Virginia DSS · Assisted Living Facility

The Park at Oak Grove

📍 4920 Woodmar Drive, Roanoke, VA, 24018

ID 46814One Year licenseActive
43
Inspections
On record
31
With violations
Visits that cited something
12
Clean visits
Nothing cited
99
Violations cited
Individual findings
63
Standards cited
Distinct rules
21
Complaint visits
Prompted by a complaint

The Park at Oak Grove was inspected 43 times between December 16, 2020 and May 28, 2026 by the Virginia Department of Social Services. 31 of those visits ended with violations cited and 12 with none. Across that history VDSS cited 99 violations under 63 distinct standards. 21 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. 40 of these 43 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
08/14/2026
Administrator
Dorothy Gring
Licensing inspector
Angela Swink
Inspector phone
(276) 623-6575
Approved for
Assisted Living · Non-Ambulatory

Inspection History

43

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

May 28, 2026Inspection0 violations
Inspection dates
05/28/2026
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 PERSONNEL
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: 05/28/2026 11:20 to 12:45 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 05/08/2026 regarding allegations in the area(s) of: Resident Care and Related Services 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: 3 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 Angela Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
April 1, 2026Complaint survey1 violation
Inspection dates
04/01/2026
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 04/01/2026 11:00 to 13:30 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 3/21/2026 regarding allegations in the area(s) of: Resident Care and Related Services Number of interviews conducted with residents: 6 Number of interviews conducted with staff: 4 Observations by licensing inspector: Lunch Meal An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation(s) of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint(s) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. 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 Angela Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov
Violations
22VAC40-73-610-B
Based on lunch meal observation and staff interviews, the facility failed to ensure that any menu substitutions or additions shall be recorded on the posted menu.
Evidence
  1. The Licensing Inspector observed the daily posted menu that contained documentation for Sweet Treats for the day as chef’s dessert of the day or ice cream.
  2. The Licensing Inspector observed during the lunch meal that residents were not provided the option for the chef’s dessert of the day or ice cream.
  3. Interview with Staff 2 and Staff 3 confirmed the facility did not have ice cream as an option even though it was on the posted menu.
Plan of correction
1) Substitutions of any item on the menu or additions to the menu will be recorded on the menu for residents and logged on the substitution log. – Director of Culinary and/or designee to start 4/1/2026 2) Education provided to all culinary team members regarding substitutions, additions and menu items at time of inspection. – Director of Culinary and/or designee to start 4/1/2026
February 19, 2026Inspection3 violations
Inspection dates
02/19/2026
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 02/19/2026 10:00 to 12:16 and 12:55 to 13:00 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 02/7/2026 regarding allegations in the area(s) of: Resident Care and Related Services, Emergency Preparedness, and Part X – Mixed Population Number of resident records reviewed: 1 Number of interviews conducted with staff: 3 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, and Part X – Mixed Population 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 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 Angela Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink @dss.virginia.gov
Violations
22VAC40-73-1040-A
Based on staff interview, the facility failed to ensure that doors leading to the outside shall have a system of security monitoring of residents with serious cognitive impairments, such as door alarms, cameras, constant staff oversight, security bracelets that are part of an alarm system, or delayed egress mechanisms. Residents with serious cognitive impairments may be limited but not prohibited from exiting the facility or any part thereof. Before limiting any resident from freely leaving the facility, the resident's record shall reflect the behavioral observations or other bases for determining that the resident has a serious cognitive impairment and cannot recognize danger or protect his own safety and welfare.
Evidence
  1. Resident 1 record contained a History and Physical, dated 1/5/2026, with documentation of the Resident’s significant medical history of Alzheimer’s Dementia.
  2. Interview with Staff 1 confirmed that the facility serves a mixed population. Staff 1 confirmed that the facility does not have a continuous system of security monitoring for the front doors that lead to the outside for residents with serious cognitive impairments. Staff 1 confirmed that there is not always a staff person scheduled to be at the front desk, specifically no staff person at night and before 10am on Saturdays, and the monitor for the camera for the front doors is at the nurses station which is not always being watched as staff have to provide direct care, which are the facility’s ways of security monitoring the front doors that lead to the outside.
Plan of correction
Correction: resident assigned 1:1 until transfer to secured memory care neighborhood. Plan: Front Door installation of delayed egress and locking system for residents with serious cognitive impairment. Monitoring: The Executive Director or designee will verify installation and functionality of the delayed egress system and conduct weekly checks of the entrance security system for 30 days and monthly thereafter Completed by ED, Director of Facilities, and/or designee
22VAC40-73-430-H-1
Based on resident record review and staff interview, the facility failed to ensure that at the time of discharge, the assisted living facility shall provide to the resident and, as appropriate, his legal representative and designated contact person a dated statement signed by the licensee or administrator that contains all the required information.
Evidence
  1. Resident 1 record, date of discharge 02/07/2026, did not contain a dated discharge statement at the time of inspection, 2.Interview with Staff 1 confirmed the facility had not completed a discharge statement on the day of discharge for Resident 1.
Plan of correction
Correction: notice written and sent to POA at time of inspection Plan: Have discharge notification written at time of each move-out. Use move-out checklist to verify its completion. The Executive Director or designee will verify completion of the discharge notice and ensure a copy is placed in the resident record and sent to the POA/legal representative. Monitoring: The Executive Director or designee will review all move-outs for the next 30 days and then monthly for 3 months to ensure discharge notices are completed and filed appropriately. Completed by ED and/or designee
22VAC40-73-460-D
Based on resident record review and staff interview, the facility failed to ensure that the facility shall provide supervision of resident schedules, care, and activities, including attention to specialized needs, such as prevention of falls and wandering from the premises.
Evidence
  1. The Licensing Inspector (LI) received a self report from the facility, dated 2/7/2026, that Resident 1 was last seen at the facility at 9:15am after breakfast. At 12:40pm, facility staff realized that the resident was no longer at the facility. The staff immediately notified the police. The staff completed a full search of the inside of the facility and started a grid of the outside of the facility. The police located the Resident at 1:50pm and transported the Resident back to the facility. The resident was discharged to a different facility in a memory care unit on this same date.
  2. Interview with Staff 1 confirmed that Resident 1 had exited the facility via the front doors around 9:22am on 02/07/2026. Staff 1 confirmed that no staff knew the Resident had left the facility at this time. Staff 1 confirmed that the Resident routinely took daily walks with an escort however did not have an escort on this date outside of the facility. Staff 1 confirmed the resident had been discharged out of the facility to a safe, secure environment in another facility. Staff 1 confirmed the facility had a recent conversation with the Power of Attorney of the Resident that the Resident was in need of a safe, secure environment due to wandering.
  3. Resident 1 record contained a Uniform Assessment Instrument (UAI), dated 1/30/2026, with documentation that the resident wanders/passive weekly or more, specifically wandering outside, and disoriented some spheres, some of the time, specifically place and time.
  4. Resident 1 record contained an Individualized Service Plan, date completed 2/6/2026, with documentation for description of needs and date identified of 12/31/2025 for Mobility: Resident does not go outside of the community without an escort, though he will come outside of his/her room with care staff/escort providing the service, Behavior Pattern: Wandering/Passive, Weekly or More, Resident exhibits wandering behavior weekly or more, redirect to their room, activity, or memory box during periods of disorientation with care staff providing the service, Disoriented: some spheres, all of the time, Reorient Resident to time and place, as needed, with the Resident providing the service and Round Checks (1 hr) Resident will be checked on frequently for safety and wandering with care staff providing the service.
  5. Resident 1 record contained an Hourly Rounding Form, dated 02/07/2026, with documentation that the Resident was not rounded on during the 10am, 11am, 12pm, and 1pm hour.
  6. Resident 1 record contained a History and Physical, dated 1/5/2026, with documentation of the Resident’s significant medical history of Alzheimer’s Dementia.
  7. Resident 1 record contained a Discharge Notification and Statement, dated 2/19/2026, with documentation of the date of discharge being 2/7/2026 with the reason for the discharge was that Resident went out for a walk without a staff member and was found to be at an apartment complex, approximately half a mile away from the facility, on Grandin Road .
Plan of correction
Correction: resident assigned 1:1 until transferred to secure memory care neighborhood Plan: Add “Rounding” to the 24-hour Communication binder to ensure residents requiring rounding have completed documentation. Create a binder to keep “Working ISP” accessible for all team members to reference current service plans for residents requiring additional monitoring or supervision. In-Service team members on use of the Communication binder and Working ISP binder and expectations related to supervision and monitoring of residents at risk for wandering. Monitoring: The Director of Health and Wellness or designee will audit rounding documentation and ISP implementation weekly for 30 days and monthly thereafter to ensure compliance. Completed by DHW and/or designee
February 19, 2026Complaint survey0 violations
Inspection dates
02/19/2026
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 2/19/2026 10:00 to 12:15 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 2/5/2026 regarding allegations in the area(s) of: Resident Care and Related Services, Admission, Retention, and Discharge of Residents Number of resident records reviewed: 2 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 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 Angela Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
February 5, 2026Inspection0 violations
Inspection dates
02/05/2026
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: 02/05/2026 10:10 to 13:10 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: 80 Number of resident records reviewed: 3 Number of staff records reviewed: 3 Number of interviews conducted with staff: 4 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Angela Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
January 6, 2026Complaint survey0 violations
Inspection dates
01/06/2026
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 01/06/2026 10:30 to 11:15 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 11/24/2025 regarding allegations in the area(s) of: Admission, Discharge, and Retention of Residents, and Resident Care and Related Services Number of resident records reviewed: 2 Number of staff records reviewed: Number of interviews conducted with residents: Number of interviews conducted with staff: 2 Observations by licensing inspector: Additional Comments/Discussion: 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 A Marie Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
November 17, 2025Complaint survey1 violation
Inspection dates
11/17/2025
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/17/2025 12:00 to 14:45 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 11/1/2025 regarding allegations in the area(s) of: Staffing and Supervision, Buildings and Grounds, and Resident Care and Related Services 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 interviews conducted with staff: 5 Observations by licensing inspector: Medication Cart Audit An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; 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 complaints 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 A Marie Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov
Violations
22VAC40-73-680-I
Based on resident record review, medication cart audit, and staff interview, the facility failed to ensure that the Medication Administration Record (MAR) shall include any medication errors or omissions.
Evidence
  1. Resident 1 record contained a November 2025 MAR with documentation for Eliquis 5mg Tablet, Take One Tablet By Mouth in the Morning and at Bedtime for Atrial Fibrillation on 11/1/25 through 11/3/25, 11/5/25, and 11/6/25 at 8am and on 11/1/25, 11/3/25, and 11/5/25 at 8pm that the facility was awaiting the medication from the pharmacy. The MAR contained documentation that the medication was administered to the Resident on 11/2/25, 11/4/25, and 11/6/25 at 8pm and 11/4/25 and 11/7/25 at 8am. The MAR contained no documentation for the medication on 11/7/25 at 8pm.
  2. Medication Cart Audit revealed that there 161 doses remaining of the Eliquis 5mg Tablet for Resident 1 from the 180 tablets delivered from the pharmacy, therefore 19 doses had been given since the facility received the medication from the pharmacy.
  3. Interview with Staff 1, Staff 2, and Staff 4 confirmed that the facility was awaiting the pharmacy to send the medication therefore it was not administered as documented on the MAR on 11/2/25, 11/4/25, and 11/6/25 at 8pm and 11/4/25 and 11/7/25 at 8am.
Plan of correction
By December 5, 2025, the Director of Health and Wellness or designee will review the medication cart and storage areas to ensure all prescribed medications are present, labeled appropriately, and available for administration. By December 5, 2025, the Director of Health & Wellness or designee will conduct an in-service for all medication aides on complete and accurate MAR documentation. A sign-in sheet will be maintained. Beginning December 5, 2025, the Director of Health and Wellness or designee will perform weekly medication cart audits to ensure all prescribed medications are present, properly labeled, and ready for administration Should there be a delay in receiving medications from the VA, a backup pharmacy will be contacted to ensure uninterrupted delivery of the order.
October 22, 2025Inspection1 violation
Inspection dates
10/22/2025, 11/17/2025
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: 10/22/2025 10:00 to 15:00, 11/17/2025 12:00 to 14:45 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 10/22/2025 regarding allegations in the area(s) of: Resident Care and Related Services The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of interviews conducted with staff: 2 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 A Marie Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov
Violations
22VAC40-73-470-B
Based on resident record review and staff interview, the facility failed to ensure that a resident's need for skilled nursing treatments within the facility shall be met by the facility's employment of a licensed nurse or contractual agreement with a licensed nurse, or by a home health agency or by a private duty licensed nurse.
Evidence
  1. Resident 1 record contained a signed physicians order, dated 9/1/2025, with documentation for Miracle Cream 1:1:1 apply topically to posterior scrotum and sacrum three times daily for wound care.
  2. Resident 1 record contained a progress note, dated 8/28/2025, with documentation on the physical exam of the resident’s skin with a full thickness stage II/stage III PUE R sacrum and stage II scrotal PU.
  3. Resident 1 September 2025 Medication Administration Record contained documentation for Miracle Cream 1:1:1 apply topically to posterior scrotum and sacrum three times daily for wound care being administered by Staff 1 on 9/1/2025 at 3pm, 9/2/2025 at 9am and 3pm, 9/3/2025 at 9am and 3pm, 9/5/2025 at 3pm, 9/6/2025 at 9am and 3pm, 9/7/2025 at 3pm, 9/10/25 at 3pm, 9/11/2025 at 9am and 3pm, 9/20/2025 at 3pm, 9/21/2025 at 9am, 9/25/2025 at 9am and 3pm, by Staff 2 at 9/12/2025 at 3pm, 9/13/2025 at 9am and 3pm, 9/18/2025 at 9am and 3pm, by Staff 3 at 9/2/2025 at 9pm, 9/5/2025 to 9/7/2025 at 9pm, 9/7/2025 at 9am, 9/10/2025 at 9pm, 9/11/2025 at 9pm, 9/14/2025 to 9/16/2025 at 9pm, 9/19/2025 to 9/21/2025 at 9pm, 9/21/2025 at 3pm, 9/23/2025 at 9pm, and 9/25/2025 at 9pm, by Staff 4 at 9/8/2025 at 9am and 3pm, 9/14/2025 at 9am and 3pm, 9/16/2025 at 9am and 3pm, 9/22/2025 at 9am and 3pm, by Staff 5 at 9/15/2025 at 3pm, 9/17/2025 at 9am and 3pm, 9/19/2025 at 9am and 3pm, 9/24/2025 at 9am and 3pm, 9/26/2025 3pm, 9/27/2025 at 3pm, and 9/29/2025 at 3pm, and by Staff 6 at 9/1/2025 at 9pm, 9/3/2025 to 9/4/2025 at 9pm, 9/8/2025 to 9/9/2025 at 9pm, 9/12/2025 to 9/13/2025 at 9pm, 9/18/2025 at 9pm, 9/24/2025 at 9pm, and 9/26/2025 to 9/28/2025 at 9pm. The MAR had documentation that Staff 1, Staff 2, Staff 3, Staff 4, Staff 5, and Staff 6 were Med Techs (Registered Medication Aides).
  4. Interview with Staff 7 confirmed Staff 1, Staff 2, Staff 3, Staff 4, Staff 5, and Staff 6 were all registered medication aides, which are not licensed healthcare professionals, administering wound care on Resident 1.
Plan of correction
· Med Tech’s educated on “skilled nursing treatments to be completed by LPN, RN, home health or hospice agency” by Director of Health and Wellness by 12/5/25 · All resident’s skilled nursing needs will be completed by home health, hospice or in-house LPN by 12/3/25. Hold bi-weekly meetings to discuss skilled nursing needs of residents.
October 22, 2025Inspection6 violations
Inspection dates
10/22/2025
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/22/2025 09:30 to 15:05 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self report was received by VDSS Division of Licensing on 10/07/2025 regarding allegations in the area(s) of: Administration and Administrative Services, Personnel, Staffing and Supervision, Resident Care and Related Services The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed:4 Number of interviews conducted with staff: 2 Observations by licensing inspector: Medication Cart Audit 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 A Marie Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov
Violations
22VAC40-73-250-C
Based on staff record review and staff interview, the facility failed to ensure that personal and social data to be maintained on staff and included in the staff record included all required documentation.
Evidence
  1. Staff 2 record, hire date 10/3/2025, did not contain documentation verification that the staff person had received a copy of their current job description.
  2. Interview with Staff 5 confirmed Staff 2 record to be current.
Plan of correction
Not published by VDSS.
22VAC40-73-290-A
Based on facility record review and staff interview, the facility failed to ensure to maintain a written work schedule that includes the names and job classifications of all staff working each shift, with an indication of whomever is in charge at any given time and any absences, substitutions, or other changes shall be noted on the schedule.
Evidence
  1. Licensing Inspector received a final self report, dated 10/13/2025, from the facility with documentation that Staff 6 was involved with the incident and was working at the facility at the time of the incident. The incident occurred between 10/1/2025 to 10/6/2025.
  2. The facility staff schedule did not have Staff 6 name and job classification on the schedule between 10/1/2025 to 10/6/2025.
  3. Interview with Staff 5 confirmed Staff 6 was worked at the facility on 10/5/2025 however the staff schedule was not updated to reflect this change.
Plan of correction
Not published by VDSS.
22VAC40-73-250-A
Based on staff interview, the facility failed to ensure that a record shall be established for each staff person.
Evidence
  1. Licensing Inspector received a final self report, dated 10/13/2025, from the facility with documentation that Staff 6 was involved with the incident and was working at the facility at the time of the incident.
  2. Interview with Staff 5 revealed that Staff 6 was not an employee of the facility. Staff 5 stated that Staff 6 was no longer employed with the facility as of 4/10/2025. Staff 5 confirmed the facility did not have a current employee record for Staff 6. Staff 5 reported Staff 6 was employed at a sister facility however under a different licensee.
Plan of correction
Not published by VDSS.
22VAC40-73-680-D
Based on resident record review, the facility failed to ensure that medications shall be administered in accordance with the physician's or other prescriber’s instructions.
Evidence
  1. Resident 1 record contained a physicians orders with documentation for Alprazolam .25mg Tablet Take One Tablet By Mouth at Bedtime for Anxiety, Docusate Sod 100mg SoftGel Take 2 Capsules by mouth at bedtime *Do Not Crush*, Eliquis 2.5mg Tablet Take One tablet by mouth every 12 hours for DVT Prevention, Melatonin 10mg Tablet Take One tablet by mouth at bedtime, Mirtazapine 30mg Tablet Take 1.5 Tablets (45mg) by mouth every day for antidepressant, Trazodone 50mg Tablet Take ½ Tablet (25mg) by mouth at bedtime take with 100mg to Equal 125mg.
  2. Resident 1 record contained an October 2025 Medication Administration Record that the resident was not administered any of the medications on 10/9/2025 and 10/18/2025, with the exception of the AM dose of Eliquis 2.5mg Tablet.
Plan of correction
Not published by VDSS.
22VAC40-90-30-B
Based on staff record review and staff interview, the facility failed to ensure that the sworn statement or affirmation shall be completed for all applicants for employment.
Evidence
  1. Staff 2 record, hire date 10/3/2025, did not contain a sworn statement or affirmation.
  2. Interview with Staff 5 confirmed that Staff 2 record was current.
Plan of correction
Not published by VDSS.
22VAC40-73-640-A
Based on facility record review, physical plant observation and staff interview, the facility failed to follow their medication management plan in regard to methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes and methods to ensure that each resident's prescription medications and any over- the- counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages;.
Evidence
  1. The facility’s medication administration plan/medication management plan contained documentation that all employees administering medications will participate in the count of controlled substances whenever assigned medication administration staff changes; staff will initial a log sheet to count controlled substances and all medications are to be kept in their original, pharmacy issued container with the legible prescription label or direction label attached until administered.
  2. “Two Odd” Medication Cart contained a October 2025 Narcotic Shift Count record with no documentation of initials on 8am – 8pm for On/Off for 10/1/2025, 10/6/2025, 10/14/2025, 10/18/2025, and 8pm – 8am for On/Off for 10/3/2025, 10/4/2025, 10/5/2025, 10/9/2025, 10/15/2025, and 10/19/2025. “3 Even” Medication Cart contained a October 2025 Narcotic Shift Count record with no documentation of initials on 8am – 8pm for On/Off for 10/1/2025, 10/5/2025, 10/16/2025, 10/17/2025, 10/18/2025,10/20/2025, 10/21/2025, and 8pm – 8am for On/Off for 10/12/2025 and 10/13/2025. “1 Odd” Medication Cart contained a October 2025 Narcotic Shift Count record with no documentation of initials on 8am – 8pm for On/Off for 10/1/2025, 10/2/2025, 10/4/2025 through 10/6/2025, 10/10/2025, 10/12/25 through 10/14/2025, 10/19/2025, and 8pm – 8am for On/Off for 10/3/2025, 10/18/2025.
  3. During the physical plant tour, the Licensing Inspector (LI) observed a pale pink, oval shaped pill with 894 imprinted on it and a small circular pill with a U imprinted on it, laying on the floor next to the “1 Odd” Medication cart not in a pharmacy issued container.
  4. Staff 5 observed the same pills laying on the floor next to the 1 Odd medication cart. Staff 5 confirmed to the LI that they were pills.
Plan of correction
Not published by VDSS.
October 22, 2025Complaint survey3 violations
Inspection dates
10/22/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/22/2025 09:30 to 15:10 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 10/20/2025 regarding allegations in the area(s) of: Resident Care and Related Services, Buildings and Grounds The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation(s) of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint(s)/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 A Marie Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov
Violations
22VAC40-73-325-C
Based on resident record review and staff interview, the facility failed to ensure that should a resident who meets the criteria for assisted living care fall, the facility must show documentation of an analysis of the circumstances of the fall and interventions that were initiated to prevent or reduce risk of subsequent falls.
Evidence
  1. Resident 1 record contained Observations for Resident 1 with documentation that the resident had a fall on 10/20/2025. There was not documentation of the interventions that were initiated to prevent or reduce risk of subsequent falls.
  2. Interview with Staff 1 confirmed the resident meet criteria for assisted living care.
Plan of correction
By 11-3-25, the Director of Health and Wellness or designee will complete the post-fall intervention documentation for Resident 1’s 10/20/2025 fall, including analysis of circumstances and interventions initiated to reduce subsequent fall risk. 2. By 11-21-25, the Director of Health and Wellness or designee will audit all fall incident records for assisted living residents over the past 90 days to identify records that lacked documentation of analysis or interventions. Any that lacked documentation were corrected. 3. By 11-15-25, the Executive Director or designee conducted an in-service for the Director of Health and Welleness and direct care staff on documentation requirements following resident falls, specifically the need for analysis and intervention documentation. 4. Beginning 12-1-25, monthly audits will be performed for three months on all fall incident records to verify documentation of circumstances and initiated interventions.
22VAC40-73-870-E
Based on physical plant observation, the facility failed to ensure that all furnishings, fixtures, and equipment, including furniture, window coverings, sinks, toilets, bathtubs, and showers, shall be kept clean and in good repair and condition, except that furnishings and equipment owned by a resident shall be, at a minimum, in safe condition and not soiled in a manner that presents a health hazard.
Evidence
  1. Licensing Inspector (LI) observed in Resident 1 bathroom, near the commode, that the toilet paper holder had been removed from the wall leaving the drywall exposed to where it had been screwed into the wall and it had not been replaced. On that same wall, dry wall was exposed and paint missing with an indent in the wall of where the grab bar had been screwed into the wall and then had been removed.
Plan of correction
By 10-23-25 the Maintenance Supervisor or designee reviewed the stated exposed drywall and hole from the removed toilet-paper holder and grab-bar wall indent in Resident 1’s bathroom, ensuring the area is safe and in good repair. It was determined that the resident requested the holder moved higher due to his height. 2. By 10-31-25 a facility-wide inspection of all resident bathrooms, common areas, furniture, fixtures, and equipment was conducted to identify any furnishings, fixtures, or equipment in disrepair or posing a hazard. 3. By 11-10-25 the Maintenance Supervisor or designee will hold an in-service for maintenance and housekeeping staff on the inspection process, hazard identification, documentation of defects, and timely correction. 4. Beginning 11-3, monthly inspections will be conducted for three months of all furnishings, fixtures, and equipment to ensure they are maintained and in safe condition. Any identified issues will be corrected
22VAC40-73-450-E
Based on resident record review and staff interview, the facility failed to ensure that the individualized service plan shall be signed and dated by the licensee, administrator, or his designee, (i.e., the person who has developed the plan), and by the resident or his legal representative. The plan shall also indicate any other individuals who contributed to the development of the plan, with a notation of the date of contribution. The title or relationship to the resident of each person who was involved in the development of the plan shall be included. These requirements shall also apply to reviews and updates of the plan.
Evidence
  1. Resident 1 record contained an Individualized Service Plan (ISP), dated 12/1/2024, with a signature that was not the licensee, administrator, or their designee (the person who developed the plan). The signature was of a previous employee of the facility.
  2. Interview with Staff 1 confirmed the signature was not the licensee, administrator, or designee at the time of the completion of the ISP on 12/1/2024.
Plan of correction
By 10-25-2025, the Director of Health and Wellness or designee updated Resident 1’s ISP to include the proper signature of the licensee/administrator/designee and the resident/legal representative, dated appropriately. 2. By 10-31-2025, an audit will be conducted of all ISPs completed in the last 90 days to identify any that lacked proper signatures, dates or contributor designations and determine which residents may also be affected. Any discrepancies were corrected immediately. 3. By 11-15-2025, the Executive Director or designee will provide an in-service training to the Director of Health and Wellness and direct care staff on correct ISP development, signing, dating, and documentation of contributors. Including titles/relationship to the resident. 4. Beginning 12-1-2025, monthly audits will be performed for three months to ensure all ISPs meet signature, date and contributor requirements
October 22, 2025Complaint survey1 violation
Inspection dates
10/22/2025
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/22/2025 09:30 to 15:15 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 10/7/2025 regarding allegations in the area(s) of: Staffing The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of interviews conducted with staff: 1 Observations by licensing inspector: Facility record review An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact A Marie Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov
Violations
22VAC40-73-280-B
Based on facility record review and staff interview, the facility failed to ensure that the assisted living facility shall maintain a written plan that specifies the number and type of direct care staff required to meet the day-to-day, routine direct care needs and any identified special needs for the residents in care. This plan shall be directly related to actual resident acuity levels and individualized care needs.
Evidence
  1. Facility record contained a Disclosure Statement with documentation that the written staffing plan for the facility was 3 -5 direct care staff for the 8pm – 8am shift.
  2. Facility record contained a direct care staffing schedule with documentation that on 10/4/2025 only two direct care staff were working on the 8pm to 8am shift.
  3. Interview with Staff 1 confirmed that only two direct care staff were working on 10/4/2025 on the 8pm to 8am shift. Staff 1 confirmed the disclosure statement was the facility’s written staffing plan.
Plan of correction
On 10-28-25, the Executive Director or designee adjusted upcoming shifts to ensure direct-care staff numbers meet the written staffing plan after identifying that the 8 pm–8 am shift on 10/4/2025 had only two direct-care staff. 2. On 10-28-25, the Executive Director or designee conducted an in-service for scheduling supervisors and direct-care staff on compliance with the staffing plan, escalation procedures when staffing falls below plan, and ensuring staffing correlates with resident acuity and care needs. 3. Beginning 11-2-25, monthly audits will be performed for three months monitoring each shift’s direct care staffing numbers against the written staffing plan, with results reported to leadership and corrective actions taken if any shift falls below plan.
October 22, 2025Complaint survey0 violations
Inspection dates
10/22/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/22/2025 09:30 to 14:00 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 10/03/2025 regarding allegations in the area(s) of: Resident Care and Related Services, Buildings and Grounds 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 interviews conducted with residents: 3 Number of interviews conducted with staff: 1 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 A Marie Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
October 22, 2025Complaint survey0 violations
Inspection dates
10/22/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/22/2025 09:30 to 14:15 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 10/14/2025 regarding allegations in the area(s) of: Resident Care and Related Services The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 1 Observations by licensing inspector: Facility record review 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 A Marie Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
October 22, 2025Complaint survey0 violations
Inspection dates
10/22/2025
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/22/2025 09:30 t0 14:00 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 10/7/2025 regarding allegations in the area(s) of: Personnel, Staffing and Supervision The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of interviews conducted with staff: 1 Observations by licensing inspector: Facility Record review An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. 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 A Marie Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
September 9, 2025Complaint survey3 violations
Inspection dates
09/09/2025
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 9/9/2025 9:15 to 12:30 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 9/3/2025 regarding allegations in the area(s) of: Personnel, Staffing and Supervision, and Resident Care and Related Services 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: 2 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the (allegation(s)/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 complaint(s) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact A Marie Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov
Violations
22VAC40-73-450-F
Based on resident record review and staff interview, the facility failed to ensure that Individualized service plans shall be reviewed and updated at least once every 12 months and as needed for a significant change of a resident’s condition. The review and update shall be performed by a staff person with the qualifications specified in subsection B of this section and in conjunction with the resident and, as appropriate, with the resident's family, legal representative, direct care staff, case manager, health care providers, qualified mental health professionals, or other persons.
Evidence
  1. Resident 1 record contained a report of resident physical examination, dated 8/5/2025, with documentation of a significant medical history of orthopedic surgery with fixation of R hip fracture.
  2. Interview with Resident 1 disclosed that Resident 1 needs physical assistance from staff for toileting.
  3. Resident 1 record, admission date 9/30/2021, contained an Individualized Service Plan, dated 9/21/2024, with documentation that the Resident needs mechanical help only for toileting, with only needing the assistance of available grab bars.
  4. Interview with Staff 1 confirmed that the resident did need physical assistance with toileting since 8/5/2025 therefore the ISP had not been updated for the significant change.
Plan of correction
The Director of Health and Wellness and/or other designee will complete an individualized service plan for all residents to ensure that any change of condition is noted.
22VAC40-73-460-B
Based on resident record review, facility record review, and staff interview, the facility failed to ensure that care provision and service delivery shall be resident-centered to the maximum extent possible and include prompt response by staff to resident needs as reasonable to the circumstances.
Evidence
  1. Facility record contained a call bell log dated 8/27/2025 for Resident 1 pendant with documentation that at approximately 15:19 it took staff 1 hour and 9 minutes to respond to the call bell for the Resident.
  2. Interview with Resident 1 disclosed that they nap during the afternoon and upon awaking need assistance with toileting. Resident 1 disclosed that on 8/27/2025 it was reasonable to believe they would have needed assistance with toileting when they used their call bell at 15:19.
  3. Interview with Staff 1 confirmed that Resident 1 did need assistance with toileting and that over an hour response to the call bell would not have been prompt to the circumstances.
Plan of correction
An in-service will be held for all staff ensuring awareness of the community expectation of responding to resident needs in a timely manner.
22VAC40-73-440-A
Based on resident record review and staff interview, the facility failed to ensure that all residents of and applicants to assisted living facilities shall be assessed face to face using the uniform assessment instrument in accordance with Assessment in Assisted Living Facilities (22VAC30-110). The UAI shall be completed prior to admission, at least annually, and whenever there is a significant change in the resident's condition.
Evidence
  1. Resident 1 record contained a report of resident physical examination, dated 8/5/2025, with documentation of a significant medical history of orthopedic surgery with fixation of R hip fracture.
  2. Interview with Resident 1 disclosed that Resident 1 needs physical assistance from staff for toileting.
  3. Resident 1 contained the most current Uniform Assessment Instrument, dated 9/21/2024, with documentation that the resident needs mechanical help only for toileting.
  4. Interview with Staff 1 confirmed that Resident 1 has needed physical assistance from staff for toileting since their return to the facility on 8/5/2025. Staff 1 confirmed the UAI was incorrect and needed to be updated to reflect the change.
Plan of correction
The Director of Health and Wellness and/or other designee will complete an uniform assessment for all residents to ensure that any change of condition is noted.
July 21, 2025Complaint survey1 violation
Inspection dates
07/21/2025
Areas reviewed
22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7/21/2025 11:00 to 12:00 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 7/14/2025 regarding allegations in the area(s) of: Buildings and Grounds, Resident Accommodations and Related Provisions The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of interviews conducted with staff: 3 Observations by licensing inspector: Lunch meal An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s); area(s) of non-compliance with standard(s) or law were: Buildings and Grounds A violation notice was issued; any violation(s) not related to the complaint(s) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact A Marie Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov
Violations
22VAC40-73-870-A
Based on physical plant observation and staff interviews, the facility failed to ensure that the interior and exterior of all buildings shall be maintained in good repair and kept clean and free of rubbish.
Evidence
  1. During the physical plant tour at approximately 11:16am, the Licensing Inspector (LI) observed there to be waste on the floor in the dining room near and underneath Tables 3, 10, 15, 16, 17, 18, 20, 21, and 24. There were no residents in the dining room at this time. A subsequent tour at 11:44am with Staff 1 present, the LI observed there to continue to be the same waste on the floor in the dining room under Tables 3, 10, 16, 17, 20, 21, and 24 as during the initial tour. Residents were in the dining room at this time.
  2. Interview with Staff 3 during the initial tour, Staff 3 confirmed that the floor had not been vacuumed due to not having enough time to complete the task. Interview with Staff 2 during the initial tour, Staff 2 confirmed that the dining staff had not vacuumed the floor after the breakfast meal. Interview with Staff 1 during the subsequent tour, Staff 1 confirmed the observation of waste on the floor near and underneath the tables in the dining room .
Plan of correction
Standard Violation Number – 870A The Director of Culinary Services or designee will perform daily inspections of the dining room floors, between each meal, to ensure any trash or food is removed and the floors are free from debris. The Director of Culinary Services or designee will audit cleaning logs daily to ensure proper cleaning. Correction Date - 8/31/25
July 10, 2025Inspection12 violations
Inspection dates
07/10/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS63.2 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
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: 7/10/2025 08:30 to 17:10 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 75 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 5 Observations by licensing inspector: Medication Pass Observations, Medication Carts Audit, Breakfast and Lunch meal, Morning and Afternoon activities 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 A Marie Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov
Violations
22VAC40-73-470-B
Based on resident record review, facility documentation, and staff interview, the facility failed to ensure that a resident's need for skilled nursing treatments within the facility shall be met by the facility's employment of a licensed nurse or contractual agreement with a licensed nurse, or by a home health agency or by a private duty licensed nurse.
Evidence
  1. Resident 5 record contained a signed physician’s order, dated 6/16/2025 with documentation for Mupirocin Bactroban 2%, Dispense 22 Grams, Sig: 1 Applic Topical 3 Times a Day. The record contained additional instructions with documentation of Apply antibiotic ointment as prescribed. Keep wound covered until it heals. Clean your wound with soapy water and dry completely before reapplying dressing. Return if you have increase in swelling, redness, pain or have any other concerning symptoms.
  2. The June and July 2025 Medication Administration Record (MAR) has documentation of staff 1, staff 2, staff 8, staff 9, staff 10, staff 11, and staff 12 initials from June 17, 2025 through July 10, 2025, with the exceptions of 6/20/2025 at 1:00pm due to the resident being out of the facility, and 7/1/2025 at 7:00am by a licensed nurse, for completion of these treatments three times daily. The MARs have documentation that staff 1, staff 2, staff 8, staff 9, staff 10 staff 11 and staff 12 are Registered Medication Aides (RMA) however this treatment should have been completed by a licensed healthcare professional.
  3. Interview with Staff 4 confirmed Resident 5 was being administered wound care treatment by RMAs in June and July 2025.
Plan of correction
Standard Number – 470B – The ED/DHW will ensure that if any resident requires the need for skilled nursing, that a licensed nurse shall perform any skilled nursing treatments. Date to be corrected: 8/31/2025
22VAC40-73-640-A
Based on facility record review and staff interview, the facility failed to follow their medication management plan in regard to methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes.
Evidence
  1. The facility’s medication administration plan/medication management plan contained documentation that all employees administering medications will participate in the count of controlled substances whenever assisted medication administration staff changes; staff will initial a log sheet to count controlled substances.
  2. “Two Even” Medication Cart contained a July 2025 Narcotic Shift Count record with no documentation of initials on 8am – 8pm for On/Off for 7/2/2025, 7/4/2025, 7/5/2025, 7/7/2025, 7/9/2025, or 7/10/2025 and 8pm – 8am for On/Off for 7/1/2025 through 7/6/2025.
  3. Interview with Staff 2 confirmed there were no initials on those dates.
Plan of correction
Standard Number – 640A – The DHW/RCC will monitor the narcotic count book every morning to ensure the narcotic medication counts are complete and staff has properly signed off. Date to be corrected: 8/31/2025
22VAC40-73-250-C
Based on staff record review and staff interview, the facility failed to ensure that personal and social data to be maintained on staff and included in the staff record included verification that the staff person has received a copy of his current job description.
Evidence
  1. Staff 3 record, date of hire 7/1/2025, contained no documentation of verification that staff 3 received a copy of their current job description.
  2. Interview with Staff 8 confirmed there wasn’t verification for Staff 3.
Plan of correction
Standard Number – 250C – The BOM will audit all employee files to confirm that each file contains signed verification that the employee has received a current job description. Date to be corrected: 8/31/2025
22VAC40-73-260-A
Based on staff record review and staff interview, the facility failed to ensure that each direct care staff member shall maintain current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. The certification must either be in adult first aid or include adult first aid. To be considered current, first aid certification from community colleges, hospitals, volunteer rescue squads, or fire departments shall have been issued within the past three years.
Evidence
  1. Staff 2, date of hire 2/21/2020, contained the most current American Red Cross Adult First Aid/CPR-r.21 certificate dated 4/27/2023. The American Red Cross Adult First Aid/CPR-r.21 is current for two years.
  2. Interview with Staff 8 confirmed that Staff 2 First Aide was out of date and therefore was not currently certified.
Plan of correction
Standard Number – 260A – The BOM/DHW will ensure that all direct care staff will maintain current and up to date first aid certifications. The BOM/DHW will monitor the need for annual training. Date to be corrected: 8/31/2025
22VAC40-73-350-B
Based on resident record review and staff interview, the facility failed to ensure that the assisted living facility shall ascertain, prior to admission, whether a potential resident is a registered sex offender if the facility anticipates the potential resident will have a length of stay greater than three days or in fact stays longer than three days and shall document in the resident's record that this was ascertained and the date the information was obtained.
Evidence
  1. Resident 2 record, admission date 6/19/2025, did not contain documentation whether Resident 2 was a registered sex offender.
  2. Interview with Staff 8 confirmed that Resident 2 record did not contain documentation whether Resident 2 was a registered sex offender.
Plan of correction
Standard Number – 350B – The ED/BOM will ensure that a sex offender background check will be conducted for all residents prior to admission. Date to be corrected: 8/31/2025
22VAC40-73-650-A
Based on resident record review and staff interview, the facility failed to ensure that no medication, dietary supplement, diet, medical procedure, or treatment shall be started, changed, or discontinued by the facility without a valid order from a physician or other prescriber. Medications include prescription, over-the-counter, and sample medications.
Evidence
  1. Resident 4 record contained a Hospice Recommendation Form, dated 6/11/2025, with documentation of a nurse recommendation for Paint right heel blister with betadine and cover with Kerlix, wrap daily until healed.
  2. Resident 4 record contained Task Orientated Note/Routine visit from Hospice with documentation that hospice administered treatments to Resident 4 on 6/16/2025, 6/23/2025, 6/25/2025, 6/30/2025, and 7/2/2025, of dressing with betadine, covered with non adherent dressing 2x2 and secured with kerlix on right pressure ulcer to right heel.
  3. Resident 4 record does not contain a signed physicians order for this treatment.
  4. Interview with Staff 4 confirmed the facility did not have a signed physicians order for Resident 4 for this treatment therefore it should not have been started.
Plan of correction
Standard Number – 650A – The ED/DHW will meet with each hospice provider that provides services to The Park Oak Grove and educate them on standards and regulations related to physician orders in Assisted Living Facilities. Date to be corrected: 8/31/2025
22VAC40-73-450-C
Based on resident record review and staff interview, the facility failed to ensure that the comprehensive individualized service plan (ISP) shall be completed within 30 days after admission and include all required information.
Evidence
  1. Resident 5 record, admission date 5/15/2025, did not contain a Comprehensive ISP.
  2. Interview with Staff 4 confirmed a comprehensive ISP had not been completed on Resident 5.
Plan of correction
Standard Number – 450C – The DHW or designee will ensure that all residents’ comprehensive Individualized Service Plans will be completed with all required information within 30 days, after admission to the community. Date to be corrected: 8/31/2025
22VAC40-73-210-D
Based on staff record review and staff interview, the facility failed to ensure the training shall be in addition to (i) required first aid training; (ii) CPR training, if taken; and (iii) for medication aides, continuing education required by the Virginia Board of Nursing.
Evidence
  1. Staff 2 record, date of hire 2/21/2020, contained the most current Registered Medication Aide 4 Hour Refresher Course with the date of 7/14/2023.
  2. Interview with Staff 8 confirmed that the facility did not have documentation that Staff 2 completed the RMA 4 Hour Refresher Course annually.
Plan of correction
The ED/DHW/BOM will ensure that all nursing staff complete the required first aid training. The ED/DHW/BOM will monitor all staff CPR certifications to confirm they are up to date and will schedule CPR training as needed. All Registered Medication Assistants will complete the 4-hour refresher course annually. Date to be corrected: 8/31/2025
22VAC40-73-210-B
Based on staff record review and staff interview, the facility failed to ensure that in a facility licensed for both residential and assisted living care, all direct care staff shall attend at least 18 hours of training annually.
Evidence
  1. Staff 1 record, date of hire 2/6/2024, contained documentation for a total of 6 hours of annual training hours. Staff 1 is a direct care staff.
  2. Staff 2 record, date of hire 2/21/2020, contained no documentation for hours of annual training. Staff 2 is a direct care staff.
  3. Interview with Staff 8 confirmed that Staff 1 and Staff 2 did not have the required annual training hours and were direct care staff.
Plan of correction
The BOM or designee will perform a complete audit of all staff relias training records. After the audit is complete, any staff that is behind on required relias training will have 1 week to complete the training or they will be removed from the schedule. Date to be corrected: 8/31/2025
22VAC40-73-680-I
Based on medication pass observation, resident record review and staff interview, The Medication Administration Record (MAR) shall include the date and time given and initials of direct care staff administering the medication.
Evidence
  1. Resident 1 record contained a signed physicians order dated 7/3/2025 with documentation for Lasix 20mg PO daily x 1wk.
  2. Medication Pass Observation revealed the Lasix 20mg medication was discontinued on 7/9/25. Staff 1 did not administer the medication to Resident 1 as there was no medication to administer.
  3. Resident 1 record contained a July 2025 MAR with documentation that Staff 1 administered the medication on 7/10/2025 even though the medication was not administered.
Plan of correction
Standard Number – 680I – The ED/DHW will re-educate all registered medication aides on the facility’s medication management plan and procedures. Date to be corrected: 8/31/2025
22VAC40-73-1070-B
Based on physical plant observation, the facility failed to ensure when there are indications that ordinary materials or objects may be harmful to a resident with a serious cognitive impairment, these materials or objects shall be inaccessible to the resident except under staff supervision.
Evidence
  1. The facility has in care residents with serious cognitive impairments.
  2. At approximately 9:27AM, licensing inspector (LI) noted that the door to the second-floor laundry room was unlocked and unattended. The LI observed a spray bottle of Fast and Easy Hard Surface and Glass Cleaner on a shelf and Gain laundry detergent in a cart near a washer.
Plan of correction
Standard Number – 1070B – The ED/DFO will ensure that all staff and residents will be educated on the importance of keeping the laundry room door closed and that any cleaning supplies can not be kept or stored in the laundry room. Date to corrected: 8/31/2025
22VAC40-73-100-C-1
Based on medication pass observation, staff interview and facility record review, the facility failed to follow their Infection Control Program in regard to ensuring that there are procedures for the implementation of infection prevention measures by staff and volunteers to include use of personal protective equipment.
Evidence
  1. The facility’s Infection Control Policy and Procedure (Program) contained documentation that Personal Protective Equipment (PPE), specifically gloves, were to be worn when there is contact with blood, bodily fluids, or other potentially infectious materials.
  2. During a medication pass observation with the licensing inspector (LI) and staff 1, the LI observed staff 1 administer the medication Levobunolol 0.5% Eye drop, Instill 1 drop into both eyes every day and Rocklatan 0.02 -0.005%, Instill 1 drop into both eyes every day to resident 2 without any gloves on staff 2 hands during the administration even though there is potential contact with body fluids.
  3. Interview with Staff 1 revealed that Staff 1 knew they should have worn gloves however there wasn’t any gloves on the medication cart at the time of administration, so they did not wear gloves.
Plan of correction
Standard Number – 100C – The ED/DHW/BOM will conduct an all staff meeting to review and train staff on the Infection Control Policy. Date to be corrected: 8/31/2025
July 10, 2025Inspection1 violation
Inspection dates
07/10/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7/10/2025 08:30 to 17:00 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 75 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of interviews conducted with residents:1 Number of interviews conducted with staff: 3 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 A Marie Swink Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov
Violations
22VAC40-73-870-B
Based on physical plant observation and staff interview, the facility failed to ensure all buildings shall be well-ventilated and free from foul, stale, and musty odors.
Evidence
  1. During on-site inspection on 7/10/2025, the licensing inspector (LI) noted a smell of urine in the hallway prior to arriving at the door of Resident 1 room. The LI also noted a strong smell of urine throughout Resident 1 room.
  2. Interview with staff 1 confirmed that resident 1 room smelt of urine and the hallway prior to arriving to resident 1 room. Staff 1 revealed that the urine smell has decreased some, but it still remains strong.
Plan of correction
Not published by VDSS.
July 1, 2025Complaint survey0 violations
Inspection dates
07/01/2025
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint 62775 Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/01/2025 from 11:45 AM to 12:45 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 06/12/2025 regarding allegations in the area(s) of: Personnel Resident care and related services Number of residents present at the facility at the beginning of the inspection: 82 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 2 Number of interviews conducted with residents: N/A Number of interviews conducted with staff: 2 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 29, 2025Inspection5 violations
Inspection dates
05/29/2025
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: 05/29/2025 from 12:00 PM to 1:00 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 05/12/2025 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: 77 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 2 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A 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 Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
22VAC40-73-220-B
Based on record review and staff interview, the facility failed to ensure that when private duty personnel who are not employees of a licensed home care organization provide companion services to residents in an assisted living facility, the facility shall obtain, in writing, information on the type and frequency of the services to be delivered to the resident by private duty personnel, and the companion services provided to meet identified needs shall be reflected on the individualized service plan (ISP).
Evidence
  1. The ISP for resident 1, dated 10/24/2024, indicates that the resident receives the assistance of a companion due to loneliness; however, the ISP does not indicate what services that the companion will receive and how often.
  2. As a response to LI’s request for clarification on companion services, the written correspondence with staff 3, dated 06/09/2025, indicates that the non-agency private duty companions for resident 1 sit with her and assist resident 1 with doing laundry. Alternately, there was no written documentation provided to LI of those services that are provided by companions nor the frequency in which they are provided.
Plan of correction
When a resident utilizes private duty services the DHW will obtain all required documentation from private duty personnel and put on ISP. The BOM will keep a file on all private duty personnel.
22VAC40-73-440-D
Based on record review and staff interview, the facility failed to ensure that for private pay individuals, the uniform assessment instrument (UAI) is completed as required by 22VAC30-110.
Evidence
  1. The UAI for resident 1, dated 10/24/2024, indicates that the resident is disoriented to some spheres all the time; however, which spheres of disorientation are not indicated.
  2. An interview with staff 3 during the on-site follow-up resulted in LI’s receipt of this UAI as being the most current.
Plan of correction
The ED, DHW, and RCC will print out the UAI manual and will use it to properly complete all UAI’s.
22VAC40-73-450-C
Based on record review and staff interview, the facility failed to ensure that the comprehensive individualized service plan (ISP) shall include a description of identified needs, a written description of what services will be provided to address identified needs and who will provide them.
Evidence
  1. During the on-site follow-up at the facility, LI requested to review the ISP for resident 1 which resulted in LI’s receipt of this ISP as being the most current.
  2. The ISP for resident 1, dated 10/24/2024, indicates for mobility that the resident requires mechanical help only; however, it does not elaborate as to the type of mechanical device that is utilized for mobility.
  3. For allergies, the same ISP for resident 1 indicates that “Staff will report any hypersensitivities to food or medication to physician. Resident will not be administered noted allergen”. The ISP indicates an allergy to SULFA DRUGS; however, physician progress notes dated 05/07/2025 and the May 2025 medication administration record for resident 1 indicate allergies to SULFA DRUGS and SULFITES.
  4. For psychiatric care, the same ISP for resident 1 indicates that “[Resident] will receive psychiatric services due to the diagnosis of Depression. [Insert Physician will monitor medications and treatment regimen”. Alternately, the ISP does not indicate the name of the physician who will provide the psychiatric services.
  5. The same ISP for resident 1 indicates that “[Resident] will have hearing aid in place to [Left/Right/Both] ears”; however, there is no clarification on the ISP if resident 1 requires hearing aids in both ears or just in the left or right ear.
Plan of correction
The ED, DHW, and RCC will be retrained by the area ED on the ISP process.
22VAC40-73-680-D
Based on record review and staff interview, the facility failed to ensure that medications shall be administered in accordance with physician’s or other prescriber’s instructions.
Evidence
  1. On 05/12/2025, Licensing received a self-reported incident from staff 4 indicating that on 05/05/2025 at 06:00 PM, staff 1 and staff 2 were working the same medication cart when staff 2 administered to resident 1 the METFORMIN 500 MG belonging to resident 2. As a result, the resident’s responsible party was notified, and resident 1’s physician was notified and new orders were obtained to monitor the resident hourly for the subsequent eight hours for signs and symptoms of hypoglycemia: nausea, headache, dizziness, and to call 911 and send the resident out immediately if the resident becomes symptomatic. The self-report further indicates that resident 1 was monitored hourly with no signs noted, and no complaints or concerns voiced.
  2. During the on-site follow-up to the report, LI interviewed staff 3 and then reviewed resident 1’s charting notes by staff 4 from 05/05/2025, each were consistent with the medication error from the self-reported incident.
  3. During the same on-site follow-up, a review of the most current physician’s order list for resident 2, signed 02/28/2025, confirmed that there are orders for METFORMIN 500 MG TAB. Alternately, a review of the most current physician’s order list for resident 1, signed 04/16/2025, revealed that there are no physician’s orders for resident 1 to receive METFORMIN.
Plan of correction
All nursing staff will review the Park Oak Grove medication management plan and the responsibilities for properly administering medications. All medication technicians will be monitored, by the DHW or designee, while performing medication pass procedures x 2 shifts to confirm proper medication administration.
22VAC40-73-450-D
Based on record review and staff interview, the facility failed to ensure that when hospice care is provided to a resident, the services provided by each shall be included on the individualized service plan (ISP).
Evidence
  1. The written correspondence with staff 3 on 06/05/2025 revealed that resident 1 has been on hospice since 05/12/2025, which was also confirmed by reviewing the hospice agreement with the facility.
  2. Alternately, the ISP for resident 1, dated 10/24/2024, has not been updated to indicate that there are any hospice services being provided to resident 1.
Plan of correction
The ED, DHW and RCC will be retrained by the area ED on the ISP process.
May 12, 2025Complaint survey0 violations
Inspection dates
05/12/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint # 62339 Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/12/2025 from 11:15 AM to 12:45 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 04/30/2025 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: 82 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: N/A Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
April 11, 2025Complaint survey5 violations
Inspection dates
04/11/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 04/11/2025 9:00AM to 12:45PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 03/20/2025 regarding allegations in the area of: resident care and related services Number of residents present at the facility at the beginning of the inspection: 74 Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegations of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.stokes@dss.virginia.gov
Violations
22VAC40-73-680-B
Based on observation of resident’s room, resident record review, and medication cart audit, the facility failed to ensure medications shall remain in the pharmacy issued container, with the prescription label or direction label attached, until administered to the resident.
Evidence
  1. At approximately 9:19AM, the licensing inspector (LI) observed a white round pill on the coffee table in the resident’s living room. The pill was also observed by staff persons 1 and 3. Staff person 3 stated that the pill was scored and had an inscription of an “I” and “133” on the same side. At approximately 9:48AM, the LI observed a white egg-shaped pill on the floor under the kitchen counter in the resident’s kitchenette. This pill was also observed by staff persons 1 and 3. Staff person 3 stated that the pill contained an inscription of “H” on one side of the pill and “145” on the other side of the pill.
  2. During an audit of the medication cart, these two pills were observed in the medication cart for the resident by the LI and staff persons 1, 2 and 3. The pill that was scored with an “I” and “133” on the same side is Allopurinol 100MG and the pill that contained an “H” on one side of the pill and “145” on the other side of the pill is Losartan-potassium 100MG.
Plan of correction
All medication technicians will receive re-training on the Terra Bella medication policy. Date to be corrected: 5/31/2025
22VAC40-73-870-E
Based on staff interview, the facility failed to ensure all furnishings, including furniture, shall be kept clean and in good repair and condition, except that furnishings owned by a resident shall be, at a minimum, in safe condition and not soiled in a manner that presents a health hazard.
Evidence
  1. Interview with staff person 1 during on-site inspection on 04/10/2025 revealed that the facility is aware that the resident’s couch in their living room and mattress on the bed in their bedroom is soiled with urine and needs to be replaced.
Plan of correction
The DFO or a designee, will assign daily room checks to management staff to monitor any resident furniture concerns. Any issues or concerns will be documented, and the room checks will be reviewed at our daily stand-up meetings. Date to be corrected: 5/31/2025
22VAC40-73-870-B
Based on observation during a tour of the facility and staff interview, the facility failed to ensure all buildings shall be well-ventilated and free from foul, stale, and musty odors.
Evidence
  1. During on-site inspection on 04/11/2025, the licensing inspector (LI) noted a strong smell of urine in the hallway prior to arriving at the door of resident 1’s room. The LI also noted a strong smell of urine throughout resident 1’s room.
  2. Interview with staff person 1 revealed that they are aware of the smell of urine in the hall leading to the resident’s room and in the resident’s room and that the facility has also placed an air purifier in the hallway to try to remedy the smell.
Plan of correction
The DFO or a designee, will inspect the interior of the facility twice daily to monitor for proper ventilation and will immediately notify housekeeping and the ED of any foul, stale or musty odors. This will be documented on a daily inspection checklist. Date to be corrected: 5/31/2025
22VAC40-73-440-A
Based on resident record review and staff interview, the facility failed to ensure the uniform assessment instrument (UAI) shall be completed prior to admission, at least annually, and whenever there is a significant change in the resident’s condition.
Evidence
  1. The UAI in the record for resident 1, dated 06/26/2024, does not contain information on whether the resident needs assistance with eating/feeding, stairclimbing and mobility.
  2. The UAI for resident 1 indicates that the resident requires mechanical help only with bathing. Interview with staff person 1 on 04/11/2025 revealed that they had been made aware of the resident having a strong smell of urine. Interview with staff person 2 revealed that staff persons 4 and 5 gave the resident a shower on 03/22/2025 and that the facility feels like the resident’s condition has declined and the resident does need some assistance with bathing. Staff person 1 revealed that the resident requires mechanical help and human help supervision with bathing and that the resident’s UAI should have been updated to reflect this identified need prior to the on-site inspection on 04/11/2025.
Plan of correction
The DHW and the RCC will audit all resident Uniform Assessment Instruments (UAI) to ensure they are up to date and complete. Date to be corrected: 5/31/2025
22VAC40-73-450-H
Based on facility documentation review, resident record review and staff interview, the facility failed to ensure that the care and services specified in the individualized service plan (ISP) shall be provided to each resident.
Evidence
  1. The ISP in the record for resident 1, dated 06/14/2024, contains an identified need that the resident requires assistance with meal preparation and that the resident will have at least 3 well-balanced meals, served at regular intervals, provided daily with opportunity for snacks and hydration between meal and resident will self-manage diet in their room. Interview with staff person 1 revealed that when a resident receives a tray of food in their room instead of eating in the dining room for breakfast, lunch and dinner, it will be recorded on the document “Resident Tray Charges”. Interview with staff person 2 revealed that when a resident eats breakfast, lunch and dinner in the dining room, the resident’s name is recorded on a meal consumption log that is located in the dining room for staff to document the resident’s name. During on-site inspection on 04/11/2025, staff persons 1 and 3 were unable to produce on either the “Resident Tray Changes” documents or on the facility’s meal consumption logs that the resident was served breakfast on 03/13/2025 and 03/14/2025, was served lunch on 03/13/2025, 03/14/2025 and 03/17-20/2025, and was served dinner on 03/13/2025, 03/14/2025, 03/16/2025, 03/17/2025, and 03/19/2025 during the time period of 03/13/2025 to 03/20/2025.
  2. The ISP in the record for resident 1, dated 06/14/2024, contains an identified need that the resident is bladder incontinent weekly or more, the resident will receive assistance with incontinence care as needed, staff will provide physical assistance to change soiled brief and clothing, and that the resident “refused staff assistance” and the expected outcome is that the resident will receive incontinence care as needed following frequent bladder incontinence. Interviews with staff persons 1, 2 and 3 confirmed that the resident does have urine incontinence. Interview with staff person 2 revealed that this is an identified need for resident 1; however, staff are not completing the required assistance to met this identified need.
Plan of correction
The DHW and the RCC will audit all resident Individualized Service Plans (ISP) to ensure they are up to date and complete. Date to be corrected: 5/31/2025
March 7, 2025Inspection1 violation
Inspection dates
03/07/2025
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: 3/5/2025 12:30 to 14:00 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of resident records reviewed: 1 Number of interviews conducted with staff: 2 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 A Marie Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov
Violations
22VAC40-73-680-D
Based on resident record review and facility record review, the facility failed to ensure that medications were administered in accordance with the physician's or other prescriber’s instructions.
Evidence
  1. Resident 1 record contained a physician order, dated 1/29/2025, with documentation for Milk of Magnesia 30ml PO QOD at HS (by mouth every other day at bedtime).
  2. Resident 1 record contained a January 2025 Medication Administration Record with documentation that staff 3 administered this medication at 9am on 1/31/2025, instead of before bedtime.
  3. During an interview on the day of inspection with the licensing inspector and staff 1, staff 1 confirmed that staff 3 administered the medication at the wrong time and did not follow physician orders.
Plan of correction
All staff will review the Park Oak Grove medication management plan and the responsibilities for properly administering medications. All staff will be monitored, by the DHW or designee, while performing medication pass procedures x 2 shifts to confirm proper medication administration.
January 9, 2025Inspection2 violations
Inspection dates
01/09/2025
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: 1/9/25 08:45 to 9:50 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 11/22/24 regarding allegations in the area(s) of: Resident Care and Related Services Number of resident records reviewed: 1 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported 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 A Marie Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov
Violations
22VAC40-73-680-D
Based on resident record review and facility record review, the facility failed to ensure that medications were administered in accordance with the physician's or other prescriber’s instructions.
Evidence
  1. The licensing inspector received a final incident report on 11/26/2024 from the facility which contained documentation that resident 1 was prescribed Fluconazole 150mg, Take one tablet by mouth at bedtime every 72 hours x 3 doses. The report noted the first dose was administered to resident 1 on 11/21/2024, and the next dose was administered on 11/22/2024 by staff 1.
  2. Resident 1 record contained a signed physician order dated 11/20/2024 with documentation for Fluconazole 150mg po at HS q 72 hours x3 doses.
  3. Resident 1 record contained a Triage Note with documentation that the resident was administered the medication on 11/21/2024, and the next dose should have been administered on 11/24/2024, however it was administered to the resident on 11/22/2024 due to staff 1 not reading the order correctly.
Plan of correction
All RMA’s will be in-serviced on our Medication Management Plan.
22VAC40-73-680-I
Based on resident record review, The facility failed to ensure that the Medication Administration Record (MAR) included date and time given and initials of direct care staff administering the medication.
Evidence
  1. Resident 1 record contained a November 2024 Medication Administration Record with documentation that Fluconazole 150mg Tablet, take one tablet by mouth at bedtime every 72 hours x 3 doses was administered on 11/24/2024.
  2. Resident 1 record contained a Triage Note with documentation that the resident was administered the medication on 11/22/2024 by staff 1, instead of 11/24/2024.The next dose to be administered on 11/25/2024.
Plan of correction
Staff #1 and staff #2 will be reoriented with the medication cart and shadowed by the DHW or other designee for 3 days to confirm proper documentation on the Medication Administration Record.
November 14, 2024Inspection0 violations
Inspection dates
11/14/2024
Areas reviewed
22VAC40-73 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: 11/14/2024 13:30 to 14:00 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact A Marie Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
September 24, 2024Inspection1 violation
Inspection dates
09/24/2024
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 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: 09/24/2024 10:30am to 11:45am The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 75 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of interviews conducted with staff: 2 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 A Marie Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov
Violations
22VAC40-73-1040-B
Based on physical plant observation and staff interview, the facility failed to ensure there were protective devices on windows in common areas accessible to residents to prevent the windows from being opened wide enough for a resident to crawl through.
Evidence
  1. During a walk-through of the physical plant on the day of inspection with the licensing inspector (LI) and staff 1, the licensing inspector observed the common area window accessible to residents leading to the outside of the building on the 1st Floor Southwest Even near the stairwell to be able to be opened wide enough for a resident to crawl through. The LI observed a wooden stake in the window sash that was easily removed and the window able to be opened wide enough for a resident to crawl through. Staff 1 confirmed the window was able to be opened wide enough for a resident to crawl through.
  2. On the day of inspection during an interview with the licensing inspector and staff 2, staff 2 confirmed the facility had a mixed population with some residents having serious cognitive impairments.
Plan of correction
Window restrictors will be installed on all windows of The Park Oak Grove common areas and in the apartments of any residents with serious cognitive impairments.
August 21, 2024Inspection2 violations
Inspection dates
08/21/2024
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 08/21/2024 13:30 to 16:30 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 08/17/2024 regarding allegations in the area(s) of: Resident Care and Related Services, Personnel, Buildings and Grounds Number of residents present at the facility at the beginning of the inspection: 78 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: 1 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the (allegation(s)/self-report); area(s) of non-compliance with standard(s) or law were: Personnel and 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. 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 A Marie Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov
Violations
22VAC40-73-680-H
Based on resident record review and staff interview, the facility failed to ensure that at the time the medication is administered, the facility shall document on a medication administration record (MAR) all medications administered to residents, including over-the- counter medications and dietary supplements.
Evidence
  1. Resident 1 record contained a verbal physician’s order dated 8/17/2024 to Treat skin tear to arm Monday, Wednesday, Friday until healed which was charted by staff 5.
  2. On the day of inspection, Resident 1 record contained an August 2024 MAR which did not contain the physician’s order dated 8/17/2024 to Treat skin tear to arm Monday, Wednesday, and Friday until healed.
  3. On the day of inspection during an interview with the licensing inspector and staff 5, staff 5 revealed they had administered the treatment to the resident per the order, however they did not update the MAR to include the order.
Plan of correction
Plan of correction: Staff reeducated on process for receiving orders and transcribing to MAR
22VAC40-73-280-A
Based on facility records, staff record review, resident record review, and staff interview, the facility failed to ensure they had staff adequate in knowledge, skills, and abilities and sufficient in numbers to provide services to attain and maintain the physical, mental, and psychosocial well-being of each resident as determined by resident assessments and individualized service plans, and to ensure compliance with this chapter.
Evidence
  1. The licensing inspector received a self-report of noncompliance on 8/17/2024 from the facility which contained documentation that staff 1 walked out during their shift at 5:30am, resident 1 was left on their sit to stand lift by staff 1 from 5:30am to 6:00am and staff 1 removed resident 2 nurse call pendant and it was not able to be located.
  2. The facility record contained a staffing sheet for 8/16/2024 for the 8pm – 8am shift which had documentation for staff 1, staff 2, and staff 3 to be on duty and providing direct care to residents.
  3. Staff 1 record contained a Counseling Documentation Form dated 8/17/2024 with documentation that staff 1 was terminated due to abandoning their shift, leaving resident on a transfer lift alone, and taking a resident’s emergency pendent.
  4. Resident 1 record contained an Individual Service Plan that was updated on 08/01/2024 which had an identified need for a sit to stand lift, with staff using the lift to assist the resident with transfers.
  5. Resident 2 record contained Charting Notes with documentation that resident had returned from rehabilitation center on 8/16/2024 with resident needing assistance with incontinent care, transport to and from meals, and dressing, as well as an increase in the level of care.
  6. During an interview on the day of inspection with the licensing inspector and staff 4, staff 4 revealed that resident 2 currently only had the physical capability to use the nurse call pendant on their person as they had just returned from rehabilitation services. Staff 4 revealed that staff 2 had left resident 1 on their lift alone before another staff person was able to assist the resident with the transfer. Staff 4 revealed they were present in the facility when staff 1 left their shift however was not made aware until later.
Plan of correction
Community will be staffed per our disclosure statement. Staff was terminated who walked out of community without notice.
July 30, 2024Inspection1 violation
Inspection dates
07/30/2024
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: 7/30/2024 12:10pm to 1:10pm 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 7/25/2024 regarding allegations in the area(s) of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 75 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: 3 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 A Marie Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov
Violations
22VAC40-73-680-D
Based on resident record review and staff interview, the facility failed to ensure medications were administered in accordance with the physician's or other prescriber’s instructions.
Evidence
  1. Resident 1 record contained a Charting Note for 7/25/2024 at 12:08am with documentation stating that staff contacted RCC on call and advised that RMA had given resident a third dose of Coreg 25mg and Metformin 500mg, RMA in charge was advised to contact physician on call and to contact POA around 6am due to after 11pm. 2.Resident 1 record contained physician’s orders dated 7/22/2024 with documentation for Carvedilol (Coreg) 25mg Tablet, take one tablet by mouth twice daily for hypertension and Metformin Tab 500mg take one tablet by mouth twice daily for diabetes mellitus.
  2. Resident 1 record contained a physician order dated 7/25/2024 with documentation for Hold Coreg (Carvedilol) 25mg, Hold Metformin 500mg AM dose due to extra dose given at 8pm, Resume order at 8pm.
  3. Resident 1 record contained a July 2024 Medication Administrative Record (MAR) with documentation of Suspended 25 Jul 2024 to 25 Jul 2024: hold due to given extra dose on 7/24/2024 8pm for Metformin and Carvedilol.
  4. On the day of inspection during an interview with the licensing inspector and staff 1, staff 1 confirmed resident 1 received two doses of the 8pm medications on 7/24/2024 for Metformin and Carvedilol due to the MAR not updating between shift change due to the WiFi not being accessible in the entirety of the building.
Plan of correction
RMA going OFF shift will sync computer at end of shift and will write on the 24 hour communication log that the computer has been sync’d and all meds given. The On coming shift will initial the 24 hour communication log next to where previous RMA noted that computer had been sync’d and all meds given
July 15, 2024Inspection6 violations
Inspection dates
07/15/2024
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 IMPAIRMENTS32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7/15/2024 09:00 to 16:40 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: 81 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Number of staff records reviewed: 3 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 6 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 A Marie Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov
Violations
22VAC40-73-650-A
Based on medication pass observation, resident record review and staff interview, the facility failed to ensure that no medication, dietary supplement, diet, medical procedure, or treatment was started, changed, or discontinued by the facility without a valid order from a physician or other prescriber.
Evidence
  1. On the day of inspection during the 11am medication pass observation, the licensing inspector observed staff 3 administer Methocarbamol (Robaxin) 500mg tablet to resident 3.
  2. Resident 3 record contained June and July 2024 Medication Administration Record with documentation by staff initials of the administering of Methocarbamol 500mg Tab, take one tablet by mouth four times daily for lumbar pain/muscle spasms
  3. Resident 3 record contained a physician’s order dated 5/9/2024 for an increase in Robaxin to 500mg PO QID (4 daily) for lumbar pain/muscle spasms.
  4. Resident 3 record contained a subsequent physician’s order dated 6/21/2024 for Methocarbamol (Robaxin) take 500mg in the morning, 500mg at noon, and 500mg in the evening by mouth. Take with meals.
  5. On the day of inspection during an interview with the licensing inspector and staff 1, staff 1 confirmed the physician order dated 6/21/2024 had not been faxed to the pharmacy for an update on the prescription, and that the resident was receiving this medication 4 times a day and not receiving it with the currently ordered 3 times a day.
Plan of correction
DHW,ED, or designee will be re-educated on 4 BIN system and Medication Management Plan. RCC,DHW, or Designee will review 4 BIN system every morning to ensure all orders have been processed.
22VAC40-73-1040-B
Based on physical plant observation and staff interview, the facility failed to ensure there were protective devices on windows in common areas accessible to residents to prevent the windows from being opened wide enough for a resident to crawl through.
Evidence
  1. During a walk through of the physical plant on the day of inspection, the licensing inspector observed the common area windows accessible to residents leading to the outside of the building on the 3rd Floor Southwest Even and 1st Floor Southwest Even near the stairwell to be able to be opened wide enough for a resident to crawl through.
  2. On the day of inspection during an interview with the licensing inspector and staff 1, staff 1 confirmed the facility had a mixed population with some residents having serious cognitive impairments.
Plan of correction
Director of Facility Operation (Maintenance) or designee will place protective devices on all windows in common areas accessible to residents to prevent the windows from being opened wide enough for a resident to crawl out.
22VAC40-73-640-A
Based on staff observation, facility record review, and staff interview, the facility failed to ensure their Medication Management Plan (MMP) was followed to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes.
Evidence
  1. During a medication cart observation, the licensing inspector (LI) observed the Narcotic Count Verification Form for July 2024 for the 1st Odd medication cart to have no documentation of staff initials on the 8am – 8pm shift for 7/2, 7/3, 7/5, 7/9, 7/10, and 7/15, and 8pm – 8am shift for 7/4. The LI observed the Narcotic Count Verification Form for July 2024 for the 2nd Even medication cart to have no documentation of staff initials on the 8am – 8pm shift for 7/2, 7/3 and 8pm – 8am shift for 7/1.
  2. The MMP contains documentation that all employees administering medications will participate in the count of controlled substances whenever assigned medication administration staff changes; staff will initial a log sheet to count controlled substances.
  3. On the day of inspection during an interview with the licensing inspector and staff 3, staff 3 confirmed the narcotic count verification for 1st Odd to be current during the medication cart observation.
  4. On the day of inspection during an interview with the licensing inspector and staff 4, staff 4 confirmed the narcotic count verification for 2nd Even to be current during the medication cart observation.
Plan of correction
DHW, ED, or designee will re-educate all RMA's on the Medication Management Plan. DHW, RCC's, or designee will audit narcotic count sheet daily to ensure narcotic count has been completed.
22VAC40-73-680-I
Based on resident record review and staff interview, the facility failed to ensure the dosage of the medication given was on the Medication Administration Record (MAR).
Evidence
  1. Resident 4 record contained a July 2024 MAR with documentation for Humalog 100 U/ML Kwikpen: Check FSBS Before Meals and Inject Sliding Scale: 15 – 20 min before meals: Under 200= 9U, 200 – 249 = 10U, 250-259= 11U, 300-349 = 12U, 350-399 = 13U, Over 400 = 14U (Prime Pen with 2 Units prior to each Use – Pen expires 28 days after opening). The MAR has documentation for July 1 through July 15 for number of units administered inconsistently documented by staff for the total units given. The MAR has documentation that staff 5, staff 6, staff 7, staff 10, and staff 11 would document the total amount of units given, and staff 7, staff 8, and staff 9 would only document the units given if the blood sugars were over 200.
  2. On the day of inspection during an interview with the licensing inspector and staff 1, staff 1 confirmed that the staff administering the medication were not being consistent with the documentation of the units administered.
Plan of correction
All RMA's will attend a diabetic refresher class. DHW, RCC, or designee will perform daily audits of all diabetic MAR's to ensure insulin is being administered and documented correctly in MAR
22VAC40-73-450-D
Based on resident record review and staff interview, the facility failed to ensure the services provided by hospice care is included on the individualized service plan (ISP).
Evidence
  1. Resident 1 record contained a signed report of resident physical examination, dated 5/2/2023, with documentation for the resident to receive hospice services.
  2. Resident 1 record contained an ISP, dated 6/10/2024, which included hospice as a need however did not include the services provided by hospice. 3.On the day of inspection during an interview with the licensing inspector and staff 1, staff 1 confirmed record for resident 1 was current.
Plan of correction
DHW,RCC or Designee will review all residents on hospice ISP's and update to add all services being provided by hospice.
22VAC40-73-560-E
Based on resident record review and staff interview, the facility failed to ensure that resident records are kept current.
Evidence
  1. Resident 1 record contained the Annual Review of Resident Rights form with documentation that it was signed and dated by the resident on 6/30/2023.
  2. Resident 2 record contained the Annual Review of Resident Rights form with documentation that it was signed and dated by the resident on 6/30/2023.
  3. On the day of inspection during an interview with the licensing inspector and staff 2, staff 2 revealed that the Annual Review of Resident Rights had been completed with resident 1 and resident 2 around January 2024, however the signed forms were not able to be located on the day of inspection.
Plan of correction
ED,BOM, or designee will have all residents review and sign Resident Rights and file in business folder
July 15, 2024Complaint survey0 violations
Inspection dates
07/15/2024
Areas reviewed
22VAC40-73 BUILDINGS AND GROUND22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7/15/2024 09:00 to 16:40 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 6/30/2024 regarding allegations in the area(s) of: Building and Grounds, Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 80 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of interviews conducted with residents: 5 Number of interviews conducted with staff: 6 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 A Marie Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
June 26, 2024Complaint survey1 violation
Inspection dates
06/26/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 6/26/2024 09:15am to 11:30am The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 79 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 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 standards or law. However, violations 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 A Marie Swink, Licensing Inspector at 276-625-6575 or by email at angela.swink@dss.virginia.gov
Violations
22VAC40-73-450-F
Based on resident record review and staff interview, the facility failed to ensure the Individualized Service Plan (ISP) shall be reviewed and updated at least once every 12 months and as needed for a significant change of a resident’s condition.
Evidence
  1. Resident 1 record has a Uniform Assessment Instrument (UAI) dated 6/14/2024 with documentation that the resident is incontinent of their bladder weekly or more. The record has a UAI dated 6/14/2023 with documentation that the resident is incontinent of their bladder weekly or more.
  2. Resident 1 record has an ISP dated 6/14/2024 which has documentation that the resident needs no help with bladder incontinence and that the resident is continent of their bladder.
  3. During an interview with the licensing inspectors and staff person 1, staff person 1 revealed that the UAI for the resident was accurate.
Plan of correction
ISP was updated 7/1/2024 to reflect that Resident is incontinent of bladder weekly or more. Resident frequently refuses staff assistance. Facility will place Resident on q 2hour checks to be offered toileting assistance.
June 26, 2024Inspection0 violations
Inspection dates
06/26/2024
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 6/26/2024 09:15am to 11:30am The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 79 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact A Marie Swink, Licensing Inspector at 276-625-6575 or by email at angela.swink@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
April 4, 2024Complaint survey1 violation
Inspection dates
04/04/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 4/4/2024 09:35am to 11:40am 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 3/22/2024 regarding allegations in the area(s) of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 88 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation(s)of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint(s) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact A Marie Swink, Licensing Inspector at 276-635-6575 or by email at angela.swink@dss.virginia.gov
Violations
22VAC40-73-450-G
Based on resident record review and staff interview, the facility failed to ensure a current copy of the Comprehensive Individual Service Plan (ISP) was provided to the resident.
Evidence
  1. During a phone conversation on 3/22/2024 with the licensing inspector (LI) and resident 1, resident 1 revealed they requested a copy of their comprehensive ISP and a copy had not been provided by the facility.
  2. During the on-site inspection on 4/4/2024, a comprehensive ISP, dated 10/21/2023, was noted in the record for resident 1.
  3. During an interview on 4/4/2024 with one LI and staff person 1, staff person 1 revealed that a copy of the comprehensive ISP had not been provided to resident 1 because a medical release form needed to be signed however staff person 1 also revealed that a medical release had not been provided to resident 1.
Plan of correction
Resident 1 was given a copy of her ISP on 4/4/2024. ED, DHW, local Ombudsman, private pay advocate, and Resident met 4/12/2024 and ISP was reviewed and explained to resident.
March 20, 2024Complaint survey2 violations
Inspection dates
03/20/2024, 04/04/2024
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Dates of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 3/20/2024 08:00am to 11:20am, 4/4/2024 09:35am to 11:40am 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 3/18/2024 regarding allegations in the area of: Staffing and Supervision and Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 88 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegations of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violations will be addressed in order to return the facility to compliance and maintain future compliance with applicable standards 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 A Marie Swink, Licensing Inspector at 276-635-6575 or by email at angela.swink@dss.virginia.gov
Violations
22VAC40-73-450-C
Based on resident record review and staff interview, the facility failed to ensure the comprehensive individualized service plan was completed within 30 days after admission.
Evidence
  1. During the on-site inspection on 3/20/2024, the record for resident 1, admission date 7/18/2023, did not contain a comprehensive individualized service plan. 2.During an interview on 3/20/2024 with one licensing inspector and staff person 1, staff person 1 confirmed that the record was current.
Plan of correction
Comprehensive ISP will be completed by DHW, reviewed and explained to resident and signature obtained. A copy will be placed in resident file and given to resident
22VAC40-73-280-B
Based on document review and staff interview, the facility failed to implement their written plan that specifies the number and type of direct care staff required to meet the day-to-day, routine direct care needs and any identified special needs for the residents in care.
Evidence
  1. The facility’s written plan, provided by staff person 2, that specifics the number and type of direct care staff required to meet the day-to-day, routine direct care needs and any identified special needs for the residents in care, showed that the facility will have 4 - 6 staff providing direct care from 8AM - 8PM daily and 3 – 5 staff providing direct care from 8PM – 8PM daily.
  2. Staff schedule, provided by staff person 2, has documentation for approximately 6 days from 3/11/2024 through 3/17/2024 that the facility did not have the number of direct care staff working at all times that the written plan stated is needed. 3.During an interview on 4/4/2024 with one licensing inspector and staff person 2, staff person 2 disclosed that 8 non-ambulatory residents reside in the facility and the facility has a mixed population. Staff person 2 confirmed the staff schedule provided accurately represented the number of staff providing direct care each day.
Plan of correction
Facility had a hiring blitz 4/1/2024-4/5/2024, have increased 4/15/2024 clinical staff to 22 employees. DHW will oversee the schedule and utilize OnShift scheduling program. The schedule will be staffed per disclosure statement: 4-6 providing direct care from 8AM-8PM, 3-5 providing. direct care from 8P-8A. If there is a call out, we have an on-call system consisting of DHW and (2) RCC’s to cover call outs. DHW will review staffing needs daily and make adjustments as necessary.
March 20, 2024Complaint survey1 violation
Inspection dates
03/20/2024, 03/28/2024
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Dates of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 3/20/2024 08:00am to 11:20am, 3/28/2024 1:00pm to 1:30pm 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 3/12/2024 regarding allegations in the area of: Admission, Retention, and Discharge of residents Number of residents present at the facility at the beginning of the inspection: 88 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: 1 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact A Marie Swink, Licensing Inspector at 276-635-6575 or by email at angela.swink@dss.virginia.gov
Violations
22VAC40-73-50-A
Based on resident record review and staff interview, the facility failed to provide a statement to the prospective resident and his legal representative, if any, that discloses information about the facility.
Evidence
  1. The record for resident 1 and resident 2 has documentation for the date of admission as 3/18/2020. The facility was licensed to the current licensee in February 2021. The record for resident 1 and 2 does not have documentation that a disclosure statement has been provided by the current licensee. 2.During an interview on 3/28/2024 with one licensing inspector and staff person 1, staff person 1 confirmed that a disclosure statement was not provided to resident 1 and 2 for the facility’s current licensee.
Plan of correction
ED and/or designee will do 100% audit of all resident business files for current disclosure statement. For any files found that do not have current disclosure statement, ED and/or designee will provide/ review current disclosure statement and obtain resident signature and/or responsible party signature and place in resident business file.
January 9, 2024Complaint survey1 violation
Inspection dates
01/09/2024
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES
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: 09/01/2024 1:00pm until 4:15pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 01/02/2024 regarding allegations in the area(s) of: Staffing and resident care and related services. Number of residents present at the facility at the beginning of the inspection: 40 Number of resident records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s); area(s) of non-compliance with standard(s) or law were: Resident care and related services A violation notice was issued; any violation(s) not related to the complaint(s) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Violations
22VAC40-73-450-E
Based on resident record review, the facility failed to ensure that individualized service plans (ISP) were signed by the resident or their legal representative.
Evidence
  1. The ISP developed on 10/21/2023 in the record for resident 1does not have documentation of the signature of the resident or their legal representative.
Plan of correction
Executive Director will perform 100% chart audit of all resident charts for signatures on ISP. ED will review any found unsigned ISP’s with resident and obtain signature by 1/31/2024
July 20, 2023Inspection10 violations
Inspection dates
07/20/2023
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Comments
Type of inspection: Renewal Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/20/2023 8:40am until 2:30pm 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: 81 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 12 Number of staff records reviewed: 7 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 4 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Violations
22VAC40-73-100-C-1
Based on observations of the facility medication carts, the facility failed to follow their policy and procedures for infection control in regards to assisted blood glucose monitoring.
Evidence
  1. The facility infection control policy has documentation that “Blood Glucose Monitors should never be used for more than one person. Should be cleaned and disinfected after every use”. The facility medication management plan has documentation that “All glucometers and cases are to be labeled with residents name”.
  2. A glucometer bag with a glucometer was noted in the second-floor odd medication cart. No name was observed on the bag or meter as of the day of inspection. Room # 233 was noted to be documented on the test strip located in the bag.
Plan of correction
Glucometer was labeled at time of inspection. Cart audits were completed on 7/20/2023 and all glucometers were labeled as well as the container. RMA’s will check each glucometer before each use to ensure that they are labeled. RCC or Designee will conduct bi-weekly medication cart audits to ensure that glucometers are labeled and are in individual containers which are labeled.
22VAC40-73-200-B
Based on record review, the facility failed to ensure that direct care staff, who are responsible for caring for residents with special health care needs, shall only provide services within the scope of their practice and training.
Evidence
  1. The July 2023 medication administration record (MAR) record for resident 10 has documentation of a physician order for a Freestyle Libre 2 Sensor to “Check blood sugar. Change every 2 weeks”. The July 2023 MAR has documentation of the initials of Staff person 7, who is a registered medication aide (RMA), on 07/07/2023 for changing the Freestyle Libre 2 Sensor. The site placed was documented to be resident 10’s right anterior thigh (RAT). This procedure is not within the scope of practice for an RMA as training for the changing/care of a Freestyle Libre 2 Sensor is not included in the medication aide curriculum.
Plan of correction
Education was provided by RN to all RMA’s on 7/21/2023. RN or LPN will change freestyle Libre sensors as ordered by MD and document on MAR.
22VAC40-73-950-E
Based on review od facility documentation, the facility failed to ensure that a 6-month review of emergency preparedness policies and procedures was completed with all residents.
Evidence
  1. Documentation of a 6-month review of the facility emergency preparedness and response plan with all residents was not available for review on the day of inspection.
Plan of correction
ED will review facility emergency preparedness and response with all residents by 8/15/2023 during Resident Counsel/Communication Meeting and every 6 months thereafter. ED will meet with any resident who does not attend meeting by 8/31/2023 to review on 1:1 basis.
22VAC40-73-450-D
Based on resident record review, the facility failed to ensure that when hospice care is provided to a resident, the agreed upon coordinated plan of care and the services provided by each were included on residents individualized service plans (ISP).
Evidence
  1. The ISP dated 10/04/2022 in the record for resident 5 has documentation of an identified need for Hospice care dated 10/04/2022. The ISP does not identify/include documentation of the coordinated plan of care or any details of services that are being provided by the Hospice provider.
Plan of correction
All current Residents that receive Hospice services will have their ISPs updated by 8/18/2023 and will include each disciplinary, care provided, and outcome according to the plan of care by Hospice. Any new Hospice orders will be updated by the DHW or designee at the time of the order.
22VAC40-73-450-F
Based on resident record review and staff interview, the facility failed to ensure that all required information was included when individualized service plans (ISPs) are reviewed and updated.
Evidence
  1. The ISP for resident 4, dated 01/13/2023, indicates that the resident has a wander guard located on her right ankle due to disorientation of place; however, the record for resident 4 contains a signed physician’s order, dated 04/24/2023, that the physician discontinued the resident’s wander guard. Interview with staff 1 confirmed on date of inspection that resident 4 no longer wears a wander guard and this should no longer be included on the resident’s ISP.
  2. The uniform assessment instrument (UAI) dated 09/20/2022 in the record for resident 5 has documentation that the resident is disoriented to some spheres some of the time with date being listed as the sphere affected. The ISP dated 10/4/2022 in the record for resident 5 is inconsistent as it has documentation that resident 5 is orientated to all spheres. When interviewed by two LIs, staff 1 indicated that the UAI was correct, and that it was an error on the completed ISP.
Plan of correction
ISP was updated at the time of the inspection; Any future Residents that require wander guard for safety will be updated on the ISP at the time the order is written and/or discontinued. ISP’s will be audited monthly by the DHW or designee to ensure the ISP is updated.
22VAC40-73-680-G
Based on observations of the facility medication carts, the facility failed to ensure that all over the counter medications were labeled with a residents name.
Evidence
  1. The second-floor odd medication cart contained a bottle of Tylenol PM in the second drawer that did not have documentation of the residents name in which the medication is for.
Plan of correction
100% Audit was completed on 7/21/2023, 7/24/2023, and 7/25/2023. All unlabeled OTC medications have been labeled with the Residents full name. All new OTC medications that are not labeled will be labeled immediately before being placed on medication cart. Bi-weekly audits will be performed by the RCC or Designee to ensure compliance.
22VAC40-73-440-B
Based on resident record review, the facility failed to ensure a completed private pay uniform assessment instrument (UAI) was signed by the administrator or the administrator’s designated representative.
Evidence
  1. The UAI in the record for resident 6, with a reassessment date of 06/25/2023, does not include the signature of the assessor, the administrator or designee’s signature on page 2.
Plan of correction
100% audit of all UAI’s will be completed by 8/18/2023 on all current Residents. DHW or Designee will audit all UAI’s upon admission, at change of condition and annually to ensure that the signatures are correct.
22VAC40-73-270-1
Based on review of staff records, the facility failed to ensure that aggressive behavior for direct care staff included all required components.
Evidence
  1. Documentation of aggressive behavior training in the records for staff 2 and 3 has that the training was an on-line/video-based training. The training does not have documentation of the qualified health professional who completed the training or of any demonstration and practical experience in self-protection and in the prevention and de-escalation of aggressive behavior.
Plan of correction
Aggressive Behavior training will be held on 8/18/2023 for all staff and will include all components of the training including the demonstration and practical experience. This training will be completed by the RN upon hire and annually and will include all components of the training.
22VAC40-73-980-H
Based on observations of the facility emergency food and water supply, the failed to ensure an on-site 48-hour supply of emergency water.
Evidence
  1. The emergency water stored in a storage closet located on the facility first floor was noted to have an expiration date of 03/31/2023 as of the day of inspection.
Plan of correction
All emergency water in storage closet with expired dates was pulled and disposed of on date of inspection. Director of Culinary Services purchased emergency water same day. DCS will audit emergency water closet monthly to ensure water is not expired.
22VAC40-73-250-D
Based on review of staff records, the facility failed to ensure that staff received a screening for tuberculosis annually.
Evidence
  1. The record for staff persons 2 and 3 both hired on 02/15/2021, has documentation that the last annual screening for tuberculosis was completed on 06/07/2022.
Plan of correction
100% audit will be completed on all staff members by 8/18/2023. TB screenings will be current and up to date. Screening will be performed by RN or LPN upon hire and annually thereafter.
June 27, 2022Inspection16 violations
Inspection dates
06/27/2022
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Comments
Type of inspection: Renewal Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/27/2022 8:30am until 3:00pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 62 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 4 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Violations
22VAC40-73-325-B
Based on resident record review, the facility failed to review and update the fall risk rating for residents who meet the criteria for assisted living care after a fall.
Evidence
  1. The uniform assessment instrument (UAI) for resident 1, dated 04/19/2022, indicates that the resident is assessed as assisted living level of care. The record for the resident 1 contained documentation on a facility fax form of the resident falling on 01/27/2022 and 02/23/2022. The record for resident 1 did not contain documentation of a fall risk rating being completed for these falls.
  2. The UAI for resident 2, dated 03/01/2022 indicates that the resident is assessed as assisted living level of care. The record for the resident 2 contained documentation on a facility fax form of the resident falling on 10/19/2021, 01/02/2022 and 05/23/2022. The record for resident 2 did not contain documentation of a fall risk rating being completed for these falls.
  3. The UAI for resident 4, dated 04/04/2022, indicates that the resident is assessed as assisted living level of care. The record for the resident contained a staff note, dated 05/19/2022, with the following information: “RSD was in group exercise with therapy and lost her balance and fell.” The record for the resident contained documentation that the last fall risk rating completed for the resident was on 04/04/2022.
  4. The UAI for resident 6, dated 03/10/2022, indicates that the resident is assessed as assisted living level of care. The record for the resident contained a staff note, dated 04/15/2022, with the following information: “Resident stated she had a fall.” The record for the resident contained documentation that the last fall risk rating completed for the resident was on 03/10/2022.
Plan of correction
1. Fall risk ratings will be completed annually, at change in condition and after each fall. Director of Health & Wellness, or designee, will ensure compliance. 2. Education has been provided to all nursing staff members regarding fall risk rating tool requirement on 6/27/22.
22VAC40-73-860-D
Based on observation during a tour of the physical plant, the facility failed to ensure all operable windows (i.e., a window that may be opened) were effectively screened.
Evidence
  1. During on-site inspection on 06/27/2022, the following windows, located by rooms 115, 118 and 130 at the end of the hallways on the first floor, were operable and did not contain a screen.
Plan of correction
1. Director of Facility ops or designee will replace screens in rooms 115, 118 and 130 and ensure operational status. 2. Director of Facility Ops or designee will conduct an audit of all Resident rooms to ensure window compliance.
22VAC40-73-550-G
Based on resident record review, the facility failed to ensure that the rights and responsibilities of residents in assisted living facilities were reviewed annually with residents and staff.
Evidence
  1. The record for resident 7, admitted on 06/10/2021, did not include documentation that a review of the rights and responsibilities of residents in assisted living facilities had been completed with the resident since 06/10/2021.
  2. The record for resident 1 has documentation that the last annual review of resident rights and responsibilities was completed on 04/14/2021.
  3. The record for resident 8 has documentation that the last annual review of resident rights and responsibilities was completed on 12/03/2020.
  4. The record for staff person 2 has documentation that the last annual review of resident rights and responsibilities was completed on 12/18/2020.
Plan of correction
1. Residents 7, 1 & 8 have received annual review of Resident Rights. 2. Staff member 2 has received review of Resident Rights. 3. Residents & Staff member will receive review of Resident Rights upon admission/hire. 4. Executive Director or designee will ensure compliance.
22VAC40-73-440-D
Based on resident record review, the facility failed to ensure that private pay uniform assessment instruments (UAIs) were completed as required.
Evidence
  1. The UAI dated 03/01/2022 in the record for resident 2 is incomplete as it has that the resident is disoriented to some spheres all the time but does not have documentation of which spheres are affected.
  2. The UAI dated 10/05/2021 in the record for resident 8 is incomplete as it has that the residents behavior pattern is abusive, aggressive, disruptive weekly or more but does not have documentation of the residents specific behaviors.
Plan of correction
1. UAI’s for Resident 2 and 8 have been updated by Director of Health & Wellness. 2. Director of Health & Wellness or designee will conduct audit of all current Resident UAI’s to ensure compliance. 3. Director of Health & Wellness or designee will review all new Resident UAI’s to ensure compliance.
22VAC40-73-250-D
Based on a review of staff records, the facility failed to ensure that staff received a screening for tuberculosis on or within seven days prior to the first day of work.
Evidence
  1. The record for staff person 4, hired on 05/09/2022 has documentation that this employees screening for tuberculosis was not completed until 05/23/2022.
Plan of correction
1. Business Office Manager will ensure that all new staff members have a TB screening on or before hire. 2. Executive Director, or designee, will review all new employee files for compliance upon hire.
22VAC40-73-970-E
Based on a review of facility documentation , the facility failed to ensure that all required information was included on the facility fire drill logs.
Evidence
  1. The facility fire drill logs for April, May and June 2022 did not include the identity of the person conducting the drill, the method used for notification of the drill; the number of staff participating; the number of residents participating; any special conditions simulated; the time it took to complete the drill; weather conditions; and problems encountered, if any.
Plan of correction
1. Director of Facility Ops has been educated regarding fire drill procedures. 2. Executive Director has provided Director of Facility Ops with state required form to document fire drills accordingly. 3. Executive Director will conduct routine audits of fire drill documentation to ensure compliance.
22VAC40-73-270-1
Based on a review of staff records, the facility failed to ensure that direct care staff received training in methods of dealing with residents who have a history of aggressive behavior or of dangerously agitated states prior to being involved in the care of such residents.
Evidence
  1. The record for staff person 1, hired on 04/07/2022 and staff person 3, hired on 04/27/2022 do not have documentation that these employees have received any training in residents with aggressive behaviors. The facility houses a mixed population of residents of which some have been assessed with a history of abusive, aggressive or disruptive behavior such as resident 8 as documented of their uniform assessment instrument dated 10/05/2021.
Plan of correction
1. Direct Care staff will receive training on aggressive behavior by 8/5/22, upon hire and annually thereafter. 2. Business office Manager, or designee, will be responsible for ensuring staff training is documented and meets annual requirements.
22VAC40-73-680-D
Based on resident record review, the facility failed to ensure that medications were administered in accordance with the physician’s or other prescriber’s instructions.
Evidence
  1. The record for resident 6 contained a physician’s order, dated 03/25/2022, for the following: “Humalog 100U/ML inject sub-q per sliding scale before meals for diabetes mellitus: 0-199=0 units (U); 200-250=2U; 251-300=4U; 301-350=6U; 351-400=8U: Above 400=10U and recheck BS (blood sugar) in 1 hour. If BS remains above 400, call MD (medical doctor)”.
  2. The June 2022 medication administration record (MAR) for resident 6 indicated that the resident’s blood sugar was 310 at 11:00AM on 06/02/2022 and 6 units of Humalog should have been administered according to the aforementioned physician’s order; however, the MAR indicated that 4 units of Humalog was administered to the resident.
  3. The June 2022 MAR for resident 6 indicated that the resident’s blood sugar was 518 at 5:00PM on 06/06/2022; however, there was no documentation that the resident’s blood sugar had been retaken at 6:00PM by the appropriate facility staff as indicated by the aforementioned physician’s order dated 03/25/2022.
Plan of correction
1. Staff member responsible listed violation has re-educated and disciplinary coaching regarding following physician order and documentation of med administration. 2. Med refresher class for all med administration staff has been scheduled for 7/8/22. 3. Director of Health & Wellness or designee will conduct Medication Administration Record audits to ensure compliance.
22VAC40-73-940-A
Based on a review of facility documentation, the facility failed to ensure compliance with the Virginia Statewide Fire Prevention Code (13VAC5-51) as determined by at least an annual inspection by the appropriate fire official.
Evidence
  1. The most recent Fire Marshall inspections available for review on the day of inspection was dated 11/23/2020.
Plan of correction
1. Director of Facility Ops or designee will contact Fire Marshall to schedule inspection.
22VAC40-73-860-I
Based on observation during a tour of the physical plant, the facility failed to ensure all cleaning supplies and other hazardous materials were in a locked area.
Evidence
  1. At approximately 9:29 AM on the day of inspection, the LI noted an unlocked door on the first floor labeled “Employees Only”. The door led into a hallway area and a closet with a propped open door was observed. The closet contained the following cleaning products: Super Suds Dish Detergent, Dawn Dish Detergent, Spray Nine Heavy Duty cleaner, Sani-Tyze, Ecolab Lime-A-Way and Windex. This was also observed by staff persons 4 and 6.
Plan of correction
1. Door to cleaning closet has been locked. 2. Sign has been placed on door notifying all staff that door must be locked. 3. All staff have been educated on 6/28/22 regarding requirement. 4. Dining Director & Maintenance Director will monitor door frequently to ensure door is secure.
22VAC40-73-450-F
Based on resident record review, the facility failed to update the individualized service plan (ISP) as needed for a significant change of a resident’s condition.
Evidence
  1. The record for resident 5 contained a durable do not resuscitate order (DNR), signed and dated 05/31/2022; however, the resident’s ISP, dated 05/27/2022, indicated that the resident is a Full Code and that the resident will receive CPR in the event of a cardiac and/or respiratory arrest.
  2. The record for resident 1 has a physician order dated 02/23/2022 for knee immobilizer between knees while the resident is in bed. The ISP dated 04/18/2022 in the record for resident 1 does not reflect this identified need.
  3. The uniform assessment instrument dated 03/01/2022 in the record for resident 2 has documentation that the resident requires physical assistance with transfers. The record also has a physician order dated 07/29/2021 to crush resident 2’s medications. The ISP dated 03/01/2022 for resident 2 does not reflect these identified needs.
Plan of correction
1. ISP’s for Residents 5, 1 and 2 have been updated. 2. Director of Health & Wellness or designee will conduct audit of all current Resident ISP’s to ensure compliance.
22VAC40-73-580-B
Based on observation during on-site inspection and staff interviews, the facility failed to have a written agreement signed and dated by both the resident and the licensee or administrator when the facility offers routine or regular room service when residents have the option of having meals in their rooms.
Evidence
  1. During on-site inspection on 06/27/2022, one licensing inspector observed food being delivered to resident 9’s room during the noon-time meal. During interview with staff persons 4 and 5, both staff revealed that the resident does eat her meals in her room and that the facility does not have a written agreement signed and dated by both the resident and the licensee or administrator regarding the resident eating her meals in her room.
Plan of correction
1. Executive Director or designee will ensure that Residents who choose to have meals in their rooms will sign a room service agreement upon admission or change in meal delivery status. 2. Resident 9 has signed a room service agreement.
22VAC40-73-210-B
Based on a review of staff records, the facility failed to ensure that direct care staff received the required number of hours of annual training.
Evidence
  1. The record for staff person 2, hired on 02/15/2021 has documentation that the employee has only received 1 hour of the required 18 hours of training annually from 02/15/2021 through 02/15/2022.
Plan of correction
1. Staff person 2 will attend required trainings for current period 2/15/22-2/15/23 and will attend 6 hours of training by 7/31/22 to begin compliance for current year. 2. Executive Director or designee will ensure that staff members attend required trainings through monthly in-services or online education. 3. Business office Manager, or designee, will be responsible for ensuring staff training is documented and meets annual requirements.
22VAC40-73-210-F
Based on a review of staff records, the facility failed to ensure that all direct care staff received at least 2 hours of infection control training annually.
Evidence
  1. The record for staff person 2, hired on 02/15/2021 did not have documentation that this employee had received any training in infection control between 02/15/2021 through 02/15/2022.
Plan of correction
1. Staff person 2 will receive 2 hours of infection control training by 7/31/22. 2. Staff members will receive 2 hours of infection control training by 7/31/22 and ongoing. 3. 3. Business office Manager, or designee, will be responsible for ensuring staff training is documented and meets annual requirements.
22VAC40-73-320-A
Based on resident record review, the facility failed to ensure that the physical examination and report for a person contained all required components.
Evidence
  1. The “Report of Resident Physical Examination” for resident 6, dated 03/03/2022, did not include documentation regarding the resident’s general physical condition including a systems review as is medically indicated.
Plan of correction
1. Report of Resident Physical Examination for Resident 6 will be updated by physician to include documentation regarding resident’s general condition. 2. Director of Health & Wellness, or designee, will review all new Residents physical exams prior to admission to ensure compliance. 3. Director of Health & Wellness, or designee, will conduct audit of all Resident physical examinations to ensure compliance.
22VAC40-73-380-A
Based on resident record review, the facility failed to ensure that prior to or at the time of admission to an assisted living facility, all required personal and social information was obtained.
Evidence
  1. The resident-personal social data sheet for resident 4, dated 04/04/2022, did not contain documentation of the resident’s strengths and problems.
  2. The resident-personal social data sheet for resident 5 was lacking the following requirements: date of admission, current behavioral and social functioning, strengths and problems.
  3. The resident –personal social data sheet for resident 6, dated 03/14/2022, indicated that the resident is a DNR; however, the resident is a Full Code. In addition, the sheet did not contain information on the resident’s current behavioral and social functioning.
Plan of correction
1. Personal social data sheets have been updated for Residents 4, 5 & 6. 2. Executive Director or designee will ensure personal social data sheets are completed correctly upon admission. 3. Director of Health & Wellness or designee will an conduct audit of personal social data sheets on all current Resident files to ensure compliance.
April 19, 2022Inspection1 violation
Inspection dates
04/19/2022
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date of inspection the licensing inspector was on-site at the facility for each day of the inspection: 04/29/2022 and 06/27/2022 A self-reported incident was received by VDSS Division of Licensing on 04/19/2022 regarding allegations in the area of resident care and related services. Number of resident records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Violations
22VAC40-73-470-F
Based on a review of resident records, the facility failed to ensure that medical attention from a licensed healthcare professional was secured immediately when a resident suffered a serious accident, injury, illness or medical condition or reason to suspect that such has occurred.
Evidence
  1. A facility self reported incident was received by the LI on 04/19/2022 in regards to resident 1 falling on 04/17/2022 at 10:10pm.
  2. Charting Notes in the record for resident 1 has documentation that at 10:10pm on 04/17/2022, resident 1 rang her call bell for staff assistance. Staff arrived to resident 1’s room and found resident 1 lying on the floor on her right side. Charting notes express that resident 1 indicated that she lost her balance while exiting her kitchen and had no complaints of pain or discomfort at this time. Charting notes explain that staff assisted resident 1 up off the floor and that resident 1 ambulated back to her bedroom.
  3. Documentation in charting notes for resident 1 has that resident 1 was complaining of some discomfort with her right hip during rounds that were made at 2:00am on 04/18/2022. There is no documentation that resident 1 received medical attention from a licensed healthcare professional until 10:22am on 04/18/2022 when staff person 3, who is a licensed health care professional documented in charting notes on resident 1.
  4. Charting notes in the record for resident 1 has documentation at 5:46pm on 04/18/2022 that resident 1’s family was in to see the resident and called 911 due to complaints of right hip pain. A hospital discharge summary dated 04/22/2022 has documentation that resident 1 was diagnosed with a comminuted fracture right greater trochanter requiring non-operative management.
Plan of correction
LPN on duty the day of the incident states that when she went in to administer medications, resident complained of pain on right side. LPN offered ER for assessment; Resident declined. LPN then followed Resident to the bathroom, LPN states that ROM was normal, and that Resident walked without difficulty to and from bathroom. Upon returning to her bed, Resident then refused any assistance. LPN notified Residents son that she complained of pain, who stated “I will be there later to check on her, this is Mom, she is spoiled”. 1. Nursing staff have been re-educated regarding post fall protocol to include notifying the LPN on call and notifying the hospice provider at the time of fall, if applicable. 2. Post- fall protocol has been attached to fall risk assessment for charge staff person review and completion post fall. 3. A licensed healthcare provider will be on call 24/7 and be available to provide immediate guidance to nursing staff regarding any incidents.
April 13, 2022Complaint survey1 violation
Inspection dates
04/13/2022
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
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: 04/13/2022 12:00pm until 3:30pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 03/04/2022 regarding allegations in the area of: Resident care and related services. Number of resident records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violations were issued. 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Violations
22VAC40-73-680-B
Based on observations made, review of resident records and staff interviews, the facility failed to ensure that medications remained in the pharmacy issued container, with the prescription label or direction label attached, until administered to the resident.
Evidence
  1. During an interview with resident 1 in their room, a weekly Sunday through Saturday medication box was observed with a yellow pill numbered H126 in the boxes for Thursday, Friday and Saturday. Resident 1 expressed that facility staff prepare and bring this box to her weekly. In an interview with staff persons 1 and 2 it was expressed that this medication was resident 1’s prescribed Protonix 40mg, one tablet by mouth every day for GERD. Staff persons 1 and 2 explained that facility staff were placing the medication in a weekly medication box and giving it to resident 1 to take herself.
  2. The uniform assessment instrument (UAI) dated 03/10/2022 in the record for resident 1 has documentation that the resident requires assistance from a layperson for medication administration. Physician orders signed on 10/3/2021 for resident 1 does not include an order that the resident can self administer the prescribed medication Protonix 40mg.
Plan of correction
1. Medication administration staff have been re-educated regarding medication administration procedures to include residents who self-administer vs residents who require medication administration from staff. 2. Letter will be sent to all Residents & families regarding policy for self-administering medications and the role that the medication administration staff have when a resident self-administers. 3. Resident #1 has since been discharged from community.
July 12, 2021Inspection5 violations
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity32.1 Reported by persons other than physicians63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE
Comments
A renewal inspection was initiated on 7/12/2021 and concluded on 7/15/2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 63. The inspector emailed the Administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed 4 resident records, 4 staff records, healthcare and special diet oversight, Fire and Health Department inspections, fire drill logs, activities calendar and staff schedules, etc. submitted by the facility to ensure documentation was complete. The inspector conducted the on-site portion of the inspection on 7/15/2021. An exit interview was conducted with the Administrator and Director of Nursing on the date of inspection, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. Information gathered during the inspection determined non-compliances with applicable standards or law, and violations were documented on the violation notice issued to the facility.
Violations
22VAC40-73-660-A-7
Based on observations made of the facility medication carts during an on-site inspection conducted on 7/15/2021, the facility failed to ensure that dedicated medical equipment was appropriately labeled.
Evidence
  1. The glucometer on the medication cart for resident 3 was noted to be in a labeled bag for the resident but the glucometer itself was not labeled with the residents name.
Plan of correction
1. The bag the glucometer was in was labeled, although the glucometer itself was not. The glucometer was immediately labeled with resident 3’s name on the day of the inspection. 2. The Director of Health & Wellness or designee will continue to check glucometers for the appropriate labeling during monthly medication cart audits monthly medication cart audits. 3. The Director of Health & Wellness or designee will ensure compliance with the standard.
22VAC40-73-680-M
Based on observations of the facility medication carts made during an on-site inspection conducted on 7/15/2021, the facility failed to ensure medications for PRN use were properly stored at the facility.
Evidence
  1. The record for resident 2 has a physician order for Acetaminophen 500mg, 2 tablets every 6 hours as needed for pain. This PRN was not available on the medication cart at the time of this inspection.
Plan of correction
1. The PRN medication was ordered and available in the medication cart the day following the inspection. 2. The Director of Health & Wellness or designee will continue to ensure the availability of PRN medications during monthly medication cart audits. 3. The Director of Health & Wellness or designee will ensure compliance with the standard.
22VAC40-73-700-1
Based on a review of resident records, the facility failed to insure tht oxygen orders contained all required iformation.
Evidence
  1. The oxygen order in the records for residents 2 and 4 did not contain the source of the oxygen or the times for when the oxygen should be worn.
Plan of correction
1. The oxygen orders for residents 2 and 4 were received as a portion of hospital discharge orders. The orders did not contain the source of the oxygen or the times for when the oxygen should be worn. The oxygen orders for residents 2 and 4 have been clarified and updated in the medical record to include all required information. An audit of all other resident oxygen orders was completed to ensure that the orders contained required information. 2. The nursing staff have been re-educated that all oxygen orders must include the following: the oxygen source, the delivery device, and the flow rate deemed therapeutic for the resident. 3. The Director of Health & Wellness or designee will ensure compliance with the standard.
22VAC40-73-870-A
Based on observations made during an on-site inspection conducted on 7/15/2021, the facility failed to ensure the interior of the building was kept clean and good repair.
Evidence
  1. During a tour of the facility physical plant conducted with the presence of the administrator, the carpet in the hallways on the 1st, 2nd and 3rd were noted to be soiled, stained and rolling up/raveling in numerous areas on all 3 floors.
Plan of correction
1. The carpet in the hallways on all 3 floors were last extracted on 7/12/2021. Estimates will be obtained and repairs where the carpet is rolling up and raveling will occur as soon as possible. 2. The Director of Facility Operations and/or Facility Operations Assistant will obtain estimates for the carpet to be replaced on all 3 floors. The carpet will be replaced in phases as follows: the 3rd floor will be replaced within the next 3 months, the 1st within 6 months, and the 2nd within 9 months. The Director of Facility Operations or designee will ensure that the carpet on all 3 floors continues to be extracted on a bi-weekly basis until the replacement occurs. 3. The Executive Director or designee will ensure compliance with the standard.
22VAC40-73-870-B
Based on observations made during an on-site inspection conducted on 7/15/2021, the facility failed to ensure that the building was free from foul dors.
Evidence
  1. The 1st floor hallway outside of room 105 and inside room 105 was noted to have a very strong cat urine odor on the day of inspection. It was noted that a cat is currently living in room 105.
Plan of correction
1. The housekeeper assigned to apartment 105 replaces the litter in the litter box on a weekly basis and the apartment is deep cleaned on a monthly basis. After further investigation, it has been determined that the cat urine odor is being caused by the cat spraying. The Executive Director and Director of Health & Wellness will assess the residents continued ability to care for the cat and respond accordingly. 2. The housekeeping staff and/or Executive Director will continue to monitor and assess resident ability to care for animals within the Community. 3. The Executive Director or designee will ensure compliance with the standard.
May 12, 2021Inspection2 violations
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity32.1 Reported by persons other than physicians63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Comments
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 5/12/2021 and concluded on 5/12/2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 59. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 4 resident records, 4 staff records, fire and health inspections, staff schedule, health care and special diet oversights, facility medication management plan, facility infection control policy and fire drill logs submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility.
Violations
22VAC40-73-440-A
Based on a review of resident records, the facility failed to ensure that private pay uniform assessment instruments (UAI) were updated when there was a significant change in a residents condition.
Evidence
  1. The record for resident 3 has documentation in charting notes dated 4/19/2021 that a wander guard was placed on resident 3 due to the resident having wandering/exit seeking behaviors. The private pay UAI dated 3/1/2021 was not updated to reflect the significant change in resident 3's behavior as it has documentation that resident 3's behavior is appropriate.
Plan of correction
1. The private pay UAI for resident 3 will be updated to reflect the significant change in resident 3’s behavior. 2. The Director of Health and Wellness will continue to monitor the accuracy of the UAI’s during quarterly healthcare oversight reviews and random chart audits. 3. The Executive Director or designee will ensure compliance with the standard.
22VAC40-73-450-C
Based on a review of resident records, the facility failed to ensure that all identified needs were addressed on residents individualized service plans (ISPs).
Evidence
  1. The comprehensive ISP dated 9/30/2020 in the record for resident 1 has documentation of the resident being a risk for falls. The record for resident 1 has documentation in charting notes of the resident falling on 3/16/2021 and 3/23/2021. In a phone interview with staff person 5 on 5/12/2021 it was expressed that interventions for falls would be documented on residents ISP's. The ISP for resident 1 does not address any additional interventions put in place for fall prevention since these falls occurred.
  2. The history and physical dated 4/5/2021 in the record for resident 2 has documentation that the resident is allergic to adhesives and hand sanitizer. The comprehensive ISP dated 4/7/2021 does not address these identified needs.
  3. The record for resident 3 has documentation in charting notes dated 4/19/2021 that a wander guard was placed on resident 3 due to the resident having wandering/exit seeking behaviors. The comprehensive ISP dated 4/19/2021 was not updated to address the identified need for wandering behaviors as it has documentation that resident 3's behavior is appropriate.
  4. The comprehensive ISP revised on 4/19/2021 in the record for resident 3 has documentation of the resident being identified as a risk for falls on 3/1/2021. The record for resident 3 has documentation in charting notes of the resident falling on 3/1/2021, 3/12/2021, 4/14/2021, 4/23/2021 and 4/26/2021. In a phone interview with staff person 5 on 5/12/2021 it was expressed that interventions for falls would be documented on residents ISP's. The ISP for resident 3 does not address any additional interventions put in place for fall prevention since these falls occurred.
Plan of correction
1. The comprehensive ISP’s for resident 1, 2, and 3 will be updated to reflect all identified needs. 2. The Director of Health and Wellness will continue to monitor the accuracy of the ISP’s during quarterly healthcare oversight reviews and random chart audits. 3. The Executive Director or designee will ensure compliance with the standard.
December 16, 2020Inspection2 violations
Inspection dates
Dec. 16, 2020
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 BUILDING AND GROUNDS
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. An announced virtual initial inspection was initiated on 12/16/20 and concluded on 12/16/20. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 58. The Inspector virtually observed the facility physical plant, required postings and the facility first aid kit. All policy and procedures submitted by the facility were reviewed 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
22VAC40-73-100-A
Based on a review of the facility infection control polices, the facility failed to ensure that all required information was included in their infection control policy.
Evidence
  1. The facility infection control policy reviewed on 12/16/2020 did not contain policies regarding the determination of whether prospective or returning residents have acute infectious disease and use of appropriate measures to prevent disease transmission; Initial training as specified in 22VAC40-73-120 C 4 and annual retraining of staff and volunteers in infection prevention methods, as applicable to job responsibilities and as required by 22VAC40-73-210 F or documentation on the facility staff health program.
Plan of correction
1.The facility infection control policy and procedure will be updated to include policies regarding the determination of whether prospective or returning residents have acute infectious disease, use of appropriate measures to prevent disease transmission, and initial training as specified in 22VAC40-73-120 C 4 and annual retraining of staff and volunteers in infection prevention methods, as applicable to job responsibilities and as required by 22VAC40-73-210 F. 2.The Executive Director and/or Wellness Director will review the infection control policies and procedures at least annually to ensure compliance with the standard and to make any necessary updates. 3. The Executive Director or designee will ensure compliance with the standard.
22VAC40-73-300-A
Based on a review of facility policies, the facility failed to establish procedures for communication among administrators, designated assistant administrators, managers, and designated staff persons in charge.
Evidence
  1. The facility was unable to provide procedures for communication among administrators, designated assistant administrators, managers, and designated staff persons in charge on the day of inspection.
Plan of correction
1. The facility does have a policy for written communication amongst staff that serves as a means of keeping direct care staff on all shifts informed of significant happenings or problems experienced by residents. 2. The Executive Director will update the policy to include procedures for communication among administrators, designated assistant administrators, managers, and designated staff persons in charge. 3. The Executive Director or designee will ensure compliance with the standard.