hour time frame to note the effectiveness of the PRN administered. 3. Staff Training and Development Licensed nurses, medication aides, RCC, and HWD were re-educated on requirements of the diagnosis on all prescriber’s orders and trained to review the documented effectiveness of PRN medications at the end of each shift. 4. Monitoring of Plan of Correction Items Weekly MAR and PRN documentation audits will be completed through July 31st, 2026. 5. Responsible Parties who will monitor Plan of Correction Items Executive Director Health & Wellness Director

22VAC40-73-440-A

Based on record reviews, it was determined that the facility did not ensure that all residents are assessed, face to face, using the Uniform Assessment Instrument (UAI), prior to admission.

Evidence

The record for Resident #4 did not contain a UAI.
Staff #2 acknowledged there was no UAI in the file for the Licensing Inspector to review at the time of the inspection.

Plan of correction

1. Immediate Corrective Actions Taken Resident #4 was a short-term respite stay and is not a current resident. 2. Systemic Changes to Prevent Recurrence All residents will have a completed UAI prior to admission. The move-in checklist will be utilized to ensure compliance with the standard. 3. Staff Training and Development The HWD, RCC, and admissions team were re-educated on admission requirements, including completion and filing of the UAI prior to admission. 4. Monitoring of Plan of Correction Items All new admissions will be audited weekly for UAI compliance through July 31st, 2026. Audit to be completed on all residents to ensure UAI was completed prior to admission. 5. Responsible Parties who will monitor Plan of Correction Items Executive Director Health & Wellness Director

22VAC40-73-320-A

Based on a review of resident records the facility failed to ensure that within the 30 days preceding admission, a person shall have a physical examination by an independent physician. The report of such examination shall be on file at the assisted living facility and shall contain the following: 1. The person's name, address, and telephone number; 2. The date of the physical examination; 3. Height, weight, and blood pressure; 4. Significant medical history; 5. General physical condition, including a systems review as is medically indicated; 6. Any diagnosis or significant problems; 7. Any known allergies and description of the person's reactions; 8. Any recommendations for care including medication, diet, and therapy; 9. Results of a risk assessment documenting the absence 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; 10. A statement that the individual does not have any of the conditions or care needs prohibited by 22VAC40-73-310 H; 11. A statement that specifies whether the individual is considered to be ambulatory or non-ambulatory as defined in this chapter; 12. A statement that specifies whether the individual is or is not capable of self- administering medication; and 13. The signature of the examining physician or his designee. Evidence:
The record for Resident # 2 (admit date: 8/6/2025) contained a physical dated 8/1/2025, that did not indicate if the resident is capable of managing their own medication and the significant medical history portion of the form was blank.
The physical for Resident #4 did not indicate if the resident is capable of managing their own medication.
Photographic evidence of the physicals was obtained during the inspection.

Plan of correction

1. Immediate Corrective Actions Taken The physicals for Residents #2 and #4 were reviewed, and missing documentation regarding medication self-administration and medical history was addressed. 2. Systemic Changes to Prevent Recurrence A review process was implemented to ensure all required sections are completed on H&Ps prior to admission and verified for compliance. 3. Staff Training and Development The HWD, RCC, and admissions team were re-educated on physical examination requirements and documentation standards for admission. 4. Monitoring of Plan of Correction Items All new admission physicals will be audited weekly through July 31st, 2026. 5. Responsible Parties who will monitor Plan of Correction Items Executive Director Health & Wellness Director

22VAC40-73-1090-A

Based on a review of resident records the facility failed to ensure that prior to his/her admission to a safe, secure environment, the resident shall have been assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare. The physician shall be board certified or board eligible in a specialty or subspecialty relevant to the diagnosis and treatment of serious cognitive impairments (e.g., family practice, geriatrics, internal medicine, neurology, neurosurgery, or psychiatry). The assessment shall be in writing and shall include the following areas: 1. Cognitive functions (e.g., orientation, comprehension, problem-solving, attention and concentration, memory, intelligence, abstract reasoning, judgment, and insight); 2. Thought and perception (e.g., process and content); 3. Mood/affect; 4. Behavior/psychomotor; 5. Speech/language; and 6. Appearance.

Evidence

The Assessment of Serious Cognitive Impairment for Resident #1 did not include assessment documentation of the resident’s speech and language. This section on the assessment form is blank.
Photographic evidence of the assessment form obtained during the inspection.

Plan of correction

1. Immediate Corrective Actions Taken Resident #1’s assessment of serious cognitive impairment was reviewed, and the missing speech and language documentation was addressed. 2. Systemic Changes to Prevent Recurrence A review process was implemented to ensure all required sections of cognitive impairment assessments are completed prior to admission to a safe, secure environment. Audit to be conducted on all assessments of serious cognitive impairment for current residents in special care unit to ensure all required sections are completed. 3. Staff Training and Development The HWD, RCC, MCD and SMD were re-educated on documentation requirements for assessments of serious cognitive impairment, including completion of all required sections. 4. Monitoring of Plan of Correction Items Weekly audits of cognitive impairment assessments will be completed through July 31st, 2026. 5. Responsible Parties who will monitor Plan of Correction Items Executive Director, Memory Care Director, Health & Wellness Director

22VAC40-73-260-A

Based on a review of staff records, the facility did not ensure that each direct care staff who did not have a current certification in first aid received within 60 days of employment.

Evidence

The record for Staff #6 (hire date 12/10/2025) did not contain a current first aid certification.
Staff # 3 acknowledged there was no first aid certification documentation for the Licensing Inspector to review.

Plan of correction

1. Immediate Corrective Actions Taken Staff #6 to be scheduled for first aid certification class. 2. Systemic Changes to Prevent Recurrence A tracking process was implemented to monitor required certifications and ensure all direct care staff complete first aid certification within required timeframes. The Health & Wellness Director has obtained BLS Instructor Certification to support ongoing compliance. 3. Staff Training and Development First aid training will be conducted every other month to ensure all direct care staff complete certification within 60 days of hire. Department managers and leadership were re-educated on certification requirements. 4. Monitoring of Plan of Correction Items Staff records will be audited weekly for certification compliance through August 31st, 2026. 5. Responsible Parties who will monitor Plan of Correction Items Executive Director Health & Wellness Director Business Office Director

22VAC40-73-680-D

Based on a review of facility records, the facility failed to ensure medications shall be administered in accordance with the physician’s or other pre-scriber’s instructions.

Evidence

The June 2026 MAR for Resident #8 did not document the resident received the prescribed Risperidone 0.5 mg on 6/1/2026 and the prescribed acetaminophen 500 mg, Ensure plus vanilla, glycopyrrol 1 mg, and preservision areds 2 capsule on 6/2/2026.
The Licensing Inspector obtained a copy of the MAR during the inspection.

Plan of correction

1. Immediate Corrective Actions Taken Resident #8’s MAR was reviewed to ensure all physician orders were accurately transcribed and administered as ordered. Documentation discrepancies were reviewed with clinical staff and Nurse Practitioner. 2. Systemic Changes to Prevent Recurrence The Nurse or Med Tech will review the Pass Med Report at the end of shift to ensure medications are administered and documented in accordance with physician orders. 3. Staff Training and Development Nurses and Med Techs were educated on the Pass Med Report to review at the end of each shift to ensure medications are administered and documented. 4. Monitoring of Plan of Correction Items Weekly Pass Med Report audits will be completed through July 31st, 2026. 5. Responsible Parties who will monitor Plan of Correction Items Executive Director Health & Wellness Director

August 21, 2025Inspection0 violations

Inspection dates

08/21/2025

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Technical assistance

22VAC40-73-520- activity calendar and activities 22VAC40-73-610-menu

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: 8/21/2025 10:30 am- 12:30 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: 4 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. 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.

August 21, 2025Inspection0 violations

Inspection dates

08/21/2025

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: 8/21/2025 12:30 pm- 2:18 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 8/1/2025 regarding allegations in the area(s) of: Resident Care and Related Service 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 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact 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.

August 21, 2025Inspection0 violations

Inspection dates

08/21/2025

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

August 21, 2025Inspection0 violations

Inspection dates

08/21/2025

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: 8/21/2025 12:30 pm- 2:18 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 6/10/2025 regarding allegations in the area(s) of: Resident Care and Related Service 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 self-report of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact 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.

June 16, 2025Inspection2 violations

Inspection dates

06/16/2025

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: 6/16/2025 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incidents were received by VDSS Division of Licensing on (date) 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: 61 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 5 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. 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 staff interviews and documentation review, the facility failed to provide supervision of resident schedules, care, and activities including attention to the specialized need of wandering from the premises for one resident in care.

Evidence

The facility provided an Incident Report on 1/8/2025, acknowledging that Resident #1 who resides in the second floor safe, secure, unit, was able to exit the unit, into the stairwell, and go down to the first floor. The Resident’s observation notes stated the staff was alerted by the fire alarm in the hall 1 stair well where the resident was found. Staff members on the first floor discovered the resident and assisted her back to the safe, secure unit.
The facility provided an Incident Record on 1/13/2025, acknowledging that Resident #2 who resides in the safe, secure, unit was able to exit the unit and was found in the elevator.
The facility provided an Incident Report on 5/16/2025, acknowledging that Resident # 4 was able to exit the safe, secure unit. The resident’s observation notes stated the resident was located near the elevators.
The facility provided an Incident Report on 5/22/2025, acknowledging that Resident # 5 was able to exit the safe, secure unit. The resident’s observation notes stated the resident was able to exit from the memory care kitchen location. The resident’s ISP identified wandering as a behavior pattern effective 2/13/2024, and staff is to redirect her to her room, an activity, or to her memory box during periods of disorientation.
The facility provided an Incident Report on 5/30/2025, acknowledging that Resident # 3 was able to exit the safe, secure, unit.

Plan of correction

Not published by VDSS.

22VAC40-73-440-A

Based on a review of resident records, the facility failed to ensure Uniform Assessment Instruments (UAIs) were reviewed/completed whenever there is a change in condition.

Evidence

The observation notes for Resident #1 document instances of wandering. The resident’s most recent UAI dated 7/1/2024, has not been updated to reflect the changes.
The observation notes for Resident #3 document instances of wandering and disorientation. The resident’s most recent UAI dated 11/21/2024, has not been updated to reflect the changes.

Plan of correction

Not published by VDSS.

June 12, 2025Inspection5 violations

Inspection dates

06/12/2025,06/16/2025

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: 6/12/2025 9:00 am- 1:36 pm, 6/16/2025 9:25 am- 12:42 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: 61 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Number of staff records reviewed: 4 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia Walker@dss.virginia.gov

Violations

22VAC40-73-680-D

Based on a review of facility records, the facility failed to ensure medications shall be administered in accordance with the physician’s or other prescriber’s instructions.

Evidence

Resident #1 was prescribed Omeprazole 40 mg to be administered 30 minutes before other medication or food.
Staff # 2 administered Omeprazole with along with Amlodipine 5mg, Ferrous Sulfate 325 mg, Metoprol Tar 50 mg, Primidone 50 mg, Sertraline 50 mg, Vitamin D3 50 mcg, and Xarelto 15 mg. All of these medications were administered after the resident ate breakfast.
Staff # 2 acknowledged the medication was not administered as prescribed.

Plan of correction

Not published by VDSS.

22VAC40-73-680-I

Based on resident record review and review of the Medication Administration Record (MAR), the facility failed to have all items required by standards on the MAR.

Evidence

Resident # 2 was prescribed Lorazepam 0.5 mg. There was no diagnosis, indication or specific indication for administering the drug or supplement on the June 2025 MAR for the medication.
Resident # 3 was prescribed Stool Softnr 8.6-50 mg, Tramadol HCL 50 mg. There was no diagnosis, indication or specific indication for administering the drug or supplement on the June 2025 MAR for the medications.
Resident # 7 was prescribed Acetaminophe 325 mg. There was no diagnosis, indication or specific indication for administering the drug or supplement on the June 2025 MAR for the medication.

Plan of correction

Not published by VDSS.

22VAC40-73-450-C

Based on record review, the facility failed to ensure the comprehensive individualized service plan (ISP) shall include identified needs and date identified.

Evidence

The ISP for Resident # 4 did not list the dates the needs were identified.

Plan of correction

Not published by VDSS.

22VAC40-73-450-F

Based on a review of resident records the facility failed to ensure that each resident’s individualized service plan (ISP) were reviewed to include significant changes in the resident’s condition.

Evidence

Resident # 4’s ISP dated 4/27/25 did not list the mechanical assistance the resident requires for bathing, dressing and toileting per the resident’s UAI dated 3/31/25.
Resident # 5 has a private sitter. Sitter services are not outlined on the resident’s ISP.

Plan of correction

Not published by VDSS.

22VAC40-73-450-E

Based on review of resident records 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 ISP (dated 4/27/25) for Resident # 3 did not contain a resident or POA signature.
The ISP (dated 3/23/25) for Resident # 6 did not contain a resident or POA signature.

Plan of correction

Not published by VDSS.

February 25, 2025Complaint survey4 violations

Inspection dates

02/25/2025

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: 2/25/2025 10:00 am- 3:05 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 2/18/2025 regarding allegations in the area(s) of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 61 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 1 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 Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov

Violations

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 #1’s medication administration record document the resident was prescribed Bupropion XL 150 mg for depression, Buspirone 5 mg for anxiety, and Quetiapine 50 mg for anxiety. There were no psychotropic treatment plans in the resident’s file for those medications.

Plan of correction

Not published by VDSS.

22VAC40-73-110-1

Based on records reviewed and documentation submitted by the facility, the facility failed to ensure staff was considerate and respectful of the rights, dignity, and sensitives of person who are aged, infirmed, or disabled.

Evidence

The Division received a report that a former employee witnessed Staff #3 flicking Resident #1 on the nose. Resident #1 resides in the memory care unit. The former employee notified the facility of the incident.
The facility suspended Staff #2 and conducted an internal investigation. Based upon the facility conducted investigation, interviews and statements obtained, Staff #2 was terminated.

Plan of correction

Not published by VDSS.

22VAC40-73-640-A

Based on record review, the facility failed to implement its written plan for medication management, specifically regarding its methods to ensure accurate counts of all controlled substances whenever assigned medication staff changes.

Evidence

A review of the Narcotic Shift Count Sheet for months of January 2025 through February 2025 documented staff failed to ensure counts of all controlled substances occurred between oncoming staff and off going staff.

Plan of correction

Not published by VDSS.

22VAC40-73-325-B

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

Evidence

Resident #1 had documented falls on 2/5/2025, 1/15/2025, 9/7/2024, 9/5/2024 and 8/31/2024. There were no corresponding fall risk assessments in the resident file for the listed falls.

Plan of correction

Not published by VDSS.

February 25, 2025Complaint survey0 violations

Inspection dates

02/25/2025

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: 2/25/2025 10:00 am- 3:05 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 1/27/2025 regarding allegations in the area(s) of: Resident Accommodations and Related Provisions Number of residents present at the facility at the beginning of the inspection: 61 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the (allegation(s)/self-report) of non-compliance with standard(s) or law. However, violation(s) not related to the (complaint(s)/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

✅

No violations cited

The inspector documented no violation of standards at this inspection.

February 25, 2025Complaint survey2 violations

Inspection dates

02/25/2025

Areas reviewed

22VAC40-73 BUILDINGS AND GROUND22VAC40-80 COMPLAINT INVESTIGATION

Comments

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 2/25/2025 10:00am- 3:05 pm A complaint was received by VDSS Division of Licensing on 1/15/2025 regarding allegations in the area(s) of: Buildings and Grounds Number of residents present at the facility at the beginning of the inspection: 61 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed:0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 4 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

22VAC40-73-930-D

Based on a review of resident records, the facility failed to ensure for each resident with an inability to use the signaling device, the facility documented the rounds were made, including the time of the rounds and the staff member who made the rounds.

Evidence

Staff # 4 stated the residents on the memory care unit were not able to use the call bell due to their cognitive decline. The Licensing Inspector asked if the staff conducted rounds. Staff #4 stated yes rounds were being conducted. The Licensing Inspector asked if the rounds were being documented and Staff #4 stated no, rounds were not documented.

Plan of correction

Not published by VDSS.

22VAC40-73-870-A

Based on staff interviewed, the facility failed to ensure the interior of the building was maintained in good repair.

Evidence

During the on-site inspection with Staff # 2 the Licensing Inspector (LI) conducted a test of the facility’s call bell system on random rooms on the memory care and assistant living areas of the facility. While on the memory care unit, LI activated the call bell at 11:24 am in the bathroom of room #217. The call bell lit up. The LI waited until 11:30 am and there was no staff response. The LI then activated the call bell in the bathroom of room 209. The light on the call bell did not light up. The LI inquired if the boxes were supposed to light up. Staff #4 stated she did not know. The LI inquired as to where the audible alert sounds, that alerts the staff that the call bell has been activated. Staff # 4 stated the call bell alert is located downstairs at the nurse’s station which is staffed 24 hours a day. The staff at the nurse’s station then radios the staff in the memory care unit that the call bell has been activated. The LI attempted to activate the call bell in the bathroom of room # 206. The call bell in the resident’s bathroom did not light up. At no point did a staff member respond to any of the call bells. The LI went downstairs and was joined by the Staff # 3. The LI asked to see view the nurse’s station where the call bell system was located. The nurse’s station was vacant. The LI asked Staff # 3 how the staff members in the Memory Care Unit were alerted when a resident on the memory care unit pulled the call bell. Staff # 3 stated none of the residents in the memory care unit were able to use the system, so the system was deactivated. The LI informed Staff # 3 that one of the call boxes in the memory care unit lit up. Staff # 3 did not have an explanation and again stated to their knowledge the system was deactivated in the memory care unit. LI asked if staff on the memory care unit were documenting their rounds and was told the staff were not. The LI inspected the call bell in resident room #133 in the assistant living area of the building with the Staff #3. The LI pulled the call bell in the bathroom and the call bell light did not light up. The LI then pulled the call bell by the resident’s bed. The call bell box did not light up. The LI requested to go back to the nurse’s station to review the computer system which logs when the call system was activated. Out of the 4 call bells pulled by the LI only 1 call bell registered as being activated, which was room #214 (bathroom).

Plan of correction

Not published by VDSS.

February 25, 2025Complaint survey1 violation

Inspection dates

02/25/2025

Areas reviewed

22VAC40-73 STAFFING AND SUPERVISION22VAC40-80 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: 2/25/2025 10:00 am- 3:05 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Complaints were received by VDSS Division of Licensing on 12/27/2024 and 2/18/2025 regarding allegations in the area(s) of: Staffing Number of residents present at the facility at the beginning of the inspection: 61 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the (allegation(s)/self-report) of non-compliance with standard(s) or law. However, violation(s) not related to the (complaint(s)/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

22VAC40-73-290-A

Based on the review of facility records the facility failed to maintain a current work schedule that includes documentation of any absences, substitutions, or other changes to the posted schedule.

Evidence

The staff schedule provided by Staff #2 on the day of the inspection for the time of 11/3/2024-3/8/2025 did not reflect the absences, substitutions, or assigned locations of the staff members who worked.

Plan of correction

Not published by VDSS.

February 25, 2025Complaint survey2 violations

Inspection dates

02/25/2025

Areas reviewed

22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 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: 2/25/2025 10:00 am- 3:05 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 12/27/2024 regarding allegations in the area(s) of: Resident Accommodations and Related Provisions Number of residents present at the facility at the beginning of the inspection: 61 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the (allegation(s)/self-report) of non-compliance with standard(s) or law. However, violation(s) not related to the (complaint(s)/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-F

Based on record review and interview with staff, the facility failed to ensure individualized service plans (ISPs) were reviewed and updated at least once every 12 months and as needed.

Evidence

The Licensing Inspector requested the current ISP for Resident # 1. The most current ISP provided for Resident #1 was documented as having a review date of 12/5/2023, and a next review date of 11/8/2024. There was no 11/8/2024 ISP provided to the Licensing Inspector.
The Licensing Inspector requested the current ISP for Resident #2. The most current ISP provided for Resident was documented as having a need date identified as 12/4/2022 and the review date as 12/3/2023. There was no 12/3/2023 ISP provided to the Licensing Inspector.

Plan of correction

Not published by VDSS.

22VAC40-73-450-E

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 with a review date of 12/5/2023, did not contain a signature of the resident/authorized representative or the individual who developed the plan.
The ISP for Resident #2 with a review date of 12/3/2023, did not contain a signature of the resident/authorized representative or the individual who developed the plan.

Plan of correction

Not published by VDSS.

May 16, 2024Inspection1 violation

Inspection dates

05/16/2024

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

Type of inspection: Other- Self-Report Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 5/16/2024 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 4/22/2024 regarding allegations in the area(s) of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 66 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. 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

Evidence

The facility provided an Incident Report on 4/22/2024 acknowledging that Resident #1 who resident in the safe, secure, unit, was able to leave the unit by exiting behind a dietary staff member. A team member on break saw the resident and escorted her back into the building.

Plan of correction

HWD and/or MCD and/or Designee will hold mandatory staff training on missing resident procedures. Beginning 5.23.2024, the HWD and/or MCD 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, beginning 5.23.2024, HWD and/or MCD and/or Designee will hold elopement drills quarterly. HWD 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 HWD 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 ED and discussed at quarterly Quality Assurance meeting.

May 14, 2024Inspection12 violations

Inspection dates

05/14/2024

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: 5/14/2024 and 5/16/2024 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 66 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 5 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 4 Observations by licensing inspector: The Licensing Inspector observed medication passes, inspected resident rooms, pulled call bell, and took water temperatures. 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. T he 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

22VAC40-73-310-D

Based on record review 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 or a legal representative and kept in the resident’s record.

Evidence

Resident #4 was admitted on 4/23/2024, the resident’s file did not contain documentation of written assurance being provided to the resident or responsible party.

Plan of correction

The Business Office Manager (BOM) and/or Designee will audit each resident’s file to ensure that the Written Assurance was obtained prior to Admission. Going forward the BOM (Business Office Manager) and/or Designee will audit the incoming admission paperwork, using the admission checklist, to ensure this document is included on every new Admission. Any missing paperwork will be reported to the ED and reviewed quarterly at our QA meeting.

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 dated 12/5/2023.
Staff #1 acknowledged the facility’s health inspection was not current.

Plan of correction

Submitted to licensing inspector email from February 2024 where administrator requested Food Establishment License and Full Inspection Report from Inspection completed on 12/5/24. VDH sent community email stating that they were in good standing but due to staffing challenges, there was a delay in sending full report and sending license.

22VAC40-73-210-B

Based on the on-site record review and staff interview 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. (Exception: Direct care staff who are licensed health care professions or certified nurse aides shall attend at least 12 hours of annual training).

Evidence

The record for Staff #4, a certified nurse aide, did not include documentation of 12 hours of annual training.
The record for Staff #2, a certified nurse aide did not include documentation of 12 hours of annual training.

Plan of correction

The BOM (Business Office Manager) and/or Designee will review each staff member’s training file to ensure that their monthly Relias training courses are up to date. Going forward, the BOM (Business Office Manager) and/or Designee will audit at least 10% of the staff’s training records monthly to ensure that the required 12 hours of annual training are completed for each staff member. Any incomplete training courses will be reported to the Executive Director (ED) and reviewed quarterly during our QA meeting.

22VAC40-73-410-A

Based on record reviewed and staff interviewed, the facility failed to ensure the record included an acknowledgement of the resident having received an orientation and the acknowledgment signed and dated by the resident, and as appropriate legal representative and kept in the resident’s record.

Evidence

Resident #10’s record did not include documentation of an orientation for new residents which included information regarding mealtimes, the use of the call system, and the emergency response procedures.

Plan of correction

The Business Office Manager (BOM ) and/or Designee will audit each current resident’s chart to ensure that the orientation checklist is in place. Going forward, the BOM and/or Designee will ensure, using the new admission checklist, that each new Resident and/or Legal Representative has completed an Orientation to the community, and it is documented in the Resident Chart within the Business Office. The BOM and/or Designee will audit 10% of resident charts monthly to ensure that all orientation checklists are in place. Any missing paperwork will be reported to the ED and reviewed quarterly at our QA meeting.

22VAC40-73-450-E

Based on resident record review and interview with staff, 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

Resident #5 has an ISP dated 8/25/2023. There were no signatures on the ISP of the licensee, administrator, or designee and the resident or his legal representative.
Resident #6 has an ISP not dated 8/15/2023 and the ISP did not include a signature of the resident or his legal representative.

Plan of correction

The HWD and/or Designee has Audited all existing Resident Healthcare records to ensure that all Individualized Service Plans have appropriate signatures from the resident or his/her legal representative. Going forward the HWD and/or Designee will audit 10% of the residents’ ISPs monthly to ensure that all ISPs have appropriate dates and/or signatures. The HWD and/or Designee will coordinate in the weekly Wednesday Care Plan meeting which residents are due for their next assessment and ensure it is completed in a timely manner and has appropriate signatures and dates. Any ISPs without proper signatures and/or dates will be reported to the ED and reviewed quarterly at our QA meeting.

22VAC40-73-640-B

Evidence

A review of the Narcotic Inventory Count Verification forms for Hall 1 and Hall 4 documented staff failed to ensure counts of all controlled substances occurred between oncoming staff and off going staff.
Staff members #2 and #5 acknowledged the forms did not document narcotic medication counts were conducted during the change of each shift.

Plan of correction

The HWD and/or Designee will provide an in-service training to all medication aides on the narcotic policy by 7/31/24. The HWD (Health and Wellness Director) and/or Designee ensure that narcotic medication counts are conducted at the change of each shift and are to be monitored weekly by the HWD and/or Designee going forward. The narcotic inventory count verification forms will be signed by each off going and oncoming staff member for all controlled substances. Any missing signatures will be reported to the ED and reviewed quarterly at our QA meeting.

22VAC40-73-640-D

Based on observation and staff interviewed, the facility failed to ensure the pharmacy reference book, drug guide, or medication handbook was no more than two years old as reference for staff who administer medications.

Evidence

The pharmacy drug guide on-site on 5/14/2024 was dated 2019.
Staff #2 acknowledged the pharmacy reference book was not dated within the past two years.

Plan of correction

The HWD and/or Designee has Audited all medication carts to ensure that all pharmacy reference books are current or within the past two years. Going forward the HWD and/or RCC (Resident Care Coordinator) and/or Designee will complete medication cart audit form for each med cart weekly to include ensuring the most up-to-date pharmacy reference books are current and inside the med cart. Any missing items will be reported to the ED and reviewed quarterly at our QA meeting.

22VAC40-73-680-D

Based on observations made during the review of the resident record, the facility failed to administer medications in accordance with the physician’s or other prescriber’s instructions.

Evidence

Resident #5 was prescribed Omeprazole 20mg tablet for Gerd to be administered daily before breakfast. During the medication observation pass on 5/14/2024 at 9:05 am, the resident was administered the medication. The resident was returning from eating breakfast.

Plan of correction

The HWD and/or Designee will provide an in-service training for all medication aides on the medication administration policy by 07/31/24. The HWD and/or Designee will conduct a competency test for all medication aides upon hire and any time a medication error has been identified. The HWD (Health and Wellness Director) and/or Designee will review medication pass report and med exception report to ensure all medications are administered per physicians' orders. Any errors will be reported to the ED and reviewed at our quarterly QA meeting.

22VAC40-73-260-A

Based on a review of staff records the facility failed to ensure that each direct care staff member maintained current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department.

Evidence

The employee file for Staff #5 contained a CPR certification card from National CPRFoundation which is not an approved provider as listed in 22VAC40-73-260-A.

Plan of correction

The BOM (Business Office Manager) and/or Designee did initial audit on all team member files to ensure that their CPR Certification is up to date and from an approved provider. Going forward, the BOM (Business Office Manager) and/or Designee will use a tickler system that notifies the community when a staff member’s license is nearing expiration. The Business Office Manager (BOM) and/or Designee will coordinate to have the American Heart Association CPR/First Aid trainings on a monthly basis to ensure that each staff member obtains the required CPR/First Aid Certifications. Any expired certifications will be reported to the ED and reviewed quarterly during our QA meeting.

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 disclosed information about the facility. Written acknowledgement of this form shall be retained in the resident’s record.

Evidence

The resident record for Resident #4 did not have documentation a disclosure statement had been provided to the resident before admission.

Plan of correction

The BOM (Business Office Manager) and/or Designee will audit all current Resident’s Files to ensure that the Disclosure statement was obtained prior to Admission. Going forward the BOM (Business Office Manager) and/or Designee will audit the incoming admission paperwork, using the move-in checklist, to ensure this disclosure statement is included on every new Admission. Any missing items from the move in checklist will be reported to the Executive Director (ED) and reviewed quarterly at our Quality Assurance (QA) meeting.

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 #5 did not contain an annually completed TB risk assessment as the assessment form provided at the time of inspection was dated 7/5/2022.

Plan of correction

The BOM (Business Office Manager) and/or Designee will audit each staff member’s file to ensure that their TB risk assessment form is in file, completed, and not expired. Going forward the BOM (Business Office Manager) and/or Designee will audit at least 10% of the Team Member files monthly to ensure that no staff member’s TB risk assessment form is out of compliance. Any missing TB paperwork will be reported to the ED and reviewed quarterly during our QA meeting.

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 5/14/2024 during the inspection of the First-Aid kit for the building, the Triple Antibiotic Ointment had an expiration date of 5/2021 and the hand sanitizer had an expiration date of 9/2023.

Plan of correction

The HWD and/or Designee has replaced all first aid kits in the community and on the community bus. All required items inside the first aid kit have been replaced. HWD or Designee will be reviewed monthly utilizing checklist to ensure there are no contents that are missing or expired. The ED will be notified of any expired or missing items and review quarterly at QA meeting.

May 12, 2023Inspection11 violations

Inspection dates

05/12/2023, 06/29/2023

Areas reviewed

Technical assistance

CPR and First-aid certification must be through approved trainers

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: 5/12/2023 from 8:42 am- 1:10 pm and 6/29/2023 from 10:48 am -5:47 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 48 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 11 Number of staff records reviewed: 3 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 4 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alyshia E. Walker, Licensing Inspector at 757- 670-0504 or by email at Alyshia.Walker@dss.virginia.gov

Violations

22VAC40-73-325-B

Based on records reviewed and staff interviewed, the facility failed to ensure that a fall risk assessment was reviewed and updated after every fall.

Evidence

Resident # 4’s record included documentation of falls on 5/12/23 and 3/22/23. The resident record provided to the licensing inspector at the time of inspection did not contain fall assessments for those falls.
Resident # 5’s record included documentation of falls on 2/4/23, 4/8/23, 4/15/23, and 4/25/23. The resident record provided to the licensing inspector at the time of inspection did not contain fall assessments for those falls.
Staff members #2 acknowledged the record did not contain fall risk assessments for the above dates.

Plan of correction

Not published by VDSS.

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 had an admission date of 7/23/22 and the resident’s record did not contain a Sex Offender Screening.
Resident # 5 had an admission date of 9/27/22 and the resident’s record did not contain a Sex Offender Screening.
Staff members #1 and #2 acknowledged the file did not contain the screening.

Plan of correction

Not published by VDSS.

22VAC40-73-680-I

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

Evidence

The April 2023 MAR for Resident #1 did not contain the initials of the staff member who administered the resident’s Doxycycline 100 mg on 4/14 9pm, 4/19 9pm, and 4/21 9 am and there was no information documented on the back of the MAR. The staff member’s initials were missing for Resident #1’s Caltrate 600 on 4/19 9pm, Donepezil HCL 5mg on 4/19 9pm, and Mirtazapine 15 mg 4/19 9 pm and there was no information documented on the back of the MAR. April MAR for Resident # 8 did not contain initials for the folling medications and doses: Omeprazole 20 mg 4/9/23 at 9am Quetiapine 50 mg at 9am Vitamin d3 2000u 9 am Diclofenac Sodium 1% 4/4/23 5pm Diclofenac Sodium 1% 4/5/23 5pm Diclofenac Sodium 1% 4/9/23 9am

Plan of correction

Not published by VDSS.

22VAC40-73-550-G

Based on record review, the facility failed to ensure that the annual review of resident rights and responsibilities is filed in the resident’s record.

Evidence

The record for Staff #4 did not contain a recent resident rights review which was reviewed and signed in the past year. The Resident Rights document in the staff file did not contain a date.

Plan of correction

Not published by VDSS.

22VAC40-73-650-C

There were following verbal order were obtained for resident #6 and there were no physician’s signature on the orders.

Evidence

There was a verbal order obtained on 4/21/23 for Zofran 8 mg.
There was a Verbal order was obtained on 5/2/23 for Omeprazole 20 mg for GERD. There was no physician’s signature on the documented verbal order.
Verbal orders were obtained on 5/19/23 for Keflex 500mg there was no physician’s signature on the documented verbal order.

Plan of correction

Not published by VDSS.

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

Resident # 8’s record did not have documentation of a current ISP. The ISP in the record was signed 4/31022. The resident’s date of admit noted as 7/23/18.

Plan of correction

Not published by VDSS.

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 #1 did not contain a Virginia State Police Criminal history check. Staff #1’s date of hire was documented as 11/28/2022.

Plan of correction

Not published by VDSS.

22VAC40-73-490-D

Based on the review of resident records, the facility failed to have a list of specific residents for whom the health care oversight was provided.

Evidence

The last health care oversight was completed did not include a list of specific residents which the health care oversight was provided.

Plan of correction

Not published by VDSS.

22VAC40-73-390-B

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

Evidence: Resident #5 was admitted to the facility on 9/27/22 and there was no signed resident agreement in the file presented to the licensing inspection at the time of the inspection.

Plan of correction

Not published by VDSS.

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

The files for residents #4 and #5 record did not include documentation of an interview.

Plan of correction

Not published by VDSS.

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 #4 was admitted to the facility on 2/162023 and the resident record did not contain verification the resident received orientation.
Resident #6 was admitted to the facility on 10/24/2022 and the resident record did not contain verification the resident received orientation.
Staff #1 and #2 acknowledged the resident’s file did not contain documentation the resident received orientation upon admission.

Plan of correction

Not published by VDSS.

February 8, 2023Complaint survey0 violations

Inspection dates

02/08/2023

Areas reviewed

22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 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: 2/8/2023 12:43pm- 1:30pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 11/17/2023 regarding allegations in the area(s) of: Resident Care and Related Services Buildings and Grounds Number of residents present at the facility at the beginning of the inspection: 42 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: 3 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the 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 E. 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.

June 21, 2022Inspection7 violations

Inspection dates

06/21/2022

Areas reviewed

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

Comments

An unannounced renewal inspection was conducted on 06/21/2022 (11:30 am-3:30 pm) by two licensing representatives. At the time of the inspection there were 48 residents in care including 10 residents in memory care. Eight resident and four staff files were reviewed as well as other required documentation. All new personnel records since the last inspection wererequested for criminal history record reports compliance. See the violation notice for non-compliance. Lunch was observed, a musical in the garden activity was scheduled for later in the afternoon. Medication administration records were reviewed. Building and grounds were inspected. The Acknowledgement of Inspection form was signed and left at the facility with the Administrator on the date of the inspection. The evidence gathered during the renewal inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The applicant has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to maintain future compliance with applicable standard(s) or law. If the applicant 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. 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 a licensed facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Tamara Watkins, Licensing Inspector at (804) 662-7422 or by email at tamara.g.watkins@dss.virginia.gov

Violations

22VAC40-73-250-C

Based on a review of four staff files, two of four staff files did not contain verification of current professional license, certification, registration, or completion of a required approved training course.

Evidence

Staff # 2 is documented as Med Tech- MC with a hire date of 5/19/2006. Licensing staff requested from Staff #1 verification of registration as a medication aide for staff # 2. Verification was not given or found in the file provided for review.
Staff # 3 is documented as Caregiver-Assisted Living with a hire date of 6/19/2019. Licensing staff requested from Staff #1 verification of qualifications as a direct care staff person for staff # 3. Verification was not given or found in the file provided for review.

Plan of correction

1-Immediate correction made on the day of the inspection. 2- Business office manager and health and wellness director re- educated on the professional certification requirements, updates, and approved trainings. 3- The process will be reviewed by the executive director/designee monthly for 3 months with an audit of 3 staff members. 4- All findings will be communicated to the BOM, staff members and reported to the QA committee for continued improvement and analysis.

22VAC40-73-110-1

Based on a review of background checks for staff hired since 11/1/2021, the facility failed to ensure that Staff meet the requirements specified in the Regulation for Background Checks for Assisted Living Facilities and Adult Day Care Centers (22VAC40-90).

Evidence

Section 63.2-1720 of the Code of Virginia requires all employees of assisted living facilities and adult day care centers, as defined by § 63.2-100 of the Code of Virginia, to obtain a criminal history record report from the Department of State Police.
Regulation for Background Checks for Assisted Living Facilities and Adult Day Care Centers (22VAC40-90) defines a criminal history record report as “either the criminal record clearance or the criminal history record issued by the Central Criminal Records Exchange, Department of State Police.
Licensing staff requested from the facility administrator (staff # 1) background checks for all staff hired since 11/1/2021. Staff # 1 provided a list of 75 staff with names, job titles and hired dates along with background checks. A review of the list provided found that 17 staff were hired from 11/1/2021 to present. Of the background checks provided by only staff # 1, 3 of the 17 staff had background checks from the Virginia State Police.

Plan of correction

1- Corrections were made as of January 2022 per an internal audit. Due to the delays at the VA Police department, the facility was not able to start using the updated account prior to March 2022. 2- Background checks will be reviewed and maintained by business office manager. Records will be maintained in staff files. 3- Business office manager will be re-educated on the state regulations and hiring process 4- The process will be reviewed monthly by the Executive Director. All findings will be corrected and reported to the QA committee for continued improvement and analysis.

22VAC40-73-580-A

Based on information provided the facility failed to provide

Evidence

of an annual health inspection by the Virginia Department of Health. Evidence: Facility staff provided a Food Establishment Inspection Report for review dated 1/15/2020 and a Food Establishment permit with a listed expiration dated1/31/2022.

Plan of correction

1-Facility’s renewal application was up to date on the day of the inspection. Food Establishment Permits confirmed by the department of health; however, they were not able to complete the inspection. 2- Dietary Services Director and Business office manager educated on the requirements. 3- Application follow up by the dietary services director/business office manager/ designee and recorded. 4 An annual audit will be conducted by the executive director and communication records will be reported to the QA committee for continued improvement and analysis.

22VAC40-73-490-A-2

Based on a review of documentation requested and provided the facility failed to ensure that a health care oversight for assisted living residents was completed every three months.

Evidence

The health care oversight provided by Staff #1 was dated 7/31/2021 and offered as the last oversight conducted. Staff #1 stated that regional staff were coming on 6/23/2022 to conduct health care oversights.

Plan of correction

1-Health care oversight will be completed immediately. 2- Health and wellness director re- educated on the requirements for health care oversight by the Executive Director. 3- The process will be reviewed by the Executive Director /Designee every 3 months with an audit to ensure the biannual health care oversight is in progress or completed. 4- All findings will be corrected and reported to the QA committee for continued improvement and analysis.

22VAC40-73-260-C

Based on an inspection of the facility, the facility failed to have a listing of all staff who have current certification in first aid and/or CPR always posted and readily available to all staff.

Evidence

A posting of staff who have current certification in first aid and/or CPR was not found during an inspection of the building and grounds on 6/21/2022 by two licensing inspectors. Facility staff acknowledged that it was not posted but available in the office.

Plan of correction

1-Corrections made immediately on the day of the inspection per the CPR training that was completed on 6/16/2022. 2- Business office manager (BOM) and health and wellness director (HWD) will monitor CPR certification needs and update the CPR list monthly. 3- BOM/HWD re-educated on CPR certificate updates and state requirements. Process will be monitored by the Executive Director/designee every 3 months. 4-All findings will be corrected and reported to the QA committee for continued improvement and analysis.

22VAC40-73-40-A

Based on a review of the renewal application submitted and a State Corporation Commission business entity search, the facility failed to ensure compliance with relevant state laws.

Evidence

A renewal application was submitted on 6/21/2022 that listed the name of the LLC applying for the license as SNH/LTA Properties Trust.
A search of the Virginia State Corporation Commission found that this LLC Entity ID:C0000382 has an inactive/cancelled status in the State of Virginia since 12/31/2021. An active status is required to do business in the State of Virginia.

Plan of correction

1- Correction was done immediately and renewal application completed. 2- Renewal application will be followed annually. 3- Responsible party of SNH/LTA will be educated on VA state requirements. 4- Executive Director/designee will monitor renewal application annually.

22VAC40-73-970-A

Based on a review of documentation requested and provided the facility failed to ensure that fire drills were conducted on each shift in a quarter and not conducted in the same month.

Evidence

The fire drills provided and reviewed were dated: 3/30/22 (11:15p), 4/14/2022 (10:50a). There were no drills provided for 5/2022.

Plan of correction

1-Records reviewed, and missing reports updated. 2- Fire drills scheduled per the regulations. 3- Environmental Services Director educated on the fire drill requirements and record keeping. 4- Process will be monitored monthly audits by the Executive Director. All findings will be reported to the QA committee for continued improvement and analysis.

February 25, 2022Complaint survey0 violations

Inspection dates

02/25/2022

Areas reviewed

22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS

Comments

A Licensing Inspector with the Division of Licensing conducted an unannounced, non-mandated, complaint inspection on 02/25/2022. The complaint inspection was in reference to staffing and resident related care. During the inspection the Licensing Inspector observed the facility memory care unit, staff records and reviewed additional facility documentation for compliance. During the inspection there was not enough evidence to support the allegation and the complaint is found not valid. 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

✅

No violations cited

The inspector documented no violation of standards at this inspection.

June 21, 2021Inspection0 violations

Areas reviewed

22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISHCHARGE22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS22VAC40-73 EMERGENCY PREPAREDNESS

Comments

The inspection was conducted by Licensing Staff using alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 06/21/2021 and concluded on 06/21/2021. The director or in-charge person was contacted by telephone to initiate the inspection. The inspector reviewed 4 resident and 4 staff records and additional documentation provided by the facility to ensure compliance. The information gathered during the inspection determined no violations with applicable standards or law. no violations were issued.

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

January 22, 2021Inspection0 violations

Inspection dates

Jan. 22, 2021

Areas reviewed

22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS

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 focused monitoring inspection was initiated on 01-22-2021 and concluded on 01-22-2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 52. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 3 resident records, 3 staff records, staff schedules, staff training and additional items requested to ensure compliance with the facility Intensive Plan of Correction submitted by the facility to ensure documentation was complete. The information gathered during the inspection determined no violations with applicable standards or law. No violations were issued.

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.