Virginia DSS · Assisted Living Facility

English Meadows Blacksburg Campus

📍 3400 South Point Dr., Blacksburg, VA, 24060

ID 45939One Year licenseActive
48
Inspections
On record
24
With violations
Visits that cited something
24
Clean visits
Nothing cited
85
Violations cited
Individual findings
47
Standards cited
Distinct rules
20
Complaint visits
Prompted by a complaint

English Meadows Blacksburg Campus was inspected 48 times between May 11, 2021 and May 20, 2026 by the Virginia Department of Social Services. 24 of those visits ended with violations cited and 24 with none. Across that history VDSS cited 85 violations under 47 distinct standards. 20 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. 47 of these 48 are still on the state's site; the other 1 has since dropped off it and is reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type
Assisted Living Facility
License type
One Year
License expires
07/06/2026
Administrator
Paul Englehart
Licensing inspector
Angela Swink
Inspector phone
(276) 623-6575
Approved for
Non-Ambulatory · Special Care Unit · Assisted Living

Inspection History

48

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

May 20, 2026Inspection11 violations
Inspection dates
05/20/2026
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS63.2- (1) GENERAL PROVISIONS63.2- (17) LICENSURE AND REGISTRATION PROCEDURES63.2- (18) FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS
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: 05/20/2026 08:25 to 15:45 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 96 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: Observations by licensing inspector: Medication Cart Audits, Medication Pass Observation, Breakfast and Lunch Meal, Morning and Afternoon Activities 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 Angela Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov
Violations
22VAC40-73-310-H
Based on resident record review and staff interview, the facility failed to ensure that in accordance with § 63.2-1805 D of the Code of Virginia, assisted living facilities shall not admit or retain individuals with any of the following conditions or care needs including individuals requiring continuous licensed nursing care.
Evidence
  1. Resident 1 record, admission date 2/27/2026, contained a Report of Resident Physical Examination, dated 2/26/2026, with documentation that the resident requires continuous licensed nursing care. 2.Interview with Staff 1 confirmed Resident 1 record to be current.
Plan of correction
Administrator or Health & Wellness Director will oversee all history and physical forms and during initial resident assessment the category will be discussed with physician completing form.
22VAC40-73-650-C
Based on resident record review and staff interview, the facility failed to ensure that Physician's or other prescriber's oral orders shall be reviewed and signed by a physician or other prescriber within 14 days.
Evidence
  1. Resident 1 record contained a signed physicians order, dated 5/19/2026, to D/C Levetiracetam oral tablet 500mg BID for seizure activity, that was written by the receiving nurse on 4/28/2026. Resident record contained a signed physicians order, dated 5/20/2026, to discontinue the following medications due to patient continues to refuse to take Keppra 500mg BID, Aspirin 81mg qday, Plavix 75mg qday, that was written by the receiving nurse on 4/28/2026.
  2. Interview with Staff 1 confirmed Resident 1 record to be current.
Plan of correction
Health & Wellness Director will inservice RMA staff on physician orders being signed within the 14 day compliance timeframe. Audits will be conducted on all new physician orders to ensure proper compliance.
22VAC40-73-680-G
Based on medication cart audit and staff interviews, the facility failed to ensure that over-the-counter medication shall remain in the original container, labeled with the resident's name, or in a pharmacy-issued container, until administered.
Evidence
  1. During the medication administration observation, the licensing inspector observed Staff 5 take a tablet from an over the counter bottle of Vitamin D3 Tablet 25mcg that did not contain a resident’s name on it to administer to Resident 2. 2.Interview with Staff 5 confirmed the over the counter bottle did contain medication prescribed to Resident 2 however no medication persons put the Resident’s name on the bottle. 3.Interview with Staff 1 confirmed the bottle did not have a resident’s name on it.
Plan of correction
New OTC labels have been purchased and will be placed on containers with residents name in original containers to ensure compliance. In- service with staff will be conducted and additional education provided.
22VAC40-90-40-B
ased on staff record reviews and staff interview, the facility failed to ensure that the criminal history record report shall be obtained within 30 days of employment for each employee.
Evidence
  1. Staff 8 record, hire date 2/19/2026, did not contain a Criminal History Record Report issued by the Central Criminal Records Exchange, Department of State Police.
  2. Staff 9 record, hire date 2/19/2026, did not contain a Criminal History Record Report issued by the Central Criminal Records Exchange, Department of State Police.
  3. Staff 10 record, hire date 3/10/2026, did not contain a Criminal History Record Report issued by the Central Criminal Records Exchange, Department of State Police.
  4. Staff 1 record, hire date 04/01/2026, did not contain a Criminal History Record Report issued by the Central Criminal Records Exchange, Department of State Police.
  5. Staff 12 record, hire date 02/03/2026, contained a Criminal History Record Report dated 03/11/2026.
  6. Interview with Staff 4 confirmed Staff 8, 9, 10, 11, and 12 records were current.
Plan of correction
All staff criminal history report will be obtained within 48 hours of offer and acceptance of employment.
22VAC40-73-640-A
Based on facility record review and staff interviews, the facility failed to ensure that the facility shall have, keep current, and implement a written plan for medication management. The facility's medication plan shall address procedures for administering medication and shall include methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes.
Evidence
  1. The facility’s Medication Management Plan and Reference Material, not dated, included documentation that during shift change, all narcotics, cards, bottles, sheets are counted and recorded by the oncoming and off-going medication persons. The oncoming and off-going medication persons both sign off on the accurate counts of all narcotics on the Narcotic Administration Record.
  2. The Lavender Hills medication cart contained a May 2026 Narcotic Shift Count form with no signature on 05/01/2026 for oncoming and off-going 7am, 5/6/2026 for off-going 7am, 5/10/2026 for off-going 7am, 5/11/2026 for oncoming 7am, 5/15/2026 for off-going 7am, 5/20/2026 for oncoming and off-going 7am, 5/1/2026 for off-going 7pm, and 5/11/2026 for off-going 7pm.
  3. Interview with Staff 1 and Staff 6 confirmed the Narcotic Shift Count form to be current.
Plan of correction
New narcotic sheet for RMA staff to complete. Health & Wellness Director will complete additional inservices on facility medication plan and audits will be conducted randomly to ensure compliance.
22VAC40-73-450-C
Based on resident record review and staff interview, the facility failed to ensure that the comprehensive individualized service plan (ISP) shall be completed within 30 days after admission and shall include all required information. 1. Resident 1 record, admission date 02/27/2026, contained a signed Durable Do Not Resuscitate Order (DNR), dated 11/11/2023. 2. Resident 1 record, admission date 02/27/2026, contained an Assessment of Serious Cognitive Impairment, dated 2/27/2026, with documentation that the Resident had a serious cognitive impairment due to a primary psychiatric diagnosis of dementia and was unable to recognize danger or protect their own safety and welfare. 3. Interview with Staff 1 confirmed Resident 1 did require observation rounds due to not being able to use the signaling device. 3. Resident 1 record, admission date 02/27/2026, contained a Comprehensive ISP, dated 02/27/2026, that did not contain the identified needs for the DNR or the inability to use the signaling device and requiring observation rounds. 4. Interview with Staff 1 confirmed Resident 1 record to be current.
Plan of correction
Administrator/HWD will ensure all new admits ISP's will be complete within 30 days of admission. Audits will be conducted on all new admit files to ensure compliance.
22VAC40-73-260-A
Based on staff record review and staff interview, the facility failed to ensure that each direct care staff member shall maintain 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. The certification must either be in adult first aid or include adult first aid. To be considered current, first aid certification from community colleges, hospitals, volunteer rescue squads, or fire departments shall have been issued within the past three years..
Evidence
  1. Staff 5 record, date of hire 04/02/2025 as direct care staff, contained a Basic Life Support certificate from the American Heart Association with documentation to renew by 12/2025 as the most current certificate in the record.
  2. Interview with Staff 4 confirmed Staff 5 record to be current.
Plan of correction
Administrator or Designee will conduct an audit monthly on staff first aid status to maintain compliance.
22VAC40-73-680-I
Based on resident record reviews and staff interviews, the facility failed to ensure that the Medication Administration Record (MAR) shall include the date and time given and initials of direct care staff administering the medication.
Evidence
  1. Resident 1 record contained a May 2026 MAR with no documentation for administration of medication on 5/2/2026 and 5/17/2026 at 11:30 for Novolog Flex Pen Inject 6 Units Subcutaenously after meals R/T DM.
  2. Resident 3 record contained a May 2026 MAR with no documentation for administration of medication on 5/3/2026 for Levothyroxin Tab 137mcg take one tablet by mouth once daily hypothyroidism and on 5/13/2026 for Midodrine Tab 2.5mg Take one tablet by mouth three times daily at 2:00pm.
  3. Interview with Staff 1 confirmed Resident 1 and Resident 3 record to be current.
Plan of correction
Health & Wellness Director to re-educate and inservice RMA staff on proper documentation for facility's MAR. Audit will be conducted monthly to ensure compliance.
22VAC40-73-990-B
Based on facility record review and staff interview, the facility failed to ensure that the procedures in the plan for resident emergencies required in subsection A of this section shall be reviewed by the facility at least every six months with all staff. Documentation of the review shall be signed and dated by each staff person.
Evidence
  1. An In-Service form, dated 7/14/2025, contained documentation for the topics covered to include Medical Emergencies, Mental, and Missing Persons for staff.
  2. Interview with Staff 7 confirmed the last review for procedures in the plan for resident emergencies with staff was on 7/14/2025.
Plan of correction
Education will be provided to our Maintenance Director and staff on the procedures for the 6 month emergency plan for residents. These drills and training will be conducted every 6 months per policy.
22VAC40-73-440-B
Based on resident record review and staff interview, the facility failed to ensure that for private pay individuals, the UAI shall be completed by one of the following qualified assessors an assisted living facility staff person who has successfully completed state- approved training on the uniform assessment instrument and level of care criteria for either public or private pay assessments, provided the administrator or the administrator's designated representative has successfully completed such training and approves and then signs the completed UAI, and the facility maintains documentation of completed training.
Evidence
  1. Resident 2 record contained a Uniform Assessment Instrument, dated 02/01/2026, with documentation that Staff 3 approved the assessment on 02/01/2026 however the assessor’s name, assessor’s signature, ALF name, or date was not included on the assessment.
  2. Interview with Staff 3 confirmed Staff 3 was the assessor however the administrator or their designee did not approve the assessment.
Plan of correction
Administrator/ HWD will audit each UAI after completion to ensure accuracy and compliance.
22VAC40-73-450-D
Based on resident record review and staff interview, the facility failed to ensure when hospice care is provided to a resident, the assisted living facility and the licensed hospice organization shall communicate and establish an agreed upon coordinated plan of care for the resident. The services provided by each shall be included on the individualized service plan (ISP).
Evidence
  1. Staff 1 stated Resident 1 was receiving services from a hospice company.
  2. Resident 1 record contained documentation including recent clinical notes from a hospice company.
  3. Resident 1 record contained an ISP, dated 2/27/2026, with no documentation regarding the Resident receiving services from hospice.
  4. Interview with Staff 1 confirmed Resident 1 record to be current,
Plan of correction
Any hospice residents will be added to the ISP as needed to establish an agreed upon coordinated plan of care.
December 23, 2025Inspection1 violation
Inspection dates
12/23/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/23/2025, 11:02am to 11:37am The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 11/06/2025 regarding allegations in the area(s) of: Resident care and related services. Number of residents present at the facility at the beginning of the inspection: 88 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: n/a Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.
Violations
22VAC40-73-640-A
Based on interviews with staff and review of facility documentation, the facility failed to implement its written plan for medication management including methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes.
Evidence
  1. According to the facility’s medication management plan, during shift change, all narcotics, cards, bottles, sheets are counted and recorded by the oncoming and off-going medication persons. The oncoming and off-going medication persons both sign off on the accurate counts of narcotics on the Narcotic Administration Record.
  2. Based on the November 2025 Narcotic Count Sheet for cart #3, staff did not document counts of the numbers of cards, sheets and bottles on the following dates: 11/05/2025 (7a to 7p shift), 11/07/2025 (7p to 7a shift), 11/12/2025 (7p to 7a shift), 11/15/2025 (7p to 7a shift), 11/16/2025 (7p to 7a shift), and 11/25/2025 (7p to 7a shift) through 11/28/2025 (7a to 7p shift). Additionally, staff did not document the number of bottles on 11/01/2025 (7p to 7a shift), 11/17/2025 (7p to 7a shift) and 11/20/2025 (7p to 7a shift) and the number of cards and sheets were not documented on 11/29/2025 (7p to 7a shift).
  3. Based on the November 2025 Narcotic Count Sheet for Cart #3, the number of cards at the beginning of the 7p shift on 11/05/2025 was noted to be 21. Staff recorded the addition of two cards and subtraction of three cards, which should have resulted in a total of 20 cards, but the number of cards recorded at the beginning of of the 7a shift on 11/06/2025 was 22.
  4. The Medication Monitoring/Control Record for the 9am dose of Hydroco/APAP 10-325mg tablets for resident #1 contained the following errors in documentation: a. On 11/01/2025, 28 tablets were noted to be on hand; one tablet was documented as given with 27 remaining. A line was drawn through this entry. b. On 11/02/2025, 28 tablets were noted to be on hand; one tablet was documented as given with 26 remaining. c. The next entry documents the date as 11/02/2025 (again) with 27 tablets on hand; one tablet was documented as given with 25 tablets remaining.
Plan of correction
The Health and Wellness Director has created a new NARC count shift change form. Health and Wellness Director or Designee will in-service all RMA's and LPN on Narc count and proper disposal per regulations and company policy. Health & Wellness Director or designee will do weekly audits for 6 weeks for all carts • then monthly audits for 3 months. [SIC]
December 23, 2025Inspection1 violation
Inspection dates
12/23/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/23/2025, 11:38am to 11:50am. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 11/20/2025 regarding allegations in the area(s) of: Resident care and related services. Number of residents present at the facility at the beginning of the inspection: 88 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: n/a Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.
Violations
22VAC40-73-640-A
Based on interviews with staff and review of facility documentation, the facility failed to implement its written plan for medication management including a plan for proper disposal of medication.
Evidence
  1. According to the facility’s medication management plan, documentation of destruction and disposal of controlled medications will be noted on the drug destruction log including the following information: Resident’s name, date, name of medication, strength, quantity, and reason for destruction and name of individuals destroying the medication. Controlled medications are destroyed by two designated staff person(s) including director of nursing (DON)/resident care coordinator (RCC) and/or nurse and/or nursing supervisor.
  2. Staff #1 documented on the medication monitoring/control record for resident #1 that a total of 51 Alprazolam 0.25mg tablets were destroyed on 10/17/2025. There was no documentation that a second staff member was present during the destruction and disposal of the medication.
  3. Staff #1 documented on the medication monitoring/control record for resident #2 that a total of 29 Lacosamide 50mg tablets were destroyed on 10/27/2025. There was no documentation that a second staff member was present during the destruction and disposal of the medication.
  4. Staff #1 documented on the medication monitoring/control record for resident #3 that a total of 84 Tramadol HCL 25mg tablets and 29 Pregabalin 25mg capsules were destroyed on 11/19/2025. Staff #2 signed the medication monitoring/control record as a witness on 11/19/2025 and provided a signed written statement dated 11/20/2025 reporting she had witnessed the destruction of the medications by staff #1. Staff #2 is a registered medication aide and is not the RCC according to interview with staff #3.
  5. Staff #1 documented on the medication monitoring/control record for resident #4 that a total of 12 Oxycodone HCL 5mg tablets were destroyed on 11/19/2025. Staff #2 signed the medication monitoring/control record as a witness on 11/19/2025 and provided a signed written statement dated 11/20/2025 reporting she had witnessed the destruction of the medications by staff #1.
  6. Staff #1 reported in a written statement dated 11/20/2025 that she had not been aware of or used the required drug destruction log prior to 11/20/2025.
Plan of correction
The Health and Wellness Director has created a new NARC count shift change form. Health and Wellness Director or Designee will in-service all RMA's and LPN on Narc count and proper disposal per regulations and company policy. Health & Wellness Director or designee will do weekly audits for 6 weeks for all carts, then monthly audits for 3 months. [SIC]
September 30, 2025Inspection1 violation
Inspection dates
09/30/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/30/2025, 11:58am to 12:43pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 08/04/2025 regarding allegations in the area(s) of: Resident care and related services Number of residents present at the facility at the beginning of the inspection: 89 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: n/a Number of interviews conducted with residents: n/a Number of interviews conducted with staff: 2 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. However, violation(s) not related to the self-report but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.
Violations
22VAC40-73-930-D
Based on a review of records and interview with staff, the facility failed to ensure that for each resident with an inability to use the signaling device, the facility shall document the rounds that were made, which shall include the name of the resident, the date and time of the rounds, and the staff member who made the rounds.
Evidence
  1. The individualized service plan (ISP) for resident #1, dated 06/17/2025, states the resident does not recognize the need for signaling.
  2. The ISP for resident #1, dated 06/17/2025, states the resident does not understand or maintain the ability to signal for staff and thus one-hour rounds will be performed.
  3. At the time of inspection, no documentation was observed in the record for resident #1 indicating hourly rounds were being made.
  4. Staff #1 confirmed there was no documentation available of hourly rounds for resident #1.
Plan of correction
Administrator/Designee will re-educate and in-service staff on following the residents needs on the ISP and ensure proper rounding documentation is available and documented appropriately. [SIC]
September 30, 2025Inspection2 violations
Inspection dates
09/30/2025
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/30/2025, 11:16am to 11:57am The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 09/02/2025 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: 89 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: n/a Number of interviews conducted with residents: n/a Number of interviews conducted with staff: 2 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. However, violation(s) not related to the self-report but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.
Violations
22VAC40-73-325-C
Based on a review of resident records and interview with staff, the facility failed to ensure that should a resident who meets the criteria for assisted living care fall, the facility must show documentation of an analysis of the circumstances of the fall and interventions that were initiated to prevent or reduce risk of subsequent falls.
Evidence
  1. Per facility report, resident #1 had a fall on 09/01/2025.
  2. There was no documentation observed in the record for resident #1 of an analysis of the circumstances of the fall and interventions that were initiated to prevent or reduce risk of subsequent falls.
  3. Staff #1 confirmed an analysis of the circumstances of the fall did not occur.
Plan of correction
Administrator/Designee will in-service & re-educate RMA’s and care staff on the importance and policy regarding fall documentation including the analysis of the circumstances of the fall and any interventions put in place to prevent or reduce the risk of future falls. [SIC]
22VAC40-73-325-B
Based on a review of resident records and interview with staff, the facility failed to ensure the fall risk rating shall be reviewed and updated after a fall.
Evidence
  1. Per facility report, resident #1 had a fall on 09/01/2025.
  2. The most recent fall risk rating observed in the record for resident #1 was dated 10/01/2024.
  3. Staff #1 confirmed a more recent fall risk rating was not available.
Plan of correction
Administrator/Designee will provide an in-service and re-educate RMA’s and care staff of fall protocols and fall policies. Completion of updated fall risk rating to occur after each incident. [SIC]
June 25, 2025Complaint survey1 violation
Inspection dates
06/25/2025, 07/11/2025
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/25/2025, 11:30am to 1:05pm and 07/11/2025, 10:45am to 11:56am The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 06/16/2025 regarding allegations in the area(s) of: Staffing and supervision, resident care and related services, building and grounds and the safe, secure environment. Number of residents present at the facility at the beginning of the inspection: 78 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: n/a Number of staff records reviewed: 0 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 5 Observations by licensing inspector: Reviewed staff schedules, daily staffing sheets and employee timecards Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s); area(s) of non-compliance with standard(s) or law were: Staffing and supervision A violation notice was issued; any violation(s) not related to the complaint(s) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.
Violations
22VAC40-73-290-A
Based on a review of staff schedules, daily staffing sheets and employee timecards, the facility failed to ensure that any absences, substitutions, or other changes shall be noted on the written work schedule.
Evidence
  1. The following discrepancies were observed on the daily staffing sheets: a. On May 3, 2025, staff #1 was noted to be working from 3pm to 11pm in both the assisted living portion of the facility, as well as the safe, secure environment. This would leave the safe, secure environment staffed at times with only two employees providing direct care rather than the required three. Staff #3 and staff #4 reported either staff #2 or other staff members were present in the safe, secure environment during that time. b. On May 4, 2025, staff #5 was noted to be working from 3pm to 11pm in both the assisted living portion of the facility, as well as the safe, secure environment. This would leave the safe, secure environment staffed at times with only two employees providing direct care rather than the required three. Staff #3 and staff #4 reported staff #2 or other staff members were present in the safe, secure environment during that time. c. On May 9, 2025, only two staff members rather than the required three were noted to be working in the safe, secure unit from 11pm to 7am. Staff #4 reported that other staff would have been pulled from the assisted living portion of the facility to cover. d. On May 23, 2025, staff #6 was noted to be working in the safe, secure unit from 3pm to 11pm. Per the timecard for staff #6, she worked from 6:45am to 3:54pm, leaving only two other employees providing direct care rather than the required three after she finished working at 3:54pm. Staff #4 reported that other staff would have been pulled from the assisted living portion of the facility to cover the remainder of the shift.
  2. Staff #2 is a non-hourly employee and is identified as PRN (as needed) staff on the May 2025 RMA (Registered Medication Aide) schedule. Staff #3 reported the typical schedule for staff #2 is 9am to 5pm Monday through Friday. No changes were noted on the written work schedule indicating staff #2 was present in the safe, secure unit outside regular work hours on the dates noted above.
  3. No changes were noted on the direct care staff schedules provided to the LI for the month of May 2025, indicating whether other staff had been pulled to work in the safe, secure environment as needed on the dates noted above.
Plan of correction
Administrator/ Designee will re-educate and train shift supervisors and scheduler that when any changes with staffing are made, the daily work sheet and physical schedule needs to be updated to reflect changes with assignments and coverage on AL and MC. [SIC]
June 25, 2025Inspection0 violations
Inspection dates
06/25/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/25/2025, 1:10pm to 1:58pm 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: 78 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: n/a Number of interviews conducted with residents: n/a Number of interviews conducted with staff: 3 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 21, 2025Inspection1 violation
Inspection dates
05/21/2025
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: 05/21/2025, 2:18pm to 2:38pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 03/27/2025 regarding allegations in the area(s) of: Resident care and related services. Number of residents present at the facility at the beginning of the inspection: 77 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: n/a Number of interviews conducted with residents: n/a Number of interviews conducted with staff: 2 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.
Violations
22VAC40-73-680-D
Based on a review of resident records and interviews with staff, the facility failed to ensure that medications shall be administered in accordance with the physician's or other prescriber’s instructions.
Evidence
  1. Per physician orders and the March 2025 medication administration record (MAR), resident #1 is prescribed the following medications: Lisinopril 40mg tablet, take one tablet by mouth every day, and Memantine ER 7mg ER capsule, take 1 capsule by mouth every day.
  2. The licensing inspector received a facility self-reported incident from staff #1 on 03/27/2025 stating resident #1 had not received the two medications noted in item #1 from 03/15/2025 to 03/21/2025 due to a clerical error discovered by a registered medication aide (RMA) on 03/22/2025.
  3. The March 2025 MAR for resident #1 indicates the 8am doses of the two medications noted in item #1 were not administered from 03/15/2025 to 03/21/2026, for a total of 14 missed doses.
  4. Staff #1 and staff #2 confirmed at the time of inspection this incident did occur as described in the incident report.
Plan of correction
Administrator or designee will train and re-educate Medication Aides to notify a supervisor or myself when there are pharmacy issues and discrepancies in physician orders. Regional Nurse and RCC will audit and monitor med pass and log reports to ensure accuracy and timely administration. [SIC]
May 20, 2025Inspection7 violations
Inspection dates
05/20/2025, 05/21/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
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: 05/20/2025, 10:15am to 3:17pm and 05/21/2025, 9:48am to 2:27pm. 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: 77 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 9 Number of staff records reviewed: 5 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 6 Observations by licensing inspector: Noon meal, activities, medication pass Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.
Violations
22VAC40-73-1180-B
Based on a tour of the building, the facility failed to ensure that when there are indications that ordinary materials or objects may be harmful to a resident, these materials or objects shall be inaccessible to the resident except under staff supervision.
Evidence
  1. In resident room #H101 in the safe, secure environment, a bottle of Remedy No-Rinse Foam Cleanser was observed on the bathroom sink.
  2. In resident room #H115 in the safe, secure environment, two bottles of DermaVera Skin & Hair Cleanser was observed in the shower.
  3. In the room for resident #10 in the safe, secure environment, a 7.5 ounce bottle of clear liquid hand soap was observed on the bathroom sink, and a 50 ounce bottle of clear liquid hand soap was observed on a shelf in the same bathroom.
  4. In resident room #H108 in the safe, secure environment, a bar of soap and a clear plastic box containing the following toiletries were observed in the shower: Mitchem men’s deodorant stick and Ultrabrite Advance Whitening toothepaste.
Plan of correction
Adminsitrator/Designee will complete room sweeps in the memory care area to capture in issues involving any harmful objects and materials. All personal hygienic items will be stored and locked in a designated area. [SIC]
22VAC40-73-440-D
Based on a review of resident records, the facility failed to ensure that for private pay individuals, the uniform assessment instrument (UAI) is completed as required.
Evidence
  1. Per the February 2024 Department for Aging and Rehabilitative Services, APS Division, ALF Private Pay Assessment Manual: It is important that an accurate assessment of the individual's functional status and other needs be recorded on the UAI, since this information forms the basis for a determination of whether the individual meets assisted living facility level of care criteria. The assessor must note the individual's degree of independence or dependence in various areas of functioning.
  2. On the UAI completed 03/27/2025 for resident #1, the following errors were observed: a. Bowel and bladder needs are marked as incontinent, less than weekly. The individualized service plan (ISP) dated 03/27/2025 indicates the resident is continent of bowel, and incontinent of bladder more than weekly. b. Per the UAI, resident #1 requires mechanical & human help, physical assistance, with walking; The ISP states walking is not performed. c. The UAI indicates resident #1 requires human help only, supervision, with wheeling; the ISP indicates the resident requires mechanical and physical assistance including assistance of one staff to help with propelling. d. The UAI indicates that medications are administered by professional nursing staff. Residents at this facility also receive medication administration from Registered Medication Aides (RMAs) who are considered laypersons on the UAI form.
  3. On the UAI completed 03/10/2025 for resident #2, the following errors were observed: a. Bathing and stairclimbing were identified on the UAI as needs requiring mechanical help only; the ISP completed 03/10/2025 indicates the resident requires mechanical and physical assistance with both bathing and stairclimbing. b. The UAI notes resident #2 requires no assistance with the following: Dressing, toileting, transferring, bladder, walking, wheeling, and mobility. These needs are all addressed on the ISP dated 03/10/2025 as areas in which the resident requires mechanical and/or physical assistance. c. The UAI indicates that medications are administered by professional nursing staff. Residents at this facility also receive medication administration from Registered Medication Aides (RMAs) who are considered laypersons on the UAI form.
  4. On the UAI completed 03/05/2025 for resident #4, the following errors were observed: a. The UAI notes resident #4 requires no assistance with the following: Bathing, dressing, toileting, transferring, wheeling, stairclimbing and walking. These needs are all addressed on the ISP dated 03/10/2025 as areas in which the resident requires mechanical and/or physical assistance, or supervision. b. The UAI indicates that medications are administered by professional nursing staff. Residents at this facility also receive medication administration from Registered Medication Aides (RMAs) who are considered laypersons on the UAI form.
Plan of correction
Administrator/ Designee will provide additional training for UAI/ISP for any individual completing these forms. ---provided the link to access training. These forms will be completed as required per regulation. Monthly chart audits will be completed.
22VAC40-73-870-A
Based on a tour of the building, the facility failed to ensure that the interior and exterior of all buildings shall be maintained in good repair and kept clean and free of rubbish.
Evidence
  1. In resident room #225, small dark stains were observed on the carpet in front of the blue recliner.
  2. In resident room #211, several small dark stains were observed on the carpet throughout the main living area.
  3. In resident room #H101, several small black specks of dirt/debris were observed in the bathroom, especially in the area in front of the toilet. In the living area, a dark red mark/stain was observed on the wall behind the leather recliner. Dark marks were also observed on the wall by the entrance to the bathroom.
  4. In resident room #H121, dark marks were observed on the walls on each side of the entry way.
Plan of correction
Administrator/ Designee will in-service our Maintenance Director and housekeeping staff on maintaining and auditing each room for stains and marks on the wall, carpets and furniture. Weekly room rounds to be completed and monitored. [SIC]
22VAC40-73-640-A
Based on review of facility documentation, the facility failed to implement its written plan for medication management including methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes.
Evidence
  1. The facility’s medication management plan states: “During shift change, all narcotics, cards, bottles, sheets are counted and recorded by the oncoming and off-going medication persons. The oncoming and off-going medication persons both sign off on the accurate counts of all narcotics on the Narcotic Administration Record.”
  2. On the narcotic count sheet for the medication cart in the safe, secure environment, there was no 7p – 7a ongoing staff signature on 05/16/2025.
  3. On the narcotic count sheet for the medication cart in the safe, secure environment, there were no 7a – 7p off going staff signatures on 05/17/2025 and 05/20/2025.
  4. On 05/18/2025, the total number of cards, pages and bottles was not recorded for the 7a – 7p shift.
Plan of correction
Administrator/Designee will re- educate all Medication Aides on the facility Med Management Plan. Ensure each RMA is documenting appropriately and timely per policy and procedures. Ensure that during shift change each RMA counts and records all narcotics, cards, bottles and sheets per policy and procedure, Bi Monthly documentation audits. [SIC]
22VAC40-73-350-B
Based on a review of resident records, the facility failed to ascertain, prior to admission, whether a potential resident is a registered sex offender if the facility anticipates the potential resident will have a length of stay greater than three days or in fact stays longer than three days.
Evidence
  1. Resident #4 was admitted to the facility on 03/10/2025.
  2. The record for resident #4 indicates the search of the Virginia State Police sex offender registry did not occur until 04/17/2025.
Plan of correction
Administrator/ Designee will ensure all sex offender checks are completed through the database on all new admissions at least 24 hours before physical move in. [SIC]
22VAC40-73-380-A
Based on a review of resident records, the facility failed to ensure that prior to or at the time of admission to an assisted living facility, all required personal and social information on a person shall be obtained.
Evidence
  1. In the record for resident #4, the Resident – Personal/Social Data form did not contain any information in the section addressing current behavioral and social functioning including strengths and problems. The response in this section states only, “NONE.”
  2. In the record for resident #2, the Resident – Personal/Social Data form did not contain any information in the section addressing current behavioral and social functioning including strengths and problems. The response in this section states only, “NONE.”
  3. In the record for resident #1, the Resident – Personal/Social Data form did not contain any information in the section addressing current behavioral and social functioning including strengths and problems. The response in this section states only, “NA.”
Plan of correction
Administrator/Designee will ensure the social data sheets and all demographic information for all move ins are complete and chart audited 48 hours before Physical move in. Each section of the personal/ social data sheet will be addressed and complete per requirements. [SIC]
22VAC40-73-450-E
Based on a review of resident records, the facility failed to ensure that the individualized service plan (ISP) shall be signed and dated by the licensee, administrator, or his designee, (i.e., the person who has developed the plan).
Evidence
  1. There were no staff signatures observed on the ISP for resident #2, dated 03/10/2025.
  2. There were no staff signatures observed on the ISP for resident #2, dated 03/10/2025.
Plan of correction
Administrator will ensure each ISP is signed in a timely manner. Within 24 hour of ISP completion the form will be signed per regulation. [SIC]
October 1, 2024Inspection0 violations
Inspection dates
10/01/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/01/2024 11:23am to 11:55am. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 09/02/2024 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: 72 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: n/a Number of interviews conducted with residents: n/a Number of interviews conducted with staff: 1 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
October 1, 2024Complaint survey0 violations
Inspection dates
10/01/2024
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 BUILDINGS AND GROUND
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/01/2024 10:48am to 11:20am The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 08/05/2024 regarding allegations in the area(s) of: Building and grounds, administrative services. Number of residents present at the facility at the beginning of the inspection: 72 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: n/a Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Review of policy & procedure Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the (allegation(s)/self-report) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
July 2, 2024Inspection0 violations
Inspection dates
07/02/2024
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/02/2024 11:40am to 12:05pm 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: 82 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: N/A Number of staff records reviewed: N/A Number of interviews conducted with residents: N/A Number of interviews conducted with staff: 1 Observations by licensing inspector: Facility training records and documentation of audits Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
June 20, 2024Inspection1 violation
Inspection dates
06/20/2024, 06/27/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/20/2024, 1:08pm to 2:05pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 06/14/2024 regarding allegations in the area(s) of: Resident care and related services, medication management plan and reference materials. Number of residents present at the facility at the beginning of the inspection: 75 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: n/a Number of interviews conducted with residents: n/a Number of interviews conducted with staff: 6 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.
Violations
22VAC40-73-640-A
Based on review of facility documentation and interviews with staff, the facility failed to implement a written plan for medication management including methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes.
Evidence
  1. The facility’s medication management plan states: “During shift change, all narcotics, cards, bottles, sheets are counted and recorded by the oncoming and off-going medication persons. The oncoming and off-going medication persons both sign off on the accurate counts of all narcotics on the Narcotic Administration Record.”
  2. A physician’s order was provided on 01/25/2024 for resident #1 stating the following: Give morphine sulfate conc. 0.25mL under tongue Q 4 hr. PRN for pain, facial grimacing, moaning, or labored breathing, respiratory rate > 24.
  3. On 06/12/2024 at 1500, a physician’s order was provided for resident #1 stating the following: Give morphine sulf. (conc) 20mg/mL, 0.5 mL under tongue Q 4 hr; Give morphine sulf. 0.5mL under tongue Q 2 hr PRN pain, grimacing, moaning or shortness of breath.
  4. On 06/13/2024 a physician’s order was provided for resident #1 stating the following: D/C morphine conc. 0.25mL Q 4 hr PRN, order was changed to 0.5mL scheduled and PRN.
  5. The controlled drug record for the medication noted in item #1 above states the prefilled morphine syringes (0.25mL=5mg) were received by the facility on 01/26/2024 and the amount documented as received was 60 prefilled syringes.
  6. Per interview with staff #1 and staff #2, they counted the medication on 06/12/2024 at approximately 7am during staff changeover and there were 60 syringes counted.
  7. Per documentation by staff #1 on the controlled drug record and the June 2024 Medication Administration Record (MAR), two 0.25mL syringes were administered to resident #1 on 06/12/2024 at 6pm as a scheduled medication per the order noted in item #2 above: Give morphine sulf. (conc) 20/mg/mL, 0.5 mL under tongue Q 4 hr. The amount remaining following administration was documented as 58 syringes.
  8. Per interview with staff #2, she arrived to work at approximately 8:35pm on 06/12/2024 and staff #3 stayed until approximately 9pm on 06/12/2024. Staff #2 reports they did not count the 0.25mL morphine syringes during staff changeover as they were no longer being administered at that point due to the new orders requiring 0.5mL syringes. The 0.5mL syringes had been delivered to the facility and were being administered per physician orders per staff #2.
  9. Per interview with staff #4, she and staff #2 “did not count all three bags” of the 0.25mL morphine syringes during staff changeover at approximately 7am on 06/13/2024, but when she pulled the 0.25mL syringes from the cart later that day for disposal, she only counted 57 syringes, instead of the previously documented 58 syringes. She reports she counted the medication again with staff #5 and staff #6 and they counted 57 syringes as well.
Plan of correction
Administrator and DON held a Mandatory Meeting with all med management staff on June 14, 2024 to re-educate all staff on counting narcotics with every change in Med tech on the cart. Educating on the importance of the accuracy of this count. They will be informed that if the count is incorrect at any time, they must contact DON and Administrator immediately. All med staff were informed that if they are found not to have completed a count they will be immediately terminated. All med staff drug tested on June, 14, 2024. Administrator and/or DON will have begun daily audits of narcotic count books in the mornings and evenings daily. Administrator and/or DON will do narcotic counts on all med carts weekly. These audits will take place for 3 months and then randomly thereafter. [SIC]
June 20, 2024Complaint survey0 violations
Inspection dates
06/20/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 04/20/2024, 12:00pm to 12:46pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 06/04/2024 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: 75 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: N/A Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the 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 Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
June 20, 2024Inspection0 violations
Inspection dates
06/20/2024
Areas reviewed
22VAC40-73 PERSONNEL
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/20/2024, 11:46am to 11:59am 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: 75 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: N/A Number of staff records reviewed: N/A Number of interviews conducted with residents: N/A Number of interviews conducted with staff: 2 Observations by licensing inspector: Staff training records Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. Should you have any questions, please contact Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
June 20, 2024Inspection0 violations
Inspection dates
06/20/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/20/2024, 11:26am to 11:45am 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: 75 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: N/A Number of staff records reviewed: N/A Number of interviews conducted with residents: N/A Number of interviews conducted with staff: 2 Observations by licensing inspector: Med cart audit Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. Should you have any questions, please contact Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 16, 2024Complaint survey0 violations
Inspection dates
05/16/2024, 06/20/2024
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/16/2024 12:22pm to 2:15pm and 06/20/2024 12:47pm to 1:07pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 04/21/2024 regarding allegations in the area(s) of: Personnel, resident care and related services. Number of residents present at the facility at the beginning of the inspection: 72 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: N/A Number of interviews conducted with staff: 5 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the 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 Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 9, 2024Inspection7 violations
Inspection dates
05/09/2024, 05/10/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/09/2024 10:10am to 2:31pm and 05/10/2024 9:45am to 3:27pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 73 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Number of staff records reviewed: 3 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 5 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.
Violations
22VAC40-73-450-C
Based on a review of resident records, the facility failed to address all identified needs on the comprehensive individualized service plan (ISP) for two of the seven resident files that were reviewed.
Evidence
  1. The ISP for resident #2 dated 02/05/2024 identifies “FULL CODE” as a need, however, a Do Not Resuscitate (DNR) order dated 04/08/2024 was observed in the record for resident #2. The ISP was not updated to reflect the change in status.
  2. Resident #2 was admitted to the safe secure unit on 02/25/2023; this need was not addressed on the ISP dated 02/05/2024 for resident #2.
  3. Resident #6 was admitted to the safe secure unit on 01/22/2020; this need was not addressed on the ISP dated 12/13/2023 for resident #6.
Plan of correction
Administrator has conducted an audit of all resident code status to ensure they are correct. Administrator and/or DON will conduct periodic code status audits moving forward to ensure accuracy. [SIC]
22VAC40-73-870-E
Based on observations made during a tour of the building, the facility failed to ensure that all furnishings, fixtures, and equipment, including furniture, window coverings, sinks, toilets, bathtubs, and showers, shall be kept clean and in good repair and condition, except that furnishings and equipment owned by a resident shall be, at a minimum, in safe condition and not soiled in a manner that presents a health hazard.
Evidence
  1. In the bathroom for resident room #219, the front portion of the toilet seat and rim of the toilet appeared slightly soiled with yellow/dark spots.
  2. In the bathroom for the resident room #201, the bottom portion of the shower curtain appeared soiled/stained.
  3. In resident room H119, the chest of drawers to the left of the window had a missing knob on the top drawer (knob was found on floor and placed on top of the chest of drawers), and the handle on the bottom drawer was partially detached. In the same room, the cover of the seat cushion on the chair by the bed had been removed (it was laying on the back of the chair), and the seat cushion had several visible stains on approximately one third of the surface.
Plan of correction
Toilet in room 219 cleaned to ensure all soiled spots were removed, 201 the shower curtain was removed washed and returned, and H119 repairs made to dresser as well as chair that was soiled has been removed and replaced with a new chair. The Maintenance Director will make random room checks to ensure cleanliness moving forward. [SIC]
22VAC40-73-870-A
Based on observations made during a tour of the building, the facility failed to ensure the interior and exterior of all buildings shall be maintained in good repair and kept clean and free of rubbish.
Evidence
  1. In the bathroom for resident room #H115, there were several used towels and washcloths observed in the shower. In the same bathroom, dark spots were observed on the floor to the right of the base of the toilet.
  2. In the bathroom for resident room #H111, there were several dark spots observed on the floor in front of the shower.
  3. In resident room #112, there were several dark spots observed on the lower left side of the back of the entry door to the room, resembling a liquid that may have been spilled/splashed onto the door.
Plan of correction
Room 112 door was cleaned and all spots removed on 5/21/24. Rooms H111 and H115 will have vinyl flooring replaced to eliminate the spots. Staff re-educated on 5/21/24 to ensure no towels or washcloths are left in the showers. Administrator and/or maintenance director will randomly check flooring for any stains or issues moving forward. DON will periodically monitor showers to ensure no towels or washcloths have been left in these areas. [SIC]
22VAC40-73-640-A
Based on observations made during the medication cart audit, the facility failed to implement a written plan for medication management, including methods to prevent the use of outdated, damaged, or contaminated medications.
Evidence
  1. The May 2024 Medication Administration Record (MAR) and physician’s order dated 02/02/2024 indicate resident #11 receives Lantus 100U/ML Solostar Injection, Inject 8 units sub-q every morning for diabetes mellitus type II. The Lanutus SoloStar pen observed in the medication cart for resident #11 had an open date of 03/13/2024. Instructions on the manufacturer label affixed to the medication state: “Use within 28 days after initial use.” The medication cart audit occurred on 05/10/2024.
  2. The May 2024 MAR and physician’s order dated 02/17/2024 indicate resident #12 receives Insulin Aspart Soln Pen-Injector 100 unit/ML (Generic for NovoLog FlexPen), Check FSBS twice a day – before breakfast and at bedtime and inject per sliding scale: 0-180=0U; 180-250=6U; 251-299=8U; 300 and greater=10U for diabetes mellitus type II. There were two NovoLog FlexPens observed in the medication cart for resident #12; one appeared nearly empty and the other nearly full and neither contained an open date. Per manufacturer instructions found at www.mynovoinsulin.com, unused NovoLog pens can be stored at room temperature up to 86 degrees Fahrenheit for up to 28 days; after use, NovoLog pens can be kept at room temperature (below 86 degrees Fahrenheit) or refrigerated for up to 28 days. The instructions also state the medication should be disposed of after 28 days, even if there is insulin left in the pen.
Plan of correction
Both insulin pens were removed from cart immediately and replaced with new insulin pens that were labeled per policy. DON and/or designee will conduct med cart audits monthly moving forward to ensure no outdated medications are left on the carts. [SIC]
22VAC40-73-610-B
Based on observations made during a tour of the building, the facility failed to ensure menus for meals and snacks for the current week shall be dated and posted in an area conspicuous to residents.
Evidence
  1. There was no menu posted in the safe secure unit at the time of inspection on 05/09/2024, 11:05am.
  2. The licensing inspector checked again for the menu at 11:28am the same date and it had not yet been posted.
Plan of correction
Menu was posted on Secure Care Unit that afternoon. The administrator and/or Dining Manager will do random checks to ensure menus are up and the correct date. [SIC]
22VAC40-73-210-B
Based on a review of staff records and interviews with staff, the facility failed to ensure that in a facility licensed for both residential and assisted living care, all direct care staff shall attend at least 18 hours of training annually.
Evidence
  1. The date of hire for staff #2 was 04/26/2022.
  2. Between 04/26/2023 and 04/25/2024, staff #2 attended five total hours of training.
  3. Between 01/01/2023 and 12/31/2023, staff #2 attended 13.25 hours of training.
  4. Per staff #4 and #5, the documentation provided includes all training hours attended by staff #2.
Plan of correction
All staff of facility will have training hours tracked from date of hire to anniversary date. DON will monitor nursing staff monthly to ensure that hours are completed in a timely manner. BOM will monitor all other department’s staff monthly to ensure all training hours are completed timely. [SIC]
22VAC40-73-380-A
Based on a review of resident records, the facility failed to obtain all required personal and social information on a person prior to or at the time of admission to an assisted living facility, for four of the seven resident records reviewed.
Evidence
  1. Resident #2 was admitted to the facility on 02/25/2023; the section entitled "Current behavioral and social functioning including strengths and problems” on page 2 of the Resident - Personal/Social Data form was not completed.
  2. Resident #3 was admitted to the facility on 04/20/2022. The Resident - Personal/Social Data form did not contain the following information: Previous mental health or intellectual disability services history, if any, and if applicable for care or services; current behavioral and social functioning including strengths and problems; and any substance abuse history if applicable for care or services. (There was no second page, only the first was completed and in the record)
  3. Resident #4 was admitted to the facility on 04/17/2023; the section entitled "Current behavioral and social functioning including strengths and problems” on page 2 of the Resident - Personal/Social Data form was not completed.
  4. Resident #5 was admitted to the facility on 04/12/2024; the section entitled "Current behavioral and social functioning including strengths and problems” on page 2 of the Resident - Personal/Social Data form was not completed.
Plan of correction
Administrator will ensure all current social data sheets are corrected and will review periodically moving forward to ensure all information is correctly documented on the social data sheets. [SIC]
April 11, 2024Complaint survey1 violation
Inspection dates
04/11/2024, 05/16/2024, 05/24/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 04/11/2024 10:58am to 12:45pm, 05/16/2024 12:04pm to 12:21pm, 05/24/2024 12:36pm to 12:41pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 03/18/2024 regarding allegations in the area(s) of: Resident care and related services, health care services. Number of residents present at the facility at the beginning of the inspection: 72 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: n/a Number of interviews conducted with residents: n/a Number of interviews conducted with staff: 6 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported 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 Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.
Violations
22VAC40-73-470-C
Based on review of facility documentation and interviews with staff, the facility failed to ensure health care services shall be provided to prevent clinically avoidable complications, including pressure ulcer development or worsening of an ulcer.
Evidence
  1. Resident #1 was admitted to hospice on 12/06/2023.
  2. Per notes by staff #1, a skin tear was observed on resident #1’s right hip on 01/01/2024. Staff #1 confirmed during a phone interview on 05/06/2024 she did observe the skin tear and reports she covered it with a “circle band-aid.” She reported the Director of Nursing (DON) and hospice should be notified when a skin impairment is observed, because unlicensed staff are not permitted to provide first aid for any skin impairment requiring “anything bigger than a band-aid.” Staff #1 reported she sent a text to staff #2 notifying her of the skin impairment, but reported she did not notify hospice.
  3. Staff #3 worked with resident #1 on 01/02/2024 and documented in notes the presence of the skin tear. She reported during a phone interview on 05/06/2024 she was aware of the skin tear but did not see it because it was covered. She reported she did not clean or dress the skin impairment because unlicensed staff “are not allowed.” She reported if a skin impairment is observed and the resident is receiving hospice services, hospice is to be notified. Otherwise, she stated skin impairments are to be reported to the DON.
  4. The skin tear was documented again in notes on 01/04/2024, on the Daily Charting forms from 01/01/2024-01/05/2024 and the 24 Hour Communication Report on 01/01/2024, 01/03/2024 and 01/04/2024.
  5. Per notes by staff #4 on 01/05/2024, resident #1 had a wound on her right hip. Per phone interview with staff #4 on 05/06/2024, she did not provide any care related to the wound as she is unlicensed, and she noted wounds are to be reported to hospice or the DON.
  6. Per staff #2, she was not notified on 01/01/2024 when the skin tear was initially observed. She reports she was notified by staff #5 on 01/05/2024. She reported the wound was covered with a gauze pad and taped on all four corners when she was notified, and she was not aware of who dressed the wound. She stated the wound was “at least a stage 2” at that point. Staff #2 reported individuals that should be notified when a skin impairment is observed include the assistant DON (ADON), DON or other facility management staff, family and hospice staff. She reported unlicensed staff are only permitted to perform “simple first aid.”
  7. Per hospice notes, a hospice nurse visited resident #1 on 01/03/2024, but there was no documentation regarding a skin tear or a wound. A different hospice nurse visited on 01/05/2024 from 3:00pm to 3:45pm, with no documentation regarding a skin tear or a wound. The same nurse visited again on 01/05/2024 from 4:55pm to 5:40pm and provided care for an “unstageable pressure ulcer/injury.” Her notes documented “Pressure areas to right hip and right ear, not reported earlier in visit.” Wound care was provided by hospice staff again on 01/07/2024 and 01/09/2024.
  8. There was no documentation provided by the facility that indicated direct care staff notified the ADON, DON, other facility management staff or hospice staff when the skin tear was initially observed on 01/01/2024, or at any time prior to 01/05/2024.
Plan of correction
DON/Administrator to provide re-education to all RMAs and LPNs to ensure that with all skin issues that DON/Lavender Hills Coordinator are notified and for all residents on Hospice/Home Health Services, that these agencies are notified as well. DON/Administrator to to provide reducation to all RMAs and LPNs to ensure all skin issues and notifications to management and outside agencies are documented appropriately in residents’ charts. DON/Administrator to perform audits at random for 3 months and intermittently moving forward in order to ensure compliance. [SIC]
December 20, 2023Complaint survey0 violations
Inspection dates
12/20/2023
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/20/2023, 2:07pm to 2:25pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 10/20/2023 regarding allegations in the area(s) of: Staffing and supervision, resident care and related services. Number of residents present at the facility at the beginning of the inspection: 80 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: n/a Number of staff records reviewed: n/a Number of interviews conducted with residents: n/a Number of interviews conducted with staff: 2 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the 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 Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
December 20, 2023Complaint survey0 violations
Inspection dates
12/20/2023
Areas reviewed
22VAC40-61 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/20/2023, 12:25pm to 2:06pm 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 12/11/2023 regarding allegations in the area(s) of: Personnel, resident care and related services. Number of residents present at the facility at the beginning of the inspection: 80 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 4 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the 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 Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
October 17, 2023Inspection0 violations
Inspection dates
10/17/2023
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/17/2023, 12:28pm to 1:02pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 09/26/2023 regarding allegations in the area(s) of: Resident care and related services Number of residents present at the facility at the beginning of the inspection: 87 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: n/a Number of interviews conducted with residents: n/a Number of interviews conducted with staff: 2 Observations by licensing inspector: Additional Comments/Discussion: 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 Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
September 21, 2023Inspection0 violations
Inspection dates
09/21/2023
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/21/2023, 11:43am to 11:45am. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 91 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: N/A Number of interviews conducted with residents: N/A Number of interviews conducted with staff: 2 Observations by licensing inspector: Additional Comments/Discussion: Reviewed housekeeping log for one resident room. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
September 21, 2023Complaint survey0 violations
Inspection dates
09/21/2023
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/21/2023, 10:03am to 11:28am. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 09/18/2023 regarding allegations in the area(s) of: Resident care and relates services. Number of residents present at the facility at the beginning of the inspection: 91 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: N/A Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the 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 Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
August 15, 2023Inspection0 violations
Inspection dates
08/15/2023
Areas reviewed
22VAC40-73 PERSONNEL
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 08/15/2023, 2:45pm to 3:00pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 94 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. N/A Number of resident records reviewed: N/A Number of staff records reviewed: N/A Number of interviews conducted with residents: N/A Number of interviews conducted with staff: 1 Observations by licensing inspector: Reviewed staff training records provided by the facility Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
August 4, 2023Complaint survey5 violations
Inspection dates
08/04/2023
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 08/04/2023, 10:55am to 3:07pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 07/25/2023 regarding allegations in the area(s) of: Personnel, resident care and related services, building and grounds. Number of residents present at the facility at the beginning of the inspection: 94 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 12 Number of staff records reviewed: 8 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: Resident care and related services, building and grounds. A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@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, to document the rounds that were made, including the time of the rounds.
Evidence
  1. Resident #3 was admitted to the secure unit on 11/01/2022 with a diagnosis of dementia and was noted to be unable to recognize danger.
  2. Per a progress note dated 01/17/2023, “Resident (#3) was found on back in floor in room at approx. 0800. States that she had fallen and unable to let staff know.”
  3. The individualized service plan (ISP) dated 11/01/2022 states “Rounds to be performed Q1 hours and call lights to be in place and operational.”
  4. The caregiver assignment sheet shows documentation is only made one time per 8 hour shift, not each hour.
Plan of correction
New one hour rounding sheet has been created and will be signed off by direct care staff for hourly rounds. These will be maintained with ADL records for each individual resident. DON or designee will conduct random audits to ensure compliance. [SIC]
22VAC40-73-870-D
Based on a video recording and interviews with staff, the facility failed to ensure the building shall be kept free of infestations of insects and vermin.
Evidence
  1. A video recording showed ants crawling on resident #2 on 03/18/2023.
  2. Staff #1 confirmed the presence of ants in the room for resident #2 in March 2023 and reports a spray was used when the ants were first observed and the exterminator came to the facility the following week.
Plan of correction
All insects observed by staff or reported to staff will be reported immediately to Maintenance staff to be addressed. Exterminator will be contacted to arrange for them to treat appropriate areas. [SIC]
22VAC40-73-460-A
Based on a tour of the building and interviews with staff, the facility failed to assume general responsibility for the health, safety and well-being of the residents.
Evidence
  1. Resident #1 has two cats in her room.
  2. Per interview with staff #1, he confirmed there has been an ongoing issue with the cats and related foul smell in her room.
  3. During the tour of the building on 08/03/2023, LI observed the two cats in the room for resident #1, and an odor resembling urine.
  4. Per video footage provided to LI, ants were observed to be crawling on the face, neck/chest and arms of resident #2 while she appeared to be resting. The video was dated March 18, 2023, 6:21am.
  5. Per interview with staff #1, he was promptly notified of the incident regarding the ants observed on resident #2 and reports the situation was addressed immediately.
Plan of correction
Housekeeping staff and nursing staff will check Resident #1 's room three times a week and clean as appropriate to reduce odors in the room. Housekeeping will complete a sign off sheet that this has been completed. Resident #1 has been on 30 day notice of discharge and will be transferring to another facility as soon as possible. All insects reported to staff or observed by staff will be addressed immediately by Maintenance staff and exterminator will be contacted to treat needed areas. [SIC]
22VAC40-73-840-B
Based on observations made during a tour of the building and review of facility policies and documentation, the facility failed to adhere to their policy regarding pets living on the premises.
Evidence
  1. Per the facility’s Pet Policy included in the Residency Agreement, it states “One (1) pet per unit (dog or cat).”
  2. Based on facility documentation and observations made by LI during a tour of the building, there were two cats in the room for resident #1.
  3. Per veterinary records maintained at the facility, the cats housed in the room for resident #1 last had an exam and vaccinations on 02/11/2021. The records indicate the cats should have had another exam with vaccinations by 02/11/2022.
Plan of correction
Guardian of resident #1 has been contacted and informed that one of this resident's cats will need to be removed from facility and that remaining cat will need to be vaccinated as soon as possible and records provided to this facility. Administrator or designee will check vet records on admission and annually to ensure compliance. [SIC]
22VAC40-73-870-B
Based on observations made during a tour of the building, the facility failed to ensure all buildings shall be well-ventilated and free from foul, stale and musty odors.
Evidence
  1. The room for resident #1 was observed to have a foul odor resembling urine at 11:35am on the date of inspection.
  2. During the inspection staff # 1 reported that the odor in resident # 1’s room was bad and offered a mask for LI wear due to the strong urine odor.
  3. A strong odor resembling urine was observed in room #130 at 11:55am on the date of inspection, as well as a soiled brief in the trash can.
Plan of correction
All direct care staff will be re-educated to ensure that residents are rounded on every 2 hours on AL side of facility and soiled items removed immediately. Will reeducate all direct care staff to address all odors observed immediately. [SIC]
July 5, 2023Inspection0 violations
Inspection dates
07/05/2023
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/05/2023, 1:30pm to 1:35pm 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: 94 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: n/a Number of staff records reviewed: See below Number of interviews conducted with residents: n/a Number of interviews conducted with staff: 1 Observations by licensing inspector: Additional Comments/Discussion: Staff training records reviewed An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
June 20, 2023Complaint survey0 violations
Inspection dates
06/20/2023, 08/04/2023, 08/15/2023
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/20/2023 1:26pm to 2:13pm, 08/04/2023 1:45pm to 1:58pm, 08/15/2023 3:01pm to 3:11pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 05/31/2023 regarding allegations in the area(s) of: Resident care and related services, medication administration Number of residents present at the facility at the beginning of the inspection: 94 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: N/A Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. 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 Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 15, 2023Complaint survey5 violations
Inspection dates
05/15/2023, 07/05/2023
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 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: 05/15/2023, 2:05pm to 2:40pm, 07/05/2023, 1:20pm to 1:30pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 03/08/2023 regarding allegations in the area(s) of: Resident care and related services, administration of medications Number of residents present at the facility at the beginning of the inspection: 95 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: 3 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegations of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.
Violations
22VAC40-73-450-E
Based on a review of resident records, the facility failed to ensure the Individualized Service Plan (ISP) shall be signed and dated by the resident or his or her legal representative.
Evidence
  1. The ISP dated 03/22/2023 provided to LI is not signed by resident #1 or resident #1’s legal representative.
  2. The ISP updated on 02/27/2023 and 03/07/2023 provided to LI was originally signed by the legal representative for resident #1 on 12/05/2022 but is not signed by resident #1 or the legal representative for resident #1 acknowledging updates on 02/27/2023 and 03/07/2023.
  3. Collateral #1 reports the family did not receive an updated ISP after the 03/07/2023 assessment.
Plan of correction
This resident has been discharged. Moving forward will work to ensure all residents and/or responsible parties sign ISPs and are provided with a copy upon their signature. [SIC]
22VAC40-73-450-C
Based on a review of resident records, the facility failed to ensure the comprehensive Individualized Service Plan includes an accurate description of who will provide certain services, and failed to address all identified needs on Individualized Service Plans (ISPs).
Evidence
  1. The ISP updated 02/07/2023 for resident #1 indicates all direct care staff, hospice staff and family will provide assistance with bathing. Collateral #1 reports family never assisted resident #1 with bathing and would not have agreed to being added to the ISP in this area.
  2. The Uniform Assessment Instrument dated 08/05/2022 for resident #1 identifies mobility, mechanical and human help, physical assistance, as an area in which the resident requires assistance. The ISP dated 08/17/2022 for resident #1 states with regard to mobility: “Resident is to utilize walker/ w/c when ambulating, as needed, for steadiness when being mobile throughout the community.” In the column labeled Persons Who will Provide Services, the ISP states: “self”.
Plan of correction
This resident has been discharged. Moving forward ISPs will be audited sporadically to assist to prevent errors. [SIC]
22VAC40-73-680-D
Based on information received via anonymous complaint and per interview with staff, the facility failed to administer medications in accordance with the physician's or other prescriber’s instructions and consistent with the standards of practice outlined in the current medication aide curriculum approved by the Virginia Board of Nursing.
Evidence
  1. Per report from collateral #1, on 03/04/2023, staff #3 documented on the MAR she administered the 6am dose of Carbidopa-Levodopa ER 50-200 MB TBCR, give twice daily for Parkinson’s disease, when she did not actually administer the medication. Per documentation received from staff #1, staff #3 “stated meds were mistakenly signed off as given and were in fact not given.”
Plan of correction
This resident has been discharged. Employee involved has been addressed and re-educated as well as all medication staff being re-educated. DON or designee will complete random audits of Medication carts and Medication Administration Records to ensure compliance. [SIC]
22VAC40-73-930-A
Based on a review of two of the resident signaling and call system logs, the facility failed to respond timely when direct care staff was notified when a resident needs assistance.
Evidence
  1. The call system log was reviewed for two pendants from the date ranges of 09/01/2022-02/10/2023 for pendant 240 and 12/01/2022-03/30/2023 for pendant MC 102. According to an interview with staff #1 and staff #2, they both agreed a 30-minute response time is an appropriate time frame.
  2. Pendant 240 requested assistance on 12 occasions in which more than 30 minutes passed before a direct care staff member responded to the resident’s need. The following dates, times, and response times were documented for pendant 240: 09/21/2022 – 1:09pm 00:36:11 09/30/2022 – 6:59am 00:44:11 10/07/2022 – 6:51am 00:32:19 10/11/2022 – 7:04am 00:30:55 10/16/2022 – 7:00am 00:34:58 10/27/2022 – 6:59am 00:33:23 11/06/2022 – 6:50am 01:23:37 11/09/2022 – 6:54am 00:38:42 11/11/2022 – 7:16am 00:40:02 11/12/2022 – 7:04am 00:54:32 (Bath) 11/13/2022 – 6:57am 00:32:41 11/20/2022 – 11:33am 00:31:27 (Shower) 11/30/2022 – 7:51pm 00:34:32
  3. Pendant MC 102 requested assistance on six occasions in which more than 30 minutes passed before a direct care staff member responded to the resident’s need. The following dates, times, and response times were documented for pendant MC 102: 12/08/2022 – 3:39pm 00:31:20 12/13/2022 – 2:33pm 00:41:59 12/27/2022 – 9:06am 00:47:13 03/15/2023 – 6:43pm 00:31:52 03/15/2023 – 7:20pm 00:41:28 03/29/2023 – 7:38pm 00:48:23
Plan of correction
All staff have been re-educated regarding timely answering of call lights. The administrator or designee will monitor call lights periodically to ensure compliance. [SIC]
22VAC40-73-460-F
Based on a review of resident records, the facility failed to notify next of kin of any incident of a resident falling or wandering from the premises, whether or not it results in injury. The facility failed to include documentation of notification, including time, caller and person notified.
Evidence
  1. Per collateral #1, next of kin was not notified when resident #1 fell on 01/22/2023.
  2. There was an incident report that included a date of when next of kin was notified, but it did not include a name of who was notified, time of notification or identity of staff person making the notification.
  3. There was no documentation of the fall or notification of next of kin in interdisciplinary notes (other falls and notifications were documented in interdisciplinary notes).
Plan of correction
Will re-educate all medication staff regarding notifying resident and/or responsible parties of incidents and ensuring this is documented. DON or designee will complete random audits of incident reports to assist with ensuring compliance. [SIC]
May 15, 2023Inspection1 violation
Inspection dates
05/15/2023, 06/20/2023
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/15/2023, 2:45pm to 3:15pm and 06/20/2023, 1:14pm to 1:25pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 04/28/2023 regarding allegations in the area(s) of: Resident care and related services, resident rights Number of residents present at the facility at the beginning of the inspection: 95 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: Number of interviews conducted with staff: 1 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported 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 Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.
Violations
22VAC40-73-550-C
Description: Based on facility self-report and documentation review, the facility failed to ensure two residents have the rights and responsibilities as provided in § 63.2-1808 of the Code of Virginia.
Evidence
  1. On 04/28/2023, LI received a report from staff #1 stating “Last night two RAs were taunting, threatening and making videos of two of our MC residents.” Staff #1 reported the videos were posted to social media.
  2. A detailed written report provided by staff #1 states a photo of resident #1 “was posted on social media.”
  3. A detailed written report provided by staff #1 states a video of resident #2 “where foul language and potential verbal abuse was used was posted by a Team Member on social media.”
  4. Per video recording, staff #2 is seen sticking her tongue out and pointing at resident #2, running from resident #2 while resident #2 attempted to follow, and using inappropriate language directed at resident #2. The video also included a photo of staff #3 with resident #1 that was posted to social media.
Plan of correction
Both employees were terminated immediately on 4/28/23. All facility staff provided with training regarding resident rights by local Ombudsman on 5/3/23. Will provide on-going periodic training regarding resident rights. [SIC]
May 15, 2023Inspection6 violations
Inspection dates
05/15/2023
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/15/2023, 10:15am to 5:20pm 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: 95 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 9 Number of staff records reviewed: 4 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 4 Observations by licensing inspector: Noon medication pass, lunch, activities Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.
Violations
22VAC40-73-350-B
Based on a review of resident records, the facility failed to ascertain, prior to admission, whether a potential resident is a registered sex offender if the facility anticipates the potential resident will have a length of stay greater than three days, for one of nine resident files reviewed.
Evidence
  1. Resident #8 was admitted to the facility on 04/19/2022; there was no documentation found in the record indicating the facility ascertained whether the resident is a registered sex offender.
  2. The sex offender screening for resident #8 was obtained by staff #5 during the onsite inspection on 05/15/2023.
Plan of correction
Corrected during inspection. Administrator and/or designee will conduct random audits ongoing to ensure continued compliance. [SIC]
22VAC40-73-325-B
Based on a review of resident records, the facility failed to ensure the fall risk rating was updated at least annually for one of nine resident files reviewed.
Evidence
  1. Resident #8 was rated at the assisted living level of care on the Uniform Assessment Instrument (UAI) dated 09/23/2022.
  2. Resident #8 was admitted to the facility on 04/19/2022; there was no documentation acknowledging a fall risk rating had been completed during the previous 12 months.
  3. Staff #5 completed a fall risk rating for resident #8 during the onsite inspection on 05/15/2023.
Plan of correction
Corrected during inspection. Administrator and/or designee will conduct random audits ongoing to ensure continued compliance. [SIC]
22VAC40-73-450-C
Based on a review of resident records, the facility failed to address all identified needs on Individualized Service Plans (ISPs) for two of nine resident files reviewed.
Evidence
  1. The Uniform Assessment Instrument (UAI) dated 05/03/2023 in the record for resident #6 identifies eating/feeding as an area in which the resident needs help (human help only, supervision). The Individualized Service Plan (ISP) dated 05/09/2023 in the record for resident #6 states “Resident is able to feed herself at this time. Encourage independence.” The ISP does not indicate supervision is being provided, but staff #5 confirms resident does receive supervision/cueing as needed while eating.
  2. The UAI dated 09/23/2022 for resident #8 identifies bathing as an area in which the resident needs help (mechanical help only, shower chair and grab bars). The ISP dated 09/23/2022 for resident #8 indicates the resident is to utilize grab bars as needed, but does not indicate the resident may use a shower chair.
  3. The UAI dated 09/23/2022 for resident #8 identifies money management as an area in which the resident needs help; the ISP dated 09/23/2022 for resident #8 does not address this need.
Plan of correction
ISPs for two residents updated by Administrator on 5/29/23. All ISPs to be randomly audited ongoing to ensure continued compliance. [SIC]
22VAC40-73-410-A
Based on a review of resident records, the facility failed to document acknowledgement of having received orientation for one of nine resident files reviewed.
Evidence
  1. Resident #1 was admitted on 02/28/2022. The New Resident Orientation form in the record for resident #1 was signed and dated by the administrator at that time on 03/01/2022, however it was otherwise completely blank and not signed and dated by the resident and/or the legal representative.
Plan of correction
Resident’s orientation check list completed with resident by Administrator on 6/2/23. Administrator and/or designee will conduct random audits ongoing to ensure continued compliance. [SIC]
22VAC40-73-680-D
Based on observations made during the noon medication pass and the medication cart audit, the facility failed to administer medications in accordance with the physician’s or other prescriber’s instructions and consistent with the standards of practice outlined in the current medication aide curriculum approved by the Virginia Board of Nursing. 1. On medication cart #1, there was no open date on resident #10’s Refresh Tears 0.5mL, one drop in each eye three times daily.
Plan of correction
Eye drops have an open date of 5/15/23 completed by Med Tech on cart 5/15/23. All med carts to be audited for compliance by DON or designee by 6/10/23 and randomly ongoing to ensure continued compliance. [SIC]
22VAC40-73-550-G
Based on a review of resident records, the facility failed to maintain written acknowledgement of annual review of rights and responsibilities of residents in assisted living facilities for one resident.
Evidence
  1. Resident #7 was admitted to the facility on 05/01/2015; there was no documentation acknowledging annual review of resident rights and responsibilities observed in the record for resident #7.
  2. The most recent acknowledgement of annual review of resident rights and responsibilities occurred in 2021.
Plan of correction
Resident rights completed with resident/Daughter by Administrator on 6/1/23. Administrator or designee will conduct random audits ongoing to ensure continued compliance. [SIC]
November 4, 2022Complaint survey3 violations
Inspection dates
11/04/2022
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 IMPAIRMENTS
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/04/2022 Begin: 11:00am End: 1:15pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Use this statement only if the inspection is related to a complaint or self-reported incident: A complaint was received by VDSS Division of Licensing on 10/12/2022, 10/13/2022, 10/15/2022, 10/17/2022 and 10/25/2022 regarding allegations in the area(s) of: resident care Number of residents present at the facility at the beginning of the inspection: 58 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: 3 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 4 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations of non-compliance with standard(s) or law. A violation notice was issued; any violation(s) not related to the (complaint(s) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. 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 Crystal B. Henson Licensing Inspector at 276-608-1067 or by email at crystal.b.mullins@dss.virginia.gov
Violations
22VAC40-73-930-A
Based on observations of call device log and staff interview, the facility failed to act in a timely manner to the signaling device used by residents to alert direct care staff that they need assistance.
Evidence
  1. According to Staff #2 30 minutes is a good response time for any resident needing assistance by a direct care person. Anything over 30 minutes is viewed as excessive.
  2. Resident #1’s pendant alarmed for 59:25 minutes on 10/17/2022; 42:36 on 10/19/2022; and 38:56 on 10/22/2022.
Plan of correction
Administrator and/or DON will audit call light log weekly to ensure timely answering of call lights X 3 months. Staff re-educated regarding timely response to all call lights. Administrator and/or DON will continue to conduct random call light audits to ensure continued compliance. Corrected date 11/15/22 [sic]
22VAC40-73-680-I
Based on observations of the October and November 2022 MAR, the facility failed to ensure the MAR included all medications ordered by a physician.
Evidence
  1. Resident #1 was prescribed Acetaminophen 650 suppository on the physician’s order dated for 08/25/2022. This medication was not listed on the MAR.
Plan of correction
DON will do random MAR to POC audits X 3 months to ensure all orders are on the MAR. DON will do random audits thereafter to ensure compliance. Corrected date 11/11/22 [sic]
22VAC40-73-680-M
Based staff interview, the facility did not have all PRN medications available for one resident.
Evidence
  1. Resident #1 was prescribed Calmoseptine Ointment, apply topically four times daily as needed for wound care and Metronidazole 0.75% cream, use as needed on lesion on wound on back. Neither of these medications were available to the resident at the time of this inspection on 11/04/22.
  2. Staff #3 stated the above mentioned medications were not on the medication cart in the facility.
Plan of correction
Administrator and/or DON will audit call light log weekly to ensure timely answering of call lights X 3 months. Staff re-educated regarding timely response to all call lights. Administrator and/or DON will continue to conduct random call light audits to ensure continued compliance. Corrected date 11/15/22 [sic] DON will audit Med carts 2 X a month X 3 months to ensure all PRNs are available. DON will thereafter complete random audits to ensure continued compliance. Corrected date 11/5/22
November 4, 2022Inspection0 violations
Inspection dates
11/04/2022
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: 11/04/2022 Start: 10:40am-11:00am The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Crystal B. Mullins Licensing Inspector at 276-608-1067 or by email at crystal.b.mullins@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
November 4, 2022Inspection0 violations
Inspection dates
11/04/2022
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: 11/04/2022 Start: 9:48am-10:21am The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Crystal B. Mullins Licensing Inspector at 276-608-1067 or by email at crystal.b.mullins@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
November 4, 2022Inspection0 violations
Inspection dates
11/04/2022
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: 11/04/2022 Start: 10:22am-10:40am The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Crystal B. Mullins Licensing Inspector at 276-608-1067 or by email at crystal.b.mullins@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
September 20, 2022Complaint survey1 violation
Inspection dates
Sept. 20, 2022
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/20/2022 Begin: 3:55pm Conclude: 5:18 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. However, violation(s) not related to the complaint but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Crystal B. Mullins, Licensing Inspector at 276-608-1067 or by email at crystal.b.mullins@dss.virginia.gov
Violations
22VAC40-73-930-A
Based on a review of three of the resident signaling and call system logs, the facility failed to respond timely when direct care staff was notified when a resident needs assistance. 1. The call system log was reviewed for three pendants from the date range of 09/13/2022-09/21/2022. According to an interview with Staff #1 and Staff #2, they both agreed a 15 minute response time is an appropriate time frame. 2. Pendant 244 requested assistance on four occasions in which more than 30 minutes passed before a direct care staff member responded to the resident’s need. The following dates, times, and response times were documented for pendant 244: 9/18/22 10:55pm 39:10 9/19/22 10:26pm 1:02:05 9/19/22 11:50pm 31:28 9/20/22 12:33am 1:05:00 3. Pendant 130 requested assistance on two occasions in which more than 30 minutes passed before a direct care staff member responded to the resident’s need. The following dates, times, and response times were documented for pendant 130: 9/17/22 5:15am 1:10:28 9/17/22 12:46pm 38:15 4. Pendant 203 did not have any occasions in which more than 30 minutes passed before a direct care staff member responded to the resident’s need.
Plan of correction
Administrator initiated facility Call Light System review for upgrade prior to inspection. Call Light System upgrade service date pending. Nursing Department provided instruction on Call Light Response Time by Administrator on 9/21/22. [sic]
September 8, 2022Complaint survey2 violations
Inspection dates
Sept. 8, 2022
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/08/2022 9:45AM through 1:00PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 09/07/2022 regarding allegations in the area of resident care and related services. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-650-B
Based on resident record review, the facility failed to ensure a physician or other prescriber’s oral order for administering a medication included the route, dosage, and how often the medication is to be given to a resident.
Evidence
  1. The record for resident 1 contained a physician’s order, dated 09/02/2022, for Zithromax 250MG take as directed for seven days. The order does not include the route, dosage, nor how often the medication is to be administered to the resident. Interview with staff 1 confirmed this is accurate.
Plan of correction
A educational meeting was conducted on 9/8/22 with Medication Administration Staff. The subjects covered during the meeting were as follows: Medication Administration Guidelines, Medication Management Plan (including ensuring physician or other prescriber’s oral orders for administering a medication include the route, dosage, and how often the medication is to be given.), and Documentation. A clarification order was obtained on 9/9/22 to include the route and dosage for the Zithromax 250MG. DON/Designee will conduct an educational Medication Management meeting monthly for 3 months and intermittently moving forward in order to review the aforementioned topics as a method of ensuring requirements of VDSS standards are maintained.
22VAC40-73-640-A
Based on resident record review and document review, the facility failed to ensure to implement their medication management plan.
Evidence
  1. The facility’s medication management plan provided during on-site inspection on 09/08/2022 indicated the following: “5. Methods for verifying that medication orders have been accurately transcribed to the Electronic Medication Administration Record: B. The Pharmacy is responsible for transcribing orders to the Electronic Medication or Treatment Record at the time they are received from the Physician or Prescriber within 24 hours of receipt of the the [sic] New Order of Change in the Order. The DON/Nurse/MT is responsible for verifying accurate input of the new order or change in the order. The record for resident 1 contained a physician’s order, dated 09/02/2022, for the following medications due to the resident’s diagnosis of pneumonia: Doxycycine 100MG by mouth two times a day for seven days, Zithromax 250MG take as directed for seven days, and Culturelle two capsules by mouth every day for 14 days. The aforementioned medications were delivered to the facility on 09/02/2022; however, the administration of the three medications did not start until 09/06/2022. Interview with staff 2 confirmed this was accurate as the medications were not transcribed to the electronic medication administration record until 09/06/2022 therefore staff were unaware to administer the medications to the resident until 09/06/2022.
Plan of correction
A educational meeting was conducted on 9/8/22 with Medication Administration Staff. The subjects covered during the meeting were as follows: Medication Administration Guidelines, Medication Management Plan (including methods to verify that medication orders have been accurately transcribed to the Electronic Medication Administration Record at the time that they are received from the Physician or Prescriber within 24 hours of receipt of the new or changed order.), and Documentation. Reeducation was provided to the Medication Administration Staff directly involved with the occurrence on or before 9/15/22. Regional Director of Resident Care/Designee performed Medication Pass Observations, at random, on 9/11/22 in order to verify accurate medication administration guidelines were followed. Regional Nursing Supervisor completed Medication Cart audits for accuracy by 9/14/22. DON/Designee will conduct an educational Medication Management meeting monthly for 3 months and intermittently moving forward in order to review the aforementioned topics as a method of ensuring requirements of VDSS standards are maintained.
September 8, 2022Complaint survey4 violations
Inspection dates
09/08/2022
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/08/2022 9:45AM through 1:00PM. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 07/29/2022 regarding allegations in the areas of: resident care and related services and personnel. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. However, violation(s) not related to the complaint but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-640-A
Based on document review, the facility failed to implement their medication management plan regarding methods to ensure accurate counts of controlled substances whenever assigned medication administration staff changes.
Evidence
  1. Section 14.A. of the facility’s medication management plan states, “During shift change, all narcotics, cards, bottles, sheets are counted and recorded by the oncoming and off-going medication persons. The oncoming and off-going both sign off on the accurate counts of all narcotics on the Narcotic Administration Record.”
  2. Schedule 2 drugs are counted on a different form, the Narcotic Count Sheet. The Narcotic Count Sheets for August 2022 for Cart 3 show numerous omissions as noted below: 8/1/2022, no oncoming signatures at 3 pm or 11pm, no bottle count on 1st shift, no counts for 3rd shift; 8/4/2022, no oncoming signature at 3 pm, no counts for 1st shift; 8/5/2022, no oncoming signature at 3 pm, no off-going signature at 7 am; 8/6/2022, no oncoming signature at 7 am, no counts for 1st shift, no bottle counts for any shift; 8/7/2022, no off-going signature at 3 pm, no oncoming signature at 3 pm, no counts for 1st shift; 8/9/2022, no off-going or oncoming signatures at 3 pm, no counts for 1st shift; 8/12/2022, no bottle count for 1st shift; 8/15/2022, no counts entered for cards, pages, or bottles; 8/16/2022, no counts for bottles on 1st or 2nd shift; 8/17/2022, no off-going or oncoming signatures at 3 pm, no counts for 1st shift; 8/18/2022, no signatures at all for 2nd or 3rd shift, no counts at all; 8/19/2022, no signatures and no counts; 8/20/2022, no oncoming signature for 7 am, no page count for 1st shift; 8/21/2022, no oncoming signature for 3 pm, no off-going signature for 7 am, no counts for 2nd or 3rd shift; 8/22/2022, no signatures and no counts; 8/23/2022 no signatures for first shift and oncoming at 3 pm, no off-going signature for 7 am, no counts at all; 8/24/2022, no oncoming signature at 7 am, no counts for 1st or 2nd shift; 8/26/2022, no signatures for 3 pm; 8/27/2022, no signatures for 3 pm, no counts for 1st shift; 8/28/2022, no signatures for 3 pm, no counts for 1st shift; 8/29/2022, no counts at all, no signatures for off-going or oncoming at 11 pm, no signature for oncoming at 7 am; 8/30/2022, no signature for oncoming at 7 am, no off going signature for 7 am at end of day, no counts for 1st or 3rd shift; 8/31/2022, no oncoming signature at 1 am, no page counts.
Plan of correction
Resident no longer resides within the facility. A educational meeting was conducted on 9/8/22 with Medication Administration Staff. The subjects covered during the meeting were as follows: Medication Administration Guidelines, the Facility Medication Management Plan (including methods to ensure accurate counts of controlled substances whenever assigned Medication Administration Staff changes), and Documentation. A Controlled Substance Count audit to be conducted by the Administrator/DON/Designee, at random, weekly for 3 months and intermittently moving forward in order to ensure that accurate counts of controlled substances are documented as required by VDSS standards.
22VAC40-73-450-D
Based on resident record review, the facility failed to specify what hospice services were being provided on the individualized service plan (ISP).
Evidence
  1. The ISP for resident 1, dated 11/18/2021 and updated 7/18/2022, shows that hospice services began 11/17/2021; however, the services to be provided were not specified.
Plan of correction
Resident no longer resides within the facility. An ISP audit will be conducted by the Administrator/DON/Designee, at random, monthly for 3 months and intermittently moving forward in order to ensure that hospice provided services are notated as required by VDSS standards.
22VAC40-73-450-E
Based on resident record review, the facility failed to obtain some required signatures on the individualized service plan (ISP).
Evidence
  1. The ISP for resident 1 was initially done on 11/18/2021 and there is no signature from the resident or the resident’s legal representative. This plan was updated on 1/26/2022, 1/27/2022, and 06/20/2022 and there are no signatures from the facility or the resident/legal representative. This plan was updated 7/18/2022 and there is no signature from the resident or legal representative.
Plan of correction
Resident no longer resides within the facility. An ISP audit will be conducted by the Administrator/DON/Designee, at random, monthly for 3 months and intermittently moving forward in order to ensure that required signatures are obtained as required by VDSS standards.
22VAC40-73-700-1
Based on resident record review, the facility failed to obtain a complete oxygen order for a resident.
Evidence
  1. The oxygen order for resident 1 lacks information regarding the source of the oxygen, for example: tank or concentrator.
Plan of correction
Resident no longer resides within the facility. A educational meeting was conducted on 9/8/22 with Medication Administration Staff. The subjects covered during the meeting were as follows: Medication Administration Guidelines, Medication Management Plan (including requirements for complete oxygen orders), and Documentation. A Physician’s Oxygen Order audit to be conducted by the DON/Designee, at random, monthly for 3 months and intermittently moving forward in order to ensure that oxygen orders contain information regarding the source of the oxygen per VDSS standards.
September 8, 2022Complaint survey7 violations
Inspection dates
09/08/2022
Areas reviewed
22VAC40-73 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: 09/08/2022 9:45AM until 1:00PM. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 07/29/2022 regarding allegations in the areas of: resident care and related services and resident accommodations and related provisions. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. However, violation(s) not related to the complaint but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-660-B
Based on observation made of the facility’s physical plant and resident record review, the facility failed to ensure that dietary supplements kept in resident rooms are only permitted for residents who are indicated as capable of self-administering their own medications.
Evidence
  1. The refrigerator resident 1’s room contained multiple containers of Ensure original supplement. The uniform assessment instrument (UAI) for resident 1, dated 07/19/2022, indicated that the resident requires all medications to be administered by professional nursing staff and/or registered medication aides (RMAs). The record for resident 1 contained a physician’s order, dated 08/23/2022, for Ensure drink one bottle/carton by mouth twice daily for lack of appetite/weight loss if patient can tolerate and does not contain information that the resident can keep the aforementioned supplement in their room.
Plan of correction
Order obtained from Hospice FNP on 9/15/22 for 1 Ensure prn to be kept at bedside for supplement. Family member notified of necessity of a physician or other prescriber’s order in order to maintain medications or supplements in the resident’s room. DON/Designee to review Nutritional Supplement orders moving forward in order to ensure that appropriate orders are obtained when such supplements are requested and deemed appropriate to be kept in the Resident’s room.
22VAC40-73-450-C
Based on resident record review and staff interview, the facility failed to ensure that all identified needs were addressed on individualized services plans (ISPs).
Evidence
  1. The uniform assessment instrument (UAI) for resident 1, dated 07/19/2022, indicated that the resident requires physical human help and mechanical help with dressing. The ISP for the resident, dated 07/19/2022, indicated that the resident only requires physical human help with dressing. Interview with staff 2 revealed that the UAI is correct and the ISP is incorrect.
Plan of correction
Administrator completed updated ISP on 9/9/22 in order to accurately reflect the Resident’s needs in regard to dressing. Administrator/Designee to perform ISP audits, at random, monthly for 3 months and intermittently moving forward in order to ensure that all identified resident needs are addressed accurately on Individualized Service Plans.
22VAC40-73-440-D
Based on resident record review and staff interview, the facility failed to ensure that private pay uniforms assessments (UAIs) were completed as required.
Evidence
  1. The UAI for resident 1, dated 07/19/2022, indicated that the resident requires mechanical help only with eating/feeding. During on-site inspection it was expressed to the licensing inspector by staff 2 that resident 1 requires staff to sit her up in her bed prior to eating and sometimes spoon feed her food because she is not able to feed herself some days. Interview with staff 2 revealed that the resident does require mechanical help and human physical help with eating/feeding therefore the UAI is incorrect.
Plan of correction
Administrator completed updated UAI on 9/9/22 in order to accurately reflect the Resident’s needs in regard to eating/feeding. Admin./Designee to perform UAI audits, at random, monthly for 3 months and intermittently moving forward in order to ensure that Private Pay Uniform Assessments are completed and accurate as required by VDSS.
22VAC40-73-460-H
Based on observation, resident record review, and staff interview, the facility failed to ensure that personal assistance and care were provided to each resident as necessary so that the needs of the resident are met.
Evidence
  1. During on-site inspection on 09/08/2022, the licensing inspector observed at approximately 10:03AM a Styrofoam container on the resident’s bed side tray that contained mechanically altered food and a Styrofoam cup of coffee. The licensing inspector observed resident 1 lying in her bed at this time as well. This was also observed by staff 2 and staff 2 revealed that the Styrofoam container contained the resident’s breakfast and that kitchen staff bring the containers to residents’ room and then direct care staff are to feed the residents that require feeding assistance. Staff 2 acknowledged that the food had not been given to the resident. The licensing inspector and staff 2 also noted that the resident was holding an empty Styrofoam cup in her right hand. Interview with staff 4 and 5 revealed that they were the staff responsible for the resident on this date. Staff 4 stated the following: “I didn’t come into her room this morning because I forgot to come and feed her” and when asked what she would do for the resident staff 4 stated that “I would come in and sit her up in her bed and feed her.” The resident expressed that she wanted water and staff 2 proceeded to get a small bottle of water with a straw and the licensing inspector observed that the resident drank half of the small bottle of water and staff 2 held the bottle of water for the resident so she could drink.
Plan of correction
Reeducation was provided to the two staff members directly involved in the occurrence on 9/8/22. Reeducation included: Nutrition and Hydration as well as meeting and documenting identified needs of the resident. Education to be provided to all Team Members of the facility by 9/21/22 in regard to current residents requiring assistance with eating/feeding as well as the importance of proper nutrition and hydration and scheduled meal times.
22VAC40-73-870-A
Based on observations made of the facility’s physical plant, the facility failed to maintain and keep clean the interior of the building.
Evidence
  1. The carpet next to resident 1’s bed and in front of the door of the closet contained multiple stains. Underneath the resident’s bed the licensing inspector observed a balled up tissue, a white, small piece of cardboard, and other multiple small items of objects and the wall behind the head of the resident’s bed contained multiple, black scuff marks.
Plan of correction
Carpets in the involved room have been cleaned and sanitized as well as paint touch ups several times prior to inspection. Carpets scheduled to be replaced by 9/16/22. Scuffed marks and debris removed on 9/8/22. Maintenance Director or Designee to monitor cleanliness and maintenance of resident room once weekly moving forward.
22VAC40-73-450-D
Based on resident record review, the facility failed to ensure when hospice care is provided to a resident, the services provided by the licensed hospice organization are included on the individualized service plan (ISP).
Evidence
  1. Resident 1 receives hospice care; however, the ISP for the resident, dated 07/19/2022, does not indicate which hospice organization is providing hospice services to the resident nor what services the hospice organization is providing to the resident.
Plan of correction
Administrator completed updated ISP on 9/9/22 in order to accurately reflect the resident’s needs in regard to services provided by a Licensed Hospice Organization. Administrator/Designee to perform ISP audits, at random, monthly for 3 months and intermittently moving forward in order to ensure that the entity name and services provided are included in the plan of care per VDSS standards.
22VAC40-73-325-B
Based on resident record review and staff interview, the facility failed to ensure the fall risk rating for a resident was updated at least annually.
Evidence
  1. The most recent fall risk rating for resident 1 was dated 02/04/2021. Interview with staff 1 confirmed this was accurate.
Plan of correction
Annual Fall Risk Rating completed by Administrator on 9/8/22. Administrator to conduct audits of Annual Fall Risk Ratings, at random, monthly for 3 months and intermittently moving forward in order to ensure compliance with VDSS regulations.
July 19, 2022Inspection5 violations
Inspection dates
07/19/2022
Comments
¿ 22VAC40-73-(1) GENERAL PROVISIONS ¿ 22VAC40-73-(2) ADMINISTRATION AND ADMINISTRATIVE SERVICES ¿ 22VAC40-73-(3) PERSONNEL ¿ 22VAC40-73-(4) STAFFING AND SUPERVISION ¿ 22VAC40-73-(5) ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS ¿ 22VAC40-73-(6) RESIDENT CARE AND RELATED SERVICES ¿ 22VAC40-73-(7) RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS ¿ 22VAC40-73-(8) BUILDINGS AND GROUND ¿ 22VAC40-73-(9) EMERGENCY PREPAREDNESS ¿ 22VAC40-73-(10) ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/19/2022 Start: 10:00am conclude 11:55am The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/19/2022 Start: 10:00am conclude 11:55am 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 07/15/2022 regarding allegations in the area of medication administration. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: Additional Comments/Discussion: 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 Crystal B. Mullins, Licensing Inspector at (276) 608-1067 or by email at crystal.b.mullins@dss.virginia.gov Violation Notice Issued: Yes A copy of this document will be sent to the licensee/provider for signature.
Violations
22VAC40-73-680-K
Based on the review of a resident record and the MAR (Medication Administration Record), the facility failed to obtain from the physician or other prescriber a detailed medication order when PRN (as needed) medication is administered by Based on the review of a resident record and the MAR (Medication Administration Record), the facility failed to obtain from the physician or other prescriber a detailed medication order when PRN (as needed) medication is administered by medication aides to residents that are not capable of determining when medication is needed
Evidence
  1. Resident #1 is prescribed Hydromorphone HCL 1mg/mL, give 0.5mL every four hours as needed for pain or shortness of breath; Acetaminophen 500mg tablet, take one tablet by mouth every six hours as needed for pain/fever; and Tramadol HCL 50mg tablet, take one tablet by mouth every four hours as needed for pain. The physician’s or other prescriber’s order does not include symptoms that indicate the use of the medication, the exact time frame the medications are to be given in a 24 hour period, or directions as to what to do if symptoms persist.
  2. Staff #3, #4, and #5 which are medication aides at the facility, have administered the above PRN medications to Resident #1.
  3. According to Staff #6, Resident #1 was able to ask for medications and express she was in pain until approximately two weeks ago, and stated now they have to look for facial grimacing or moaning and groaning as signs/symptoms that resident is in pain.
  4. On the date of the inspection (07/19/2022) the LI attempted to speak with Resident #1 but she did not answer verbally; she did smile, open her eyes and nodded her head.
Plan of correction
Staff person involved in medication administration was removed from the position of medication administration on 7/19/22 PRN medications reviewed by Regional DORC/DON/Designee on 8/24/22 to verify that signs and symptoms of PRN medications are documented accordingly, standard reviewed with DON on 8/24/22. DON/Designee to perform Physician Order Sheet audits monthly for 3 months and intermittently moving forward to ensure that PRN medication signs and symptoms are appropriately documented. [sic]
22VAC40-73-680-D
Based on staff interview and documentation, the facility failed to administer medications in accordance with the physician or other prescriber’s instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing.
Evidence
  1. Resident #1 is prescribed Hydromorphone HCL 1mg/mL, give 0.5mL every four hours as needed for pain or shortness of breath. Based on staff interview and documentation, the facility failed to administer medications in accordance with the physician or other prescriber’s instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. EVIDENCE:
  2. Resident #1 is prescribed Hydromorphone HCL 1mg/mL, give 0.5mL every four hours as needed for pain or shortness of breath.
  3. According to a statement from Staff #1, on 07/14/2022 at approximately 2:28pm Staff #6 administered Resident #1 5.0mL (ten times the prescribed dose) to residents that are not capable of determining when medication is needed of Hydromorphone after she complained of back pain.
  4. Staff #7 documented on 07/14/2022 in the facility Interdisciplinary Notes at 3:30 pm she checked on Resident #1, she was lying in bed, her color was very pale, had oxygen on and was noted to be very diaphoretic and unresponsive. Again at 7:00pm Resident #1 was noted as being unresponsive but not diaphoretic.
  5. During an interview with Collateral #1 she stated “dose could have killed her” in regards to the 5.0mL dose of Hydromorphone and stated that facility staff should have notified Hospice of the discrepancy and the change in Resident #1’s condition.
  6. Staff #2 discovered a discrepancy in the narcotic count for Hydromorphone for Resident #1 on 07/15/2022, it was discovered 45mL was the start dose of Hydromorphone. After Staff #6 administered the incorrect dose of 5.0mL, the balance was 40.0mL of Hydromorphone.
Plan of correction
Staff person involved in medication administration was removed from the position of medication administration on 7/19/22. Medication Administration meeting with Med Staff took place on 8/2/22. Regional Director of Resident Care and COO present at facility beginning 8/2/22 for increased monitoring and oversight of medication administration. Ongoing. Medication Administration training scheduled for 9/6/22 for all medication staff. Medication Administration oversight to be performed at random, moving forward, to ensure compliance. [sic]
22VAC40-73-450-F
Based on staff interview and review of a resident record, the facility failed to update the ISP (Individualized Service Plan) at least once every 12 months.
Evidence
  1. Documentation review and interview with Staff #1, confirm the most up to date ISP for Resident #1 was dated 02/04/2021.
Plan of correction
The resident ISP was updated on 7/19/22. ISPs to be updated annually or upon any significant change in condition. DON/Designee to perform ISP audits, at random, monthly for 3 months and intermittently moving forward as a preventative measure. [sic]
22VAC40-73-680-E
Based on the review of a resident record, the facility failed to record pertinent information such as services ordered by a physician and provided by an outside agency and the resulting evaluations of progress.
Evidence
  1. Resident #1 receives hospice. On the day of inspection, 07/19/2022 hospice note in the file was dated 06/30/2022.
  2. According to Staff #2, the hospice notes are kept by the company providing the service and left at the facility at the end of the month for which service was provided.
Plan of correction
On 7/19/22, DON requested and initiated Hospice notes to be left after each visit from provider. Notes to be placed in the Resident file by designated staff member(s). DON/Designee to monitor monthly for 3 months and intermittently moving forward as a preventative measure. [sic]
22VAC40-73-450-D
Based on the review of a resident record, the facility failed to include hospice care as a provided service on the on the ISP.
Evidence
  1. The ISP dated 02/04/2021 did not include hospice and the specifics of the services they provide to Resident #1.
Plan of correction
The resident ISP was updated on 7/19/22. ISPs to be updated upon any significant change in condition. DON/Designee to perform ISP audits, at random, monthly for 3 months and intermittently moving forward as a preventative measure. [sic]
July 19, 2022Complaint survey0 violations
Inspection dates
07/19/2022
Areas reviewed
¿22VAC40-73 GENERAL PROVISIONS¿22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES¿22VAC40-73 PERSONNEL¿22VAC40-73 STAFFING AND SUPERVISION¿22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS¿22VAC40-73 RESIDENT CARE AND RELATED SERVICES¿22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS¿22VAC40-73 BUILDINGS AND GROUND¿22VAC40-73 EMERGENCY PREPAREDNESS¿22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS¿ARTICLE 1 – SUBJECTIVITY¿32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS
Comments
Type of inspection: Complaint Date(s) of inspection: 07/19/2022 and time the licensing inspector was on-site at the facility for each day of the inspection: 12:14pm-2:20pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 07/12/2022regarding allegations in the area of resident records and resident care and staffing ratios: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of resident records and resident care 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 Crystal B. Mulliins, Licensing Inspector at 276-608-1067 or by email at crystal.b.mullins@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
July 19, 2022Complaint survey0 violations
Inspection dates
07/19/2022
Areas reviewed
¿22VAC40-73 GENERAL PROVISIONS¿22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES¿22VAC40-73 PERSONNEL¿22VAC40-73 STAFFING AND SUPERVISION¿22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS¿22VAC40-73 RESIDENT CARE AND RELATED SERVICES¿22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS¿22VAC40-73 BUILDINGS AND GROUND¿22VAC40-73 EMERGENCY PREPAREDNESS¿22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS¿ARTICLE 1 – SUBJECTIVITY
Comments
Type of inspection: Complaint Date(s) of inspection: 07/19/2022 and time the licensing inspector was on-site at the facility for each day of the inspection: 11:58am-12:11pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 06/28/2022regarding allegations in the area of resident records and resident care: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of resident records and resident care 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 Crystal B. Mulliins, Licensing Inspector at 276-608-1067 or by email at crystal.b.mullins@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
June 15, 2022Inspection7 violations
Inspection dates
06/15/2022
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/15/2022 10:15 AM – 03:30 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
22VAC40-73-700-1
Based on record review, the facility failed to ensure that oxygen orders contained the oxygen source, such as compressed gas or concentrators; the delivery device, such as nasal cannula, reservoir nasal cannulas, or masks; and the flow rate deemed therapeutic for the resident.
Evidence
  1. The record for resident 8, admitted 02/21/2022, contained signed physician’s orders, effective 06/01/2022, that stated “Continue home O2” with no other clarifying oxygen orders found in the resident’s record.
Plan of correction
The DON will review oxygen orders monthly to ensure accuracy and containment of source, delivery device and flow rate.
22VAC40-73-870-A
Based on observations made during tour of the building, the facility failed to ensure the interior and exterior of all buildings shall be maintained in good repair and kept clean.
Evidence
  1. The door to the restroom and the door to the medication room at the entrance of the safe and secure unit had a brown and black substance or stain on the surface in an approximate three foot section.
  2. The resident room doors had been painted blue, the blue paint is worn and scratched off from the surface leaving the under color of paint visible. The room numbers are: H101, 102, 103, 104, 105, 106, 107, 117, and 122 all in the safe, secure unit.
  3. The dining area in the safe, secure unit near the exit to the outdoors was observed to have black scrapes, scratches, and scuffs all around the perimeter which appeared to be wheelchair level along the wall.
Plan of correction
The walls, resident room doors and dining area were in process of repair and touch up paint prior after areas were identified during a facilities self-audit, then again at inspection. Areas were completed 07-01-22.
22VAC40-73-650-A
Based on record review, the facility failed to ensure that no medication shall be started, changed, or discontinued by the facility without a valid order from a physician or other prescriber.
Evidence
  1. Resident 15 has a signed physician’s order for sliding scale insulin for Humalog Kwikpen 100 unit/mL injection, effective 06/03/2021, which indicates “INJECT SUBCUTANEOUSLY PER SLIDING SCALE BEFORE MEALS AND AT BEDTIME FOR DM AS FOLLOWS; 250-299 =8U; 300-349 =10U, 350-399 = 12U, 400-449 = 14U, 450-499 = 18U, OVER 500 = 24U, IF “HI” CONTACT MD/NP”.
  2. Per a review of the June 2022 medication administration record for resident 15, documentation from medication administration staff indicates that Humalog Kwikpen 100 unit/mL injection was given incorrectly based on the sliding scale on the following dates and times: 06/01/2022 at 09:00 PM, blood glucose (BG) = 500, was given 14 U; 06/02/2022 at 04:30 PM, BG = 268, was given 0 U; 06/03/2022 at 06:30 AM, BG = 174, was given 13 U; 06/07/2022 at 09:00 PM, BG = 384, was given 14 U; 06/08/2022 at 06:30 AM, BG = 336, was given 0 U; and 06/13/2022 at 09:00 PM, BG =346, was given 120 U.
Plan of correction
All medication staff will receive additional review for sliding scale medications. DON will conduct random monthly audits for residents receiving sliding scale medications for 3 months.
22VAC40-73-550-G
Based on review of resident files, the facility failed to review the rights and responsibility with one resident on an annual basis.
Evidence
  1. Resident 3 was admitted to the facility on 07/07/2020.
  2. Resident rights were documented as reviewed on 07/07/2020 and 01/04/2021.
  3. The rights were not documented as reviewed again in the resident file.
Plan of correction
Resident 3’s Rights were reviewed and signed on 06/16/2022.
22VAC40-73-440-D
Based on record review, the facility failed to ensure that for a private pay individual, the uniform assessment instrument (UAI) is completed as required.
Evidence
  1. The UAI for resident 6, dated 12/01/2021, indicated that this resident requires supervision when bathing; however, the resident’s individualized service plan (ISP), dated 12/15/2021, indicated that the resident requires mechanical assistance and human supervision for bathing. In addition, the UAI for resident 6 indicated that this resident requires human physical assistance only while toileting; however, the ISP indicated that this resident requires mechanical and physical assistance for toileting. Also, the UAI for resident 6 indicated that this resident requires physical assistance for mobility; however, the ISP indicated that this resident requires mechanical and physical assistance. Finally, the UAI for resident 6 indicated that the resident requires supervision when walking; however, the ISP for this resident indicated that the resident requires mechanical assistance.
  2. Interview with staff 6 indicated that for bathing, toileting, mobility, and walking, the UAI for resident 6 is incorrect.
  3. The UAI for resident 8, dated 03/01/2022, indicated that the resident requires mechanical assistance for stairclimbing; however, the ISP for resident 8, dated 03/01/2022, indicated that the resident requires mechanical and physical assistance.
  4. Interview with staff 6 indicated the UAI for resident 8 is incorrect.
Plan of correction
The DON and Administrator will review UAIs and ISPs to ensure documents are completed as required. The Director of Resident Care will audit 3 completed UAIs and ISPs monthly for 3 months.
22VAC40-73-870-E
Based on observations made during the tour of the building, the facility failed to keep all furnishings, fixtures, and equipment clean and in good repair.
Evidence
  1. The bottom cabinet area of the fish tank in the safe and secure unit had scratches and scrapes in the wood finish.
Plan of correction
The fish tank cabinet was noted to need repair during a facilities self-audit, and at inspection. Area was completed on 07-01-22.
22VAC40-73-980-A
Based on the audit of the first aid kit, the facility failed to include all items required by the standards in the first aid kit.
Evidence
  1. The first aid kit did not contain the required disposable single-use breathing barriers or shields for use with rescue breathing or CPR.
Plan of correction
The DON or designee will complete monthly audits for the first aid kit. The CPR barrier was replaced on 06-16-22.
June 15, 2022Inspection0 violations
Inspection dates
06/15/2022
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
he evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Crystal B. Mullins, Licensing Inspector at 276-608-1067 or by email at crystal.b.mullins@dss.virginia.gov Type of inspection: Monitoring 06/15/2022 the licensing inspector was on-site at the facility for each day of the inspection: The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
June 15, 2022Inspection0 violations
Inspection dates
06/15/2022
Areas reviewed
¿22VAC40-73 GENERAL PROVISIONS¿22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES¿22VAC40-73 PERSONNEL¿22VAC40-73 STAFFING AND SUPERVISION¿22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS¿22VAC40-73 RESIDENT CARE AND RELATED SERVICES¿22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS¿22VAC40-73 BUILDINGS AND GROUND¿22VAC40-73 EMERGENCY PREPAREDNESS¿22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS¿ARTICLE 1 – SUBJECTIVITY¿32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS¿63.2 GENERAL PROVISIONS¿63.2 PROTECTION OF ADULTS AND REPORTING¿63.2 LICENSURE AND REGISTRATION PROCEDURES¿63.2 FACILITIES AND PROGRAMS¿22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES¿22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION¿22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT¿22VAC40-80 THE LICENSE¿22VAC40-80 THE LICENSING PROCESS¿22VAC40-80 COMPLAINT INVESTIGATION¿22VAC40-80 SANCTIONS
Comments
The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Crystal B. Mullins, Licensing Inspector at 276-608-1067 or by email at crystal.b.mullins@dss.virginia.gov Type of inspection: Monitoring 06/15/2022 the licensing inspector was on-site at the facility for each day of the inspection: The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
January 4, 2022Complaint survey4 violations
Inspection dates
01/04/2022
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Two licensing inspectors conducted an unannounced complaint inspection in response to a complaint that was received by the licensing office on 01/04/2022. Interviews were conducted with resident and staff and the resident file and other documents were reviewed relating to the allegations of resident not receiving prescribed medications. The information gathered did support the allegations in the complaint; and other non reported violations were cited during the inspection. Please complete a corrective action plan for the four violations cited and the date of correction and send it back to the licensing office within 10 calendar day (2/26/2022) of receipt. If you have any questions or need assistance, contact your licensing inspector at (276) 608-3514. Arrived: 11:20 am Exit: 2:00 pm
Violations
22VAC40-73-460-A
Based on documentation review and interviews with staff, the facility failed to assume general responsibility for the health, safety and well-being of one resident in care.
Evidence
  1. According to the most recent Uniform Assessment Instrument (UAI) for resident # 1 dated 06/26/2020 rates her dependent in medication administration.
  2. According to the Individualized Service Plan (ISP) for resident # 1 dated 7/12/2021 it is documented she needs assistance with medication administration and will receive all medications as prescribed by the doctor.
  3. According to the Physical Examination report for resident # 1 dated November 1, 2019 she has a diagnosis of congestive heart failure, hypertension and has a medical history of aspiration pneumonia.
  4. According to the most recent physicians orders for resident # 1 dated December 7, 2021 she is prescribed the following medications: Ferrous Sulfate 325 mg tablets take one tablet by mouth once daily for supplement, Furosemide 20 mg tablets take one tablet by mouth once daily for congestive heart failure, Metoprolol Succinate 25 ext-release tablets take one tablet by mouth once daily for atrial fibrillation hold if systolic blood pressure is less than 120 and diastolic blood pressure is less than 75, Mytbetriq 25 ext-release tablets take one tablet by mouth once daily for stress incontinence, Spironolactone 25 mg tablet take one tablet by mouth once daily for edema. According to the Medication Administration Record (MAR) for resident # 1 she did not receive these five medications from December 7-31, 2021. According to the MAR the five medications listed above had been discontinued. There was no corresponding discontinue order. The Licensing inspector spoke with resident # 1’s prescribing physician and he confirmed these medications had not been discontinued.
  5. According to a written statement submitted to the LI on 02/15/2022 from resident #1’s prescribing physician he reported missing these medications could have caused resident # 1 to have an exacerbation of congestive heart failure that potentially could have been lethal.
Plan of correction
The resident’s medications were reordered from the pharmacy on 12/6/21 with signed physicians’ orders. EMAR privileges, at that time, did not permit medication staff to view expiration dates of orders. This has since been updated. The pharmacy did not send medications as reordered on 12/6/21 and medication staff were unable to see expired prescriptions. Medications were not knowingly withheld from the resident by the facility. The pharmacy has begun sending a routine report which shows upcoming expiration dates for medication orders so POs can be sought to continue or d/c medications. The DON will review expiring medication report weekly to ensure compliance. [sic]
22VAC40-73-450-H
Based on documentation review of Individual Service Plans (ISPs), the facility failed to ensure the care and services specified in the ISP are provided to each resident.
Evidence
  1. According to the ISP for resident # 1 dated 7/12/2021 it is documented she needs assistance with medication administration and will receive all medications as prescribed by the doctor. According to the December 2021 Medication Administration Record resident # 1 did not receive five of her prescribed medications from December 7-31, 2021.
  2. According to the ISP for resident # 1 dated 7/12/2021 it is documented she wears hearing aides and needs assistance putting them on in the mornings and making sure that the battery is working. The Licensing Inspector observed resident # 1 holding her hearing aides in their case at lunchtime on the day of inspection. Resident # 1 told the licensing inspector no one had helped her put them in.
Plan of correction
Resident 1 requests the community assist her with putting in hearing aids in the morning and at night. The facility placed a nursing measure on the EMAR which will require the medication staff to document assistance or declination of assistance in the EMAR. DON will conduct random HA audits at least 2x/wk, for 2 months to ensure compliance on Resident 1. [sic]
22VAC40-73-650-A
Based on documentation review of the Medication Administration Record (MAR) and interviews with staff, the facility failed to ensure that a physician's order was obtained prior to stopping or changing one resident's medication and treatment.
Evidence
  1. The licensing office received a complaint on 01/03/2022 regarding resident # 1 not receiving her prescribed medications and her daily weights in accordance with physician’s orders.
  2. According to the Physical Examination report for resident # 1 dated November 1, 2019 she has a diagnosis of congestive heart failure, hypertension and has a medical history of aspiration pneumonia.
  3. According to the most recent physicians orders for resident # 1 dated December 7, 2021 she is prescribed the following medications: Ferrous Sulfate 325 mg tablets take one tablet by mouth once daily for supplement, Furosemide 20 mg tablets take one tablet by mouth once daily for congestive heart failure, Metoprolol Succinate 25 ext-release tablets take one tablet by mouth once daily for atrial fibrillation hold if systolic blood pressure is less than 120 and diastolic blood pressure is less than 75, Mytbetriq 25 ext-release tablets take one tablet by mouth once daily for stress incontinence, Spironolactone 25 mg tablet take one tablet by mouth once daily for edema. According to the Medication Administration Record (MAR) for resident # 1 she did not receive these five medications from December 7-31, 2021. According to the MAR the five medications listed above had been discontinued. There was no corresponding discontinue order by the physician. The Licensing inspector spoke with resident # 1’s prescribing physician on 01/14/2022 and he confirmed these medications had not been discontinued.
  4. According to physicians orders dated 11/1/2019 resident # 1 is prescribed an additional treatment that daily weights are to be conducted.
  5. According to physician’s orders dated 11/01/2019 and an interview with the administrator, resident # 1 is to be weighed daily. Resident # 1 was admitted to the hospital in November 2019 and returned from the hospital to the facility with the daily weight order still in place. According to the administrator the daily weights have not been maintained since November 2019.
Plan of correction
Daily weight orders were not on the signed physicians’ orders for seven (7) cycles after a hospitalization in 2019. On 2/15/22, an order was written to discontinue the daily weight checks. The new order stated to start weekly weight checks, and to notify the PCP if there is a weight gain over 3 pounds. The facility will seek physicians’ orders prior to stopping or changing orders. [sic]
22VAC40-73-440-H
Based on documentation review, the facility failed to ensure Uniform Assessment Instruments (UAI) were completed on an annual basis for one resident in care.
Evidence
  1. The most recent private pay UAI provided to the LI on the day of inspection for resident # 1 was dated 06/26/2020. This is past the annual assessment date.
Plan of correction
Resident 1’s UAI was updated. The Facility will complete the UAI on an annual basis or as needed. The administrator will conduct 5 random UAI audits/month for 3 months to ensure compliance. [sic[
December 29, 2021Complaint survey1 violation
Inspection dates
12/29/2021
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Two licensing inspectors conducted an inspection regarding a complaint received by the licensing office involving resident care at English Meadows Blacksburg on 1/04/2022. The complaint was received on 12/29/2021. The inspection started at 11:20 am and concluded at 12:00 pm. During the inspection resident records were reviewed and staff interviews were conducted, documentation was also gathered in regards to the complaint information. An exit meeting was held with the administrator on 01/04/2022 and at that time opportunity was given to find items not available during the inspection. As a result of this inspection 1 violation is being cited. Please complete a plan of correction for each violation cited along with a date of correction. Please return a signed and dated copy back to the licensing office within 10 calendar day (01/29/2022) of receipt. If you have any questions or concerns please contact your inspector at 276-608-3514. Thank you for your cooperation and assistance.
Violations
22VAC40-73-450-C
Based on documentation review of Individual Service Plans (ISPs), the facility failed to ensure a comprehensive ISP shall be completed within 30 days after admission for one resident in care.
Evidence
  1. Resident # 1 was admitted to the facility on 9/29/2021. The most recent ISP in resident # 1's file was a preliminary ISP dated 9/29/2021 on the day the resident was admitted. Staff # 1 advised a comprehensive ISP could not be located in the resident's file.
Plan of correction
The ISP was completed on 1/14/2022. The administrator and DON will perform random chart audits of six months to ensure compliance of paperwork. [sic]
May 11, 2021Inspection0 violations
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report
Comments
This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 05/11/2021 and concluded on 05/11/2021. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 74. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed 4 resident records, 4 staff records, staff schedules for the past two weeks, health care and dietitian oversights for the past year, the most recent fire and health inspection reports, fire and emergency drills for the past year 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.