Virginia DSS · Assisted Living Facility

Greenbrier Assisted Living

📍 8204 Madrillon Estates Drive, Vienna, VA, 22182

ID 46361Two Year licenseActive
10
Inspections
On record
5
With violations
Visits that cited something
5
Clean visits
Nothing cited
122
Violations cited
Individual findings
94
Standards cited
Distinct rules
3
Complaint visits
Prompted by a complaint

Greenbrier Assisted Living was inspected 10 times between February 16, 2021 and August 27, 2025 by the Virginia Department of Social Services. 5 of those visits ended with violations cited and 5 with none. Across that history VDSS cited 122 violations under 94 distinct standards. 3 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. 8 of these 10 are still on the state's site; the other 2 have since dropped off it and are reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type
Assisted Living Facility
License type
Two Year
License expires
10/25/2025
Administrator
Roxana Gharavi
Licensing inspector
Alexandra Roberts
Inspector phone
(804) 845-6956
Approved for
Assisted Living · Non-Ambulatory

Inspection History

10

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

August 27, 2025Inspection52 violations
Inspection dates
08/27/2025, 09/04/2025 & 09/05/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 8/27/2025 from 7:00am – 5:46pm and 9/04/2025 from 8:45am – 3:25pm and 9/05/2025 from 9:55am – 11:15am. 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: 7 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 3 Number of interviews conducted with residents: 6 Number of interviews conducted with staff: 5 Observations by licensing inspector: Observed residents in the common area and staff cooking lunch. 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 Alexandra Roberts, Licensing Inspector at 804-845-6956 or by email at Alexandra.N.Roberts@dss.virginia.gov
Violations
22VAC40-73-640-A
Based on document review, observation, and staff interview, the facility failed to implement their written plan for medication management.
Evidence
  1. During the inspection on 08/27/2025, Staff 3 provided a copy of the facility’s medication management plan.
  2. The medication management plan states under the heading “Methods to ensure that each resident’s prescription medications and any over-the-counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages” that “Medications are ordered when a given medication is down to no less than a 7 day supply” and “During each shift it shall be determined which if any, [sic] medications are in need of ordering/re-ordering and the process shall be initiated”
  3. On 08/27/2025 the following scheduled medications were not onsite for administration for Resident 8: Morphine Sulfate ER 10 mg cap, take 1 capsule by mouth every evening for fibromyalgia and chronic pain ordered 07/19/2025. Tramadol HCL 50 mg tab, take one tablet by mouth every day at 6PM for pain ordered 02/9/2025.
  4. Staff 3 confirmed during interview on 08/27/2025 that the above medications were not on site and that a request to refill those medications had not yet been placed.
  5. On 08/27/2025, three licensing staff observed Staff 3 call the pharmacy to request refills.
  6. The medication management plan states under the heading “Methods for verifying that medication orders have been accurately transcribed to medication administration records (MARs) within 24 hours of receipt of a new order or change in an order” that “on the original order from the prescriber, write ‘noted’ on it, with your signature and date. This tells the reader that you received the order, and that you transcribed it onto the MAR.”
  7. On 08/27/2025 physician/prescriber orders were reviewed for Residents 7 and Resident 8. None of the reviewed orders included a notation that the orders were ‘noted’ or a signature and date of the reviewing facility staff.
  8. The medication management plan states under the heading “Methods to ensure accurate counts of all controlled substances whenever assigned medication staff changes that “Controlled substances are kept double-locked, with the keys available only to staff responsible for the medication delivery.”
  9. During a medication pass observation on 08/27/2025 at approximately 8:45 am performed by Staff 3, licensing staff observed that a controlled substance (Clonazepam 0.5 mg tab) for Resident 8 was not stored in the double-locked area of the medication cart prior to administration. Staff 3 acknowledged that the clonazepam was not properly stored in the double-locked area.
  10. The medication management plan states under the heading “Methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes” that “Each time a controlled substance is removed from its storage area, its removal is documented in a specific book or binder, one page for each controlled substance. Each staff must sign out the medication used; and must not wait until the end of his/her shift to sign them out of the book/binder, as he/she may forget.”
  11. During a medication pass observation on 08/27/2025, licensing staff observed Staff 3 administer a controlled substance, clonazepam 0.5 mg tablet, to Resident 8. Licensing staff did not observe Staff 3 to document the administration of the controlled substance on a controlled substance count sheet at the time of medication administration. Staff 3, when asked, stated that they would document later. (Due to the limited space allowed by the DSS computer licensing system, the remainder of the violation is on a separate document and available upon request.)
Plan of correction
Not published by VDSS.
22VAC40-73-920-A
Based on documentation, observation and interview, the facility failed to ensure toilets, face/hand washing sinks and bathtubs or showers are in separate rooms for men and women where more than four persons live on a floor. Bathrooms equipped to accommodate more than one person at a time should be labeled by gender. Gender designation of bathrooms should remain constant during the course of a day.
Evidence
  1. The floor plans, submitted by the facility on 5/21/2020, as well as the floor plans included in the emergency preparedness and response plan (requested 09/08/2025 via email and provided via fax 09/10/2025), showed the second floor includes 5 bedrooms with private bathrooms and 2 bedrooms, each with a door for access to a shared bathroom. No updated plans have been submitted to licensing.
  2. During a tour of the facility on 09/04/2025, three licensing staff observed that Resident 7 (male) and Resident 10 (female) share a private bathroom connecting their two bedrooms with a shared toilet and bath area on the second floor. No common showers were observed on the main or second floors.
  3. Staff 4 confirmed to three licensing staff that the shared bathroom with Resident 7 is used to bathe Resident 10.
  4. Resident 7 confirmed utilizing the bathroom shared with Resident 10.
  5. During inspection on 08/27/2025, Resident 7 expressed to licensing staff feeling uncomfortable sharing a bathroom with Resident 10.
  6. Licensing staff confirmed that the other 5 residents (all female) reside on the second floor and have a private toilet and bathing facilities within their rooms.
  7. This violation was previously cited during the 7/29/2025, 8/5/2025, and 8/25/2025 inspection.
Plan of correction
Not published by VDSS.
22VAC40-73-100-A
Based on observation and document review, the facility failed to implement their infection control program addressing the surveillance, prevention and control of disease and infection.
Evidence
  1. On 08/27/2025 the facility’s infection control program was provided by Staff 3 and was reviewed by licensing staff.
  2. Under the heading “5. Hand Washing” the infection control program states “Staff will wash hands ... 4. Before handling medication.” and “5. Before and after helping residents with personal care tasks of daily living.”
  3. On 08/27/2025, licensing staff observed a morning medication pass performed by Staff 3 for the six residents in care from approximately 7:35 am to approximately 8:50 am.
  4. Licensing staff accompanied Staff 3 from the location where the entrance conference was completed to the medication cart, throughout morning medication pass and back to the dining room location where document review was performed.
  5. Staff 3 was not observed performing any type of hand hygiene and did not wear any type of gloves at any time during the medication pass, during the medication pass which included administration of medication to six different residents, or immediately after concluding the medication pass.
  6. During an interview with Staff 3 on 08/27/2025, when questioned about the lack of hand hygiene, Staff 3 stated that they were not obligated to perform hand hygiene because they did not touch the medications for administration with their bare hands.
Plan of correction
Not published by VDSS.
22VAC40-73-290-A
Based on documentation and an interview, the facility failed to ensure a written work schedule for all staff was maintained that included any absences, substitutions or changes.
Evidence
  1. On 08/27/2025, licensing staff interviewed Staff 5 who stated that they worked mostly during the day with different hours but did not keep a written schedule of their hours.
  2. On 8/27/2025, staff 5 arrived at approximately 10:00am.
  3. The posted schedule listed staff 3 as working on 08/27/2025 from 7:00 a.m. to 3:00 p.m.; however, licensing staff arrived at the facility at approximately 7:00 a.m. and Staff 3 was not in the facility and on duty. Staff 3 arrived at the facility at approximately 7:30 a.m.
  4. The staff schedule listed staff 3 as working on 9/4/2025 from 7:00 a.m. to 5:00 p.m.; however, licensing staff were in the facility from approximately 8:48 a.m. to 3:25 p.m. and staff 3 was not in the facility.
  5. The staff schedule listed staff 3 as working on 9/5/2025 from 7:00 a.m. to 11:00 p.m.; however, licensing staff arrived at the facility at approximately 9:55 a.m. and left the facility at approximately 11:15 a.m. and staff 3 was not in the facility.
  6. The written staff schedule for 08/8/2025 through 09/13/2025, was faxed to licensing on 09/10/2025. The schedule did not include Staff 5’s (administrator) hours on site.
  7. The schedule submitted to licensing on 9/10/2025 did not reflect changes to the schedule for staff 3 not being at the facility during the scheduled times on 8/27/2025, 9/4/2025, and 9/5/2025 or staff 5 being present on 8/27/2025.
Plan of correction
Not published by VDSS.
22VAC40-73-210-B
Based on interview and record review, the facility failed to ensure all direct care staff attend at least 18 hours of training annually.
Evidence
  1. During the course of the three-day inspection, Staff 3 (in charge 08/27/2025) and Staff 4 (in charge 09/04/2025) did not provide training records upon request to verify compliance for Staff 4, Staff 6, and Staff 7.
  2. On 09/08/2025, licensing staff requested documentation for all staff training records for Staff 4, Staff 6, and Staff 7 from Staff 3 via email.
  3. On 09/10/2025, Staff 3 faxed the following information to licensing staff: a. Staff 6’s first day of work was 09/08/2022 per the “Record of Initial ALF Staff Training” document. Additionally, the document “Direct Care Staff Training Plan & Log (20-Hour Requirement)” indicates Staff 6’s hire date as 09/08/2022 with 40 hours of training all completed on 09/08/2022. Staff 3 did not submit any training completed in the year 2023, 2024, or 2025 for Staff 6.
  4. This violation was previously cited during the 7/9/2024, 7/17/2024, 08/27/2024, and 12/23/2024 inspection.
Plan of correction
Not published by VDSS.
22VAC40-73-810-A
Based on documentation, observations and interview, the facility failed to ensure at least one operable telephone was easily accessible to staff.
Evidence
  1. On 8/27/2025, two licensing staff observed the posted emergency evacuation drawing which listed a telephone in the dining/kitchen area on the main floor and in the living room/medication area on the second floor.
  2. During the beginning of facility tour on 8/27/2025, licensing staff did not observe a telephone on the main floor in the area shown on the posted drawing.
  3. On 8/27/2025, licensing staff asked Staff 1 and 2 where the facility telephone was located. Both staff looked around and stated they did not know where the telephone was. Staff 1 stated that it is usually on the counter in the living room but sometimes it is taken. Staff 1 stated the boss was here last night and sometimes he takes it. Staff 1 stated he left last night sometime around 10:30 p.m.
  4. On 8/27/2025, two licensing staff did not observe an operable telephone in the location listed on the posted second floor evacuation drawing. An inoperable, unplugged cordless telephone was observed by licensing staff in a cabinet nearby.
  5. Photo evidence taken.
Plan of correction
Not published by VDSS.
22VAC40-73-520-F
Based on observation, the facility failed to ensure during an activity, that there were staff persons or volunteers to lead and assist the residents with the activity.
Evidence
  1. During 09/04/2025 inspection, three licensing staff observed the scheduled 10:00 a.m. exercise activity. Residents were observed sitting alone in the common living room with an exercise video playing on the television. Licensing staff observed Staff 4 and Staff 6 in the kitchen and not leading the activity nor assisting or encouraging the residents to participate in the activity.
  2. During 09/05/2025 inspection, two licensing staff observed the same exercise video playing from the 09/04/2025 inspection. Residents were sitting in the common living room and Staff 4 and Staff 6 were not in the living room leading the activity nor assisting, encouraging, or helping the residents participate.
  3. Video evidence taken.
Plan of correction
Not published by VDSS.
22VAC40-73-710-B
Based on observation and staff interview, the facility failed to ensure that physical restraints not be used for purposes of discipline or convenience and that they may only be used (i) as a medical/orthopedic restraint for support, according to a physician's written order and with the written consent of the resident or their legal representative.
Evidence
  1. During the inspection on 09/04/2025, two licensing staff observed a bed with two full bedrails in Resident 10’s room.
  2. During an interview on 09/04/2025, Staff 4 explained that two full bedrails are used for Resident 10 at night and demonstrated how both siderails are engaged and stated that they put both up every night.
  3. Staff 4 confirmed during interview on 09/04/2025, that the bedrails are used for the purpose of preventing Resident 10 from attempting to get out of the bed and confirmed that Resident 10 would be unable to exit the bed on their own with the two bedrails up.
  4. During the inspection on 09/04/2025 at approximately 1:20 pm, two licensing staff observed Resident 10 in the family room area adjacent to the kitchen, positioned in a geriatric chair with tray table attached, restricting the residents’ freedom of movement. No staff were in the immediate vicinity.
  5. During 09/04/2025 inspection, two licensing staff observed Resident 11’s having two bedrails. Staff 4 confirmed that Resident 11 is unable to get out of the bed with the bedrails up.
  6. During the inspection on 09/04/2025, all physician/prescriber orders were requested for review from the staff person in charge, Staff 4, and no orders for restraint use were provided.
  7. Licensing staff requested, in part, via email to Staff 3 on 9/8/2025, all Medication Administration Records, Treatment Administration Records, and all physician or other prescriber orders for Resident 2, Resident 5, Resident 9, and Resident 11.
  8. On 9/10/2025, staff 3 sent an email with other requested documentation that stated staff 3 was still working on items requested. As of 10/09/2025, the requested documentation had not been received.
  9. Photo and video evidence taken.
Plan of correction
Not published by VDSS.
22VAC40-73-660-A-3
Based on observation, the facility failed to ensure that the individual responsible for medication administration kept the keys to the storage area on his person.
Evidence
  1. During a medication pass observation on 08/27/2025 by Staff 3, licensing staff observed Staff 3 walk away from the medication cart at approximately 8:04 am to go downstairs, leaving the medication cart unattended with the key in the lock. Staff 3 returned approximately two minutes later.
  2. Photo evidence taken.
  3. This violation was previously cited during the 7/9/2024, 7/17/2024, 08/27/2024, and 12/23/2024 inspection.
Plan of correction
Not published by VDSS.
22VAC40-73-550-F
Based on observation, the facility failed to ensure that rights and responsibilities of residents be printed in at least 14-point type and posted conspicuously in a public place in all assisted living facilities.
Evidence
  1. During 09/04/2025 and 09/05/2025 inspection, three licensing staff did not observe the posted rights and responsibilities of residents.
  2. A previous plan of correction submitted to licensing on 09/02/2025 from Staff 3 for the inspection conducted on 7/29/2025 and 8/5/2025 noted that the rights and responsibilities of residents had been printed and posted in the facility as of 08/30/2025.
Plan of correction
Not published by VDSS.
22VAC40-73-1070-B
Based on observation and interview, when there are ordinary materials or objects may be harmful to a resident with a serious cognitive impairment, these materials or objects shall be inaccessible to the resident except under staff supervision.
Evidence
  1. The facility serves a mixed population.
  2. On 9/04/2025, three licensing staff observed what appeared to be a cosmetic pouch on a cart in the dining room.
  3. The pouch contained Equate Extra Strength Acetaminophen 500mg and Vitamin D3 1000iu and a prescription bottle containing unidentifiable light colored tablets with an illegible label.
  4. On 8/27/2025, 9/4/2025 and 9/5/2025, three licensing staff observed residents accessing the area as they were walking through the area to exercise.
  5. Resident 2 confirmed that residents eat dinner in the dining room where the cosmetic pouch was accessible.
  6. Licensing staff inquired with facility staff about who the pouch belongs. Staff 7 informed licensing staff that the pouch belongs to Staff 1 who was on vacation. Staff 7 then took the pouch.
  7. On 08/27/2025 and 09/04/2025, two licensing staff observed wooden boards outside under the porch with exposed rusted nails.
  8. Photo and video evidence taken of boards.
Plan of correction
Not published by VDSS.
22VAC40-73-40-A
Based on observation, record review and interview, the licensee failed to ensure compliance with all regulations for licensed assisted living facilities and terms of the license issued by the department; with relevant federal, state, and local laws; with other relevant regulations; and with the facility's own policies and procedures.
Evidence
  1. Facility building evaluation completed 07/07/2020 limits the facility to 4 non-ambulatory residents restricted to reside on the main floor.
  2. The facility’s current license includes the following stipulation (effective 10/26/2020): As per Building Official, non-ambulatory residents are restricted to the main floor. No more than four (4) residents can be non-ambulatory.
  3. During inspection on 08/27/2025, Staff 5 informed licensing staff that Resident 10 and Resident 11 are non-ambulatory and unable to exit independently in an emergency.
  4. On 8/27/2025, staff 5 provided a list of residents that were non-ambulatory (cannot exit with just a single verbal command) which included residents 7, 10 and 11.
  5. During interview on 08/27/2025, Resident 7 stated that they would not be able to exit the facility as they do not know how to open the gate on the top of the stairway independently and stated facility staff would need to help them exit.
  6. Residents 5, 7, 8, 9, 10 and 11 all reside on the second floor of the facility.
  7. During the 9/4/2025 inspection, two licensing staff observed Resident 11’s bed having two side rails. Staff 4 confirmed that Resident 11 is a 2-person assist.
  8. The Uniform Assessment Instrument (UAI) for Resident 8 (dated as assessment completed on 1/26/2025), had physical assistance needed with bathing, dressing, toileting, transferring, and physical assistance and mechanical help with walking.
  9. The individualized Service Plan (ISP) for Resident 8 (dated 1/26/2025), listed physical assistance with dressing and eating (at all times); mechanical help (walker) and physical assistance with walking; fall risk.
  10. In a telephone interview with Collateral Contact 5 on 09/19/2025 with two licensing staff, Collateral Contact 5 confirmed that Resident 5,8,9,10 and 11 are non-ambulatory as they are not physically and/or mentally capable of self-preservation by evacuating in response to an emergency to a refuge without assistance of another person or staff.
  11. On 8/27/2025, staff 5 (administrator) provided licensing staff with a list of residents who were receiving home health services. No residents were listed as receiving speech therapy.
  12. The facility dietary manual under section five stated, “Dysphagia - residents with swallowing difficulties should receive meals that are appropriately modified in texture to prevent choking. A speech therapist should be consulted to create a suitable plan.” Licensing staff did not observe evidence that the facility consulted a speech therapist to create a suitable plan for Resident 2, Resident 8, or Resident 11 to prevent the resident from choking as stated in the diet manual.
  13. During interview on 08/27/2025, Staff 3 informed three licensing staff that the facility does not have any residents with a special or altered diet, that has received diet oversight, or consultation with speech therapy.
  14. During an inspection on 08/27/2025, licensing staff observed the following: a. Resident 11 eating a mechanically altered diet (a cut up hot dog). b. Resident 8 eating a mechanically altered diet (a hot dog cut into very small pieces).
  15. During 09/04/2025 inspection, licensing staff reviewed the facility’s “911 Documents” binder. Staff 4 confirmed that the binder contained the documents that would be sent out with resident in the event that they went to the hospital. These documents indicated that the following residents were to receive special diets: (Due to the limited space allowed by the DSS computer licensing system, the remainder of the violation is on a separate document and available upon request.)
Plan of correction
Not published by VDSS.
22VAC40-73-660-A-6
Based on observation and interview, the facility failed to ensure that when it is necessary to store medication in a refrigerator that is routinely used for food storage that the medication shall be stored together in a locked container in a clearly defined area.
Evidence
  1. During a tour of the facility on 09/04/2025, two licensing staff observed a bottle of IHS Magic Mouthwash (w/o Nystatin) suspension in the kitchen refrigerator, routinely used for food storage, with a prescription label for Resident 8.
  2. The medication was located in an open unlocked compartment in the refrigerator door behind various food bottles and not in a locked container.
  3. Staff 4 confirmed that the medication was a prescribed medication for Resident 8 and acknowledged that the medication was being stored in the refrigerator door with food.
  4. Photo evidence taken.
Plan of correction
Not published by VDSS.
22VAC40-73-680-D
Based on documentation review and observation, the facility failed to ensure that medications were administered in accordance with the physician’s or other prescriber's instructions.
Evidence
  1. Resident 5 was scheduled to receive Levothyroxine 50 mcg 1 tab by mouth at 6:00am on an empty stomach. At approximately 7:10am, licensing staff observed Resident 5 seated at the kitchen table, eating breakfast that included sausage, mandarins and grapes. At approximately 7:55am licensing staff observed Staff 3 administer Levothyroxine 50 mcg 1 tab with four additional medications.
  2. Resident 11 was scheduled to receive Levothyroxine 75 mcg 1 tab at 6:00am on an empty stomach. Licensing staff observed Staff 3 administer Levothyroxine 75 mcg (administered as 1.5 50 mcg tablets) at 8:36am with three additional medications that were scheduled for administration one hour later at 7:00 am.
  3. On 8/27/2025, Resident 5 was scheduled to receive Cholestyramine 4 G Pow at 0700. Cholestyramine 4 G pow was not administered. Staff 3 confirmed that Cholestyramine 4 G pow was not in the medication cart and would not be administering it at that time. Licensing staff observed all medication passes while onsite and the medication was not administered.
  4. On 08/27/2025, Resident 2 was scheduled to receive citrucel powder and modafinil 200 mg. Citrucel powder and modafinil 200 mg were not administered. Staff 3 confirmed that neither medication was available in the medication cart for administration, and they would not be administering those medications at that time. Licensing staff observed all medication passes while onsite and neither medication was administered.
  5. During the inspection on 08/27/2025, Staff 3 provided licensing staff with a prescriber order stating that the Invega injection for Resident 7 is to be given every 28 days at 8:00am with a handwritten note on the order that stated, “last given 08/6/2025 @ 12:28”.
  6. During phone interview on 09/23/2025, Collateral contact 5 informed two licensing staff of the following regarding Resident 7: a. The facility did not provide discharge information or a copy of new/updated orders when Resident 7 was discharged from a rehabilitation facility back to the assisted living in August 2025, therefore they were unaware that the rehabilitation facility had administered a dose of Invega or that another dose was due. b. On 09/10/2025 Staff 3 called and notified Collateral Contact 5 that Resident 7 had not received their prescribed Invega 78mg intramuscular injection which had been due to be given one week earlier on 09/03/2025. c. Collateral Contact 5 confirmed that they went to the facility to administer the Invega injection on 09/10/2025.
  7. During phone interview on 09/23/2025, Collateral contact 5 informed two licensing staff of the following regarding Resident 8: a. On 08/30/2025 Staff 3 informed Collateral Contact 5 that Resident 8 had not received ordered Gabapentin 100 mg cap 1 cap by mouth nightly for neuropathy for approximately six (6) weeks and the facility had none on site. b. Collateral Contact 5 confirmed to licensing staff that the last script was written and sent to the pharmacy on 04/07/2025 for 90 capsules, and that the medication had not been filled by the pharmacy for the doses scheduled between 07/07/2025 to 08/30/2025. c. The Virginia Department of Health Professions Prescription Monitoring Program report provided by Collateral Contact 5 for Resident 8 confirms that the Gabapentin 100 mg capsules were filled from the pharmacy on 4/7/2025 (35 capsules), 5/7/2025 (31 capsules) with the last dispensed from the pharmacy on 06/09/2025 (24 capsules dispensed). (Due to the limited space allowed by the DSS computer licensing system, the remainder of the violation is on a separate document and available upon request.)
Plan of correction
Not published by VDSS.
22VAC40-73-650-A
Based on record review and interview, the facility failed to ensure that no medication, dietary supplement, diet, medical procedure, or treatment be started, changed, or discontinued by the facility without a valid order from a physician or other prescriber.
Evidence
  1. During an inspection on 08/27/2025, licensing staff observed the following: a. Resident 11 eating a mechanically altered diet (a cut up hot dog). Staff 5 informed licensing staff that Resident 11 cannot eat big pieces of food as they are a choking hazard. b. Resident 8 eating a mechanically altered diet (a hot dog cut into very small pieces). Staff 5 informed licensing staff that Resident 8 has no teeth and has a hard time swallowing so cannot eat big pieces of food.
  2. During 08/27/2025 inspection, Resident 8’s ISP dated 01/26/2025 indicated a soft diet.
  3. During 08/27/2025 inspection, Staff 5 confirmed that Resident 8 and Resident 11 have altered diets to prevent choking.
  4. Resident 7’s physical examination (dated 03/30/2023) indicated they are vegetarian. On 08/27/2025, licensing staff interviewed Resident 7 who confirmed being a vegetarian. Resident 7 stated they continue to give them meat – turkey for multiple days.
  5. During 08/27/2025 inspection interview, Staff 3 confirmed there were no physician or prescriber orders for special diets for any of the residents.
  6. During an interview on 9/4/2025, Collateral Contact 3 confirmed resident 8 is on a soft diet.
  7. During 09/04/2025 inspection, licensing staff reviewed the facility’s “911 Documents” binder. Staff 4 confirmed that the binder contained the documents that would be sent out with resident in the event that they went to the hospital. These documents indicated that the following residents were to receive special diets: a. Resident 11: “Diet: Pureed, thin liquids” "Diet: Gluten free, no red meat” b. Resident 2: “Diet: Heart Healthy”
  8. On 09/04/2025, physician/prescriber orders were requested for review and were not provided in order to ensure that Residents 2, 7, 8, and 11 were receiving the proper diet.
  9. This violation was previously cited during the 7/29/2025, 8/5/2025, and 8/25/2025 inspection.
Plan of correction
Not published by VDSS.
22VAC40-73-160-D
Based on record review and interviews, the facility failed to ensure that administrators who supervise medication aides, as allowed by 22VAC40-73-670 3 b, but are not registered medication aides themselves, shall successfully complete a training program approved by the Virginia Board of Nursing for the registration of medication aides.
Evidence
  1. Staff 3 is the only registered medication aide (expiration 07/31/2026) employed at the facility.
  2. During inspection on 08/27/2025, Staff 3 confirmed that the facility does not have a full-time RN or other licensed health professionals employed at the facility.
  3. Facilities medication management plan includes “methods to ensure that staff who are responsible for administering medications are adequately supervised, including periodic direct observation of medication administration”. The facility’s policy states that “medication aides must also be supervised by a staff licensed by the Commonwealth of Virginia to administer medications, or an administrator who is licensed by Virginia Board of Nursing.”
  4. During inspection on 08/27/2025, Staff 3 and Staff 5 confirmed that Staff 5 has not attended or successfully completed a training program approved by the Virginia Board of Nursing for the registration of medication aides to provide supervision.
Plan of correction
Not published by VDSS.
22VAC40-73-1040-B
Based on observation and interview, the facility failed to ensure that there were protective devices on the bedroom and the bathroom windows of residents with serious cognitive impairments and on windows in common areas accessible to these residents to prevent the windows from being opened wide enough for a resident to crawl through. The protective devices on the windows shall be in conformance with the Virginia Uniform Statewide Building Code (13VAC5-63).
Evidence
  1. During interview on 8/27/2025 with three licensing staff present, Staff 5 confirmed that the facility serves a mixed population.
  2. During inspection on 08/27/2025, two licensing staff on tour with Staff 5 observed that Resident 2’s second floor windows protective device locks were not engaged to prevent the window from being opened wide enough for a resident to crawl through. Staff 5 confirmed multiple windows being able to fully open.
  3. During inspection on 09/04/2025, three licensing staff on tour with Staff 4 observed Resident 5,7,9 and 10’s second floor bedroom windows protective device locks were not engaged to prevent the window from being opened wide enough for a resident to crawl through. Staff 4 acknowledged that the windows could be fully opened.
  4. Video evidence taken.
Plan of correction
Not published by VDSS.
22VAC40-73-870-I
Based on record review and interview, the facility failed to ensure that elevators were inspected annually and in accordance with the Virginia Uniform Statewide Building Code (13VAC5-63). The signed and dated certificate of inspection issued by the local authority shall be
Evidence
  1. of such inspection. Evidence:
  2. During the inspection on 08/27/2025 and 09/04/2025, licensing staff observed that the facility elevator had an out of order sign.
  3. During the inspection on 08/27/2025 and 09/04/2025 licensing staff observed the facility’s elevator being used to transport residents and staff.
  4. During the inspection on 08/27/2025 Staff 3 confirmed that the elevator is routinely used to transport residents between the first and second floor and that the out of order sign is used to deter residents from using the elevator unaccompanied.
  5. During 08/27/2025 inspection, three licensing staff requested the elevator inspection certificate from Staff 3. Staff 3 confirmed that the facility has not had an elevator inspection by the local authority completed and did not provide documentation of an annual elevator inspection.
  6. During the inspection on 09/04/2025, Staff 4 stated that the elevator is not out of order and that the sign is there to keep residents out of the elevator unless staff are present.
  7. During inspection on 7/9/2024, 7/17/2024, 08/27/2024, two licensing staff informed Staff 3 that elevators must be inspected annually and in accordance with the Virginia Uniform Statewide Building Code (13VAC5-63).
Plan of correction
Not published by VDSS.
22VAC40-73-650-E
Based on record review, observation and staff interview, the facility failed to ensure that residents’ records contained the physician’s or other prescriber’s signed written order or a dated notation of the physician's or other prescriber's oral order and that orders were organized chronologically in the residents’ records.
Evidence
  1. During the inspection on 08/27/2025, three licensing staff requested to review physician’s or other prescriber's orders for all residents in care.
  2. On 08/27/2025, orders for Resident 7 were provided for review by Staff 3 and were compared to the August 2025 Medication Administration Records (MAR) provided.
  3. The following medications were listed in the current month’s MAR for Resident 7 for which no corresponding signed provider order was in the resident record at the facility at the time of the record review:
  4. Amlodipine 2.5 mg tab
  5. Atorvastatin 20 mg tab
  6. Ingrezza 40 mg cap
  7. Acetaminophen 325 mg
  8. Polyethylene Glycol 3350 powd
  9. Quetiapine Fumarate 24 mg(D)
  10. Staff 3 confirmed that Resident 7 was currently receiving the medications and that there should be a signed provider order available and stated that they were unable to find a copy of the provider orders in the resident record and that Staff 3 would call to request one.
  11. Three licensing staff observed Staff 3 call the pharmacy to request a copy of the signed prescriber orders for Resident 7. Staff 3 provided a copy of signed provider orders upon their receipt from the pharmacy.
  12. On 08/27/2025, during an interview with Staff 3, licensing staff asked Staff 3 to show the facility’s method of organization of resident records, to verify that orders were being stored together and chronologically in the resident records. Staff 3 would not allow licensing staff to observe how the physician or prescriber orders for each resident were stored and organized in the resident record, stating “I am not required to show you that.”
  13. During the inspection on 08/27/2025 and again during the inspection on 09/04/2025 orders for Resident 2, Resident 5, Resident 9, and Resident 11 were requested for review and were never received.
  14. During a tour of the facility on 09/04/2025, two licensing staff observed a bottle of IHS Magic Mouthwash (w/o Nystatin) suspension in the kitchen refrigerator with a prescription label for Resident 8 that indicated that the prescription was filled the previous day on 09/03/2025.
  15. During the inspection on 09/04/2025 at approximately 2:50 pm the physician or other prescriber order for IHS Magic Mouthwash for Resident 8 was requested from Staff 4, who stated only Staff 3 has access to orders. Licensing staff remained on site until approximately 3:25 pm, and no physician or prescriber order was provided.
  16. Photo evidence taken.
  17. This violation was previously cited during the 7/9/2024, 7/17/2024, 08/27/2024, and 12/23/2024 inspection.
Plan of correction
Not published by VDSS.
22VAC40-73-610-B
Based on observation and interview, the facility failed to ensure that menus for meals and snacks for the current week were dated and posted in an area conspicuous to residents.
Evidence
  1. During inspection 08/27/2025, three licensing staff observed a menu that only included lunch and dinner. Three licensing staff also observed an “Always available menu” with breakfast, lunch, dinner and dessert options (there were no dates on this posting).
  2. Staff 3 was asked if there was a menu for breakfast with dates posted in which Staff 3 confirmed that the “Always Available Menu” was the facility breakfast menu.
  3. During inspection on 09/04/2025 and 09/05/2025, two licensing staff observed the same posting.
  4. Photo evidence taken.
  5. This violation was previously cited during the 7/9/2024, 7/17/2024, 08/27/2024, and 12/23/2024 inspection.
Plan of correction
Not published by VDSS.
22VAC40-73-250-B
Based on interview, the facility failed to ensure all staff records be retained at the facility, treated confidentially, and kept in a locked area. Emergency contact information required by subdivision C 9 of this section also be kept in an easily accessible place.
Evidence
  1. During 09/04/2025 inspection, Staff 4, the designated person in charge, was unable to provide licensing staff any staff records for review upon request to include emergency contact information as the information was not retained at the facility.
  2. During 09/05/2025 inspection, Staff 4 confirmed at 11:03am that nobody onsite has access to records for staff.
Plan of correction
Not published by VDSS.
22VAC40-73-250-C
Based on record review and interview, the facility failed to ensure personal and social data are maintained on staff and required items identified in the standard are included in the staff record.
Evidence
  1. During 09/04/2025 inspection, Staff 4, the designated person in charge, was unable to provide licensing staff with any staff, resident or facility staff records upon request. Staff 4 informed licensing staff that they do not have access to the requested records.
  2. Licensing staff requested staff and facility records to verify compliance with the regulations on 8/27/2025, 9/4/2025, and 9/5/2025.
  3. On 09/08/2025, licensing staff requested all staff record components pertaining to the regulations for all staff via email.
  4. On 09/10/2025, Staff 3 faxed the information pertaining to this request to licensing staff.
  5. The submitted information did not include the following: a. Current address and telephone number for Staff 4, Staff 6, and Staff 7. b. Sworn statement for Staff 6. c. Name and telephone number of person to contact in an emergency for Staff 4, Staff 6, and Staff 7.
  6. This violation was previously cited during the 7/9/2024, 7/17/2024, 08/27/2024, and 12/23/2024 inspection.
Plan of correction
Not published by VDSS.
22VAC40-73-680-M
Based on observation, document review, and staff interview, the facility failed to ensure that medications ordered for PRN administration were available.
Evidence
  1. The August 2025 medication administration record (MAR) for Resident 8 was reviewed on 08/27/2025.
  2. On 08/27/2025 an audit of the medication cart was performed, and the following PRN medications were not onsite for administration: • Clonazepam 0.5 mg tablet, take 1 tablet by mouth 2 times as day as needed for anxiety ordered 01/27/2025; • Eletriptan HBR 20 mg tablet, take 1 tablet by mouth as needed for migraine ordered 01/27/2025; • Morphine Sulfate ER 10 mg cap, take one capsule by mouth as needed for breakthrough pain ordered 06/23/2025; • Ondansetron HCL 8 mg tablet, take 1 tablet by mouth every 8 hours as needed for nausea/vomiting ordered 01/27/2025; • Senna 8.6 mg tablet, take 2 tablets by mouth at bedtime as needed for constipation ordered 03/03/2025; and • Tramadol HCL 50 mg tablet, take 1 tablet by mouth every 8 hours as needed for pain ordered 01/27/2025.
  3. Staff 3 confirmed during an interview on 08/27/2025 that the PRN medications for Resident 8 were not onsite for administration.
Plan of correction
Not published by VDSS.
22VAC40-73-1020-A
Based on observation and interview, the facility failed to ensure that when residents were present, there were at least two direct care staff members awake and on duty at all times in each building who were responsible for the care and supervision of the residents.
Evidence
  1. The facility serves a mixed population.
  2. On 08/27/2025, Staff 3 stated “We are a mixed population.”
  3. Upon arrival on 08/27/2025 at 7:00am, Staff 1 and Staff 2 were the only staff members present at the time with six (6) residents with serious cognitive impairments.
  4. On 8/27/2025, Staff 1 confirmed they were direct care staff.
  5. On 8/27/2025, Staff 3 confirmed that Staff 2 was not direct care staff.
  6. On 8/27/2025, the facility administrator stated that Resident 5 was highly demented, they had never seen anything like it, and that Resident 11 needed to be assessed for major schizophrenia or something.
  7. On 8/27/2025, Staff 3 provided three licensing staff the facility’s written staffing plan that showed one direct care staff was scheduled to be present during the 11-7 shift.
  8. During 09/04/2025 inspection, the staff schedule for the day was reviewed with Staff 4 and Staff 6. Staff 4 and Staff 6 both confirmed to three licensing staff that only one direct care staff was scheduled to work and be on duty from 1pm to 5pm that day.
  9. On 9/4/2025, Staff 4 stated Staff 4’s work hours were from 7:00 a.m. to 1:00 p.m. and then Staff 4 goes on break and comes back at 5:00 p.m. and works to 11:00 p.m.
  10. On 09/23/2025 during a telephone interview, Collateral Contact 5 informed licensing staff that they typically only see “a cook” and one direct care staff. Collateral Contact 5 confirmed that Resident 2,5,7,9 and 11 all have serious cognitive impairments. Collateral Contact 5 stated that Resident 10 has severe serious cognitive impairment.
Plan of correction
Not published by VDSS.
22VAC40-73-750-B
Based on observation and interview, the facility failed to ensure that bedrooms have window coverings for privacy.
Evidence
  1. During facility tour on 09/04/2025, two licensing staff observed that Resident 10’s bedroom window did not have curtains or window blinds. The window looks out to the facility backyard and two neighboring homes backyards.
  2. Staff 4 acknowledged there was no window covering and was unsure why the resident did not have coverings on the window.
  3. Staff 4 did not provide documentation of written specification indicating Resident 10 did not wish to have window coverings in the bedroom.
  4. Photo and video evidence taken.
Plan of correction
Not published by VDSS.
22VAC40-73-680-C
Based on documentation review and observation, the facility failed to ensure that medications were administered not earlier than one hour before and not later than one hour after the facility's standard dosing schedule, except those drugs that are ordered for specific times, such as before, after, or with meals.
Evidence
  1. Licensing staff observed the morning medication pass by Staff 3 for six residents in care on 08/27/2025, from approximately 7:35 am to approximately 8:50 am.
  2. During the morning medication pass observed on 08/27/2025 medications were scheduled for administration at 6:00am and 7:00am. Six residents in care received scheduled medication more than one hour past the scheduled dose time. • Resident 5 was scheduled to receive medication at 6:00 am that was administered at approximately 7:55 am. • Resident 2 was scheduled to receive medications at 7:00 am that were administered at approximately 8:08 am • Resident 7 was scheduled to receive medications at 7:00 am that were administered at approximately 8:12 am. • Resident 9 was scheduled to receive medications at 7:00 am that were administered at approximately 8:20 am • Resident 11 was scheduled to receive medications at 6:00 am and 7:00 am that were administered at approximately 8:36 am • Resident 10 was scheduled to receive medications at 7:00 am that were administered at approximately 8:45 am.
Plan of correction
Not published by VDSS.
63.2-1808-A-11
Based on observation, the facility failed to ensure that residents are treated with courtesy, respect, and consideration as a person of worth, sensitivity, and dignity.
Evidence
  1. During an observation of a medication pass on 08/27/2025, licensing staff observed Staff 3 enter the common area restroom off the lower-level family room area that was in use by Resident 5.
  2. Staff 1 was standing outside of the restroom, waiting to assist Resident 5, Staff 1 requested that Staff 3 not enter as Resident 5 was on the toilet.
  3. Licensing staff observed Staff 3 disregard the request of Staff 1 and Staff 3 extended a souffle cup of medications to Resident 5 while the resident was seated on the commode.
  4. Licensing staff heard Resident 5 state “No, no, no.” while Staff 3 attempted to give Resident 5’s medication. Staff 3 disregarded Resident 5’s denial and Staff 3 proceeded to give Resident 5 their medications at that time.
  5. During an observation of the morning medication pass on 08/27/2025, licensing staff observed Staff 3 prepare nine medications for administration for Resident 9 by placing them in a souffle cup.
  6. Staff 3 approached Resident 9 seated on a sofa and told them it was time to take their medications. Resident 9 stated that they did not want to take their medications at that time. Staff 3 disregarded Resident 9’s request, Staff 3 placed their hand on Resident 9’s head and demanded that they open their mouth. Resident 9 stated “no.” again. Staff 3 disregarded Resident 9’s second request of not wanting to take the medication and Staff 3 poured the entire contents of the souffle cup containing nine medications into Resident 9’s open mouth. Licensing staff observed that Resident 9 was unable to swallow all nine medications, and spat them back into the cup, stating “That’s too many. Who does that?” Resident 9 then requested to receive one pill at a time on a spoon with applesauce. Staff 3 disregarded Resident 9’s third request and they stated to Staff 3 “Give me one! I see two.”
  7. Staff 3 failed to ensure that Resident 5 and Resident 9 were treated with courtesy, respect, and consideration as a person of worth, sensitivity, and dignity during medication administration.
Plan of correction
Not published by VDSS.
22VAC40-73-980-A
Based on observation and interview, the facility failed to ensure that a complete first aid kit was on hand in the facility.
Evidence
  1. During 08/27/2025 inspection, Staff 5 checked the first aid kit along with licensing staff. Licensing staff observed the first aid kit did not include tweezers or antiseptic wipes/ointment.
  2. On 8/27/2025, Staff 5 confirmed that the items were missing during observation of the first aid kit. Staff 5 later located antiseptic ointment that was found to be expired in 2023.
  3. This violation was previously cited during the 7/9/2024, 7/17/2024, 08/27/2024 and 12/23/2024 inspection.
Plan of correction
Not published by VDSS.
22VAC40-73-250-D
Based on record review, the facility failed to ensure that health information required by these standards are maintained at the facility and included in each staff record to include each staff person on or within seven days prior to the first day of work and evaluated annually submit the results of a risk assessment, documenting that the individual is free of tuberculosis (TB) in a communicable form as
Evidence
  1. d by completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence:
  2. During the inspection on 09/04/2025, Staff 4 stated that they were the designated person in charge.
  3. Upon request on 9/4/2025, Staff 4 was unable to provide to licensing staff the annual TB risk assessment for Staff 1, Staff 3, Staff 4, and Staff 5 as Staff 4 did not have access to those records.
  4. On 09/08/2025, licensing staff requested all staff record components pertaining to 22VAC40-73-250.
  5. Staff 3 submitted the results of the TB risk assessment for Staff 4, Staff 6, and Staff 7 via fax on 9/10/2025, but not Staff 1, Staff 3, or Staff 5.
  6. Staff 7’s (date of hire date is 04/22/2025) TB risk assessment dated as completed on 06/03/2025, approximately six weeks after date of hire.
Plan of correction
Not published by VDSS.
22VAC40-73-40-B-12
Based on observation, record review and interview, the licensee failed to ensure that the facility kept and maintained at the facility records, reports, plans, schedules, and other information as required by this chapter for licensed assisted living facilities and ensure that at all times the department's representative was afforded reasonable opportunity to inspect all of the facility's buildings, books, and records and to interview agents, employees, residents, and any person under its custody, control, direction, or supervision as specified in §63.2-1706 of the Code of Virginia.
Evidence
  1. During the inspection on 08/27/2025, licensing staff attempted to interview facility staff. Staff 3 stated multiple times to licensing staff that licensing staff were not allowed to talk to staff, that staff do not have any of the answers that we will need and that staff would not be allowed to answer any questions. Licensing staff informed Staff 3 of the requirement to provide reasonable opportunity to interview staff. Staff 3 stated that all questions must be directed to Staff 3 only.
  2. During the inspection on 08/27/2025, licensing staff attempted on three occasions to privately interview Staff 5. Staff 3 called Staff 5 and one licensing staff back to the dining room and informed all three licensing staff that all questions were to be directed to Staff 3 only.
  3. During the inspection on 08/27/2025, during an interview with Staff 3, licensing staff requested to review records of written communication utilized as a means of keeping direct care staff on all shifts informed of significant happenings or problems experienced by residents. Staff 3 stated that all communication happens using an application-based chat group (WhatsApp). Licensing staff requested to review the communications. Staff 3 refused, stating he was not required to provide that information.
  4. During the inspection on 08/27/2025, licensing staff requested multiple times during the inspection to tour the entirety of the facility. Staff 3 did not permit licensing staff to tour any resident bedrooms and bathrooms, the kitchen, laundry area located on the main floor, storage areas, or the rear exterior of the facility during the 8/27/2025 inspection, stating that we must complete “the paperwork” first, referring requests to review documentation by licensing staff.
  5. During the inspection on 08/27/2025, two licensing staff were speaking with Resident 7 when Staff 3 intervened to let Resident 7 know they do not need to speak with licensing staff.
  6. During inspection on 08/27/2025, two licensing staff requested the QuickMAR audit logs, part of the residents’ electronic health record for medication administration, which include the time the medications are supposed to be administered and the time the medications were documented as administered. Staff 3 stated that they are not required to provide the audit logs to licensing staff. Licensing staff requested to view the QuickMAR system by using Staff 3’s facility computer. Staff 3 stated that licensing staff are not allowed to use the computer and were denied access to the computer and QuickMAR.
  7. During inspection on 08/27/2025, two licensing staff requested Staff 3 to provide the dates when prescriptions were last filled for Resident 8. Licensing staff were present and observed Staff 3 call the pharmacy to obtain requested information. Licensing staff requested the information again once Staff 3 was off the phone call with the pharmacy. Staff 3 did not provide the dates or information that was requested of Staff 3. (Due to the limited space allowed by the DSS computer licensing system, the remainder of the violation is on a separate document and available upon request.)
Plan of correction
Not published by VDSS.
22VAC40-73-610-E
Based on record review and interview, the facility failed to provide or access a copy of a diet manual containing acceptable practices and standards for nutrition to be kept current and readily available to personnel responsible for food preparation.
Evidence
  1. During inspection on 08/27/2025, licensing staff observed Staff 2 in the kitchen preparing hot dogs, including cutting them up into small pieces, and requested a copy of the facility's diet manual. Staff 2 stated “no” and that they did not know where the diet manual was and to ask Staff 3.
  2. On 8/27/2025, Staff 2 confirmed their primary responsibility was to work in the kitchen and prepare food.
  3. On 8/27/2025, Staff 3 provided a copy of the facility’s diet manual and confirmed that Staff 2 would not have known where to find it. Staff 3 stated that Staff 2 doesn’t prepare food, just serves it.
  4. On 9/4/2025, two licensing staff asked Staff 4 and Staff 6 the roles of other staff in the facility. Staff 4 and Staff 6 described Staff 2’s role as responsible for food preparation.
  5. Photo evidence taken.
  6. This violation was previously cited during the 7/9/2024, 7/17/2024, 08/27/2024, and 12/23/2024 inspection.
Plan of correction
Not published by VDSS.
22VAC40-73-870-E
Based on observation and interview, the facility failed to ensure that all furnishings, fixtures, and equipment, including furniture, window coverings, sinks, toilets, bathtubs, and showers, be kept clean and in good repair and condition, except that furnishings and equipment owned by a resident shall be, at a minimum, in safe condition and not soiled in a manner that presents a health hazard.
Evidence
  1. During facility tour on 08/27/2025, 09/04/2025 and 09/05/2025, three licensing staff observed that the 2nd floor ceiling HVAC vent panel is missing a screw and not properly secured. The vent panel was covered in what appeared to be thick dust.
  2. During facility tour on 08/27/2025, 09/04/2025 and 09/05/2025, outside of the front entrance left handrail is leaning against the side of the facility and not secured to the front entry way steps.
  3. During 08/27/2025 inspection, three licensing inspectors observed a water stain in the ceiling of the dining room. Staff 3 confirmed that Resident 7’s toilet leaked causing the stain.
  4. During 09/04/2025 inspection, Resident 7 informed licensing staff that they just used the restroom and that their toilet was unable to be flushed after use.
  5. During 09/04/2025 inspection, two licensing staff observed in Room 6, used by Resident 10, a bed with two full length rails that were extended using plastic tubes. The parts of the bedrails were not fastened or secured together and were noted to be loose and flex away from the bed several inches. Staff 4 confirmed that the bedrails were used in that condition every night when the resident was in bed.
  6. Photo/video evidence taken.
  7. This violation was previously cited during the 7/9/2024, 7/17/2024, 08/27/2024 and 12/23/2024 inspection.
Plan of correction
Not published by VDSS.
22VAC40-73-870-F
Based on observation, the facility failed to ensure that all inside and outside steps, stairways, and ramps have nonslip surfaces.
Evidence
  1. The back yard and ground level patio are accessed by staff and residents via a ramp from the rear screened porch.
  2. During facility tour on 08/27/2025 and 09/04/2025, two licensing staff observed the outdoor patio ramp to be smooth-surfaced and noted that the ramp was slippery and slick while using the ramp to go into the yard. Licensing staff did not observe anything on the ramp to ensure it was a nonslip surface.
  3. This violation was previously cited during the 7/9/2024, 7/17/2024, 08/27/2024 inspection.
Plan of correction
Not published by VDSS.
22VAC40-73-860-J
Based on observation and interview, the facility failed to ensure that a resident may be permitted to keep their own cleaning supplies or other hazardous materials in an out-of-sight place only if they do not have serious cognitive impairment.
Evidence
  1. The facility serves a mixed population.
  2. During 08/27/2025 staff 3 stated in an interview “we are a mixed population.”
  3. During 09/04/2025 inspection, three licensing staff observed Comet Bleach spray and Spic and Span cleaning spray under Resident 9’s bathroom sink unsecured.
  4. In a telephone interview with Collateral Contact 5 on 09/23/2025, they confirmed that Resident 9 has a serious cognitive impairment.
  5. Photo evidence taken.
  6. This violation was previously cited during the 7/9/2024, 7/17/2024, 08/27/2024 and 12/23/2024 inspection.
Plan of correction
Not published by VDSS.
22VAC40-73-200-C
Based on record review and interview, the facility failed to ensure that direct care staff shall meet one of the requirements of the subsection including successful completion of a personal care aide training program approved by the Virginia Department of Medical Assistance Services.
Evidence
  1. During inspection on 09/04/2025 and 09/05/2025, two licensing staff requested staff records to verify training. Staff 4 who identified themselves as the staff person in charge on 09/04/2025 and 09/05/2025 stated that they do not have access to the records. The requested records were not provided on 9/4/2025 or 9/5/2025.
  2. On 09/10/2025, Staff 3, provided via fax to licensing staff, personal care aide training program certificates for Staff 4 (completed 01/12/2025), Staff 6 (completed 01/12/2025) and staff 7 (completed 04/11/2025).
  3. During a telephone interview on 9/17/2025, Collateral Contact 4 verified that their personal care aide training program was used to train Staff 4, 6, and 7 was not approved by the Virginia Department of Medical Assistance Services.
Plan of correction
Not published by VDSS.
22VAC40-73-150-C
Based on observation, record review, and interviews, the administrator failed to be responsible for the general administration and management of the facility and to oversee the day-to-day operation of the facility.
Evidence
  1. The inspection conducted on 07/9/2024, 7/17/2024, 8/27/2024 and 12/23/2024 inspection resulted in 36 violations. 2.The inspection conducted on 7/29/2025, 8/5/2025, and 8/25/2025 resulted in approximately 21 violations in the areas of resident care and related services, resident accommodations and related provisions, and building and grounds.
  2. During the 7/9/2024, 7/17/2024, 08/27/2024, and 12/23/2024 inspection and the 07/29/2025, 08/05/2025 and 8/25/2025 inspection, as well as the 09/04/2025 and 09/05/2025 onsite inspection days, a total of seven (7) different licensing staff had not observed Staff 5 onsite. Staff that were on site did not know if Staff 5 would be coming onsite during licensing inspections.
  3. During the 7/9/2024, 7/17/2024, 08/27/2024, and 12/23/2024 inspection, the 07/29/2025, 08/05/2025 and 8/25/2025 inspection, as well as the 09/04/2025 and 09/05/2025 onsite inspection days, Staff 5 did not contact licensing staff at any time while on site to aid in the general administration and management. Staff 5 had never made contact via email or telephone with licensing staff.
  4. During inspections on 08/27/2025, three licensing staff observed Staff 5 for the first time as they arrived on site at 10:00am. Staff 3 who is not a licensed administrator stated that all questions should be directed to them.
  5. During phone interview on 09/23/2025, Collateral Contact 5 confirmed that they were on site weekly and had not seen Staff 5 on-site very often. Collateral Contact 5 confirmed that all communication was with Staff 3 who is not a licensed administrator.
  6. During phone interview on 09/23/2025, Collateral Contact 6 stated that they have not seen Staff 5 on-site during their weekly visits at the facility. Collateral Contact 6 confirmed that all communications pertaining to their services were with Staff 3 who is not a licensed administrator.
  7. During 08/27/2025 inspection, Staff 5 confirmed not having a written administrator schedule.
  8. During 08/27/2025, 09/04/2025 and 09/05/2025, evidence was gathered that Staff 5 failed to ensure (22VAC40-150-C-1) that care is provided to residents in a manner that protects their health, safety, and well-being.
  9. Licensing staff observed Staff 3 administering medications to Residents 5 and 9 that included: licensing staff observed Staff 3 prepare two incorrect medications for administration, one for Resident 11 (Clopidogrel 1 tab was placed into the cup for administration instead of Cefaclor), and one for Resident 2 (Melatonin 3 mg was placed into the cup instead of Memantine).
  10. The administrator did not ensure that medications were administered by qualified personnel. Staff 4 confirmed that they have administered medications to residents over the course of 3 years and are not registered or licensed to administer medication.
  11. On 09/08/2025, licensing staff requested all incident reports for the past 3 months. On 09/10/2025, Staff 3 provided via fax two written reports but did not include written reports or documentation for incidents pertaining to Resident 4, Resident 10 or Resident 8.
  12. On 08/27/2025, Staff 3 provided documentation that Resident 7’s Invega injection is to be given every 28 days at 8:00am with a handwritten note on the order that stated, “last given 08/6/2025 @ 12:28” making the next dose due 9/3/2025.
  13. During 08/27/2025, 09/04/2025 and 09/05/2025, evidence was gathered that Staff 5 failed to ensure (22VAC40-150-C-2) that the facility maintains compliance with applicable laws and regulations. (Due to the limited space allowed by the DSS computer licensing system, the remainder of the violation is on a separate document and available upon request.)
Plan of correction
Not published by VDSS.
22VAC40-73-490-D
Based on record review and interview, the facility failed to ensure that the identification of specific residents for whom the health care oversight was provided was documented in writing.
Evidence
  1. During the 08/27/2025 inspection, Staff 3 provided the health care oversight (HCO) form completed on 07/22/2025. The HCO did not document or identify the residents reviewed.
  2. Staff 3 called the licensed health care professional who completed the HCO and spoke on speakerphone with three licensing staff present and confirmed that the specific residents reviewed were not documented in writing.
  3. Photo evidence taken.
Plan of correction
Not published by VDSS.
22VAC40-73-740-D
Based on record review, the facility failed to develop and implement a written policy regarding procedures to be followed when a resident's clothing or other personal possessions, such as jewelry, television, radio, or other durable property, are reported missing. Attempts shall be made to determine the reason for the loss and any reasonable actions shall be taken to recover the item and to prevent or discourage future losses.
Evidence
  1. On 09/04/2025, licensing staff requested the facility's written policy regarding procedures to be followed when a resident's clothing or other personal possessions are reported missing. Staff 4 was the designated person in charge during the inspection and was unable to provide the policy for review upon request during the onsite visit, as documented on the acknowledgment form.
  2. On 09/08/2025, licensing staff requested via email for the policy to be sent by 09/09/2025.
  3. On 09/10/2025, licensing staff received via fax, facility policy documented “740.D Resident Stolen Items Policy”.
  4. Facility policy states that the facility is “not responsible for Resident’s valuables should they be misplaced, lost or stolen” and that the facility is not “an insurer for Resident’s property and is not liable for property damage, loss of theft.”
  5. Policy also included that “Residents acknowledge that security devices or measures may fail…..Therefore, Residents acknowledges that they should not rely upon the presence of such devices or measures and should protect themselves and their property as if these devices or measures did not exist.”
  6. The policy did not include any procedures to be followed when a resident’s clothing or other personal possessions were reported missing.
Plan of correction
Not published by VDSS.
22VAC40-73-540-B
Based on observation and interview, the facility failed to ensure that visiting hours were not restricted, except by a resident when it was the resident's choice.
Evidence
  1. During inspection on 08/27/2025, three licensing staff observed “visiting hours” written on the whiteboard on the first-floor common area to be from “10:00am – 6:00pm.”
  2. Staff 3 and staff 5 confirmed on 08/27/2025 that the visiting hours’ time was displayed on the whiteboard. Staff 5 questioned licensing staff if visitors were allowed to come in at night. Licensing staff clarified to Staff 3 and Staff 5 that visiting hours could not be restricted unless by resident choice.
  3. On 8/27/2025 and 9/4/2025, licensing staff requested a copy of the visitation policy, and it was not provided.
  4. During the inspection on 09/04/2025, Staff 6 confirmed that the facility had visiting hours and were written on the whiteboard, which were the same visiting hours as noted on 8/27/2025. Staff 6 also stated that families can visit during visiting hours.
  5. On 9/4/2025, licensing staff interviewed Collateral Contact 6 who stated families must let Staff 3 know when they are coming.
Plan of correction
Not published by VDSS.
22VAC40-73-470-F
Based on document review and interview, the facility failed to ensure that when the resident suffers a serious illness or medical condition, or there is reason to suspect that such has occurred, that medical attention from a licensed health care professional shall be secured immediately; and that the circumstances involved and the medical attention received or refused shall be documented in the resident's record; and that the resident's physician shall be notified as soon as possible but no later than 24 hours from the situation and action taken, or if applicable, the resident's refusal of medical attention.
Evidence
  1. On 08/27/2025 during an interview with multiple licensing staff, Staff 3 stated that Resident 7 had experienced an illness that required hospitalization and rehabilitation during the month prior.
  2. On 08/27/2025 the resident record for Resident 7 was requested for review, including records for physician/provider orders and communication logs. Records were specifically requested for review regarding the resident’s illness requiring hospitalization and all associated documentation.
  3. During a phone interview on 09/23/2025 with Collateral Contact 5, Collateral Contact 5 stated to two licensing staff that in July 2025 that Resident 7 had an infection that was serious and required evaluation and treatment in a hospital, that Staff 3 was aware of the recommendation for treatment, and the recommended medical attention was delayed.
  4. Collateral Contact 5 provided licensing staff documentation from 07/25/2025 on 9/30/2025 that stated “Due to concern for possible complications including sepsis, the facility was advised to transfer the patient to the emergency room for further evaluation, IV antibiotics, and possible septic workup. However, facility staff have not acted on this recommendation and have not initiated transfer at this time. Provider reiterated the importance of prompt medical intervention given the patient’s condition. In addition, Staff were also instructed to contact the provider who ordered the initial UA [urinalysis] to discuss the goals of treatment and determine if they will initiate management. The importance of timely intervention was reiterated given the patient’s acute change in condition.”
  5. Collateral contact 5 provided documentation from 07/26/2025 that stated “called Staff 3 this morning to follow up regarding the patient's transfer to the hospital. Staff 3 stated he will speak with the patient again, but the patient continues to refuse hospitalization... I reiterated the importance of hospital evaluation”
  6. The facility’s resident record for Resident 7 did not include any documentation of the resident’s serious medical condition, circumstances involved, or any refusal of medical attention. The records did not include any documentation of communication by the facility to the primary care provider or any other provider involved in the resident’s care.
  7. During a phone interview on 09/23/2025 with two licensing staff, Collateral Contact 5 stated that they had been the primary care provider for all residents of the facility and that there have been multiple instances where residents have been sent to the hospital for evaluation of serious illnesses or other medical conditions where no notification was made to Collateral Contact 5 or their colleague. Collateral Contact 5 stated they were notified that Resident 10 was admitted to the hospital on 09/18/2025 through an automatic alert in the hospital’s electronic record’s system. Collateral Contact 5 stated that they never received any notification from the facility regarding Resident 10’s medical condition and hospitalization. Collateral Contact 5 confirmed the prior statements via email communication to licensing staff on 09/30/2025.
Plan of correction
Not published by VDSS.
22VAC40-73-870-A
Based on observation, the facility failed to ensure that the interior and exterior of all buildings be maintained in good repair and kept clean and free of rubbish.
Evidence
  1. During 08/27/2025, 09/04/2025 and 09/05/2025 inspection, two licensing staff observed siding on the upper side of the facility had fallen off, interior patio ceiling panels not fully intact.
  2. During facility tour on 09/04/2025, two licensing staff observed that the exterior patio back door did not have a handle or other mechanism to open the door from the outside. The two licensing staff could only reenter that door by inserting their fingers into the crack at the edge of the door panel to pull the door open.
  3. Photo/video evidence taken.
Plan of correction
Not published by VDSS.
22VAC40-73-680-G
Based on observation and staff interview, the facility failed to ensure that an over-the-counter medication was labeled with the resident’s name or in a pharmacy-issued container.
Evidence
  1. During an observation of a morning medication pass on 08/27/2025, licensing staff observed that only oral medications were administered. During an interview with Staff 3, Staff 3 explained that non-oral medications were stored in a separate area and had been administered earlier that morning, prior to the arrival of licensing staff for inspection.
  2. Licensing staff requested to review the non-oral medications that had been administered prior to the medication pass observation.
  3. Staff 3 presented a bottle of Sarna lotion, stating that it was the topical medication that they themself had administered earlier that morning to Resident 9. The bottle was not labeled with the resident’s name or in a pharmacy-issued container.
  4. Photo evidence taken.
  5. This violation was previously cited during the 7/9/2024, 7/17/2024, 08/27/2024 and 12/23/2024 inspection.
Plan of correction
Not published by VDSS.
22VAC40-73-950-A
Based on record review and interview, the facility failed to ensure to develop a written emergency preparedness and response plan that includes documentation of initial and annual contact with the local emergency coordinator to determine (i) local disaster risks, (ii) communitywide plans to address different disasters and emergency situations, and (iii) assistance, if any, that the local emergency management office will provide to the facility in an emergency.
Evidence
  1. On 09/08/2025, licensing staff requested via email the facility to provide licensing staff the annual contact with the local emergency coordinator. Licensing staff did not receive documentation of the annual contact with the local emergency coordinator.
  2. During telephone interview on 09/25/2025, Collateral contact 6 confirmed that the facility had not made initial contact in 2020 or 2021. Collateral contact 6 also confirmed that the first contact made by the facility was on 09/11/2025 via email requesting emergency preparedness and response plan review.
Plan of correction
Not published by VDSS.
22VAC40-90-40-B
Based on record review, the facility failed to ensure the criminal history record report be obtained on or prior to the 30th day of employment for each employee.
Evidence
  1. Staff 3 faxed Staff 7’s record on 09/10/2025 upon request and it noted the following: a. Staff 7’s first day of work was documented as 04/22/2025 on the “Record of Initial ALF Staff Training” form and the document “Direct Care Staff Training Plan & Log (20-Hour Requirement)”. b. Staff 7’s signed Job Description Acknowledgment Form notes the date of hire as 4/22/2025. c. Staff 7’s criminal history record report request was signed and dated by Staff 3 on 06/09/2025 and was completed by the Virginia State Police on 06/13/2025 almost two months after hire.
Plan of correction
Not published by VDSS.
22VAC40-73-290-B
Based on observation and interview, the facility failed to develop and implement a procedure for posting the name of the current on-site person in charge.
Evidence
  1. During 08/27/2025 inspection, three licensing staff observed a dry erase board with “Staff member in charge:” and indicated three staff members (Staff 1, 3, and 4); however, Staff 4 was not scheduled to work that day and Staff 3 was not present at time of licensing staff arrival.
  2. During 09/04/2025 and 09/05/2025 inspection, two licensing staff observed the same dry erase board with “Staff member in charge:” and indicated three staff members (Staff 1, 3, and 4); however, Staff 1 or Staff 3 were not present at time of arrival and did not come on site.
  3. During the course of the three day inspection on 8/27/2025, 9/4/2025, and 9/5/2025, the posting of the name of the current on-site person in charge was not current nor accurately reflected the individual on-site and in charge.
  4. Photo evidence taken.
Plan of correction
Not published by VDSS.
22VAC40-73-680-B
Based on observation, the facility failed to ensure that medications were removed from the pharmacy container, or the container was opened, by a staff person licensed, registered, or acting as a medication aide on a provisional basis as specified in 22VAC40-73-670 and administered to the resident by the same staff person. Medications shall remain in the pharmacy issued container, with the prescription label or direction label attached, until administered to the resident.
Evidence
  1. During an interview with two licensing staff on 09/04/2025, Staff 4 confirmed that Staff 3 who is a registered medication aide has been preparing medications for Staff 4 to administer.
  2. Staff 4 stated that Staff 3 has been preparing the medications in the pre-filled boxes for residents who are not up, ready or downstairs at the time Staff 3 is giving medications for Staff 4 to administer for the past three years.
  3. During a facility tour on 09/04/2025, two licensing staff observed a plastic zip container with a stack of lidocaine patches, marked as “Rx Only” in an area being used for resident medication storage. The lidocaine patches were not in a pharmacy-issued container and did not have a prescription label or direction label attached.
  4. Photo evidence taken.
  5. This violation was previously cited during the 7/9/2024, 7/17/2024, 08/27/2024, and 12/23/2024 inspection.
Plan of correction
Not published by VDSS.
22VAC40-73-70-C
Based on interview, the facility failed to submit a written report of each incident specified in subsection A of this section to the regional licensing office within seven days from the date of the incident.
Evidence
  1. Resident 8 was taken from the facility to the hospital by a family member (Collateral Contact 3) on 9/3/2025 who reported Resident 8 received an endoscopy after reporting she was unable to swallow.
  2. Upon arrival on 09/04/2025 at 9:55am, three licensing staff observed Resident 8 coming outside with Staff 4. Collateral Contact 3 had pulled their car up and opened the car door to take Resident 8 back to the emergency room. Collateral Contact 3 and Staff 4 confirmed that Resident 8 had been to the hospital the day before on 09/03/2025 for an incident involving not eating and being unable to swallow their medication. Collateral Contact 3 informed licensing staff that the night before they had provided a new medication that was prescribed by the hospital on 09/03/2025 visit. Collateral Contact 3 stated that staff had not given Resident 5 their medication as instructed. Collateral Contact 3 stated they prepared the medication on 09/03/2025 before leaving the facility for the night. Upon arrival on 09/04/2025, Collateral Contact 3 stated that the medication was not moved or administered by staff to Resident 5.
  3. Collateral Contact 3 informed licensing staff on 09/04/2025 that Resident 8 had an endoscopy and discovered a piece of shrimp lodged in their throat and was the reason Resident 8 was choking and unable to swallow for about 48 hours.
  4. Licensing staff did not receive a written report for Resident 8 going to the hospital on 09/03/2025 within seven days.
  5. During phone interview on 09/23/2025, Collateral Contact 5, one of the facility medical providers, informed licensing staff that on 08/13/2025 Resident 4, was diaphoretic, hypotensive, febrile and septic with a temperature of 103 that required emergency services. The incident was not reported to licensing at all.
  6. During phone interview on 09/23/2025, Collateral Contact 5 informed two licensing staff that on 09/18/2025 Resident 10 was admitted to the hospital for hypotension. The incident was not reported to licensing staff at all.
  7. During phone interview on 09/23/2025, Collateral contact 5 informed two licensing staff that on 08/30/2025 Staff 3 informed them that Resident 8 had not received their Gabapentin for approximately six (6) weeks. Collateral Contact 5 confirmed that the last script was written and sent to the pharmacy on 04/07/2025 for 90 capsules. The incident was not reported to licensing staff at all.
  8. During phone interview on 09/23/2025, Collateral contact 5 informed two licensing staff that on 09/10/2025 Staff 3 called and notified them that Resident 7 had not received their prescribed Invega 78mg intramuscular injection. Collateral Contact 5 stated they went to the facility on 9/10/2025 and administered the shot and that the shot was administered late. Licensing staff did not receive a written report that a medication error had occurred.
Plan of correction
Not published by VDSS.
22VAC40-73-260-C
Based on observation and interview, the facility failed to ensure that a listing of all staff who have current certification in first aid or CPR, in conformance with subsections A and B of this section, be posted in the facility so that the information is readily available to all staff at all times.
Evidence
  1. During 09/04/2025 inspection, three licensing staff did not observe any posting that listed all staff who had current certification in first aid or Cardiopulmonary Resuscitation (CPR) posted within the facility.
  2. When licensing staff inquired where the posting was located, Staff 4 informed licensing staff that Staff 3 (who was not at the facility) had that list.
  3. Staff 4 was unable to produce the list or show where it was posted at the time of inspection.
  4. This violation was previously cited during the 7/9/2024, 7/17/2024, 08/27/2024, and 12/23/2024. inspection.
Plan of correction
Not published by VDSS.
22VAC40-73-670-1
Based on record review and interview, the facility failed to ensure that each person who administers medications be authorized and licensed by the Commonwealth of Virginia to administer medications.
Evidence
  1. During 08/27/2025 inspection, Resident 7 informed two licensing staff that Staff 1 and Staff 4 administer resident medications. Resident 7, who is alert and oriented, stated that they could not recall the last time Staff 3 administered their medications.
  2. During 09/04/2025 inspection, Resident 7 informed that Staff 4 administered his medications that morning.
  3. During 09/04/2025 inspection, Staff 4 stated Staff 3 has pre-filled resident pill boxes, and they have been instructed to administer medications to some residents in Staff 3’s absence over the last three years.
  4. Staff 4 confirmed that they are not licensed or registered by the Commonwealth of Virginia to administer medications; or registered with the Virginia Board of Nursing as a medication aide and administers medications to the residents at the facility.
  5. According to the Department of Health Professions website, Staff 1 and Staff 4 are not Registered Medication Aides.
Plan of correction
Not published by VDSS.
22VAC40-73-650-F
Based on record review and interview, the facility failed to ensure that whenever a resident is admitted to a hospital for treatment of any condition, the facility shall obtain new orders for all medications and treatments prior to or at the time of the resident's return to the facility and that the facility shall ensure that the primary physician is aware of all medication orders and has documented any contact with the physician regarding the new orders.
Evidence
  1. During an interview on 08/27/2025, staff 3 confirmed that Resident 7 had been hospitalized the prior month and then transferred to a rehabilitation facility before returning to the assisted living facility.
  2. During inspection on 08/27/2025 the resident record for resident 7 was requested for review, including records for physician/prescriber orders, communication logs and records regarding the resident’s illness and hospitalization.
  3. Records received for review included physician orders for Resident 7 that included discharge documentation with updated orders for medications from a rehabilitation facility dated 08/08/2025.
  4. The August 2025 MAR for resident 7 stated “resident out of facility 26 Jul 2025 to 09 Aug 2025.”
  5. Resident records reviewed did not include any documentation of communication with the primary physician regarding the resident’s return to the facility or updated orders.
  6. On 09/23/2025 during an interview with Collateral Contact 5, they stated that the facility did not notify them that Resident 7 had been discharged from the rehabilitation facility back to the assisted living facility, and that they did not receive any notification regarding updates or changes to orders for the resident.
  7. On 09/30/2025 Collateral Contact 5 provided written communication via email regarding Resident 7, confirming the statements made during interview on 09/23/2025.
Plan of correction
Not published by VDSS.
22VAC40-73-660-A-1
Based on observation and staff interview, the facility failed to ensure that a medicine cabinet, container, or compartment used for storage of medications and dietary supplements prescribed for residents when such medications and dietary supplements are administered by the facility be locked.
Evidence
  1. During a medication pass observation on 08/27/2025 by Staff 3, licensing staff observed Staff 3 walk away from the medication preparation area at approximately 8:04 am to go downstairs, leaving medication packages out of the cart and unattended on the table where medications were being prepared, prepared/poured medications for a resident in a souffle cup, and the third drawer of the medication cart unlocked and pulled open. Staff 3 went to the kitchen area and then returned upstairs to the medication preparation area, approximately two minutes later.
  2. During an interview with Staff 3, licensing staff asked about leaving the cart open and medications out when they walked away. Staff 3 acknowledged that he had walked away from the medications without securing them and stated that he believed that the medication was safe with a member of the licensing staff.
  3. During a facility tour on 09/04/2025, two licensing staff observed that there were prescription medications labeled for Residents 5, 7, 9, 10, and 11 stored in an unlocked and unsecured laundry area, which included polyethylene glycol, cholestyramine, lidocaine patches, scopolamine patches, and refresh eye drops.
  4. Photo evidence taken.
Plan of correction
Not published by VDSS.
22VAC40-73-660-A-2
Based on observation and staff interview, the facility failed to ensure that that schedule II drugs and any other drugs subject to abuse were kept in a separate locked storage compartment.
Evidence
  1. During a medication pass observation on 08/27/2025, licensing staff observed that a controlled substance (Clonazepam 0.5 mg tab) for Resident 8 was stored in the medication cart in the open bin/area, secured by a single lock system, with the resident’s other non-controlled oral medications.
  2. During an interview with Staff 3 on 8/27/2025, Staff 3 confirmed that the red “C” marked on the clonazepam bubble pack and the red designation on the electronic MAR system were indicators that the medication was a controlled substance that should be in a double locked area and agreed that the medication should have been secured in the separate locked compartment but was not.
  3. Upon completion of the medication administration pass, at approximately 8:50 am, the bubble pack of clonazepam for Resident 8 was not returned to the double locked area. Licensing staff requested Staff 3 return the controlled medication to the double locked area. Staff 3 stated that they were going to keep the medication with them for now. Staff 3 was observed by three licensing staff to have kept the clonazepam with Staff 3’s personal belongings during the inspection. Licensing staff requested multiple times that Staff 3 put the clonazepam in the double locked area. The medication was not returned to the separate locked compartment of the medication cart until approximately 12:30 pm.
Plan of correction
Not published by VDSS.
July 29, 2025Complaint survey16 violations
Inspection dates
07/29/2025 and 08/05/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7/29/2025 from 9:10am – 11:30am and 8/05/2025 from 9:05am – 3:26pm 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 7/29/2025 regarding allegations in the area(s) of: Physical plant, Medication/Medical Issues, Emotional Abuse/Neglect, Physical Abuse/Neglect, Records, Admissions/Discharge Number of residents present at the facility at the beginning of the inspection: 6 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: Observed residents in the common area and staff cooking lunch. Additional Comments/Discussion: None. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s); area(s) of non-compliance with standard(s) or law were: Physical plant, Medication/Medical Issues, Emotional Abuse/Neglect, Records, Admissions/Discharge 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 Alexandra Roberts, Licensing Inspector at 804-845-6956 or by email at Alexandra.N.Roberts@dss.virginia.gov
Violations
22VAC40-73-390-A
Based on record review and interview, the facility failed to ensure that the written resident agreement shall include all requirements and special acknowledgments within the document.
Evidence
  1. Resident 1's agreement did not include the following: - Requirements or rules regarding resident conduct, other restrictions, or special conditions have been reviewed by the resident or the resident’s legal representative; - The resident has been informed that the resident may refuse release of information regarding the resident’s personal affairs and records to any individual outside the facility, except as otherwise provided in law and except in case of the resident’s transfer to another caregiving facility, notwithstanding any requirements of this chapter; - The resident has been informed that interested residents may establish and maintain a resident council, that the facility is responsible for providing assistance with the formation and maintenance of the council, whether or not such a council currently exists in the facility, and the general purpose of a resident council (See 22VAC40-73-830); - The resident has been informed of the policy or guidelines regarding visiting in the facility if the facility has such a policy or guidelines (See 22VAC40-73-540 C); - The resident has been informed of the rules and restrictions regarding smoking on the premises of the facility, including those required by 22VAC40-73-820; - The resident has been informed of the policy regarding the administration and storage of medications and dietary supplements - The resident, upon request, has been notified in writing that the facility maintains liability insurance.
  2. Resident 1’s agreement indicates the resident would reside in Room 6; however, Resident 1 was observed to be Room 9.
  3. Staff 1 acknowledged Resident 1’s agreement does not accurately reflect the room the resident currently resides in.
Plan of correction
This citation is improper. The inspector was provided a copy of the resident contract containing the camera use policy, yet proceeded to audit the entire contract without knowledge of additional documents maintained separately, including resident council acknowledgments, insurance disclosures, and many other required records. This represents another instance of LI bad faith and bias conduct.
22VAC40-73-650-A
Based on observation and interview, the facility failed to ensure that no medication, dietary supplement, diet, medical procedure, or treatment shall be started, changed, or discontinued by the facility without a valid order from a physician or other prescriber. Medications include prescription, over-the-counter, and sample medications.
Evidence
  1. During the onsite visit on 07/29/2025, two licensing staff observed the use of a wound vac on Resident 1.
  2. On 07/29/2025, Staff 1 confirmed that the facility does not have orders for the wound vac or orders for wound care treatment provided by the home health agency.
  3. On 07/29/2025, after the onsite inspection, Staff 1 emailed a portion of a progress note regarding Resident 1’s wound to licensing staff that referenced the use of Juven and Ensure.
  4. On 08/05/2025, Staff 1 stated Resident 1 has refused Ensure. Staff 1 was unable to provide orders for Ensure and Juven or a copy of the full note provided via email on 07/29/2025. Both dietary supplements were also not indicated on Resident 1’s medication administration record.
Plan of correction
We respectfully oppose this finding. Resident 1’s wound care, including the wound vac, is managed exclusively by licensed home health providers. The facility is neither licensed nor equipped to provide wound vac management. Nutritional supplements such as Ensure and Juven require a valid physician’s order and must be either supplied by the resident’s POA or authorized for the facility to purchase on the resident’s behalf under an active order. A chart note does not constitute an order; therefore, the presence of a recommendation note without a corresponding physician’s order does not indicate that the facility received an order and failed to comply.
22VAC40-73-440-B
Based on record review and interview, the facility failed to ensure that the Uniform assessment instrument (UAI) was completed by one of the following qualified assessors: An assisted living facility staff person who has successfully completed state-approved training on the uniform assessment instrument and level of care criteria for either public or private pay assessments.
Evidence
  1. Staff 2 completed and signed Resident 1’s UAI dated 03/08/2025.
  2. During onsite inspection on 08/05/2025, Staff 1 did not provide documentation of completion of state-approved training on the uniform assessment instrument for Staff 2 upon request.
Plan of correction
We respectfully oppose this finding. Documentation confirming that Staff 2 successfully completed the state-approved UAI training, along with the ISP certification, was previously provided to licensing staff. The facility maintains that Staff 2 was a fully qualified assessor at the time the UAI was completed. Furthermore, the same licensing inspector returned two days after the exit interview and was provided with a copy of this certification, which demonstrates full compliance with this requirement.
22VAC40-73-920-A
Based on observation and interview, the facility failed to ensure that on each floor where there are residents' bedrooms, there shall be at least one bathtub or shower.
Evidence
  1. On 07/29/2025 and 08/05/20205, two licensing staff observed Resident 1 to occupy a room off the main entry of the facility.
  2. On 08/05/2025, Staff 1 provided access to the bedroom on the main floor that has access to a shower. Staff 1 indicated the room was not being occupied by a resident and they were utilizing the room and bathroom. The bedroom to include closet and bathroom attached were observed to have personal items of Staff 1.
  3. During an interview with Resident 1 on 08/05/2025, Resident 1 indicated they only receive sponge baths in bed and does desire to have a bath or shower but they are unable at the facility.
  4. Staff 1 acknowledged the facility is only able to offer a sponge bath for Resident 1 at this time due to the resident’s needs.
Plan of correction
Resident 1 is bedridden, and her Individualized Service Plan (ISP) signed in 03/2025 clearly documents that she currently receives sponge baths due to her personal needs and mobility limitations. The fact that Resident 1 does not use a shower does not indicate noncompliance, as the regulation requires that showers or bathtubs exist on each floor. We never stated we cannot accommodate her showering as we do shower all of our residents per their care plan. The shower location on the same floor was verified and shown to the inspector’s supervisor on the date of inspection.
22VAC40-73-470-A
Based on record review and interview, the facility failed to ensure, either directly or indirectly, that the health care service needs of residents are met.
Evidence
  1. On 07/29/2025, following the onsite inspection, Staff 1 emailed a portion of a progress note (no date) that indicated Resident 1 “is supposed to receive pre medication prior to wound care, though this is often missed.”
  2. The emailed progress note also referenced the use of Ensure and Juven in relation to Resident 1’s wound. The note (no date indicated) stated the following: a. “Nutritional support includes Ensure and Juven.” b. “However, because she is unable to feed herself, she does not receive the Ensure and Juven consistently.” c. “Staff have been reminded to ensure she receives both Ensure and Juven regularly to aid in the wound healing.”
  3. During inspection on 08/05/2025, Resident 1’s Resident Agreement provided by Staff 1 indicated the following: “You or Your representatives are responsible for monitoring Your health status and for taking appropriate action. In no event is Greenbrier Assisted Living responsible for your medical care other than conducting daily activities as provided in Your Care Plan, assisting in arranging transportation to and from appointments and providing information Greenbrier Assisted Living has to Your medical care givers.”
  4. During inspection on 08/05/2025, Staff 1 provided a copy of another note regarding Resident 1’s wound dated 07/25/2025 with the following statements regarding Ensure and Juven:
  5. “Reinforce staff education to ensure she receives nutritional supplements (Ensure and Juven) regularly.” During inspection on 08/05/2025, when asked about the progress note emailed on 07/29/2025, Staff 1 stated the facility is not responsible for the health care service needs of residents to include the care provided by home health services.
Plan of correction
The facility does not provide direct medical care, nor can it administer supplements without a valid physician’s order, as we are not a hospital. Ordering of nutritional supplements such as Ensure or Juven—must be prescribed by licensed home health providers and supplied by the resident’s POA, in accordance with the resident’s care plan and physician’s orders. A chart note does not constitute an order; it is a recommendation, and no supplement is provided without a formal order. The facility’s role is limited to assisting with daily activities, medication management , administering supplements when provided, and facilitating communication with healthcare providers, as outlined in the Resident Agreement given to the inspector. This contract clearly defines our responsibilities and demonstrates that the facility is in full compliance.
22VAC40-73-530-B
Based on observation and interview, the facility failed to ensure that the door leading to the outside not be locked from the inside or secured from the inside in any manner that amounts to a lock.
Evidence
  1. During on-site inspection on 07/29/2025, two licensing staff observed the double door front entrance to the facility having a Master U-bike lock on the inside of the door which is fed through two rings that are drilled into the door.
  2. The lock was observed again during the on-site inspection on 08/05/2025.
  3. Staff 3 informed that the pad lock is kept in the entry table under the sign in book.
  4. Staff 1 confirmed that the door is new and there is no other way to lock the door.
  5. Staff 3 indicated the lock is used at night.
  6. Photo evidence obtained
Plan of correction
We acknowledge this finding. The double front entrance door has now been replaced as the facility awaits delivery of a custom door lock designed to meet safety and regulatory requirements Once the new lock is installed, it will ensure compliance with 22VAC40-73-500. For the record, the door does not even have a lock so not sure how residents are not free to exit.
22VAC40-73-750-D
Based on observation and interview, the facility failed to ensure adequate and accessible closet or wardrobe space be provided for each resident. The closet or wardrobe space shall be in the resident's bedroom.
Evidence
  1. On 07/29/2025, the space Resident 1 resides in did not have a closet or wardrobe in the room.
  2. Staff 1 stated a closet in the hallway, not in resident’s room, is used for Resident 1.
Plan of correction
We respectfully oppose this finding. The inspector never requested documentation regarding Resident 1’s preference for storage. The report misrepresents the situation by citing unrelated issues. Resident 1 declined having a wardrobe or closet in her room and requested a dresser instead. This preference is documented in the resident’s record. The facility provided adequate and accessible storage in accordance with the resident’s wishes, and the finding does not reflect noncompliance with 22VAC40-73-750-D. Furthermore, this inspector falsely reported the facility to the county, and the report was subsequently dismissed by the county official clearly showing unsubstantiated issue
22VAC40-73-380-A
Based on record review and interview, the facility failed to ensure that all resident personal and social information is obtained prior to or at time of admission.
Evidence
  1. On 08/05/2025, Staff 1 provided personal and social information for Resident 1 to include a resident emergency contact and incomplete face sheet.
  2. Resident 1’s personal and social information was missing the following: - Name, address, and telephone number of all legal representatives. - Name, address, and telephone number of designated contact person authorized by the resident or legal representative.
  3. Staff 1 acknowledged the information provided to the two licensing staff was all of the personal and social information on-site for Resident 1.
Plan of correction
Resident 1’s personal and social information was part of the admission record at the time of placement. The resident is no longer residing in our facility, and as such, we cannot retroactively add or modify documentation after discharge. While some information may not have been present in the record reviewed by licensing staff, the facility collected all information made available by the resident and/or their legal representative during admission.
63.2-1808
Based on observation and interview, the facility failed to ensure the rights and responsibilities of residents be printed in at least 14-point type and posted conspicuously in a public place in all assisted living facilities.
Evidence
  1. During on-site inspection on 08/05/2025, two licensing staff did not see the rights and responsibilities of residents posted within the facility.
  2. Staff 1 and Staff 3 confirmed that the rights and responsibilities of residents were not posted at time of inspection.
Plan of correction
A copy has already been printed and posted in the faculty
22VAC40-73-670-3
Based on record review and interview, facility failed to ensure that medication aides are supervised by an individual employed full time at the facility who is licensed by the Commonwealth of Virginia to administer medications or by the administrator who is licensed by the Commonwealth of Virginia to administer medications or who has successfully completed a training program approved by the Virginia Board of Nursing for the registration of medication aides.
Evidence
  1. On 08/05/2025, Staff 1 confirmed the facility does not have an individual employed full time at the facility who is licensed by the Commonwealth of Virginia to administer medications to supervise medication aides. Staff 1 did not provide documentation of Staff 2 successfully completing a training program approved by the Virginia Board of Nursing for the registration of medication aides upon request.
Plan of correction
The shift schedule (photo evidenced by the inspector) clearly shows that Staff 1 is employed full-time at the facility. Under 22VAC40-73-670, medication aides must be supervised by an individual employed full-time at the facility and licensed by the Commonwealth of Virginia to administer medications. The regulation does not explicitly require additional supervision when a full-time licensed medication aide is administering and supervising medications. In this case, Staff 1 meets the regulatory requirement, and no further supervisory arrangement is mandated under 22VAC40-73-670-3.
22VAC40-73-440-A
Based on record review and interview, the facility failed to ensure that the Uniform assessment instrument (UAI) was completed whenever there is a significant change in the resident's condition.
Evidence
  1. On 08/05/2025, Resident 1’s UAI dated 03/08/2025 was completed by Staff 2 and did not address the resident being catheter dependent (ordered 06/24/2024).
  2. Staff 1 was unable to provide clarification on how long the resident has utilized a catheter and acknowledged the resident's UAI does not indicate the use of one.
  3. Photo evidence obtained
Plan of correction
We acknowledge this finding. Resident 1’s catheter was added and managed by the home care agency providing skilled care. The facility recognizes that this change should have been updated in the UAI and will ensure that any such updates are completed promptly in the future.
22VAC40-73-450-F
Based on observation, record review, and interview, the facility failed to ensure individualized service plans be reviewed and updated at least once every 12 months and as needed for a significant change of a resident’s condition.
Evidence
  1. On 07/29/2025 and 08/05/2025, licensing staff observed 2 cameras, use of a catheter and wound vac in Resident 1's room.
  2. Staff 1 provided Resident 1's record which included the resident's allergies of sulfa (sulfonamide antibiotics) and augmentin from the June, July, and August 2025 Medication Administration Record (MAR) and the June 2025 physician order sheet, 07/23/2025 progress note indicating stage 4 and stage 2 wound on sacrum, and use of home health services to include use of wound vac.
  3. Resident 1’s ISP dated 03/01/2025 did not include having 2 cameras in their bedroom, correct code status, correct notation of allergies, stage 4 wound with wound vac as the treatment, stage 2 wound, pure wick, and having home health with details of the services provided.
  4. Staff 1 acknowledged the identified items were missing from Resident 1’s ISP.
Plan of correction
A new ISP was completed in March 8 2025. The cameras in Resident 1’s room are not part of the resident’s care plan and are used solely for quality assurance of facility operation mainly to verify staff completion of required two-hour rounds; therefore do not belong in the ISP. Additionally, medication allergies, including specific drug names, are appropriately documented in physician orders and the MAR, not in the ISP. The items cited as missing were already recorded in the proper clinical documentation. This finding reflects a misunderstanding of ALF standards by the inspector, or misapplication of rules, not noncompliance.
22VAC40-73-560-I
Based on record review and interview, the facility failed to have a current picture of each resident readily available for identification purposes or, if the resident refuses to consent to a picture, there shall be a narrative physical description, which is annually updated, maintained in his file.
Evidence
  1. On 07/29/2025, LI observed Resident 1’s picture to be outdated and not accurate to what Resident 1 currently looks like.
  2. Staff 1 acknowledged that the picture is not current.
Plan of correction
The resident is no longer in our custody.
22VAC40-73-470-B
Based on record review and interview, the facility failed to ensure a contractual agreement with a licensed nurse, or by a home health agency or by a private duty licensed nurse when a resident requires skilled nursing treatments.
Evidence
  1. During the onsite visit on 07/29/2025, two licensing staff observed the use of a wound vac on Resident 1.
  2. Resident 1 confirmed the wound vac observed in their room is to treat wounds to sacral area and it treated by home health weekly.
  3. Staff 1 and Staff 3 acknowledged and confirmed Resident 1 requires wound care and wound vac treatment that are managed by a home health agency.
  4. On 08/05/2025, Staff 1 provided a progress note on one of Resident 1’s wounds (entered 07/25/2025 regarding 07/23/2025 visit by provider) that indicates “patient to be seen by home health 3x per week prior to next wound care visit.”
  5. Staff 1 confirmed the facility does not employ a licensed nurse and did not provide evidence of a contractual agreement with a licensed nurse, or by a home health agency or by a private duty licensed nurse for the services being provided to Resident 1 upon request.
Plan of correction
Resident 1's wound care, Skilled care services fall under private duty nursing services and are provided by a licensed home health agency directly hired by the resident's family. Greenbrier Assisted Living was not involved in hiring or contracting this agency and therefore does not have a contract with them. Under Virginia regulations, specifically 12VAC30-122-480, private duty nursing services are defined as individual and continuous nursing care provided due to the intensity of medical supports required by individuals with complex health care needs. These services are arranged privately by the resident or their family and are outside the facility's contractual responsibility
22VAC40-73-680-H
Based on observation, interview, and record review, the facility failed to ensure at the time the medication is administered, the facility document on a medication administration record (MAR) all medications administered to residents, including over-the- counter medications and dietary supplements.
Evidence
  1. The June, July, and August 2025 MARs for Resident 1 were requested and provided at 12:26 pm on 08/05/2025 by Staff 1.
  2. Resident 1’s August 2025 MAR did not indicate the resident received the following medications on 08/05/2025: a. 8:00 AM Alendronate Sodium 70 mg tablet a. 7:00 AM Baclofen 10 mg tablet b. 12:00 AM and 6:00 AM dose of Diazapam 2 mg tablet c. 7:00 AM Duloxetine HCL 5 mg tablet d. 7:00 AM Fiber Gummies e. 7:00 AM Folic Acid 1 mg tablet f. 7:00 AM Gabapentin CV 100 mg capsule g. 7:00 AM Lansoprazole DR 30 mg capsule h. 7:00 AM L-Carnitine 250 mg capsule i. 8:00 AM Lidocaine 5% patch j. 6:00 AM NP Thyroid 30 mg tablet k. 7:00 AM Sertraline HCL 50 mg tablet l. 8:00 AM Vit D2 1.25 mg capsule m. 8:00 AM Vitamin B12 1,000 mcg tablet
  3. On 08/05/2025, licensing staff did not observe any staff administering medication during the course of the onsite inspection.
  4. Staff 1 indicated they administered the medications prior to licensing arrival on 08/05/2025 and that they had not documented administration on Resident 1’s MAR at the time of administration. On 08/05/2025, two licensing and Adult Protective Service worker arrived at the facility at approximately 9:00am. Staff 3 was the only direct care staff present upon arrival and stated Staff 1 had not arrived at the facility yet.
Plan of correction
On 08/05/2025, the licensing inspector arrived at the facility around 9:30 a.m. Medications for Resident 1 had been administered by 7:00 a.m., prior to the inspector’s arrival. The inspector requested MARs for the past three months, which were promptly provided. The complaint regarding the 08/05/2025 MAR not reflecting medication administration misrepresents the sequence of events; the inspector was informed that her request was for prior 3 months, not the current day. She was offered the current day’s MAR but refused to review it. Her claim that she did not observe the medication technician leaving the room is false. Video evidence shows Staff 1 exiting the room to administer medications, with a timer on his phone confirming the timing, demonstrating proper medication administration and documentation practices. This finding is a misinterpretation of the facts and does not reflect a violation of 22VAC40-73-680. Additionally, the inspector panicked during the exit interview on 08/25/2025 upon being informed of the video recording and subsequently scheduled another retaliatory inspection for 08/27/2025.
22VAC40-73-290-A
Based on record review and interview, the facility failed to maintain a written work schedule that includes the names and job classifications of all staff working each shift, with an indication of whomever is in charge at any given time.
Evidence
  1. On 08/05/2025, two licensing staff observed written work schedule for “May – July” and “July-August”. Both written schedules did not include all staff, job classifications of all staff nor indication of who is in charge at any given time.
  2. Staff 1 acknowledged the posted schedules observed by licensing staff only included Staff 1 and their job classification.
  3. Photo evidence obtained.
Plan of correction
We have the work schedule for the entire year 2025 on display. The concern noted appears to be related to formatting rather than a lack of compliance. While staff job classifications were included, they were listed as Care Staff at the top of the 1st page rather than directly in front of each staff member’s name. To avoid any confusion in the future, we will revise our scheduling format to ensure that each staff member’s job classification is written directly in front of their name. We remain committed to full compliance with 22VAC40-73-290-A and ensuring transparency regarding staff roles and accountability at all times.
July 29, 2025Complaint survey0 violations
Inspection dates
07/29/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 STAFFING AND SUPERVISION22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/29/2025 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 07/03/2024 regarding allegations in the area(s) of: Health related services Number of residents present at the facility at the beginning of the inspection: 6 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: 2 Observations by licensing inspector: Observed physical plant and residents in common area. Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alexandra Roberts, Licensing Inspector at (804)845-6956 or by email at Alexandra.N.Roberts@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
July 9, 2024Inspection36 violations
Inspection dates
07/09/2024,07/17/2024,08/27/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONSAND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVEIMPAIRMENTS63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES
Comments
Type of inspection:Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facilityfor each day of the inspection:7/9/24, 7/17/24 and 8/27/24(12:15pm-10:00 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:7 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: 5 Number of interviews conducted with residents: 3 Number of interviews conducted with staff:4 Observations by licensing inspector: Licensing staff observed residents during meals and interacting with staff. Additional Comments/Discussion: Licensing staff was present when resident was readmitted to facility from a skilled nursing facility. 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 Alex Roberts, Licensing Inspector at (804) 845-6956 or by email at alexandra.n.roberts@dss.virginia.gov
Violations
22VAC40-73-870-E
Based on observation, facility failed to ensure that all furnishings, fixtures, and equipment, including furniture shall be kept clean and in good repair and condition.
Evidence
  1. On 7/9/2024, LI observed furniture outside in the patio area that was ripped and had large holes.
  2. On 7/17/2024, LI observed that the front doorknob/handle was loose.
  3. Photo evidence taken.
Plan of correction
Not published by VDSS.
22VAC40-73-40-B-12
Based on observation and interview, facility failed to ensure that at all times the department's representative is afforded reasonable opportunity to inspect all of the facility's buildings, books, and records and to interview agents, employees, residents, and any person under its custody, control, direction, or supervision as specified in § 63.2-1706 of the Code of Virginia.
Evidence
  1. During an inspection on 07/09/2024, LI was not able to review requested documents due to staff 1 not having access to any electronic record or computer.
  2. On 07/09/2024, staff 3 confirmed via telephone that all records are electronic and that staff 1 did not have access and therefore could not access any documents. Staff 3 stated that they were on leave and asked LI to come back another day.
  3. On 7/17/2024 Staff 3 denied the LI access to basement space that website states to be for recreational activities.
Plan of correction
Not published by VDSS.
22VAC40-73-870-F
Based on observation and interview, facility failed to ensure stairways have non-slip surfaces.
Evidence
  1. On 7/9/2024 and on 7/17/2024, LI observed the wooden stairs leading to the second floor did not have non-slip surfaces.
  2. On 8/27/2024, LI observed that non-slip grip had been added to one step. The remaining steps did not have non-slip surfaces.
  3. Photo evidence taken.
Plan of correction
Not published by VDSS.
22VAC40-73-680-G
Based on observation, the facility failed to ensure that over-the-counter medication shall remain in the original container, labeled with the resident’s name, or in a pharmacy-issued container, until administered.
Evidence
  1. Licensing staff observed unlabeled AZO cranberry tablets in the resident medication cart. Staff 3 removed AZO pills from resident medication cart that were unlabeled stating that item should not be in there.
  2. Photo and video evidence taken.
Plan of correction
Not published by VDSS.
22VAC40-73-650-E
22VAC40-73-650-E Based on observation and interview, the facility failed to ensure that the resident's record shall contain the physician's or other prescriber's signed written order.
Evidence
  1. On 7/17/2024, LI reviewed Resident 1’s electronic record that did not contain any physician or other prescriber’s signed orders.
  2. Staff 3 stated that they do not have to get signed orders and “the pharmacy gets the signatures not me” Staff 3 stated that he doesn’t “have physical signatures since it is done electronically.”
  3. On 8/27/2024, LI reviewed electronic physician order sheets for Resident 1, which did not contain any signatures. Staff 3 stated that he does not obtain signed orders.
  4. On 7/17/2024, LI observed current supplies of cyanocobalamin 1000 mcg tablets (origin date 01/09/2024 1 of 3 refills before 01/08/2025) and Metformin 500mg tablets in resident 1’s medication supply in the medication cart.
  5. A review of the physician order sheets for resident 1 revealed no orders for Metformin 500 mg or cyanocobalamin 1000 mcg.
  6. When licensing staff requested to view copies of physician’s or prescriber’s orders for the metformin and cyanocobalamin, Staff 3 stated he would “have to call family” and that resident 1’s “daughter would know”.
  7. Photo and video evidence taken.
Plan of correction
Not published by VDSS.
22VAC40-73-260-C
Based on observation and staff interview, facility failed to ensure a listing of all staff who have current certification in first aid or CPR be posted in the facility so that the information is readily available to all staff at all times.
Evidence
  1. On 7/09/2024, LI requested staff posting of certifications in First Aid/CPR from Staff 1.
  2. Staff 1 stated that they cannot access any form of staff documentation and does not know where that information is.
  3. LI asked how staff knows who can provide CPR and they stated that they would have to ask Staff 3.
Plan of correction
Not published by VDSS.
22VAC40-73-610-E
Based on interview, facility staff failed to provide or access a copy of a diet manual containing acceptable practices and standards for nutrition shall be kept current and readily available to personnel responsible for food preparation.
Evidence
  1. LI asked Staff 1 and Staff 2 for the dietary book or manual.
  2. Staff 2 stated that they don’t have anything written and “it is written in my head”.
  3. LI asked what if they are not working or another staff needs to look at the book for reference. Staff 2 stated that they make the meals in bulk. LI asked for clarification of what cooking in “bulk” meant. Staff 2 stated that when they are not in the home, they will cook the meals for the week.
  4. LI returned on 7/17/2024, for follow-up and requested diet manual from staff 3. Staff 3 stated that there are no special diets. LI did not receive or view diet manual.
Plan of correction
Not published by VDSS.
22VAC40-73-70-A
Based on record review, 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. Resident 5 had major incident that took place on 6/25/2024 around 12:30pm.
  2. Fairfax Region licensing office received notification on 07/02/2024) that an APS report was made on 06/27/2024 regarding Resident 5 being involved in an incident on 6/25/2024 that required hospitalization due to resident 5 having a fracture.
  3. Staff 3 reported incident report to LI via email on 07/08/2024 at 2:00am.
  4. Staff 3 stated in email notification that the incident that took place on 06/25/2024 was “not considered to be a major incident” that would need to be reported.
Plan of correction
Not published by VDSS.
22VAC40-73-450-G
Based on interview, facility failed to maintain service plan in a location accessible at all times to direct care staff, but that protects the confidentiality of the contents.
Evidence
  1. During an inspection on 07/09/2024, the LI requested Resident 1’s Individualized Service Plan (ISP) from Staff 1. Staff 1 stated that they do not have access to any documentation when Staff 3 is not present.
  2. LI requested if they had access to any ISP for any of the residents currently residing in the facility. Staff 1 stated that they do not have any documentation.
  3. Staff 3 confirmed via telephone on 07/09/2024 that Staff 1 does not have access to the resident ISPs because they are stored electronically and staff 1 does not have access to the electronic records.
Plan of correction
Not published by VDSS.
22VAC40-73-925-B
Based on observation, facility failed to ensure that common face/hand washing sinks have paper towels or an air dryer.
Evidence
  1. On 8/27/2024, two licensing staff observed that no paper towels or air dryer was present in the common restroom on main level closest to the entrance of the facility.
Plan of correction
I am writing in response to the violation report issued during the annual inspection of Greenbrier Residential Assisted Living on August 27, 2024, regarding the absence of paper towels or an air dryer in the common restroom on the main level closest to the entrance of the facility. We acknowledge that paper towels may not have been available at the time of the inspection. It is likely that the paper towels had been used, and we have since replenished the supply. We apologize for this oversight and have taken immediate steps to ensure that paper towels are always available in the restroom moving forward. We understand the importance of this requirement and are committed to maintaining a clean and well-stocked facility for the comfort and safety of our residents and visitors. Our facility remains committed to maintaining full compliance with all VDSS regulations and providing the highest standard of care to our residents. Thank you for your attention to this matter. Please do not hesitate to contact me if you require any further clarification.
22VAC40-73-680-B
Based on observation and interview, facility failed to ensure that medications shall remain in the pharmacy issued container, with the prescription label or direction label attached, until administered to the resident.
Evidence
  1. On 7/9/2024, LI observed unknown pills in a pill cup in an unsecured kitchen cabinet. LI asked Staff 1 who the pills belong to. Staff 1 stated that they do not know
  2. On 7/17/2024, during medication cart review LI observed several unknown pills in unlabeled zip lock bags, in unlabeled pill organizers, and loose pills at the bottoms of the medication cart drawer.
  3. LI asked Staff 3 why pills were loose and not in bottles. Staff 3 stated that the daughter of Resident 1 put the pills in the zip lock bags and into the pill organizer. Staff 3 began grabbing and cleaning up the loose pills from the bottom of the drawer of the medication cart.
  4. LI observed prescription medication Myrbertriq 50mg that did not have a resident name or prescription label on the bottle.
  5. LI observed Preparation H suppositories not in the original box and unlabeled.
  6. Photo and video evidence taken
Plan of correction
Not published by VDSS.
22VAC40-90-40-B
Based on record review and interview, facility failed to ensure that the criminal history record report shall be obtained on or prior to the 30th day of employment for each employee.
Evidence
  1. Staff 1 (date of hire 12/24/2022) criminal check with a Date of Request of 01/03/2023. Staff 3 did not provide a copy of a completed criminal history check.
  2. Staff 3 (date of hire 12/24/2022) stated that he had a criminal check on 08/05/2024 with results on 8/14/2024. LI requested original criminal history check for staff 3. Staff 3 confirmed that he does not have an original criminal history check to provide.
  3. Staff 4’s (date of hire 05/03/2022) record contained criminal history check with a date of request of 6/03/2022, the 30th day of employment. Staff 3 emailed LI copy that Staff 4 had a requested a criminal background check on 08/05/2024 with results 08/14/2024.
  4. Photo evidence taken.
Plan of correction
We have a strict policy that requires all employees to undergo a criminal background check prior to hiring. Every staff member at our facility has a criminal background check on file. This violation was issued due to our provision of an electronic copy of the background check rather than the original document. We recognize this oversight and will ensure that original copies of all criminal history checks are maintained on file moving forward.
22VAC40-73-730-C
Based on interview, facility failed to ensure that information regarding advance directives shall be readily available to other authorized persons, such as emergency medical technicians (EMTs), when necessary.
Evidence
  1. LI spoke with Staff 3 via phone who informed that Staff 1 does not have access to any documentation as it is all electronic.
  2. Staff 1 stated that they do not have access to advance directives if Staff 3 is not present. LI inquired how Staff 1 provides documentation directives to EMTs and Staff 1 stated that if an EMT would need information they would have to call Staff 3. Staff 1 stated that they do not have access to advance directives.
  3. On 7/17/2024, LI requested staff 1 provide any documentation of advance directive. Staff 1 stated “nothing has changed”.
Plan of correction
Not published by VDSS.
22VAC40-73-520-I
Based on observation and interview, the facility failed to ensure a current month's activity schedule is posted in a conspicuous location in the facility or otherwise be made available to residents and their families.
Evidence
  1. On 7/9/2024, LI observed posting of activity scheduled dated April 2024 in living room. April dates were incorrect in correspondence to the days of the week.
  2. LI requested updated version from Staff 1. Staff 1 stated that is “managements duty” and they do not have an updated schedule. Staff 1 stated that they do not have access to any documentation while Staff 3 is gone.
  3. Staff 1 stated that residents are watching the news instead participating in an activity because they do not want to “disturb them”. No update made to outdated April posting for the substitution or errors.
  4. LI witnessed residents sitting in the kitchen, one resident was in the living room independently and another was in his bedroom.
  5. LI returned for 2nd inspection on 7/17/2024 and observed updated July 2024 calendar. July dates and days are the same as April 2024 and incorrect in correlation to days and dates.
  6. Photo evidence taken.
Plan of correction
Not published by VDSS.
22VAC40-80-120-E-2
Based on observation and interview, facility failed to ensure that the findings of the most recent inspection are posted on the premises.
Evidence
  1. On 7/9/2024 and 8/27/2024, LI observed that the most recent inspection findings dated 9/21/2023 were not conspicuously posted.
  2. On 7/9/2024, LI asked Staff 1 where the inspection findings are posted, and Staff 1 stated that they did not know.
Plan of correction
Not published by VDSS.
22VAC40-73-970-E
Based on record review, facility failed to ensure that a record of the required fire and emergency evacuation drills contained all required provisions.
Evidence
  1. On 7/17/2024, LI reviewed the fire and emergency evacuation drill documentation dated 06/02/2023. The record for the drill marked “day shift” did not include time of the drill, special conditions simulated, or the time it took to complete the drill.
  2. On 8/27/2024, LI reviewed the fire and emergency evacuation drill documentation dated 09/01/2023, 12/01/23, 3/1/2024, and 6/2/2024 at the top of document. The date in the ‘Fire drill’ section was 09/01/22. The record for each drill for day shift did not include - time of the drill, special conditions simulated, and the time it took to complete the drill.
  3. Photo evidence taken
Plan of correction
Not published by VDSS.
22VAC40-73-70-E
Based on a record review and interview, facility failed to ensure that a written report of each incident is maintained by the facility.
Evidence
  1. On 8/27/2024, LI requested 1 years’ worth of incident reports for the facility at 1:13pm. Staff 3 stated that incident reports are kept with resident records and would provide when LI reviews specific resident charts.
  2. On 08/27/2024, the LI requested Resident 5 at time of record review, for whom an incident report had been received. Staff 3 stated that the report was sent to LI via email. LI confirmed that that it was emailed to LI but requested to see written report that is to be maintained in the record. Staff 3 did not produce a copy of the written report of the incident as requested by the conclusion of the inspection at 9 pm.
Plan of correction
Not published by VDSS.
22VAC40-73-660-A
Based on observation and interview, facility failed to ensure use of a medicine cabinet, container, or compartment for storage of medications and dietary supplements prescribed for residents when such medications and dietary supplements.
Evidence
  1. On 8/27/2024, LI observed anti-diarrheal medication in the kitchen refrigerator. The refrigerator was not secured of locked.
  2. On 8/27/2024, LI observed a labeled prescribed medication for Resident 5 (Cholestyramine 4GM Packets 60S) in the pantry, in a food storage area. Pantry doors do not have any method of locking it.
  3. Photo evidence taken.
Plan of correction
Not published by VDSS.
22VAC40-73-980-E-1
Based on record review and interview, facility failed to ensure that on-site emergency generator shall be tested monthly and maintain records of the tests.
Evidence
  1. LI requested generator monthly testing logs from Staff 3. Staff 3 stated that no one has ever asked for this before and that it is tested by the maintenance company and that he does not have any documentation of the tests.
  2. LI did not receive evidence that the generator had been tested.
Plan of correction
I am writing in response to the violation cited under 22VAC40-73-980-E.1, regarding the monthly testing of our on-site emergency generator and the maintenance of corresponding records. We acknowledge the violation and accept responsibility for addressing this matter. However, we would like to note that this requirement is a new regulation, and we were not previously aware of the need to document monthly generator tests. While our generator has been tested regularly by a maintenance company, we recognize that it is our obligation to maintain logs as evidence of compliance with this regulation. To rectify this issue, we have taken immediate steps to ensure compliance: 1. A monthly generator testing log has been implemented and will be maintained at the facility, detailing the date, time, and results of each test. 2. Staff members responsible for overseeing this process have been informed of the new requirement and trained to ensure proper documentation. We appreciate your feedback and will continue to work diligently to adhere to all regulations moving forward.
22VAC40-73-350-A
Based on record review and interview, the assisted living failed to register with the Department of State Police to receive notice of the registration or reregistration of any sex offender within the same or a contiguous zip code area in which the facility is located, pursuant to § 9.1-914 of the Code of Virginia.
Evidence
  1. Resident 1, 2, 3, and 4 records all contained national searches for sex offenders.
  2. LI inquired if residents 1, 2, 3, and 4 had Virginia searches. Staff 3 stated that he does not have Virginia searches.
  3. LI requested evidence that facility is registered with the Department of State Police to receive notice of the registration or reregistration of any sex offender within the same or a contiguous zip code.
  4. Staff 3 did not provide evidence upon request.
Plan of correction
We acknowledge the finding that our facility conducted national sex offender searches rather than limiting searches to Virginia, as specified in § 9.1-914 of the Code of Virginia. We understand the requirement to register with the Virginia Department of State Police to receive notifications of sex offender registration or reregistration within the same or a contiguous zip code area where our facility is located. 1. Corrective Action: Moving forward, we will ensure compliance by conducting sex offender searches exclusively within Virginia. We already have registred with the Virginia Department of State Police to receive the required notifications. 2. Current Status: We have already conducted sex offender searches for all current residents and included this information in our database. While these searches were previously conducted on a national level, we will now limit them to Virginia to align with state requirements. We appreciate the guidance provided during the inspection and will implement these changes immediately to ensure full compliance. Thank you for bringing this matter to our attention, and we remain committed to maintaining the highest standards of care and regulatory adherence.
22VAC40-73-300-B
Based on record review and interview, facility failed to establish a method of written communication that shall be utilized as a means of keeping direct care staff on all shifts informed of significant happenings or problems experienced by residents, including complaints and incidents or injuries related to physical or mental conditions.
Evidence
  1. During 8/27/2024 inspection, LI requested progress notes for resident 1, 2, 3, 4, 5 & 6. Staff 3 stated that they do not have any written progress notes beyond a ’24 hour report’.
  2. LI reviewed the provided ’24 hour report” which only contained blood pressure and vitals. No other written details were included.
  3. LI requested written communication notes and Staff 3 stated that the staff members “talk to each other”
  4. Staff 3 confirmed that they do not have a method of written communication for direct care staff.
Plan of correction
Not published by VDSS.
22VAC40-73-250-C
Based on record review and interview, facility failed to ensure that personal and social data is maintained on staff and included in the staff record.
Evidence
  1. Staff 1’s record did not contain staff 1’s current address and telephone number, verification that the staff person received a copy of the current job description, original criminal record report, or name and telephone number of person to contact in an emergency.
  2. Staff 4’s record did not contain Staff 4’s current address and telephone number, verification that the staff person received a copy of the current job description (was not signed or dated), original criminal record report or name of person to contact in an emergency.
  3. Staff 3 stated that “[staff 1] is here and can get this information now”.
Plan of correction
Not published by VDSS.
22VAC40-73-720-C
Based on interview, facility failed to ensure that Do Not Resuscitate Order (DNR) shall be readily available to other authorized persons, such as emergency medical technicians (EMTs), when necessary.
Evidence
  1. On 7/9/2024, LI spoke with Staff 3 via telephone who stated that Staff 1 does not have access to any documentation as it is all electronic.
  2. Staff 1 stated that there is no access to DNR orders if Staff 3 is not present. LI asked Staff 1 how they would provide directives to EMT’s or show LI documentation of directives.
  3. LI observed that residents have DNR/Full code status posted on room door but Staff 1 unable to provide DNR order.
  4. LI completed follow-up inspection on 7/17/2024 Staff 3 was not present at arrival. LI asked staff 1 to provide documentation of DNRs. Staff 1 stated “nothing has changed I can’t get you anything”. Staff 3 arrived and used their laptop to show DNR documentation.
Plan of correction
Not published by VDSS.
22VAC40-73-210-B
Based on record review and interview, the facility licensed for both residential and assisted living care, failed to ensure that all direct care staff shall attend at least 18 hours of training annually.
Evidence
  1. During 8/27/2024 inspection, LI reviewed Staff 4’s (hire date 05/03/2022) training transcript indicated that staff 4 only had 14 hours of training between 5/3/2023 and 5/2/2024.
Plan of correction
Residential Care Home, where the annual training requirement for direct care staff is 14 hours, we will make sure to arrange for Staff 4 to complete an additional 4 hours of training to meet the 18-hour annual requirement cited in the violation. Our facility remains committed to maintaining full compliance with all VDSS regulations and providing the highest standard of care to our residents.
22VAC40-73-980-A
Based on interview and observation, facility failed to ensure complete first aid kit shall be on hand at the facility that is easily accessible to staff but not to residents, that contains all required items, and which does not contain expiration dates that have already passed.
Evidence
  1. On 7/9/2024, LI requested first aid kit from Staff 1 who stated that they do not have access to a first aid kit.
  2. LI asked what they have access to without Staff 3 being on-site. Staff 1 stated that “pain tabs and band-aids”.
  3. On 7/17/2024, Staff 3 provided first aid kit which included expired antiseptic wipes (expired 05/2019) and antiseptic ointment (Expired 06/2024).
  4. The first aid kit did not contain adhesive tape, Band-aids, in assorted sizes, blankets, disposable single use barriers or CPR masks, cold packs, gloves, hand cleaner, plastic bags, scissors, flashlight and extra batteries, triangular bandages, tweezers and the first aid instructional manual.
  5. Photo evidence taken.
Plan of correction
I am writing in response to the violation cited under 22VAC40-73-980-A, regarding the completeness of the first aid kit at our facility. During the inspection, it was noted that our first aid kit contained expired antiseptic wipes and antiseptic ointment. While the antiseptic wipes were unexpired at the time of their initial inclusion, we recognize the importance of ensuring that all items in the kit are current and meet regulatory standards. Following your observation, we reevaluated our first aid kit requirements and have taken immediate steps to address this issue. The first aid kit has been restocked with all required items, including adhesive tape, assorted Band-Aids, blankets, disposable single-use barriers or CPR masks, cold packs, gloves, hand cleaner, plastic bags, scissors, a flashlight with extra batteries, triangular bandages, tweezers, and a first aid instructional manual. Additionally, we have implemented a regular monitoring schedule to ensure all items remain unexpired and compliant moving forward. We appreciate your attention to this matter and confirm that we are now in full compliance with the requirements.
22VAC40-73-290-A
Based on observation and interview, facility failed to ensure and implement updated postings of the name of the current on-site person in charge.
Evidence
  1. On 7/09/2024, LI observed posting with the names of the current on-site person in charge which was Staff 3.
  2. Staff 1 stated that the listed person Staff 3 was not present and is on leave and the reason they had to call Staff 3.
  3. Staff 3 spoke with LI via phone. Staff 3 stated that he was on leave and Staff 1 was in charge and asked LI to come back another time.
  4. Last date visible on the board was May 18, 2024.
  5. LI asked Staff 1 who oversees updating posting. Staff 1 stated that Staff 3 keeps board updated but has not updated it recently.
  6. Photo evidence taken
Plan of correction
Not published by VDSS.
22VAC40-73-40-B-8
Based on observation and interview, facility failed to ensure that the most recently issued license is posted in the facility in a place conspicuous to the residents and the public.
Evidence
  1. On 7/9/2024, 07/17/2024 and 08/27/2024, LI observed on entry hall a posted license for a licensure period of October 26, 2022 through October 25, 2023.
  2. The most recent license is for a licensure period of October 26, 2023 – October 25, 2025.
  3. LI asked Staff 1 if there was an updated posting. Staff 1 stated that they do not have any documentation and does not know anything about that posting.
  4. Photo evidence obtained.
Plan of correction
Not published by VDSS.
22VAC40-73-980-C
Based on record review and staff interview, facility failed to provide
Evidence
  1. that the First aid kit is checked at least monthly to ensure that all items are present and items with expiration dates are not past their expiration date. Evidence:
  2. LI requested monthly check sheet or evidence that first aid kit is checked monthly from staff
  3. LI did not receive evidence that the first aid kits are checked monthly.
Plan of correction
I am writing in response to the violation cited under 22VAC40-73-980-C, regarding the monthly checks of the first aid kit at our facility. We acknowledge that this is a repeated violation, and we take full responsibility for the oversight in maintaining a log to document monthly inspections of the first aid kit. While the kit itself has been appropriately restocked and updated as needed, we understand the importance of providing clear and consistent evidence that these checks are being conducted. To address this issue, we have implemented a new system to ensure compliance moving forward. A dedicated log has been created to record monthly inspections, verifying that all required items are present and unexpired. Staff members have been instructed on the importance of maintaining this log and will ensure it is updated regularly. We appreciate your diligence in identifying this area for improvement and confirm that we are taking steps to prevent this from happening again.
22VAC40-73-680-D
Based on observation and interview, facility failed to ensure that Medications shall be administered in accordance with the physician's or other prescriber’s instructions and consistent with the standards of practice outlined in the current medication aide curriculum approved by the Virginia Board of Nursing.
Evidence
  1. During 7/17/2024 inspection, LI reviewed Resident 1’s medications and physician order sheet as of 7/17/2024. Resident 1 was prescribed on 12/13/2023 Metoprolol Succinate ER 100mg Tab - Take one tablet by mouth every day for hypertension, do not crush or chew.
  2. The medication cart contained Metoprolol Succinate ER 25mg mg/24 hour tablet – Take 1 tablet (25mg total) by mouth 1 (one) time each day, do not crush or chew. Take with 100mg tablet. This 25mg medication was attached by rubber band to Metoprolol Succinate ER 100mg mg/24 hour tablet – Take 1 tablet (100mg total) by mouth 1 (one) time each day, do not crush or chew.
  3. There was no physician or other prescriber’s order for the dose of 25mg. LI asked staff 3 why there was a 25mg and a 100mg when Resident 1 is prescribed 100mg.
  4. Staff 3 stated that Resident 1 takes 100mg and if they run out then they take 4 of the 25mg to equal 100mg.
Plan of correction
Not published by VDSS.
22VAC40-73-660-A-3
Based on observation, facility failed to ensure that the individual responsible for medication administration shall keep the keys to the storage area on his person.
Evidence
  1. On 7/17/2024. LI requested staff 3 to show LI to medication cart for review. Staff 3 pulled the medication cart key from the shelving space above the sink in a red silicone1 microwave splash guard cover on 2nd floor.
Plan of correction
Not published by VDSS.
22VAC40-73-970-A
Based on record review and interview, facility failed to ensure that the required drills for each shift in a quarter shall not be conducted in the same month.
Evidence
  1. On 7/17/2024, LI requested one year of fire & emergency evacuation drill documentation and was provided one month dated 6/02/2023. Documentation revealed that each shift was completed in the same day in the same month.
  2. Day shift documented in the ‘Fire Drill’ section dated 06/02/2023. Night shift drill is documented in the ‘In-service’ section of the document dated 06/02/2023 with the same date as day shift. No time was indicated on any of the dated documents.
  3. Staff 3 stated that he works all shifts and conducts the fire drill therefore he is unable to separate the shift for the drills and come in at different times.
  4. On 8/27/2024, LI was shown one year of documentation (09/01/2023, 12/01/23, 03/01/24 & 06/02/24) all documentation included day shift in the ‘fire drill’ section and night shift on the same dates in the ‘in-service’ section. Staff 3 confirmed that he completes drills for both shifts together. No time of the drills were indicated on any of the documents.
  5. Photo evidence taken
Plan of correction
I am writing in response to the violation issued during the annual inspection of Greenbrier Residential Assisted Living regarding fire drills being conducted in the same month for each shift, as outlined in 22VAC40-73-970-A. We acknowledge this oversight and confirm that moving forward, we will ensure that fire drills for each shift are conducted in different months as required. Thank you for bringing this to our attention, and we will take the necessary steps to comply with this regulation. Our facility remains committed to maintaining full compliance with all VDSS regulations and providing the highest standard of care to our residents.
22VAC40-73-640-A
Based on record review and observation, facility failed to implement the medication management plan and procedures to prevent the use of outdated, damaged or contaminated medications and methods to ensure that staff who are responsible for administering medications meet the qualification requirements of 22VAC40-73-670..
Evidence
  1. LI reviewed facility medication management plan and section titled “Methods to prevent the use of outdated, damaged, or contaminated medications” which states “check to be sure that medications are not expired. If so, store them securely in locked cabinet area to prevent misuse or accidental ingestion.”
  2. During 7/17/2024 inspection, LI observed the following expired medications for resident 1, which were not removed and stored in a locked cabinet awaiting disposal: A. Expired 10/18/2021 – Betameth Aug (Diprolene) 0.05% Cream 15GM B. Expired 01/18/2023 – Triamcinolone (Kenalog) 0.1% Oint 80GM C. Expired 03/04/2023 - Losartan Potassium 50 MG tab D. Expired 08/16/2023 – Sod Phos/ Biphoe (Fleet) E. Expired 10/02/2023 - Trazadone 50 MG tablet F. Expired 03/28/2024 – Senna Plus Tablet (D) G. Expired 05/23/2024 - Losartan Potassium 25 MG tab (Current order for 50mg) H. Expired 01/05/2024 – Polyethylene Glycol I. Expired 04/05/2024 - Hydrocortisone 25 mg rectal suppository J. Expired 01/05/2024 – Hydrocortisone 25 mg rectal suppository K. Expired 03/08/2024 – senna plus tablet
  3. LI reviewed section within the medication management plan titled “Methods to ensure that staff who are responsible for administering medications meet the qualification requirements of 22VAC40-73-670” plan indicates that staff will be licensed by Commonwealth of Virginia. Staff 1 is not registered as a medication aide in the Commonwealth of Virginia. Staff 1 is registered in the state of Maryland. Staff 3 showed documentation that Staff 4 has Maryland credentials but when LI completes search Staff 4 credentials in Maryland are expired.
  4. Photo and Video evidence taken.
Plan of correction
Not published by VDSS.
22VAC40-73-610-B
Based on observation and interview, facility failed to ensure menus for meals and snacks for the current week shall be dated and posted in an area conspicuous to residents and any substitutions or additions shall be recorded on the posted menu.
Evidence
  1. On 7/9/2024, LI observed the posted weekly menu was dated for April 2024. The days of the week were not dated.
  2. Staff 2 stated that they are unable to provide an updated menu.
  3. On 7/17/2024, the same menu was posted with the only change being the monthly date. The days of the week were not dated. The menu/food items were not changed.
  4. On 8/27/2024, LI observed residents eating lunch. Menu posted for Tuesdays indicate lunch is always Spinach, quiche, mixed green salad. Residents were observed eating sandwiches, tomato soup with corn & potato salad. No changes were made to the menu.
  5. On 8/27/2024, LI observed the September menu posted. The days of the week were not dated, and the same menu/food items remained in the same order.
  6. On 8/27/2024, LI asked Staff 2 where the August menu was posted. Staff 2 stated that “it’s the same every month”. LI asked if that means the food items and rotation is the same every month. Staff 2 said “yes”.
  7. Photo evidence taken.
Plan of correction
Not published by VDSS.
22VAC40-73-860-I
Based on observation and interview, facility failed to store cleaning supplies and other hazardous materials in a locked area.
Evidence
  1. On 7/9/2024, LI observed that the laundry room was unlocked, one of the doorknobs of the bi-fold doors was missing and the door was left open, providing open access to ZEP, Fabuloso, window cleaner, bleach, hand labeled disinfectant spray and other potentially hazardous substances.
  2. When asked how the laundry room is secured, Staff 1 showed LI a bike lock. LI noted that the bike lock would not be able to secure the room due to the missing doorknob.
  3. On 8/27/2024, LI observed ZEP antibacterial disinfectant spray unsecured in bathroom cabinet.
  4. Photo evidence taken.
Plan of correction
1. Observation of Cleaning Supplies on 7/9/2024: o During the inspection, staff were actively engaged in laundry-related tasks, which temporarily resulted in cleaning supplies being left visible and accessible. o We recognize the importance of securely storing hazardous materials and have since replaced the missing doorknob and ensured the laundry room is properly locked at all times. 2. Observation of Cleaning Supplies on 8/27/2024: o The unsecured ZEP antibacterial disinfectant spray in the bathroom cabinet was an oversight. This item has been promptly relocated to a locked storage area to prevent future occurrences. 3. Security Measures: o We have implemented additional training for staff to reinforce the importance of immediately securing hazardous materials after use. o A comprehensive review of all storage areas has been conducted to ensure compliance with regulatory requirements. Corrective Action Taken • The missing doorknob on the bi-fold doors has been replaced, and the laundry room is now fully secured with a functional lock. • All hazardous materials, including cleaning supplies, are stored in locked areas when not in use. • Staff have been instructed to double-check that all hazardous materials are secured after completing their tasks. We take the safety of our residents and compliance with VDSS regulations very seriously. The steps we have taken ensure that similar incidents will not occur in the future. Our facility remains committed to maintaining full compliance with all VDSS regulations and providing the highest standard of care to our residents. Thank you for bringing this matter to our attention. Please let us know if further documentation or clarification is needed.
22VAC40-73-380-A
Based on record review and interview, facility failed to ensure that all resident personal and social information is obtained prior to or at time of admission.
Evidence
  1. Two licensing staff observed that Resident 1,4,5 & 6 records did not contain the following social information: Last home address, birthplace, name, address, and telephone number of all legal representatives, personal MD, personal dentist, clergyman, service in the armed forces, lifetime vocation, special interest and hobbies, current strengths and problems.
  2. LI requested if the information is elsewhere in the record. Staff 3 showed two licensing staff the VDSS model form for social information form for resident 1 that was incomplete.
  3. Staff 3 confirmed that he does not have all the information required.
Plan of correction
Not published by VDSS.
22VAC40-73-530-B
Based on observation, facility failed to ensure that the door leading to the outside shall not be locked from the inside or secured from the inside in any manner that amounts to a lock.
Evidence
  1. On 7/9/2024, two licensing staff observed the front door entrance to the facility had a combination code lock on the inside and a door latch attached to the top of the door.
  2. The combination code lock and latch were observed again on 7/17/2024 and 8/27/2024.
Plan of correction
Not published by VDSS.
September 21, 2023Inspection0 violations
Inspection dates
09/21/2023
Areas reviewed
Administration and Administrative ServicesPersonnelStaffing and SupervisionAdmission, Retention and Discharge of ResidentsResident Care and Related ServicesResident Accommodations and Related ProvisionsBuilding and GroundsEmergency PreparednessBackground Checks for Assisted Living FacilitiesSworn Statement
Comments
Date of Inspection: September 21, 2023 Type of Inspection: Renewal inspection Census: 7 Number of records reviewed and interviews conducted- 6 records, 2 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. The Licensing Inspector observed residents eating lunch. If you have any questions or email changes, please do not hesitate to contact me at sarah.pearson@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.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
December 1, 2022Inspection0 violations
Inspection dates
12/01/2022
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 ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESSArticle 1Subjectivity32.1 Reported by persons other than physicians63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Comments
An unannounced renewal inspection was conducted on 12/1/2022. At the time of entrance four residents were in care with one staff providing care. The sample size consisted of four resident records, two staff records and one individual interview. Resident and staff records and other documentation were reviewed. Virginia State Police background checks reviewed for all new staff hired since the previous inspection. Medication administration was reviewed. An exit meeting was 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 Lynette Storr, Licensing Inspector at (703) 479-4708 or by email at lynette.storr@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
April 22, 2022Inspection8 violations
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS32.1 Reported by persons other than physicians63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Technical assistance
Please note: a written policy should be developed regarding the use of surveillance cameras in and around the facility Reminder: All staff are required to be certified in First Aid within 60 days of employment Please consider using the DSS model form for fire drills to ensure consistent documentation of all of the requirements Please note: Standard 490.D requires that the specific residents for whom the Healthcare Oversight was provided must be identified.
Comments
An unannounced renewal inspection was conducted on 4/13/2022. At the time of entrance five residents were in care with one staff providing care. The sample size consisted of three resident records, three staff records and one individual interview. Resident and staff records and other documentation were reviewed. Residents were observed eating breakfast and engaging in activities including music appreciation and exercise. Medication administration was reviewed. All violations were verified by Administrator during the exit interview held on 4/13/2022. Areas of non-compliance are identified on the violation notice. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word "corrected" is not acceptable. The plan of correction must contain: 1) steps to correct the non-compliance with the standard(s), 2) measures to prevent the non-compliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s). Thank you for your cooperation and if you have any questions please call 703-479-4708 or contact me via e-mail at lynette.storr@dss.virginia.gov.
Violations
22VAC40-73-320-A
Based on documentation review facility failed to ensure that the admission physical examination included recommendations for care including medication, diet, and therapy and a statement that specifies whether the individual is considered to be ambulatory or non-ambulatory as defined in this chapter
Evidence
  1. Resident #1's physical dated 8/27/2021 and Resident #3's physical dated 1/11/2022 indicate that the medication recommendation was attached however there was not a medication recommendation attached to the physical. Resident #3's physical dated 1/11/2022 assesses the resident as ambulatory however the most recent UAI dated 1/26/2022 assesses Resident #3 as requiring physical and mechanical assistance to transfer and walk and The Fall Risk Rating dated 1/26/2022 documents that Resident #3 is "bedbound". These assessments demonstrate that Resident #3 is non-ambulatory.
Plan of correction
Inspection was done with absence of the Facility administrator, the documents in question are part of resident’s old medical records produced by Cherrydale Nursing home, he was not even our resident back in 8/27/2021, we have nothing to do with his old medical records nor allowed to change or correct his old medical information and record. The physical report was done by Cherrydale Nursing home, as permitted Under code of Virginia 22VAC40-73-440, a qualified assessor in our facility determined a new AUI was needed due to Resident #3 ambulation, therefore this violation has no supportive substance, disputed and must be disregarded.
22VAC40-73-580-A
Based on documentation and interview facility failed to ensure the completion of subsequent annual reports from the Virginia Department of Health. The report shall be retained at the facility for a period of at least two years.
Evidence
  1. Facility did not provide documentation of an annual Health Inspection
Plan of correction
We had an annual inspection and this document was presented to the inspector, the “county” health department failed to date stamp their original inspection. We have already been re-inspected and in full compliance. This is NOT a care related issue.
22VAC40-73-680-I
Based on documentation review the facility failed to document symptoms for which medication was given on the Medication Administration Record (MAR).
Evidence
  1. Resident #1's April 2022 MAR does not document the reason for which the medication is prescribed.
Plan of correction
Medication for resident 1 is being managed and supplied by resident’s family, our MAR system does not document medication details if meds are supplied by a 3 rd party supplier. We cannot control a 3 rd party pharmaceutical company nor is this a care related matter.
22VAC40-73-450-C
Based on documentation review the facility failed to ensure that the comprehensive Individualized Service Plan (ISP) includes a description of identified needs and date identified based upon the (i) UAI; (ii) admission physical examination; (iii) interview with resident; (iv) fall risk rating, if appropriate; (v) assessment of psychological, behavioral, and emotional functioning, if appropriate; and (vi) other sources.
Evidence
  1. Resident #2's ISP dated1/27/2022 does not include the identified need regarding a behavioral need documented on Resident #2's Resident-Personal/Social Data Sheet. Resident #3's ISP dated 1/26/2022 does not include his use of a bedrail
Plan of correction
Inspection was done absence of the facility administrator, Resident #2's Resident-Personal/Social Data Sheet was part of Cherrydale Nursing home’s records, we develop our Service plan based on our qualified assessor’s UAI, and this violation has no supportive substance and under dispute. This is NOT a care related issue.
22VAC40-73-860-I
Based on observation facility failed to ensure that each facility shall store cleaning supplies and other hazardous materials in a locked area, except as noted in subsection J of this section.
Evidence
  1. Upon the Licensing Inspector's arrival Cascade dishwasher detergent, Dawn dishwashing liquid and Lysol were observed in an unlocked cabinet under the kitchen sink.
Plan of correction
We will make sure to lock on the cabinet, thank you for brining this to our attention.
22VAC40-73-940-A
Based on documentation and interview the facility failed to ensure that compliance with the Virginia Statewide Fire Prevention Code (13VAC5-51) as determined by at least an annual inspection by the appropriate fire official. Reports of the inspections shall be retained at the facility for at least two years.
Evidence
  1. The facility could not provide documentation of an annual Fire Inspection.
Plan of correction
Our annual fire inspection has already been done for 2nd time. Fire drill records were all in compliance and presented to the inspector. This is NOT a care related matter.
22VAC40-73-440-D
Based on documentation review facility failed to ensure that the Uniform Assessment Instrument (UAI) is completed as required by 22VAC30-110.
Evidence
  1. Resident #1's UAI dated 9/15/2021 did not assess if a current psychiatric or psychological evaluation in needed.
Plan of correction
Resident #1 did not need psychiatric or psychological evaluation, an uncheck checkbox in his UAI has been marked and corrected. This is a paperwork related issue, has already been corrected and not care related.
22VAC40-73-350-B
Based on documentation review the facility failed to ensure that prior to admission, the facility shall ascertain whether a potential resident is a registered sex offender if the facility anticipates the potential resident will have a length of stay greater than three days or in fact stays longer than three days and shall document in the resident's record that this was ascertained and the date the information was obtained.
Evidence
  1. Residents #1, #2 and #3 do not have documentation in the record to indicate their sex offender status.
Plan of correction
None of our residents are part of sex offender registry and our standard sex offender forms were signed by ALL residents and presented to the inspector. We have added a print out of the search results to their file, this is NOT a care related issue.
October 27, 2021Complaint survey10 violations
Inspection dates
10/27/2021
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDING AND GROUNDS
Comments
Licensing Inspector (LI) conducted unannounced complaint investigation on 10/27/2021 regarding resident medication, staff qualifications and billing practices. LI reviewed resident and staff records and medication administration records. Spoke with Administrator/Owner and the staff on duty. The complaint is deemed valid as a preponderance of evidence gathered during the investigation supported the allegations regarding resident medication and staff qualifications. Exit interview conducted on 11/9/2021 and the violation notice regarding the standards deemed valid was left for correction. Areas of non-compliance are identified on the violation notice. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word "corrected" is not acceptable. The plan of correction must contain: 1) steps to correct the non-compliance with the standard(s), 2) measures to prevent the non-compliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s). Thank you for your cooperation and if you have any questions please call 703-479-4708 or contact me via email at lynette.storr@dss.virginia.gov.
Violations
22VAC40-73-440-B
Based on document review and interview the facility failed to ensure that for private pay individuals, the UAI shall be completed by an assisted living facility staff person who has successfully completed state-approved training on the uniform assessment instrument and level of care criteria for either public or private pay assessments.
Evidence
  1. Resident #1's most recent UAI was completed by Staff #1. There is no documentation to indicate that Staff #1 completed the state-approved training on the uniform assessment instrument and level of care criteria for either public or private pay assessments.
Plan of correction
Secured electronic copy of the state approved UAI certification has already been provided, facility to ensure to retain a paper copy inside the facility. This is not a care related matter.
22VAC40-73-680-G
Facility failed to ensure that over-the-counter medication shall be labeled with the resident's name, or in a pharmacy-issued container, until administered.
Evidence
  1. Based on observation and interview Ipratropium Bromide Nasal Solution and Moisture Eye Drops were not labelled with the resident's name.
Plan of correction
This was an over the counter eye drop (no risk). The staff in charge of the shift was immediately terminated, the facility to ensure staff are informed of this requirement. This is not a care related matter.
22VAC40-73-450-B
Based on documentation review and interview the facility failed to ensure that the person who develops the ISP has successfully completed the department-approved individualized service plan (ISP) training.
Evidence
  1. Resident #1's most recent ISP was developed by Staff #1. There is no documentation to indicate that Staff #1 has completed the approved ISP training.
Plan of correction
Secured electronic copy of the state approved ISP certification has already been provided, facility to ensure to retain a paper copy inside the facility. This is not a care related matter.
22VAC40-73-440-F
Based on documentation review and interview the facility failed to ensure that the UAI shall be completed within 90 days prior to admission to the assisted living facility.
Evidence
  1. Resident #1's most recent UAI was incomplete. It did not indicate the assistance required in each of the ADL categories.
Plan of correction
The UAI was partially complete due resident #1 was new and was still under additional evaluation. We will make sure to comply with this requirement. This is not a care related matter.
22VAC40-73-660-B
Facility failed to ensure that the medication and any dietary supplements shall be stored so that they are not accessible to other residents.
Evidence
  1. Based on observation and interview Ipratropium Bromide Nasal Spray and Moisture Eye Drops were found on a cabinet in the living room and were not being stored in a manner consistent with current standards of practice.
Plan of correction
This was an over the counter eye drop (no risk). The staff in charge of the shift was immediately terminated, the facility to ensure staff are informed of this requirement. This is not a care related matter.
22VAC40-73-925-B
Facility failed to ensure that common face/hand washing sinks shall have paper towels or an air dryer and liquid soap for hand washing.
Evidence
  1. Upon the Licensing Inspector's arrival there were no paper towels or an air dryer available in the common bathroom.
Plan of correction
We had ran out of paper towel in one toilet, we will make sure to put additional paper towel.
22VAC40-73-560-H
Facility failed to ensure that for at least the first year after the resident leaves the facility, the record shall be retained at the facility.
Evidence
  1. Based on documentation review and interview Resident #2 who was discharged from the facility did not have a resident record at the facility. The Owner indicated that the record had been moved offsite.
Plan of correction
As informed, we are a technologically advanced company, electronic copy of the discharged resident was available and has already been provided, facility to ensure to retain a paper copy inside the facility. This is not a care related matter.
22VAC40-73-290-A
Based on documentation review, observation and interview the facility failed to ensure that a written work schedule that includes the names and job classifications of all staff working each shift, with an indication of whomever is in charge at any given time is maintained.
Evidence
  1. Upon the Licensing Inspector's arrival on 10/27/2021 the posted work schedule did not correctly indicate the staff member that was currently working in the facility.
Plan of correction
We had one staff called out due to being sick, an unscheduled employee was covering the shift, we re-printed the shift schedule. This is not a care related matter.
22VAC40-73-290-B
Based on observation and interview the facility failed to ensure that the current on-site person in charge is posted.
Evidence
  1. Upon the Licensing Inspector's arrival on 10/27/2021 the current on-site person in charge was not posted.
Plan of correction
We had one staff called out due to being sick, an unscheduled employee was covering the shift, we re-printed the shift schedule. This is not a care related matter.
22VAC40-73-250-A
Facility failed to ensure that a record shall be established for each staff person.
Evidence
  1. Staff #2 who was working at the facility when the Licensing Inspector arrived did not have a staff record established.
Plan of correction
Secured electronic copy of the staff record was available and provided, we will make sure to retain a paper copy inside the facility. This is not a care related matter.
April 20, 2021Inspection0 violations
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS32.1 Reported by persons other than physicians63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Comments
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 mandated monitoring inspection was initiated on 4/6/2021 and concluded on 4/20/2021. The Administrator was contacted by email to initiate the inspection. The Administrator reported that the current census is one. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed one resident record, one staff record, local fire and health inspection and other documentation submitted by the facility to ensure documentation was complete. All background checks of staff hired after the most recent inspection were reviewed. The information gathered during the inspection determined no violations with applicable standards or law. No violations were issued. Thank you for your cooperation and if you have any questions please call 703-479-4708 or contact me via e-mail at lynette.storr@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
February 16, 2021Inspection0 violations
Inspection dates
Feb. 16, 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 PREPAREDNESS32.1 Reported by persons other than physicians63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Technical assistance
Please note: The Fire Drill documentation that was submitted met all of the required standards however I suggest revising the form to indicate what the required information is or using the DSS model form.
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 mandated monitoring inspection was initiated on 2/12/2021 and concluded on 2/16/2021. The Administrator was contacted by email to initiate the inspection. The Administrator reported that the current census is one. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed one resident record, one staff records, medication administration records, local fire and health inspection and other documentation submitted by the facility to ensure documentation was complete. All background checks of staff hired after the most recent inspection were reviewed. The information gathered during the inspection determined no violations with applicable standards or law. No violations were issued. Thank you for your cooperation and if you have any questions please call 703-479-4708 or contact me via e-mail at lynette.storr@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.