The Villages of Rosemont — Virginia Inspection Report

Inspections

On record

With violations

Visits that cited something

Clean visits

Nothing cited

Violations cited

Individual findings

Standards cited

Distinct rules

Complaint visits

Prompted by a complaint

The Villages of Rosemont was inspected 16 times between December 14, 2020 and April 7, 2026 by the Virginia Department of Social Services. 11 of those visits ended with violations cited and 5 with none. Across that history VDSS cited 45 violations under 37 distinct standards. 5 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. 13 of these 16 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

Two Year

License expires

04/30/2028

Administrator

Steve De Jesus

Licensing inspector

Donesia Peoples

Inspector phone

757 353-0430

Approved for

Assisted Living

Inspection History

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

April 7, 2026Inspection4 violations

Inspection dates

04/07/2026

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 04/07/2026 at 8:10 am to 4:00 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 63 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: 3 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 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. 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. 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

22VAC40-73-450-A

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 his health, safety, and welfare. Exception: A preliminary plan of care is not necessary if a comprehensive individualized service plan (ISP) is developed, in conformance with this section, on the day of admission.

Evidence

The record for resident #1, admission date of 01/02/26, contains a preliminary plan of care dated 01/07/26 and an ISP dated 01/20/26. The resident’s record did not contain a preliminary plan of care completed on or within seven days prior to the day of admission nor an ISP completed on the day of admission. Photographic evidence is available.
The record for resident #2, admission date of 01/16/26, contains an ISP dated 01/22/26. The resident’s record did not contain a preliminary plan of care completed on or within seven days prior to the day of admission nor an ISP completed on the day of admission. Photographic evidence is available
The record for resident #3, admission date of 01/30/26, contains a preliminary plan of care dated 02/04/26 and an ISP dated 02/22/26 The resident’s record did not contain a preliminary plan of care completed on or within seven days prior to the day of admission nor an ISP completed on the day of admission. Photographic evidence is available
The record for resident #5, admission date of 02/02/26, contains a preliminary plan of care dated 02/07/26 and an ISP dated 03/31/26. The resident’s record did not contain a preliminary plan of care completed on or within seven days prior to the day of admission nor an ISP completed on the day of admission. Photographic evidence is available
During an interview on 04/07/26 with staff #6, staff #6 confirmed a preliminary plan of care was not completed on or within seven days of admission nor was an ISP completed on the day of admission for residents #1, #2, #3, and #5.

Plan of correction

Resident Care Director will ensure all new admissions will have a preliminary plan of care developed on or within seven days prior to the day of admission or have a comprehensive individualized service plan (ISP) developed on the day of admission. The Executive Director will monitor to ensure compliance with standard. Resident Care Director (RCD) and Executive Director (ED) June 1, 2026 and ongoing

22VAC40-73-930-B

Based on observation and staff interview the facility failed to ensure in buildings licensed to care for 20 or more residents under one roof, there shall be a signaling device that terminates at a central location that is continuously staffed and permits staff to determine the origin of the signal or is audible and visible in a manner that permits staff to determine the origin of the signal.

Evidence

During monitoring of the call alert system on 04/07/26 at 3:52 pm with staff #2, the Licensing Inspector (LI) tested the call alert system in the room of resident #8 and the following was observed: • A flashing red light was observed outside of the resident’s room hanging from the ceiling and a flashing red light was observed in the facility’s hallway located on the top of the wall. • An audible signal was not heard during the observation.
During an interview on 04/07/26 with staff #2, staff #2 stated an audible signal is alerted in the facility’s nursing station, however the audible signal has not been working as of 7:30 am on 04/07/26. Staff #2 stated an audible signal is also located in the staff’s break room however the staff break room is not continuously staffed nor is the nursing station continuously staffed.
During the monitoring of the call alert system on 04/07/26 the LI entered the staff break room at 3:53 pm and then heard an audible signal in the staff’s break room however prior to entering the break room the door was closed, locked, unstaffed and the call alert system could not be heard in the hallway or outside of the staff’s break room.

Plan of correction

The Executive Director will coordinate with the contracted service provider to evaluate the current nurse call system and determine whether the audible signal can be increased or optimized. The building layout will be assessed and an attempt to identify strategic areas where additional signaling devices (e.g., repeaters, visual alerts, or auxiliary alarms) may be installed to enhance staff awareness throughout the community. Staff will be re-educated on maintaining awareness of call systems and ensuring appropriate monitoring practices during their shifts. Executive Director (ED) July 1, 2026

22VAC40-73-660-A-6

Based on observation and staff interview the facility failed to ensure when required, medications shall be refrigerated.

Evidence

During the medication cart observation on 04/07/26 at 3:31 with staff #1, the following medication labeled to Refrigerate was located on the medication cart and was not refrigerated: Lorazepam Oral liquid for resident #5. Photographic evidence is available.
During an interview on 04/07/26 with staff #1, staff #1 confirmed the Lorazepam Oral liquid prescribed to resident #5 is required to be refrigerated however it was located on the medication cart and not refrigerated.

Plan of correction

Resident Care Director or designee will conduct an audit of medication carts on a weekly basis to ensure all medications are stored appropriately. Resident Care Director will in-service all LPNs and Medication Aides on the medication policy and procedures of the storage of medications. Resident Care Director (RCD) and Executive Director (ED) June 1, 2026

22VAC40-73-640-A

Based on observation and staff interview 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

During the medication cart observation on 04/07/26 at 3:24 pm to 3:26 pm with staff #1, the following outdated medications prescribed to resident #7 were located on the cart: • Furosemide is labeled by the pharmacy to use by 04/01/26. • Omeprazole is labeled by the pharmacy to use by 04/04/26. Photographic evidence is available.
During an interview on 04/07/26 with staff #1, staff #1 confirmed the Furosemide, and Omeprazole medications for resident #7 was outdated according to the pharmacy label.

Plan of correction

Resident Care Director or designee will conduct an audit of medication carts on a weekly basis to ensure all medications are current and all expired medications are removed in an appropriate timely manner. Audits to be provided to Executive Director. Resident Care Director will in-service all LPNs and Medication Aides on the medication policy and procedures of the removal of expired medications. Resident Care Director (RCD) and Executive Director (ED) June 1, 2026

April 7, 2026Complaint survey0 violations

Inspection dates

04/07/2026

Areas reviewed

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: The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 03/19/2026 regarding allegations in the area(s) of: Resident Care and Related Services, and Mixed Population and Related Services Number of residents present at the facility at the beginning of the inspection: 63 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 0 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: The emergency alert system was monitored. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact 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.

February 26, 2026Complaint survey0 violations

Inspection dates

02/26/2026

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-80 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 02/26/2026 at 10:35 am to 11:10 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 01/30/2026 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: 60 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: Dining menus and the facility's health inspection report were reviewed. The facility's emergency water and food supply were observed. Residents were observed in the common areas. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact 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.

November 20, 2025Complaint survey0 violations

Inspection dates

11/20/2025

Areas reviewed

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: 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 10/21/2025 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: 51 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 0 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 4 Observations by licensing inspector: Dining menus were reviewed. Residents were observed in the common areas. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact 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.

March 25, 2025Inspection2 violations

Inspection dates

03/25/2025

Areas reviewed

Technical assistance

22VAC40-73-50

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: 03/25/2025 from 8:30 am to 1:45 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 59 Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 5 Number of interviews conducted with staff: 3 Observations by licensing inspector: Breakfast and an activity were observed. A medication pass observation was completed for 3 residents. The following were reviewed: resident and staff records, medication carts, and water temperatures. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations

22VAC40-73-680-D

Based on record review, the facility failed to ensure medications be administered in accordance with the physician's or other prescriber’s instructions.

Evidence

Resident #1 has an order to be administered 5 units of insulin before meals if their blood sugar is above 200. The following are days Resident #1’s blood sugar was under 200; however, Resident #1’s MAR indicates insulin was administered: 03/02/2025 (111), 03/03/2025 (107), 03/04/2025 (99), 03/06/2025 (108), 03/09/2025 (175), 03/10/2025 (116), 03/11/2025 (190), 03/12/02025 (103), 03/14/2025 (197), 03/15/2025 (154), 03/16/2025 (182), 03/17/2025 (115), 03/20/2025 (132), 03/23/2025 (122 and 122 (2 doses)), and 03/25/2025 (109).

Plan of correction

Not published by VDSS.

22VAC40-73-320-A

Based on record review, the facility failed to ensure, within the 30 days preceding admission, the physical examination include results of a risk assessment documenting the absence of tuberculosis in a communicable form as

Evidence

d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence:
Resident #1 admitted to the facility on 09/03/2024; however, the admitting physical examination for Resident #1 (dated 08/12/2024) includes a TB risk assessment completed on 07/12/2024.

Plan of correction

Not published by VDSS.

January 8, 2025Inspection1 violation

Inspection dates

01/08/2025

Areas reviewed

22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 01/08/2025 from 10:00 am to 11:11 am. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Two self-reported incidents were received by VDSS Division of Licensing on 12/30/2024 and 1/6/2025 regarding allegations in the area(s) of: Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 67 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: 1 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 5 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations

22VAC40-73-640-A

Based on record review, observation, and interview, the facility failed to implement their written plan for medication management which includes methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes.

Evidence

On 12/27/2024, Resident #3’s PRN Lorazepam 2mg/1ml concentrate and narcotic inventory sheet were unable to be located despite documentation that it was delivered to the facility on 12/24/2024 to Staff #2.
On 01/08/2025 during a review and count of narcotics, there were only 1 narcotic inventory sheet available for two bottles of the following narcotics for Resident #4: PRN Morphine 100mg/5ml sol and PRN Lorazepam 2mg/1ml concentrate.
The facility was unable to account for Resident #3’s PRN Lorazepam. The facility also acknowledged the two bottles of narcotics did not have a narcotic inventory sheet to account for the controlled substances.

Plan of correction

Resident Care Director will ensure all narcotics have proper count sheets and our medication management plan is followed. An audit on every controlled substance will be completed to ensure compliance with our medication management plan. Education will be provided to all staff on the medication management plan as it pertains to the handling of controlled substances. Audits will be conducted weekly X4 to ensure the facility remains in compliance.

May 2, 2024Complaint survey1 violation

Inspection dates

05/02/2024

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/02/2024 from 1:45 pm to 2:55 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 05/01/2024 regarding allegations in the area(s) of: Administration and Administrative Services, Staffing and Supervision, and Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 55 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: 2 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations

22VAC40-73-460-H

Based on record review, the facility failed to ensure that personal assistance and care are provided to each resident as necessary so that the needs of the resident are met.

Evidence

Resident #1 was scheduled to received showers on Tuesdays and Fridays in the evening. The following are the documented completion or attempts of bathing for Resident #1 from January 2024 to April 2024: 1/2/24, 1/16/24 (refused), 1/19/24 (refused), 1/26/24 (refused), 1/30/24 (refused), 1/29/24, 2/13/24, 2/16/24, 3/1/24, 4/12/24, and 4/16/24. Resident #1 was noted in the hospital from 3/26/24-4/3/2024.
The documentation for Resident #1 does not indicate the resident received or attempted to receive bathing at least twice a week.

Plan of correction

Not published by VDSS.

April 18, 2024Inspection0 violations

Inspection dates

04/18/2024

Areas reviewed

22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 04/18/2024 from 1:15 pm to 1:25 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 04/12/2024 regarding allegations in the area(s) of: Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 56 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 2 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Additional Comments/Discussion: LI followed up on a self-reported incident. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

March 12, 2024Inspection15 violations

Inspection dates

03/12/2024

Areas reviewed

Technical assistance

22VAC40-73-690 22VAC40-73-980

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: 03/12/2024 from 8:45 am to 3:00 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 53 Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: Breakfast and an activity were observed. A medication pass observation was completed for 3 residents. The following were reviewed: resident and staff records, medication carts, and water temperatures. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations

22VAC40-73-450-C

Based on record review, the facility failed to ensure the comprehensive individualized service plan include a description of identified needs and the time frame for expected outcome.

Evidence

Resident #1’s UAI (dated 12/8/2023) indicates the resident is disoriented and requires physical assistance with bathing and dressing, bladder incontinence weekly or more, and assistance with money management and laundry; however, Resident #1’s ISP (dated 3/5/2024) does not address these needs. Resident #1’s ISP also does not include their allergies.
Resident #2’s UAI (dated 12/6/2023) indicates the resident requires physical assistance with toileting and assistance with medication administration; however, Resident #2’s ISP (dated 12/6/2023) does not address these needs. Resident #2’s ISP also does not include their code status.
Resident #3’s UAI (dated 1/26/2024) indicates the resident requires assistance with money management and laundry; however, Resident #3’s ISP (dated 2/9/2024) does not address these needs. Resident #3’s ISP also does not include their allergies. Additionally, Resident #3’s ISP indicates the resident requires mechanical assistance with bathing, toileting, and transfers; however, Resident #3’s UAI indicates the resident does not require assistance in these areas.
Resident #4’s UAI (dated 1/18/2024) indicates the resident requires physical assistance with toileting and wheeling and assistance with laundry, meal prep, and housekeeping; however, Resident #4’s ISP (dated 1/30/2024) does not address these needs. Resident #4’s ISP also does not include their code status. The ISP for Resident #4 does indicate the resident requires assistance with bathing, dressing, transferring, and incontinence; however, it does not indicate the type of assistance needed.
Resident #5’s ISP (dated 2/14/2024) states the resident requires mechanical and physical assistance with bathing and supervision with ambulation/mobility; however, Resident #5’s UAI (dated 1/31/2024) indicates the resident does not require assistance in these areas.
The ISPs for Resident #1 (dated 3/5/2024), Resident #2 (dated 12/6/2023), and Resident #4 (dated 1/30/2024) did not include the time frame for expected outcome.

Plan of correction

1. Resident Care Director or designee will ensure all identified needs be present on resident’s ISPs. 2. An audit of all ISPs was conducted to identify needs not present on the ISPs and will be corrected. 3. Education will be provided to all staff eligible to complete ISPs on how to properly complete an ISP and the information that must be present. 4. An audit will be conducted weekly X 4 weeks on all newly completed ISPs to ensure they are completed appropriately and accurately.

22VAC40-73-450-E

Based on record review, the facility failed to ensure the individualized service plan be signed and dated by the resident or their legal representative.

Evidence

The ISPs for Resident #1 (dated 3/5/2024), Resident #2 (dated 12/6/2023), Resident #3 (dated 2/9/2024), Resident #4 (dated 1/30/2024), and Resident #5 (dated 2/14/2024) were not signed and dated by the resident or their legal representative.

Plan of correction

1. Administrator will ensure all that ISPs are signed by the resident and/or their legal representative upon completion of each new ISP. 2. An audit of all ISPs was conducted to identify ISPs that may be lacking appropriate signatures from either the Resident or their legal representative. All signatures will be obtained. 3. Education will be provided to all staff eligible to complete the ISP on obtaining proper signatures on all documents. 4. An audit will be conducted weekly X 4 weeks on all newly completed ISPs to ensure they are signed.

22VAC40-73-990-C

Based on interview, the facility failed to document staff participation in practice exercises for resident emergencies at least once every six months.

Evidence

Staff #1 was unable to provide documentation that staff had participated in an exercise in which the procedures for resident emergencies were practiced at least every six months.

Plan of correction

1. Administrator or designee will ensure that the facility practices and exercise for resident emergencies at least every 6 months. 2. An audit was conducted of resident emergency drills to ensure future compliance. 3. Education will be provided to the maintenance director about practicing emergency drills. 4. Monthly audits will be conducted to ensure future compliance with the practicing of emergency drills.

22VAC40-73-410-A

Based on record review, the facility failed to ensure upon admission, the assisted living facility provide an orientation for new residents and their legal representatives, including emergency response procedures, mealtimes, and use of the call system. Acknowledgment of having received the orientation shall be signed and dated by the resident and, as appropriate, his legal representative, and such documentation shall be kept in the resident's record.

Evidence

Resident #3 (admitted 5/15/2023) and Resident #5 (admitted 2/5/2024) did not have evidence of receiving orientation in their resident records.

Plan of correction

1. Administrator or designee will ensure all Resident’s who admit to the facility receive a proper orientation as outlined in the regulation and ensure proper documentation of the meeting is obtained. 2. An audit of all admission from the last 6 months was conducted to monitor for missing documentation as it relates to this requirement and missing documentation will be completed at the current time. 3. Education will be provided to the Marketing Director on the importance of completing and documenting a proper orientation with all new admissions. 4. An audit will be conducted weekly X 4 weeks of all new admissions to ensure that a proper orientation was documented and completed to prevent future deficient practice.

22VAC40-73-1030-B

Based on record review, the facility failed to ensure within four months of the starting date of employment, direct care staff attend six hours of training in working with individuals who have a cognitive impairment, and the training shall meet the requirements of subsection C of this section.

Evidence

Staff #1 was unable to provide evidence of the required six hours of training in working with individuals who have a cognitive impairment within four months of the starting date of employment for Staff #2 (hired 11/6/2023) and Staff #3 (hired 10/16/2023).

Plan of correction

1. Administrator will ensure that all staff members attend 6 hours of training in working with individuals who have a cognitive impairment within their first four months of work. 2. An audit of all staff members hired within the last 4 month was conducted to ensure all staff who have net met this requirement are assigned 6 hours of training in this area. 3. Current training plan will be revised with the appropriate corporate contact to ensure the training plan going forward meets the specified regulation. 4. An audit will be conducted on 3/31/2023 to ensure all staff have been brought current on appropriate education as it relates to residents’ mental impairments.

22VAC40-73-100-C-2

Based on observation and interview, the facility failed to ensure when assisted blood glucose monitoring is required, fingerstick devices shall not be used for more than one person.

Evidence

During a review of the medication carts, unlabeled fingerstick devices were noted.
Staff #4 and Staff #5 verified fingerstick devices are utilized for more than one person.

Plan of correction

1. Resident Care Director will ensure that all residents have their own glucose monitor that is labelled with the resident’s name and stored individually. 2. An audit was then conducted to ensure each resident confirmed to require glucose monitoring had an individual glucose monitor. 3. Glucometers will be obtained for all residents who require them and staff will be educated on the proper use and storage of glucometers as well as the regulation requiring the use of separate monitors for each individual. 4. Audits will be conducted weekly X 4 weeks to ensure all residents have their own glucose monitor and they are on the medication carts and labelled accordingly.

22VAC40-73-210-F

Based on record review, the facility failed to ensure staff’s annual training include at least four hours of training focused on topics related to residents’ mental impairments.

Evidence

Staff #4’s 2023 annual training did not include 4 hours of training focused on topics related to residents’ mental impairments.

Plan of correction

1. Administrator will ensure that all staff who do not meet this requirement are assigned and complete 4 hours of training relating to residents’ mental impairments. 2. An audit of all staff members education was conducted to ensure all staff who have net met this requirement are assigned 4 hours of training in this area. 3. Current training plan will be revised with the appropriate corporate contact to ensure the training plan going forward meets the specified regulation. 4. An audit will be conducted on 3/31/2023 to ensure all staff have been brought current on appropriate education as it relates to residents’ mental impairments.

22VAC40-73-260-A

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

Evidence

Staff #2 (hired 11/6/2023) works as direct care staff and does not have a current certification in first aid.

Plan of correction

1. Resident Care Director will ensure all direct care staff members are current with First Aid Certification. 2. An audit was conducted of all direct care staff member First Aid certification to ensure that all staff are First Aid Certified. 3. First Aid classes will be scheduled and all direct care staff members who are missing the certification will be enrolled in and complete a First Aid course approved by the Virginia Department of Social Services. 4. An audit will be conducted weekly X 6 weeks of all direct care staff to ensure all staff obtain the First Aid certification.

22VAC40-73-650-A

Based on record review and interview, the facility failed to ensure no medication, dietary supplement, diet, medical procedure, or treatment shall be started, changed, or discontinued by the facility without a valid order from a physician or other prescriber.

Evidence

Staff #1 was unable to provide signed physician orders for the following medications: Ensure, Acetaminophen 500 mg tablets, Advanced Antacid, Ayr Nasal spray, Vitamin D 1250 mcg capsules, Desvenlafaxine 50 mg tablets, Esomeprazole Magnesium 40 mg capsules, Lamotrigine 150 mg tablets, Melatonin 10 mg capsules and Systane eye drops for Resident #1, Olmesartan 20 mg tablets and Aspirin 81 mg tablets for Resident #4, all active orders (18 total) for Resident #5, and Iron 325 mg tablets and Vitamin C 500 mg tablets for Resident #7.

Plan of correction

1. Resident Care Director will ensure that all medications, dietary supplements, diet, medical procedures, or treatments will have a valid order form a physician that is signed within 14 days if given verbally. 2. An audit was conducted of all orders to ensure all orders have a valid physicians signature. 3. Education will be provided to the RCD and all Nursing staff on obtained physicians signatures on verbal orders within 14 days. 4. RCD will audit all new orders weekly X 6 to ensure they have a physician’s signature within 14 days of the order.

22VAC40-73-440-B

Based on record review, the facility failed to ensure the administrator or the administrator's designated representative approves and then signs the completed UAI for private pay individuals.

Evidence

The UAIs for Resident #1 (dated 12/8/2023), Resident #3 (dated 1/26/2024), Resident #4 (dated 1/18/2024), and Resident #5 (dated 1/31/2024) were not approved and signed by the administrator or the administrator’s designated representative.

Plan of correction

1. Administrator will ensure that all ISPs have the appropriate Administrator signature. 2. An audit of all UAIs was conducted and all missing signature lines were signed. 3. Education will be provided too all staff who are able to complete the UAI for private pay individuals on the requirement of Administrator Signatures being present on all private pay UAIs 4. An audit will be conducted weekly X 4 weeks on all Public Pay UAIs to ensure they have the Administrator’s Signature.

22VAC40-73-640-A

Based on observation, the facility failed to implement their written plan for medication management which includes methods to prevent the use of outdated medications and plan for proper disposal of medication.

Evidence

The following expired medications were observed in the medication carts at the facility: Glipizide 5 mg tablets expired 2/24/2024 for Resident #7, PRN Meclizine 12.5 mg tablets expired 1/31/2024 for Resident #8, Pantoprazole Sodium 40 mg tablets expired 10/31/2023, Ferrous Sulfate 325 mg tablets expired 12/31/2023, and Magnesium Oxide 400 mg tablets expired 2/29/2024 for Resident #9, PRN Benzonatate 100 mg capsules expired 11/30/2023 for Resident #10.

Plan of correction

1. Resident Care Director will ensure that all staff members are compliant with the medication plan including policies to prevent the use of outdated medication and proper disposal of medications. 2. An audit was completed of both medication carts and any medications violating our medication management plan were removed. 3. Education will be provided to all staff who are certified to pass medications on the medication plan, including methods to prevent the use of outdated medication. 4. RCD will complete weekly audits X 6 to ensure the medication carts are free from expired medications and that medications are disposed of properly.

22VAC40-73-680-I

Based on record review, the facility failed to ensure the MAR include a diagnosis, condition, or specific indications for administering the drug or supplement and dosage.

Evidence

The following medications did not have a diagnosis on the MAR: Advanced Antacid, Airsupra, Albuterol Sulfate, Aspirin 81 mg tablet, Bisacodyl 10 mg suppository, Desvenlafaxine 50 mg tablet, Esomeprazole Magnesium 40 mg capsule, Ensure, Lamotrigine 150 mg tablet, Letrozole 2.5 mg tablet, Linzess 145 mcg capsule, Magnesium Hydroxide, Myrbetriq 25 mg tablet, Risperdal .5 mg tablet (two separate orders), Rosuvastatin 20 mg tablet, Saline Nasal spray, and Tramadol 50 mg tablets for Resident #1, Aspirin 81 mg tablet, Vitamin C 500 mg tablet, Carvedilol 25mg table Klor-Con 20 mEq tablet, Lisinopril 10 mg tablet, Melatonin 5 mg tablet, Metformin 500 mg tablet, and Vitamin D3 25 mcg tablet for Resident #3, and Aspirin 81 mg tablets, Vitamin D3 50 mcg capsules, Crestor 20 mg tablets, Melatonin 5 mg tablets, Olmesartan 20 mg tablets, Omeprazole 20 mg capsules, Sinemet 25-100mg tablets, Theragran-M Premier 50 Plus Multi-Vitamin, and Rivastigmine patch for Resident #4.
Resident #1’s order for Melatonin is in the form of capsule; however, the MAR for Resident #1 documents Melatonin is in tablet form.

Plan of correction

1. Resident Care Director will ensure all medications include a diagnosis, condition, of specific indication on the medication administration record. 2. An audit was conducted of all resident’s MARs to ensure they include a diagnosis, condition, or specific indication. 3. All nursing staff will be educated on the need for a indication on all orders that are on the medication administration record. 4. RCD will audit all new orders weekly X 6 to ensure that all new orders have a proper indication on the medication administration record.

22VAC40-73-680-D

Based on observation and record review, the facility failed to ensure medications be administered in accordance with the physician's or other prescriber’s instructions and consistent with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing.

Evidence

Resident #1’s order for Trazodone 150 mg tablet reads to give .5 tablet by mouth in the evening; however, the MAR for Resident #1 indicates to administer 1 150mg tablet at bedtime.
Resident #1’s order for Vitamin D 1250 mcg capsule reads to give every 10 days; however, the MAR for Resident #1 indicates it is scheduled to be administered once a day on Mondays.
Resident #4 has two Carbidopa-Levodopa 25-100 mg orders which are to give 1.5 tablet by mouth 2 times a day and give 2 tablets by mouth 3 times a day; however, the MAR for Resident #4 indicates 1 order to administer 2 tablets every 4 hours.
Resident #4 has an order for PRN Acetaminophen that is not included on their MAR for administration.
The MAR indicates Resident #7’s Vitamin D3 is in capsule form; however, the resident was administered the medication in tablet form.

Plan of correction

1. Resident Care Director will ensure all orders for medication will match the medication administration record. 2. An audit of all orders was conducted on to ensure orders and medication administration records match. 3. Education will be provided to all nurses to ensure physicians orders and the medications administration match. 4. RCD will audit all conduct 5 medication administration pass observations weekly to ensure appropriate medication administration

22VAC40-73-680-C

Based on record review, the facility failed to ensure medications 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.

Evidence

The following medications were scheduled, but not administration during the medication pass observation on 3/12/2024: Vitamin C, Milk of Magnesia, Omeprazole, Vitamin D3, and Methimazole for Resident #3 and Thera-M tablet for Resident #4.
Resident #3 has an order (dated 1/29/2024) to administer .5 of a Furosemide 20 mg tablet in the morning; however, it is not reflected on Resident #3’s MAR for administration.

Plan of correction

1. Resident care director will ensure that all medications are given within one hour before and one hour after the scheduled medication time. 2. An audit of the last 3 weeks of medication administration was complete. 3. All staff certified to pass medications will be educated on the medication administration policy as it relates to timeliness of medication administration times. 4. Resident Care Director will complete weekly audits X 6 to ensure compliance with medication administration times.

22VAC40-73-490-A

Based on interview, the facility failed to retain a licensed health care professional who has at least two years of experience as a health care professional in an adult residential facility, adult day care center, acute care facility, nursing home, or licensed home care or hospice organization, either by direct employment or on a contractual basis, to provide on-site health care oversight.

Evidence

Staff #1 was unable to provide a copy of a completed Health Care Oversight.

Plan of correction

1. Administrator will ensure that healthcare oversight is provided to all residents timely and in accordance with VDSS regulations. 2. An audit was conducted to compile a list of all residents who need healthcare oversight. All residents’ healthcare oversight has been updated. 3. Education has been provided to the Administrator and RCD regarding the requirement of healthcare oversight. 4. Audits will be conducted monthly until all residents have a healthcare oversight.

September 28, 2023Inspection2 violations

Inspection dates

09/28/2023, 10/04/2023

Areas reviewed

22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/28/2023. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 09/27/2023 regarding allegations in the area(s) of: Personnel. Number of residents present at the facility at the beginning of the inspection: 54 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: 1 Number of interviews conducted with staff: 1 Additional Comments/Discussion: LI followed up on a self-reported incident. 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations

22VAC40-73-40-B-12

Based on interview, the facility failed to ensure that at all times the department's representative is afforded reasonable opportunity to inspect all of the facility's buildings, books, and records and to interview agents, employees, residents, and any person under its custody, control, direction, or supervision as specified in § 63.2-1706 of the Code of Virginia.

Evidence

Staff #2’s record was requested for review at 1:30 pm upon entry into the facility and was unavailable for review at 3:15 pm upon licensing departure.

Plan of correction

Facility completed an audit of all files and will be transitioning employee files online so that they can be more accessible when surveyors enter the building. This file change will be completed by December 15th, 2023 to ensure employee files are more easily attainable when requested.

22VAC40-73-250-C

Based on record review, the facility failed to ensure personal and social data be maintained on staff and included in the staff record.

Evidence

Staff #2’s record does not include verification that the staff person has received a copy of their current job description.

Plan of correction

All HR files will be audited to ensure signed job descriptions are included in everyone’s file. Any employee who is missing a signed job description will be presented with a current job description and an acknowledgement will be obtained to ensure all staff members are aware of assigned job duties.

March 7, 2023Inspection7 violations

Inspection dates

03/07/2023

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 PREPAREDNESS22VAC40-90 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: 03/07/2023 from 8:30 am to 3:45 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 48 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Number of interviews conducted with staff: 4 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations

22VAC40-90-30-B

Based on record review, the facility failed to ensure a sworn statement or affirmation be completed for all applicants for employment.

Evidence

The following sworn disclosure statements were not properly completed: Staff #3, Staff #5, Staff #6, Staff #7, Staff #8, and Staff #9.

Plan of correction

Sworn Disclosure Statements for Staff #3, Staff #5, Staff #6, Staff #7, Staff #8, and Staff #9 have been completed appropriately and all background checks have been rerun through the Virginia State Police database. A 100% audit of all staff files to be done to ensure completeness and accuracy of all sworn disclosure statements. The Facility Administrator will educate the Human Resources and Payroll Manager on ensuring accuracy of sworn disclosure statements for any new hire personnel. Facility Administrator to audit any new hire personnel weekly for the next 3 months to ensure completeness and accuracy of sworn disclosure statements.

22VAC40-73-640-A

Evidence

The following expired medications were observed in the medication carts at the facility: two bottles of Linzess 145 mcg capsules expired 11/2022 for Resident #8, Glipizide 2.5 mg tablets expired 2/25/23 for Resident #9, Januvia 50 mg tablets expired 2/14/23 and 2 packs of Xifaxan 550 mg tablets expired 11/30/22 and 2/25/23 for Resident #10, Donepezil 10 mg tablets expired 2/25/23 and Vitamin D-3 2000-unit tablets expired 2/25/23 for Resident #11, and Losartan 50 mg tablets expired 10/31/22 and two bottles of Bumetanide 2 mg tablets expired 10/7/22 and 2/19/23 for Resident #12.
The following medications of discharged residents were observed in the medication carts at the facility: Orgovyx 120 mg tablets and Mirtrazapine 30 mg tablets for Resident #6, Lorazepam .5 mg tablets, Tramadol 50 mg tablets, Loperamide 2 mg capsules for Resident #13, and Ondansetron 4 mg tablets for Resident #14.

Plan of correction

The two bottles of Linzess 145 mcg capsules expired 11/2022 for Resident #8, Glipizide 2.5 mg tablets expired 2/25/23 for Resident #9, Januvia 50 mg tablets expired 2/14/23 and 2 packs of Xifaxan 550 mg tablets expired 11/30/22 and 2/25/23 for Resident #10, Donepezil 10 mg tablets expired 2/25/23 and Vitamin D-3 2000-unit tablets expired 2/25/23 for Resident #11, and Losartan 50 mg tablets expired 10/31/22 and two bottles of Bumetanide 2 mg tablets expired 10/7/22 and 2/19/23 for Resident #12 were immediately removed from the medication cart and destroyed. The following medications of discharged residents were observed in the medication carts at the facility: Orgovyx 120 mg tablets and Mirtrazapine 30 mg tablets for Resident #6, Lorazepam .5 mg tablets, Tramadol 50 mg tablets, Loperamide 2 mg capsules for Resident #13, and Ondansetron 4 mg tablets for Resident #14 were immediately removed from the medication cart. A 100% Medication Carts audit was completed on all medication carts to ensure no discharged residents medications or expired medications were on the cart. All discontinued medications and discharged resident’s medications have been removed from carts and properly disposed. 100% Education to all licensed nursing and medication technicians on the Rights of Medication Administration and the Facility Medication storage policy and procedure. RCD or designee will audit medication carts weekly for 3 months. All audits will be forwarded to the IDT Team.

22VAC40-73-325-B

Based on record review, the facility failed to ensure a fall risk rating is completed at least annually, when the condition of the resident changes, and after a fall.

Evidence

Upon review of the resident’s record, Resident #1 fell on 9/29/2022; however, there is no documentation of a fall risk rating being completed after the fall in the resident’s record.
Upon review of the resident’s record, the last annual fall risk rating for the Resident #2 was completed 06/10/2021.
Upon review of the resident’s record, Resident #3 fell on 9/17/2022; however, there is no documentation of a fall risk rating being completed after the fall in the resident’s record.

Plan of correction

Resident #1, #2, and #3 have had fall risk rating completed. A 100% audit of all residents’ medical records has been completed to ensure that fall risk ratings are current and accurate in each record. 100% Education for all licensed nurses by RCD on fall risk rating procedure and requirements and completion requirements. Resident Care Director (RCD) or designee will audit charts of all new resident each month to ensure annual fall risk rating is completed. RCD or designee will audit all charts of residents reviewed at weekly high risk meeting with fall to ensure fall risk rating post fall has been completed. RCD will complete audits for next 3 months. All findings will be forwarded to the community IDT team.

22VAC40-73-650-C

Based on record review, the facility failed to ensure physician's or other prescriber's oral orders are reviewed and signed by a physician or other prescriber within 14 days.

Evidence

Resident #3 has a verbal order for Melatonin 3mg tablet (ordered 11/6/2022); however, there is not an order signed by a physician or other prescriber within 14 days in the resident’s record.
The following are verbal physician orders for Resident #4: PRN oxygen (ordered 12/19/2022), Mylanta Suspension 200-200-20 MG/5ml (ordered 12/6/2022), and Omeprazole 40 mg capsule (ordered 12/6/2022). There were no signed orders for these medications by a physician or other prescriber within 14 days in the resident’s record.
The following are verbal physician orders for Resident #5: Citalopram Hydrobromide 40 mg tablet (ordered 9/12/2022), Imodium A-D 2mg capsule (ordered 1/9/2023), Mylanta Suspension 200-200-20 MG/5ml (ordered 9/12/2022), and Prilosec 20mg tablet. There were no signed orders for these medications by a physician or other prescriber within 14 days in the resident’s record.

Plan of correction

Medication orders for residents #3, 4, and 5 signed by physician on 3/7/2023. 100% Education of all licensed nurses and Med Techs by RCD on the facility policy and procedure or physician order’s and active physician order summaries was completed. RCD or designee will audit complete weekly audit to ensure all verbal orders are signed timely, and all physician order summaries are signed monthly by the resident’s primary care physician. All audit findings will be forwarded to the IDT team.

22VAC40-73-325-A

Based on record review, the facility failed to ensure for residents who meet the criteria for assisted living care, by the time the comprehensive ISP is completed, a written fall risk rating be completed.

Evidence

Upon review of the resident’s record, Resident #5 meets the criteria for assisted living care; however, there is no documentation of a fall risk rating being completed in the resident’s record.

Plan of correction

Resident #5 fall risk rating has been completed. A 100% audit of all residents’ medical records has been completed to ensure that fall risk ratings are current and accurate in each record. 100% Education for all licensed nurses by RCD on fall risk rating procedure and requirements and completion requirements. Resident Care Director (RCD) or designee will audit charts of all new residents within the first 72 hours for completeness, accuracy, and interventions of fall risk ratings for the next 3 months. All findings will be forwarded to the community IDT

22VAC40-73-690-G

Based on interview and record review, the facility failed to act in response to the recommendations noted in subsection F of this section.

Evidence

Upon record review and interview, a pharmacy medication review was conducted on 1/16/2023. Two of the six resident records reviewed included medication recommendations for physician review and response; however, there was no documentation that the recommendations were sent for physician review and response at the time of inspection.

Plan of correction

The pharmacy recommendations from last completed pharmacy review in inspection sample were sent to physician for review. 100% of all pharmacy recommendations from the last 6 months were faxed to providers on 3/8/2023. RCD or designee to ensure all physician determinations regarding pharmacy review will be appropriately addressed upon receipt. RCD to receive education regarding the community’s procedure for pharmacy recommendations from the Regional Director of Clinical Services. RCD and/or designee will conduct 100% pharmacy recommendation audits monthly. All results of findings will be reviewed by the IDT team monthly.

22VAC40-73-950-F

Based on interview, the facility failed to review the emergency preparedness plan annually or more often as needed, documenting the review by signing and dating the plan, and making necessary plan revisions. Such revisions should be communicated to staff, residents, and volunteers and incorporated into the orientation and semi-annual review for staff, residents, and volunteers.

Evidence

Staff #1 could not provide documentation of an annual review of the emergency preparedness and response plan.

Plan of correction

The Facility Administrator and Maintenance Director will develop an Emergency Preparedness and Response Plan for the community. Regional Vice President of Operations will educate the Administrator and IDT team on Emergency Preparedness and Response Plan. Emergency preparedness plan reviewed and annual sign off sheet completed. Administrator will ensure annual review completed and signed of yearly. The plan will be forwarded to the IDT team.

December 22, 2022Inspection1 violation

Inspection dates

12/22/2022

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/22/2022 from 9:15 am to 10:10 am. 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 12/10/2022 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: 47 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 interviews conducted with staff: 2 Additional Comments/Discussion: All exit doors of the facility observed. 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations

22VAC40-73-460-A

Based on discussion and record review, the facility failed to assume general responsibility for the health, safety, and well-being of the residents.

Evidence

On 12/10/2022 around 2:30 pm, Resident #1 was unable to be located. The resident was last seen in the facility by staff around 2:00 pm. The resident was found by local police around 5:00 pm behind the neighboring nursing center into a wooded area on the edge of a creek. The resident was transported and admitted to a local hospital.
Resident #1’s ISP acknowledges the resident wanders actively less than weekly. Additionally, based on the Elopement Risk Assessment, the intervention of a wander guard is in place for Resident #1 and checked for placement every shift.

Plan of correction

1. A facility incident and accident report was immediately completed. A 100% confirmation that all doors of egress were appropriately functioning was completed. Audible alarm identified as not turned on one exit door was activated and verified as functioning. Completed on 12/10/2022 2. All residents are potentially affected. Resident Care Director and/or designee to complete 100% reassessment of all resident’s elopement risk assessment has been completed. All appropriate changes to resident’s ISP’s and appropriate interventions were put in place for any resident newly identified as an elopement risk. Completed on 12/12/2022. 3. 100% in person education provided to all staff on elopement risks, signs, prevention, and protocol by Administrator and/or designee. 100% Education to dining staff to ensure kitchen door is closed when staff is not at steam table and review functioning of audible alarm in kitchen by Administrator. Completed on 12/13/2022. 4. Resident Care Director and/or designee will complete weekly elopement audit tool created to ensure compliance with risk assessment and monitor for changes in resident status. Audit will be forwarded to IDT team and reviewed during High Risk Meeting weekly. Completed on 12/16/2022.

February 18, 2022Inspection10 violations

Inspection dates

02/18/2022

Areas reviewed

22VAC40-73 PERSONNEL22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-90 The Sworn Statement or Affirmation

Comments

An unannounced renewal inspection was conducted by two Licensing Inspectors (LI) from the Eastern Regional Office on 02-18-2022 from 8:12 AM to 2:23 PM. There were 47 residents in care at the time of the inspection. All of the required postings were in place, water temperatures were sampled and in range, and lunch meal observed. LI reviewed 3 staff records, 4 resident records, emergency supply, and conducted medication observations. 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. The areas of noncompliance were discussed with the Administrator throughout the inspection and during the exit interview.

Violations

22VAC40-73-870-A

Based on observation, the facility failed to ensure the interior and exterior of all buildings be maintained in good repair and kept clean and free of rubbish.

Evidence

During a tour of the facility on 02-18-2022, two shower rooms and hall bathrooms were observed. In one shower room, the vents had a grey substance as well as broken tile in the shower. The other shower room observed had black substance on the vent and the overhead light was not operable. One of the hall bathrooms observed had the light cover missing over the sink and a black substance on the vent. The other hall bathroom observed also had grey, black substance on the vent, and the toilet was not operable.
Throughout the facility, brown stains were observed sporadically on ceiling tiles.
A broken window was observed covered with tape overlooking the contained courtyard.

Plan of correction

Maintenance Director or designee will repair broken tile in shower room and clean vents in all shower rooms and hall bathrooms. Missing light fixture cover will be replaced with new fixture and overhead light bulbs replaced. Inoperable toilet had been repaired but water line had not been turned back on, water line is on and toilet operating as expected. Maintenance Director or designee will perform weekly safety checks for all shower rooms and hall bathrooms. Maintenance Director or designee will replace all stained ceiling tiles. Maintenance Director or designee will do daily rounds of all hallways to observe for stained or damaged ceiling tiles. Maintenance Director or designee will coordinate to have cracked window pane replaced via company approved vendor.

22VAC40-90-30-B

Based on record review and interview, the facility failed to ensure the sworn statement or affirmation be completed for all applicants for employment.

Evidence

Staff #5 (hired 01-24-2022) did not have a completed sworn statement in the record.
Staff #1 acknowledged Staff #5 did not have a completed sworn statement in the record at the time of inspection.

Plan of correction

Sworn statement for Staff #5 placed in employee file. HR coordinator educated that all staff, including transfers from a company facility, requires a sworn statement maintained in their employee file.

22VAC40-73-680-D

Based on record review and interview, the facility failed to ensure medications be administered in accordance with the physician's or other prescriber’s instructions.

Evidence

On 12-09-2021, Resident #2’s order for PRN Acetaminophen was changed to every 8 hours as needed; however, Resident #2’s current MAR states for every 6 hours as needed and does not reflect the change.
Resident #1’s medication order for Norvasc 5mg Tablet included a parameter that states hold if SBP below 100 effective 2/15/22; however, there is no evidence that the resident’s blood pressure was taken on 2/15/22-2/18/22 and the resident was administered the medication.
Staff #1 and Staff #2 acknowledged the physician’s or other prescriber’s instructions on the aforementioned medications that were not reflected on the MAR and in administration.

Plan of correction

Resident #2’s order updated on MAR to reflect accurate order of Acetaminophen every 8 hours as needed. Resident #1’s order updated in electronic MAR to force documentation of blood pressure prior to administering Norvasc. Education for all LPN and Med Techs to check the returned signed physician order sheets for any changes that the primary care provider may have made. Education for all LPN’s to enter any order that contains parameters to force documentation of the parameter.

22VAC40-73-320-B

Based on record review and interview, the facility failed to ensure a risk assessment for tuberculosis be completed annually on each resident as

Evidence

d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence:
Two of the four resident records reviewed did not have an annual risk assessment for tuberculosis: Resident #2’s last risk assessment completed 10-23-2020 and Resident #3’s last risk assessment completed on 09-27-2020.
Staff #1 acknowledged the risk assessments for tuberculosis for Resident #2 and Resident #3 were not completed annually.

Plan of correction

Administrator or designee will ensure tuberculosis risk assessments for residents #2 and #3 are completed by RDCS. Administrator or designee will audit all residents to ensure all tuberculosis risk assessments are current.

22VAC40-73-260-C

Based on observation and interview, the facility failed to ensure a listing of all staff who have current certification in first aid or CPR be posted in the facility so that the information is readily available to all staff at all times.

Evidence

Staff #1 confirmed and acknowledged a listing of all staff who have current certification in first aid or CPR is not posted in the facility.

Plan of correction

Current first aid and CPR certification status for staff added to posted schedule in the nurse’s station, location is available to all staff at all times. Resident Care Director (RCD) or designee will update status monthly.

22VAC40-73-450-C

Based on record review, the facility failed to ensure the Individualized Service Plan (ISP) included a description of the resident’s identified needs based on the Uniform Assessment Instrument (UAI).

Evidence

Resident #2’s ISP (dated 10/23/20) identifies a need for bladder incontinence weekly or more; however, the last UAI (dated 10/23/20) for Resident #2 states the resident does not require assistance with bladder incontinence.
Resident #3’s ISP (dated 9/27/20) does not address a need for assistance with eating/feeding; however, the UAI (dated 9/27/20) for Resident #3 states the resident requires physical assistance with eating/feeding.
Resident #4’s ISP (9/21/21) identifies a need for mechanical assistance with mobility via a wheelchair; however, the UAI (10/20/21) for Resident #4 states the resident does not require assistance with mobility.

Plan of correction

Resident #2’s UAI and ISP (updated on 2/23/2022) both reflect the need for bladder incontinence weekly or more. Resident #3’s UAI and ISP (updated on 2/22/2022) both reflect the need for assistance with eating/feeding. Resident #4’s UAI and ISP (updated on 2/23/2022) both reflect the need for mechanical assistance for mobility. Administrator or designee will audit all current resident’s UAI and ISP to ensure the required assistance is reflected on both the UAI and ISP.

22VAC40-73-450-F

Based on record review and interview, the facility failed to review and update resident’s individualized service plans at least once every 12 months.

Evidence

Two of the four resident records reviewed did not have an updated ISPs: Resident #2’s last ISP reviewed 10-23-2020 and Resident #3’s last ISP reviewed on 09-27-2020.
Staff #1 acknowledged the ISPs for Resident #2 and Resident #3 were not reviewed at least once every 12 months.

Plan of correction

ISP for resident #2 and resident #3 to be completed by the administrator or designee. The administrator or designee will audit all residents for current ISPs and update any resident that is found to not have an ISP completed in the past 12 months.

22VAC40-73-610-B

Based on observation and interview, the facility failed to post the menus for meals and snacks for the current week in an area conspicuous to residents.

Evidence

The breakfast and lunch menu for 02-18-2022 was observed to be posted in the dining room.
Staff #6 acknowledged the menus for meals and snacks for the current week are not posted in an area conspicuous to residents.

Plan of correction

Dining Services Director will post weekly menus that include the date and day of the week, are posted in the dining room for all residents to view as they please.

22VAC40-73-980-B

Based on observation, the facility failed to ensure a first aid kit for the building and all vehicles being used to transport residents contain items as identified in the standard.

Evidence

A review of a first aid kit of the building and vehicle were reviewed. The building first aid kit did not include a blanket or triangular bandages. The vehicle first kit did not include triangular bandages or a first aid instructional manual.

Plan of correction

On day of inspection, administrator and life enrichment director did observe foil blanket in the building’s first aid kit and the vehicles first aid kit contained a cotton blanket. Building and vehicle’s first aid kits are supplied with a triangular bandage. First aid manual added to the vehicle’s first aid kit. Resident Care Director (RCD) and Life Enrichment Director or their designee will complete monthly checks of first aid kits utilizing check list that has all required supplies as well as check for expiration dates as applicable.

22VAC40-73-440-A

Based on record review and interview, the facility failed to complete resident’s UAI at least annually.

Evidence

Two of the four resident records reviewed did not have an updated UAI: Resident #2’s last UAI completed 10-23-2020 and Resident #3’s last UAI completed on 09-27-2020.
Staff #1 acknowledged the UAIs for Resident #2 and Resident #3 were not completed at least annually.

Plan of correction

UAI for resident #2 and resident #3 update completed by administrator or designee. Administrator or designee will audit all residents for current UAIs and reassess any resident that is found to not have an UAI completed in the past 12 months.

April 5, 2021Inspection1 violation

Inspection dates

April 5, 2021 and April 6, 2021

Areas reviewed

22VAC40-73 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 PREPAREDNESS

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 4/5/21 and concluded on 4/6/21. The Administrator was contacted to initiate the inspection. The Administrator reported that the current census was 45. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 3 resident records, 3 staff records, staff schedules, fire and emergency evacuation drills, and Health Care Oversight submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations

22VAC40-73-970-A

Based on record review and discussion the facility failed to conduct fire and emergency evacuation drills as required during each shift in a quarter.

Evidence

Fire and emergency evacuation drills were conducted and dated 1/29/21 at 10am (7am-3pm 1st shirt); 2/28/21 at 6:55pm (3pm-11am 2nd shift); and 3/23/21 at 1pm (7am-3pm 1st shift).
During January ?March 2021 (first quarter); no fire and emergency evacuation drill was conducted on the 11pm-7am third shift.
Staff #4 acknowledged there was no fire and emergency evacuation drill conducted on the 11pm-7am third shift for the first quarter.

Plan of correction

Maintenance director educated on regulation requirements and will ensure fire and emergency evacuation drill are conducted on each shifts at least once a quarter. Fire and emergency evacuation drill will be conducted on 11pm-7am third shift in April 2021. Administrator or designee will audit fire and emergency evacuation log weekly to ensure compliance.

March 1, 2021Complaint survey1 violation

Inspection dates

March 1, 2021 and March 2, 2021

Areas reviewed

22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS

Comments

This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A complaint inspection was initiated on 3/1/21 and concluded on 3/2/21. A complaint was received by the department regarding allegations in the area of a resident only given a shower once a week and not being served food that is liked. The Administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the Administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the allegation of no ?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

22VAC40-73-440-A

Based on record review and discussion, the facility failed to complete the Uniform Assessment Instrument (UAI) whenever there is a change in the resident’s condition.

Evidence

Resident #3’s UAI dated 6/11/2020 documented Human Help Supervision for walking. Resident #3’s Individualized Service Plan (ISP) dated 6/11/2020 documented physical assistance was needed for walking.
Staff #4 acknowledged the aforementioned UAI was not accurate.

Plan of correction

Resident Care Director (RCD) or designee will ensure accuracy of the UAI assessment. RCD or designee will ensure all updates of ISP are reflected on UAI. DRC or designee will pause and review all information before filing UAI and ISP for accuracy to ensure both documents convey the same information.

December 14, 2020Inspection0 violations

Inspection dates

Dec. 14, 2020

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 12/14/2020 and concluded on 12/15/2020. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 51. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 4 resident records, 4 staff records, staff schedules, fire and health inspection reports, and fire and emergency drills submitted by the facility to ensure documentation was complete. The information gathered during the inspection determined no violations with applicable standards of law. No violations were issued.

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.