Virginia DSS · Assisted Living Facility

Belvoir Woods Health Care Center at The Fairfax

📍 9160 Belvoir Woods Parkway, Fort Belvoir, VA, 22060

ID 46699One Year licenseActive
16
Inspections
On record
10
With violations
Visits that cited something
6
Clean visits
Nothing cited
37
Violations cited
Individual findings
32
Standards cited
Distinct rules
2
Complaint visits
Prompted by a complaint

Belvoir Woods Health Care Center at The Fairfax was inspected 16 times between January 7, 2021 and April 10, 2026 by the Virginia Department of Social Services. 10 of those visits ended with violations cited and 6 with none. Across that history VDSS cited 37 violations under 32 distinct standards. 2 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
One Year
License expires
04/15/2027
Administrator
Rochelle Hale
Licensing inspector
Jacquelyn Kabiri
Inspector phone
(703) 397-3017
Approved for
Assisted Living · Special Care Unit

Inspection History

16

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

April 10, 2026Inspection1 violation
Inspection dates
04/10/2026
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: 04/10/2026, 10:00 a.m. to12:45 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 03/24/2026 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: 69 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents:0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Lunch Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the self-report; 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 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. 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 t hese 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 Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017 or by email at Jacquelyn.Kabiri@dss.virginia.gov
Violations
22VAC40-73-460-H
Based on resident record review and staff interview, 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, including assistance or care with bathing at least twice a week, but more often if needed or desired.
Evidence
  1. On 03/24/2026, the facility self-reported an allegation of neglect as it relates to resident 1’s care to include showering/ bathing, and skin care, to licensing.
  2. Resident 1’s uniform assessment instrument (UAI), dated 03/16/2026, indicates that the resident requires physical human assistance with bathing, and the individualized service plan (ISP) for resident 1, dated 03/16/2026, indicates that 1 staff person will provide physical assistance with showering, bathing, and washing.
  3. Resident 1’s ISP lists resident 1’s bathing/shower schedule as two times weekly on Wednesday and Saturday morning, with an initiation date of 03/03/2026.
  4. The monthly schedule sheet for resident 1’s bathing/showering indicates the dates for the month of March and an indication when the resident receives the service with a box for staff to initial and document the time the service was received.
  5. Resident 1 was admitted on 03/02/2026 and discharged 03/18/2026; however, resident 1’s record indicated 1 bath/shower on March 18, 2026, at 11:03 a.m. There was no other documentation of bathing/showering for resident 1 in their record or provided during the onsite inspection.
  6. In an interview with the LI, Staff 1 confirmed resident 1’s bathing/shower log provided, which included documentation of 1 shower provided during their stay at the facility from 03/02/2026-03/18/2026 during the inspection.
Plan of correction
A. Immediate Solution: Resident 1 no longer lives in the community. B. Expand Scope: On 04/20/2026, the Resident Care Director (RCD) reviewed the Task Records of current residents to confirm showers are scheduled and given according to their individualized service plan (ISP). Any deficiencies were corrected immediately. C.Systemic Change: 1.On 04/22/2026, the Administrator (ADMIN) re-educated current care team staff to complete showers according to each resident's ISP. Newly hired care team staff will receive education as part of the orientation process. 2.The Resident Care Coordinator (RCC)/designee will review the Task Records of current residents to confirm showers are scheduled and given according to their ISP. Any deficiencies will be corrected immediately. D.Monitoring: The RCD/designee will audit (5) resident Task Records shower documentation weekly x 4 and monthly x 2. Findings from the audit will be reviewed during QAPI Meeting. The Administrator is responsible for confirming the implementation and compliance of this POC and addressing and resolving any variations that may arise.
February 26, 2026Inspection9 violations
Inspection dates
02/26/2026
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS for FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS63.2- (18) Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report
Technical assistance
TA: Application needs to be submitted prior to the expiration. Staff T.B assessment forms.
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: 02/26/2026, 9:30 a.m. to 5:00 p.m. Number of residents present at the facility at the beginning of the inspection: 69 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Number of staff records reviewed: 3, and 1 partial review. Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: Activities, lunch, medication pass. Additional Comments/Discussion: 3 staff observations only 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. f 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 Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017 or by email at Jacquelyn.Kabiri@dss.virginia.gov
Violations
22VAC40-73-320-A
Based on record review and interview, the facility failed to ensure that a person shall have a physical examination by an independent physician. The report of such examination shall be on file at the assisted living facility and shall contain all required components.
Evidence
  1. Resident 7’s physical examination report dated 05/12/2025 was missing ambulatory or non-ambulatory status.
  2. During the onsite inspection on 02/26/2026, Staff 1 and staff 3 acknowledged LI’s findings.
Plan of correction
Not published by VDSS.
22VAC40-73-490-D
Based on record review and interview, the facility failed to ensure the licensed health care professional identified the specific residents for whom the health care oversight was provided.
Evidence
  1. Health Care Oversight dated 12/19/2025 to 06/08/2025 did not document the names of the residents for whom the oversight was provided.
  2. During the onsite inspection on 02/26/2026, Staff 1 and Staff 2 acknowledged the LI’s findings.
Plan of correction
Not published by VDSS.
22VAC40-73-1180-A
Based on observation, the facility failed to ensure that when there are indications that ordinary materials or objects may be harmful to a resident, these materials or objects shall be inaccessible to the resident except under staff supervision.
Evidence
  1. During the inspection on 02/26/2026 at approximately 11:40 a.m., the LI toured the secure environment of the facility. The following observations were made in the hallway outside of resident rooms where active remodeling or repair services appeared to be in progress. At the time of observation, no staff members, maintenance personnel, or contractors were present in the area to supervise or secure the materials. The following items were observed accessible in the hallway: a. One orange ladder and one piece of drywall leaning against a laundry basket containing soiled bed sheets and a plastic trash bag with cleaning cloths. b. One white ceramic bathroom toilet positioned upright against the hallway wall. c. One tool bag containing tools, a set of knee pads, and a metal carpet knee-kicker tool. d. One upright vacuum and one caulking gun with a container of caulk.
  2. Photos taken as evidence.
Plan of correction
Not published by VDSS.
22VAC40-73-680-G
Based on direct observations and an interview during the medication cart audit, the facility failed to have any over-the-counter medication labeled with the resident's name or in a pharmacy-issued container until administered.
Evidence
  1. On 02/26/2026, at approximately 12:28 p.m.,the LI observed a medication pass with staff 4 and conducted a medication cart audit. A bottle of extra-strength Tylenol, 500 mg tablets, was observed unlabeled with no identifiable information to indicate who it belonged to.
  2. Staff 4 acknowledged there was no name or label on the bottle of Tylenol but stated it belonged to Resident 2.
  3. Photo evidence taken.
Plan of correction
Not published by VDSS.
22VAC40-73-640-A
Based on documentation and interview, the facility failed to implement the medication management plan to include that each resident's over-the-counter medications and supplements were labeled.
Evidence
  1. The facility’s medication management plan states that, “Non-prescription medications not labeled by the pharmacy are kept in the manufacturer’s original container. Nursing care center personnel may write the resident’s name on the container or label as long as the required information is not covered”.
  2. On 02/26/2026, the LI observed the medication cart located in the safe secure unit. One bottle of extra-strength Tylenol, 500 mg tablets, was observed unlabeled, with no resident name.
  3. During the onsite inspection on 02/26/2026, Staff 1 and staff 3 acknowledged the LI’s findings.
  4. Photo evidence taken.
Plan of correction
Not published by VDSS.
22VAC40-73-320-B
Based on record review, the facility failed to ensure a risk assessment for tuberculosis (TB) shall be completed annually on each resident as
Evidence
  1. d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence:
  2. The record for resident 6, (admitted 10/10/2022); contained a risk assessment for TB dated 09/17/2025.
  3. The record for resident 3, (admitted 10/01/2021) contained risk assessments for TB dated 09/12/2024 and for 09/08/2025.
  4. Resident 6 and Resident 3’s assessments for TB were not consistent within the Virginia Department of Health’s assessment screening. The facility’s TB assessment form states, “None of the above symptoms were noted”, but does not list or indicate what those symptoms were. Additionally, the facility’s TB assessment form states” No above risk factors noted” but does not list or indicate what those risk factors were.
  5. During the onsite inspection on 02/26/2026, Staff 1, and staff 2 reviewed the LI’s findings.
Plan of correction
Not published by VDSS.
22VAC40-73-460-I
Based on direct observation and interviews, the facility failed to ensure that each resident shall be dressed in clean clothing and be free of odors related to hygiene.
Evidence
  1. On 02/26/2026 at approximately 12:10 p.m., the LI observed staff 4 administering medication to resident 5. Resident 5 was seated in a wheelchair. The LI observed several wet areas on the lap of the resident’s pants, as well as what appeared to be food and food stains on the clothing. Additionally, the LI observed what appeared to be a small piece of orange cheese on the upper portion of the resident’s shirt. The LI asked resident 5 for permission and removed the cheese piece from the resident’s shirt.
  2. Staff 4 stated that resident 5 was on the way to lunch after receiving the medication.
  3. During an interview, the LI discussed the observations with staff 1 and staff 2. Resident 5 appeared to be wearing clothing that was visibly wet and stained, with food present on the clothing and body, which appeared consistent with food remaining from breakfast, as the resident was being taken to lunch immediately following the medication pass.
Plan of correction
Not published by VDSS.
22VAC40-73-860-D
Based on direct observation and staff interview, the facility failed to ensure that any operable window was effectively screened.
Evidence
  1. During the facility tour on 02/26/2026, at approximately 11:05 a.m., the LI observed that the secure memory unit dining area window was operable and missing its window screen.
  2. During the onsite inspection on 02/26/2026, Staff 1 confirmed the dining room window is missing a window screen.
  3. Photo evidence obtained.
Plan of correction
Not published by VDSS.
22VAC40-73-550-F
Based on a tour of the building and staff interview, the facility failed to ensure that the rights and responsibilities of residents are posted conspicuously in a public place with correct information available to the public.
Evidence
  1. During the onsite inspection on 02/26/2026, the LI observed that a list of Residents’ Rights and Responsibilities was posted in the assisted living hallway in six wall frames. 2.The information displayed in wall frame number six contained incorrect contact information for the Virginia Department of Social Services Licensing Division’s Licensing Administrator. 3.During the onsite inspection on 02/26/2026, Staff 1 confirmed the LI’s findings.
Plan of correction
Not published by VDSS.
January 6, 2026Inspection2 violations
Inspection dates
01/06/2026
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Technical assistance
Email updated signatures/TB update.
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: 01/06/2026, 11:00 a.m. to 2:30 p.m. 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 12/29/2025, 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: 65 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 4 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Breakfast Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017, or by email at Jacquelyn.Kabiri@DSS.virginia.gov.
Violations
22VAC40-73-1110-B
Based on a review of resident records the facility failed to perform a six-month review of the appropriateness of continued residence in the memory care unit.
Evidence
  1. Resident 2 was admitted to the secure facility on 04/05/2024. The most recent review determining the continued appropriateness of this placement was completed on 10/01/2024.
  2. Staff 1 confirmed the date of resident 2’s most current continued appropriateness of placement.
Plan of correction
On 01/09/2026, the Wellness Nurse completed the annual placement review on Resident 2. Continued residence in the special care unit was deemed appropriate for this individual. On 01/09/2026, the Resident Care Coordinator completed a review of all residents’ records in the Reminiscence Memory Care neighborhood to ensure the annual placement review was current and present in the record. On 01/08/2026, the Resident Care Coordinator, Wellness Nurse, and Senior Resident Care Coordinator were re-educated by the Administrator. Education included the VA Assisted Living Facilities 22VAC40-73-1100 Approval regulation and accompanying form. On 01/09/2026, the Wellness Nurse created an ongoing Viriginia Review of Appropriateness of Continued Residence in Special Care Unit – V1 assessment to populate annually for all current residents in the Reminiscence Memory Care neighborhood. The Resident Care Coordinator or designee will review the clinical dashboard for upcoming scheduled assessments during the daily Stand-Up Meeting. A monthly random audit will be performed to confirm the continued appropriate placement is completed timely. The Administrator is responsible for confirming the implementation and compliance of this POC and addressing and resolving any variations that may occur. Findings will be reviewed during QAPI Meeting.
22VAC40-73-70-A
Based on the record review, the facility failed to ensure that a report was submitted within 24 hours of any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident.
Evidence
  1. On 12/26/2025, a potential resident-to-resident incident occurred at the facility that required eporting. The required report was not submitted to the Department of Social Services Licensing Division until 12/29/2025.
  2. During an interview with the Licensing Inspector (LI), Staff 1 stated that the report was not submitted within the required timeframe.
Plan of correction
On 12/29/2025, the Administrator provided training to the Associate Executive Director regarding the importance of reporting allegations of abuse timely. Education included the Center’s policy on Abuse, Neglect & Exploitation – Prevention, Reporting and Investigation. On 12/29/2025, the Nurse completed a head-to-toe skin assessments on all female residents in Reminiscence Memory Care Neighborhood. No evidence of abuse. On 12/29/2025, the Administrator initiated training to current staff. Education included the Center’s policy on Abuse, Neglect & Exploitation – Prevention, Reporting and Investigation. Current staff were provided the Administrator’s phone number to contact and report known or suspected abuse, neglect and/or exploitation. Resident events will be reviewed during daily Stand Up Meeting to ensure any reportable events are reported timely. The Administrator is responsible for confirming the implementation and compliance of this POC and addressing and resolving any variations that may occur. Findings will be reviewed during QAPI Meeting.
December 12, 2025Inspection0 violations
Inspection dates
12/12/2025
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 Complaint Investigation
Technical assistance
22VAC40-73-450. ISP needs to be reviewed, signed, and dated timely.
Comments
Type of inspection: ¿Complaint¿ Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/12/2025, 10:30a.m. to 11:30 a.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on (12/08/2025) regarding allegations in the area(s) of: Resident Care and Related Services and Staffing and Supervision. Number of residents present at the facility at the beginning of the inspection: 65 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Activities 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 Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017 or by email at Jacquelyn.Kabiri@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
November 6, 2025Complaint survey0 violations
Inspection dates
11/06/2025
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 Complaint Investigation
Technical assistance
Keep kitchen cabinets locked in memory care.
Comments
Type of inspection: ¿Complaint¿ Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/06/2025, 9:00a.m. to 11:00 a.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on (11/03/2025) regarding allegations in the area(s) of: Resident Care and Related Services and Staffing and Supervision. Number of residents present at the facility at the beginning of the inspection: 69 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 6 Observations by licensing inspector: Activities and Lunch Additional Comments/Discussion: None. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) 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 Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017 or by email at Jacquelyn.Kabiri@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
September 2, 2025Inspection1 violation
Inspection dates
09/02/2025
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/02/2025, 1:00 p.m. to 4:00 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 2 Self-reports were received by VDSS Division of Licensing on 08/20/2025 and 08/28/2025, regarding allegations in the area(s) of: Direct Care and Related Services, Staffing and supervision, Building and Grounds, and Additional Requirements for Facilities That Care for Adults with Serious Cognitive Impairment. Number of residents present at the facility at the beginning of the inspection: 109 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: None Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-reports of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the (complaint(s)/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 Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017 or by email at Jacquelyn.Kabiri@dss.virginia.gov
Violations
22VAC40-73-1150-A
Based on observation and interview, the facility failed to ensure doors that lead to unprotected areas be monitored or secured through devices that conform to applicable building and fire codes, including door alarms, cameras, constant staff oversight, security bracelets that are part of an alarm system, pressure pads at doorways, delayed egress mechanisms, locking devices, or perimeter fence gates for residents residing in a safe, secure environment.
Evidence
  1. On 08/21/2025 and 08/28/2025, the facility self-reported the following elopements due to a malfunctioning door on the safe, secure environment: Resident 1 on 08/21/2025 and Resident 2 on 08/28/2025.
  2. On 09/02/2025, at approximately 1:26 p.m. the licensing inspector (LI) toured the facility to inspect all exit doors on the secure unit to include the exit door resident 1 and resident 2 eloped through 08/20/2025 and 08/28/2025.
  3. During this tour, the exit door located in wing 1, with a sign labeled “East exit Stair”, was noted to be a delayed egress door designed to open after pushing the middle handle for 15 seconds. The LI tested the handle for 15 seconds, 30 seconds, and 60 seconds, but the door did not open. Staff 1 also performed the same test with identical results.
  4. During an interview with staff 1 and staff 3, it was confirmed that two identified exit doors within the safe, secure environment were malfunctioning, with one resulting in the elopement of resident 1 on 08/21/2025 and resident 2 on 08/28/2025, and the other not operating as a delayed egress door as designed.
  5. A video and photos taken as evidence.
Plan of correction
The Director of Facilities ordered delayed egress maglocks to replace the existing straight maglocks on the exit doors on the secure unit. On 09/02/2025, the Director of Facilities inspected exit doors on the secure unit for the delay functionality and having direct maglocks. The Director of Facilities initiated training for the engineering team on how to conduct door test and inspections properly and how to resolve identified test failures. The Director of Facilities and or designee will conduct monthly door inspections to confirm that delayed egress maglocks are functioning properly. For 6 months the Director of Facilities will review the findings with their supervisor to confirm issues identified are resolved timely and the documentation for testing and inspection are complete. Findings and resolutions from the monthly door inspection will be presented to QAPI program meetings and discuss plan of correction. The Skilled Nursing Administrator is responsible for confirming the implementation and ongoing compliance of this POC and addressing and resolving any variations that may occur.
June 27, 2025Inspection0 violations
Inspection dates
06/27/2025
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: 06/27/2025, 10:00 A.M. to 12:15 A.M. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 06/09/2025 regarding allegations in the area(s) of: Resident Care and Related Services, Personnel. Number of residents present at the facility at the beginning of the inspection: 69 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 Observations by licensing inspector: Activities. Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the 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 Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017, or by email at Jacquelyn.Kabiri@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
September 24, 2024Complaint survey2 violations
Inspection dates
09/24/2024
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESSARTICLE 1 – SUBJECTIVITY63.2- (1) GENERAL PROVISIONS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 09/24/2024 regarding allegations in the area(s) of: RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS & RESIDENT CARE AND RELATED SERVICES. Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/24/2024 12:15 PM to 2:05 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: 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: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 4 Observations by licensing inspector: Meals in Special Care Unit. Additional Comments/Discussion: Staff interviews were conducted off-site via telephone. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. However, violation(s) not related to the complaint but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Violations
22VAC40-73-930-D
Based on resident record review and staff interview, the facility failed to ensure that the Individualized Service Plan (ISP) specified a minimal frequency of daily rounds to be made by direct care staff to monitor for emergencies or other unanticipated resident needs.
Evidence
  1. Resident 1’s record contains an ISP, with a focus that states “Inability to use signaling device with need for night safety checks” initiated on 09/23/2022 and revised on 03/13/2024. The goal states “My safety needs will be met daily due to my inability to use my signaling device through the next review date. The interventions state “I am unable to use my signaling device due to [psychosis] and require safety needs to be anticipated and met. I require night safety check due to inability to use my signaling device.
  2. The ISP does not contain the minimum frequency of rounds to be completed due to the resident’s inability to use the signaling device.
Plan of correction
With respect to the specific resident/situation cited: There is no evidence that the cited issue affected any specific resident(s). With respect to how the facility will identify residents/situations with the potential for the identified concerns: The community’s Assisted Living Coordinator (ALC) and Reminiscence Coordinator (RC) performed 100% audit of ISP to confirm the compliance with regulation related to ISP on resident’s inability to use the signaling device and a minimal frequency of daily rounds. All residents found non-compliant with the regulation was corrected. With respect to what systemic measures have been put into place to address the stated concern: The community’s administrator provided education to Assisted Living Coordinator, Reminiscence Coordinator, Resident Care Director, Activities and Volunteer Coordinator, and Certified Dietary Manager regarding the regulation related to ISP on resident’s inability to use the signaling device and a minimal frequency of daily rounds. With respect to how the plan of correction will be monitored: The community’s administrator and/or designee will perform audit of random 3 ISPs monthly for 3 months to confirm the compliance with the regulation. The community’s administrator and/or designee will report the results of the audits to the Quality Assurance and Performance Improvement Committee for the next 3 months. During and at the conclusion of the 3 months, the QAPI Committee will re-evaluate and initiate the necessary action or extend the review period. The Administrator and/or designee is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction and addressing and resolving variances that may occur.
22VAC40-73-70-A
Based on resident record review and staff interview, the facility failed to ensure that any major incident that has negatively affected or that threatens the health, life, safety and welfare of any resident was reported to the regional licensing office within 24 hours.
Evidence
  1. A complaint was received on 09/24/2024 regarding resident accommodations and related provisions, as well as resident care and related services for Resident 1.
  2. Resident 1’s record contains a progress note written by Staff 4 on 06/30/2024 at 7:32 AM that states “…EMT pronounce death of resident at 5:15 am…”
  3. Staff 1 confirmed that Resident 1 was not on hospice and an initial incident report was not sent to the regional licensing office.
Plan of correction
With respect to the specific resident/situation cited: There is no evidence that the cited issue affected any specific resident(s). With respect to how the facility will identify residents/situations with the potential for the identified concerns: The community’s administrator performed 100% audit of all resident deaths this year to confirm the compliance with the regulation and the administrator submitted a FRI to DSS on 9/24/24 regarding one death on 9/14/24. There were no other issues noted from the audit. With respect to what systemic measures have been put into place to address the stated concern: The community’s administrator provided education to Assisted Living Coordinator, Reminiscence Coordinator, Resident Care Director, Activities and Volunteer Coordinator, and Certified Dietary Manager regarding the incident report guideline related to death of residents who are not under hospice services at the time of death. With respect to how the plan of correction will be monitored: The community’s administrator and/or designee will perform audit of all residents’ deaths for the next 3 months to confirm the compliance with the regulation. The community’s administrator and/or designee will report the results of the audits to the Quality Assurance and Performance Improvement Committee for the next 3 months. During and at the conclusion of the 3 months, the QAPI Committee will re-evaluate and initiate the necessary action or extend the review period. The Administrator and/or designee is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction and addressing and resolving variances that may occur.
May 15, 2024Inspection11 violations
Inspection dates
05/15/2024, 05/16/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STA TEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/15/2024: 9:30 AM to 5:00 PM 05/16/2024: 8:25 AM to 4:35 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: 70 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Number of staff records reviewed: 6 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 5 Observations by licensing inspector: Meals, Activities, Medication Pass. Additional Comments/Discussion: N/A 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 Amanda Velasco, Licensing Inspector at (571) 510 2058 or by email at Amanda.Velasco@dss.virginia.gov
Violations
22VAC40-73-680-K
Based on resident record review and staff interview, the facility has failed to obtain a detailed PRN medication order from the resident’s physician or other prescriber that include symptoms that indicate the use of the medication when medication aides administer the PRN medication.
Evidence
  1. Resident 3 has an order for 02/17/2023 for LORazepam Oral Tablet 1 MG (Lorazepam).
  2. The order states “Give 1 tablet by mouth every 2 hours as needed for anxiety.”
  3. Staff 1 confirmed the order does not have detailed symptoms that indicate the use of medication.
Plan of correction
A. With respect to the specific resident/situation cited: The community’s Resident Care Director (RCD) updated the order to reflect the symptoms for use of the prn medication for the resident identified. (05/20/2024) B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: The RCD added specific symptoms on prn psychotropic medications orders for other residents to be compliant with the regulation. (05/20/2024) C. With respect to what systemic measures have been put into place to address the stated concern: The RCD and/or designee will add specific symptoms on prn psychotropic medications orders going forward. (05/20/2024) The RCD and/or designee will initiate education for nurses to include detailed symptoms on writing an order of prn psychotropic medications. (07/01/2024) D. With respect to how the plan of correction will be monitored: The community’s Resident Care Director and/or designee will perform audit of random 3 residents with prn medication weekly for the first month and then monthly for two months to confirm the compliance with the regulation. The community’s RCD and/or designee will report the results of the audits to the Quality Assurance and Performance Improvement Committee for the next 3 months. During and at the conclusion of the 3 months, the QAPI Committee will re-evaluate and initiate the necessary action or extend the review period. The Administrator and/or designee is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction and addressing and resolving variances that may occur. (09/30/2024)
22VAC40-73-410-A
Based on resident record review and staff interview, the facility failed to ensure acknowledgment of having received the facility orientation was signed and dated by the resident and such documentation shall be kept in the resident's record.
Evidence
  1. Resident 2 (date of admission 02/06/2023) and 5’s (date of admission 11/01/2022) records contained a facility orientation that was signed by the facility and the resident’s legal representative, but not the resident signature.
  2. Staff 1 confirmed the facility orientation was signed by the legal representative and not the resident.
  3. Resident 1’s (date of admission 10/26/2022) record did not contain an acknowledgement of the facility orientation.
  4. Staff 1 confirmed they did not complete the facility orientation.
Plan of correction
A. With respect to the specific resident/situation cited: The community’s ALC and RC will provide resident #2 and #5 orientation to the community with signed acknowledgement. (07/05/2024) B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: The community’s ALC and RC will perform 100% audit of new resident files since last survey and identify any resident agreement signed only by resident’s representative(s). Any issues identified will be corrected with orientation to the resident(s) with acknowledgement. (07/24/2024) C. With respect to what systemic measures have been put into place to address the stated concern: The community’s administrator provided education for Director of Sales, Assisted Living Coordinator and Reminiscence Coordinator on requirement of 22VAC40-73-410. (06/27/2024) D. With respect to how the plan of correction will be monitored: The community’s Administrator and/or designee will perform audit of each new resident agreement for 3 months to confirm the compliance with the regulation. The community’s Administrator will report the results of the audits to the Quality Assurance and Performance Improvement Committee for the next 3 months. During and at the conclusion of the 3 months, the QAPI Committee will re-evaluate and initiate the necessary action or extend the review period. The Administrator and/or designee is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction and addressing and resolving variances that may occur. (09/30/2024)
22VAC40-73-260-C
Based on direct observation and staff interview, the facility failed to ensure A listing of all staff who have current certification in first aid or CPR was posted in the facility so that the information is always readily available to all staff.
Evidence
  1. A list of all staff with current certification in first aid or CPR was not posted in the facility.
  2. Staff 1 confirmed the facility did not have a list posted.
Plan of correction
A. With respect to the specific resident/situation cited: Care team members’ schedule was posted in the wellness office as a list for 1st Aid and CPR certified staff list. (06/24/2024) B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: Since all care team members are 1st Aid and CPR certified, team member schedule can be used for the certified team members list. The community posted care team member schedule in Wellness office. (06/24/2024) C. With respect to what systemic measures have been put into place to address the stated concern: The community’s RCD, ALC and RC will continue to post the care team member schedule at Wellness office weekly and as needed in case of updates to be compliant with the regulation. (06/24/2024) D. With respect to how the plan of correction will be monitored: The community’s Administrator and/or designee will perform audit of schedule posting in wellness office weekly for the next 3 months to confirm the compliance with the regulation. The community’s Administrator will report the results of the audits to the Quality Assurance and Performance Improvement Committee for the next 3 months. During and at the conclusion of the 3 months, the QAPI Committee will re-evaluate and initiate the necessary action or extend the review period. The Administrator and/or designee is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction and addressing and resolving variances that may occur. (09/30/2024)
22VAC40-73-950-E
Based on resident record review and staff interview, the facility failed to ensure semi-annual review on the emergency preparedness and response plan was conducted for all residents with emphasis placed on an individual's respective responsibilities.
Evidence
  1. Resident 1’s (date of admission 10/26/2022) record did not contain review of emergency preparedness and response plan semi-annually.
  2. Resident 1’s last dated review was 10/10/2022.
  3. Staff 1 confirmed the semi-annual review had not been completed.
Plan of correction
A. With respect to the specific resident/situation cited: Community’s ALC will review the emergency preparedness and response plan with resident #1. (06/28/2024) B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: The community implemented the semi-annual review of the community’s emergency preparedness and response plan with signature for all residents during semi-annual ISP meetings. (06/16/2024) C. With respect to what systemic measures have been put into place to address the stated concern: The semi-annual review for all residents continues to be done during semi-annual ISP meetings. (06/16/2024) The administrator educated team members including leadership team regarding the importance of semi-annual review of the community’s emergency preparedness and response plan and also reviewed the community’s plan during Town Hall on 6/25/24. D. With respect to how the plan of correction will be monitored: The community’s Administrator and/or designee will perform audit of random 3 residents monthly for 3 months to confirm the compliance with the regulation. The community’s Administrator and/or designee will report the results of the audits to the Quality Assurance and Performance Improvement Committee for the next 3 months. During and at the conclusion of the 3 months, the QAPI Committee will re-evaluate and initiate the necessary action or extend the review period. The Administrator and/or designee is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction and addressing and resolving variances that may occur. (09/30/2024)
22VAC40-73-350-C
Based on facility document review and staff interview, the assisted living facility failed to ensure that each resident or his legal representative is fully informed upon admission and annually, that he should exercise whatever due diligence he deems necessary with respect to information on any sex offenders registered, including how to obtain such information.
Evidence
  1. Residents 1 (date of admission 010/26/2022), 2 (date of admission 02/06/2023), and 6’s (date of admission 11/01/2022) records did not contain an annual notification that he should exercise whatever due diligence he deems necessary with respect to information on any sex offenders registered, including how to obtain such information.
  2. Staff 1 confirmed the annual notification had not been completed.
  3. Resident 5’s (date of admission 4/05/2024) record did not contain notification that he should exercise whatever due diligence he deems necessary with respect to information on any sex offenders registered, including how to obtain such information upon admission.
  4. Staff 1 confirmed the notification had not been completed upon admission.
Plan of correction
A. With respect to the specific resident/situation cited: Community’s ALC will provide information on any sex offenders registered, including how to obtain such information, for resident #1, #2, and #6. Community’s RC will provide information on any sex offenders registered, including how to obtain such information, for resident #5’s representative. (06/28/2024) B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: The community will implement the annual review of sex offender information during ISP meetings. (05/31/2024) C. With respect to what systemic measures have been put into place to address the stated concern: The community’s administrator provided education for Director of Sales, Assisted Living Coordinator (ALC) and Reminiscence Coordinator (RC) on requirement of 22VAC40-73-350. (05/20/2024) D. With respect to how the plan of correction will be monitored: The community’s Administrator and/or designee will perform audit of random 3 residents’ ISPs monthly for 3 months to confirm the compliance with the regulation. The community’s Administrator will report the results of the audits to the Quality Assurance and Performance Improvement Committee for the next 3 months. During and at the conclusion of the 3 months, the QAPI Committee will re-evaluate and initiate the necessary action or extend the review period. The Administrator and/or designee is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction and addressing and resolving variances that may occur. (09/30/2024)
22VAC40-73-960-B
Based on direct observation and staff interview, the facility failed to ensure a fire and emergency evacuation drawing was posted in a conspicuous place on each floor of each building used by residents containing primary and secondary escape routes, areas of refuge, assembly areas, telephones, fire alarm boxes, and fire extinguishers.
Evidence
  1. It was observed by two licensing inspectors that the third-floor emergency evacuation drawing contained an image of a telephone.
  2. There was no phone available on the third floor.
  3. Staff 1 confirmed the evacuation drawing contained a phone that didn’t exist.
Plan of correction
A. With respect to the specific resident/situation cited: The fire and emergency evacuation drawings were all updated during the survey and informed the surveyor of the immediate correction. (05/16/2024) B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: 100% house audit of the telephone was conducted, and evacuation drawing was revised accordingly. (05/16/2024) C. With respect to what systemic measures have been put into place to address the stated concern: The community’s administrator provided education for key team members regarding importance of accurate evacuation plan and emergency numbers readily available on the community telephones. (05/16/2024) D. With respect to how the plan of correction will be monitored: The community’s administrator and/or designee will perform monthly audits of the community telephones and evacuation plans for the next 3 months. The community’s administrator and/or designee will report the results of the audits to the Quality Assurance and Performance Improvement Committee for the next 3 months. During and at the conclusion of the 3 months, the QAPI Committee will re-evaluate and initiate the necessary actions or extend the review period. The Administrator and/or designee is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction and addressing and resolving variances that may occur. (09/30/2024)
22VAC40-73-620-B
Based on facility document review and staff interview, the facility failed to ensure the special diet oversight was certified that the requirements of this subsection (22VAC40-73-620) were met including the date of oversight and identification of the residents for whom the oversight was provided.
Evidence
  1. The facility’s special diet oversights completed on 09/15/2023, 01//11/2024, and 03/28/2024 did not contain a certification statement that the requirements of 22VAC40-73-620 were met.
  2. Staff 1 confirmed the special diet oversight did not contain a certification statement that the requirements of 22VAC40-73-620 were met.
Plan of correction
A. With respect to the specific resident/situation cited: A Certification of Oversight of Special Diets was created, and the dietitian certified and signed the form per 22VAC40-73-620 of Standards for Licensed Assisted Living Facilities and obtained the signature on the Crandall form during the survey. (05/16/2024) B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: The community’s administrator provided education for community’s Food Services Director and Certified Dietary Manager to ask Crandall dietitian to certify and sign the Crandall form per 22VAC40-73-620 of Standards for Licensed Assisted Living Facilities going forward. (05/16/2024) C. With respect to what systemic measures have been put into place to address the stated concern: The Certification of Oversight of Special Diets on the Crandall Form will be implemented going forward and community’s Food Services Director and/or Certified Dietary Manager will verify the compliance.(06/24/2024) D. With respect to how the plan of correction will be monitored: The Food Services Director and/or designee will perform audit of Crandall Form during their next visit in July to confirm the compliance with 22VAC40-73-620 of Standards for Licensed Assisted Living Facilities. (07/15/2024) The Food Services Director and/or designee will report the results of the compliance with 22VAC40-73-620 to the Quality Assurance and Performance Improvement Committee for the next 6 months. (07/15/2024) During and at the conclusion of the 6 months, the QAPI Committee will re-evaluate and initiate the necessary actions or extend the review period. (10/15/2024) The Administrator and/or designee is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction and addressing and resolving variances that may occur. (10/15/2024)
22VAC40-73-240-F
Based on volunteer record review and staff interview, the facility failed to ensure all volunteers, prior to beginning volunteer service, attended an orientation including information on their duties and responsibilities, resident rights, confidentiality, emergency procedures, infection control, the name of their supervisor, and reporting requirements.
Evidence
  1. Volunteer records for Staff 10, 11, 12, 13, and 14 did not contain documentation of orientation or their assigned duties and responsibilities prior to beginning volunteer service.
  2. Staff 4 confirmed the volunteer records were not completed.
Plan of correction
A. With respect to the specific resident/situation cited: The community’s Activities and Volunteer Coordinator (AVC) provided the community specific orientation to volunteer #10, #11, #12, #13 and #14. (06/19/2024) B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: The AVC performed 100% audit of current volunteers in the community and completed community specific orientation program to all current volunteers, who did not have an evidence of the community specific orientation. (05/16/2024) C. With respect to what systemic measures have been put into place to address the stated concern: The community’s administrator provided education for Activities and Volunteer Coordinator on volunteer requirements and community specific orientation program prior to beginning volunteer services. (05/16/2024) D. With respect to how the plan of correction will be monitored: The community’s administrator and/or designee will perform monthly audits of volunteer binder for the next 3 month to confirm the compliance with volunteer requirements. The community’s administrator and/or designee will report the results of the audits to the Quality Assurance and Performance Improvement Committee for the next 3 months. During and at the conclusion of the 3 months, the QAPI Committee will re-evaluate and initiate the necessary action or extend the review period. The Administrator and/or designee is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction and addressing and resolving variances that may occur. (09/30/2024)
22VAC40-73-220-A
Based on private duty record review, the facility failed to ensure information on the type and frequency of the services to be delivered to the resident by private duty personnel was obtained in writing.
Evidence
  1. The records of seven (7) private duty personnel were provided by Staff 1.
  2. All seven (7) records did not contain written information on the type and frequency of services to be rendered.
  3. Staff 1 confirmed the records did not contain documentation of the duties provided by the private duty personnel.
Plan of correction
A. With respect to the specific resident/situation cited: The Assisted Living Coordinator and the Reminiscence Coordinator will perform 100% audit of current PDAs in the community. (07/11/2024) B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: The Assisted Living Coordinator and the Reminiscence Coordinator will complete each PDA specific type and frequency of the services to be delivered. (07/11/2024) C. With respect to what systemic measures have been put into place to address the stated concern: The community’s administrator provided education for Assisted Living Coordinator and the Reminiscence Coordinator on PDA requirements. (05/16/2024) D. With respect to how the plan of correction will be monitored: The community’s administrator and/or designee will perform monthly audits PDA binder for the next 3 months to confirm the compliance with PDA requirements. The community’s administrator and/or designee will report the results of the audits to the Quality Assurance and Performance Improvement Committee for the next 3 months. During and at the conclusion of the 3 months, the QAPI Committee will re-evaluate and initiate the necessary action or extend the review period. The Administrator and/or designee is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction and addressing and resolving variances that may occur. (09/30/2024)
22VAC40-73-390-A
Based on facility document review, the facility failed to ensure that the written agreement/acknowledgment included financial arrangement for accommodations services and care such as the description of all accommodations, services, and care that the facility offers and any related charges and failed to clarify that the written agreement/acknowledgment included requirements to be imposed regarding the resident conduct other restrictions or special conditions.
Evidence
  1. Staff 1 provided the current resident agreement dated as revised 10/2022.
  2. On page 4, article III, section A states the fees as “The resident will pay the fees indicated on Exhibit 1.”
  3. Exhibit 1 is titled “Your Suite and Fees” and states both the base fees for “Assisted Living Suite” and “Reminiscence Suite” and lists the following care levels: Assisted Living Select, Assisted Living Plus, Assisted Living Plus Plus, Reminiscence Program Fee, Reminiscence Plus, Reminiscence Plus Plus, Terrace Club Program Fee, Terrace Club Plus, and Enhanced Care.
  4. Each care level did not include a description of all accommodations, services, and care that the facility offers.
  5. Staff 1 provided the current resident agreement dated as revised 10/2022.
  6. On page 2, article II, section B states: “Smoking is not allowed in any resident suite. Smoking is only allowed in designated “Smoking Areas.” Whether to designate any Smoking Areas is within the sole discretion of the Community. The Community may require residents to be supervised when smoking.”
  7. Staff 1 confirmed that they are a non-smoking community and they do not permit smoking on the property in any location.
Plan of correction
A. With respect to the specific resident/situation cited: There is no evidence that the cited issue affected any specific resident(s). (05/16/2024) B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: The community’s team will work with community’s regional and corporate office team to update the current residency agreement to be specific to the community. (07/24/2024) C. With respect to what systemic measures have been put into place to address the stated concern: The community will review new residency agreement when it is updated annually and confirm the compliance with the regulation. (07/24/2024) D. With respect to how the plan of correction will be monitored: The community’s administrator and/or designee will perform audit of new residency agreement(s) for the next 3 months to confirm the compliance with the regulation. The community’s administrator and/or designee will report the results of the audits to the Quality Assurance and Performance Improvement Committee for the next 3 months. During and at the conclusion of the 3 months, the QAPI Committee will re-evaluate and initiate the necessary action or extend the review period. The Administrator and/or designee is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction and addressing and resolving variances that may occur. (09/30/2024)
22VAC40-73-440-A
Based on resident record review and staff interview, the facility failed to ensure a new Uniform Assessment Instrument (UAI) was completed prior to admission, annually, or when there is a significant change in condition.
Evidence
  1. Resident 6’s record contained a UAI dated on 10/26/2022 and re-assessed on 03/08/2023.
  2. Staff 1 confirmed that Resident 6’s UAI had not been updated once the previous assessment is more than 12 months old.
Plan of correction
A. With respect to the specific resident/situation cited: The community’s Assisted Living Coordinator (ALC) immediately completed new UAI for resident #6. (05/29/2024) B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: The community’s ALC and RC performed 100% audit of UAI and ISP to confirm the compliance with the regulation and there were no other findings. (06/06/2024) C. With respect to what systemic measures have been put into place to address the stated concern: Administrator provided education to Assisted Living Coordinator, Reminiscence Coordinator, Resident Care Director, Wellness Nurse and Activities and Volunteer Coordinator regarding the timeliness and completeness of the UAI and ISP. (05/18/2024) D. With respect to how the plan of correction will be monitored: The community’s administrator and/or designee will perform audit of random 3 UAIs and ISP monthly for 3 months to confirm the compliance with the regulation. The community’s administrator and/or designee will report the results of the audits to the Quality Assurance and Performance Improvement Committee for the next 3 months. During and at the conclusion of the 3 months, the QAPI Committee will re-evaluate and initiate the necessary action or extend the review period. The Administrator and/or designee is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction and addressing and resolving variances that may occur. (09/30/2024)
June 28, 2023Inspection0 violations
Inspection dates
06/28/2023, 07/07/2023
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Unannounced monitoring inspections were conducted on 6/28/23 and 7/7/23 in response to a facility reported incident. Medication administration and one resident record was observed. Interview was conducted and facility documentation was reviewed. No violations were cited during the inspection. Thank you for your cooperation and if you have any questions, please contact me at m.massenberg@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
February 16, 2023Inspection4 violations
Inspection dates
02/16/2023
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 ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS
Comments
An unannounced renewal inspection was conducted on 2/16/23 (8:00 AM – 6:30 PM). At the time of entrance, 68 residents were in care. Meals, medication administration, and activities were observed. Building and grounds were inspected and records were reviewed. The sample size consisted of 10 resident records and five staff records. Violations were discussed and an exit meeting was held. 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (703) 431-4247 or by email at m.massenberg@dss.virginia.gov.
Violations
22VAC40-73-680-M
Based on observation and interview, the facility failed to ensure that medications ordered for PRN administration are available and properly stored at the facility.
Evidence
  1. PRN Ativan Solution, for Resident #3, was not present during the medication cart inspection. The cart contained Ativan tablets, ordered for Resident #3, but not the Ativan solution.
Plan of correction
It was a transcription error from hospice provider. Hospice nurse wrote order for liquid Ativan but hospice MD sent script to pharmacy with Ativan tablet. Accordingly, the community had Ativan tablet only. Upon receipt of the deficiency, the Resident Care Director contacted hospice provider and clarified the order, which is Ativan tablet. Medication carts were audited for availability of prn medications on 2/17/23 and prn medications were available in medication carts. Refresher training on verification of medication orders including hospice orders was provided by Resident Care Director (RCD) on 2/22/23 for nursing staff. Resident Care Director and/or designee will perform weekly random audits 5 residents with prn medications for 3 months to confirm compliance with accuracy and availability of prn medications. The Resident Care Director and/or designee will report the results of the audits to the Quality Assurance and Performance Improvement Committee for the next 3 months During and at the conclusion of the 3 months, the QAPI Committee will re-evaluate and initiate the necessary actions or extend the review period. The Administrator and/or designee is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction and addressing and resolving variances that may occur.
22VAC40-73-640-A
Based on observation, the facility failed to ensure that medication management plan is implemented, to prevent the use of outdated medication.
Evidence
  1. The morning medication administration, for Resident #3, was observed during the inspection. The medication cart contained an expired bottle of Resident #3’s Midodrine, at the time of the medication cart inspection. The bottle of Midodrine expired in January 2023.
Plan of correction
There is no evidence that the expired medication was given to the resident since the new medication was being used. Medication carts were audited on 2/17/23 and 2/20/23 and there were no expired medications found in the carts. Refresher training on proper and timely disposal of expired medications was provided by Resident Care Director (RCD) on 2/22/23 for nursing staff. Resident Care Director and/or designee will perform weekly random audits of medication carts for 3 months to confirm that there are no expired medications. The Resident Care Director and/or designee will report the results of the medication carts audits to the Quality Assurance and Performance Improvement Committee for the next 3 months. During and at the conclusion of the 3 months, the QAPI Committee will re-evaluate and initiate the necessary actions or extend the review period. The Administrator and/or designee is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction and addressing and resolving variances that may occur.
22VAC40-73-680-D
Based on observation and documentation, the facility failed to ensure that medications are administered in accordance with the physician’s or other prescriber’s instructions and consistent with the standards of practice approved by the Virginia Board of Nursing.
Evidence
  1. Resident #3’s February Medication Administration Record (MAR) was observed during the inspection. The MAR stated that Resident #3’s Midodrine was administered on 2/5/23 (9 AM administration) when her blood pressure was 141/93 and on 2/14/23 (5 PM administration) when her blood pressure was 157/83. Resident #3’s Midodrine order calls for the medication to be held when the resident’s Systolic Blood Pressure (SBP) is greater than 130. Resident #11’s MAR was observed during the inspection. The MAR stated that Resident #11’s Amlodipine and Losartan were administered on 2/5/23, when the resident’s blood pressure was 113/68. Resident #11’s Amlodipine and Losartan orders call for the medications to be held if the resident’s systolic blood pressure is 120 or less, or if her diastolic blood pressure is 60 or less. tice outlines in the current medication aide curriculum
Plan of correction
Nursing continued to monitor any signs and/or symptoms of side-effects from the deficient practice for resident #3 and #11 and there were no issues identified or reported by the community's nursing team. Providers for resident #3 and resident #11 were informed of BP medication given outside of parameter and both providers stated that the risk associated with the B/P medications given was minimal. The Resident Care Director (RCD) performed 100% audit of residents who are on blood pressure medications with parameter (total 45 residents) and to confirm medications were given within the parameter. There were no other residents found with BP medications given outside the parameter. Resident Care Director provided refresher training on 2/22/23 for nursing staff regarding administering medications in accordance with physician orders including blood pressure medications with administration parameter and checking e-MARs prior to administration. Resident Care Director and/or designee will perform weekly random audits 5 residents with BP medication with parameter for 3 months of medication administration records to confirm compliance with physician orders. The Resident Care Director and/or designee will report the results of the medication administration record (EMAR) audits to the Quality Assurance and Performance Improvement Committee for the next 3 months During and at the conclusion of the 3 months, the QAPI Committee will re-evaluate and initiate the necessary action or extend the review period The Administrator and/or designee is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction and addressing and resolving variances that may occur.
22VAC40-73-660-B
Based on observation and documentation, the facility failed to limit medication storage to an out-of-sight place in the rooms of residents whose UAIs have indicated that the residents are capable of self-administering their medication.
Evidence
  1. Deep Sea Nasal Spray was observed to be unlocked and unattended, in the room of Resident #4 of the memory care unit. Resident #4’s UAI, dated 8/22/22, states that she needs staff assistance for medication administration.
Plan of correction
Resident #4 came with the medication when she came back from hospital and there is no evidence that she used the medication in her room. Nurse Practitioner assessed the resident #4 and there are no harms from the medications. Full house audit of the medications in residents’ rooms was performed on 2/20/23 and there were no other findings reported. Refresher training on safe medication storage was provided by Resident Care Director (RCD) on 2/20/23 for care team. Weekly audits of one random section of the community for the next 3 months. The Resident Care Director and/or designee will report the results of the audits to the Quality Assurance and Performance Improvement Committee for the next 3 months. During and at the conclusion of the 3 months, the QAPI Committee will re-evaluate and initiate the necessary actions or extend the review period. The Administrator and/or designee is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction and addressing and resolving variances that may occur.
January 18, 2023Inspection0 violations
Inspection dates
01/18/2023
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
An unannounced monitoring inspection was conducted on 1/18/23 to follow-up on a facility-reported incident. One resident record was observed and interviews were conducted. No violations were cited during the inspection. Thank you for your cooperation and if you have any questions, please contact me at m.massenberg@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
March 24, 2022Inspection5 violations
Inspection dates
03/24/2022
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS
Comments
An unannounced renewal inspection was conducted on 3/24/22. At the time of entrance, 66 residents were in care. Meals, medication administration, and activities were observed. Building and grounds were inspected and records were reviewed. The sample size consisted of 10 resident records and five staff records. Violations were discussed and an exit meeting was held. Areas of non-compliance are identified on the violation notice. Please complete the 'plan of correction' and 'date to be corrected' for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word 'corrected' is not acceptable. The 'plan of correction' must contain: 1) Steps to correct the non-compliance with the standards, 2) Measures to prevent the non-compliance from occurring again, and 3) Person responsible for implementing each step and/or monitoring any preventative measures. Thank you for your cooperation and if you have any questions, please contact me via e-mail at m.massenberg@dss.virginia.gov.
Violations
22VAC40-73-560-E
Based on observation, the facility failed to ensure that all resident records are kept in a locked area.
Evidence
  1. The memory care wellness office was observed to be unlocked and unattended, shortly after noon. Resident charts were observed in an unlocked cabinet, in the wellness office.
Plan of correction
Wellness Office doors were immediately set up to be automatically locked when it is closed. Both Wellness Offices were checked on 3/25/22 and made the door automatically locked when closed. RCD began providing education for team members regarding the importance of locking the Wellness Offices for medication and medical records security. Weekly audit of Wellness Office will be conducted beginning week of 3/28/22 for 3 months to confirm compliance with the requirement. The Resident Care Director and/or designee will report the results of the audits to the Quality Assurance and Performance Improvement Committee for the next 3 months. During and at the conclusion of the 3 months, the QAPI Committee will re-evaluate and initiate the necessary actions or extend the review period. The Administrator and/or designee is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction and addressing and resolving variances that may occur.
22VAC40-73-660-A
Based on observation, the facility failed to ensure that a locked medicine cabinet, container, or compartment is used for storage of medications and dietary supplements prescribed for residents when such medications and dietary supplements are administered by the facility.
Evidence
  1. Allegra and sterile eye drops were observed on the dresser of Resident #2 of the memory care unit. The Uniform Assessment Instrument (UAI) for Resident #2, dated 3/8/22, states that the resident needs to have her medication administered/monitored by professional nursing staff. The memory care wellness office was found to be unlocked and unattended, shortly after noon. An open box, containing various medication packages, was observed under a desk in the office.
Plan of correction
OTC medications were immediately removed from the resident's room. Wellness Office doors were immediately set up to be automatically locked when it is closed. Family of the resident with medication in her room was educated on the importance of medication safety on 3/31/22. Both Wellness Offices were checked on 3/25/22 and made the door automatically locked when closed. Full house search for medications in residents' rooms was conducted on 3/29/22. There were no more medications found in residents' rooms. RCD began education for team members regarding the requirement of medications in resident room. RCD also began providing education to team members regarding the importance of locking the Wellness Offices for medication and medical records security. Residents and family members were educated about the requirements through weekly ED newsletter on 4/7/22 and the requirements will be also discussed during Resident Council on 4/19/22. Sales team continues to educate prospective residents and family members regarding the requirement during move-in process. Weekly audit of random three residents in Assisted Living Neighborhood and three residents in Reminiscence beginning week of 3/28/22 for 3 months to confirm compliance with the requirement. Weekly audit of Wellness Office will be conducted beginning week of 3/28/22 for 3 months to confirm compliance with the requirement. The Resident Care Director and/or designee will report the results of the audits to the Quality Assurance and Performance Improvement Committee for the next 3 months. During and at the conclusion of the 3 months, the QAPI Committee will re-evaluate and initiate the necessary actions or extend the review period. The Administrator and/or designee is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction and addressing and resolving variances that may occur.
22VAC40-73-700-1
Based on observation and interview, the facility failed to ensure that safety precautions are met and maintained, when oxygen therapy is provided.
Evidence
  1. Resident #1's oxygen was observed to be in use, during the inspection. An oxygen sign was not posted on Resident #1's door. No oxygen order was found in Resident #1's record, during the inspection. Facility staff confirmed that the oxygen order was not present, during the inspection.
Plan of correction
Immediately after the identification of the lack of oxygen sign, community placed the oxygen sign on the door of the resident. Oxygen order was obtained for the resident by resident’s physician on 3/25/22. The order was sent to DSS inspector for confirmation. Community conducted an audit regarding residents with oxygen and all other residents have oxygen sign on the door on 3/28/22. There were four residents with oxygen tank in the room and all four of them had sign on the door. Audit of residents with oxygen was conducted on 3/28/22 and there were six residents with oxygen order. Four of them have oxygen tank in the room with door signs and the other two did not have oxygen tank as it is as needed basis. RCD began providing education for team members regarding the requirement of oxygen sign on the door when resident uses oxygen. RCD also began providing education for team members regarding the requirement of obtaining oxygen order when resident uses oxygen. RCD also began providing education for team members regarding the requirement of obtaining oxygen order when resident uses oxygen. Weekly audit of oxygen sign for residents on oxygen beginning 3/28/22 for 3 months to confirm compliance with the requirement. Weekly audit of oxygen order for residents on oxygen beginning 3/28/22 for 3 months to confirm compliance with the requirement. The Resident Care Director and/or designee will report the results of the audits to the Quality Assurance and Performance Improvement Committee for the next 3 months. During and at the conclusion of the 3 months, the QAPI Committee will re-evaluate and initiate the necessary actions or extend the review period. The Administrator and/or designee is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction and addressing and resolving variances that may occur.
22VAC40-73-320-B
Based on record review, the facility failed to ensure that a risk assessment for tuberculosis is completed annually on each resident.
Evidence
  1. The record for Resident #1 was observed during the inspection. The most recent tuberculosis risk assessment in Resident #1's record was dated 2/11/21. The risk assessment was more than a year old, at the time of the inspection. The record for Resident #9 was reviewed during the inspection. The most recent tuberculosis risk assessment in Resident #9's record was dated 1/29/21. The risk assessment was more than a year old, at the time of the inspection.
Plan of correction
TB screenings were completed on 3/30/22 for two residents identified during the inspection. Audit of all residents on TB screening compliance was conducted on 3/29/22. There were three more residents who needed annual TB screening in a timely manner and the screenings for them were completed on 3/30/22. All other residents were in compliance during the audit. RCD began providing education for team members regarding the requirement of timely TB screening for residents. Tracking log was created to maintain compliance with timely TB screening for all residents. Weekly audit of random five residents beginning week of 3/28/22 for 3 months to confirm compliance with the requirement. The Resident Care Director and/or designee will report the results of the audits to the Quality Assurance and Performance Improvement Committee for the next 3 months. During and at the conclusion of the 3 months, the QAPI Committee will re-evaluate and initiate the necessary actions or extend the review period. The Administrator and/or designee is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction and addressing and resolving variances that may occur.
22VAC40-73-250-D
Based on record review, the facility failed to ensure that each staff person submits the results of a risk assessment, documenting the absence of tuberculosis in a communicable form, on or within seven days prior to their first day of work at the facility. The risk assessment shall be no older than 30 days.
Evidence
  1. The record for Staff #5, hired 10/4/21, was reviewed during the inspection. Staff #5's record contained a tuberculosis risk assessment, dated 5/7/21. The risk assessment was more than 30 days old, when Staff #5 was hired.
Plan of correction
The team member who was out of compliance received PPD on 3/29/22 and result was negative on 3/31/22. Audit of new hires in the last 12 months was done on 4/1/22 for TB compliance and there was no other team member found with non-compliance. HR team and clinic nurse were re-educated on TB policy on 3/30/22. HR team continues current Sunrise TB screening flow to maintain compliance with TM TB compliance. HR Manager will review new hire HR file to monitor compliance with TB. HR Manager will report the results of the audits to the Quality Assurance and Performance Improvement Committee for the next 3 months. During and at the conclusion of the 3 months, the QAPI Committee will re-evaluate and initiate the necessary actions or extend the review period. The Administrator and/or designee is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction and addressing and resolving variances that may occur.
July 6, 2021Inspection0 violations
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
A non-mandated self-report inspection was initiated on 7/6/21 and concluded on 7/30/21. A self-reported incident was received by the department regarding allegations in the area of Resident Care and Related Services. The administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The licensing inspector conducted an on-site observation at the facility on 7/6/21. The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
March 9, 2021Inspection1 violation
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS
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 3/11/21 and concluded on 3/16/21. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 54. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed four resident records, four staff records, medication administration records, local fire and health inspections, and other documentation 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
22VAC40-73-680-D
Based on record review, the facility failed to ensure that medications are administered in accordance with the physician's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing.
Evidence
  1. Resident #3's February MAR (medication administration record) was reviewed during the inspection. Resident #3's record contained an order for Remeron, dated 2/12/21, that called for the resident to receive 7.5mg at bedtime. The MAR documented that Resident #3's Remeron was not administered on 2/13/21, 2/15/21, 2/17/21, and 2/18/21. The MAR documented that the medication was not administered on those dates, as the medication was "pending delivery."
Plan of correction
Resident #3 was assessed by community's nurse and did not exhibit any signs or symptoms of an adverse effect. Resident #3 is currently in stable condition and has all medications available prescribed by her primary care physician. The RN Resident Care Director (RCD) and/or designee will perform a 100% audit of residents for any missing medications The RN Resident Care Director (RCD) and/or designee will perform a 100% audit of residents for any missing medications due to pending delivery. The SNA and RCD will provide education to nursing team members regarding the requirement of following physician's or other prescriber's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. Nursing team members will also be re-educated on the community's procedures related to medication not available. Resident Care Director and/or designee will perform random weekly audits of 3 residents beginning 3/22/21 for 3 months to confirm compliance with standard of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. The Resident Care Director and/or designee will report the results of the audits to the Quality Assurance and Performance Improvement Committee for the next 3 months. During and at the conclusion of the 3 months, the QAPI Committee will re-evaluate and initiate the necessary actions or extend the review period. The Administrator and/or designee is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction and addressing and resolving variances that may occur.
January 7, 2021Inspection1 violation
Inspection dates
Jan. 7, 2021
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS
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 1/7/21 and concluded on 1/8/21. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 58. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed four resident records, four staff records, medication administration records, local fire and health inspections, and other documentation 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. Please complete the 'plan of correction' and 'date to be corrected' for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word 'corrected' is not acceptable. The 'plan of correction' must contain: 1) Steps to correct the non-compliance with the standards, 2) Measures to prevent the non-compliance from occurring again, and 3) Person responsible for implementing each step and/or monitoring any preventative measures. Thank you for your cooperation and if you have any questions, please contact me via e-mail at m.massenberg@dss.virginia.gov.
Violations
22VAC40-73-320-A
Based on record review, the facility failed to ensure that each resident's physical examination contains all of the required information.
Evidence
  1. The physical examination for Resident #2, dated 11/18/20, was observed during the inspection. The physical examination form stated that the resident is allergic to: iodine-131, naproxen, tositumomab, Celebrex, Dyazide, and ACE inhibitors. The form did not list Resident #2's reactions to the allergens. The physical examination for Resident #4, dated 10/20/20, was observed during the inspection. The physical examination form stated that the resident is allergic to: gluten, lactose, milk related products, and NSAIDs. The resident's allergic reactions to NSAIDs was documented, but not the resident's reactions to the other allergens.
Plan of correction
Resident #2 and #4's reactions to allergens were reassessed and documented in their medical records. The RN Resident Care Director (RCD) and/or designee will perform a 100% audit of residents with allergies to confirm that reactions to allergens are documented in their medical records. The SNA and RCD will provide education to sales team members and coordinators regarding required documentation of resident's allergens and reactions in the initial H&P prior to move-in. Resident Care Director and/or designee will report the results of the audits to the Quality Assurance and Performance Improvement Committee for the next 3 months. During and at the conclusion of the 3 months, the QAPI Committee will re-evaluate and initiate the necessary actions or extend the review period. The Administrator and/or designee is responsible for confirming implementation and ongoing compliance with the components of the Plan of Correction and addressing and resolving variances that may occur.