Virginia DSS · Assisted Living Facility

Commonwealth Senior Living at Cedar Manor

📍 1324 Cedar Road, Chesapeake, VA, 23222

ID 46409One Year licenseActive
19
Inspections
On record
16
With violations
Visits that cited something
3
Clean visits
Nothing cited
81
Violations cited
Individual findings
46
Standards cited
Distinct rules
9
Complaint visits
Prompted by a complaint

Commonwealth Senior Living at Cedar Manor was inspected 19 times between February 3, 2021 and April 30, 2026 by the Virginia Department of Social Services. 16 of those visits ended with violations cited and 3 with none. Across that history VDSS cited 81 violations under 46 distinct standards. 9 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. 16 of these 19 are still on the state's site; the other 3 have since dropped off it and are reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type
Assisted Living Facility
License type
One Year
License expires
05/17/2027
Administrator
Gary Pelton
Licensing inspector
Donesia Peoples
Inspector phone
757 353-0430
Approved for
Special Care Unit · Assisted Living · Non-Ambulatory

Inspection History

19

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

April 30, 2026Inspection6 violations
Inspection dates
04/30/2026
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 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: An unannounced renewal inspection took place on 04/30/2026 at 8:05 am to 3:55 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: 96 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed:4 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 5 Observations by licensing inspector: Breakfast, Lunch and an activity were observed. A medication pass observation was completed for three residents. The following were reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, medication carts, fire inspection report, health inspection report, and a staffing schedule. The water temperature was measured and the call signaling system was monitored. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of these inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-690-G
Based on the record review and staff interview the facility failed to ensure action taken in response to the recommendation noted in the medication review shall be documented in the resident’s record.
Evidence
  1. Resident #1’s medication review dated 04/13/26 includes the following notes and recommendations for the prescribed order for Lisinop/HCTZ, take one tablet by mouth everyday for hypertension, hold if SBP >100 or HR >60: • MAR documentation shows the resident is not routinely receiving these medications due to hold parameters. • Clarify if the medication should be held for systolic blood pressure less than 100 or HR less than 60 • Change hold parameter to Lisinop/HCTZ take one tablet by mouth everyday for hypertension hold if SBP less than 100 or HR less than 60 or continue order as written. The resident’s record does not include actions taken in response to the recommendations noted in the medication review.
  2. During an interview on 04/30/26 with staff #4, staff #4 confirmed the notes and recommendations listed in resident #1’s medication review were not reviewed by the resident’s physician and no action was taken in response to the recommendations.
  3. Resident # 5’s medication review dated 04/15/26 includes the following recommendations: • Resident with discharge orders from hospital on 03/19/26 that are not currently active on medication profile: amiodarone 200mg 1 tab twice daily then 1 tab daily for 21 days, apixaban 2.5mg twice daily, tamsulosin 0.4mg 1 time daily. • Please clarify if the resident should have active orders for the above medications. The resident’s record does not include actions taken in response to the recommendations noted in the medication review.
  4. During an interview on 04/30/26 with staff #4, staff #4 confirmed the recommendations listed in resident #5’s medication review were not reviewed by the resident’s physician and no action was taken in response to the recommendations.
Plan of correction
What Has Been Done to Correct? Recommendations presented were shared with PCP and Resident #1 and Resident #5’s medication orders updated accordingly by RCD. No other concerns were identified. How Will Recurrence Be Prevented? Resident Care Director (RCD) and Assistant Resident Care Director (ARCD) were retrained on regulation 73-690-G. RCD/ARCD are responsible for compliance with this regulation. ED will audit 5 resident medication records for compliance with recommendations. Person Responsible: Executive Director or designee Due Date: 5/22/26 and Ongoing
22VAC40-73-680-D
Based on the record review and staff interview the facility failed to ensure medications shall be administered in accordance with the physician’s or other prescriber’s instructions.
Evidence
  1. The record for resident #1 contains a physician order dated 03/03/26 for Lisinop/HCTZ 20/25mg to take one tablet by mouth daily for hypertension hold if SBP >100 or HR >60. The March 2026 and April 2026 Medication Administration Records (MARS) for resident #1 documents on the following dates the resident was not administered Lisinop/HCTZ according to the physician’s instructions and the Lisinop/HCTZ was administered when the resident’s SBP was documented > 100 or the HR was >60. • 03/09/26,03/10/26, 03/11/26, 03/13/26, 03/14/26, 03/15/26, 03/16/26, 03/18/26, 03/21/26, 03/22/26, 03/23/26, 03/24/26, 03/27/26, 03/28/26, 03/29/26, 03/30/26, 03/31/26. • 04/01/26, 04/06/26, 04/07/26, 04/08/26, 04/09/26, 04/10/26, 04/12/26, 04/13/26, 04/14/26, 04/15/26, 04/18/26, 04/19/26, 04/20/26, 04/28/26, 04/29/26. Photographic evidence is available.
  2. During an interview on 04/30/26 with staff #4, staff #4 confirmed the March and April 2026 MARs for resident #1 does not document the resident was administered Lisinop/HCTZ according to the physician’s instructions.
  3. The record for resident #5 contains a hospital discharge summary dated 03/19/26 that includes physician instructions to start taking the following medications: • amiodarone 200mg take 1 tablet by mouth 2 times daily for 7 days, then 1 tablet daily for 21 days. • Fluconazole 200mg take 1 tablet by mouth for 7 days. • Tamsulosin 0.4mg take 1 capsule by mouth daily. • Apixaban 2.5mg take 1 tablet by mouth 2 times daily. • Cefuroxime 250mg take 1 tablet by mouth 2 times daily for 7 days. Resident #5’s March 2026 and April 2026 MARs do not include the medications nor documentation of the resident being administered the medications per the physician instructions as listed on the discharge summary dated 03/19/26. Photographic evidence is available.
  4. During an interview on 04/30/26 with staff #4, staff #4 confirmed the medications that resident #5 was to start taking 03/19/26 as listed on the discharge summary was not documented on the resident’s MARs. Staff #4 was not able to provide evidence of resident #5 being administered the medications according to the physician instructions dated 03/19/26.
  5. The record for resident #5 contains a hospital discharge summary dated 03/28/26 that includes physician instructions to start taking the following medications: • Amoxicillin 875-125 mg take 1 tablet by mouth every 12 hours for 7 days. • Docusate sodium 100mg take 1 capsule by mouth once a day. • Fluconazole 200mg take 1 tablet by mouth once a day for 7 days. • Phenazopyridine 200mg take 1 tablet by mouth 3x daily as needed. • Tamsulosin 0.4mg take 1 capsule by mouth once a day. • Trospium 20mg take 1 tablet by mouth twice a day for 7 days. Resident #5’s March 2026 and April 2026 MARs do not include the medications nor documentation of the resident being administered the medications per the physician instructions as listed on the discharge summary dated 03/28/26. Photographic evidence is available.
  6. During an interview on 04/30/26 with staff #4, staff #4 confirmed the medications that resident #5 was to start taking 03/28/26 as listed on the discharge summary was not documented on the resident’s MARs. Staff #4 was not able to provide evidence of resident #5 being administered the medications according to the physician instructions dated 03/28/26.
Plan of correction
What Has Been Done to Correct? RCD/ARCD clarified Resident #1’s medication parameters from the Primary Care Physician (PCP). RCD/ARCD updated Resident #5’s MAR to reflect all current medications as prescribed by residents PCP. How Will Recurrence Be Prevented? Resident Care Director (RCD) and Assistant Resident Care Director (ARCD) were retrained on regulation 73-680-D. RCD/ARCD retrained medication personnel to this ruling. RCD/ARCD or designee to verify resident Physician orders to the MAR to ensure all medications are administered as prescribed. RCD/ARCD or designee to audit 15 new medication orders as compared to the MAR and confirm parameters are identified as ordered. Audit weekly for next 3 months. Any discrepancies identified will be corrected immediately. Person Responsible: RCD/ARCD or designee Due Date: 5/22/26 and Ongoing
22VAC40-73-940-A
Based on the fire inspection report review and staff interview the facility failed to ensure an assisted living facility shall comply with the Virginia Statewide Fire Prevention Code (13VAC5-51) as determined by at least an annual inspection by the appropriate fire official. 1. The facility’s fire inspection report is dated as completed on 02/18/25 and 03/25/25. 2. Upon request, and during an interview on 04/30/26 with staff #5, staff #5 confirmed an annual fire inspection was not completed after 03/25/25. Staff #5 stated the local Fire Marshall Office was contacted on 04/30/26 to request an annual fire inspection to be completed at the facility.
Plan of correction
What Has Been Done to Correct? ED made several phone call attempts to connect with Fire Marshall to request review and visit. On 5/22/26, ED emailed Fire Marshall to request visit, review and approve Fire and emergency evacuation plan. How Will Recurrence Be Prevented? ED and Facilities Director (FD) are responsible for compliance to this ruling. Person Responsible: Executive Director or designee Due Date: 5/22/26 and Ongoing
22VAC40-73-450-C
Based on the record review and staff interview the facility failed to ensure the comprehensive individualized service plan (ISP) shall be completed within 30 days after admission and shall include the following: Description of identified needs and date identified based upon other sources.
Evidence
  1. The record for resident #1, admission date 03/06/26, contains an ISP completed on 03/03/26 prior to the resident’s admission. The resident’s record did not contain an ISP completed within 30 days after admission.
  2. The record for resident #2, admission date 07/14/25 contains a preliminary plan of care dated 07/14/25. The resident’s record does not contain an ISP completed within 30 days after the resident’s admission.
  3. The record for resident #5, admission date 03/04/26, contains a preliminary plan of care dated 03/03/26. The resident’s record does not contain an ISP completed within 30 days after the resident’s admission.
  4. During an interview on 04/30/26 with staff #4, staff #4 confirmed that an ISP was not completed within 30 days after the admission for the following residents: Resident #1 Resident #2 Resident #5
  5. The record for resident #1 contains a Do not Resuscitate Order (DNR) dated 03/03/26. The resident’s ISP dated 03/03/26 does not include the resident’s DNR status and documents the resident as a Full Code.
Plan of correction
What Has Been Done to Correct? RCD/ARCD/designee reassessed Resident #1, #2 and #5. ISPs were updated to reflect current care needs. RCD/ARCD/designee audited current resident records for timely and updated ISP. Concerns identified were corrected. How Will Recurrence Be Prevented? RCD/ARCD were retrained by ED on regulation 73-450-C. RCD/ARCD/designee are responsible for compliance with this ruling. RCD/ARCD/designee will audit new move-ins to ensure comprehensive ISP has been completed within 30 days after move-in and includes all the expected components. Audits will be conducted weekly for next three (3) months. Person Responsible: RCD/ARCD/designee. Due Date: 5/22/26 and ongoing
22VAC40-73-320-A
Based on the record review and staff interview the facility failed to ensure within the 30 days preceding admission, a person shall have a physical examination by an independent physician. The report of such examination shall be on file at the assisted living facility and shall contain the following: The signature of the examining physician or his designee.
Evidence
  1. The record for resident #2, admission date 07/14/25, contains a physical examination completed 07/18/25, after the resident’s admission.
  2. Upon request, and during an interview on 04/30/26 with staff #4, staff #4 was not able to provide a physical examination completed within 30 days prior to resident #2’s admission.
  3. The record for resident #1 contains a physical examination report dated as completed on 03/03/26. The physical examination is not signed by the physician.
  4. During an interview on 04/30/26 with staff #4, staff #4 confirmed resident #1’s physical exam dated 03/03/26 is not signed by the physician.
Plan of correction
What Has Been Done to Correct? Resident #1 physical examination was signed by the resident’s primary care physician. Resident Care Director (RCD), Assistant Resident Care Director (ARCD) conducted audit of current residents for this ruling and no other concerns identified at this time. How Will Recurrence Be Prevented? Executive Director and Resident Care Director (RCD) and Assistant Resident Care Director (ARCD) were retrained on regulation 73-320-A. RCD/ARCD and/or designee are responsible for compliance with this ruling. ED to audit new move-in resident records for weekly for next 3 months to confirm compliance with this ruling. Person Responsible: Executive Director or designee Due Date: 5/22/26 and ongoing
22VAC40-90-40-B
Based on the record review and staff interview the facility failed to ensure criminal history records were obtained on or prior to the 30th day of employment for each staff person.
Evidence
  1. The record for staff #6, hire date 10/07/25, does not contain a criminal history report.
  2. Upon request, and during an interview on 04/30/26 with staff #7, staff #7 was not able to provide a criminal history report completed for staff #6.
Plan of correction
What Has Been Done to Correct? Staff member #6 was not an active associate at the time of this inspection. Reviewed all current staff records to ensure each staff member has a criminal history record on file. No other concerns identified at this time. How Will Recurrence Be Prevented? Executive Director (ED) and Business Office Manager (BOM) were retrained on regulation 90-40-B. BOM and/or designee is responsible for compliance to this ruling. Business Office Manager will obtain a criminal history record for each new associate on or before the 30th day of employment. The Executive Director or designee will audit new associate files weekly for the next month, then bi-weekly for a total of three months. Concern identified will be corrected immediately. Person Responsible: Executive Director or designee Due Date: 5/22/26 and ongoing
November 19, 2025Complaint survey0 violations
Inspection dates
11/19/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-80 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: An unannounced complaint inspection took place on 11/19/2025 at 11:00 am to 2:10 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 10/07/2025 regarding allegations in the area(s) of: Personnel and Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 81 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 2 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: Lunch was observed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the (allegation(s)/self-report) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
September 15, 2025Complaint survey1 violation
Inspection dates
09/15/2025
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 IMPAIRMENTS63.2 PROTECTION OF ADULTS AND REPORTING22VAC40-80 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: An unannounced complaint inspection took place on 09/15/2025 at 11:30 am to 1:38 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 09/11/2025 regarding allegations in the area(s) of: Personnel and Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 81 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 4 Observations by licensing inspector: An observation of the safe secure unit was reviewed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the (allegation) of non-compliance with standard(s) or law. However, violation(s) not related to the (complaint) but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-130-A
Based on the record review and staff interview the facility failed to ensure all staff who are mandated reporters under § 63.2-1606 of the Code of Virginia shall report suspected abuse, neglect, or exploitation of residents in accordance with that section.
Evidence
  1. Resident #1’s progress noted dated 08/29/25 documents the following: “RMA was notified by hairstylist that resident came out from memory unit and one of the RCA was throwing hands with the resident and RCA was using cursing words to the resident.”
  2. During an interview on 09/15/25 with staff #1 and staff #2, staff #1 and staff #2 confirmed being notified on 08/30/25 of an allegation of suspected physical abuse involving staff #4 physically assaulting resident #2 on 08/29/2025, however the staff did not report the incident to Adult Protective Services (APS).
  3. During an interview on 09/15/25 with staff #3, staff #3 confirmed staff #1 notified staff #3 on 09/01/25 of an allegation of suspected abuse involving staff #4 physically assaulting resident #1 on the day of 08/29/25. Staff #3 confirmed staff #3 did not report the suspected abuse to APS.
  4. During an interview on 09/15/25 with collateral contact #1, collateral contact #1 confirmed the facility staff did not report to APS the allegation of suspected abuse involving staff #1 physically assaulting resident #1.
Plan of correction
What Has Been Done to Correct? Staff #4 is no longer employed with Commonwealth Senior Living. How Will Recurrence Be Prevented? Re-educated all associates on ALF regulation 73-130-A and CSL Policy & Procedure GP03 Abuse, Neglect and Exploitation. Person Responsible: Executive Director or designee Due Date: November 30, 2025
April 3, 2025Inspection6 violations
Inspection dates
04/03/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An announced renewal inspection took place on 04/03/2025 from 8:00 am to 5:30 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 83 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: Breakfast, Lunch and an activity were observed. A medication pass observation was completed for three residents. The following was reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, medication carts, fire inspection report, health inspection report, and a staffing schedule. The 1ater temperature was measured. 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-450-C
Based on the record review the facility failed to ensure the comprehensive individualized service plan (ISP) shall be completed within 30 days after admission and shall include a description of identified needs and dated based upon the Uniform Assessment Instrument (UAI).
Evidence
  1. The record for resident #1, admission date 07/31/24, contains a Preliminary ISP dated 07/30/24 and an ISP that is dated as completed on 09/06/24. The ISP is dated as completed more than 30 days after the resident’s admission date.
  2. Resident’s #3 UAI dated 03/31/25 documents mechanical and human help needs for toileting and transferring. The resident’s ISP dated 03/31/25 does not include the mechanical help needs for toileting and transferring.
  3. Resident’s #5 UAI dated 10/10/24 documents mechanical and human help needs for toileting and transferring. The resident’s ISP dated 10/10/24 does not include the mechanical help needs for toileting and transferring.
  4. Resident’s #6 UAI dated 10/17/24 documents mechanical and human help needs for dressing, toileting and transferring. The resident’s ISP dated 10/17/24 does not include the mechanical help needs for dressing, toileting and transferring.
Plan of correction
ISP reviewed at time of annual audit updated to reflect UAI and ISP match resident’s current needs. RCD, ED, or designee to audit current resident files to ensure ISP and UAI match to reflect resident’s current needs. For the next 60 days, the ED/designee will conduct a review of completed UAI’s and ISPs to assure that the UAI/ISP match and reflect resident’s current needs.
22VAC40-73-290-B
Based on observation and staff interview the facility failed to develop and implement a procedure for posting the name of the current on-site person in charge in a place in the facility that is conspicuous to the residents and the public.
Evidence
  1. Upon arrival at the facility on 04/03/25 at 8:00 am, the Licensing Inspector (LI) observed a posting of the Shift Supervisor listed as staff #7. Staff #7 was not on site at the facility upon the LI arrival. Staff #6 acknowledged staff #7 was not onsite at the facility upon the LI arrival.
Plan of correction
What Has Been Done to Correct? Daily name posting sheets for person in charge updated to reflect changes. How Will Recurrence Be Prevented? New and current RMAs will be provided training for the designated person in charge. Record of training to be placed in employee record. Policy and regulations to be reviewed with Concierge, BOM, RCD, RCCs, and ED to ensure being completed properly prior to posting.
22VAC40-73-640-A
Based on the record review and staff interview the facility failed to implement a written plan for medication management to include 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.
Evidence
  1. The facility’s medication management plan provided during the onsite inspection includes the following: “the RMA on duty contacts the dispensing pharmacy to obtain a refill at least seven (7) days prior to a medication running out unless the medication is on a cycle refill with the pharmacy.”
  2. During the medication pass observation with staff #2. The following medications scheduled for 7:30 am were not on the cart for resident #3: Prednisone, Calcium Vitamin D3, and Loratadine.
  3. Resident’s #1 April 2025 Medication Administration Records (MAR) documents the resident did not receive the following medications on the following dates: Loratadine not received on 04/01/25 through 04/03/25; Calcium Vitamin D3 not received on 04/03/25; Prednisone not received on 04/03/25.
  4. During an interview on 04/03/25 with staff #2, staff #2 acknowledged resident #3 missed dosages of medications (Calcium Vitamin D3, Loratadine, and Prednisone) the dates of 04/01/25 through 04/03/2025 due to the medications not being refilled in a timely manner. Staff #2 submitted a refill request for the medications on 04/03/25.
Plan of correction
What Has Been Done to Correct? Direct care staff administering medications have been re-in-serviced on organization’s Medication Management Policy to include medication reorder policy and documentation. Pharmacy Audit and review conducted following unannounced visit. Medications not meeting the regulation standard have been received and are on the medication cart. How Will Recurrence Be Prevented? For the next 30 days, the RCD, ED, or designee will perform routine cart and documentation audits to ensure medications are being ordered and documented in a timely fashion. Moving forward, the RCD, ED, or designee will complete random cart and documentation audits to ensure medications are being ordered and documented in a timely fashion.
22VAC40-73-680-D
Based on the record review and staff interview the facility failed to ensure medications shall be administered in accordance with the physician’s or other prescriber’s instructions.
Evidence
  1. 1 The record for resident #3 contains the following physician orders dated 02/14/25: Clopidogrel 75mg, take 1 tablet by mouth everyday; Losartan 50mg, take 1 tablet by mouth everyday; Pantoprazole, take I tablet by mouth everyday; Levetiraceta, take 1 tablet by mouth twice a day; Montelukast, take 1 tablet by mouth every day; Rosuvastatin, take 1 tablet by mouth every day.
  2. Resident’s # 3 March 2025 MAR documents the resident did not receive the following medications daily as prescribed on the dates of 03/04/25 through 03/11/25: Clopidogrel, Losartan, Pantoprazole, Levetiraceta, Montelukast, and Rosuvastatin. The March 2025 MAR documents “out of the facility” as the reason the resident did not receive the medications. The resident’s record does not contain documentation the resident was out of the facility the dates of 03/04/25 through 03/11/25.
  3. During an interview on 04/03/25, with staff #2, staff #2 acknowledged resident #3 was not out of the facility the dates of 03/04/25 through 03/11/25. Staff #2 was not able to provide an explanation of why staff #2 documented on resident’s #3 March 2025 MAR the resident was out of the facility. Staff #2 was not able to provide documentation of resident # 3 receiving the following medications daily on the dates of 03/04/25 through 03/11/2025: Clopidogrel, Losartan, Pantoprazole, Levetiraceta, Montelukast, and Rosuvastatin.
  4. During an interview on 04/03/25 with staff #4, staff # 4 acknowledged resident’s #1 March 2025 MAR documentation of “out of the facility” on the dates of 03/04/25 through 03/11/25 was “documented incorrectly” by staff. Staff #4 was not able to provide documentation of resident # 3 receiving the following medications on the dates of 03/04/25 through 03/11/2025: Clopidogrel, Losartan, Pantoprazole, Levetiraceta, Montelukast, and Rosuvastatin.
Plan of correction
What Has Been Done to Correct? Direct care staff administering medications have been re-in-serviced on organization’s Medication Management Policy to Medication Administration. Pharmacy Audit and review conducted following unannounced visit. Medications not meeting the regulation standard have been received and are on the medication cart. How Will Recurrence Be Prevented? For the next 30 days, the RCD, ED, or designee will perform routine cart and documentation audits to ensure medications are being administered and documented in a timely fashion. Moving forward, the RCD, ED, or designee will conduction regular, random audits of carts and documentation to ensure medications are being administered and documented in a timely fashion.
22VAC40-73-970-E
Based on the record review and staff interview the facility failed to ensure a record of the required fire and emergency evacuation drills shall be kept in the facility for two years. Such record shall include: the date and time of the drill.
Evidence
  1. The facility’s record of the fire drills completed on the following dates did not include the time of the drill: 09/30/25, 10/09/25, 11/21/25, 12/24/25.
  2. Staff #4 acknowledged the fire drill records did not include the times fire drills were completed on 09/30/25, 10/09/25, 11/21/25, and 12/24/25.
Plan of correction
What Has Been Done to Correct? The Maintenance Director has been educated on regulation as well as policy to ensure fire drills are conducted on all shifts with proper documentation. How Will Recurrence Be Prevented? ED and or Designee will ensure proper documentation will be placed on fire drill inspections to include time and date of fire drill.
22VAC40-73-410-A
Based on the record review the facility failed to ensure upon admission, the assisted living facility shall provide an orientation for new residents and their legal guardian including emergency response procedures, mealtimes, and use of the call system.
Evidence
  1. The record for resident #1, admission date 02/27/25, did not contain documentation the facility provided an orientation to the resident and/ or their legal guardian upon admission. The orientation in the record was dated as completed on 03/27/25.
Plan of correction
What Has Been Done to Correct? Auditing to be conducted on present resident files to ensure orientations are completed within standards. How Will Recurrence Be Prevented? Policy and regulations reviewed by ED, BOM, and RCD. ED, BOM, or designee to audit new incoming residents to ensure orientation is signed at the date of physical move into the community.
September 9, 2024Complaint survey3 violations
Inspection dates
09/09/2024, 09/26/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD 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: An unannounced complaint inspection took place on 9/09/24 from 8:37 am to 1:37 pm and 9/26/24 from 10:07 am to 10:43 am. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 9/06/2024 regarding allegations in the area(s) of: Personnel and Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 77 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 4 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 5 Observations by licensing inspector: Review of the medication carts was completed. 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: Resident Care and Related Services A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-70-A
Based on the record review and staff interview the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident.
Evidence
  1. The record for resident #1 contains a progress note dated 9/02/24 that states “resident was in room closet stumped over. Resident pushed the emergency call bell. Resident was unresponsive when the paramedics showed up.” During an interview with staff #5, staff #5 reported staff #5 responded to resident’s#1 emergency call bell on 9/02/24 and observed the resident to be unresponsive. Staff #5 stated 911 was called and the paramedics transported the resident to the hospital emergency room.
  2. Resident’s #1 hospital notes stated upon arrival to the emergency room, the resident “is unresponsive with sonorous respirations and hypertensive.” Resident’s #1 hospital notes document the resident date of death as 9/02/24 to include a final diagnosis of “intracranial hemorrhage.” 3.The facility did not notify the regional licensing office within 24 hours of the resident’s need for emergency services, transport to the emergency, and the resident’s death that occurred on 9/02/24.
  3. The facility’s incident reports policy dated 5/12/22 includes the following to be major incidents that have negatively affected or that threaten the life, health, safety, or welfare of any resident that must be reported as required by the standard: “the death of a resident when the death is unanticipated” “incidents that require the assistance of an outside agency such as police, fire, rescue, or emergency community service board contact.”
  4. Staff #8 confirmed, resident’s #1 need for emergency services outside of the facility and the resident’s death was not reported to the regional licensing office within 24 hours of the incident.
Plan of correction
What Has Been Done to Correct? ED and RCD have reviewed Regulation 22VAC40-73-70-A as well as the policy for incident reporting. How Will Recurrence Be Prevented? ED or Designee will notify the regional licensing office within 24 hours of any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident. Person Responsible: Executive Director or Designee
22VAC40-73-680-E
Based on the record review the facility failed to ensure medical procedures or treatment ordered by a physician or other prescribed shall be provided according to his instructions and documents. The documentation shall be maintained in the resident’s record.
Evidence
  1. The record for resident #1 contains a physician order dated 4/24/24 “check PT/INR weekly.” The resident’s record did not contain lab results and/or documentation of the resident’s INR levels being checked weekly during the following timeframes: 6/17/24 through 6/27/24, 6/27/24 through 7/08/24, 7/08/24 through 7/26/2024.
Plan of correction
What Has Been Done to Correct? ED, RCD, and ARCD have reviewed the company policy to ensure best practices are followed. How Will Recurrence Be Prevented? RCD to meet with lab to ensure that if phlebotomist is unable to address blood draw the technician notates incompletion on the rec form. RCD or Designee to follow labs to be drawn and schedule visits in event of noncompliance. Person Responsible: RCD or Designee
22VAC40-73-640-A
Based on the record review and staff interview the facility failed to implement a written plan for medication management to include a plan for proper disposal of medication.
Evidence
  1. The facility’s medication management plan dated 6/10/21 includes the following: “all discontinued medications will be returned to the pharmacy or destroyed within 72 hours of discontinuance.”
  2. The record for resident #1 contains a physician communication form, completed by staff #1 and dated 8/29/24 that includes the following: “resident had coumadin orders changed on 8/21 to 2.5mg 1/2 tab 7 days a week. Previously, order was 2.5mg 1 ½ pills 5 days a week and 1 pill on Sundays and Wednesdays. It seems a med error has been made due to previously ordered med card still being in cart and pills being popped.”
  3. The record for resident contains the following physician orders: Physician order dated 8/12/24, “Coumadin 2.5mg pills, “1 ½ pills (3.75mg) 5 days a week and 1 pill (2.5mg) on Sundays & Wednesdays, continue weekly INR.” Physician order dated 8/21/24, “out of range INR (3.46); please take 2.5mg ½ pills (1.25mg) 7 days a week.
  4. Resident’s #1 Medication Administration record documents the resident’s coumadin medication for physician order dated 8/12/24 was discontinued on 8/21/24.
  5. During an interview with staff #1, and staff #5 both staff confirmed, resident’s #1 coumadin medication (3.75mg) that discontinued on 8/21/24 was not removed from the facility’s medication cart until 8/29/24.
Plan of correction
What Has Been Done to Correct? Medication Carts will be Audited for compliance. Any items found not compliant will be address and corrected at that time. How Will Recurrence Be Prevented? RCD or Designee will conduct weekly audits on each medication cart to assure expired or discontinued medications have been appropriately removed from the cart. Person Responsible: Resident Care Director, Executive Director, or Designee
April 16, 2024Inspection10 violations
Inspection dates
04/16/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE
Technical assistance
Personal Data
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: An unannounced renewal inspection took place on 04/16/2024 at 08:38 am until 05:15 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: 84 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 5 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: Additional Comments/Discussion: Breakfast and an activity were observed. A medication pass observation was completed for four residents. The following was reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, medication carts, fire inspection report, health inspection report, and a staffing schedule. Water temperature was measured, and the call bell system was monitored. 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov.
Violations
22VAC40-73-450-C
Based on the onsite record review, it was determined that the facility did not ensure that the Comprehensive Individualized Service Plan shall be completed within 30 days after admission; and include a description of identified needs and date identified based upon the UAI, admission physical examination, and other sources.
Evidence
  1. The record for resident #1, admission date 12/11/23, contains an ISP completed on 01/31/24, which is more than 30 days from admission.
  2. The record for resident #8, admission date 02/05/24, contains an ISP completed on 03/27/24, which is more than 30 days from admission.
  3. Resident’s #6 physician order, dietary oversite dated 09/27/23, and dietary oversite dated 12/08/23 documents a dietary need of, “No Added Salt, cut foods prior to serving”. The resident’s ISP dated 02/01/24 did not include the dietary needs.
Plan of correction
What Has Been Done to Correct? Comprehensive Individualized Service Plan dates reviewed to ensure completion. How Will Recurrence Be Prevented? RCD or Designee will complete Comprehensive Individualized Service Plans prior to or on the 30th day. ED to review and audit resident files to ensure Comprehensive Individualized Service Plans are completed prior to or on the 30th day after admission. Person Responsible: RCD, ED, or Designee
22VAC40-73-325-B
Based on the onsite record review, it was determined that the facility did not ensure the Fall Risk Rating was reviewed and updated after a fall.
Evidence
  1. The progress notes in the record for resident #1 documented falls that occurred on 12/15/23, 12/16/23, 12/18/23, 1/1/24, 1/8/24, 1/20/24, 1/25/24. There was no evidence of fall risk rating being completed after experiencing a fall.
  2. The progress notes in the record for resident #2 documented falls that occurred on 3/9/24 and 3/15/24. There was no evidence of fall risk rating being completed after experiencing a fall.
  3. The progress notes in the record for resident #4 documented falls that occurred on 11/3/23, 11/5/23, 11/26/23, 12/3/23. There was no evidence of fall risk rating being completed after experiencing a fall.
  4. The progress notes in the record for resident #5 documented falls that occurred on 11/8/23 and 12/31/23. There was no evidence of fall risk rating being completed after experiencing a fall.
  5. The progress notes in the record for resident #6 documented falls that occurred on 11/2/23, 11/18/23. There was no evidence of fall risk rating being completed after experiencing a fall.
Plan of correction
What Has Been Done to Correct? Resident files to be audited for Fall Risk Ratings and ensure Fall Risk Rating is accurate and up to date. How Will Recurrence Be Prevented? Fall Risk Ratings will be completed following each fall and placed in resident’s physical chart. Person Responsible: RCD, ARCD, or Designee
22VAC40-73-350-B
Based on the onsite record review, it was determined that the facility did not ensure that prior to admission, whether a potential resident is a registered sex offender and document in the resident's record that this was ascertained and the date the information was obtained.
Evidence
  1. The record for resident #1 did not include a Sex Offender registry check prior to admission.
  2. The record for resident #2 did not include a Sex Offender registry check prior to admission.
Plan of correction
What Has Been Done to Correct? Resident files to be audited for Registered Sex Offender form. How Will Recurrence Be Prevented? ED, SD, BOM, or Designee will audit new resident files to ensure proper documentation for Registered Sex Offender is reviewed prior to admission. Person Responsible: ED, SD, BOM, or Designee
22VAC40-73-680-D
Based on the onsite record review, it was determined that the facility did not ensure medications shall be administered in accordance with the physician's or other prescriber’s instructions.
Evidence
  1. Resident’s #7 physician order dated 12/05/23, and the medication administration record for April 2024 includes the following: “Vitamin B1 50 mg, take 1 tablet by mouth every day.” During the medication pass observation, staff # 4 administered a Vitamin B1 100mg tablet to resident #7, however this is not the prescribed dosage according to the resident’s physician order.
  2. Resident’s #7 physician order dated 03/23/23, and the medication administration record for April 2024 includes the following: “Vitamin D3 1000IU, take 1 tablet daily.” During the medication pass observation, staff # 4 administered a Vitamin D3 5000IU to resident #7, however this is not the prescribed dosage according to the resident’s physician order.
Plan of correction
What Has Been Done to Correct? Medication dosage has been corrected. How Will Recurrence Be Prevented? RCD or designee to audit resident med cart for non-pharmacy OTC to ensure correct dosage. RCD or ED to provide education to families on pharmacy dispensing medication due to safety. Person Responsible: RCD, ED, or Designee
22VAC40-73-940-A
Based on a review of documentation and interview, it was determined that the facility did not ensure that an annual inspection is conducted by the appropriate fire official to comply with the Virginia Statewide Fire Prevention Code (13VAC5-51).
Evidence
  1. The most recent fire inspection completed at the facility was dated 3/10/23.
  2. Staff #6 confirmed that the annual fire inspection had not been completed.
Plan of correction
What Has Been Done to Correct? Fire Inspector called while Licensing Inspector onsite to schedule inspection. How Will Recurrence Be Prevented? ED to audit State binder and ensure all scheduled inspections are completed or scheduled prior to expiration date. Person Responsible: ED, MD, or Designee
22VAC40-73-450-E
Based on the onsite record review, it was determined that the facility did not ensure the Individualized Service Plan be signed and dated by the licensee, administrator, designee, and by the resident or his legal representative.
Evidence
  1. Resident’s #6 ISP dated 02/01/24 was not signed and dated by the resident or the legal representative.
  2. Resident’s #7 ISP dated 12/05/23 was not signed and dated by the resident or the legal guardian.
  3. Resident’s #8 ISP was not signed by the resident or the legal guardian.
Plan of correction
What Has Been Done to Correct? Individualized Service Plans to be audited for signatures. How Will Recurrence Be Prevented? RCD or Designee will complete Individualized Service Plans and review Individualized Service Plan with resident and or resident’s legal representative. ED to review Individualized Service Plans have been reviewed and are signed prior to signature of ED. Person Responsible: RCD, ED, or Designee
22VAC40-73-450-F
Based on the record review the facility failed to ensure individualized service plans (ISP) shall be reviewed and updated at least once every 12 months and as needed for a significant change in the resident’s condition.
Evidence
  1. Resident’s #1 physician order dated 02/21/24, includes “change diet to puree as tolerated.” Resident’s #1 physician order dated 2/22/24 includes “Aspiration precaution due to patient choking episode on 1/23/24”. The resident’s ISP dated 01/31/24 was not updated to reflect the change in dietary need, and the aspiration precaution.
Plan of correction
What Has Been Done to Correct? Comprehensive Individualized Service Plan change in condition reviewed to ensure completion. How Will Recurrence Be Prevented? RCD or Designee will complete Individualized Service Plans updates with each significant change in condition. ED to review and resident files to ensure Individualized Service Plans are updated with change of condition. Person Responsible: RCD, ED, or Designee
22VAC40-73-410-A
Based on the onsite record review, it was determined that the facility did not ensure that upon admission, the assisted living facility provide an orientation for new residents and their legal representatives.
Evidence
  1. The record for resident #1 did not contain an orientation for new residents to include emergency response procedures, mealtimes, and use of the call system.
Plan of correction
What Has Been Done to Correct? Resident files to be audited for Orientation. How Will Recurrence Be Prevented? ED or Designee to complete new resident Orientation and will audit resident files to ensure proper documentation and day of admission. Person Responsible: ED or Designee
22VAC40-73-660-A
Based on observation, it was determined that the facility did not ensure that medications shall be stored in a manner consistent with current standards of practice and the storage area shall be locked and the individual responsible for medication administration shall keep the keys to the storage area on his person.
Evidence
  1. During a tour of the facility, the Licensing Inspectors observed that the medication cart located on the second floor was unlocked and unstaffed.
  2. Staff #6 acknowledged that the medication cart on the second floor was unlocked and unstaffed.
Plan of correction
What Has Been Done to Correct? RCD and ED provided education to Medication Aide on regulation. How Will Recurrence Be Prevented? RCD, ED, or Designee will complete a Medication Management Plan review with all Medication Aides on staff. All Department Heads to periodically round community to ensure medication carts are locked and secure. Person Responsible: RCD, ED, or Designee
22VAC40-73-320-A
Based on the onsite record review, it was determined that the facility did not ensure the resident had within the 30 days preceding admission, a physical examination by an independent physician. The report of such examination shall be on file at the assisted living facility and shall contain the following: the date of the physical examination; results of a risk assessment documenting the absence of tuberculosis; a statement that the individual does not have any of the conditions or care needs prohibited by 22VAC40-73-310-H.
Evidence
  1. The record for resident #3, admission date, 06/29/23, contains a physical examination that does not include the date of the physical examination.
  2. The record for resident #6, admission date 6/29/23, contains a risk assessment for TB dated 5/25/23.
  3. Resident’s #6 physical examination includes a response of “yes, requires continuous licensed nursing care.”
Plan of correction
What Has Been Done to Correct? Residents Physical Examination forms have been corrected to reflect appropriate needs of residents and free of Tuberculosis. How Will Recurrence Be Prevented? ED, RCD, or Designee will audit resident files to ensure proper documentation and ability to meet care needs of resident prior to admission. Person Responsible: ED, RCD, or Designee
December 14, 2023Complaint survey2 violations
Inspection dates
12/14/2023
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-80 COMPLAINT INVESTIGATION
Technical assistance
Personal and Social Information
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: An unannounced complaint inspection took place on 12/14/2023 from 10:21 am to 2:38 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 11/27/23 and 11/28/23 regarding allegations in the area(s) of: Resident Care and Related Services, Building and Grounds, and The Safe Secure Environment Number of residents present at the facility at the beginning of the inspection: 80 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 3 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: An observation and review of the safe secure unit, round logs, staffing schedule, and the medication cart was completed. 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: Resident Care and Related Services A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-450-D
Based on the record review the facility failed to ensure when hospice care is provided to a resident, the assisted living facility and the hospice organization shall communicate and establish an agreed upon coordinated plan of care for the resident. The services provided by each shall be included on the individualized service plan (ISP).
Evidence
  1. The record for resident #2 contains the following: a hospice aide order dated 05/02/23-07/30/23; a hospice plan of care to include a start date of 05/02/23; hospice visit notes dated during the timeframe of 05/03/23 through 10/28/23. Resident’s #2 ISP dated 06/25/23 does not include the services provided by the hospice organization.
Plan of correction
What Has Been Done to Correct? Resident Files will be Audited for compliance. Any file found not compliant will address and correct at that time. How Will Recurrence Be Prevented? Resident Care Director/ Assistant Resident Care Director/ designee to appropriately update the ISP to include delineation of care tasks that the hospice provider may be providing. Executive Director will complete regular, random audits of those residents receiving hospice services to assure compliance. Person Responsible: Resident Care Director, Executive Director, or Designee
22VAC40-73-640-A
Based on the record review the facility failed to implement a written plan for medication management to include methods to prevent the use of outdated, damaged, or contaminated medications.
Evidence
  1. During the medication cart observation with staff #1 the following expired medication was observed on the medication cart located in the safe, secure unit: Senna Plus tablets, expired 09/07/23 for resident #1.
Plan of correction
What Has Been Done to Correct? Medication Carts will be Audited for compliance. Any items found not compliant will be address and corrected at that time. How Will Recurrence Be Prevented? RCD or Designee will conduct weekly audits on each medication cart to assure expired medications have been appropriately removed from the cart. Training will be provided to new and current RMAs will be trained on appropriately monitoring expiration dates. Training will be completed by 1/31/2024 Person Responsible: Resident Care Director, Executive Director, or Designee
September 21, 2023Inspection0 violations
Inspection dates
09/21/2023
Areas reviewed
22VAC40-73 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 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced monitoring inspection took place on 09/21/2023 from 8:50 am to 11:45 am The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A Self report was received by VDSS Division of Licensing on 08/27/2023 regarding allegations in the areas of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 84 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 6 Observations by licensing inspector: An observation of the safe secure unit was completed. Additional Comments/Discussion: None The evidence gathered during the investigation did not support the allegation 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 Donesia Peoples, Licensing Inspector at 757-822-9957 or by email at donesia.peoples@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
August 24, 2023Complaint survey0 violations
Inspection dates
08/24/2023
Areas reviewed
22VAC40-73 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 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 08/24/2023 from 8:13 am to 9:30 am. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 08/21/2023 regarding allegations in the areas of: Personnel and Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 79 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 3 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 3 Observations by licensing inspector: A medication pass observation was completed and review of the facility’s medication carts were completed. Additional Comments/Discussion: None The evidence gathered during the investigation did not support the allegation 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
July 20, 2023Complaint survey4 violations
Inspection dates
07/20/2023
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-80 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: An unannounced complaint inspection took place on 07/20/23 from 8:40 am to 3:00 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 07/06/2023 and 07/11/2023 regarding allegations in the area(s) of: Resident Care and Related Services and The Safe Secure Unit Number of residents present at the facility at the beginning of the inspection: 81 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 5 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: An observation of the safe secure unit, and assisted living unit was completed, and a review of the medication cart. Lunch and an activity were observed. 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: Resident Care and Related Services A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-640-A
Based on the record review the facility failed to implement a written plan for medication management to include methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes.
Evidence
  1. The review of the facility’s “Shift Change Controlled Substance Count Check” located in the assisted living unit did not contain documentation of “the off going and on-coming med aides” both signing the controlled substance count form on the following dates and times: 7/01/23 @ 7:00am, 3:00pm 7/03/23@ 3:00pm, 11:00pm 7/19/23 @ 7:00am, 3:00pm, 11:00pm 7/19/23 @ 3:00pm
Plan of correction
Registered Medication Aides/ Nurses have been in serviced on proper management of controlled substances to include completion of shift-to-shift count.. Over the next 60 days, the RCD/designee will complete review of Controlled Substances Shift to Shift log for signatures. The ED/designer will complete weekly reviews for 30 days to assure continued compliance. Resident Care Director/ Designee
22VAC40-73-450-C
Based on the record review and staff interview, the facility failed to ensure on or within seven days prior to the day of admission, a preliminary plan of care shall be developed to address the basic needs of the resident that adequately protects the health, safety and welfare. A preliminary plan of care (PPC) is not necessary if a comprehensive individualized service plan (ISP) is developed, in conformance with this section, on the day of admission.
Evidence
  1. The record for resident #2, admission date of 06/08/23, did not contain a PPC or an ISP completed on or within seven days prior to the resident’s admission.
  2. Staff # 2, acknowledged the record for resident #2 did not contain a PPC or an ISP and evidence of completion of a PPC or an ISP was not provided.
Plan of correction
Current resident charts will be audited for Preliminary Plan of Care Preliminary Plan of Care will be developed within 7 days prior to or on day of admission and given to Executive Director/ Designee for review. Over the next 60 days, the ED/designee will complete an audit of new admissions to assure Preliminary Plan of Care is signed and available in chart. Executive Director/ Resident Care Director/ Designee
22VAC40-73-680-D
Based on the record review the facility failed to ensure medications shall be administered in accordance with the physician’s or other prescriber’s instructions.
Evidence
  1. The record for resident #1 contains a physician order dated 03/06/2023 for Humalog: “check FSBS (Finger stick blood sugar) three times a day and inject SSI:151-200 =2U, 201-250=4U, 251-300=6U, 301-350=8U, 351-400=10U The resident’s medication administration record (MAR) documents on the following dates and times the resident was not administered Humalog according to the physician order: 07/10/23, BS (Blood Sugar) =367, given 8 units; 07/11/23, BS =195, given 5 units; No record of FSBS checks on 07/12/23 and 07/14/23 @ 8:30pm.
Plan of correction
Training has been completed with current medication staff on competing medication pass per MD orders. Over the next 60 days, the RCD/designee will complete a regular review of current resident MARs to assure meds are being administered per MD order. Concerns will e addressed with med staff. The ED/designee will complete a random review of current resident MARs, for the next 30 days, to assure physician orders are being followed in accordance with regulatory standards. Resident Care Director/ Assistant Resident Care Director/ Executive Director/ Designee
22VAC40-73-440-A
Based on the record review and staff interview the facility failed to ensure the Uniform Assessment Instrument (UAI) shall be completed prior to admission. 1. The record for resident #2, admission date of 06/08/23, did not contain a UAI. 2. Staff # 4, acknowledged the record for resident #2 did not contain a UAI and
Evidence
  1. of completion of a UAI was not provided.
Plan of correction
Audit will be completed of current residents for UAI completion. UAIs will be completed prior to admission and reviewed by ED/designee. For the next 60 days, the ED/designer will complete an audit of new admissions to assure UAI is completed prior to admission. Resident Care Director/ Designee
June 13, 2023Inspection1 violation
Inspection dates
06/13/2023
Areas reviewed
22VAC40-73 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 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced monitoring inspection took place on 06/13/2023 at 11:35 am to 2:30 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 05/03/2023 and 05/05/2023 regarding allegations in the area(s) of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 79 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 2 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: An observation of the safe, secure unit was completed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self- report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact (Donesia Peoples), Licensing Inspector at (757) 353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-460-A
Based on an interview and record review the facility failed to assume general responsibility for the health, safety, and well-being of the residents.
Evidence
  1. The record for resident #1 contains the following documentation: a progress noted dated 05/03/23 documents “resident #1 pushed other resident and other resident fell onto the floor;” an incident report dated 05/12/2023 documents “staff observed resident #1 pushing resident #3 against the glass window with resident #1 hands at resident’s #2 clavicle;” a progress note dated 05/18/23 documents “staff witnessed resident #1 attempting to pull another resident” out of the other resident’s bed, “resident #1 then proceeded to go into other residents’ room;” an incident report dated 06/01/23 documents “resident #1 was exiting resident’s #2 room. Resident #2 reported resident #1 beat her up and choked her. RMA noted bleeding from resident’s #2 left hand as well as swelling to resident’s face near eye. EMS arrived and transported resident #2 to the hospital.
  2. The record for resident #3 contains a progress noted dated 05/05/23 that documents “resident #1 became aggressive placing hand on resident’s #3 throat and pushing resident # 3 towards wall.”
  3. During an interview with resident # 2 on 06/13/23, resident #2 confirmed being hit in the eye and face by resident #1.
Plan of correction
Resident Care Director/ Assistant Resident Care Director/ or designee will review EHR notes weekly for any updates or changes not communicated in the 24-hour nursing book. RCD or designee will communicate changes in behaviors to Executive Director in a timely manner. RMAs and RCAs will be in serviced on documentation in EHR as well as aggressive behavior form. RMAs and RCAs will be in serviced on Aggressive behaviors and situation awareness.
April 18, 2023Inspection16 violations
Inspection dates
04/18/2023 & 04/19/2023
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE
Technical assistance
Weekly Breakfast Menu to be Kept Current in Safe. Secure Unit Review of standards for Mixed Population
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: An announced renewal inspection took place on 04/18/2023 from 8:10 am to 5:25 pm and 04/19/2023 from 8:08 am to 2:25 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: 75 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 6 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 6 Observations by licensing inspector: Breakfast, Lunch and an activity were observed. A medication pass observation was completed for four residents. The following was reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, medication carts, fire inspection report, health inspection report, and a staffing schedule. Water temperature was measured, and the call bell system was monitored. 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-450-A
Based on the record review the facility failed to ensure on or within 7 days prior to the day of admission, a preliminary plan of care shall be developed for the resident. The preliminary plan of care shall be signed and dated by the licensee, administrator, or his designee, and by the resident or his legal guardian.
Evidence
  1. The record for resident #2, admission date of 11/01/22, contains a preliminary plan of care dated 11/13/22. The preliminary plan of care is not dated as completed on or within 7 days prior to the day of the resident’s admission.
  2. Staff # 6 confirmed the admission date for resident #2 as 11/01/22.
  3. Resident’s #6 preliminary plan of care dated 02/02/23, is not signed and dated by the resident or the legal guardian. 4.Resident’s #8 preliminary plan of care is not dated and is not signed and dated by the licensee, administrator/designee, resident or the legal guardian.
  4. Resident’s #9 preliminary plan of care dated 04/14/23 is not signed and dated by the resident or the legal guardian.
Plan of correction
Resident Files will be Audited for compliance. Resident Care Director/ Assistant Resident Care Director and Resident Care Coordinator to complete ISP training. Moving forward, the Resident Care Director/ Assistant Resident Care Director/ designee to conduct and complete preliminary ISP no later than day of admission. Preliminary ISP will be provided to ISP for review and signature. Resident Care Director/ Assistant Resident Care Director/ Executive Director/ Designee
22VAC40-73-120-A
Based on the record review the facility failed to ensure the training required in subsections B and C of this section shall occur within the first seven working days of employment.
Evidence
  1. The record for staff #4, hire date 11/14/22, did not contain documentation of completion of staff orientation.
Plan of correction
Employee Files will be Audited for compliance. Any file found not compliant will address staff training and provide at that time. New hires will not begin working on the floor until orientation training is received by the Business Office Manager and approved by ED/designee. Business Office Manager will communicate with Executive Director in event new hire orientation training is not received in a timely manner. Business Office Manager/ Executive Director/ Designee
22VAC40-73-640-A
Based on observation the facility failed to implement a written plan for medication management to include methods to prevent the use of outdated medications, and methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes.
Evidence
  1. During an observation with staff # 3 the following expired medications were observed on the medication cart: Amlodipine/Benazepril Capsules use by 04/11/23 for resident # 11; Coricidin Tablets expired 02/22/23 and Banophen Tablets expired 03/08/23 for resident # 12.
  2. Staff # 2 confirmed resident #11 was administered on 04/19/23 the Amlodipine/Benazepril Capsules contained in the bottle labeled with a used by date of 04/11/23. The resident’s MAR indicates the resident was administered the Amlodipine medication the dates of 04/11/23-04/19/23.
  3. The review of the facility’s “Shift Change Controlled Substance Count Check” located in the safe, secure unit did not contain documentation of “the off going and on-coming med aides” both signing the controlled substance count form on the following dates and times: 04/05/23 @ 7:00am and 3:00pm. 04/06/23 @ 3:00pm 04/07/23 @ 7:00am 04/08/23 @ 3:00pm 04/09/23 @ 3:00pm and 11:00pm 04/10/23 @ 3:00pm 04/11/23 @ 7:00am and 3:00pm 04/12/23 @ 3:00pm 04/13/23 @ 7:00am and 3:00pm 04/17/23 @ 3:00pm 04/18/23 @ 7:00am
  4. The review of the facility’s “Shift Change Controlled Substance Count Check” located in the assisted living care unit did not contain documentation of “the off going and on-coming med aides” both signing the controlled substance count form on the following dates and times: 04/03/23 @ 3:00pm and 11:00pm 04/14/23 @ 7:00am 04/16/23 @ 7:00am and 3:00pm 04/16/23 @ 3:00pm 04/17/23 @ 3:00pm 04/18/23 @ 7:00am
Plan of correction
Narcotic Count Reconciliation will be Audited for compliance. Any items found not compliant will address and correct at that time. For the next 90 days, from 4/27/2023, the RCD or Designee will complete controlled substance counts with staff administering medications at a minimum of 3 times a week (One on each shift). The RCD or designee will then complete regular, random controlled substance counts with each shift at least monthly and as needed. RCD or Designee will conduct weekly audits on each medication cart to assure expired medications have been appropriately removed from the cart. The RCD/designee will complete medication pass audits with new medication staff prior to working alone on medication cart, periodically and as needed to meet regulatory standards. ED will conduct regular, random medication pass audits, to include controlled substance counts, at least semi-annually on current staff who administer medications to include RCD and RCC. New and current medication staff will be in-serviced on policy for signing on and off on Narcotic Count Reconciliation sheet. Form will be audited daily for signatures by Resident Care Director or Designee. Resident Care Director/ Assistant Resident Care Director/ Executive Director/ Designee
22VAC40-73-720-A
Based on the record review the facility failed to ensure Do Not Resuscitate (DNR) Orders are included in the ISP.
Evidence
  1. The record for resident #7 contains a DNR dated 02/20/23. The resident’s ISP dated 02/05/23 documents the resident as a Full Code. The ISP does not include documentation of the DNR order.
Plan of correction
Resident Files will be Audited for compliance. Any file found not compliant will address and correct at that time. Resident Care Director/ Assistant Resident Care Director and Resident Care Coordinator to complete ISP training Resident Care Director/ Assistant Resident Care Director/ designee to conduct and update to reflect appropriate changes as they occur. ED will conduct regular, random audits of resident files to assure Code Status is appropriately documented Resident Care Director/ Assistant Resident Care Director/ Executive Director/ Designee
22VAC40-73-670-1
Based on the staff record review the facility failed to ensure each person who administers medication shall be licensed by the Commonwealth of Virginia to administer medications or be registered with the Virginia Board of Nursing as a medication aide.
Evidence
  1. The record for staff #1 did not contain a license issued by the Commonwealth of Virginia to administer medications or documentation to include evidence of registration with the Virginia Board of Nursing as a medication aide.
  2. The record for staff #1 contained a North Carolina Division of Health Service Regulation verification of passing a medication aide exam, dated 05/29/22.
  3. During the medication pass observation staff #1 was observed to administer medications to residents #3 and #4.
Plan of correction
Employee Files will be Audited for compliance. Any file found not compliant will address staff training and provide at that time. New hires will not start with community (to include initial onboarding) until appropriate certifications and state license verification for position are received by Business Office Manager and approved by ED/designee. Business Office Manager will communicate with Executive Director in event criminal history record report is not received in a timely manner. Additional Copy of License Verifications to be retained in State Licensing Binder maintained in Executive Directors Office. Business Office Manager/ Executive Director/ Designee
22VAC40-73-320-B
Based on the record review the facility failed to ensure a risk assessment for (TB) shall be completed annually on each resident as
Evidence
  1. d by completion of the current screening form published by the Virginia Department of Health or form consistent with it. Evidence:
  2. The record for resident #2 contains a risk assessment for TB dated 04/16/21 and 01/28/23. The record does not contain documentation of a risk assessment for TB completed annually after 04/16/21.
  3. The record for resident #3 contains a risk assessment for TB dated 11/16/21 and 01/28/23. The record does not contain documentation of a risk assessment for TB completed annually after 11/16/21.
  4. The record for resident #5 contains a risk assessment for TB dated 09/17/21 and 01/28/23. The record does not contain documentation of a risk assessment for TB completed annually after 09/17/21.
Plan of correction
Resident Files will be Audited for compliance. Any file found not compliant will address and correct at that time. Resident Care Director/ Assistant Resident Care Director/ designee to conduct annual TB risk assessments annually, on a set month, and the Executive Director/designee will audit to verify this has been completed. Resident Care Director/ Assistant Resident Care Director/ Executive Director/ Designee
22VAC40-73-450-C
Based on the record review the facility failed to ensure the comprehensive individualized service plan (ISP) shall be completed within 30 days after admission and shall include a description of identified needs and dated based upon the UAI.
Evidence
  1. The record for resident #1, admission date 10/04/22, contains an ISP dated 02/05/23. The ISP is dated as completed more than 30 days after the resident’s admission date.
  2. Resident’s #1 UAI dated 10/04/22 documents mechanical and human help needs for dressing, transferring, and eating/feeding. The resident’s ISP dated 02/05/23 does not include mechanical help needs for dressing and transferring. The ISP does not include mechanical and human help needs for eating/feeding.
  3. The record for resident #2, admission date 11/01/22, contains an ISP dated 02/05/23. The ISP is dated as completed more than 30 days after the resident’s admission date.
  4. Resident’s #3 UAI dated 12/01/22 documents mechanical and human help needs for dressing, and human help needs for walking. The resident’s ISP dated 12/01/22 does not include mechanical help needs for dressing and does not include the human help needs for walking.
  5. The record for resident #6, admission date 02/02/23, contains an ISP dated 04/01/23. The ISP is dated as completed more than 30 days after the resident’s admission date.
  6. The record for resident #7, admission date 12/21/22, contains an ISP dated 02/05/23. The ISP is dated as completed more than 30 days after the resident’s admission date.
Plan of correction
Resident Files will be Audited for compliance. Resident Care Director/ Assistant Resident Care Director and Resident Care Coordinator to complete ISP training Moving forward, Resident Care Director/ Assistant Resident Care Director/ designee to conduct and complete no later than 30 days after admission a comprehensive ISP with signature provide from resident or Power of Attorney. Comprehensive ISP will be provided to Executive Director for signature. Resident Care Director/ Assistant Resident Care Director/ Executive Director/ Designee
22VAC40-73-680-E
Based on the record review the facility failed to ensure medical procedures or treatments ordered by a physician or other prescriber shall be provided according to his instructions and documented. The documentation shall be maintained in the resident’s record.
Evidence
  1. The record for resident #2 contains a physician order dated 02/27/23 documenting instructions to “place c-pap machine on resident at bedtime. Remove in AM and clean in AM.” The resident’s record does not contain documentation of placement or removal of the c-pap machine. The record does not contain a physician order to discontinue placement and removal of the c-pap machine.
Plan of correction
Resident Files will be Audited for compliance. Any file found not compliant will address and correct at that time. Resident orders will be filed in resident chart chronologically by date, timely once appropriately executed. Resident Care Director/ Assistant Resident Care Director/ Executive Director/ Designee
22VAC40-73-450-E
Based on the record review the facility failed to ensure the ISP shall be signed and dated by the resident or his legal guardian.
Evidence
  1. Resident’s #5 ISP dated 11/08/22 was not signed and dated by the resident or the legal guardian.
  2. Resident’s #6 ISP dated 04/01/23 was not signed by the resident or the legal guardian.
  3. Resident’s #7 ISP dated 02/05/23 was not dated by the resident’s legal guardian.
  4. Resident #8’s ISP dated 12/13/22 was not signed by the resident or the legal guardian.
Plan of correction
Resident Files will be Audited for compliance. Any file found not compliant will address and correct at that time. Resident Care Director/ Assistant Resident Care Director/ designee to ensure ISP is reviewed with signature provide from resident or Power of Attorney once completed. Appropriate measures will be taken to secure signature in a timely manner to include email, general mail, etc. Attempts to obtain signature will be documented in resident file. ED will complete regular, random audits of resident files to assure signatures are being obtained. Resident Care Director/ Assistant Resident Care Director/ Executive Director/ Designee
22VAC40-73-450-D
Based on the record review the facility failed to ensure when hospice care is provided, the services provided by each shall be included on the ISP.
Evidence
  1. The record for resident #5 contains a physician note dated 01/03/2023 for the resident to be referred to hospice. The resident’s record contains a Hospice Plan of Care completed by the hospice care organization dated 01/05/2023.
  2. Resident’s #5 ISP is dated 11/08/22. The record does not contain an ISP documenting the services provided by the assisted living facility and the hospice care organization for the resident’s hospice care needs.
Plan of correction
Resident Files will be Audited for compliance. Any file found not compliant will address and correct at that time. Resident Care Director/ Assistant Resident Care Director and Resident Care Coordinator to complete ISP training Resident Care Director/ Assistant Resident Care Director/ designee to appropriately update the ISP to include delineation of care tasks that the hospice provider may be providing. Executive Director will complete regular, random audits of those residents receiving hospice services to assure compliance. Resident Care Director/ Assistant Resident Care Director/ Executive Director/ Designee
22VAC40-73-430-H-1
Based on the record review the facility failed to ensure at the time of discharge, the assisted living facility shall provide to the resident, and as appropriate, his legal representative and designated contact person a dated statement.
Evidence
  1. The record for resident #10, discharge date of 06/15/22, did not contain documentation of a dated discharge statement.
Plan of correction
Item was in Executive Directors Office at time of Inspection. Executive Director offsite at training. DSS Discharge Statement to be attached to discharged resident file in addition to nursing files and business office files moving forward. Additional Copy of DSS Discharge Statement to be retained in State Licensing Binder maintained in Executive Directors Office. Executive Director
22VAC40-73-660-A-1
Based on observation the facility failed to ensure a medication cabinet, container, or compartment shall be used for storage of medications when such medications are administered by the facility. The storage area shall be locked.
Evidence
  1. During observation with staff # 3 the following medication was observed on the window sill in the room of resident # 1: Azelastine HCI Nasal Spray.
  2. Resident #1’s UAI dated 11/28/22 documents the resident’s medication is to be administered /monitored by a lay person or professional nursing staff.
Plan of correction
Resident Rooms will be Audited for compliance. Any resident room found not compliant will address and correct at that time. Families will be notified of any items found in residents’ rooms that are non-compliant with regulation. Executive Director/ Designee will provide Education regarding the standard to Residents, Residents Families, and Staff. Executive Director/ Designee
22VAC40-90-40-B
Based on the onsite record review, the facility failed to ensure the criminal history record report was obtained on or prior to the 30th day of employment for each staff person.
Evidence
  1. The record for staff #8, hire date 07/11/22, contains a criminal history record report dated 04/18/23.
Plan of correction
Employee Files will be Audited for compliance. Any file found not compliant will address Criminal background check at that time. New hires will not start with community (to include initial onboarding) until criminal history record report is received by Business Office Manager and approved by ED/designee. Business Office Manager will communicate with Executive Director in event criminal history record report is not received in a timely manner. Business Office Manager/ Executive Director/ Designee
22VAC40-73-200-D
Based on the record review the facility failed to obtain a copy of the certificate issued or other documentation indicating that the person has met one of the requirements of subsection C of this section, which shall be part of the staff member’s record in accordance with 22VAC40-73-250.
Evidence
  1. The record for staff #4, hire date 11/14/22, did not contain a certificate or documentation indicating staff #4 has met one of the requirements for direct care staff.
  2. Staff #7 acknowledged staff #4 was hired as direct care staff with a personal care aide certification, however the certification was not in the staff record.
Plan of correction
Employee Files will be Audited for compliance. Any file found not compliant will address staff training and provide at that time. New hires will not start with community (to include initial onboarding) until all certifications for position are received by Business Office Manager and approved by ED/designee. Business Office Manager will communicate with Executive Director in event criminal history record report is not received in a timely manner. Business Office Manager/ Executive Director/ Designee
22VAC40-73-1110-B
Based on the record review the facility failed to ensure six months after placement of the resident in the safe, secure environment and annually thereafter, the licensee, administrator, or designee shall perform a review of the appropriateness of each resident’s continued residence in the special care unit.
Evidence
  1. The record for resident #3 contains an admission and approval for placement in the safe, secure unit dated 11/17/21. The resident’s record does not contain documentation of a six month and annual review of the appropriateness of the resident’s continued residence in the special care unit.
  2. The record for resident #4 contains an admission and approval for placement in the safe, secure unit dated 04/20/22. The resident’s record does not contain documentation of a six-month review of the appropriateness of the resident’s continued residence in the special care unit.
  3. The record for resident #5 contain an admission and orientation to the safe, secure unit dated 09/28/21. The resident’s record contains a review of appropriateness for the special care unit dated 01/31/23, which is dated more than six months and annually after the resident’s admission date.
Plan of correction
Resident Files will be Audited for compliance. Any file found not compliant will address and correct at that time. Resident Care Director/ Assistant Resident Care Director/ designee to conduct Review of Continued Appropriateness of Admission to SCU 6 months after and at least annually thereafter. ED will conduct regular, random audits to assure continued compliance. Resident Care Director/ Assistant Resident Care Director/ Executive Director/ Designee
22VAC40-73-680-G
Based on observation the facility failed to ensure over-the counter medication shall remain in the original container, labeled with the resident’s name, or in a pharmacy-issued container, until administered.
Evidence
  1. During observation with staff #3 the following over the counter medications were observed on the medication cart and did not contain a label of the resident’s name: Vitamin D-3 and Vitamin C.
Plan of correction
Medication Cart will be Audited for compliance. Any items found not compliant will address and correct at that time. The Executive Director will coordinate a Pharmacy Audit and Review to be conducted following unannounced visit. RCD or Designee will conduct weekly audits on each medication cart to ensure that medications are maintained in appropriately labeled medication container until administered to resident. Resident Care Director/ Assistant Resident Care Director/ Executive Director/ Designee
January 19, 2023Complaint survey1 violation
Inspection dates
01/19/2023
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-80 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: An unannounced complaint inspection took place on 01/19/23 from 8:30 am to 5:20 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self report was received by VDSS Division of Licensing on 01/06/2023 regarding allegations in the area(s) of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 73 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 5 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 4 Observations by licensing inspector: An observation of resident rooms, activities, and lunch was observed. The call bell system was monitored. 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: Resident Care and Related Services A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-450-C
Based on the onsite record review the facility failed to ensure the ISP (Individualized Service Plan) included a description of identified needs based upon the UAI (Uniform Assessment Instrument).
Evidence
  1. The record for resident #1 contains a UAI dated 07/05/22 which documents a mechanical and human help need in the area of stairclimbing. The UAI includes a mechanical need for transferring. The ISP dated 07/12/22 does not include documentation of supports to address the needs for stairclimbing and transferring.
  2. The record for resident #2 contains a UAI dated 02/10/22 which documents mechanical needs in the areas of dressing, toileting, and transferring. The ISP dated 02/10/22 does not include documentation of supports to address the mechanical support needs for dressing, toileting, and transferring.
  3. The record for resident # 3 contains a UAI dated 09/19/22 which documents mechanical needs in the areas of dressing, toileting, transferring, walking, and wheeling. The ISP dated 09/19/22 does not include documentation of supports to address the mechanical support needs in the areas of dressing, toileting, transferring, walking, and wheeling.
Plan of correction
Resident Care Director (RCD) and Executive Director (ED) have evaluated and corrected care plans to ensure the UAI and ISP match and address each residents needs appropriately. UAIs and ISPs will continue be completed for new and current residents by community staff that are UAI and ISP certified per regulatory standard. Once the ISP is completed, for each resident per regulatory standard, the ED/designee will review the UAI against the ISP to assure they match and appropriately address current needs of that resident.
January 19, 2023Inspection3 violations
Inspection dates
01/19/2023
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced monitoring inspection took place on 01/19/23 from 8:30 am to 5:20 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-report was received by VDSS Division of Licensing on 12/30/2023 regarding allegations in the area(s) of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 73 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 5 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 4 Observations by licensing inspector: An observation and review of all medication carts in the assisted living and safe secure unit was completed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-40-B
Based on the onsite staff record review, the facility failed to ensure the criminal history record report was obtained on or prior to the 30th day of employment for each staff person.
Evidence
  1. The record for staff # 4, date of hire 09/21/21, contains a criminal history record report dated 12/21/21.
Plan of correction
Current employee files will be audited to assure compliance of regulation by Business Office Manager. New hires will not start with community (to include initial onboarding) until criminal history record report is received by Business Office Manager and approved by ED/designee. Business Office Manager will communicate with Executive Director in event criminal history record report is not received in a timely manner.
22VAC40-73-640-A
Based on observation the facility failed to implement a written plan for medication management to include methods to prevent the use of outdated medications, methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes, methods to ensure the staff who are responsible for administering medications are adequately supervised, including periodic direct observation of medication administtration, and a plan for proper disposal of medication.
Evidence
  1. The record for resident #1 contains a controlled substance count sheet for the resident’s Oxycodone medication. The count sheet documents Oxycodone was administered to the resident daily from 12/18/22 through 12/29/22. However, the MAR documents Oxycodone was only administered to the resident on 12/29/2022 and the resident was out of the facility on 12/24/22 and 12/25/22. The Count sheet and MAR for Dec. 2022 are inconsistent with one another in documenting when Oxycodone was administered.
  2. During review of Resident’s #2 controlled substance count sheet for Morphine Syringes. The count sheet documented 30 available syringes. A count completed with staff #1, counted 28 available syringes on the medication cart. The count sheet was not accurate in documenting the number of syringes.
  3. During observation with Staff #1 the following expired medication was observed on the medication cart: Dextromethorphan SUS 30 mg expired 09/2022 for resident # 3.
  4. During an observation with staff # 2 a bag of prescription labeled and over the counter medications were located in an unlocked cabinet in the medication aide office/area. Staff # 1 and staff #2 stated the medications belonged to residents who were discharged from the facility. Staff # 1 and staff #2 were not able to provide information on the plan for proper disposal of these medications.
Plan of correction
Direct care staff administering medications have been re-in-serviced on organization’s Medication Management Policy to include completion of accurate controlled substance counts when assigned medication staff changes. ED, RCD, and RCC have reviewed the Standards for Licensed Assisted Living Facilities to be used as a reference to ensure regulatory compliance relating to medication management. The ED will continue to monitor progress. For the next 30 days, from 2/7/2023, the RCD or Designee will complete controlled substance counts with staff administering medications at a minimum of 3 times a week (One on each shift). The RCD or designee will then complete regular, random controlled substance counts with each shift at least monthly and as needed. RCD or Designee will conduct weekly audits on each medication cart to assure expired medications have been appropriately removed from the cart. RCD or Designee will complete medication pass audits with current staff administering medications within 30 days of 2/7/2023. Moving forward the RCD/designee will complete medication pass audits with new medication staff prior to working alone on medication cart, periodically and as needed to meet regulatory standards. ED will conduct regular, random medication pass audits, to include controlled substance counts, at least semi-annually on current staff who administer medications to include RCD and RCC. ED, RCD, RCC and new/current staff administering medications will review and document receipt of company policy regarding proper disposal of medication.
22VAC40-73-680-B
Based on observation the facility failed to ensure medications shall remain in the pharmacy issued container, with the prescription label or direction labeled attached, until administered to the resident.
Evidence
  1. During the medication cart observation with staff #1, one round unmarked white pill was located in a pill cup in the first drawer and four round unmarked white pills were located in the fourth drawer. There were a total of five pills that were not in a pharmacy issued container and were not labeled in the drawers on the medication cart.
Plan of correction
Direct care staff administering medications have been re-in-serviced on organization’s Medication Management Policy to include medication is to remain in an appropriately labeled container until medication is to be passed resident. Pharmacy Audit and review conducted following unannounced visit. Medications not meeting the regulation standard have been removed from the medication cart. The ED will coordinate a Pharmacy Audit and Review to be conducted following unannounced visit. (Completed 1/24/23) Staff member #4 passing medication during Licensing Inspector visit will complete 4-hour Medication Aide Refresher course within 30 days of 2/7/2023. RCD or Designee will conduct weekly audits on each medication cart to ensure that medications are maintained in appropriately labeled medication container until administered to resident.
April 12, 2022Inspection4 violations
Inspection dates
04/12/2022, 04/13/2022
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 PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
An unannounced mandated renewal inspection was conducted by two Licensing Inspectors on 4/12/22 and 4/13/22. A tour of the facility was conducted and activities were observed. Medication passes were observed and staff and resident files were reviewed. Information gathered during the inspection determined non-compliances with applicable standards or law, and violations were documented on the violation notice issued to the facility.
Violations
22VAC40-73-350-B
Based on record review, the facility failed to ascertain, prior to admission, whether a potential resident was a registered sex offender and failed to document that this was ascertained and the dated the information was obtained.
Evidence
  1. Resident #1 was admitted 1/13/22 and the Sex Offender screening was completed on 2/8/22.
  2. Resident #2 was admitted 9/23/21 and the Sex Offender screening was completed on 9/27/21.
Plan of correction
Not published by VDSS.
22VAC40-73-640-A
Based on observations made during the inspection of the medication cart, the facility failed to adhere to methods to prevent the use of outdated, damaged, or contaminated medications.
Evidence
  1. Resident #6's Venlafaxine Hcl Er Caps 75mg had an expiration date of 2/2/22, Memantine Hcl Er Caps 28mg had an expiration date of 7/12/21, and the Donepzil Hcl Tabs 10mg had an expiration date of 4/9/21;
  2. Resident #7's Ondansetron tab 4mg had an expiration date of 1/18/22; and
  3. Resident #8's Acetaminophen 325mg had an expiration date of 12/15/21.
Plan of correction
Not published by VDSS.
22VAC40-73-310-D
Based on documentation review, the facility failed to provide written assurance to the resident or legal representative that the facility has the appropriate license to meet the care needs at the time of admission, this document shall be signed and kept in the resident's record.
Evidence
  1. Resident #2 was admitted 9/23/21 and the written assurance was signed on 2/24/22.
  2. Resident #4 was admitted 2/10/22 and the written assurance was signed on 3/30/22.
Plan of correction
Not published by VDSS.
22VAC40-73-410-A
Based on record review, the facility failed to provide an orientation for new residents and their legal representatives, including emergency response procedures, mealtimes, and use of the call system upon admission.
Evidence
  1. Resident #1 (admitted 1/13/22), Resident #2 (admitted 9/23/21), and Resident #4 (admitted 2/10/22) did not have acknowledgement of having received orientation in their records.
Plan of correction
Not published by VDSS.
December 21, 2021Complaint survey1 violation
Inspection dates
12/21/21
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDING AND GROUNDS
Comments
A complaint investigation was initiated on 11/30/2021 and concluded on 1/25/2022. An unannounced inspection was conducted on 12/21/21 from 8:15 a.m. to 10:45 a.m. by a Licensing Inspector and a Licensing Administrator. A complaint was received by the department regarding allegations in the areas of staffing and supervision, resident care, and call bell systems. The evidence gathered during the investigation supported the allegation of non-compliance with standards or law, and violations were issued.
Violations
22VAC40-73-870-E
Based upon observation and staff interview the facility call bell system was not in good repair, condition or fully operational.
Evidence
  1. During the physical plant inspection conducted on 12/21/21, Licensing Inspector pulled the call bell in Resident #1's room and there was no staff response. The call bell system was not operational. 2. Staff #1 was present during the inspection and acknowledged the call bell system was not fully operational. Staff #1 reported the facility had been working to repair the call bell system since the week after Thanksgiving.
Plan of correction
Nursing staff to be retrained on use of call bell system. Replacement devices to be ordered to match staffing ratio. IT to evaluate areas of connection in building to ensure proper function. Check Call bell system response time by physically checking weekly for 3 months to be preformed by Maintenance Director and nursing in tandem). 2 hour round sheets to be completed on all AL residents for 6 months.
April 27, 2021Inspection7 violations
Inspection dates
April 27, 2021 , April 29, 2021 , April 30, 2021 , May 3, 2021 and May 4, 2021
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDING AND GROUNDS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity
Comments
This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 04-27-2021 and concluded on 05-04-2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 39. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 3 resident records, 3 staff records, criminal background checks and sworn disclosures of newly hired staff, staff schedules, fire drills, fire and health inspection reports, and healthcare oversight. Information gathered during the inspection determined non-compliance's with applicable standards or law, and violations were documented on the violation notice issued to the facility.
Violations
22VAC40-73-320-A
Based on record review and interview, the facility failed to ensure the resident’s admission physical examination included a description of reactions to any known allergies.
Evidence
  1. Resident #1’s “Resident Physical Examination Report” dated 02-23-2021 did not include documentation of a description of the allergic reaction to Zolpidem.
  2. Resident #3’s “Resident Physical Examination Report” dated 02-04-2021 did not include documentation of a description of the allergic reaction to Keflex and PCN [Penicillin].
  3. Staff #1 acknowledged the residents? admission physical examinations did not include the aforementioned required information.
Plan of correction
Resident’s ISP has been updated to reflect “Unknown” reaction to medication based on interview with the resident and resident’s legal representative. All resident records have been audited to ensure documentation of reactions to allergies. Clinical team is in communication with residents/legal representatives/PCPs to obtain information regarding reactions to any known allergies. Within the 30 days preceding admission, a person will have a physical examination by an independent physician. The report of such examination will be on file at the assisted living facility and will contain the following: 1. The person's name, address, and telephone number; 2. The date of the physical examination; 3. Height, weight, and blood pressure; 4. Significant medical history; 5. General physical condition, including a systems review as is medically indicated; 6. Any diagnosis or significant problems; 7. Any known allergies and description of the person's reactions; 8 Any recommendations for care including medication diet and therapy; 8. Any recommendations for care including medication, diet, and therapy; 9. Results of a risk assessment documenting the absence of tuberculosis in a communicable form as evidenced by the
22VAC40-73-325-C
Based on record review and interview, the facility failed to document an analysis of the circumstances of the fall for residents who meet the criteria for assisted living care.
Evidence
  1. Resident #1's Uniform Assessment Instrument (UAI) dated 03-26-2021 and resident #3’s UAI dated 04-20-2021 documented the residents meet criteria for assisted living level of care.
  2. Staff “Progress Notes” indicated the following falls: A. 03-01-2021, resident #1 fell during the late night hour of 02-28-2021, due to fall resident was sent out to the hospital; B. 04-01-2021, resident #3 became unsteady on feet, fell in the common area, and was sent out to the hospital;
  3. Staff #1 did not provide documentation of an analysis of the circumstances of the fall for resident #1 and resident #3.
  4. Staff #1 acknowledged the facility did not document an analysis of the circumstances of the falls for residents? #1 and #3.
Plan of correction
Fall Analysis has been developed and implemented for any resident who sustains a fall. At the time the comprehensive ISP is completed, a written fall risk rating will be completed. The fall risk rating will be reviewed and updated under each of the following circumstances: 1. At least annually; 2. When the condition of the resident changes; and 3. After a fall. When a resident falls, the community will show documentation of an analysis of the circumstances of the fall and interventions that were initiated to prevent or reduce risk of subsequent falls. The Resident Care Director is responsible for ensuring a fall analysis is completed for each resident who sustains a fall. The Executive Director is responsible for reviewing the fall analysis after each fall
22VAC40-73-450-C
Based on record review and interview, the facility failed to ensure the Individualized Service Plan (ISP) included a description of the resident’s identified needs.
Evidence
  1. Resident #1’s current Uniform Assessment Instrument (UAI) dated 03-26-2021 documented the need for mechanical and physical assistance with bathing, mechanical assistance with supervision with mobility, and mechanical assistance with wheeling. The current ISP dated 03-26-2021 did not include documentation of the type of mechanical device needed for bathing and mobility, nor the need for mechanical assistance with mobility.
  2. Resident #3’s current UAI dated 04-20-2021 documented the need for physical assistance with wheeling; however, the current ISP dated 04-20-2021 did not include the need for wheeling. In addition, the ?Resident Physical Examination Report“ dated 02-04-2021 documented the resident’s code status ”DNR? [Do Not Resuscitate]; however, the ISP documented a Full Code status.
  3. Staff #1 acknowledged the aforementioned ISP’s did not include a description of the residents identified needs, and the discrepancy with the code status.
Plan of correction
UAIs/ISPs for both Residents“ #1 & #3 have been updated to reflect the needs of the residents. All residents” UAIs/ISPs are being reviewed to ensure consistency between the two regarding residents? documented needs. Health Care Oversight has been completed by Regional Nurse Consultant to include a summary of items to review. On 6/16/21, ED, RCD, and ARCD will review all updated UAIs/ISPs to ensure they are cohesive and include a detailed description of resident needs. Explanation was provided during the time of inspection stating the community requests all residents who desire a DNR status to submit a Durable DNR consistent with Code of Virginia ? 54.1-2987.1. Resident #3’s physical examination report did not have a Durable DNR attached and verification of resident/legal representative’s desire for DNR was not produced. When the community spoke with the resident’s legal representative regarding the DNR status, it was communicated that there was no interest in a DNR status and the resident was then listed as a Full Code, evident by her signed ISP. All residents will be assessed face to face using the uniform assessment instrument in accordance with Assessment in Assisted Living Facilities (22VAC30-110). The UAI shall be completed prior to admission, at least annually, and whenever there is a significant change in the resident's condition. The comprehensive individualized service plan will include the following: 1. Description of identified needs and date identified based upon the UAI, admission physical examination, interview with resident, fall risk rating, if appropriate, assessment of psychological, behavioral, and emotional functioning, and other sources. The Resident Care Director is responsible for ensuring resident’s UAI and ISP reflect accuracy relating to resident’s needs and preferences. The Resident Care Director and the Assistant Resident Care Director are responsible for ensuring resident UAI/ISP are completed at the time of admission, every 6 months, and when the resident experiences a change of condition.
22VAC40-73-640-A
Based on record review and interview, the facility failed to implement its medication management plan ?Handling, Ordering, and Refilling Medications (12/14/2020)? to ensure each resident's medications are refilled in a timely manner.
Evidence
  1. Staff #1 provided a copy of the facility’s medication management plan which indicated all physician ordered ill b medications will be available for the resident.
  2. Resident #1’s April 2021 Medication Administration Record documented staff did not administer Tamsulosin on 04-04- 2021, 04-05-2021, and 04-07-2021, Allergy Relief on 04-13-2021, 04-14-2021, 04-17-2021 through 04-19-2021, 04-23-2021, 04-26-2021, and 04-27-2021, Vitamin D3 on 04-13-2021, 04-20-2021, and 04-21-2021, and Vitamin B-12 on 04-04-2021, 04-05-2021, and 04-18-2021 through 04-20-2021 due to refill needed and drug not available.
  3. Staff #1 acknowledged resident #1’s aforementioned medications were not refilled in a timely manner to avoid missed dosages.
Plan of correction
Evidence was provided revealing the medication aides? routine follow-up with the pharmacy to refill the medication. The medication aides overlooked the requirement to address this issue with management after multiple unsuccessful attempts at obtaining the medication refill. All staff authorized to administer medications were in-serviced by Regional Nurse Consultant on the community’s medication management program, to include reordering medication from the pharmacy. The Regional Nurse Support Specialist, the Executive Director and Resident Care Director are in regular communication with the community’s partnering pharmacy regarding concerns relating to timely refills of medications. All staff authorized to administer medications will be in-serviced on and observe the community’s ?Handling, Ordering, & Refilling Medications? policy. When a fill is requested and not received or an error is found, staff authorized to administer medications will notify the pharmacy/Resident Care Director/Designee immediately. The Resident Care Director and the Assistant Resident Care Director are responsible for ensuring medications are refilled in a timely manner. Medications that have been ordered from the pharmacy and are not delivered in a timely manner will be addressed with the pharmacy by the Resident Care Director/Assistant Resident Care Director and/or the Executive Director.
22VAC40-73-650-B
Based on record review and interview, the facility failed to ensure prescriber’s orders, both written and oral, for administration of all prescription and over-the-counter medications, identified the diagnosis or specific indications for administering each drug.
Evidence
  1. The residents signed physician’s orders did not include a diagnosis or specific indications for administering the following medication: A. Resident #1’s order dated 04-09-2021 for Celexa 10mg and Olanzapine 2.5mg; and B. Resident #2’s order dated 04-08-2021 for Clotrimazole 10mg.
  2. Staff #1 acknowledged resident #1 and resident #2’s aforementioned prescriber’s orders did not include the diagnosis or specific indications for administering the medications.
Plan of correction
All physician’s orders are being reviewed, updated, and signed to include a diagnosis for all medications. Physician or other prescriber orders, both written and oral, for administration of all prescription and over-the-counter medications and dietary supplements will include the name of the resident, the date of the order, the name of the drug, route, dosage, strength, how often medication is to be given, and identify the diagnosis, condition, or specific indications for administering each drug. The Resident Care Director and the Assistant Resident Care Director are responsible for ensuring physician’s orders include a diagnosis.
22VAC40-73-680-D
Based on record review and interview, the facility did not administer medications in accordance with the physician’s instructions. 1. Resident #2’s signed physician’s order dated 04-08-2021 documented ?Clotrimazole 10mg Lozenge- Dissolve 1 tablet in mouth four times daily.? 2. Resident #2’s April 2021 Medication Administration Record documented staff did not administer Clotrimazole 10mg on 04-14-2021 through 04-26-2021 due to the medication being held. 3. Staff #1 did not provide a physician’s order to hold Clotrimazole10mg on 04-14-2021 through 04-26-2021 and stated there was “No order to hold located.” 4. Staff #1 acknowledged resident #2's Clotrimazole 10mg was not administered in accordance with the physician's instructions.
Plan of correction
What Has Been Done to Correct? Resident # 2 discharged from the community on 4/24/21. Clotrimazole was held after resident’s oncologist gave a verbal order to discontinue (d/c). Medication was held awaiting formal written discontinue order from oncologist. Resident Care Director (RCD) had several conversations with resident’s oncology office and sister regarding the need for d/c order but was having trouble obtaining orders from the oncologist. How Will Recurrence Be Prevented? No medication, dietary supplement, diet, medical procedure, or treatment will 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. The resident's record will contain the physician's or other prescriber's signed written order or a dated notation of the physician's or other prescriber's oral order. Orders will be organized chronologically in the resident's record. New orders will be reviewed and signed by a physician or other prescriber within 14 days. Person Responsible: The Resident Care Director and the Assistant Resident Care Director (ARCD) are responsible for ensuring medications are administered in compliance with physician’s orders. The RCD is responsible for ensuring that all oral orders are documented and signed by the physician within 14 days.
22VAC40-73-680-E
Based on record review and interview, the facility failed to ensure treatments ordered by a physician or other prescriber are provided according to his instructions and documented. The documentation was not maintained in the resident's record.
Evidence
  1. Resident #2’s signed physician’s order dated 04-07-2021 documented ?Humalog Kwikpen Solution Pen-Injector 100mg inject as per sliding scale? 401+ = 10 units Recheck BS in 1 hour, Notify MD.
  2. Resident #2’s April 2021 Medication Administration Record documented blood sugar readings of 426 on 04-20-2021 at 9:00 PM, and 486 on 04-23-2021 at 11:00 AM. There was no documentation indicating 10 units of insulin was administered; blood sugars were rechecked in 1 hour; or the physician being notified of the blood sugar readings.
  3. Staff #1 did not provide documentation of the number of units of insulin administered to resident #2, the blood sugars being rechecked on the aforementioned dates, or that the physician was made aware of the aforementioned blood sugar readings. Staff #1 stated “No written documentation located.”
Plan of correction
The Executive Director (ED) reached out to the organization’s technical support team to inquire as to why the requirement to input the administered units of insulin in the EMAR was not automatically populating during the administration of insulin, as designed. The technical support team identified an issue with the system configuration and has corrected the issue. The ED, RCD, and ARCD received virtual training on how to properly configure insulin medications in the EMAR in the event of future system malfunctions. Medical procedures or treatments ordered by a physician or other prescriber will be provided according to his/her instructions and documented. The documentation will be maintained in the resident's record. The (E)MAR will include: Prescribing provider, the name of the resident, the date of the order, the name of the drug, route, dosage, strength, how often medication is to be given, the diagnosis/ condition, and/or specific indications for administering each drug. Residents receiving insulin injections will have the proper EMAR configuration, including the requirement to document the number of insulin units administered during medication administration. The Resident Care Director and the Assistant Resident Care Director are responsible for ensuring medications are administered in compliance with physician’s orders. The Resident Care Director and the Assistant Resident Care Director are responsible for ensuring any resident with a diagnosis of diabetes mellitus receiving insulin injections has the proper EMAR configuration, including a requirement to document the number of insulin units administered during medication administration.
March 22, 2021Complaint survey12 violations
Inspection dates
March 22, 2021 , March 24, 2021 , March 29, 2021 , March 31, 2021 and April 1, 2021
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity
Comments
This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A complaint investigation was initiated on 03-22-2021 and concluded on 04-01-2021. A complaint was received by the department regarding allegations in the areas of staffing and supervision, administration of medications and related provisions, resident Agreement, medication management plan, personal care services and general supervision of care, storage of medications, and provisions for signaling and call systems. The Administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the Administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the allegations of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.
Violations
22VAC40-73-50-A
Based on record review and interview, the facility did not keep its disclosure statement current regarding the general number of direct care staff (DCS) on each shift.
Evidence
  1. The facility’s disclosure statement documented 8 DCS will work during the 3:00 PM to 11:00 PM and 11:00 PM to 7:00 AM shifts.
  2. February 2021 and March 2021 facility staff working schedules and timesheets documented: A. 02-10-2021, 6 DCS worked during the 3:00 PM - 11:00 PM and 11:00 PM - 7:00 AM shifts; B. 02-14-2021, 02-23-2021, and 03-04-2021, 4 DCS worked during the 3:00 PM - 11:00 PM and 11:00 PM - 7:00 AM shifts.
  3. Staff #1 confirmed the number of DCS who worked during the aforementioned dates and times and acknowledged the total number of DCS working did not reflect the number of DCS in the disclosure statement.
Plan of correction
Disclosure Statement is being revised to reflect current staffing numbers. Once revisions have been made, each resident/legal representative will be provided a copy of the revised Disclosure Statement to review and sign. The assisted living facility shall prepare and provide a statement to the prospective resident and his legal representative, if any, that discloses information about the facility. The statement shall be on a form developed by the department and will include current statement of the general number of direct care staff (DCS) on each shift. The Executive Director is responsible for ensuring residents/legal representative is provided a disclosure statement within standards of practice consistent with 22VAC40-73-(2)-50-A
22VAC40-73-390-A
Based on record review and interview, the written agreement did not include documentation of the resident being informed of the policy regarding the administration of medications and dietary supplements.
Evidence
  1. The licensee took ownership of the facility effective 11-18-2020.
  2. Resident #1’s written agreement, signed and dated on 12-15-2020, and resident #4 and resident #5’s written agreement, signed and dated on 03-23-2021, did not include documentation that the residents were informed of the policy regarding the administration of medications and dietary supplements.
  3. Staff #1 did not provide documentation that the aforementioned residents were informed of the facility’s policy regarding the administration of medications and dietary supplements.
  4. Staff #1 acknowledged the aforementioned written agreements did not include documentation that the residents were informed of the policy regarding the administration of medications and dietary supplements.
Plan of correction
What Has Been Done to Correct? Executive Director has submitted Notice of Violation to Home Office for review and revision. Once revisions have been made, current residents/legal representatives will be provided an agreement addendum, complaint with regulatory standard, to review and sign. All residents admitted thereafter will sign a copy of the revised resident agreement. How Will Recurrence Be Prevented? Resident agreements will be reviewed by Licensee, as needed, to ensure compliance with regulatory standards. Person Responsible: Licensee is responsible for ensuring compliance with ensuring regulatory standard of resident agreement.
22VAC40-73-450-C
Based on record review and interview, the facility failed to ensure the Individualized Service Plan (ISP) included a description of the residents identified needs.
Evidence
  1. On 03-24-2021, during a virtual tour of the facility with staff #1, right side rails was observed on resident #1 and resident #2’s beds, and left side rail on resident #3’s bed.
  2. Resident #1’s current ISP dated 12-01-2020, resident #2’s current ISP dated 01-21-2021, and resident #3’s current ISP dated 01-20-2021 did not document the needs for side rails.
  3. Staff #1 acknowledged the side rails on residents #1, #2, and #3’s bed were not documented on the residents ISP’s.
Plan of correction
Residents with side rails will have ISP updated to include the need for siderails. Resident ISPs will reflect the needs and services provided to each resident and will be reviewed and signed by of an authorized representative of the facility and the resident or resident’s legal representative. Health Care Oversight will be conducted by a non-community associate to ensure ISPs are consistent with the needs of the resident. The Resident Care Director or designee is responsible for ensuring the resident’s ISP documents the needs of the resident and the services provided to the resident. Executive Director will conduct random audits of ISPs to ensure plan of care reflects residents needs.
22VAC40-73-460-B
Based on record review and interview, the facility failed to ensure prompt response by staff to resident needs.
Evidence
  1. “Resident Council Concerns Checklist” forms dated 02-11-2021 and 03-19-2021 documented, ?Residents stated call bells are not being answered when they call for help;“ and ”Call bells are being ignored and residents are left to wait long periods of time? Showers are not to be given when they are supposed to. Residents waiting for shower and no one comes.?
  2. During interviews, residents stated ?Staff takes a long time to respond to call bell, it varies [time], but have waited up to an hour, and sometimes there is no response;“ call bells ”were a problem;“ and ”not enough staff to provide care.?
  3. Staff #1 provided a copy of the facility’s call bell log labeled “Zone Activity Report” which documented the following response times: A. On 02-10-2021, 1 hour and 7 minutes for room 106 at approximately 8:08 AM; 28 minutes for room 205 at approximately 8:05 AM; and 28 minutes for room 205 at approximately 1:11 PM; B. On 02-14-2021, 31 minutes for room 106 at approximately 2:26 AM; 48 minutes for room 106 at approximately 12:03 PM; and C. On 03-24-2021, 37 minutes for room 106 at approximately 6:48 AM.; 28 minutes for room 205 at approximately 5:04 AM; and 29 minutes for room 205 at approximately 11:36 PM.
  4. Staff #2 stated the facility’s goal is to “answer the call bells within 7 minutes”, and acknowledged the residents? concerns regarding the delayed response times to the call bells.
Plan of correction
Call bell response times have consistently improved since March 2021 and have averaged 7 min or less for the past 30 days. Routine monitoring of call be response times has been implemented. Residents have been educated on communicating malfunctioning call bell system equipment to a member of management as soon as possible. Residents will receive prompt response by staff to resident needs within a timeframe reasonable to the circumstances. The Resident Care Director and the Executive Director are responsible for monitoring call bell response times to ensure call bells are responded to in a reasonable timeframe.
22VAC40-73-640-A
Based on record review and interview, the facility failed to implement its plan for medication management.
Evidence
  1. Staff #1 provided a copy of the facility’s medication management plan labeled ?Handling, Ordering, and Refilling Medications (12/14/2020)? which indicated all physician ordered medications will be available for the resident.
  2. February 2021 and March 2021 Medication Administration Records (MAR’s) documented staff did not administer the following medications due to refills needed and drugs not available: A. Resident #1’s Carvedilol 25mg and Amlodipine 5mg on 02-02-2021; Trazadone 50mg on 02-03-2021; Rosuvastatin 10mg and Montelukast 10mg on 02-08-2021 and 02-09-2021; and Carvedilol 25mg on 03-04-2021; B. Resident #2’s Levothyroxine 25mcg on 02-13-2021 and 02-15-2021; Nystatin Ointment 100000 unit/gm on 02-06-2021 through 02-08-2021, and 02-26-2021; Furosemide 20mg 02-10-2021, 02-12-2021, 02-17-2021, 02-18-2021, 02-20-2021 through 02-22-2021, 03-12-2021, and 03-15-2021 through 03-17-2021; Hydrocodone 325mg 02-06-2021, 02-07-2021, and 02-09-2020; Cranberry Cap 200mg 03-08-2021, 03-10-2021, 03-12-2021, 03-15-2021 through 03-17-2021; and Vitamin D3 on 03-16-2021; C. Resident #3’s Co Q-10 100mg on 02-12-2021 through 02-14-2021, Gabapentin 300mg on 02-08-2021, or Rosuvastatin 20mg on 02-12-2021 through 02-17-2021; D. Resident #4’s Metoprolol 25mg on 02-21-2021 and 02-22-2021, and Ferrous Sulfate 325mg on 02-26-2021; and E. Resident #5’s Melatonin 10mg on 02-13-2021 through 02-19-2021, and Trazadone 150mg on 03-03-2021 and 03-04-
  4. Staff #1 stated there was “No documentation of physician being made aware of the resident’s missed medications” for the aforementioned residents.
  5. “Resident Council Concerns Checklist” form dated 02-11-2021 documented ?Resident stated [resident] asked med tech for [resident] medication. Med tech stated she did not have that medication on the cart and did not know how to order.?
Plan of correction
What Has Been Done to Correct? Usage of agency staff has been suspended. Routine in-servicing of the community’s medication management program and procedures for reordering medications has been implemented. Community has implemented cycled medication delivery through contracted pharmacy. How Will Recurrence Be Prevented? All new associates responsible for the administration of medication will be orientated to the community’s medication management plan, to include procedures for handling, ordering, and refilling medications. In-servicing and training on the community’s Medication Management Plan will be reviewed with associates responsible for the administration medication annually and as needed. Person Responsible: The Resident Care Director is responsible for ensuring that all associates responsible for the administration of medication are orientated to the community’s Medication Management Plan and the plan is reviewed at least annually.
22VAC40-73-650-A
Based on record review and interview, the facility failed to ensure no medications are discontinued by the facility without a valid order from a physician or other prescriber.
Evidence
  1. Resident #4’s current signed physician’s orders dated 11-24-2020 documented ?Deep Blue Complex- 1 capsule twice daily for osteoarthritis.?
  2. Resident #4’s January 2021 Medication Administration Record (MAR) documented the resident last received Deep Blue Complex on 01-27-2021. February 2021 and March 2021 MAR’s did not include documentation that the Deep Blue Complex was administered.
  3. Staff #1 did not provide documentation that staff administered Deep Blue Complex to resident #4 from 01-28-2021 through 03-17-2021.
  4. Staff #1 acknowledged the facility discontinued the aforementioned medication without a valid order from a physician or other prescriber.
Plan of correction
Order for dietary supplement was discontinued 11/19/20 in EMAR and was not administered from this date through inspection date. Evidence was provided at the time of inspection of communications between community associates, resident’s legal representative, and primary care physician regarding dietary supplement. PCP delayed order to confirm whether dietary supplement created increased risk of worsening another underlying health condition. Updated order was received for dietary supplement on 4/4/2021 documented “Deep Blue Complex- 1 capsule one time per day everyday”. All current physician’s orders have been reviewed and signed to ensure residents are administered medication based on current and accurate orders from the physician. No medication, dietary supplement, diet, medical procedure, or treatment shall be started, changed, or discontinued by the community without a valid order from a physician or other prescriber. Medications include prescription, over-the- counter, dietary supplement and sample medications. Physician or other prescriber orders, both written and oral, for administration of all prescription and over-the-counter medications and dietary supplements shall include the name of the resident, the date of the order, the name of the drug, route, dosage, strength, how often medication is to be given, and identify the diagnosis, condition, or specific indications for administering each drug. Physician's or other prescriber's oral orders will be reviewed and signed by a physician or other prescriber within 14 days. The Resident Care Director and Assistant Resident Care Director are responsible for ensuring that medications are started, changed, and/or discontinued after a valid order is received from a physician or other prescriber.
22VAC40-73-660-A
Based on observation and interview, the facility failed to ensure the medicine cabinet or compartment used for storage of medications is locked.
Evidence
  1. On 03-24-2021 at approximately 12:00 PM, during a virtual tour of the special care unit, staff #1 approached an unlocked medication cart located at the nurses? station.
  2. Staff #1 stated ?staff #3 [who was responsible for the medication cart] left the special care unit for approximately 10 to 15 minutes? while the medication cart was left unlocked and unattended by staff #3.
  3. Staff #1 acknowledged the facility did not keep the medication storage cart was not locked.
Plan of correction
Associate has received in service and training on the importance of keeping the med cart locked whenever the associate Plan of Correction: Associate has received in-service and training on the importance of keeping the med cart locked whenever the associate is not standing at the med cart preparing for administration of medications. The medicine cabinet, container, or compartment used for storage of medications and dietary supplements prescribed for residents will be utilized in a manner consistent with current standards of practice. 1. The storage area shall be locked and the individual responsible for medication administration shall keep the keys to the storage area on his person. The Resident Care Director (RCD) or designee will be responsible for ensuring that all associates responsible for the administration of medication will be in-serviced on current standards of practice regarding the storage of medications. The RCD or designee will conduct unscheduled audits to ensure medicine cabinets, containers, or compartments utilized for the storage of medications and dietary supplements are compliant with current standards of practice. The Executive Director will also conduct random unscheduled audits of medicine cabinets, containers, or compartments used for storage of medications and dietary supplements.
22VAC40-73-660-B
Based on observation, record review, and interview, a resident was permitted to keep medications in their room and the Uniform Assessment Instrument (UAI) indicated that the resident was not capable of self-administering medication.
Evidence
  1. On 03-24-2021, during a virtual tour of the facility with staff #1, the following medications were observed in residents? rooms: A. Tylenol 650mg, Miralax, Benadryl, Biofreeze, and Diclofenac topical gel in resident #1’s bathroom; B. A plastic pill cup containing an unidentified pink and yellow cream on resident #2’s nightstand, and Vicks Vapor rub, Fungi care anit-fungal liquid, and Stopain relieving roll-on in the resident’s bathroom; C. Lotemac eyedrops and Vitamin A&D ointment on resident #3’s bedside table, and Preparation H cream, Vicks Vapor rub, Fluocinonide topical solution, and Aspercreme in the resident’s bathroom.
  2. Resident #1’s current UAI dated 12-01-2020, resident #2’s current UAI dated 11-16-2020, and resident #3’s current UAI dated 11-17-2020 documented medications are to be administered by a lay person and/or professional nursing staff.
  3. Staff #1 observed and acknowledged that resident #1, resident #2, and resident #3 were not permitted to keep medications in their room for self-administration based on their current UAI’s.
Plan of correction
Education on current standards of practice regarding self-administration and storage of medications kept in the resident? s room has been implement with residents # 1, 2, & 3 and their families/legal representatives. Resident # 2 & #3 have received physician’s orders to keep specified medications in room to be stored in an out-of-sight location. Residents will be permitted to keep their own medication in an out-of-sight secured location within their room if the UAI has indicated that the resident is capable of self-administering medication. All medications and dietary supplements shall be stored so that they are not accessible to other residents. The Resident Care Director is responsible for ensuring the UAI & ISP indicate when resident is permitted to keep medications in their room and is based on the resident’s capability to self-administer medications. All associates administering medications are responsible for ensuring that a resident is only permitted to keep medication in their room if the UAI & ISP indicate that the resident is capable of self-administering medication.
22VAC40-73-680-C
Based on record review and interview, the facility failed to ensure medications are administered no earlier than one hour before and no later than one hour after the facility's standard dosing schedule.
Evidence
  1. Staff #1 provided a copy of the facility’s standard dosing schedule labeled “Medication Services” which indicated the resident’s Medication Administration Record (MAR) would identify the designated time of administration.
  2. February 2021 MAR’s and “Time Variance Report” documented the following scheduled administration times: A. Resident #1’s scheduled Montelukast 10mg and Trazadone 50mcg at 8:00 PM and Rosuvastatin 10mg at 9:00 PM was administered at 10:23 PM on 02-03-2021; and at 11:25 PM on 02-24-2021; B. Resident #2’s scheduled Amlodipine 5mg, Buspirone 10mg, and Preservision AREDS 2 at 11:40 PM on 02-24-2021; C. Resident #3’s scheduled Rosuvastatin at 9:00 PM was administered at 7:47 PM on 02-03-2021; at 7:37 PM on 02-14- 2021; and D. Resident #5’s scheduled Certavite, Fish Oil 1000mg, Saw Palmetto 500mg, Tamsulosin 0.4mg, and Vitamin D3 25mcg at 10:30 AM was administered at 1:38 PM.
  3. Staff #1 provided a copy of the “Resident Council Concerns Checklist” dated 02-11-2021 and 03-19-2021 which documented, “Medications are not being administered at appropriate times”“ and ”Not receiving medications at the correct time.?
  4. Staff #1 and staff #2 acknowledged the residents? aforementioned medications were not administered within the correct times.
Plan of correction
Usage of agency staff has been suspended. Routine audits of medication administration records are conducted to verify proper documentation of medication administration and compliance of administration of medication based on physician? s orders. Medications will be 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. Medications will be administered in accordance with the physician's or other prescriber's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. The Resident Care Director is responsible for ensuring that medications are scheduled to be administered in accordance with physician’s orders. Resident Care Director or designee is responsible for ensuring that medication administration records are routinely reviewed to ensure compliance with standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing.
22VAC40-73-680-D
Based on record review and interview, the facility did not administer medications in accordance with the physician's instructions.
Evidence
  1. Resident #2’s current signed physician’s orders dated 12-29-2020 documented, ?Furosemide 20mg- Take one tablet by mouth on Mon/Wed/Fri for CHF [Congestive Heart Failure].?
  2. Resident #2’s January 2021 and February 2021 Medication Administration Record (MAR) documented staff administered Furosemide 20mg on the following days: A. Thursday: 01-28-2021, 02-04-2021, and 02-11-2021; B. Saturday: 01-30-2021, 02-06-2021, and 02-13-2021; C. Sunday: 01-31-2021, 02-07-2021, and 02-14-2021; and D. Tuesday: 02-02-2021, 02-09-2021, and 02-16-2021.
  3. Staff #1 could not provide a physician’s order documenting a change in the administration of resident #2’s Furosemide 20mg to daily and stated there are “No signed orders after 12/29/2020.”
  4. Staff #3 was asked about the administration of resident #2’s Furosemide 20mg, and stated ?not having access to MD [physician’s] orders to review for accuracy. If medication was documented on other days, it was because it popped up on the screen for staff to administer.?
  5. Resident #1’s signed physician’s order dated 02-02-2021 documented, ?Acyclovir 400mg- 1 (one) Tablet by mouth three times daily for Cold sore; 7 day supply.?
  6. Resident #1’s February 2021 MAR documented staff administered the first dose of Acyclovir 400mg at 7:30 AM on 02- 03-2021. The last dose scheduled for 02-09-2021 at 7:30 PM was not administered.
  7. Staff #1 stated the physician was not made aware of resident #1’s missed dose of Acyclovir 400mg, and
  8. Staff #1 acknowledged resident #1 and resident #2’s aforementioned medications were not administered in accordance with the physician’s instructions.
Plan of correction
All current physician’s orders have been reviewed and signed to ensure residents are administered medications based on current and accurate orders from the physician. Training on how to properly configure medications in the EMAR system to match physician’s orders has been executed. In-services on routine checks of physician’s orders in the EMAR system against the medications has been implemented. No medication, dietary supplement, diet, medical procedure, or treatment shall be administered, changed, or discontinued by the community without a valid order from a physician or other prescriber. Missed medications will be documented and communicated with resident’s primary care physician or prescriber. The Resident Care Director and Assistant Resident Care Director are responsible for ensuring that medications are started, changed, and/or discontinued after a valid order is received from a physician or other prescriber.
22VAC40-73-680-E
Based on record review and interview, the facility failed to ensure treatments ordered by a prescriber are provided according to his instructions and documented.
Evidence
  1. Resident #2’s current signed physician’s orders dated 12-29-2020 documented, “Weigh once weekly on Tuesday.”
  2. Resident #2’s Tuesday weekly weights were not documented on the January 2021 Medication Administration Record or Treatment Administration Record.
  3. Staff #1 provided documentation of resident #2’s monthly weights labeled ?Vital signs due by the 10th of every month? for the month of January 2021; however, the form only documented the resident was weighed once for the month.
  4. Staff #1 did not provide additional documentation of resident #2’s weights being taken every Tuesday in January
  6. Staff #1 did not provide a physician's order to discontinue the weekly weights.
  7. Staff #1 acknowledged resident #2 was not weighed weekly by staff every Tuesday as ordered.
Plan of correction
What Has Been Done to Correct? Resident #2’s weights are documented monthly, consistent with physician’s orders dated 2/9/2021 and current physician’s orders dated 3/2/2021. How Will Recurrence Be Prevented? Medical procedures or treatments ordered by a physician or other prescriber will be provided according to his instructions and documented. Person Responsible: The Resident Care Director, or designee, is responsible for ensuring resident weights are documented monthly or as prescribed by residents? physician.
22VAC40-73-680-I
Based on record review and interview, the facility failed to ensure the Medication Administration Record (MAR) included the initials of direct care staff administering the medication.
Evidence
  1. February 2021 MAR’s did not include the initials of direct care staff administering the following medications: A. Resident #1’s Rosuvastatin 10mg at 8:00 PM, and Montelukast 10mg and Trazadone 50mg at 9:00 PM on 02-10-2021 and 02-14-2021; B. Resident #3’s Gabapentin 300mg and Rosuvastatin 20mg at 9:00 PM on 02-23-2021; and C. Resident #4’s Acetaminophen 500mg, Pravastatin 10mg, and Losartan 100mg at 9:00 PM on 02-23-2021.
  2. Staff #1 acknowledged the aforementioned dates did not include the initials of the direct care staff who administered the medications.
Plan of correction
Usage of agency staff has been suspended. Routine audits of medication administration records are conducted to verify proper documentation of medication administration and compliance of administration of medication based on physician? s orders. Medications will be administered in accordance with the physician's or other prescriber's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. At the time the medication is administered, the community will document on a medication administration record (MAR) all medications administered to residents, including over-the-counter medications and dietary supplements. The MAR will include: 1. Name of the resident; 2. Date prescribed; 3. Drug product name; 4. Strength of the drug; 5. Dosage; 6. Diagnosis, condition, or specific indications for administering the drug or supplement; 7. Route (e.g., by mouth); 8. How often medication is to be taken; 9. Date and time given and initials of direct care staff administering the medication; 10. Dates the medication is discontinued or changed; 11. Any medication errors or omissions; 12. Description of significant adverse effects suffered by the resident; 13. For "as needed" (PRN) medications: a. Symptoms for which medication was given; b. Exact dosage given; and c. Effectiveness; and 14. The name, signature, and initials of all staff administering medications. The Resident Care Director is responsible for ensuring medications are administered in accordance with physician’s orders. Resident Care Director or designee is responsible for ensuring that medication administration records are routinely reviewed to ensure compliance with standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing and contain initials of direct care staff administering the medication. The Executive Director is responsible for conducting random audits of MAR to ensure compliance with regulatory standard.
February 3, 2021Inspection4 violations
Inspection dates
Feb. 3, 2021 , Feb. 9, 2021 and Feb. 10, 2021
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity
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 monitoring inspection was initiated on 02-03-2021 and concluded on 02-10-2021. The Interim Administrator was contacted by telephone to initiate the inspection. The Interim Administrator reported that the current census was 46. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 3 resident records, 3 staff records, criminal background checks and sworn disclosures of newly hired staff, staff schedules, fire drills, fire and health inspection reports, and healthcare oversight. Information gathered during the inspection determined non-compliances with applicable standards or law, and violations were documented on the violation notice issued to the facility.
Violations
22VAC40-73-440-B
Based on record review and interview, the facility failed to ensure the Uniform Assessment Instrument (UAI) for private pay individuals was completed by a staff person who has successfully completed state-approved training on the UAI.
Evidence
  1. Resident #1’s UAI dated 12-01-2020 was completed by staff #4.
  2. Staff #1 could not provide documentation verifying staff #4 completed the UAI state-approved training, and stated ?We do not have a record of the UAI/ISP certification for staff #4.?
  3. Staff #1 and staff #2 acknowledged resident #1’s UAI was not completed by a staff person who has successfully completed the UAI state-approved training.
Plan of correction
What Has Been Done to Correct? Documentation of successful completion of state approved UAI training have been obtained and filed for the RCD and ED. How Will Recurrence Be Prevented UAI assessments will be completed by qualified staff who have successfully completed training via one of the following methods: ? Through a certificate for the online course, ADS 1102: Private Pay Uniform Assessment Instrument located on the Department of Social Services (DSS) Knowledge Center. The certificate of successful completion of the course must be placed in the assessor’s personnel file or; ? Through a certificate of the classroom training ADS 5011: Uniform Assessment Instrument (UAI) offered by DSS. Person Responsible: The ED will be responsible for ensuring successful completion of state-approved training for any staff person completing UAIs.
22VAC40-73-450-B
Based on record review and interview, the facility failed to ensure the designee successfully completed the department approved Individualized Service Plan (ISP) training.
Evidence
  1. Resident #1’s ISP dated 12-01-2020, resident #2’s ISP dated 01-20-2021, and resident #3’s ISP dated 01-21-2021 was developed by staff #4.
  2. Staff #1 nor Staff #4 could not provide documentation verifying completion of the department approved ISP training.
  3. Staff #1 and staff #2 acknowledged the ISP’s were developed by a staff #4 who had not successfully completed the approved training.
Plan of correction
What Has Been Done to Correct? Documentation verifying successful completion of VDSS approved ISP training has been obtained and filed for the RCD and ED. How Will Recurrence Be Prevented? Comprehensive ISPs will be developed by qualified staff who have successfully completed the department-approved individualized service plan (ISP) training, provided by a licensed health care professional practicing within the scope of his profession to meet the resident's service needs. Verification of state- approved private pay UAI training will also be obtained. Person Responsible: The ED will be responsible for ensuring successful completion of state-approved training for any staff person completing ISPs.
22VAC40-73-450-C
Based on resident record review and interview, the facility failed to ensure the Individualized Service Plan (ISP) included a description of identified needs.
Evidence
  1. Resident #2’s “Report of Resident Physical Examination” dated 10-09-2020 documented allergies to Codeine, Shellfish containing products, and Cyclobenazapin. Resident #2’s current Uniform Assessment Instrument (UAI) dated 11-19-2020 documented the need for mechanical assistance with walking and stairclimbing; however, current ISP dated 01-20-2021 did not document these needs.
  2. Resident #3’s current UAI dated 01-20-2021 documented bowel and bladder incontinence weekly or more; however, the current ISP dated 01-21-2021 did not document these needs
  3. Staff #1 and staff #2 acknowledged resident #2 and resident #3’s aforementioned needs were not identified on the ISP’s.
Plan of correction
What Has Been Done to Correct? Planned (ISP) meetings: Executive Director (ED) and Resident Care Director are scheduling Individualized Service with seven residents and their legal representatives each week beginning March 15, 2021. All necessary assessments will be completed prior to developing each ISP to ensure all identified needs are accurately notated on the plan of care. How Will Recurrence Be Prevented? Resident #2 UAI & ISP has been corrected. Resident # 3 has expired. ISPs will be reviewed and updated at least once every 6 months and as needed for a significant change of a resident's condition. The review and update shall be performed by a qualified staff person, in conjunction with the resident and, as appropriate, with the resident's family, legal representative, direct care staff, case manager, health care providers, qualified mental health professionals, or other persons. All Care and services specified in the individualized service plan will be provided to each resident, except when: 1. A deviation from the plan when mutually agreed upon between the facility and the resident or the resident's legal representative at the time the care or services are scheduled or when there is an emergency that prevents the care or services from being provided. 2. Any deviation from the plan shall: a. Be documented in writing or electronically; b. Include a description of the circumstances warranting deviation and the date such deviation will occur; c. Certify that notice of such deviation was provided to the resident or the resident's legal representative; d. Be included in the resident's file; and e. Be signed by an authorized representative of the assisted living facility and the resident or the resident's legal representative if the deviation is made due to a significant change in the resident's condition. Person Responsible: The RCD will be responsible for ensuring ISPs include a description of identified needs in conjunction with clinical assessments, physician’s orders, and resident choice.
22VAC40-73-680-I
Based on record review and interview, the facility failed to ensure the Medication Administration Record (MAR) included the initials of direct care staff administering the medication.
Evidence
  1. January 2021 MAR’s did not include the initials of direct care staff who administered the following medications: A. Resident #1’s Montelukast 10mg, Rosuvastatin 10mg, and Trazadone 50mg on 01-10-2021 at 8:00 PM; B. Resident #2’s Potassium CL 20meq, Refresh Liquigel, and Preservision Cap Areds 2 on 01-10-2021 at 5:00 PM; Atorvastatin 40mg on 01-10-2021 at 8:00 PM; Eliquis 2.5mg, Melatonin 3mg, and Mucinex 300mg on 01-10-2021 at 8:30 PM; and C. Resident #3’s Carbamazepin 200mg on 01-04-2021 at 5:30 PM; and Clonazepam 0.5mg and Nystatin Cre 100000 at 10:00 PM.
  2. Staff #1 and staff #2 acknowledged the aforementioned MAR did not include the staff initials on the aforementioned dates.
Plan of correction
What Has Been Done to Correct? Daily audits of medication administration records are conducted to verify proper documentation of medication administration on the electronic medication administration record (EMAR). Medications that are not administered per physician’s orders have a correlating reason (refusal, LOA, etc.) documented in the EMAR. d (MAR) h Paper Medication Administration Records (MAR) have been printed to ensure compliance with organizational policies during system outages. How Will Recurrence Be Prevented? Resident Care Director (RCD) called for a meeting with staff persons who administer medication. RCD reviewed organization’s Medication Management and Medication Administration Records policies. An in-service has been scheduled with Southern Pharmacy, concentrated on staff persons responsible for administering medications, to review proper user operation of the EMAR system and best practices for system outages. Community will continue to conduct daily audits of missed documentation in EMAR. Individual employee in-services will be implemented for team members who neglect organizational guidelines relating to medication management and medication administration record policies. Paper MARs will be printed monthly and as needed to ensure proper documentation of medication administration in the event of system outages. Person Responsible: The Resident Care Director and the Assistant Resident Care Director will be responsible for ensuring proper documentation of administered medications in the EMAR system. The Assistant Resident Care Director will be responsible for ensuring paper MARs are printed for each resident monthly and as needed. The Executive Director will be responsible for conducting unscheduled audits to ensure the aforementioned practices are executed continuously.