Virginia DSS · Assisted Living Facility

Regency at Augusta

📍 43 Pinnacle Drive, Fishersville, VA, 22939

ID 46135Three Year licenseActive
27
Inspections
On record
15
With violations
Visits that cited something
12
Clean visits
Nothing cited
49
Violations cited
Individual findings
34
Standards cited
Distinct rules
8
Complaint visits
Prompted by a complaint

Regency at Augusta was inspected 27 times between December 2, 2020 and February 18, 2026 by the Virginia Department of Social Services. 15 of those visits ended with violations cited and 12 with none. Across that history VDSS cited 49 violations under 34 distinct standards. 8 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. 23 of these 27 are still on the state's site; the other 4 have since dropped off it and are reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type
Assisted Living Facility
License type
Three Year
License expires
02/05/2027
Administrator
Jessica Covell
Licensing inspector
Angela Via
Inspector phone
(540) 682-1739
Approved for
Assisted Living · Special Care Unit · Non-Ambulatory

Inspection History

27

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

February 18, 2026Inspection4 violations
Inspection dates
02/18/2026
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: February 18, 2026, from 9:30 a.m. until 4:15 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 79 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: The Licensing Inspector toured the community and observed the residents during activities and meals. The Licensing Inspector reviewed the following at the time of inspection: sample of resident and employee records, medication administration, fire drills, emergency drills, pharmacy review, menus, activity calendars, verified appropriate amount of liability insurance, and dietician report. Additional Comments/Discussion: None 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 Angie Via, Licensing Inspector at (540) 682-1739 or by email at angela.via@dss.virginia.gov
Violations
22VAC40-73-980-A
Based on observation and staff interviews, the facility failed to ensure a complete first aid kit was on hand at the facility and contained items with expiration dates that had not already passed.
Evidence
  1. The facility first aid kit was inventoried by LI on 02/18/2026. The first aid kit contained Purell hand sanitizer which expired 06/2023, dermal wound cleanser which expired 03/2025, and triple antibiotic ointment which expired 08/2025.
  2. During an interview with the LI on 02/18/2026, staff 4 confirmed the Purell hand sanitizer, dermal wound cleanser, and triple antibiotic ointment were all expired.
Plan of correction
All expired items in the first aid kit were immediately removed and replaced with in-date supplies on 2/18/26 to ensure compliance with emergency equipment and supply requirements. Executive Director, or designee, will audit each first aid kit for expired items to ensure that no additional expired items are present on before 3/13/26. Executive Director, or designee, will re-educate the Reception team on or before 3/13/26 on the first aid audit check list. An audit will be conducted monthly, by Reception, or designee and given to the Executive Director of the first aid kits to ensure there are no expired items present.
22VAC40-73-320-A
Based on resident record review and staff interviews, the facility failed to obtain a physical examination, including a tuberculosis risk assessment, by an independent physician within 30 days preceding admission.
Evidence
  1. The admission date for resident 3 was 12/06/2025. The date of the face-to-face physical examination for resident 3 was 07/08/2025, which was more than 30 days preceding admission.
  2. The admission date for resident 3 was 12/06/2025. The risk assessment documenting the absence of tuberculosis for resident 3 was dated 12/11/2025, which was after admission.
  3. Staff 4 and 5 acknowledged that the physical examination report and tuberculosis risk assessment for resident 3 were not completed within the required 30 days preceding admission.
Plan of correction
The facility received a corrected H&P on 12/03/25 for Resident #3 with a physical assessment date of 12/03/25. The outdated H&P was removed from Resident #3’s file on 2/18/26 and replaced with the correct document that was electronically on file. The TB Screening form with a date of 12/11/25 was confirmed to be a clerical error, as the fax transmission date on the form was 12/3/25. The facility received a corrected tuberculosis assessment on 12/03/25 with a date of 12/02/25. The incorrectly dated TB screening was removed from the residents file on 2/18/26 and replaced with the corrected document that was electronically on file. The Regional Director of Clinical Services, or designee, will continue to do regular chart audits to ensure that required H&P and TB risk assessments are complete, accurate, and filed appropriately. The Executive Director, or designee will provide re-education to the staff responsible for collecting pre-admission documents on or before 3/13/26. The Executive Director, or designee will review the charts of incoming residents to verify that the resident has a physical examination by an independent physician within 30 days preceding admission to include a TB risk assessment.
22VAC40-73-260-A
Based on staff record review and staff interview, the facility failed to ensure staff completed first aid (FA) certification within 60 days of hire.
Evidence
  1. Staff 3, hire date 06/17/2025, had not completed FA training as of date of inspection on 02/18/2026, which was not within 60 days of hire.
  2. During an interview with LI on 02/18/2026, staff 5 confirmed FA training for staff 1 did not occur within 60 days of employment.
Plan of correction
Staff 1 completed First Aid training on 2/24/2026. An audit of all direct care staff training records will be conducted by the Executive Director, or designee, on or before 3/13/26 to verify that current First Aid certifications are on file and in compliance with regulatory requirements. The Executive Director, or designee, will re-educate supervisors on or before 3/13/26 that direct care staff are required to have First Aid certification within 60 days of employment. First Aid certifications will be reviewed monthly by the Executive Director or designee, to identify individuals who need to be recertified in First Aid.
22VAC40-73-450-C
Based on resident record review and staff interviews, the facility failed to ensure the comprehensive individualized service plan (ISP) included a written description of what services would be provided to address identified needs, and if applicable, other services, and who would provide them.
Evidence
  1. Comprehensive ISP for resident 3, admit date 12/06/2025, listed the resident’s code status as Do Not Resuscitate (DNR) and full code.
  2. During an interview with LI on 02/18/2026, staff 4 and 5 acknowledged that ISP dated 12/05/2026 in resident 3 record had both DNR and full code listed.
Plan of correction
The ISP for Resident #3 was immediately reviewed across all platforms. The electronic record indicated the resident’s correct code status. The ISP was updated on the resident’s paper chart. An audit of all resident electronic and paper charts was conducted by the Regional Director of Clinical Services, on or before 3/13/26 to ensure accurate code status is represented in the charts. The Executive Director, or designee, will provide re-education to ensure the ISP includes a written description of what services would be provided to address identified needs on or before 3/13/26. The Executive Director, or designee, will review the charts of new residents to verify the current code status is noted in the ISP on or within seven days prior to the day of admission.
October 21, 2025Inspection1 violation
Inspection dates
10/21/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS for FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY63.2- (1) General Provisions
Comments
Type of inspection: Monitoring A self-reported incident was received by VDSS Division of Licensing on 10/14/2025 regarding allegations in the area(s) of: Resident care and related services Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/21/2025 from 9:30 a.m. until 10:41 a.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 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: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: Licensing inspector reviewed resident record, interviewed resident and staff, viewed surveillance footage, and toured facility, specifically memory support. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection 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-reported incident 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 Angela Via, Licensing Inspector at (540) 682-1739 or by email at Angela.Via@dss.virginia.gov
Violations
22VAC40-73-460-A
Based on resident record review and staff interviews, the facility failed to assume general responsibility for the health, safety, and well-being of the resident.
Evidence
  1. The regional licensing office received a self-reported incident on 10/14/2025 indicating that on 10/14/2025 at 2:00 p.m. resident 1 was found outside of memory care. The self-report indicated that resident 1 was unaccounted for approximately 1 minute.
  2. Staff 1 showed licensing inspector (LI) video footage of resident 1 leaving the memory care, walking down the hall, and going outside through an exit door leading to the back of the building. Time stamp on footage confirms that resident 1 was unaccounted for approximately 1 minute. Video footage shows staff member seeing resident 1 outside and redirecting him back.
  3. Staff 1 showed LI button at nurses’ station that allows for outside doors to be unlocked. When button is activated, door leading to outside and door leading to other parts of the community are unlocked simultaneously. On 10/14/2025, button was pushed for a family member to exit memory support to outside of building. At that time, resident 1 had walked out of the memory care door that leads to rest of the community, which was unlocked as well.
  4. Staff 1 confirmed that on 10/14/2025 resident 1 was out of sight of staff and outside of memory care and the building for about 1 minute.
  5. Documentation from physician on resident 1 indicated that he requires a safe, secure environment due to cognitive decline and being unable to recognize danger.
Plan of correction
1. Resident #1 was redirected back into the household and assessed for injuries and sustained none. 2. Staff performed a headcount of all residents to ensure that all residents were accounted for. 3. Executive director sent a notification to all staff instructing them not to use the button on 10/16/2025. 4. Maintenance Assistant installed a locked box around the button so that staff are not able to use the button except in case of emergency on 10/24/25. 5. Executive director, or designee, will reeducate all staff on or before 11/30/25 that the Exit Button in memory care unlocks both doors simultaneously and they are only to use the button in case of emergency. 6. The Executive Director, or designee, will continue to educate employees upon hire and every six months around the appropriate use of the Exit Button.
September 5, 2025Inspection0 violations
Inspection dates
09/05/2025
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS63.2- (16) PROTECTION OF ADULTS AND REPORTING
Comments
Type of inspection: Monitoring A self-reported incident was received by VDSS Division of Licensing on 9/1/2025 regarding allegations in the area(s) of: Resident Care and Related Services Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 9/5/2025 12:45 p.m. - 3:00 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 74 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 1 Observations by licensing inspector: The licensing inspector reviewed resident records, incident reports, staff communication, and staff schedules. Additional Comments/Discussion: None 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 Jessica Gale, Licensing Inspector at 540-571-0358 or by email at Jessica.Gale@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
August 29, 2025Inspection0 violations
Inspection dates
08/29/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring A self-reported incident was received by VDSS Division of Licensing on 8/15/2025 regarding allegations in the area(s) of: Resident Care and Related Services Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 8/29/2025 11:05 a.m. - 12:13 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 71 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 1 Observations by licensing inspector: The licensing inspector toured the resident apartment and reviewed medication records, the medication management plan, and incident reports. Additional Comments/Discussion: None 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 Jessica Gale, Licensing Inspector at 540-571-0358 or by email at Jessica.Gale@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
July 2, 2025Inspection0 violations
Inspection dates
07/02/2025
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
Type of inspection: Monitoring A self-reported incident was received by VDSS Division of Licensing on 6/29/2025 regarding allegations in the area(s) of: Resident Care and Related Services Date of inspection and time 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. Number of residents present at the facility at the beginning of the inspection: 73 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 1 Observations by licensing inspector: The licensing inspector observed residents in their rooms and in common areas. The licensing inspector reviewed video footage, incident reports, and staff communication. Additional Comments/Discussion: None 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 Jessica Gale, Licensing Inspector at 540-571-0358 or by email at Jessica.Gale@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 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 – SUBJECTIVITY63.2- (1) GENERAL PROVISIONS63.2- (16) PROTECTION OF ADULTS AND REPORTING
Comments
Type of inspection: Monitoring A self-reported incident was received by VDSS Division of Licensing on 2/15/2025 regarding allegations in the area(s) of: Protection of Adults and Reporting Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 5/21/2025 9:00 a.m. - 10:30 a.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 70 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Licensing Inspector reviewed incident reports and staff training. Additional Comments/Discussion: None 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-reported incident 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 Jessica Gale, Licensing Inspector at (540) 571-0358 or by email at Jessica.Gale@dss.virginia.gov
Violations
63.2-1808-A-10
Based on record review and staff interview, the facility failed to ensure residents were free from physical abuse and forced isolation.
Evidence
  1. An incident report was received by the Regional Licensing office on 2/15/2025 stating resident 1 was Covid positive and being encouraged to stay in their room. The incident report stated resident 1 told staff 3 that a care aide had pushed them on the floor and banged their head on the wall, staff 3 observed resident 1 to have three skin tears. Following notification to administration, when staff 3 returned to the unit, staff 3 observed staff 2 pushing resident 1 back into their room.
  2. According to Adult Protective Services (APS) report dated 3/26/2025, it was noted that staff 2 grabbed resident 1’s wrist and used their body weight from behind to shove resident 1 back into their bedroom. Staff 2 also grabbed resident 1 by the waistband and swung them by their pants into the wall before getting resident 1 to walk back into their bedroom.
  3. APS concluded that there was a preponderance of evidence to support the allegation of physical abuse of resident 1 by staff 2.
Plan of correction
The major incident report for Resident #1 was reported to Adult Protective Service and the Ombudsman by the Executive Director on 2/15/25. The initial major incident report was reported to the Regional Licensing Office on 2/16/25 with the final incident report on 2/21/25 by the Executive Director. Staff #2 was suspended by the Executive Director pending investigation for abuse and neglect on 2/15/25 and were terminated from employment by the Executive Director on 2/17/25. The Executive Director/designee re-educated current team members on or before 6/14/25 on the requirements and procedure for detecting and reporting suspected abuse and neglect, or exploitation of residents and resident rights. New hires will be educated within 7 days of hire, and all team members will be re-educated annually on the requirements and procedure for detecting and reporting suspected abuse and neglect, or exploitation of residents and resident rights.
May 21, 2025Inspection2 violations
Inspection dates
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 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY63.2- (1) GENERAL PROVISIONS63.2- (16) PROTECTION OF ADULTS AND REPORTING
Comments
Type of inspection: Monitoring A self-reported incident was received by VDSS Division of Licensing on 1/22/2025 regarding allegations in the area(s) of: Protection of Adults and Reporting Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 5/21/2025 10:30 a.m. - 11:40 a.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 70 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 3 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Licensing Inspector reviewed incident reports and staff training. Additional Comments/Discussion: None 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-reported incident 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 Jessica Gale, Licensing Inspector at (540) 571-0358 or by email at Jessica.Gale@dss.virginia.gov
Violations
63.2-1808-A-10
Based on record review and staff interview, the facility failed to ensure residents were free from physical abuse.
Evidence
  1. An incident report was received by the Regional Licensing office on 1/22/2025 stating that staff 2 reported hearing staff 3 (hired 7/28/2025), 4 (hired 11/9/2020), and 5 (hired 10/8/2024) yelling at resident 1 (admitted 3/1/2021) asking resident 1 to stop hitting them and that they were going to call the cops if resident 1 didn’t stop hitting them.
  2. During an interview with staff 1, when asked to describe the incident, staff 1 stated that staff 3, 4, and 5, were trying to change resident 1’s clothing and provide incontinence care but the resident refused care, staff 3 was able to get resident 1 into their room but while in the room resident 1 became aggressive and grabbed staff 3. Staff 4 and 5 grabbed both of resident 1’s arms to free staff 3’s arm from the resident. Staff 3 and 4 continued to hold resident 1 down with their arms while staff 3 provided incontinence care and changing of clothes.
  3. According to Adult Protective Services (APS) report dated 1/27/2025 it was noted that there was a preponderance of evidence to substantiate the allegation of physical abuse of resident 1 by staff 3, 4, and 5.
Plan of correction
The major incident report for Resident #1 was reported to Adult Protective Service and the Ombudsman by the Executive Director on 1/23/25. The initial major incident report was reported to the Regional Licensing Office on 1/23/25 with the final incident report on 1/29/25 by the Executive Director. Staff #3, #4, and #5 were suspended by the Executive Director pending investigation for abuse and neglect on 1/23/25 and were terminated from employment by the Executive Director on 2/14/25. The Executive Director/designee re-educated current team members on or before 6/14/25 on the requirements and procedure for detecting and reporting suspected abuse and neglect, or exploitation of residents. The Executive Director/designee re-educated current team members on or before 6/14/25 on resident rights. New hires will be educated within 7 days of hire, and all team members will be re-educated annually on the requirements and procedure for detecting and reporting suspected abuse and neglect, or exploitation of residents and resident rights.
22VAC40-73-450-H
Based on record review and APS reports, the facility failed to ensure that the care and services specified in the individualized service plan (ISP) are provided to each resident.
Evidence
  1. Resident 1 (admitted 3/1/2021) had an ISP dated 12/23/2024 that stated under Psycho social and Cognition, “[they] also gets agitated and aggressive when staff tries to provide care including and especially showers. These behaviors require staff intervention and redirection as well. Several attempts to complete care may be needed.”
  2. Statements written by staff 3, 4, and 5 do not indicate that there were several attempts made to assist the resident with care when the resident became agitated and aggressive.
Plan of correction
Resident #1 no longer resides in the community. The Director of Health and Wellness/designee will re-educate wellness team members on or before 6/14/25 on ensuring that care and services specified in the individualized service plan are provided to each resident. Wellness team hires will be educated upon orientation on ensuring that care and services specified in the individualized service plan are provided to each resident. Monitoring piece The Director of Health & Wellness, or designee, will review three ISPs per month and then observe direct care staff to ensure care and services specified in the ISP are provided. The Director of Health & Wellness will submit results of the ISP monthly audits, for three months, to ensure care and services specified in the ISP are provided, to the Executive Director for review.
May 20, 2025Inspection0 violations
Inspection dates
05/20/2025
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 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
Type of inspection: Monitoring A self-reported incident was received by VDSS Division of Licensing on 3/3/2025 regarding allegations in the area(s) of: Resident Care and Related Services Date of inspection and time 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. Number of residents present at the facility at the beginning of the inspection: 70 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Licensing Inspector observed memory care resident areas and reviewed incident reports. Additional Comments/Discussion: None 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 Jessica Gale, Licensing Inspector at 540-571-0358 or by email at Jessica.Gale@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 20, 2025Inspection0 violations
Inspection dates
05/20/2025
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 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
Type of inspection: Monitoring A self-reported incident was received by VDSS Division of Licensing on 12/10/2024 regarding allegations in the area(s) of: Resident Care and Related Services Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 5/20/2025 1:40pm-2:00pm 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: 70 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: The licensing inspector observed the entrance and exits to the special care unit and residents during activities. The licensing inspector reviewed incident reports and staff training. Additional Comments/Discussion: None 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 Jessica Gale, Licensing Inspector at 540-571-0358 or by email at Jessica.Gale@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 20, 2025Complaint survey0 violations
Inspection dates
05/20/2025
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 SERVICES63.2- (1) GENERAL PROVISIONS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 5/12/2025 regarding allegations in the area(s) of: Resident Care and Related Services and safeguarding resident property. Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 5/20/2025 2:00pm-2:15pm 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: 70 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 2 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Licensing inspector reviewed grievances and missing item reports. Additional Comments/Discussion: None 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 Jessica Gale, Licensing Inspector at (540) 571-0358or by email at Jessica.Gale@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 19, 2025Inspection9 violations
Inspection dates
05/19/2025, 05/20/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 5/19/2025 from 8:30 a.m. to 5:00 p.m. and 5/20/2025 from 10:40 a.m. to 1:45 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 71 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: The Licensing Inspector observed the residents during activities and meals. The Licensing Inspector reviewed the following at the time of inspection: fire drills, emergency drills, resident council reports, pharmacy review, healthcare oversight, menus, activity calendars and dietician report. Additional Comments/Discussion: None 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 Jessica Gale, Licensing Inspector at (540) 571-0358 or by email at Jessica.Gale@dss.virginia.gov
Violations
22VAC40-73-720-A
Based on record review, the facility failed to ensure that the Do Not Resuscitate (DNR) Orders for withholding cardiopulmonary resuscitation from a resident in the event of cardiac or respiratory arrest was included on the Individualized Service Plan (ISP).
Evidence
  1. Resident 1 (admitted 4/22/2025) had a DNR order dated 5/7/2025.
  2. The ISP for resident 1 dated 4/21/2025 did not include the DNR order.
Plan of correction
1. Resident #1’s Individualized Service Plan (ISP) was updated on 5/19/25 to include DNR status. 2. DWH was reeducated by ED on 6/6/25 to ensure that correct DNR status is included on each resident’s ISP. 3. An audit was completed on 5/20/25 to ensure code status was included on the ISP by DHW/designee. Corrections will be completed on or before 6/20/25. 4. ED or designee will review ISPs upon admission to ensure proper code status is indicated. 5. When changes to code status occur, DHW or designee will receive the physician order to ensure ISP is updated. 6. Code statuses will be audited quarterly by DHW, or designee to ensure compliance.
22VAC40-73-350-B
Based on record review and staff interview, the facility failed to ascertain, prior to admission, whether a potential resident was a registered sex offender.
Evidence
  1. Resident 1 (admitted 4/22/2025), had a sex offender search dated 5/7/2025. During an interview with staff 1 when asked if the sex offender search was completed prior to admission staff 1 stated that it was not.
  2. Resident 2 (admitted 4/12/2024) had a sex offender search dated 1/20/2025. During an interview with staff 1 when asked if the sex offender search was completed prior to admission staff 1 stated that it was not.
  3. Resident 4 (admitted 1/9/2025) had a sex offender search dated 5/19/2025. During an interview with staff 1 when asked if the sex prior to admission staff 1 stated that it was not.
  4. Resident 5 (admitted 1/16/2025) did not have a sex offender search in the resident record. Upon request the facility did not provide the sex offender search for resident 5. During an interview with staff 1 when asked if the sex offender search was completed for resident 5, staff 1 stated that they could not find one.
Plan of correction
1. Resident #1 had a Sex Offender Check completed 5/7/2025 2. Resident #2 had a Sex Offender Check completed 1/20/2025 3. Resident #4 had a Sex Offender Check completed 5/19/2025 4. Resident #5 had a Sex Offender Check completed 6/11/2025 5. All department heads were reeducated by ED on 6/6/2025 to ensure registered Sex Offender Check is completed prior to admission. 6. An audit of all resident charts was completed on 6/11/2025 to ensure all residents have a Sex Offender Check completed and on file. 7. New residents’ charts will be audited by the ED, or designee, to ensure a Sex Offender Check is completed prior to admission.
22VAC40-73-640-A
Based on record review the facility failed to implement a written plan for medication management.
Evidence
  1. Page 5, section 10, numbers four of the facility medication management plan states, “if family member is unable to provide the medication, the community will utilize [pharmacy 1] as a back up to avoid missed dose of medication.”
  2. Resident 9 (admitted 11/1/2024), had a physician order dated 2/7/2025 for Nutritional Supplement Liquid, to give 1 carton 3 times a day with meals (08:00,12:00,17:00).
  3. The April Medication Administration Record (MAR) for resident 9 indicated that the Nutritional Supplement Liquid was not given with the reason not given listed as “med not available” on the following 15 dates including 4/13/2025, 4/16/2025 through 4/21/2025, 4/23/2025 through 4/30/2025.
  4. The May MAR for resident 9 indicated that the Nutritional Supplement Liquid was not given with the reason not given listed as “med not available” on the following 20 dates including 5/1/2025 through 5/20/2025.
  5. The nutritional supplement was unavailable for a total of 35 dates with approximately 105 missed doses.
  6. During an interview with staff 7, when asked how long the nutritional supplement had been unavailable, staff 7 stated “about a month.”
Plan of correction
1. Nutritional Supplement for Resident #9 was discontinued 5/22/2025. 2. DHW, or designee will reeducate the RMAs and Nurses on the Medication Management Plan to include “if family member is unable to provide the medication, the community will utilize [pharmacy 1] as a back up to avoid missed dose of medication.” On or before 6/28/25. 3. The Medication Management Plan will be reviewed upon hire and quarterly with RMAs and Nurses.
22VAC40-73-450-C
Based on record review the facility failed to ensure that the identified needs on the uniform assessment instrument (UAI) were not included on the comprehensive individualized service plan (ISP).
Evidence
  1. Resident 3 (admitted 12/23/2024) had a UAI dated 1/26/2025 that indicated orientation as disoriented some spheres, some of the time. The ISP for resident 3 dated 1/3/2025 did not include resident 3’s orientation.
  2. Resident 5 (admitted 1/16/2025) had a UAI dated 2/20/2025 that indicated orientation was disorientated all sphered some of the time. The ISP for resident 5 dated 2/20/2025 did not include resident 5’s orientation.
  3. Resident 6 (admitted 4/14/2025) had a UAI dated 4/12/2025 that indication orientation as disoriented some spheres, all of the time. The ISP for resident 6 dated 4/14/2025 did not include resident 6’s orientation.
  4. Resident 4 (admitted 1/9/2025) had a UAI dated 2/20/2025 that indicated disoriented some spheres, all of the time. The ISP for resident 4 dated 2/25/2025 did not include resident 4’s orientation.
Plan of correction
1. Resident #3’s ISP was updated on 6/15/25 by DHW/designee to indicate disorientation to some spheres, some of the time according to the UAI dated 1/26/25. 2. Resident #5’s ISP was updated on 6/15/25 by DHW/designee to indicate disorientation to all spheres, some of the time according to the UAI dated 2/20/25. 3. Resident #6’s ISP was updated on 6/15/25 by DHW/designee to indicate disorientation to some spheres, all the time according to the UAI dated 4/12/25. 4. Resident #4’s ISP was updated on 6/15/25 by DHW/designee to reflect disorientation to some spheres, all the time according to the UAI dated 4/12/25. 5. DHW was reeducated by ED on 6/6/25 to reflect resident’s disorientation to spheres on the ISP according to the UAI. 6. An audit of all residents’ ISPs will be conducted by DHW or designee on or before 6/21/25 to ensure that all residents who have disorientation indicated on their UAI is reflected in the ISP. 7. ED or designee will review ISPs upon admission to ensure that if a resident has disorientation indicated on their UAI that it is reflected in the ISP.
22VAC40-73-970-A
Based on record review the facility failed to ensure Fire and Emergency evacuation drill frequency and participation was in accordance with the current edition of the Virginia Statewide Fire Prevention Code.
Evidence
  1. The Virginia Statewide Fire Prevention Code indicated fire drills were required to be completed on each shift in a quarter and not conducted in the same month.
  2. Fire Drill records indicated the following fire drills were completed, 1/27/2024 5:15 a.m. third shift, 2/28/2024 2:31 p.m. first shift, 3/17/2024 5:45 a.m. third shift, 4/22/2024 3:32 p.m. second shift, 5/23/2024 3:10 p.m. second shift, 6/1/2024 4:31 a.m. third shift, 7/8/2024 11:00 a.m. first shift.
  3. The 1/27/2024 and 3/17/2024 fire drills were both completed on third shift indicating that a fire drill was not completed on second shift during that quarter.
  4. The 4/22/2024 and 5/23/2024 fire drills were both completed on second shift indicating that a fire drill was not completed on first shift during that quarter.
Plan of correction
1. An audit of fire drills conducted in 2025 was completed 6/6/25. 2. ED reeducated the Director of Environmental Services on 6/6/25 on the Virginia Statewide Fire Prevention Code to include the requirement of fire drills occurring on each shift in a quarter and that drills will not conducted in the same month. 3. A schedule of drills was established on 6/6/2025 to ensure a fire drill will occur each month and each shift will have a fire drill within a quarter. 4. The Director of Environment Services will document completed fire drills on the VDSS Model Form and provide documentation to the ED to ensure the established schedule is compliant.
22VAC40-73-680-D
Based on record review, the facility failed to administer medication in accordance with physician orders.
Evidence
  1. Resident 9 (admitted 11/1/2024) had a physician’s order dated 10/25/2024 for Atorvastatin 20 mg tablet, one tablet by mouth every day for hyperlipidemia and a physician’s order dated 10/25/2024 for Levothyroxine 0.05 mg tablet, one tablet by mouth 10 minutes to one hour before breakfast for hypothyroidism.
  2. The March MAR for resident 9 indicated the following medications were not administered in accordance with physician’s orders: - Atorvastatin 20 mg, was not administered 3/1/2025 through 3/4/2025 with the reason for the medication not being administered listed as “waiting for pharmacy delivery”. -Levothyroxine 0.05 mg, was not administered on 3/7/2025 through 3/9/2025 or 3/15/2025 with the with the reason for the medication not being administered listed as “waiting for pharmacy delivery”.
Plan of correction
1. Resident #9’s Atorvastatin 20mg was administered on 3/5/25. 2. Resident #9’s Levothyroxine 0.05mg was administered on 3/16/25. 3. RMAs and Nurses will be reeducated by DHW or designee on or before 6/28/25 to contact the physician for further guidance when medication is not available. 4. DHW or designee will monitor medication availability Monday-Friday at Morning Stand-up Meeting.
22VAC40-73-1120-B
Based on record review the facility failed to ensure that there was at least 21 hours of scheduled activities available to the residents each week for no less than two hours each day.
Evidence
  1. The April 2025 activity calendar for the special care unit had 20.5 hours of scheduled activities 4/6/2025 through 4/12/2025 and 20.5 hours of scheduled activities 4/20/2025 through 4/26/2025, and 19 hours of scheduled activities 4/27/2025 through 5/3/2025.
Plan of correction
1. The Director of Activities was reeducated by the ED on 6/6/25 to ensure that at least 21 hours of scheduled activities are available to the residents each week for no less than two hours each day. 2. The monthly Activity Calendar for June 2025 was audited by the ED to ensure that there were at least 21 hours of scheduled activities available to the residents each week for no less than two hours each day. 3. The monthly Activity Calendar will be reviewed by the ED prior to the start of the month to ensure that there are at least 21 hours of scheduled activities available to the residents each week for no less than two hours each day.
22VAC40-73-250-D
Based on record review and staff interview the facility failed to ensure each staff person on or within seven days prior to the first day of work at the facility, submit the results of a risk assessment, documenting the absence of tuberculosis in a communicable form as
Evidence
  1. d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence:
  2. Staff 4, hired 4/22/2025, had a tuberculosis risk assessment completed 4/23/2025.
  3. The timecard for staff 4 indicated staff 4 worked from 8:00 a.m. to 11:00 a.m. and again at 2:54 a.m. to 11:05 p.m.
  4. The staff schedule indicated that staff 4 was assigned as a direct care staff from 3:00 p.m. to 11:00 p.m.
  5. During an interview with staff 8 when asked to confirm the first day of work for staff 4, staff 8 confirmed that the first day of work was 4/22/2025 from 3:00 p.m. to 11:00 p.m.
Plan of correction
1. Staff #4’s tuberculosis risk assessment was completed on 4/23/25 by Director of Innovations Memory Care. 2. An audit of all employee files was completed by the Business Office Manager/ designee on or before 6/6/25 to be sure that all employees have a tuberculosis risk assessment on file. 3. All department heads were reeducated by the Executive Director, or designee on or before 6/6/25 to ensure that a tuberculosis risk assessment is completed on each new hire, on or within seven days prior to the first day of work at the facility. 4. On or before 7 days of hire a tuberculosis risk assessment will be completed by the Director of Health & Wellness, or LPN designee for all new employees. 5. ED, or designee will ensure each new hire has a tuberculosis risk assessment on or within 7 days of hire. The Business Office Manager, or designee, will ensure that a copy of the tuberculosis risk assessment is kept in the employee file.
22VAC40-73-930-D
Based on record review and staff interview, the facility failed to ensure for each resident with an inability to use the signaling device, the inability was included in the resident's individualized service plan (ISP).
Evidence
  1. Resident 3 (admitted 12/23/2024) resided in the special care unit. The ISP for resident 3 dated 1/3/2025 did not include resident 3’s inability to use a signaling device. During an interview with staff 1, when asked if resident 3 could use the signaling device, staff 1 stated that resident 3 could not use one and does not have one.
  2. Resident 5 (admitted 1/16/2025) resided in the special care unit. The ISP for resident 5 dated 2/20/2025 did not include resident 5’s inability to use a signaling device. During an interview with staff 1, when asked if resident 5 could use the signaling device, staff 1 stated that resident 5 could not use one and does not have one.
  3. Resident 4 (admitted 1/9/2025) resided in the special care unit. The ISP for resident 4 dated 2/25/2025 did not include resident 4’s inability to use a signaling device. During an interview with staff 1, when asked if resident 4 could use the signaling device, staff 1 stated that resident 4 could not use one and does not have one.
Plan of correction
1. Resident #3’s ISP was updated on 6/12/25 by DHW/designee to reflect resident’s inability to use a signaling device. 2. Resident #5’s ISP was updated on 6/12/25 by DHW/designee to reflect the resident’s inability to use a signaling device. 3. Resident #4’s ISP was updated on 6/12/25 by DHW/designee to reflect the resident’s inability to use a signaling device. 4. DWH was reeducated by ED on 6/6/25 that if a resident is unable to use a signaling device that it needs to be indicated on the ISP. 5. An audit of all residents’ ISPs will be conducted by DHW or designee on or before 6/21/25 to ensure that all residents who are unable to use a signaling device have it indicated on their ISP. 6. ED or designee will review ISPs upon admission to ensure that if a resident is unable to use a signaling device that it is indicated on the ISP.
May 24, 2024Complaint survey3 violations
Inspection dates
05/24/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES63.2- (16) PROTECTION OF ADULTS AND REPORTING22VAC40-80 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: 5/24/2024 1:30 pm to 5:08 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 5/6/2024 regarding allegations in the area(s) of: Resident Care Number of residents present at the facility at the beginning of the inspection: The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 2 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: Dinner being served and staff transporting residents. Additional Comments/Discussion: N/A 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 Jeff Marnien, Licensing Inspector at (540) 571-0189 or by email at jeffrey.marnien@dss.virginia.gov. Violation Notice Issued: Yes
Violations
22VAC40-73-70-A
Based on record review and interview, the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident.
Evidence
  1. The regional licensing office received a complaint on 5/20/2024 regarding an incident that occurred between Resident 1 and an employee on 5/18/2024.
  2. Licensing staff interviewed Staff 3 and asked if a report had been sent to the regional licensing office within 24hrs. Staff 3 stated that an incident had not been reported to the licensing office within 24hrs.
Plan of correction
The final major incident report for Resident 1 was sent to the regional licensing office on 5/25/2024. The Executive Director/designee will reeducate Department Directors and Shift Supervisors by 8/2/2024 on reporting to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident. The Executive Director/designee will ensure all major incidents are reported to the regional licensing office within 24 hours.
22VAC40-73-460-A
Based on a record review and staff interviews, the facility failed to assume general responsibility for the health, safety and well-being of the residents.
Evidence
  1. Resident 1, an 89-year-old female, reported to family on 5/18/2024 “being handled roughly” and as of 2:30 pm on 5/18/2024 “not having received her lunch.”
  2. Resident 1’s Individualized Service Plan (ISP) updated on 12/20/2023, states “does not come to the dining room for breakfast or dinner. She will independently use her scooter to eat lunch in the dining room every day. Staff to check on her at dinner and see if she needs any assistance getting her food ready and set up for her to eat. Meals will be served by dining staff and direct care staff. Notify supervisor if resident consumes less than 50% of meal.”
  3. Staff 2 statement: “I asked Staff 4 to put her on the toilet. I help her take her off around 2pm. Manager (staff 5) reported resident called daughter and c/o being rough handled. We went to talk to patient and noticed bruises on forearm and upper arm. She requested lunch since it had not been offered. I had not noticed bruises early, but I was not looking for them.”
  4. Staff 1 statement: “I witnessed (Staff 4) yell at resident to go back to her room. RMA (staff 5) stated Staff 4 has been yelling at and arguing with residents all day. RMA (staff 5) has reported to me suspected abuse of Resident 1. I went into her room with RMA (staff 5) and asked her if she would like to report anything and she looked upset and as if she was about to cry. Resident has purple bruises on left arm.”
  5. End of shift report (dated 5/18/24; shift: “morning”) includes statement from Staff 4: Resident 1 “didn’t get lunch, she wanted to sleep in into lunch time was over. She also said she was being handled roughly and wasn’t changed but she was.”
  6. Staff 3 verified Resident 1 had not received lunch on date in question and stated “she talked to the aides, and they said that it is the responsibility of the aide that is assigned to a particular hall to bring a resident their meal if they would like it delivered. Staff 4 was assigned to Resident 1’s hall. There were no other residents who needed/requested meal deliveries on 5/18/2024. Resident 1 was the only resident that day who should have had a meal delivered.”
  7. End of shift report (dated 5/18/24; shift 3-11) includes statement from staff 1: “Resident has new bruises and looked as if she was going to cry when asked if she was being mistreated.”
Plan of correction
The Executive Director/designee will re-educate current Health & Wellness, Dining team members and Department Directors by 8/2/2024 on meal attendance tracking form. The Executive Director/designee will monitor the meal attendance tracking forms to ensure delivery of meals to all residents. The Executive Director/designee will re-educate current team members by 8/2/2024 on the requirements and procedures for detecting and reporting suspected abuse, neglect, or exploitation of residents and for mandated reporters, the consequences for failing to make a required report, as set out in § 63.2- 1606 of the Code of Virginia.
22VAC40-73-130-A
Based on interviews and staff records, the facility failed to ensure all staff who are mandated reporters shall report suspected abuse, neglect, or exploitation of residents in accordance with Virginia Code 63.2-1606.
Evidence
  1. Facility policy GP-11 Elder Abuse, Neglect, and Exploitation dated 12/14/2020 states in section 3, All staff and volunteers at the facility are mandated reporters under Code of Virginia 63.2-1606 and reports of suspected abuse, neglect, and exploitation shall be made to the local department or adult protective services (APS).
  2. On 5/18/2024 Staff 5 collected statements from Staff 1 and Staff 2 regarding alleged abuse between Resident 1 and Staff 4.
  3. Staff 1 stated “we were told to write down what we saw, and we did and gave that to our manager.”
  4. The licensing office received a complaint on 5/20/2024 regarding allegation of resident abuse.
  5. Staff 3 acknowledged that they did not contact the licensing office or APS within the required timeframe.
  6. Staff 3 reported finding two statements regarding the incident involving Resident 1 “slid under her office door” on the morning of 5/20/2024. Staff 3 reported the incident to APS on 5/22/2024.
Plan of correction
The Executive Director/designee will reeducate current team members on or before 8/2/2024 on requirements and procedures for detecting and reporting suspected abuse, neglect, or exploitation of residents and for mandated reporters, the consequences for failing to make a required report, as set out in § 63.2- 1606 of the Code of Virginia. New hires will be educated within 7 days of hire and all team members will be reeducated annually in accordance with Virginia Code 63-2-16006.
January 29, 2024Complaint survey2 violations
Inspection dates
01/29/2024
Areas reviewed
Administration and Administrative ServicesPersonnelStaffing and SupervisionBuildings and Grounds
Comments
Date of Inspection: January 29, 2024 Type of Inspection: Complaint Inspection If you have any questions or email changes, please do not hesitate to contact me at laura.lunceford@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov. Census 63 Number of interviews conducted- 8 interviews. There was an allegation of insufficient staff for residents in care as well as the unit being dirty. The complaint was found to be valid. There were violations found at the time of inspection. The Licensing Inspector and the Administrator discussed the risk assessment ratings for the violations for this inspection. Please complete the “plan of correction” and “date to be corrected” for each violation cited on the violation notice and returned it to the office. You will need to specify how the deficient practice will be or has been corrected. 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).
Violations
22VAC40-73-1130-A
1130A-Based on staff interview, it was determined that the facility did not have sufficient in numbers to be responsible for the care and supervision of residents in the safe, secure environment.
Evidence
  1. There was a pipe burst in the safe, secure unit. The residents were moved out to an adjacent area just past the unit. Seventeen residents were moved from the unit though only twelve remained at through the night. Five residents went back to the secured unit for the night due to wandering behaviors. There were not two direct care staff with the twelve residents nor with the five residents through the night as required.
Plan of correction
The Director of Health and Wellness and or Designee will ensure there are sufficient staffing numbers on both the secured and adjacent area for the duration of the relocation.
22VAC40-73-870-A
Based on direct observation by the Licensing Inspector and facility staff, it was determined that the building was not clean and free of rubbish.
Evidence
  1. The rooms on the lower area of the building had used briefs in the bedrooms and in the bathrooms that had not been disposed of. The floors in the lower area of the building were dirty in both areas.
Plan of correction
Direct care team have a key to the soiled utility room int eh adjacent area where they can dispose of all waste appropriately. Housekeeping will be assigned to vacuum the area daily.
January 29, 2024Inspection0 violations
Inspection dates
01/29/2024
Areas reviewed
Administration and Administrative ServicesPersonnelStaffing and SupervisionAdmission, Retention and Discharge of ResidentsResident Care and Related ServicesBuildings and GroundsEmergency PreparednessMixed PopulationSafe, Secure Environment
Comments
Date of Inspection: January 29, 2024 Type of Inspection: Renewal Inspection If you have any questions or email changes, please do not hesitate to contact me at laura.lunceford@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov. Census 63 The Licensing Inspector observed the residents during activities and meals. The Licensing Inspector reviewed the following at the time of inspection: resident council reports, dietician report, pharmacy review, fire drills, emergency drills and healthcare oversight.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
February 3, 2023Inspection0 violations
Inspection dates
02/03/2023
Areas reviewed
22VAC40-73 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: 2/3/2023 from approximately 9:00 am to 9:45 am 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: 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: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: cleaning supply closet on the secured unit and toured the secured unit and assisted living unit. Additional Comments/Discussion: Continue to ensure all storage areas with cleaning supplies remain locked at all times and that cleaning and laundry carts are never left unlocked/unattended. 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 Janice Knight Licensing Inspector at (540) 430-9258 or by email at janice.knight@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
December 14, 2022Complaint survey0 violations
Inspection dates
12/14/2022
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS
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: 12/14/2022 from approximately 3:45 pm to 6:30 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 11/7/2022 regarding allegations in the area of admission and discharge. Number of residents present at the facility at the beginning of the inspection: The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 5 Observations by licensing inspector: resident record reviews 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 Janice Knight, Licensing Inspector at (540) 430-9258 or by email at janice.knight@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
December 6, 2022Inspection7 violations
Inspection dates
12/06/2022, 12/07/2022, 12/08/2022
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 PROCESS
Technical assistance
1. Carefully review all forms prior to filing to ensure all information is accurate and complete (fire drill forms, facility assessment/interview forms, initial physicals, etc. 2. Recommended having all direct care staff complete the 10 hours of dementia training within the first four months of hire. 3. Ensure staff 4 completes the emergency preparedness training before the end of December. 4. Ensure residents sign the orientation form that is reviewed on the day of admission – even if resident has a serious cognitive impairment – the family member may also sign but may not sign in place of the resident. 5. Reviewed sections of the uniform assessment manual with the director of health and wellness and answered questions. 6. Clarify on the facility assessment/interview form what is reviewed regarding the sex offender registry (refer to standard 350.C and D).
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: 12/6/2022 from approximately 7:30 am to 5:25 pm, 12/7/2022 from approximately 7:00 am to 5:30 pm and 12/8/2022 from approximately 11:45 am to 4:30 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 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: 8 + selected sections of 6 additional records Number of staff records reviewed: 4 + selected sections of 7 additional records Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 6 Observations by licensing inspector: medication administration, medication carts, activities, meals, staffing, special diets, staff/resident interactions, required postings, Additional Comments/Discussion: There were 58 residents in care, 20 on the secured unit and 38 on the assisted living unit. Upon receipt of the annual fire and health inspection reports, please forward a copy of each to this inspector. 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 Janice Knight, Licensing Inspector at (540) 430-9268 or by email at janice.knight@dss.virginia.gov
Violations
22VAC40-73-260-A
Based upon record reviews and an interview, the facility failed to ensure three of the 10 staff records reviewed had documentation of completion of first aid (FA) certification within 60 days of hire.
Evidence
  1. Staff 8 (hired 3/28/2022), staff 10 (hired 7/25/2022) and staff 11 (hired 8/4/2022) had not completed FA training.
  2. On 12/8/2022, the LI interviewed the business office manager (BOM) who stated these three staff had not completed the FA training.
Plan of correction
BOM and/or designee to ensure first aid certifications are obtained during orientation and will audit first aid certifications weekly for needed certifications and expired certifications. Certifications to be discussed during Weekly Management Meeting. Schedule classes as needed to provide appropriate training, 1/8/2022. To be monitored by BOM and executive director (ED).
22VAC40-73-1140-B
Based upon documentation and an interview, the facility failed to ensure three of the four staff records reviewed completed at least 10 hours of dementia training within the first four months of hire.
Evidence
  1. The training record for staff 1 (hired 5/3/2021) listed 7.50 hours of dementia training completed.
  2. The training record for staff 2 (hired 8/9/2022) listed 6.0 hours of dementia training completed.
  3. The training record for staff 4 (hired 7/26/2021) listed 6.25 hours of dementia training completed.
Plan of correction
BOM or ED to schedule dementia training for Staff 1, 2, and 4 immediately. At orientation, BOM or designee to assign/schedule dementia training to be completed over following 4 months for each new direct care staff. 1/8/2022. To be monitored by BOM and ED.
22VAC40-73-970-E
Based upon documentation and interviews, the facility failed to ensure all required information was documented on two of twelve fire drill forms reviewed.
Evidence
  1. On 12/6/2022, the LI reviewed the monthly fire drill forms and the forms for 3/1/2022 and 11/18/2022 did not include the number of staff and residents participating in the drills. Both sections of the forms were blank.
  2. On 12/6/2022, the LI interviewed staff 12 who confirmed the two sections of the fire drill forms were blank and the information had not been documented.
  3. On 12/8/2022, the LI reviewed the two fire drill forms with the administrator who also confirmed the two sections of the forms were blank.
Plan of correction
DES to be educated by ED immediately on ensuring all required information is documented on fire drill forms. Forms to be thoroughly reviewed by ED after fire drills to ensure accurate completion. 1/8/2022. To be monitored by DES and ED.
22VAC40-73-860-I
Based upon observations and an interview, the facility failed to ensure cleaning supplies were stored in a locked area.
Evidence
  1. On 12/6/2022, the licensing inspector (LI) and staff 4 were conducting a tour of the secured unit and the soiled linen closet door was observed closed but unlocked and unattended.
  2. The LI and staff 4 observed multiple containers of cleaning supplies (Germicidal cleaner, disinfectant spray, etc.) on the shelf in the unlocked closet.
Plan of correction
The storage room door was locked immediately by staff 4. Director of environmental services (DES) will compete an in-service with all housekeeping associates and ensure they understand the importance of storing all cleaning supplies in a locked area. 1/8/2022. To be monitored by DES and ED
22VAC40-73-1110-B
Based upon documentation and an interview, the facility failed to ensure three of the three residents’ records reviewed included a six-month or annual review of appropriateness for placement in a secured unit.
Evidence
  1. Resident 1 (admitted 12/28/2021) and resident 3 (admitted 1/20/2022) did not have a six-month review completed and on file.
  2. The last review completed for resident 2 (admitted 9/30/2020) was dated as completed on 11/17/2021.
  3. On 12/7/2022, the LI interviewed staff 13 who stated the reviews for appropriateness for continued placement in the secur4ed unit had not been completed.
Plan of correction
DHW and director of innovations memory care (DIMC) to audit appropriateness for placement in a secured unit forms on a monthly basis. DHW and/or DIMC to share audit results with ED. 1/8/2022. To be monitored by DHW, DIMC, and ED.
22VAC40-73-260-C
Based upon observations, documentation and an interview, the facility failed to ensure the posted list of staff with FA and cardiopulmonary resuscitation (CPR) remained current.
Evidence
  1. On 12/6/2022, the BOM submitted to LI a list of staff and their hire dates. The list included staff 2, 6, 7 and 9 who were newly hired direct care staff/nurses.
  2. On 12/6/2022, the LI observed the posted list of staff with certifications in FA and CPR in the nurses’ office located behind the concierge desk. The list did not include staff 2, 6, 7 and 9.
  3. On 12/8/2022, the LI interviewed the BOM who stated the list had not been updated and the new staff hired with certifications had not been added to the list.
Plan of correction
BOM and/or designee to audit first aid/CPR certifications weekly for needed certifications and expired certifications and make sure correct current list is posted. Certifications to be discussed during Weekly Management Meeting. 1/8/2022. To be monitored by BOM and ED.
22VAC40-73-950-E
Based upon documentation and interviews, the facility failed to ensure two of the seven resident records reviewed had signed documentation of a six-month review of the emergency preparedness plan.
Evidence
  1. On 12/8/2022, the LI reviewed the assessment/interview forms in each resident record, which included the emergency preparedness training review. The forms on file for residents 4 and 5 were not signed by the residents.
  2. On 12/8/2022, the LI interviewed the administrator who stated there was no other documentation on file for completion of the emergency preparedness training for these two residents.
Plan of correction
Director of health and wellness (DHW) to ensure that six-month reviews of the emergency preparedness plan for residents 4 and 5 be conducted immediately. DHW and/or designee to audit charts monthly for emergency preparedness reviews that are due. 1/8/2022. To be monitored by DHW and ED
July 28, 2022Complaint survey1 violation
Inspection dates
07/28/2022
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Technical assistance
Ensure staff carefully review all paperwork prior to filing.
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: 7/28/2022 from approximately 8:55 am to 9:45 am 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 7/21/2022 regarding allegations in the area of resident care and related services. Number of residents present at the facility at the beginning of the inspection: 62 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: 1 Observations by licensing inspector: Secured unit 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; the area(s) of non-compliance with standards or law were in the area of resident care and related services. A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. 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 Janice Knight, Licensing Inspector at (540) 430-9258 or by email at janice.knight@dss.virginia.gov
Violations
22VAC40-73-680-E
Based upon documentation and an interview, the facility failed to ensure a medical procedure for one of one resident record reviewed was completed as ordered.
Evidence
  1. Resident 1 had a physician’s order (signed 7/6/2022) for a sacral x-ray – two views and a Lidocaine patch.
  2. On 7/21/2021, the licensing inspector (LI) interviewed staff 1 via telephone and she stated she received the signed physician’s order on 7/6/2022 and faxed the order to the pharmacy but missed the request for the x-ray. She stated on 7/12/2022 the physician contacted the facility for the results of the x-ray and the x-ray had not been requested.
Plan of correction
1. The x-ray for this resident has been performed and results discussed with family. 2. The Director of Health and Wellness, or designee, will review physician’s orders five times per week to ensure no missed orders. The Director of Health and Wellness will submit results of the audits to the Executive Director for review. 3. The Executive Director and Director of Health and Wellness will be responsible for the implementation and monitoring of this plan. The Executive Director will review the audit results and address 4. Date by which plan of correction will be fully implemented and noncompliance will be corrected: Friday, August 26, 2022
June 23, 2022Inspection4 violations
Inspection dates
06/23/2022
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Technical assistance
Reviewed standard 220 regarding the requirements for agency and non-agency private sitters.
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 6/23/2022 from approximately 9:30 am to 4:10 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 6/14/2022 regarding allegations in the area of resident care and related services. Number of residents present at the facility at the beginning of the inspection: 64 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 (selected sections) Number of staff records reviewed: 4 (selected sections) Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 6 Additional Comments/Discussion: Narcotic count sheets and medications were reviewed for three residents. 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 Janice Knight, Licensing Inspector at (540) 430-9258 or by email at Janice.knight@dss.virginia.gov
Violations
22VAC40-73-450-H
Based upon interviews, the facility failed to ensure the care and services specified in the ISP was provided to one of three residents.
Evidence
  1. On 6/23/2022, the LI interviewed staff 5 who stated, “Resident 1’s laundry is done twice a week and there are times when there is only one gown.”
  2. On 6/28/2022, the LI interviewed collateral 1 who stated, “I have seen her in the same gown where the wound dressing and gown were both saturated. They don’t clean her very well and she has had feces in her vaginal area.”
  3. On 6/28/2022, the LI interviewed collateral 2 who stated, “Sometimes I would find her not as clean and it looked like she had the same gown on Friday as she did on Tuesday.”
  4. On 6/28/2022, the LI interviewed collateral 3 who stated, “The last month or so has been worse than usual. She had drainage on her gown and feces in her vaginal area. Sometimes she has the same gown on Friday as she had on Tuesday.
  5. The ISP (completed 11/30/2021) stated, “Due to immobility and incontinence, resident 1 uses incontinent products and is to be changed and cleaned by staff. Check on her frequently such as during safety checks to ensure that she is clean and does not need her incontinent products changed. She is able to tell you if she needs assistance as well.”
  6. The ISP also states, “Resident 1 needs mechanical and physical assistance with dressing. Resident 1 is able to pick out her own clothes. Staff will need to dress resident 1. Services will be provided twice a day at the community.”
Plan of correction
1. This resident’s ISP will be reviewed and updated, if applicable, to ensure care and services specified in the ISP are provided. Direct care staff will be reeducated regarding how to follow a resident’s ISP and provide indicated care. 2. The Director of Health and Wellness, or designee, will review three ISPs per month and then observe direct care staff to ensure care and services specified in the ISP are provided. 3. The Executive Director and Director of Health and Wellness will be responsible for the implementation and monitoring of this plan. The Director of Health and Wellness will submit results of the ISP monthly audits, for three months, to ensure care and services specified in the ISP are provided, to the Executive Director for review. 4. Date by which plan of correction will be fully implemented and noncompliance will be corrected: Tuesday, July 26, 2022.
22VAC40-73-640-A
Based upon documentation and interviews, the facility failed to ensure implementation of the medication management plan.
Evidence
  1. On 6/14/2022, the LI received a self-report that one pharmacy card with 30 tramadol were missing for resident 1.
  2. On 6/23/2022, the LI interviewed the administrator and the health and wellness nurse and both stated the medication was received on 5/31/2022 by staff 6; however, staff 6 could not remember who she gave the medication card to or if she put the card in the medication room.
  3. Under the section for “Controlled Substances” the facility medication plan states, “a. The pharmacy should be requested to send controlled substances separate from other medications. b. It is imperative that if there are any controlled substances present when medications are delivered that they are removed, logged, processed, and properly stored immediately.
  4. Once the medications are logged, the meds are placed in the appropriate area of the med cart or overflow meds as appropriate.”
  5. Page 7, Section 16, of the medication management plan also stated, “All medications maintained within the building that fall under the DEAs schedule II – V will be locked in a double lock box, the locks of which open with separate keys. These meds will be counted when delivered.”
Plan of correction
1. The Medication Management Plan will be reviewed and updated, if applicable. Based upon this review, and possible changes, staff will be reeducated according to Medication Management Plan. 2. Staff will be educated regarding necessary adherence to the Medication Management Plan, and how to do so. 3. The Executive Director and Director of Health and Wellness will be responsible for the implementation and monitoring of this plan. The Director of Health and Wellness, or designee, will submit documentation to the Executive Director verifying ongoing adherence to the Medication Management Plan. 4. Date by which plan of correction will be fully implemented and noncompliance will be corrected: Tuesday, July 26, 2022.
22VAC40-73-680-D
Based upon documentation and an interview, the facility failed to ensure one medication for one of three residents was administered according to the physician’s order.
Evidence
  1. Resident 1 had a signed physician’s order for one 50mg tablet Tramadol twice a day.
  2. The June 2022 electronic medication administration record (eMAR) was initialed and circled by the registered medication aides (RMAs) on duty for 6/7/2022 and 6/8/2022 for the morning and evening doses. The omission notes stated, “Waiting for pharmacy deliver
Plan of correction
1. The medication for this resident was already replaced. Staff who administer medications will be reeducated regarding community procedures for accepting, managing, and storing controlled substances. 2. The Director of Health and Wellness, or designee, will review the EMAR five times per week to ensure no missed or held medications. The Director of Health and Wellness will submit results of the EMAR audits to the Executive Director for review. 3. The Executive Director and Director of Health and Wellness will be responsible for the implementation and monitoring of this plan. The Executive Director will review the EMAR audit results and address any noted concerns. 4. Date by which plan of correction will be fully implemented and noncompliance will be corrected: Tuesday, July 26, 2022.
22VAC40-73-450-E
Based upon documentation and an interview, the facility failed to ensure one of three residents’ individualized service plans (ISPs) were signed by the resident or the resident’s legal representative.
Evidence
  1. The ISP (updated 11/30/2021) for resident 1 was not signed by the resident or the resident’s legal representative.
  2. On 6/23/2022, the licensing inspector (LI) interviewed staff 4 who stated the ISP had not been signed by the resident or the resident’s legal representative
Plan of correction
1. The resident’s ISP, updated 11/30/2021, will be signed by the resident or his or her responsible party. Other residents’ ISPs will be audited to ensure signatures from the resident or residents’ responsible parties. ISPs not signed by the resident or the residents’ responsible party will be signed by one of them. 2. An ISP tracking tool will be created to ensure the resident or his or her responsible party signs the ISP. 3. The Executive Director and Director of Health and Wellness will be responsible for the implementation and monitoring of this plan. The Executive Director, or designee, will audit the ISP tracking tool monthly to ensure the resident or his or her responsible party signed the ISP. 4. Date by which plan of correction will be fully implemented and noncompliance will be corrected: Tuesday, July 26, 2022.
April 12, 2022Inspection1 violation
Inspection dates
04/12/2022
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Technical assistance
Recommended all medication administration records and physicians' orders be audited and staff observed administering medications on a frequent basis to ensure standards are being followed.
Comments
An unannounced focused monitoring inspection was conducted on 4/12/2022 from approximately 9:03 am to 11:55 am. Medication administration observations were completed for one resident. Individual staff and resident interviews were conducted. Three residents' March and April medication administration records and physicians' orders were reviewed. The area of noncompliance was in medication administration documentation. Staff answered all questions and obtained all information requested. Thank you for your assistance and cooperation.
Violations
22VAC40-73-680-H
Based upon documentation and interviews, the facility failed to ensure staff initialed the electronic medication administration records (EMARs) when medications were administered for two of the six EMARs reviewed.
Evidence
  1. The March EMAR for resident 1 was blank for Sinemet on 3/27/2022 for the 10:00 am and 1:00 pm doses.
  2. The March EMAR for resident 3 was blank for Tylenol, Norvasc, aspirin, blood pressure check, Ferrous Gluconate and Metoprolol for the morning doses on 3/27/2022.
  3. On 4/12/2022, the licensing inspector (LI) interviewed resident 3 who stated she had not missed her morning medications since she has been at the facility.
  4. On 4/12/2022, the LI interviewed the executive director (ED) who stated staff 1 was the staff who was on duty to administer medications on the 7:00 am to 3:00 pm shift on 3/27/2022 and that she is no longer an employee at the facility.
Plan of correction
Executive director has posted the medication management plan to every med cart to be available and reviewed by all medication staff. Regional staff will assist in auditing of all med carts and EMARs on 4/18/2022. The day shift nursing staff will do so weekly and review with ED any missed submissions. Day shift nursing supervisor and director of memory care are reviewing the missed med report every morning Monday through Friday and will report discrepancies to ED.
February 18, 2022Complaint survey3 violations
Inspection dates
02/18/2022
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Technical assistance
1. Ensure medication refills are requested at least seven days prior to the last dose being administered and document the notification fully in the resident's record. 2. Ensure controlled count sheets are maintained in an organized manner and that all records are maintained as required.
Comments
The licensing inspector conducted an unannounced complaint inspection in response to a complaint that was received by the licensing office on 2/10/2022. Interviews were conducted with residents, staff and a family member relating to allegations that a medication was not ordered in a timely manner and was not administered as ordered. The information gathered during the investigation supports the allegations, so the complaint is determined to be valid. Please complete the columns for "description of action to be taken" and "date to be corrected" for each violation cited on the violation notice, and then return a signed and dated copy to the licensing office within 10 calendar days of receipt. If you have any questions, contact your licensing inspector at (540) 430-9258.
Violations
22VAC40-73-640-A
Based upon documentation and interviews, the facility failed to ensure one of four residents medications were ordered in a timely manner to avoid missed doses.
Evidence
  1. Resident 1 had a physician's order signed 11/30/2021 for, "fentanyl 12mcg/HR PT72 every 3 days, place topically every 3 day at 2200 (per residents request)."
  2. On 2/28/2022, the LI interviewed resident 1 who stated, "I went five days waiting for one and got it on day six. I missed two doses."
  3. The February EMAR was blank for 2/5/2022 and 2/8/2022 for fentanyl 12mcg/HR PT72.
  4. On 2/10/2022, the LI received an email stating staff 1 notified resident's daughter on 2/4/2022 that a refill for the fentanyl patch was needed.
  5. On 3/4/2022, the LI interviewed collateral 1 who stated she was notified on 2/5/2022 of the need for a refill of the fentanyl patch.
  6. The facility's medication management plan stated on page 6, "All medications from private pharmacies or provided by families must be called in for refills timely to ensure adequate supply. Nurses may call the private pharmacy to request refills if there are refills left on prescription. As a courtesy, nurses and medication aides will attempt to notify the family of refill needs at least 7 days prior to medication supply depletion."
Plan of correction
Resident now receives her medications through the community pharmacy. When someone has a narcotic or other medication ordered, that a family member manages, the community will notify the family, physician and pharmacy seven days prior to the medication running out. The DHW and director of innovations memory care (DIMC) will ensure that weekly cart audits are conducted on Tuesdays. They will ensure proper documentation from the registered medication aides (RMAs).
22VAC40-73-680-D
Based upon documentation and interviews, the facility failed to ensure one of four residents received one medication as ordered.
Evidence
  1. Resident 1 had a physician's order signed 11/30/2021 for, "fentanyl 12mcg/HR PT72 every 3 days, place topically every 3 day at 2200 (per residents request)."
  2. On 2/28/2022, the licensing inspector (LI) interviewed resident 1 who stated, "I went five days waiting for one and got it on day six. I missed two doses."
  3. On 2/18/2022, the LI interviewed the executive director (ED) who stated resident 1 did not receive the fentanyl patch on 2/5/2022 and 2/8/2022.
  4. The February electronic medication administration record (EMAR) was blank for 2/5/2022 and 2/8/2022 for fentanyl 12mcg/HR PT72.
Plan of correction
Resident received medication on 2/10/2022. The daughter brought the medication to the facility on 2/9/2022. The medication was ready for pick up from the resident's chosen pharmacy on 2/4/2022. Resident will now be receiving all of her medications delivered from the community pharmacy. The community will now administer all of the resident's medications versus just this one. The resident's EMAR now shows that the resident's medications are administered by community and will send alerts/notifications to ED and director of health and wellness (DHW) for any missed medications.
22VAC40-73-680-I
Based upon documentation and an interview, the facility failed to ensure one of four February EMARs reviewed documented omissions.
Evidence
  1. The February EMAR for resident 1 was blank for fentanyl patch on 2/5/2022 and 2/8/2022. Staff initials were not listed and circled and no notations were documented as to why the medication was not administered on these dates.
  2. On 2/18/2022, the LI interviewed the administrator who also checked the EMAR and stated the omissions were not documented.
Plan of correction
Resident's EMAR has been updated to reflect that the community administers medications. This will ensure that the medication will "pop" to alert the RMAs that it is due. This will allow the RMAs to sign and create a notation if a medication is missed. During daily EMAR audits by the DHW and DIMC, it will be observed if a medication is not given/not documented on. Follow up will occur at that time.
January 12, 2022Inspection0 violations
Inspection dates
01/12/2022
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report
Comments
A non-mandated monitoring inspection was initiated on 1/12/2022 and concluded on 1/12/2022. The administrator was contacted by telephone to initiate the inspection. The licensing inspector emailed the administrator a list of documentation required to complete the inspection. The licensing inspector conducted a virtual inspection on 1/12/2022 and reviewed all criminal record checks and sworn statements for all current staff hired since the last inspection. A review of the information gathered during the inspection determined no violations with applicable standards or law. No violations were cited.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
November 30, 2021Inspection8 violations
Inspection dates
11/30/2021, 12/01/2021, 12/02/2021
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity63.2 General Provisions63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS
Technical assistance
1. The staff schedule must indicate the staff member that is in charge every day for each shift. 2. Criminal record reports must be completed when a staff is rehired and should be completed prior to hire. 3. The resident orientation form must be signed by the resident and the legal representative (if applicable) but not in place of the resident. 4. Recommended all staff carefully review all paperwork prior to filing to ensure all information is accurate and complete and that blanks are filled in with the requested information (or put "not applicable" if the requested information does not apply) - such as do not resuscitate orders, physicals, etc. 5. Reviewed the fire drill requirements with the maintenance staff who conducted the fire drills. 5. Recommended adding a place on the individualized service plans (ISPs) for the residents to sign for verification that a copy of the plan was issued to them. 6. Recommended conducting an audit of the uniform assessment instruments (UAIs) and ISPs to ensure all needs are addressed and that the specific services to be provided for each activity are clearly listed. 7. Only check one area under medication management on the UAIs. Administered by a lay person must be checked when the medications are administered by a registered medication aide rather than checking "administered by professional nursing staff". 8. The frequency of safety/wellness checks was clearly documented on the ISPs; however, physical/mental inability to use the call bell was not specifically stated and needs to be included on the ISPs. 9. Recommended additional audits of the medication cart be conducted by the director of health and wellness or executive director to ensure the audits are being completed as the facility policy requires.
Comments
An unannounced renewal inspection was conducted on 11/30/2021 from approximately 8:24 am to 5:20 pm, 12/1/2021 from approximately 8:15 am to 5:10 pm and 12/2/2021 from approximately 8:10 am to 5:05 pm. There were 54 residents in care, including 19 in the secured unit. The facility was clean and free from any foul odors. The posted menu accurately reflected this inspector's observations and the special diet observed in the memory care unit was served according to the physician's order. Medication administration observations were conducted with the registered medication aides on the assisted living and secured units for a total of four residents. The November 2021 medication administration records, physicians' orders and medications were reviewed for all four residents. Eight resident, one discharge and five staff records were reviewed. Selected sections of one additional resident and staff were also reviewed. The criminal record reports for all current staff hired since the last inspection were reviewed. Individual interviews were conducted with residents, a family member and staff. The areas of noncompliance included staff schedules, individualized service plans, documentation provided to emergency personnel, implementation of medication management policy, self-administering medications, oxygen orders, fire drills and criminal record reports. Staff answered all questions and obtained all information requested. Thank you for your assistance and cooperation during this inspection.
Violations
22VAC40-73-450-C
Based upon documentation and interviews, the facility failed to ensure all assessed needs were included on the individualized service plans (ISPs) for six of eight resident records reviewed.
Evidence
  1. The uniform assessment instrument (UAI) completed 11/8/2021 indicated resident 2 required mechanical help with transferring and supervision with eating; however, these needs were not listed on the ISP completed on 11/23/2021.
  2. The UAI completed 9/23/2021 indicated resident 3 required mechanical help with toileting; however, this need was not listed on the ISP completed on 9/23/2021. Resident 3 was also receiving hospice services and hospice was listed on the ISP; however, the specific services being provided were not listed on the ISP.
  3. The UAI completed 10/20/2021 indicated resident 5 required mechanical help with bathing and eating, mechanical help and physical assistance with transferring, and assistance with wheeling; disorientation to time/event and passive wandering; however, these needs were not listed on the ISP completed on 10/20/2021.
  4. The UAI completed 11/16/2021 indicated resident 6 required mechanical help with transferring; however this need was not listed on the ISP completed 11/16/2021.
  5. On 12/1/2021, the LI interviewed the ED and DHW and both stated the ISPs did not list all of the needs assessed on the UAIs for these residents. The DHW stated, "I was trying to get them done too quickly."
Plan of correction
The ISPs for residents 2, 3, 5 and 6 were updated to include assessed needs. The ISP for resident 3 was updated to include the specific services provided by hospice. A workshop was held on 11/23/21 for staff members who conduct assessments and create ISPs. The training provided guidance on including assessed needs from the UAI and other sources on the ISP. The ED will ensure that all ISPs include the assessed needs as well as all services provided to the residents. The DHW will create all UAIs and ISPs and the ED will review all for approval. All current ISPs are actively being reviewed to ensure all assessed needs, other needs, and services provided are clearly listed.
22VAC40-73-970-A
Based upon documentation and an interview, the facility failed to ensure fire drills were conducted on each shift in a quarter.
Evidence
  1. Fire drill forms indicated fire drills were held in the same quarter on the same shift on 8/27/2021 at 2:30 pm, 9/2/2021 at 10:30 am and 10/4/2021 at 1:22 pm.
  2. On 12/1/2021, the LI interviewed staff 7 who stated, "I wasn't aware that I had to conduct a drill on each shift."
Plan of correction
The ED has created a schedule for required fire drills to ensure that they are scheduled on each shift in a quarter. The standard was reviewed with staff 7. The ED will meet with staff 7 monthly to review needs prior to the fire drill being conducted. Staff 7 will then review each completed fire drill form with ED for compliance.
22VAC40-73-640-A
Based upon documentation, observations and interviews, the facility failed to implement the medication management plan by ensuring medications were readily available for three of four residents.
Evidence
  1. Resident 4 had a physician's order signed 9/22/2021 for Acetaminophen.
  2. The November medication administration record (MAR) for resident 4 listed, "Acetaminophen 325mg two tablets by mouth every 4 hours as needed for pain/fever."
  3. On 11/30/2021, the LI and staff 5 conducted an audit of resident 4's medications and staff 5 stated she could not find the Acetaminophen in the medication cart.
  4. Resident 8 had a physician's order signed 11/12/2021 for Mucinex.
  5. The November MAR for resident 8 listed, "Mucinex DM 30/600mg one tablet by mouth every 6 hours as needed for cough/congestion."
  6. On 11/30/2021, the LI and staff 9 conducted an audit of resident 8's medications and staff 9 could not find Mucinex in the medication cart.
  7. Resident 9 had a physician's order signed 10/5/2021 for Ondansetron.
  8. The November MAR for resident 9 listed, "Ondansetron HCl 4mg one tablet under tongue every 6 hours as needed for nausea."
  9. On 11/30/2021, the LI and staff 9 conducted an audit of the medications for resident 9 and staff 9 could not find the Ondansetron in the medication cart.
  10. On 11/30/2021, the LI interviewed the nursing supervisor who stated the medications were not in the medication room and were not available on site.
  11. The facility's medication management plan stated on page 6, section 10.c, "Night shift nurse will check PRN meds weekly during cart audits and request refills as needed to ensure adequate supply."
Plan of correction
The PRN (as-needed) medications that were not in the medication cart have been provided by the pharmacy and are now at the community. The medication for resident 9 was found by the day shift supervisor in the medication cart the next day after the licensing inspector had finished her audit. The medication management plan has been adjusted to reflect that the weekly cart audits may be completed by the nurse or registered medication aide (RMA) on evening shift, night shit, or any shift assigned. This process will enable the ED to ensure compliance and to adjust the weekly audit duties based on the needs of the community. The ED will review the results of the medication cart audits weekly for the next six weeks (until 1/21/22) to ensure compliance. The pharmacy will create a "PRN" report to send to DHW on a monthly basis to review and to ensure all medications are present and still current. Medication cart audits will be done weekly and reviewed by DHW prior to turning in to be reviewed by the ED weekly.
22VAC40-73-660-B
Based upon documentation, observations and interviews, the facility failed to ensure one of eight resident records reviewed was assessed as capable of self-administering and keeping medications in the room.
Evidence
  1. The UAI (completed 11/16/2021) assessed resident 6 as needing medications to be administered/monitored by professional nursing staff.
  2. The ISP (completed 11/16/2021) for resident 6 indicated, "Resident self administers medications and keeps medications in a secure location."
  3. The initial physical (completed 7/21/2021) for resident 6 indicated resident was capable of self-administering medications.
  4. On 12/2/2021, the LI interviewed resident 6 who stated she keeps medications in her room. Resident 6 also showed the LI where she keeps the medications in her room.
  5. On 12/2/2021, the LI interviewed staff 8 who completed the UAI and ISP for resident 6 and she stated she checked the wrong section in error and was trying to do them too quickly.
Plan of correction
The UAI has been corrected to reflect the ability of resident 6 to self-administer medications. All residents that self-administer have been re-assessed and any needed corrections have been made. The DHW will correctly assess each resident prior to move in and then monthly. The ED will review all assessments to ensure compliance.
22VAC40-73-570-D
Based upon an interview, the facility failed to ensure all required information was given to emergency personnel.
Evidence
  1. On 11/30/2021, the LI interviewed the ED regarding what information staff have been instructed to give emergency personnel when a resident is being transported to the hospital. The ED stated the physicians' order sheets were given and not the medication administration records or similar documentation.
Plan of correction
The standard lists "Medication Administration Record" as an "example" of the type of information necessary to the care of the resident when hospitalized or transported by emergency personnel. The facility policy Clinical 12 - Medical Emergencies lists the following information to be provided to paramedics: a Hospital Facility Transfer Form (completed); a list of current medications, DNR status (Advance Directives/Care Orders/POST, etc.) and the Face Sheet Form. The staff have been instructed to provide this information as well as to provide the "Last Dose Administered Report." A checklist was also created and DHW will review each transport with staff.
22VAC40-73-290-A
Based upon documentation and an interview, the facility failed to ensure the written work schedule included all required information.
Evidence
  1. The staff schedule for 11/14/2021 through 11/27/2021 did not indicate the staff in charge at any time.
  2. On12/2/2021, the LI interviewed the ED who stated the staff person in charge was not included on the staff schedule.
Plan of correction
The ED will ensure that the written work schedule will reflect the staff person in charge on each shift. The written work schedule was re-printed on 12/8/21 to indicate the staff person in charge at any given time. Staff person in charge has been added to the schedule on a separate row to indicate who is in charge for each shift. The ED does schedules and the director of health and wellness (DHW) will review prior to posting to ensure compliance.
22VAC40-90-40-B
Based upon documentation and an interview, the facility failed to ensure one of 52 criminal record reports (CRR) was completed within 30 days of hire and no more than 90 days prior to hire.
Evidence
  1. The CRR for staff 6 (rehired 10/19/2021) was completed 6/3/2021.
  2. On 11/30/2021, the licensing inspector (LI) interviewed the executive director (ED) who stated a new CRR was not completed when staff 6 was rehired.
Plan of correction
The ED has reviewed with the business office manager (BOM) that a new CRR must be completed again when a former employee is rehired. An audit was conducted on all employee files to ensure compliance. A CRR was conducted for staff 6 on 12/01/21. The BOM will complete a new hire/rehire checklist at every hire and turn in weekly to the ED for review.
22VAC40-73-700-1
Based upon documentation and an interview, the facility failed to ensure two of three oxygen orders had all required information.
Evidence
  1. The oxygen orders for residents 7 (signed 11/14/2021 and 10 (signed 10/13/2021) did not include the source of the oxygen.
  2. On 12/1/2021, the LI interviewed the ED and DHW and both stated the source was not included on these two oxygen orders.
Plan of correction
The physician has re-written (on 12/8/21) the orders for resident 7 and resident 10 to include the source of the oxygen. The ED will review, with all nurses and registered medication aides, the policy Med 27 - Assistance with Oxygen, which includes details regarding information required in the orders. The DHW has created a form for "continuous" as well as "PRN" oxygen to be signed by physician to include all needed information. The signed oxygen orders will be reviewed by the ED monthly.
June 29, 2021Inspection0 violations
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS
Comments
A non-mandated self-report inspection was initiated on 6/29/2021 and concluded on 6/29/2021. A self-report was received by the department regarding allegations in the areas of resident care and related services. The administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 3, 2021Complaint survey1 violation
Inspection dates
May 3, 2021 , May 5, 2021 and May 26, 2021
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS
Technical assistance
1) Standard 460.H requires all residents be bathed at least twice a week. Discussed the admission form the families complete prior to admission and the need to add bathing twice a week as a standard requirement. 2) Any deviation from the standard must be addressed prior to implementation by completing and receiving approval of an allowable variance.
Comments
This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of ememrgency health pandemic declared by the Governor of Virginia. A monitoring inspection was initiated on 5/3/21 and concluded on 5/26/21. A complaint was received by the department regarding allegations in the areas of resident care and related services. The administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the allegation of non-compliance with standards or law, and a violation was issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.
Violations
22VAC40-73-450-H
Based upon documentation and interviews, the facility failed to ensure one of three residents received the services specified in the individualized service plan (ISP).
Evidence
  1. The ISP (dated as completed 4/16/21) indicated resident A was to be bathed once a week.
  2. Documents completed by the family/resident A indicated resident preferred to be bathed once a week.
  3. The service received form indicated resident A received a shower on 4/20/21, 4/27/21 and 5/9/21; however, . on 5/26/21, the licensing inspector interviewed staff B who stated resident A did not receive a shower on 4/27/21. Staff B stated the service received form was signed off before the shower was given but when staff went in to resident A's room to give the shower, resident A refused due to Norovirus being in the building.
  4. Neither a description of the circumstances warranting the deviation nor the date of the deviation were documented.in the resident's record.
  5. Resident A's refusal was not documented. The deviation from the ISP was not documented in the resident's file and a notice of the deviation was not provided to the resident or the legal representative.
Plan of correction
1) ISP for resident A updated on 5/16/21 to reflect bathing schedule of two times per week. 2) Director of health and wellness, along with the memory care director and executive director, will ensure future resident ISPs reflect bathing schedules of twice weekly. 3) All direct care staff (DCS) will review the proper procedures for documentation of care, along with proper documentation of any deviation from the care plan, by 6/17/21.
January 21, 2021Complaint survey0 violations
Inspection dates
Jan. 21, 2021 and Jan. 27, 2021
Areas reviewed
22VAC40-73 PERSONNEL
Comments
This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A complaint inspection was initiated on 1/21/21 and concluded on 1/27/21. A complaint was received by the department regarding an allegation in the area of administration. The director of health and wellness was contacted by telephone to conduct the investigation. The licensing inspector verbally requested the director of health and wellness submit information required to completed the investigation. The information gathered during the investigation did not support the allegation of non-compliance with standards or law.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
December 2, 2020Inspection2 violations
Inspection dates
Dec. 2, 2020 , Dec. 4, 2020 and Dec. 7, 2020
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity63.2 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 PROCESS
Technical assistance
Questions answered and discussions occurred on the following: 1) The secured unit activity person must complete the required training within six months of hire (1120.F). Please submit training certificates to licensing inspector upon completion. 2) It is the facility's responsibility to ensure the stat box remains current (expired 11/30/20 and was replaced on 12/2/20). 3) Make sure all staff carefully review all paperwork to ensure all information is accurate and complete.
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 12/2/20 and concluded on 12/7/20. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 20 (eight on assisted living unit and 12 on the secured unit). The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed three resident, two contract staff and three staff records. Selected sections of one resident and two staff records were also reviewed. The inspector also reviewed fire drill log sheets, activities calendars, menu, staff schedules, first aid kit, dietary/medication/healthcare oversights, required postings, resident council meeting minutes, stat box, staff rounds log sheets, as well as other documentation. A virtual tour of various areas of the facility, including the secured unit, was conducted along with a review of various documents. Information gathered during the inspection determined non-compliance with tuberculin skin assessments and implementation of the medication management plan, and violations were documented on the violation notice issued to the facility.
Violations
22VAC40-73-250-D
Based upon documentation and an interview, the facility failed to ensure two of the three tuberculin skin assessments (TBs) were completed prior to the first day of work.
Evidence
  1. Staff B (hired 9/23/20) had a TB assessment form signed and dated as completed on 9/23/20; staff C (hired 7/13/20), had a TB assessment form signed and dated as completed on 7/14/20; however, neither of the forms indicated the results of the assessments. Section I, titled "Screen for symptoms and check all that apply," was left blank, including the option for "none", Section III, titled "Findings (check all that apply) was also left blank, including the option of no risk factors for TB infection.
  2. On 12/4/20, the licensing inspector (LI) interviewed the administrator who stated the information was left blank as the nurse must have forgotten to check the appropriate sections and just signed the form.
Plan of correction
TB assessments were completed immediately on the staff members in question to bring them into compliance. Facility will implement and put into practice a checks and balance that will ensure all charts are audited by the business office manager, prior to staff start date, to ensure compliance. Executive director and director of health and wellness will audit all staff records monthly, along with the business office manager, to ensure compliance is maintained.
22VAC40-73-640-A
Based upon documentation and an interview, the facility failed to implement the medication management policy by ensuring all information on the medication administration records (MARs) was transcribed accurately.
Evidence
  1. The November and December MARs indicated allopurinol was to be given in the morning (AM); however, the signed physician's order indicated the medication was to be given at lunch time; the MARs listed the diagnosis for atorvastatin as hyperlipidemia; however the signed physician's order listed the diagnosis as dyslipidemia; the MARs listed the diagnosis for trazadone as depression; however, the signed physician's order listed the diagnosis as dementia; NOTE: The effective date for these medications was 11/18/20.
  2. On 12/7/20, the LI interviewed the administrator who also reviewed the MARs and stated the MARs and orders did not match.
Plan of correction
The pharmacy was contacted immediately to have the time changed to the correct time and the diagnoses corrected, according to the physicians' orders. The director of health and wellness, along with the memory care director, will audit the MARs the first of each month to ensure the proper diagnoses and time of administration are included for all medications. Director of health and wellness/memory care director will audit the charts for new orders to ensure that all new orders have been transcribed properly (immediately upon receipt), including each having the proper diagnosis and time of administration to match the order. These will also be sent to the pharmacy to ensure compliance.