Virginia DSS · Assisted Living Facility

The Providence Fairfax

📍 9490 Sprague Avenue, Fairfax, VA, 22031

ID 46836One Year licenseActive
31
Inspections
On record
20
With violations
Visits that cited something
11
Clean visits
Nothing cited
66
Violations cited
Individual findings
44
Standards cited
Distinct rules
10
Complaint visits
Prompted by a complaint

The Providence Fairfax was inspected 31 times between February 9, 2021 and April 22, 2026 by the Virginia Department of Social Services. 20 of those visits ended with violations cited and 11 with none. Across that history VDSS cited 66 violations under 44 distinct standards. 10 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. 28 of these 31 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
08/31/2026
Administrator
Michael Dorazio
Licensing inspector
Amanda Velasco
Inspector phone
(703) 397-4587
Approved for
Special Care Unit · Assisted Living · Non-Ambulatory

Inspection History

31

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

April 22, 2026Complaint survey2 violations
Inspection dates
04/22/2026
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-80 COMPLAINT INVESTIGATION
Technical assistance
Medication Administration Documentation / Change of Condition RE: ISP/UAI
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: 04/27/2026 9:00 AM to 10:55 AM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 04/07/2026 regarding allegations in the area(s) of: 1. Resident Accommodations and Related Provisions Number of residents present at the facility at the beginning of the inspection: 122 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:3 Observations by licensing inspector: 3rd Floor Nurse’s Station Additional Comments/Discussion: Time on acknowledgement form was amended and administrator made a copy. 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. 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 Amanda “AJ” Velasco, Licensing Inspector at (703) 397 4587 or by email at amanda.velasco@dss.virginia.gov.
Violations
22VAC40-73-680-C
Based on resident record review and staff interview, the facility failed to ensure medication was administered no earlier than one hour before and not later than one hour after the facility's standard dosing schedule.
Evidence
  1. Resident 1’s Medication Administration Record, Signed Orders, and Medication Administration Audit Report were reviewed for April of 2026.
  2. The Medication Administration Audit Report, dated April 2026, for Resident 1 indicates the following number of doses were administered more than one hour after the scheduled administration time: a. 04/01/2026, 9:00 AM: 13 doses b. 04/04/2026, 9:00 AM: 13 doses c. 04/07/2026, 9:00 AM: 12 doses d. 04/06/2029, 9:00 AM: 16 doses e. 04/18/2026, 9:00 AM: 16 doses f. 04/20/2026, 9:00 AM: 16 doses g. 04/02/2026 – 04/04/2026, 08:00 PM: 1 dose h. 04/14/2026 – 04/15/2026, 08:00 PM: 1 dose i. 04/18/2026, 08:00 PM: 1 dose
  3. In an interview with the LI on 04/22/206, Staff 2 and Staff 3 confirmed that the identified doses of medication for Resident 1 were administered more than one hour after the scheduled medication administration time.
Plan of correction
Correction: Medication records for Resident 1 were reviewed. Staff confirmed medications are now administered within one hour before or after scheduled times, with ongoing monitoring in place. System Change: Medication pass schedules and staff assignments have been adjusted to support timely administration within the required one-hour window. 6/08/2026 Training: Licensed nurses and medication aides were re-educated on medication administration timing requirements per 22VAC40-73-680-C. Monitoring: The DON/Designee will audit medication administration weekly for 4 weeks, then monthly for 2 months. Findings will be addressed through the QA process. The Executive Director (ED) or designee is responsible for implementation, ongoing compliance, and review through QAPI, includinq corrective action for any variances.
22VAC40-73-70-A
Based on resident record review and staff interview, the facility failed to ensure any major incident that has negatively affected or that threatens the life, health, safety or welfare of any resident was reported to the regional licensing office within 24 hours.
Evidence
  1. Resident 1’s progress notes contain two entries dated 04/06/2026 and 04/07/2026 regarding an incident in which Resident 1 alleged that they were not getting the care they needed, and police were called and dispatched to the location.
  2. Further notes, dated 04/16/2026, detail that Resident 1 has continued to have care concerns and call the police.
  3. In an interview with the LI on 04/22/2026, Staff 1, Staff 2, and Staff 3 confirmed the residents had reported concerns about not receiving medication and their trash not being removed. Staff 2 and Staff 3 confirmed that the documented incidents of care concerns and police involcement on 04/07/2026 was not reported to the regional licensing office within 24 hours.
Plan of correction
Correction: The identified incident was reviewed, and the required report was submitted to the regional licensing office. Documentation has been updated to reflect the incident and reporting. System Change: A tracking process has been implemented to identify and report all reportable incidents within the required 24-hour timeframe, including a review of daily progress notes and incident reports by the management team. 6/08/26 Training: All leadership and direct care staff were re-educated on reportable incident requirements and timelines per 22VAC40-73-70, including criteria for incidents involving health, safety, or police involvement. Monitoring: The ED/Designee will review incident reports and progress notes daily for 4 weeks, then weekly for 2 months to confirm timely reporting. Findings will be addressed through the QA process. The Executive Director (ED) or designee is responsible for implementation, ongoing compliance, and review through QAPI, including corrective action for any variances.
February 24, 2026Inspection2 violations
Inspection dates
02/24/2026
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS
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: 02/24/2026 1:15 PM and 2:15 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 02/18/2026 regarding allegations in the area(s) of: 1. Resident Accommodations and Related Provisions Number of residents present at the facility at the beginning of the inspection: 118 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed:1 Number of interviews conducted with residents:0 Number of interviews conducted with staff: 3 Observations by licensing inspector: Resident Records. Additional Comments/Discussion: Resident unavailable at time of inspection. 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. 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 Amanda “AJ” Velasco, Licensing Inspector at (703) 397 4587 or by email at amanda.velasco@dss.virginia.gov.
Violations
22VAC40-73-680-D
Based on resident record review and staff interview, the facility failed to ensure medication was administered in accordance with the physician or other prescribers’ instructions and consistent with the standards of practice approved by the Virginia Board of Nursing.
Evidence
  1. On 02/18/2026, the facility submitted a self-report in which Resident 1 was not administered a dose of scheduled Lorazepam
  2. Resident 1’s record contains an order for Lorazepam 0.5 MG that states to take tablet once a day.
  3. Resident 1’s Medication Admin Audit report indicates that the medication was not administered on 02/16/2026 at 9:00 am, as scheduled.
  4. In an interview with two licensing staff on 02/24/2026, Staff 2 confirmed that the Lorazepam was not administered per prescriber’s orders.
Plan of correction
Not published by VDSS.
22VAC40-73-680-C
Based on resident record review and staff interview, the facility failed to ensure medication was administered no earlier than one hour before and not later than one hour after the facility's standard dosing schedule.
Evidence
  1. Resident 1’s Medication Admin Report was reviewed for 02/15/2026 through 02/21/2026. Based upon the review, 90 doses of scheduled medication were administered late.
  2. In an interview with two licensing staff on 02/24/2026, Staff 2 acknowledged that Resident 1’s medication was administered late on multiple occasions from 02/15/2026-02/21/2026.
Plan of correction
Not published by VDSS.
February 24, 2026Inspection2 violations
Inspection dates
02/24/2026
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS
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: 02/24/2026 2:15 PM to 3:20 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 02/18/2026 regarding allegations in the area(s) of: 1. Resident Accommodations and Related Provisions Number of residents present at the facility at the beginning of the inspection: 118 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: 3 Number of interviews conducted with staff: 1 Observations by licensing inspector: Resident Record and Resident Room (Memory Care) 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. 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 Amanda “AJ” Velasco, Licensing Inspector at (703) 397 4587 or by email at amanda.velasco@dss.virginia.gov.
Violations
22VAC40-73-650-B
Based on resident record review and staff interview, the facility failed to ensure physician or other prescriber orders included the name of the resident, date of the order, the name of the drug, route, dosage, strength, how often the medication is to be given, and identify the diagnosis, condition, or indications for administering.
Evidence
  1. Resident 1’s record contains a signed physician’s order for Prednisone 50 MG tablet dated 02/12/2026 that states “Take 50 MG tablet 13 hours, 7 hours, and 1 prior to surgery start time.” The diagnosis, condition, or indications for administering was not included in the order.
  2. In an interview with two licensing staff on 02/24/2026, Staff 2 acknowledged that the diagnosis, condition, or indications for administering was not included in the order.
Plan of correction
Not published by VDSS.
22VAC40-73-650-A
Based on resident record review and staff interview, the facility failed to ensure a medication, dietary supplement, diet, medical procedure, or treatment had a valid order from a physician or prescriber to be started, changed, or discontinued by the facility.
Evidence
  1. On 02/17/2026, the facility submitted a self-reported incident in which Resident 1’s prednisone, scheduled to be administered for a procedure on 02/24/2026, was administered outside of the prescribed window of time.
  2. Resident 1’s record contains a signed physician’s order for Prednisone 50 MG tablet dated 02/12/2026 that states “Take 50 MG tablet 13 hours, 7 hours, and 1 prior to surgery start time.” The order did not include the surgery date (02/24/2026).
  3. Resident 1’s Medication Administration Record (MAR) indicates that the medication was administered on 02/14/2026, 02/15/2026, and 02/16/2026.
  4. In an interview with two licensing staff on 02/24/2026, Staff 2 acknowledged that Resident 1’s prednisone was started by the facility without a valid order. Staff 2 stated that the medication was entered by the pharmacy as a daily medication, resulting in administration on three dates prior to the scheduled procedure on 02/24/2026.
Plan of correction
Not published by VDSS.
February 24, 2026Inspection4 violations
Inspection dates
02/24/2026
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS
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: 02/24/2026 11:35 AM to 1:15 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 02/04/2026 regarding allegations in the area(s) of: 1. Resident Accommodations and Related Provisions Number of residents present at the facility at the beginning of the inspection: 118 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: Resident records and images of injuries. Additional Comments/Discussion: Resident unavailable for interview at time of inspection. 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. 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 Amanda “AJ” Velasco, Licensing Inspector at (703) 397 4587 or by email at amanda.velasco@dss.virginia.gov.
Violations
22VAC40-73-210-C
Based on staff record review and staff interview, the facility failed to ensure training for the first year started no later than 60 days after employment.
Evidence
  1. Staff 3 was hired as a direct care staff member on 03/12/2025.
  2. Staff 3’s training log indicated that none of the required annual training had been started as of 02/24/2026.
  3. In an interview with two licensing staff on 02/24/2026, Staff 2 acknowledged that Staff 3 had not started training within 30 60 days after employment.
Plan of correction
Not published by VDSS.
22VAC40-73-460-A
Based on resident record review and staff interview, the facility failed to assume responsibility for the general health, safety, and well-being of the residents.
Evidence
  1. On 02/04/2026, the facility submitted a self-reported incident that stated Resident 1 received injuries from Staff 3 while Staff 3 was applying compression socks to Resident 1. In a follow up report submitted on 02/13/2026, it stated that Resident 1 had injuries to bilateral lower extremities and the right arm.
  2. Resident 1’s progress note contained an entry dated 02/03/2026 written by Staff 4 that stated Resident 1 reported that Resident 1 had bruises due to staff abuse. It was noted that “…BLE and BUE small scatter bruise noted. RLE small skin tear noted.”
  3. In an interview with the LI on 02/24/2026, Staff 4 confirmed the information written in the progress note. Staff 4 stated that photos were taken of the injuries. Staff 2 provided the photos via email to the LI on 02/24/2026
  4. The photos supported the injuries documented in the progress notes.
  5. In an interview with two licensing staff on 02/24/2026, Staff 2 acknowledged that the facility did not assume responsibility for the general health, safety, and well-being of Resident 1.
Plan of correction
Not published by VDSS.
22VAC40-73-450-F
Based on resident record review and staff interview, the facility failed to ensure the individualized service plan (ISP) was 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 was admitted 07/16/2025. Resident 1’s record contained a UAI and ISP dated 07/16/2025.
  2. Resident 1’s record contained an order for daily compression sock dressing and removal dated 08/21/2025.
  3. In an interview with two licensing staff on 02/24/2026, Staff 2 confirmed that the compression socks were not added to Resident 1’s services or tasks reflected on the ISP until 02/16/2026.
Plan of correction
Not published by VDSS.
22VAC40-73-680-I
Based on resident record review and staff interview, the facility failed to ensure the medication administration record (MAR) included all 13 required components listed in this subsection.
Evidence
  1. Resident 1’s record contains an order for daily compression sock dressing and removal dated 08/21/2025.
  2. Resident 1’s Medication Administration Record (MAR) for January 2025 indicates that the compression socks were administered on 01/31/2026 by Staff 5 and removed by Staff 6.
  3. In an interview with two licensing staff on 02/24/2026, both Staff 2 and Staff 3 confirmed that direct care staff administer compression socks, but do not have access to the MAR to document. Staff 2 stated that the compression socks were applied on 01/31/2026 by Staff 3, not Staff 5.
Plan of correction
Not published by VDSS.
December 10, 2025Inspection3 violations
Inspection dates
12/10/2025
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY
Technical assistance
POC – Window Screens discussed.
Comments
Type of inspection: Monitoring A self-reported incident was received by VDSS Division of Licensing on 11/14/2025 regarding allegations in the area(s) of: 1. Resident Care and Related Services Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/10/2025 9:30 AM to 11:00 AM 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: 124 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: 3 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-reported incident 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 Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Violations
22VAC40-73-1080-A
Based on resident record review and staff interview, the facility failed to ensure that a resident had serious cognitive impairment due to a primary psychiatric diagnosis of dementia in order to be admitted or retained in a safe, secure environment.
Evidence
  1. Resident 1, admitted 05/14/2025, resides in a safe, secure unit.
  2. Resident 1’s record contains an Assessment of Serious Cognitive Impairment that states the resident does not have serious cognitive impairment. The physician completing the report wrote “Moderate, not serious” next to the checked “no” box.
  3. In an interview with the LI on 12/10/2025, Staff 1 stated that there was no additional documentation of Resident 1 having a serious cognitive impairment, and confirmed that Resident 1 was admitted into the unit without having a documented serious cognitive impairment.
Plan of correction
1. The facility immediately reviewed Resident 1’s record for documentation supporting placement in the safe, secure unit. 2. The facility contacted Resident 1’s physician to clarify the cognitive impairment determination and correct documentation as needed. 3. The facility updated Resident 1’s record and placement status to match the physician’s clarified documentation and VDSS requirements. 4. The facility audited all current safe, secure unit resident records to confirm compliant documentation is present for each resident. 5. The facility corrected any missing or inconsistent documentation identified during the audit through physician clarification and record updates. 6. The DON/ADON will complete a second-level review and approval prior to any admission or transfer into the safe, secure unit. 7. The DON/ADON will complete monthly audits of safe, secure unit records for six months and document findings and co8rrective actions. 8. The facility re-trained clinical and admissions staff on 22VAC40-73-1080 requirements and proper completion of the assessment form.
22VAC40-73-1150-A
Based on resident record review and staff interview, facility document review, and staff interview, the facility failed to ensure that doors leading to unprotected areas shall be monitored or secured through devices that conform to applicable building and fire codes.
Evidence
  1. On 11/14/2025, the facility self-reported an incident in which Resident 1, eloped from the safe, secure unit on the second floor and was found in the lobby of the facility attempting to exit through the main doors.
  2. In a progress note, dated 11/13/2025, it was documented that Resident 1 was found in the lobby with a metal oar and was aggressive/combative with staff.
  3. In an interview with the LI on 12/10/2025, Staff 1 stated that the egress door alarm connected to their signaling device system that notifies staff individually, needed a battery. Staff 1 stated that while the alarm was sounding in the hallway, staff were not notified of the door opening as they were providing care in resident rooms at the time the alarm sounded.
  4. Staff 1 provided a service record dated 12/01/2025 indicating that batteries were needed for two exit door stairwells. Staff 1 confirmed that was the doors referenced in Staff 1’s earlier statement.
Plan of correction
1. The facility immediately inspected all doors leading to unprotected areas to confirm proper monitoring and alarm functionality. 2. The facility replaced batteries and repaired the egress door alarm system identified as nonfunctional at the time of the incident. 3. The facility verified that all door alarms are connected to signaling devices that actively notify staff in accordance with building and fire codes. 4. The facility tested all exit door alarms to confirm audible and staff-notification alerts are fully operational. 5. The facility completed a full audit of all secured and monitored doors throughout the community, including stairwells and exit points. 6. The facility corrected any deficiencies identified during the audit immediately and documented all repairs and tests. 7. The facility implemented a routine preventive maintenance schedule for alarm batteries and door monitoring devices. 8. The facility updated procedures to require documented alarm testing at regular intervals and after any maintenance activity. 9. The facility re-trained staff on response expectations for door alarms and elopement prevention procedures. The Executive Director (ED) or their designee is responsible for implementing and maintaining compliance with all components of this Plan of Correction, as well as addressing and resolving any variances that may occur. Additionally, the ED or their designee is responsible for reviewing and discussing the status of this Plan of correction during QAPI Meetings and initiating necessary actions.
22VAC40-73-930-D
Based on resident record review, facility document review, and staff interview, the facility failed to ensure that staff were making rounds no less than every two hours once the resident has gone to bed each evening.
Evidence
  1. Resident 1’s ISP, dated 05/14/2025, indicates that hours will be conducted every two hours.
  2. Resident 1’s task log indicates that safety checks were scheduled every hour from 11/13/2025 at 23:00 to 11/14/2025 at 6:59. 11/13/2025 at 23:00, 11/14/2025 at 00:00,11/14/2025 at 1:00 and 11/14/2025 at 06:59 were documented as completed on 11/14/2025 at 00:42, while the rest of the scheduled times (11/14/2025 2:00 – 6:00, hourly) were documented at 11/14/2025 06:24. The task logs were all documented by Staff 2.
  3. In an interview with the LI on 12/10/2025, Staff 1 acknowledged that the rounding was not completed every two hours as scheduled.
Plan of correction
1. The facility immediately reviewed Resident 1’s ISP and overnight task logs to identify gaps in required two-hour rounding. 2. The facility reinforced the required rounding schedule for Resident 1 and corrected the task schedule to align with the ISP. 3. The facility provided immediate re-education to involved staff on two-hour overnight rounding requirements and documentation expectations. 4. The facility reviewed rounding schedules and task logs for all residents requiring overnight checks to confirm alignment with their ISPs. 5. The facility corrected any discrepancies identified between ISP requirements and task log schedules for other residents. 6. The facility updated procedures to require supervisory review of overnight rounding task logs each shift. 7. The DON or designee will complete routine audits of overnight rounding documentation to verify compliance. 8. The facility will address any missed or delayed rounds immediately through staff coaching or corrective action. 9. The facility documented staff training and supervisory oversight related to rounding requirements. The Executive Director (ED) or their designee is responsible for implementing and maintaining compliance with all components of this Plan of Correction, as well as addressing and resolving any variances that may occur. Additionally, the ED or their designee is responsible for reviewing and discussing the status of this Plan of correction during QAPI Meetings and initiating necessary actions.
December 10, 2025Inspection0 violations
Inspection dates
12/10/2025
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS
Technical assistance
640A, 680D, 260A, 260B, 450, 1080B
Comments
Type of inspection: Monitoring A self-reported incident was received by VDSS Division of Licensing on 12/9/2025 regarding allegations in the areas of: 1. Resident Care and Related Services Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/10/2025 11:00am to 12:35pm 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: 124 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Resident records Additional Comments/Discussion: Resident was out of the building and was unable to be interviewed. 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 a licensed facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Tierra Sanders, Licensing Inspector at 804-724-4703 or by email at Tierra.Sanders@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
October 29, 2025Inspection5 violations
Inspection dates
10/29/2025
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY
Technical assistance
560-F: Ensure documents are available for review by department representative.
Comments
Type of inspection: Monitoring A self-reported incident was received by VDSS Division of Licensing on 10/07/2025 regarding allegations in the area(s) of: 1. Resident Accommodations and Related Provisions Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/29/2025 9:35 AM to 12:26 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 127 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: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Activities in Lobby 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-reported incident 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 Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Violations
22VAC40-73-650-C
Based on resident record review and staff interview, the facility failed to ensure that physician or prescriber’s orders were reviewed and signed by a physician or other prescriber within 14 days.
Evidence
  1. On 10/07/2025, the facility submitted an incident report regarding a medication error in which Resident 1 received Resident 2’s medication in error on 10/05/2025 around 12:00 PM.
  2. In two progress notes dated 10/05/2025, one handwritten and one typed in the resident record for Resident 1, it is indicated that Staff 1 directed staff to hold all medication per physician orders for monitoring.
  3. After a review of Resident 1’s October 2025 Medication Administration Record (MAR), it was documented that all of Resident 1’s medication scheduled for 09:00 were marked as not administered, as well as the following afternoon and evening medications: a. Morphine Sulf 20 MG, scheduled for 1400 b. Senexon-S 8.6MG-50MG, scheduled for 1800 c. Hydralazine HCI Oral Tablet 25 MG, scheduled for 0800 and 1400
  4. In an interview with two LI’s on 10/29/2025, Staff 1 stated that the physician ordered and later removed the hold of medications. Staff 1 stated that they did not have a signed order. Staff 1 confirmed there were not any written orders regarding the hold and continuation of medication signed by the nurse practitioner.
Plan of correction
| 1 | Immediate: Obtained signed physician order for the 10/05/2025 verbal “hold/restart” order. DON re-educated all nurses that all verbal/telephone orders must be signed within 14 days. | 2 | New process: Every verbal order is logged with date received. Unsigned orders >10 days are flagged daily by DON/designee. | 3 | Updated New-Hire Checklist and Annual Competency form to include signed attestation: “I have read and understand the Medication Management Plan – date/signature.” Staff #2 signed attestation retroactively. | 4 | | Training for ALL Med Techs & nurses (all shifts) on: Verbal order 14-day signature rule • Medication Management Plan key points. | 5 | DON/designee audits: Weekly for 8 weeks: All new verbal orders for signature within 14 days • Monthly: random staff files for MMP training documentation. **Overall Responsibility:** Executive Director or designee will ensure full implementation and ongoing compliance, reviewed at QAPI meetings.
22VAC40-73-640-A
Based on facility document review, resident record review and staff interview, the facility failed to ensure that a medication management plan was implemented.
Evidence
  1. Staff 1 provided the medication management plan for review on 10/29/2025.
  2. On page 12, the medication management plan states that oral orders from the physician must be reviewed and signed by a physician or other prescriber within 14 days.
  3. In an interview with two LI’s on 10/29/2025, Staff 1 confirmed that they received a verbal order to hold and restart medications on 10/05/2025 but did not receive a signed order within 14 days.
  4. On page 20, the medication management plan states that new team members will receive training on the medication management plan upon hire and all team members will receive training annually.
  5. Staff 2’s, hired on 08/06/2025, record did not contain documentation of review of the medication management plan.
  6. In an interview with two LI’s on 10/29/2025, Staff 1 reviewed the LPN Orientation for nursing staff. The onboarding did not contain a review of the medication management plan. Staff 1 did not have a copy of Staff 2’s medication management plan review or LPN Orientation. Staff 1 confirmed Staff 2 did not review the medication management plan upon hire per the medication management plan.
  7. On page 5, the medication management plan states that medications will be administered in accordance with physician or prescriber’s order.
  8. In an interview with two LI’s, Staff 1 stated that a medication error occurred on 10/05/2025 in which Staff 2 administered the wrong medication to Resident 1. Staff 1 confirmed that the medication management plan was not followed.
Plan of correction
| 1 | Immediate: Obtained signed physician order for the 10/05/2025 verbal “hold/restart” order. DON re-educated all nurses that all verbal/telephone orders must be signed within 14 days. | 2 | New process: Every verbal order is logged with date received. Unsigned orders >10 days are flagged daily by DON/designee. | 3 | Updated New-Hire Checklist and Annual Competency form to include signed attestation: “I have read and understand the Medication Management Plan – date/signature.” Staff #2 signed attestation retroactively. | 4 | | Training for ALL Med Techs & nurses (all shifts) on: Verbal order 14-day signature rule • Medication Management Plan key points. | 5 | DON/designee audits: Weekly for 8 weeks: All new verbal orders for signature within 14 days • Monthly: random staff files for MMP training documentation. **Overall Responsibility:** Executive Director or designee will ensure full implementation and ongoing compliance, reviewed at QAPI meetings.
22VAC40-73-70-A
Based on facility document review and staff interview, the facility failed to ensure that any major incident that has negatively affected or that threatens the life, health, safety or welfare of residents is reported within 24 hours to the regional licensing office.
Evidence
  1. On 10/07/2025, the LI received an email notifying the department about a medication error that occurred to Resident 1.
  2. During an interview with two LI’s, Staff 1 confirmed the incident occurred on 10/05/2025. Staff 1 acknowledged that the report was not submitted within 24 hours.
Plan of correction
| 1 | Immediate: DON/designee now reviews every incident on the day it occurs to determine if it requires 24-hour reporting to licensing. | 2 | New process: DON/designee and Administrator discuss all incidents daily. If reportable, assign designee to submit report within 24 hours. Designee also creates 7-day follow-up calendar invite for final report completion | 3 | All appropriate staff re-educated on new daily review process and 24-hour rule. | 4 | Executive Director or designee reviews all incident reports weekly x 8 weeks to verify timely reporting and follow-up. Results reported immediately. **Overall Responsibility:** The Executive Director or designee will implement and sustain this POC, address any issues, and review progress at QAPI meetings.
22VAC40-73-680-D
Based on resident record review and staff interview, the facility failed to ensure medication was administered in accordance with physician or prescriber’s orders.
Evidence
  1. On 10/07/2025, Staff 1 submitted an incident report regarding a medication error that occurred to Resident 1. The email stated that Staff 2 confused the names of Resident 1 and Resident 2 and administered Resident 2’s crushed medications to Resident 1. The incident report stated that Resident 1 did not swallow the medication and spit it out. The incident report stated that there were no significant changes in Resident 1’s condition.
  2. In a follow up email between the LI and Staff 1, Staff 1 stated that the following 17 medications were administered in error: “lisinopril, magnesium, metformin, quetiapine, pantoprazole, rosuvastatin, sertraline, biotin, fenofibrate, fish oil, Centrum, aspirin, letrozole, hydrochlorothiazide, probiotic, Vitron-C, and vitamin B12.”
  3. Staff 1 provided Resident 1 and Resident 2’s Medication Administration Record (MAR), progress notes, signed physician orders, and medication admin audit reports for review.
  4. Resident 1’s progress notes contain an Alert Charting Note dated 10/05/2025 at 12:40 PM written by Staff 2 that states that another resident’s medication was administered to Resident 1 and [Staff 1] instructed Staff 2 to hold all medications for the day.
  5. After a review of the October 2025 MAR and orders, it was documented that Resident 1’s AM medication was never administered on 10/05/2025. The medication included the following: a. Morphine Sulf 20MG/1 ML solution, scheduled for 0800 b. Senexon-S 8.6MG-50MG, scheduled for 0900 c. Amlodipine 10 MG, scheduled for 0900 d. Escitalopram Oxalate D/C 10 MG, scheduled for 0900
  6. Resident 1’s record contains two progress notes from the Nurse Practitioner, dated 10/05/2025 and 10/07/2025. On 10/05/2025, the progress note stated that the nurse practitioner requested facility monitoring and indicated that Resident 1 had an episode of diarrhea. On 10/07/2025, the progress note stated that the resident appears at baseline.
  7. In an interview with two LI’s, Staff 1 and Staff 3 acknowledged that the medication was not administered in accordance with the physician or prescriber’s orders.
Plan of correction
| 1 | Immediate: DON re-educated Staff #2 and all Med Techs on strict “5 Rights” and mandatory use of resident photo ID + verbal name confirmation with the resident (if able) before every med pass. | 2 | New process: CHECK PHOTO & CONFIRM NAME label to every med cart. Med Techs may NOT initial MAR until resident ID is positively confirmed. | 3 | Training for ALL Med Techs and nurses (all shifts) on updated ID process and review of the 10/05/2025 error. | 4 | DON or designee observes random med passes each week (all shifts) for 8 weeks to confirm proper resident ID is performed before administration. Results reviewed at QAPI. **Overall Responsibility:** The Executive Director or designee will implement and sustain this POC, address any issues, and review progress at QAPI meetings.
22VAC40-73-680-C
Based on resident record review and staff interview, the facility failed to ensure that medication was administered not earlier than one hour before or one hour after the facility’s standard dosing schedule.
Evidence
  1. On 10/07/2025, LI received an incident report regarding Resident 1 receiving the medication for Resident 2 in error on 10/05/2025.
  2. The facility’s medication management plan, on page 9, indicates that the scheduled time for daily medication is 0900.
  3. After a review of the MAR, Medication Admin Audit Report, and orders for Resident 2, it was documented that Resident 2’s medication scheduled for 09:00 was administered between 13:00 and 13:10 on 10/05/2025 by Staff 2. The medication included the following: a. Rivastigmine Outer 12.3MG24H Patch (Removal and Placement of New Patch) b. Sertraline HCL 100 MG Tablet c. Pantoprazole, Sodium F/C 40 MG Tablet d. Vitamin B-12 1000 MCG Tablet e. Centrum Silver Women 50+ tabs f. Fish Oil 260-1200MG g. Rosuvastatin Calcium 20 MG Tablet h. Fenofibrate 160 MG tablet, scheduled for 09:00 i. Hydrochlorothiazide 12.5 MG Capsule j. Lisinopril 20 MG Tablet k. Metformin HCL F/C 500 MG Tablet l. Biotin Oral Tablet m. Magnesium Oxide 500 MG Tablet n. Vitron-C High Potency, Coated 65MG-125MG Tablet o. Letrozole 2.5 MG Tablet p. Aspirin EC 81 MG Tablet
  4. In an interview with two LI’s on 10/29/2023, Staff 1 and Staff 3 acknowledged that medication was administered late to Resident 2 on 10/05/2025.
Plan of correction
| 1 | Immediate: DON re-educated all Med Techs that no scheduled medication may be given more than 1 hour before or after the scheduled time unless a physician order allows otherwise. | 2 | New process: Med Techs must follow scheduled times in eMar and report to nursing any reasons for non-compliance. | 3 | Training for ALL Med Techs and nurses (all shifts) on the 1-hour rule. | 4 | DON or designee audits random doses weekly for the next 4 weeks, checking that every medication was compliant (or has DON note). Results reviewed at QAPI. **Overall Responsibility:** The Executive Director or designee will ensure this POC is fully implemented, sustained, and reviewed at QAPI meetings.
September 25, 2025Complaint survey3 violations
Inspection dates
09/25/2025
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 09/13/2025 regarding allegations in the area(s) of: 1. Resident Accommodations and Related Provisions Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/25/2025 9:00 AM to 12:05 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 125 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: 3 Observations by licensing inspector: Resident room. Additional Comments/Discussion: Resident refused interview. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the complaint 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 Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Violations
22VAC40-73-460-H
Based on resident record review and staff interview, the facility failed to ensure that personal care and assistance were provided to each resident as necessary to ensure that the needs of the resident are met.
Evidence
  1. On 09/13/2025, the department received a complaint regarding perineal care for Resident 1.
  2. Resident 1’s record contains a doctor’s visit note, dated 09/11/2025, written by a NP that states the patient was found “soiled with stool with underlying of sanguinous drainage.”
  3. Resident 1’s progress notes contain a previous note from the NP, dated 08/26/2025 and 08/30/2025, recommending discontinuing the use of Zinc Oxide as staff are applying too much and struggling to visualize the skin, resulting in chronic fungal infections.
  4. In an interview with the LI on 09/25/2025, Staff 3 confirmed that there was a product build-up on the residents’ skin from the provided incontinent care; however, stated they did not have any additional information.
Plan of correction
Corrective Action Taken: Resident 1 received immediate perineal care and skin assessment. Zinc Oxide was discontinued per NP order. DON or designee verified documentation and follow-up care completion. Residents Potentially Affected: All residents requiring incontinence care were reviewed. Any concerns found were addressed, and care documentation was checked for accuracy. Systemic Changes: Staff re-educated on perineal care, proper product use, and documentation. Ongoing observation of care by nursing leadership during daily rounds. New hires to receive perineal care training during orientation. Monitoring: DON/designee to audit 2 residents weekly for 4 weeks, then monthly. The Executive Director (ED) or their designee is responsible for implementing and maintaining compliance with all components of this Plan of Correction, as well as addressing and resolving any variances that may occur. Additionally, the ED or their designee is responsible for reviewing and discussing the status of this Plan of Correction during QAPI Meetings and initiating necessary actions.
22VAC40-73-660-B
Based on resident record review and staff interview, the facility failed to ensure that if a resident was permitted to keep medication in his room, the UAI indicated the resident was able to self-administer and medication was stored in an out-of-sight area that was inaccessible to other residents.
Evidence
  1. On 09/25/2025, two licensing staff entered the unlocked room of Resident 1 with Staff 3. Two licensing staff observed Zinc Oxide on the counter of the bathroom in Resident 1’s room. The bottle did not have a lid, and a plastic container containing white cream, like Zinc Oxide, was on the counter beside the open tube.
  2. A bottle of prescription Ketoconazole shampoo, and a container of prescription Aquaphor 41% ointment were also seen in the bathroom of Resident 1.
  3. During an exit interview with Staff 1 and Staff 2, the photo evidence was reviewed and acknowledged.
  4. Photo evidence obtained.
Plan of correction
Corrective Action Taken: All medications and topical products were removed from the resident’s room and secured per medication storage policy. The resident’s ability to self-administer medications was reassessed, and the UAI updated accordingly. Staff were re-educated on medication storage requirements and documentation standards. Residents Potentially Affected: A review of all resident rooms was completed to confirm medications and topical items are properly secured. Any resident with self-administer privileges was reassessed for appropriateness, and documentation was updated as needed. Systemic Changes: Staff re-educated on the facility’s self-administration and storage policy, including ensuring all medication and topical products are stored securely and out of sight. Nursing leadership will include random checks of resident rooms during routine rounds to confirm compliance. Monitoring: The Director of Nursing or designee will conduct random room checks weekly to verify proper medication storage. The Executive Director (ED) or their designee is responsible for implementing and maintaining compliance with all components of this Plan of Correction, as well as addressing and resolving any variances that may occur. Additionally, the ED or their designee is responsible for reviewing and discussing the status of this Plan of Correction during QAPI Meetings and initiating necessary actions.
22VAC40-73-470-A
Based on resident record review and staff interview, the facility failed to ensure that the health care service needs of residents are met either directly or indirectly.
Evidence
  1. Resident 1’s record contained the following documentation regarding the use of Zinc Oxide products for perineal care and wound care. a. A Wound Care order that stated to apply zinc oxide cream, dated 08/11/2025. This note was also signed by the NP on 08/30/2025, after a requested review. b. A Physician Progress Note, signed electronically by the NP, that stated to D/C all zinc oxide products as “staff is applying too much in that area and [Resident 1] is developing chronic fungal infections,” dated 08/26/2025. c. A Progress Note written by Staff 5, dated 08/28/2025, detailed a request by Resident 1’s care manager that there was coordination of care challenges and conflicting orders that needed clarification by the NP. d. A Physician Progress Note, signed by the NP on 08/30/2025, again recommending that the use of Zinc Oxide be stopped due to staff being unable to visualize the skin. e. A Physician Progress Note, signed by the NP on 09/11/2025, that stated that Resident 1’s sacrum wound was covered in stool and drainage. f. A Wound Care Order, dated 09/15/2025, that stated “Apply barrier cream (like Zinc Oxide).
  2. On 09/25/2025, two licensing staff observed Zinc Oxide on the counter of the bathroom of Resident 1’s room.
  3. In an interview with two licensing staff on 09/25/2025, Staff 3 confirmed that they were aware of the product build-up that was occurring with Resident 1.
  4. During the onsite inspection, the facility was unable to provide clarification on Resident 1’s health care services as it related to the use of Zinc Oxide and their wound as the notes observed throughout the record were inconsistent.
Plan of correction
Corrective Action Taken: Resident orders were clarified with the provider. Zinc Oxide products were removed from the resident’s room, and current wound care orders were verified. Staff were re-educated on following the most current physician orders and verifying that discontinued items are not left in resident care areas. Residents Potentially Affected: All residents with wound or skin care orders were reviewed. Any findings were corrected as needed. Systemic Changes: Staff re-educated on communication protocols between nursing, providers, and care associates. Nursing leadership will review wound care orders regularly to confirm accuracy. Monitoring: The Director of Nursing or designee will review new and revised care orders regularly. The Executive Director (ED) or their designee is responsible for implementing and maintaining compliance with all components of this Plan of Correction, as well as addressing and resolving any variances that may occur. Additionally, the ED or their designee is responsible for reviewing and discussing the status of this Plan of Correction during QAPI Meetings and initiating necessary actions.
August 13, 2025Inspection5 violations
Inspection dates
08/13/2025, 08/14/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Technical assistance
490 - D: Ensure resident-specific recommendations are documented on the Healthcare Oversight Ensure resident records are audited and required information is included in the record including 50-A, 350-B, 410-A, and 480-E. Update Medication Management Plan and Infection Control Program to reflect required handwashing during medication passes.
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: 08/13/2025: 9:00 AM to 4:00 PM 08/14/2025: 9:05 AM to 5:25 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 126 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: 0 Number of interviews conducted with staff: 4 Observations by licensing inspector: Activities, Meals, and Medication Pass on both Assisted Living and Safe, Secure Units. Additional Comments/Discussion: Per facility, LI could not observe/ review resident council due to resident council refusal. Additionally, LI shared concerns with staff member regarding the length of time required to obtain documents during inspection. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Violations
22VAC40-73-260-A
Based on staff record review and staff interview, the facility failed to ensure each direct care staff member maintained a current first aid certification from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer, rescue squad or fire department.
Evidence
  1. Staff 5’s record contained a first aid certification from Collateral Contact 1 dated as completed 07/14/2025.
  2. Staff 8’s record contained a first aid certification from Collateral Contact 1 dated as completed 01/23/2025.
  3. In an interview with two LI’s on 08/13/2025, Staff 1 confirmed that Collateral Contact 1 is not the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer, rescue squad or fire department.
Plan of correction
Both staff were scheduled to complete certification through an approved organization. To prevent recurrence, the facility has revised its onboarding and compliance monitoring process to require verification of first aid certification from only the organizations listed in regulation. Documentation will be maintained in each personnel file, and staff will not be permitted to work without an approved certificate on record. Ongoing audits of staff files will be conducted by the Human Resources Manager in collaboration with the Director of Nursing to ensure compliance. The Executive Director (ED) or their designee is responsible for implementing and maintaining compliance with all components of this Plan of Correction, as well as addressing and resolving any variances that may occur. Additionally, the ED or their designee is responsible for reviewing and discussing the status of this Plan of Correction during QAPI Meetings and initiating necessary actions.
22VAC40-73-860-I
Based on direct observation and staff interview, the facility failed to ensure that cleaning supplies were stored in a locked area.
Evidence
  1. During a tour of the facility with Staff 1, two LI’s observed a bottle of Sani-Cloth germicidal disposable wipes in an unlocked cabinet of a nurse’s station.
  2. In an unlocked bathroom on the Safe, Secure Unit, two LI’s observed a bottle of Sani-Cloth germicidal disposable wipes in the bathroom to the left of the sink. The LI’s handed the cleaning wipes to Staff 16.
  3. In an interview with the LI, Staff 1 acknowledged that the cleaning supplies were found by licensing staff in an unsecured area.
  4. Photo evidence obtained.
Plan of correction
The sanitation wipes found unsecured in the bathroom were immediately removed and placed in locked storage. Staff present were re-educated on the requirement that all cleaning supplies, disinfectants, and hazardous materials must be kept in locked areas at all times and never left unattended in resident-accessible spaces. To prevent recurrence, the facility has reinforced its policy for hazardous material storage and implemented daily safety rounds by unit managers to confirm compliance. Staff have been instructed to immediately report and correct any unsecured cleaning supplies. Additionally, environmental audits will be conducted by the Director of Nursing or designee to ensure that all cleaning products remain secured. The Executive Director (ED) or their designee is responsible for implementing and maintaining compliance with all components of this Plan of Correction, as well as addressing and resolving any variances that may occur. Additionally, the ED or their designee is responsible for reviewing and discussing the status of this Plan of Correction during QAPI Meetings and initiating necessary actions.
22VAC40-73-210-B
Based on staff record review and staff interview, the facility failed to ensure that all direct care staff attended at least 18 hours of training annually.
Evidence
  1. Staff 10’s, hired 02/19/2024, record contained 4.25 hours of training completed in the last year.
  2. Staff 5’s, hired 01/17/2024, record contained 5.5 hours of training completed in the last year.
  3. Staff 8’s, hired -3/18/2024, record contained no hours of training completed in the last year.
  4. Staff 11’s, hired 05/15/2024, record contained 3.25 hours of training completed in the last year.
  5. In an interview with the LI on 08/13/2025, Staff 1 confirmed that Staff 5, Staff 8, Staff 10, and Staff 11’s record did not contain 18 hours of training annually.
Plan of correction
Each staff member has been scheduled for enrollment in additional training modules to meet and maintain the required annual hours. Staff were re-educated on the importance of ongoing training and the regulatory requirement for completion each year. To prevent recurrence, the facility revised its onboarding and orientation process to include automatic enrollment of all new direct care staff in required training. A training tracker has been established to monitor hours completed against the regulatory requirement. The Human Resource Director will review the tracker monthly to verify compliance, and deficiencies will be addressed. The Executive Director (ED) or their designee is responsible for implementing and maintaining compliance with all components of this Plan of Correction, as well as addressing and resolving any variances that may occur. Additionally, the ED or their designee is responsible for reviewing and discussing the status of this Plan of Correction during QAPI Meetings and initiating necessary actions.
22VAC40-73-1140-B
Based on staff record review and staff interview, the facility failed to ensure that direct care staff attended at least 10 hours of training in cognitive impairment within four months of the starting date of employment in the safe, secure unit.
Evidence
  1. Staff 10 was hired 02/19/2024 as a direct care staff member in the safe, secure unit. Staff 10’s record contained 4.25 hours of training completed in the last year.
  2. Staff 5 was hired 01/17/2024 as a direct care staff member on the safe, secure unit. Staff 5’s record contained 3 hours of training in cognitive impairment.
  3. Staff 11 was hired on 05/15/2024 as a direct care staff member in the safe, secure unit. Staff 11’s record contained no hours of training in cognitive impairment.
  4. Staff 12 was hired on 11/06/2024 as a direct care staff member in the safe, secure unit. Staff 12’s record did not contain any hours of training in cognitive impairment. Staff 12’s employment ended on 07/30/2025.
  5. In an interview with two LI’s on 08/13/2025, Staff 1 confirmed that Staff
Plan of correction
Staff were scheduled to complete the necessary training hours through an approved program. Staff assigned to the safe, secure unit have been re-educated on the regulatory requirement. To prevent recurrence, the facility revised its onboarding and orientation process to include automatic enrollment of all new direct care staff in required training. A training tracker has been established to monitor hours completed against the regulatory requirement. The Human Resource Director will review the tracker monthly to verify compliance, and deficiencies will be addressed. The Executive Director (ED) or their designee is responsible for implementing and maintaining compliance with all components of this Plan of Correction, as well as addressing and resolving any variances that may occur. Additionally, the ED or their designee is responsible for reviewing and discussing the status of this Plan of Correction during QAPI Meetings and initiating necessary actions.
22VAC40-73-450-F
Based on facility document review, resident record review, and staff interview, the facility failed to ensure that the individualized service plan (ISP) was updates as needed for a significant change in resident’s condition.
Evidence
  1. The facility provided the Dietician Oversight completed on 07/23/2025. The oversight states that Resident 1 has had a “…13% wt loss in 3 months (Severe)…” The recommendations included encouraging po (by mouth) intake, offering favorite foods, and adding high calorie or high protein supplements.
  2. Resident 1’s progress notes include a health status note from Resident 1’s Physical Therapist that recommends trials with use of thermal gustatory stimulation and high caloric foods, dated 07/24/2025.
  3. Resident 1’s speech therapy notes, dated 07/24/2025, indicate safe feeding strategies were reviewed with a caregiver on Resident 1’s unit.
  4. Resident 1’s ISP, dated 08/05/2025, includes a goal for eating/meals/and hydration that states the resident requires assistance to eat, and that staff will provide monitoring and supervision while observing for swallowing problems. The ISP also includes that Resident 1 is on a regular diet, pureed texture, with thin consistency.
  5. In an interview with two LI’s on 08/14/2025, Staff 2 confirmed that Resident 1’s ISP was not updated to reflect strategies or interventions due to the change in condition.
Plan of correction
Resident 1’s ISP was reviewed and updated to include interventions and strategies recommended by the dietician, physical therapist, and speech therapist. Staff responsible for Resident 1’s care were re-educated on the changes and instructed to implement the recommended interventions, including dietary modifications, safe feeding strategies, and encouragement of oral intake. To prevent recurrence, the community has strengthened its process for reviewing and updating ISPs following significant changes in a resident’s condition. Clinical oversight now includes ISP review and revision whenever therapy notes, dietician reports, or physician orders document new needs or risks. Nursing leadership conducts audits of ISPs to confirm that interventions align with current clinical recommendations. The Executive Director (ED) or their designee is responsible for implementing and maintaining compliance with all components of this Plan of Correction, as well as addressing and resolving any variances that may occur. Additionally, the ED or their designee is responsible for reviewing and discussing the status of this Plan of Correction during QAPI Meetings and initiating necessary actions.
July 30, 2025Complaint survey0 violations
Inspection dates
07/30/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-80 COMPLAINT INVESTIGATION
Technical assistance
430-H: Ensure D/C form is completed accurately.
Comments
Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 06/30/2025 regarding allegations in the area(s) of: 1. Admissions, Retention and Discharge of Residents Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/30/2025 9:20 AM to 11:35 AM 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: 124 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 4 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 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 Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
July 30, 2025Complaint survey3 violations
Inspection dates
07/30/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 07/22/2025 regarding allegations in the area(s) of: 1. Staffing and Supervision 2. Resident Care and Related Services 3. Resident Accommodations and Related Provisions Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/30/2025 11:35 MA to 4:47 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 124 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: 5 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 4 Observations by licensing inspector: Resident Room – Safe, Secure Unit. Additional Comments/Discussion: Resident was not present at facility at time of inspection. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the complaint 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 Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Violations
22VAC40-73-220-A
Based on facility document review and staff interview, the facility failed to monitor the delivery of direct care and companion services to the residents by private duty personnel when the resident received private duty services from a licensed home care organization.
Evidence
  1. Resident 1’s Individualized Service Plan (ISP), dated 01/31/2025, states that a private aide was hired for 12 hours per day to provide escorts to and from the dining area, events, and to assist with Hygiene.
  2. In an interview with the LI on 07/30/2025, Staff 1, Staff 2, and Staff 3 were unable to provide of the name of the licensed home care organization providing services to Resident 1.
  3. The “Reporting In and Out” policy, undated, states that companions must sign in/out upon arrival departure.
  4. Staff 3 provided sign-in-out sheets for the following evenings of private duty caregivers that indicate the following: a. Collateral Contact 1 signed in at 07:17 PM on 08/28/2024 as a visitor or guest b. Collateral Contact 2 signed in at 8:13 AM on 11/11/2024 as a CNA from 'self employed' c. Collateral Contact 3 signed in at 3:51 PM on 06/27/2025 as an in-home care provider from [Collateral Contact 4]. Staff 3 was unable to provide sign-in-out sheets for 05/22/2025 and 07/21/2025 or verify who the Collateral Contacts were there to provide care for.
  5. In an interview with the LI on 07/30/2025, Staff 1, Staff 2, and Staff 3 acknowledged that the requirements regarding private duty aides from licensed home care organizations were not met for the private duty providing care services to Resident 1.
  6. In an email to the LI on 07/31/2025, Staff 1 provided the name of the Home Health Organization, Collateral Contact 5, and the names of the two individuals on site for the following dates, which contradicts the sign in sheets provided on 07/30/2025: a. Collateral Contact 6 (08/29/2024, 11/11/2024) b. Collateral Contact 7 (05/22/2025, 06/28/2025, 07/21/2025)
Plan of correction
Resident’s #1 was no longer residing in the community at the time of the survey. To prevent recurrence, the community revised its monitoring process to include verification of the licensed home care organization upon initiation of services, confirmation of staff credentials, and consistent use of the sign-in/out policy. Supervisors are responsible for conducting periodic spot checks to confirm that private duty aides are providing services as outlined in resident ISPs. The Executive Director (ED) or their designee is responsible for implementing and maintaining compliance with all components of this Plan of Correction, as well as addressing and resolving any variances that may occur. Additionally, the ED or their designee is responsible for reviewing and discussing the status of this Plan of Correction during QAPI Meetings and initiating necessary actions.
22VAC40-73-70-A
Based on resident record review, the facility failed to ensure that each incident that has negatively affected or that threatens the life, health, safety or welfare of any resident was reported to the licensing office within 24 hours.
Evidence
  1. Resident 1’s record contained documentation of two falls resulting in injuries. a. 03/26/2025, Wrist Fracture b. 06/28/2025, Rib Fracture
  2. In an interview with the LI on 07/30/2025, Staff 1, Staff 2, and Staff 3 confirmed that these incidents were not reported to the licensing office within 24 hours.
Plan of correction
Resident’s #1 was no longer residing in the community at the time of the survey. Staff directly involved were re-educated on the requirement to report all incidents affecting life, health, safety, or welfare within 24 hours. A facility-wide audit of incident reports was completed to verify that all events had been properly submitted, and any late or missing reports were corrected. To prevent recurrence, managers and supervisors received training on the 24-hour reporting standard. The Executive Director (ED) or their designee is responsible for implementing and maintaining compliance with all components of this Plan of Correction, as well as addressing and resolving any variances that may occur. Additionally, the ED or their designee is responsible for reviewing and discussing the status of this Plan of Correction during QAPI Meetings and initiating necessary actions.
22VAC40-73-460-D
Based on resident record review and staff interview, the facility failed to ensure supervision of resident schedules, care, and activities including attention to specialized needs, such as falling.
Evidence
  1. Resident 1’s Individualized Service Plan (ISP), dated 01/31/2025, includes a goal for falls to reduce the risk of serious injuries by implementing proper interventions. Resident 1’s ISP states, “Assist resident to/from bathroom as needed, do not leave [Resident 1] unattended…” and “…do not leave me alone/ unattended during ADLs…”
  2. Resident 1’s record contains a physician’s visit note, dated 08/29/2024, that states Resident 1 requires one on one or staff oversight at all times due to frequent falls.
  3. Resident 1's record contains the following falls in November 2024: a. progress note documenting an unwitnessed fall on 11/03/2024 b. progress note documenting an unwitnessed fall on 11/07/2024 resulting to ER visit c. progress note documenting a witnessed fall on 11/09/2024 d. physician notes documenting a fall on 11/11/2024 resulting to ER visit with note indicating C4 displaced fracture.
  4. Resident 1’s progress notes, dated 03/26/2025, detail an unwitnessed fall that occurred during activities resulting in Resident 1 being sent to the emergency room. Resident 1’s record contains an after-visit summary from the emergency department that includes a diagnosis of a “closed fracture of left wrist.”
  5. Resident 1’s progress notes, dated 06/28/2025, detail a fall that occurred in the dining room which resulted in an ER visit. Resident 1’s record contains an after-visit summary from the emergency department that includes a diagnosis of “rib fracture.”
  6. Resident 1’s progress notes, dated 07/21/2025 9:50, detail an unwitnessed fall that occurred in the dining area. Resident 1 was sent to the ER where multiple fractures were identified.
  7. In an interview with the LI on 07/30/2025, Staff 1, Staff 2, and Staff 3 could not provide additional information regarding supervision during these incidents which resulted in injuries. Staff 1, Staff 2, and Staff 3 acknowledged that the facility failed to ensure supervision of specialized needs, including prevention of falls.
Plan of correction
Resident’s #1 was no longer residing in the community at the time of the survey. Care staff re-educated on supervision requirements and fall prevention interventions. Audit of residents with fall risk or physician orders for enhanced supervision completed; ISPs corrected where needed. Discrepancies addressed and documented. Staff in-service training provided on fall risk interventions, supervision requirements, and documentation. Staffing assignments reviewed to align with resident acuity and supervision needs. The Executive Director (ED) or their designee is responsible for implementing and maintaining compliance with all components of this Plan of Correction, as well as addressing and resolving any variances that may occur. Additionally, the ED or their designee is responsible for reviewing and discussing the status of this Plan of Correction during QAPI Meetings and initiating necessary actions.
June 16, 2025Complaint survey3 violations
Inspection dates
06/16/2025
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 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY22VAC40-80 COMPLAINT INVESTIGATION
Technical assistance
Criminal Record Reports Window Openings (1150-B) Staff’s Treatment of Residents, 110-A
Comments
Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 05/07/2025 regarding allegations in the area(s) of: 1. Resident Care and Related Services 2. Resident Accommodations and Related Provisions 3. Staffing and Supervision 4. Buildings and Grounds Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/16/2025 8:30 AM to 12:55 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 122 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: 5 Observations by licensing inspector: Memory Care – Activities and Resident Room Additional Comments/Discussion: Resident no longer resides in the facility for interviews. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the complaint 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 Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Violations
22VAC40-73-860-D
Based on resident record review and staff interview, the facility failed to ensure that any operable window was effectively screened.
Evidence
  1. On 05/20/2025, as part of an ongoing complaint investigation, video footage was received by the department documenting two wild birds in Resident 1’s room on 05/11/2025 through 05/13/2025.
  2. In an interview with the LI on 06/13/2025, Staff 3 and 4 confirmed that there were birds in the Resident 1’s room.
  3. Upon inspection of Resident 1’s room on 06/13/2025, the LI observed that the window on the right did not have a screen.
  4. In an interview with the LI, Staff 3 confirmed that the window was operable and did not have a screen.
  5. Photo evidence obtained.
Plan of correction
Correction for the Specific Resident: At the time of the incident, the referenced resident was no longer residing in the community. The community promptly removed the birds and thoroughly cleaned the room. Correction for Overall Issue and Review for Other Residents: A plan is currently in development to address the identified requirements and ensure alignment with the applicable standards. Time frame provided is not acceptable by licensing. Facility needs to have screens in place within 60 days.
22VAC40-73-450-H
Based on resident record review and staff interview, the facility failed to ensure that the care and services specified in the Individualized Service Plan (ISP) are provided to each resident.
Evidence
  1. Resident 1's ISP (dated 01/31/2025) includes required assistance with grooming/oral hygiene to include an intervention to attempt to brush teeth in the AM and PM.
  2. In an interview with the LI on 06/16/2025, Staff 3 confirmed that on the task log “grooming” covered dental care and provided task logs from January 2025 to April 2025 for Resident 1. The task log reads “Grooming: Daily 1 person assist with grooming.”
  3. The task log indicates Resident 1 requires grooming daily and was only assisted once a day for the following instances a month: a. Five (5) dates in January 2025 b. Four (4) dates in February 2025 c. Three (3) dates in March 2025 d. One (1) date in April 2025
  4. In an interview with the LI on 06/16/2025, Staff 3 acknowledged that the care and services in Resident 1’s ISP, related to dental hygiene, were not completed as specified.
Plan of correction
Correction for the Specific Resident: The resident referenced in this citation had been discharged from the community prior to the citation being issued. No direct action will be taken toward this individual resident. Correction for Overall Issue and Review for Other Residents: All resident ISPs will be reviewed to confirm that the services and care needs identified are being clearly documented and assigned for completion. Task logs and care assignment sheets will be updated to reflect the frequency and details of each service, including grooming and oral hygiene, to ensure clarity and accountability for staff. Staff training will be conducted to reinforce the requirement that all services outlined in the ISP must be provided as specified. Monitoring and Prevention Measures: ISPs and task logs will be reviewed monthly to verify that all care and services listed are being completed as specified. A random audit of 5 residents’ ISPs and corresponding task logs will be conducted each month by the Director of Nursing or designee. The Executive Director (ED) or their designee is responsible for implementing and maintaining compliance with all components of this Plan of Correction, as well as addressing and resolving any variances that may occur. Additionally, the ED or their designee is responsible for reviewing and discussing the status of this Plan of Correction during QAPI Meetings and initiating necessary actions.
22VAC40-73-450-F
Based on resident record review and staff interview, the facility failed to ensure that the Individualized Service Plan (ISP) was reviewed and updated as needed for significant change of a resident’s condition.
Evidence
  1. Resident 1 was admitted to the Safe, Secure unit on 09/02/2022.
  2. Resident 1’s progress notes contain documented incidents of abusive, aggressive, or disruptive (including refusal of care) behavior starting on 09/18/2022, with an increase in documented occurrences starting 04/15/2024.
  3. In an interview with the LI on 06/16/2025, Staff 4 described Resident 1 as combative and resistant to care.
  4. Resident 1’s records include ISP’s signed 09/06/2022, 03/27/2023, and 06/11/2024 that do not include any interventions or goals for abusive/ aggressive/ or disruptive behavior.
  5. Resident’s ISP, dated 01/31/2025, contains interventions initiated on 04/17/2025 and 04/21/2025 located under “Psychosocial” and “Mood Problems.” “Resistive to Care” contains interventions that were started on 01/31/2025 and 04/17/2025. “Behavior” has two interventions for aggressive, abusive/ disruptive behavior that were initiated on 04/17/2025.
  6. In an email dated June 13, 2025, Staff 1 informed the Licensing Inspector that behavioral unmet needs, including behavior management, were not incorporated into the care plan until January 2025 and April 2025, despite the increase in occurrences starting April of 2024.
Plan of correction
Correction for the Specific Resident: The resident referenced in this citation had been discharged from the community prior to the citation being issued. No direct action will be taken toward this individual resident. Correction for Overall Issue and Review for Other Residents: All resident ISPs will be reviewed to confirm they accurately reflect each resident’s current condition and include appropriate interventions and goals for any identified behavioral needs. Any missing or outdated information will be corrected. Care team meetings will be held to reinforce the procedure for updating ISPs immediately following any significant change in a resident’s condition. Monitoring and Prevention Measures: ISPs will be reviewed following any significant change in a resident’s condition, including behavioral changes, to confirm that appropriate interventions and goals are documented. A monthly audit of a random sample of 5 ISPs will be conducted to monitor compliance. The Executive Director (ED) or their designee is responsible for implementing and maintaining compliance with all components of this Plan of Correction, as well as addressing and resolving any variances that may occur. Additionally, the ED or their designee is responsible for reviewing and discussing the status of this Plan of Correction during QAPI Meetings and initiating necessary actions.
April 24, 2025Inspection6 violations
Inspection dates
04/24/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION
Technical assistance
Criminal Record Reports
Comments
Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 04/24/2025 11:55 AM to 7:30 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 120 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: 1 Number of interviews conducted with staff: Observations by licensing inspector: Meals, Activities, Medication Pass on both Assisted Living and Safe, Secure Units Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Violations
22VAC40-90-40-C
Based on staff record review and staff interview, the facility failed to ensure that each employee’s criminal history record did not contain any barrier cries.
Evidence
  1. Staff 7 provided the Criminal History Record Report for Staff 6.
  2. Staff 6’s, hired 04/08/2025, Criminal History Record report, dated 03/20/2025, contained two convictions of “MSDMNR 18.2-57.”
  3. In an interview with the LI on 04/24/2025, Staff 1 and Staff 7 reviewed the barrier crimes with the LI. Staff 1 and 7 acknowledged that 18.2-57 is a barrier crime.
Plan of correction
Staff 6, was immediately removed from the schedule and is no longer employed by the facility. No residents were affected as a result of this oversight. All criminal background checks are reviewed and approved by the Executive Director or designee prior to an official offer being extended. No staff will be allowed to begin orientation or training until the background check is fully cleared. HR and hiring managers participated in an in-service on proper criminal background review procedures, with a focus on identifying barrier crimes under Virginia Code. A full audit of all current employee criminal history records was completed to confirm no other employees have disqualifying offenses. The Executive Director (ED) or their designee is responsible for implementing and maintaining compliance with all components of this Plan of Correction, as well as addressing and resolving any variances that may occur. Additionally, the ED or their designee is responsible for reviewing and discussing the status of this Plan of Correction during QAPI Meetings and initiating necessary actions.
22VAC40-73-950-E
Based on staff interviews the facility failed to ensure, a semi-annual review on the emergency preparedness plan was implemented for all staff, residents, and volunteers.
Evidence
  1. On 04/24/2025, the LI requested a copy of the semi-annual review of the emergency preparedness plan for staff, residents, and volunteers.
  2. In an interview with the LI on 04/24/2025, Staff 4 confirmed a semi-annual review of the emergency preparedness plan for staff, residents, and volunteers had not been completed.
Plan of correction
A full review of the emergency preparedness plan was completed and documented accordingly. No adverse outcomes were identified as a result of this oversight. A calendar-based tracking system has been created to schedule emergency preparedness plan reviews every six months. An in-service was held to review the emergency preparedness plan with all staff and to orient volunteers to their roles during an emergency. A resident safety meeting was conducted, during which key elements of the emergency plan were shared and reviewed, including shelter-in-place, evacuation routes, and communication protocols. The Executive Director (ED) or their designee is responsible for implementing and maintaining compliance with all components of this Plan of Correction, as well as addressing and resolving any variances that may occur. Additionally, the ED or their designee is responsible for reviewing and discussing the status of this Plan of Correction during QAPI Meetings and initiating necessary actions.
22VAC40-73-490-A
Based on resident record review, facility document review and staff interview, the facility failed to ensure that all residents were included in the healthcare oversight at least annually.
Evidence
  1. The facility census on 04/24/2025 was 125.
  2. On 04/24/2025, Staff 2 provided health care oversight for 01/01/2024-06/01/2024 and 01/10/2025. There was no list of residents attached.
  3. In an interview the LI on 04/24/2024, Staff 2 stated that they did not realize they had to include a list of residents. Staff 2 stated a list of residents could be generated based on notes during the healthcare oversight period.
  4. On 04/25/2025, Staff 1 submitted an emailed list of residents reviewed that contained 5 residents.
Plan of correction
There was no direct impact on residents as a result of this oversight. The Director of Nursing or designee has updated the healthcare oversight process to require that all documentation include the names of residents reviewed. The Executive Director (ED) or their designee is responsible for implementing and maintaining compliance with all components of this Plan of Correction, as well as addressing and resolving any variances that may occur. Additionally, the ED or their designee is responsible for reviewing and discussing the status of this Plan of Correction during QAPI Meetings and initiating necessary actions.
22VAC40-73-680-B
Based on resident record review and staff interview, the facility failed to ensure medication was administered according to physician orders.
Evidence
  1. On 4/24/2025, the Li observed staff 5 passing medications. To resident one. Staff 5 put the medication in the cup and was asked to stop the medication pass. Staff 5 labeled the cup., and put it in the top drawer of the cart. Staff. I've closed the drawer of the cart and locked the cart. Staff 5 stated they would attempt to administer the medication later. The LI asked when the medication would get destroyed. Staff 5 stated that they did not destroy medication unless they were sure the resident was not going to take the medication.
  2. In an interview with the LI on 04/24/2025, Staff 1 acknowledged. That the medication should have remained in the pharmacy issued container.
  3. Photo evidence obtained.
Plan of correction
The incident involving Staff 5 on 04/24/2025 was immediately addressed. The medication that had been pre-poured and stored improperly was discarded. Resident 1 did not experience any adverse effects. The Director of Nursing provided immediate coaching to the staff involved, and the incident was documented. All licensed nurses and medication aides were re-educated regarding safe medication handling practices, including the requirement that medications remain in their pharmacy-issued containers until time of administration and must not be pre-poured. The facility’s Medication Administration policy was reviewed and clarified to explicitly prohibit storing medications outside of the labeled container for later administration. This revised policy was redistributed to all nursing staff. Audits of medication carts, led by the Director of Nursing or designee, to confirm compliance with medication storage and administration procedures. Audits will continue daily for 30 days and then weekly for 60 days A progressive discipline process was re-emphasized for noncompliance with med pass procedures. All staff have been informed that deviations from the policy without clinical justification and documentation will result in corrective action. The Executive Director (ED) or their designee is responsible for implementing and maintaining compliance with all components of this Plan of Correction, as well as addressing and resolving any variances that may occur. Additionally, the ED or their designee is responsible for reviewing and discussing the status of this Plan of Correction during QAPI Meetings and initiating necessary actions.
22VAC40-73-680-C
Based on resident record review and staff interview, the facility failed to ensure that medications were administered not earlier than one hour before and not later than one hour after the facility’s standard dosing schedule.
Evidence
  1. Resident 1’s record contained a signed order summary dated 04/02/2025. The order summary contained an order for Acetaminophen 500 MG that states “Give 1 caplet by mouth twice daily for pain…” and Mirtazapine F/C 7.5 MG that states “Give 1 tab by mouth at bedtime for dementia…”
  2. On Page 10 of the Medication Management Plan, the facility’s standard dosing time is listed. The plan states “…2 times a day: (BID) 0900, 1700…Bedtime: 2100…”
  3. Resident 1’s Medication Admin Audit Report indicates that Acetaminophin was administered outside of the scheduled dose time on the following dates: a. March 2nd, 2025, at 10:08 b. March 14th, 2025, at 2208 c. March 16th, 2025, at 10:13 d. March 22nd, 2025, at 22:16 e. March 23rd, 2025, at 10:06 f. March 28th, 2025, at 11:41 g. March 28th, 2025, 22:08 h. March 29th, 2025, at 12:29 i. March 29th, 2025, at 22:34 j. March 30th, 2025, at 10:15 k. April 4th, 2025, at 22:19 l. April 20th, 2025, at 10:19
  4. Resident 1’s Medication Admin Audit Report indicates that Mirtrazapine was administered outside of the scheduled dose time on the following dates: a. March 14th, 2025, at 22:08 b. March 22nd, 2025, 22:16 c. March 28th, 2025, 22:08 d. March 29th, 2025, at 22:34 e. April 4th, 2025, at 22:19
  5. In an interview with the LI on 4/24/2025, staff one acknowledged that the medication was administered outside of the scheduled dosing time.
Plan of correction
Resident 1’s Medication Administration Record (MAR) and physician orders were reviewed. All medications were reconciled with the standard dosing schedule, and adjustments were made where needed. No adverse outcomes were identified. The nurse responsible was counseled regarding adherence to policy. All licensed nurses and medication aides received refresher training regarding the facility’s Medication Management Plan, with specific emphasis on the dosing window: medications must be administered no earlier than one hour before and no later than one hour after scheduled times. The Director of Nursing or designee began conducting audits of Medication Administration Records (MARs) to track timing compliance. This will continue daily for 30 days, then weekly for 60 days. A progressive discipline process was re-emphasized for noncompliance with med pass procedures. All staff have been informed that deviations from the policy without clinical justification and documentation will result in corrective action. The Executive Director (ED) or their designee is responsible for implementing and maintaining compliance with all components of this Plan of Correction, as well as addressing and resolving any variances that may occur. Additionally, the ED or their designee is responsible for reviewing and discussing the status of this Plan of Correction during QAPI Meetings and initiating necessary actions.
22VAC40-73-640-A
Based on resident record review, direct observation and staff interview, the facility failed to ensure the medication management plan was followed.
Evidence
  1. On 04/24/2025, LI observed Staff 5 administering medications on the Safe, Secure unit around 4:30 pm.
  2. Resident 1’s record contained a signed order summary dated 04/02/2025. The order summary contained an order for Acetaminophen 500 MG that states “Give 1 caplet by mouth twice daily for pain…” and Mirtazapine F/C 7.5 MG that states “Give 1 tab by mouth at bedtime for dementia…”
  3. Resident 1’s April 2024 Medication Administration Record has the scheduled time for Acetaminophen at 9:00 and 21:00 and Mirtazapine at 9:00.
  4. In an interview with the LI on 04/24/2025, Staff 5 stated that they would be administering a medication a little early to Resident 1 to ensure it was received prior to Resident 1’s preferred bedtime. As Staff 5 was getting the medication ready to administer, the LI read the order as scheduled for 9:00 PM. Staff 5 stated that this was how it was always done, and that Resident 1 would be asleep and hard to wake if they attempted to pass the medication at 9:00 PM. Staff 5 confirmed the medication was scheduled for 9:00 PM, and there was no order to administer at 4:30 PM. The LI stopped the medication pass.
  5. Staff 1 provided the LI with a copy of the facility’s medication management plan. On page 6 of the Medication Management Plan, the procedure states the following: “C. Medications shall be administered not one hour before and to later than one hour after the facility’s standard dosing schedule…”
  6. On Page 10 of the Medication Management Plan, the facility’s standard dosing time is listed. The plan states “…2 times a day: (BID) 0900, 1700…Bedtime: 2100…”
  7. In an interview with the LI on 04/24/2024, Staff 1 acknowledged that the medication was not administered per the dosing schedule.
Plan of correction
On 04/24/2025, upon identification of early administration outside the allowable window, the medication pass was immediately stopped. Resident 1 was not adversely affected. The incident was documented, and a review of their Medication Administration Record (MAR) was conducted. Orders were verified for accuracy and compliance with facility protocol. All nursing and medication administration staff received re-education regarding the facility's Medication Management Plan, including adherence to scheduled times and the “no earlier than one hour before, and no later than one hour after” rule. The Medication Management Plan was reviewed and reinforced during the June 2025 nursing meeting. The Director of Nursing or designee will conduct random audits of med passes across all shifts to confirm compliance with scheduled medication administration windows. The Executive Director (ED) or their designee is responsible for implementing and maintaining compliance with all components of this Plan of Correction, as well as addressing and resolving any variances that may occur. Additionally, the ED or their designee is responsible for reviewing and discussing the status of this Plan of Correction during QAPI Meetings and initiating necessary actions.
April 24, 2025Inspection2 violations
Inspection dates
04/24/2025
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 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY
Comments
Type of inspection: Monitoring A self-reported incident was received by VDSS Division of Licensing on 04/24/2025 regarding allegations in the area(s) of: Resident Care and Related Services. Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 04/24/2025 9:05 AM to 11:52 AM 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: 120 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 4 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: Meals, Activities, and Resident Room in Memory Care Unit 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-reported incident 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 Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Violations
22VAC40-73-460-A
Based on resident record review and staff interview, the facility failed to assume the general health, safety, and well-being of the resident.
Evidence
  1. On 04/16/2025, Staff 1 submitted an initial incident notification via email of an allegation of abuse to Resident 1.
  2. On 04/24/2025, Staff 1 provided video footage of the alleged incident on 04/14/2025 around 5:00 AM involving Staff 3 and Staff 4 during the provision of care assistance to Resident 1. Upon review, the video depicts Staff 3 and Staff 4 engaging with Resident 1 in an aggressive manner both physically and verbally while using inappropriate transfer techniques.
Plan of correction
Upon receipt of the allegation, the resident involved was assessed by the nursing team to confirm there were no physical injuries. Psychological and emotional support was provided, and the resident’s responsible party was notified promptly. The two staff members identified in the incident (Staff 3 and Staff 4) were immediately suspended pending investigation and (Staff #3) is longer employed at the facility. The incident was reported to Adult Protective Services (APS), VDSS Licensing Inspector and Fairfax County Police. All direct care staff, nurses, and supervisors completed re-training on Resident Rights, Abuse Prevention, and Appropriate Transfer Techniques. In partnership with corporate clinical leadership, the community held a staff town hall and team culture reset, reinforcing the community’s zero-tolerance approach to mistreatment and prioritizing dignity-driven care. The facility’s Abuse Prevention and Reporting policy and Resident Rights policy were reviewed and reissued to all staff. Staff were required to sign a policy acknowledgment form confirming their understanding and commitment to uphold the standards of care and dignity. The Executive Director (ED) or their designee is responsible for implementing and maintaining compliance with all components of this Plan of Correction, as well as addressing and resolving any variances that may occur. Additionally, the ED or their designee is responsible for reviewing and discussing the status of this Plan of Correction during QAPI Meetings and initiating necessary actions.
22VAC40-73-1140-B
Based on staff record review and staff interview, the facility failed to ensure that direct care staff attended at least 10 hours of training in cognitive impairment within four months of the starting date of employment.
Evidence
  1. Staff 3’s record, hired on 03/06/2024, did not contain the required 10 hours of training in cognitive impairment within 4 months of their starting date of employment.
  2. In an interview with the LI on 04/24/2025, Staff 5 confirmed that Staff 3 did not have the required training and provided confirmation from [Collateral Contact 1], the facility’s online learning platform.
Plan of correction
Staff #3 had completed dementia-related training and had several years of relevant experience; however, the documentation confirming this training was not properly maintained in their personnel file. No further action was taken regarding this individual, as they are no longer employed at the community. An audit of training records for all remaining staff has been completed. Any deficiencies identified during this review are currently being corrected to align all records with regulatory requirements. The Executive Director (ED) or their designee is responsible for implementing and maintaining compliance with all components of this Plan of Correction, as well as addressing and resolving any variances that may occur. Additionally, the ED or their designee is responsible for reviewing and discussing the status of this Plan of Correction during QAPI Meetings and initiating necessary actions.
April 23, 2025Complaint survey2 violations
Inspection dates
04/23/2025
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on (03/03/2025) regarding allegations in the area(s) of: 1. Staffing and Supervision 2. Resident Care and Related Services Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 04/23/2025 2:55 PM to 5:45 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 120 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 4 Number of interviews conducted with residents: 2 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 some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: 1. Resident Care and Related Services A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Violations
22VAC40-73-280-B
Based on facility document review and staff interview, the facility failed to maintain a written staffing plan that includes the number and type of staff required to meet day-to-day, routine direct care needs and any specialized needs.
Evidence
  1. Staff 2 provided a policy from the facility’s Standard and Guidelines titled “Nursing Services” dated 07/01/2023. The policy reviewed the nursing staff sufficient for memory care.
  2. Staff 2 provided a document titled “Assisted Living Assignment for CNA’s [Certified Nursing Assistants]” which included a table of assignments for a 5, 6, 7 group assignments with lunch breaks and room numbers.
  3. In an interview with the LI, Staff 2 stated the schedule covered the staffing assignments dependent on how many CNA’s were available (5, 6, or 7.) Staff 2 stated that if only 5 CNAs were on site, the facility contacts an agency to send supplemental staff.
  4. In an interview with the LI, Staff 1 and 2 confirmed the staffing plan does not specify the number and type of staff needed to provide services in the facility.
Plan of correction
Although no specific residents were found to have unmet needs, the facility conducted a thorough review of current staffing coverage to confirm that all routine and specialized care needs are consistently being met. Any identified gaps were promptly addressed through scheduling modifications and the use of supplemental staff. A formal written staffing plan was developed and implemented. This plan outlines the minimum number and type of direct care staff (including CNAs, Med Techs, and nurses) required per shift, based on occupancy and resident acuity across Assisted Living and Memory Care. An in-service training was conducted on [Insert Date] for all leadership and supervisory staff to review the new staffing plan, clarify expectations, and walk through coverage scenarios. The Executive Director (ED) or their designee is responsible for implementing and maintaining compliance with all components of this Plan of Correction, as well as addressing and resolving any variances that may occur. Additionally, the ED or their designee is responsible for reviewing and discussing the status of this Plan of Correction during QAPI Meetings and initiating necessary actions.
22VAC40-73-460-B
Based on resident record review and staff interview, the facility failed to ensure prompt response to needs as reasonable to the circumstances.
Evidence
  1. In an interview with the LI on 04/23/2025, Staff 1 stated there was not a written policy regarding the expected time to respond to the emergency call system. Staff 1 stated the staff expectation was less than 20 minutes.
  2. Staff 1 provided the emergency call report for Resident 1. The emergency call report for Resident 1 indicates there were 12 instances that the resident had to wait longer than 20 minutes. The times below exclude the seconds. a. 02/21/2025 9:13 AM: 45 minutes b. 02/23/2025 8:11 AM: 38 minutes c. 02/24/2025 11:45 AM: 25 minutes d. 02/25/2025 10:08 AM: 32 minutes e. 02/25/2025 2:40 PM: 26 minutes f. 02/26/2025 9:11 AM: 33 minutes g. 02/28/2025 8:29 AM: 38 minutes h. 03/02/2025 9:07 PM: 37 minutes i. 03/03/2025 7:07 AM: 58 minutes j. 03/03/2025 9:44 AM: 57 minutes k. 03//03/2025 11:54 AM: 30 minutes
Plan of correction
Resident #1's care plan was reviewed to confirm that all current care needs are being met. An in-service training was provided to staff focusing on the importance of prompt response, thorough documentation, and appropriate prioritization of resident calls. Staff were instructed to immediately inform the nurse or supervisor if a delay in response is unavoidable. The Director of Nursing or designee will review the call log daily for 30 days, followed by weekly reviews for 90 days. Any instance of delayed response will be examined and addressed through corrective coaching or procedural adjustments. The community maintains a preventative maintenance agreement with the emergency call system vendor and will request a full system audit to verify proper operation. The Executive Director (ED) or their designee is responsible for implementing and maintaining compliance with all components of this Plan of Correction, as well as addressing and resolving any variances that may occur. Additionally, the ED or their designee is responsible for reviewing and discussing the status of this Plan of Correction during QAPI Meetings and initiating necessary actions.
April 23, 2025Complaint survey3 violations
Inspection dates
04/23/2025
Areas reviewed
22VAC40-80 COMPLAINT INVESTIGATION22VAC40-73 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 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 01/24/2025 regarding allegations in the area(s) of: 1. Resident Care and Related Services 2. Resident accommodations and Related Provisions Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 04/23/2025 10:40 AM to 2:52 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 120 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: Meals and Activities on Memory Care Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the complaint 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 Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Violations
22VAC40-73-610-B
Based on direct observation, facility document review and staff interview, the facility failed to ensure that any menu substitutions or additions are recorded on the posted menu.
Evidence
  1. On 04/23/2025, the LI observed the posted menu and lunch being served in the safe, secure environment. The food served to residents was not consistent with the menu posted.
  2. In an interview with the LI on 04/23/2025, Staff 1 acknowledged the menu did not include the substitutions given on 04/23/2025 during the lunch meal.
  3. Photo evidence obtained.
Plan of correction
A review of menu posting procedures was completed. Dietary and care staff were reminded of the requirement to clearly document all menu changes, substitutions, or additions on the daily posted menu at the time they occur. Dietary team members, including all cooks and servers, were re-educated on proper procedures for updating posted menus when changes are made.. The Dining Services Director or designee will perform routine spot checks of posted menus to verify that they reflect what is being served. The Executive Director (ED) or their designee is responsible for implementing and maintaining compliance with all components of this Plan of Correction, as well as addressing and resolving any variances that may occur. Additionally, the ED or their designee is responsible for reviewing and discussing the status of this Plan of Correction during QAPI Meetings and initiating necessary actions.
22VAC40-73-680-D
Based on resident record review and staff interview, the facility failed to ensure medication was administered according to physician order.
Evidence
  1. Resident 3’s record contains an order dated 01/28/2025 for Hydralazine 25 mg tablet that states “Take BP TID and document give one tab hydralazine PO for systolic 160 or above.”
  2. Resident 3’s MAR for January 2025 indicates that four (4) doses of Hydralazine were administered when the Systolic was under 160. a. January 30th, 2025, at 9:00 AM (BP 138/67) b. January 30th, 2025, at 2:00 PM (BP 126/81) c. January 31st, 2025, at 2:00 PM (BP 150/90) d. January 31st, 2025, at 9:00 PM (BP 123/76)
  3. Resident 3’s record contains a signed Order Summary report dated 04/02/2025. The order summary report contains an order for Hydralazine HCI Oral Tabley 25 mg that states “Give 1 tablet by mouth three times a day related to [diagnosis [] Hold for systolic below 140.”
  4. Resident 3’s MAR for April 2025 indicates that there were 14 doses administered when systolic was below 140. a. April 04th, 2025, at 8:00 AM (BP 137/71) b. April 04th, 2025, at 2:00 PM (BP 127/64) c. April 04th, 2025, at 8:00 PM (BP 130/86) d. April 05th, 2025, at 8:00 AM (BP 137/71) e. April 05th, 2025, at 2:00 PM (BP 132/68) f. April 06th, 2025, at 8:00 AM (BP 128/66) g. April 08th, 2025, at 2:00 PM (BP 137/76) h. April 11th, 2025, at 8:00 AM (BP 134/64) i. April 11th, 2025, at 2:00 PM (BP 118/71) j. April 11th, 2025, at 8:00 PM (BP 130/68) k. April 13th, 2025, at 8:00 AM (BP 133/70) l. April 19th, 2025, at 2:00 PM (BP 126/75) m. April 20th, 2025, at 8:00 AM (BP 138/69) n. April 20th, 2025, at 2:00 PM (BP 126/68)
  5. In an interview with the LI on 04/23/2025, Staff 1, 2, and 3 confirmed that the medication was not administered according to physician orders.
Plan of correction
Resident # 3's medication administration record (MAR) was reviewed, and the discrepancies were addressed with the licensed staff responsible. No adverse outcomes were reported for the resident. An audit of current MARs and corresponding physician orders has been completed to identify and correct any inconsistencies related to blood pressure parameters and medication administration. Licensed nurses have received focused re-education on interpreting and following parameters listed in physician orders, with particular attention to medications tied to blood pressure readings. Training included documentation practices and when to hold medications per specific order guidelines. The Director of Nursing or designee will conduct random audits of blood pressure medications with hold parameters for adherence to physician orders. Any deviations will be reviewed, addressed with the staff involved, and documented for quality improvement purposes. The Executive Director (ED) or their designee is responsible for implementing and maintaining compliance with all components of this Plan of Correction, as well as addressing and resolving any variances that may occur. Additionally, the ED or their designee is responsible for reviewing and discussing the status of this Plan of Correction during QAPI Meetings and initiating necessary actions.
22VAC40-73-680-M
Based on direct observation, resident record review, and staff interview, the facility failed to ensure that PRN [as needed] medication was available for the specific resident.
Evidence
  1. Resident 2’s record contains a signed Order Summary Report dated 04/02/2025. The Order Summary Report lists orders for PRN medication including Acetaminophen 325 mg, started 11/15/2024, Anti-diarrheal 2 mg, started 02/04/2025, and Hyoscyamine, started 11/15/2024.
  2. On 04/23/2025, the LI completed a medication cart audit for Resident 2 and 3. Resident 2’s Acetaminophen, Anti-Diarrheal, and Hyoscyamine were not on the cart.
Plan of correction
The medications for resident # 3 have since been reordered, received, and verified as available and accessible to nursing staff. No adverse outcomes were reported for the resident. A review of current residents' PRN orders was conducted to confirm that all prescribed as-needed medications are on hand and stored appropriately. Any discrepancies identified were corrected. Nursing staff received re-education on medication cart audits, PRN medication availability, and the importance of ensuring all ordered medications are properly stocked and maintained for resident use. The Director of Nursing or designee will conduct medication cart audits focused on PRN medications to verify availability and compliance with physician orders. The Executive Director (ED) or their designee is responsible for implementing and maintaining compliance with all components of this Plan of Correction, as well as addressing and resolving any variances that may occur. Additionally, the ED or their designee is responsible for reviewing and discussing the status of this Plan of Correction during QAPI Meetings and initiating necessary actions.
April 23, 2025Complaint survey0 violations
Inspection dates
04/23/2025
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 02/11/2025 regarding allegations in the area(s) of: Resident Privacy and Dignity During Health Services Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 04/23/2025 9:40 AM to 10:37 AM 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: 120 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 4 Observations by licensing inspector: N/A Additional Comments/Discussion: Selective review of facility documents that included resident information (not full records) was reviewed. 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 Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
January 15, 2025Inspection2 violations
Inspection dates
01/15/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
Type of inspection: Monitoring A self-reported incident was received by VDSS Division of Licensing on 10/29/2024 regarding allegations in the area(s) of: resident care and related services. Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 01/15/2025 12:30 PM to 2:30 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 117 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 4 Observations by licensing inspector: Activities, Breakfast/Lunch Meals Additional Comments/Discussion: 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-reported incident 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 Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Violations
22VAC40-73-1140-B
Based on staff record review and staff interview, the facility failed to ensure that direct care staff in the special care unit attend at least 10 hours of training in cognitive impairment within 4 months of starting employment.
Evidence
  1. The LI reviewed the schedule for 10/23/2024. Staff 4 was scheduled to work on the Special Care Unit.
  2. In an interview with the LI, Staff 5 confirmed that Staff 4 is typically assigned to the Special Care Unit.
  3. Staff 4’s, hired on 03/18/2024, record does not contain documentation of any completed training in cognitive impairment.
  4. In an interview with the LI, Staff 1, 2, and 3 acknowledged that Staff 4 did not have the required training.
Plan of correction
The Community has revised its best practice guidelines, mandating that all new employees complete their essential dementia training prior to beginning floor duties. This will be accomplished through a blend of orientation sessions and online coursework. Additionally, the Community will maintain its schedule of monthly group training sessions and quarterly workshops to support compliance with this requirement The Executive Director (ED) or their designee is responsible for implementing and maintaining compliance with all components of this Plan of Correction and addressing and resolving any variances that may occur. Additionally, the ED or their designee is responsible for reviewing and discussing the status of this Plan of Correction during QAPI Meetings and initiating necessary actions.
22VAC40-73-930-D
Based on resident record review and staff interview, the facility failed to ensure that an inability to use the call bell was documented in the individualized service plan (ISP) and that written approval of rounds that occurred at a frequency other than two hours was documented in the resident’s record for each resident with the inability to use the signaling device.
Evidence
  1. During an interview with the LI on 01/15/2025, Staff 1, 2 and 3 confirmed that Resident 1, admitted 03/18/2021, was unable to use the call bell.
  2. Resident 1’s, admitted 03/18/2021, record contained an (ISP) dated 10/17/2024. The ISP stated, “Assurance checks: SAFETY CHECK EVERY 4 hours.” The ISP did not state that the resident was unable to use the call bell.
  3. Resident 1’s record contains a Task Log for October 2024. The Task log indicates that safety checks were not completed every 4 hours on 10/20/2024 through 10/31/2024. There was no documentation of any safety checks 10/17/2024 through 10/19/2024.
  4. In an interview with the LI on 01/15/2025, Staff 1, 2, and 3 confirmed that there was not written approval for rounds outside of a frequency of two (2) hours was documented. Staff 1, 2, and 3 acknowledged that the rounds were not being completed according to the schedule.
Plan of correction
Following the discovery, Resident #1's Individualized Service Plan (ISP) was updated to comply with the required standard. Additionally, Resident #1's Person-Centered Care (PCC) Tasks were adjusted to accurately reflect the rounding schedule as outlined in the ISP. The Director of Nursing or their designated representative will conduct a review of all ISPs and PCC Tasks for residents unable to operate a signaling device, addressing and correcting any identified discrepancies. The Executive Director (ED) or their designee is responsible for implementing and maintaining compliance with all components of this Plan of Correction and addressing and resolving any variances that may occur. Additionally, the ED or their designee is responsible for reviewing and discussing the status of this Plan of Correction during QAPI Meetings and initiating necessary actions.
January 15, 2025Inspection0 violations
Inspection dates
01/15/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS
Comments
Type of inspection: Monitoring A self-reported incident was received by VDSS Division of Licensing on 10/16/2024 regarding allegations in the area(s) of resident care and related services. Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 01/15/2025 09:35 AM to 12:30 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 117 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 4 Observations by licensing inspector: Activities, Breakfast/Lunch Meals Additional Comments/Discussion: 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 Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
January 15, 2025Inspection0 violations
Inspection dates
01/15/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
Type of inspection: Monitoring A self-reported incident was received by VDSS Division of Licensing on 11/26/2024 regarding allegations in the area(s) of: resident care and related services. Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 01/15/2025 2:30 PM to 4:00 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 117 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 4 Observations by licensing inspector: Activities, Breakfast/Lunch Meals 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 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 Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
June 11, 2024Inspection1 violation
Inspection dates
06/11/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND
Comments
Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/11/2024: 3:00 PM to 3:45 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 05/17/2024 regarding allegations in the area of Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 105 The licensing inspector completed a tour of the physical plant that included the resident’s rooms. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. However, violation(s) not related to the self-report but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Amanda Velasco, Licensing Inspector at (703) 397 4587 or by email at Amanda.Velasco@dss.virginia.gov
Violations
22VAC40-73-70-A
Based on resident record review and staff interview, the facility failed to ensure that an initial report was sent to the regional licensing office for any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident within 24 hours.
Evidence
  1. Staff 1 provided the progress notes from 05/12/2024 through 06/12/2024 for Resident 1 who resides in the secure unit.
  2. On 05/18/2024 at 13:22, Staff 3 documented the following health status note “… and today member found by staff in the morning in the facility garage, easy to redirect this morning, but while giving education to direct staff, and staff stated [Resident 1] was making first when staff stop him from exit door, member on 1:1 monitor checking since 05/16/2024, and staff assigned, writer did call [Doctor’s Name], stated [Doctor] will call us back, awaiting call from [Doctor’s Name].”
  3. The incident was not reported to the regional licensing office for the elopement that occurred on 05/18/2024.
Plan of correction
Immediately, Resident #1 photo was updated in their record. The Executive Director (ED), Director of Nursing (DON), and Assistant Director of Nursing (ADON) have revised our procedure for reporting incidents that occur on Saturdays to comply with the 24-hour reporting requirement. The Executive Director (ED) or their designee is responsible for implementing and maintaining compliance with all components of this Plan of Correction, as well as addressing and resolving any variances that may occur. Additionally, the ED or their designee is responsible for reviewing and discussing the status of this Plan of Correction during QAPI Meetings and initiating necessary actions.
June 11, 2024Inspection1 violation
Inspection dates
06/11/2024
Areas reviewed
63.2- (1) GENERAL PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/11/2024: 4:30 PM to 5:30 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 05/14/2024 and 05/29/2024 regarding allegations in the area of Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 105 The licensing inspector completed a tour of the physical plant that included the resident’s rooms. Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. However, violation(s) not related to the self-report but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Amanda Velasco, Licensing Inspector at (703) 397 4587 or by email at Amanda.Velasco@dss.virginia.gov
Violations
22VAC40-73-560-I
Based on resident record review, the facility failed to ensure that the residents record included a current photo, or a narrative physical description which is updated annually.
Evidence
  1. Resident 1’s record contained a face sheet, dated 01/26/2023, with a black and white photo of the resident.
  2. Resident 1’s individualized service plan (ISP) dated 06/20/2023 had the same photo in color as the main identifier of the resident.
Plan of correction
Immediately, Resident #1 photo was updated in their record. The Executive Director (ED), Director of Nursing (DON), and Assistant Director of Nursing (ADON) have revised our procedure for reporting incidents that occur on Saturdays to comply with the 24-hour reporting requirement. The Executive Director (ED) or their designee is responsible for implementing and maintaining compliance with all components of this Plan of Correction, as well as addressing and resolving any variances that may occur. Additionally, the ED or their designee is responsible for reviewing and discussing the status of this Plan of Correction during QAPI Meetings and initiating necessary actions.
June 11, 2024Inspection5 violations
Inspection dates
06/11/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION
Comments
Type of inspection:Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/11/2024: 8:35 AM to 3:00 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 105. 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: 6 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: Meals, Activities, Medication Pass. Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Amanda Velasco, Licensing Inspector at (703) 397 4587 or by email at Amanda.Velasco@dss.virginia.gov
Violations
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 each resident or his legal representative or responsible individual.
Evidence
  1. Residents 4, 6, and 7 did not have annual reviews of the rights and responsibilities of residents in their records.
  2. Resident 4, admitted 12/12/2022, had signed copy of the rights and responsibilities of residents in assisted living facilities upon admission on 11/14/2022 in their record.
  3. Resident 6, admitted 11/01/2021, had a signed copy of the rights and responsibilities of residents in assisted living facilities upon admission on 10/21/2022 and documentation that the legal representative was provided an additional copy for signature via email on 04/06/2022 in their record.
  4. Resident 7, admitted 03/31/2021, had a signed copy of the rights and responsibilities of residents in assisted living facilities dated 04/11/2021 in their record.
Plan of correction
Residents #4, #6, and #7 were presented with their Resident Rights and signed documents obtained for their records. The community will conduct a resident rights review as follows to verify that the regulation is met: • At resident move-in. • Quarterly at Resident Council Meetings. • Annually during assessment updates. • Additionally, the community will set up a table twice annually to provide Resident Rights forms. The Executive Director (ED) or their designee is responsible for implementing and maintaining compliance with all components of this Plan of Correction, as well as addressing and resolving any variances that may occur. Additionally, the ED or their designee is responsible for reviewing and discussing the status of this Plan of Correction during QAPI Meetings and initiating necessary actions.
22VAC40-73-560-E
Based on direct observation, the facility failed to ensure that all resident records retained at the facility were kept in a locked area.
Evidence
  1. In the hallway outside of the 6th floor nurses’ station, an unlocked drawer contained a census list of residents.
  2. Staff 2 removed the census list.
  3. In the special care unit on the second floor, an electronic tablet was open on a side table listing the name, tasks, gender, DOB, age, current vitals, physician, room number, code status, and allergies of Resident 9.
Plan of correction
No immediate action was taken concerning any specific resident, as this is a general action applicable to the entire community. Immediately, the community removed the census and updated the tablet to screen lock when not in use. An in-service was conducted with the wellness staff on the proper storage of residents' personal information (PI). Additionally, a systemic ongoing review of common areas will be conducted, and any findings will be corrected. The Executive Director (ED) or their designee is responsible for implementing and maintaining compliance with all components of this Plan of Correction, as well as addressing and resolving any variances that may occur. Additionally, the ED or their designee is responsible for reviewing and discussing the status of this Plan of Correction during QAPI Meetings and initiating necessary actions.
22VAC40-73-970-A
Based on facility document review, the facility failed to ensure that fire and emergency evacuation drill frequency and participation shall be in accordance with the current addition of the Virgina Statewide Fire Prevention Code.
Evidence
  1. Staff 2 provided the Fire Drill logs for the facility.
  2. There was a fire drill completed on 03/28/2024 during the first shift, and 05/24/2024 during the second shift.
  3. There was not a completed fire drill for the month of April 2024.
Plan of correction
No immediate action was taken concerning any specific resident, as this is a general action applicable to the entire community. The community completed a Fire Drill for the overnight team on 6/25/24. Additionally, a systemic quarterly review of Fire Drills will be conducted, and any findings will be corrected. The Executive Director (ED) or their designee is responsible for implementing and maintaining compliance with all components of this Plan of Correction, as well as addressing and resolving any variances that may occur. Additionally, the ED or their designee is responsible for reviewing and discussing the status of this Plan of Correction during QAPI Meetings and initiating necessary actions.
22VAC40-73-680-B
Based on direct observation, the facility failed to ensure that medications remained in the pharmacy issued container, with the prescription label attached, until administered to the resident.
Evidence
  1. At 9:33 AM, the Licensing Inspector observed Staff 6 returning to the medication cart with a cup of pills and a cup of liquid medication. The two cups were placed in the top drawer of the cart, and another cup of unlabeled pills was observed in the medication cart that did not belong to Resident 8.
  2. Staff 6 confirmed that the medication she was returning to the cart with was for Resident 8, who was not in her room.
  3. Staff 6 located Resident 8 and administered the medication and threw away the pills from the unlabeled cup.
  4. Photo Evidence Taken.
Plan of correction
No immediate action was taken concerning any specific resident, as it was corrected in real time. The Director of Nursing or their designee will conduct medication management in-service training for all current LPNs and RMAs. In addition, random medication pass observations will be carried out to verify proper medication administration The Executive Director (ED) or their designee is responsible for implementing and maintaining compliance with all components of this Plan of Correction, as well as addressing and resolving any variances that may occur. Additionally, the ED or their designee is responsible for reviewing and discussing the status of this Plan of Correction during QAPI Meetings and initiating necessary actions.
22VAC40-73-620-B
Based on facility document review, the facility failed to ensure the special diet oversight was certified that the requirements of this subsection (22VAC40-73-620) were met including the date of oversight and identification of the residents for whom the oversight was provided.
Evidence
  1. Staff 9 provided the special diet oversight form.
  2. The special diet oversight form was completed on 03/05/2024 and contained a statement saying, “In my professional opinion as a Registered Dietician, had federal survey been conducted today, this community would have most likely passed deficiency free (No “H” items observed.”
  3. There was no certification statement verifying that the requirements of 22VAC4-73-620 were met.
Plan of correction
No immediate action was taken concerning any specific resident, as this is a general action applicable to the entire community. The community immediately reached out to our dietitian vendor to request that their reports reflect the necessary documentation to meet the regulation standard. According to the dietitian vendor, the dietitian review will meet the regulation standard moving forward. Additionally, a systemic semi-annual review of dietitian oversights will be conducted, and any findings will be corrected. The Executive Director (ED) or their designee is responsible for implementing and maintaining compliance with all components of this Plan of Correction, as well as addressing and resolving any variances that may occur. Additionally, the ED or their designee is responsible for reviewing and discussing the status of this Plan of Correction during QAPI Meetings and initiating necessary actions.
June 11, 2024Inspection0 violations
Inspection dates
06/11/2024
Areas reviewed
22VAC40-73 BUILDINGS AND GROUND22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS
Comments
Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/11/2024: 3:45 PM to 4:30 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 06/03/2024 regarding allegations in the area of Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 105. The licensing inspector completed a tour of the physical plant that included the resident’s rooms. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Amanda Velasco, Licensing Inspector at (703) 397 4587 or by email at Amanda.Velasco@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 14, 2024Complaint survey9 violations
Inspection dates
05/14/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-80 COMPLAINT INVESTIGATION22VAC40-73 GENERAL PROVISIONS
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/14/2024 | 11:25 AM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on (date) regarding allegations in the area(s) of: Staffing & Supervision and Resident Care & Related Services. Number of residents present at the facility at the beginning of the inspection: 93 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 3 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Additional Comments/Discussion: 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: Staffing & Supervision, Resident Care & Related Services, and Administration and Administrative Services. A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Amanda Velasco, Licensing Inspector at (703) 397 4587 or by email at Amanda.Velasco@dss.virginia.gov
Violations
22VAC40-90-50-A
Based on staff record review and staff interview, the facility failed to ensure all substitute staff records contained a letter from the agency containing a statement verifying that the criminal history record report has been obtained within 30 days of employment, is on file at the temporary agency, and does not contain barrier crimes.
Evidence
  1. Staff 6, 7, 8, 9, and 10 were contracted by the agency to provide direct care and/or nursing services in the facility.
  2. Staff 6, 7 8, 9, and 10’s records did not contain a letter verifying that a criminal history record reports conducted by Virginia State Police was completed and does not contain any barrier crimes.
  3. Staff 1 and 2 confirmed that the agency did not provide letters verifying that criminal history record reports were complete and do not contain any barrier crimes.
Plan of correction
No immediate action was taken concerning any specific resident, as this is a general action applicable to the entire community. . The community is working with the local staffing agency's administration to verify they follow all new hire procedures during their onboarding process. The Executive Director (ED) or their designee is responsible for implementing and maintaining compliance with all components of this Plan of Correction, as well as addressing and resolving any variances that may occur. Additionally, the ED or their designee is responsible for reviewing and discussing the status of this Plan of Correction during QAPI Meetings and initiating necessary actions.
22VAC40-73-120-B
Based on resident record review and staff interview, the facility failed to ensure All staff were oriented to: 1. The purpose of the facility; 2. The facility's organizational structure; 3. The services provided; 4. The daily routines; 5. The facility's policies and procedures; 6. Specific duties and responsibilities of their positions; and 7. Required compliance with regulations for assisted living facilities as it relates to their duties and responsibilities.
Evidence
  1. Staff 6, 7, 8, 9, and 10 were contracted by the agency to provide direct care and/or nursing services in the facility.
  2. Staff 6, 7 8, 9, and 10’s records did not contain documentation of facility orientation prior to completing work on site.
  3. Staff 1 and 2 confirmed that no facility orientation or training was completed for staff 6, 7, 8, 9, or 10.
Plan of correction
No immediate action was taken concerning any specific resident, as this is a general action applicable to the entire community. The community will develop documentation for the use of agency/private duty aides, providing information regarding the community's policies, procedures, and orientation related to their assigned roles. Additionally, a systemic quarterly review of Private Duty Aide (PDA) records will be conducted. The Executive Director (ED) or their designee is responsible for implementing and maintaining compliance with all components of this Plan of Correction, as well as addressing and resolving any variances that may occur. Additionally, the ED or their designee is responsible for reviewing and discussing the status of this Plan of Correction during QAPI Meetings and initiating necessary actions.
22VAC40-73-50-A
Based on facility document review and staff interview, the facility failed to utilize the disclosure form developed by the department.
Evidence
  1. Staff 1and 2 provided a copy of the disclosure form provided to prospective residents and the public.
  2. The form had been updated, with the department footer indicating the version number removed.
Plan of correction
No immediate action was taken concerning any specific resident, as this is a general action applicable to the entire community. Immediately, the community updated the disclosure statement to include the information required by regulation and sent it to DSS for review. The Executive Director (ED) or their designee is responsible for implementing and maintaining compliance with all components of this Plan of Correction, as well as addressing and resolving any variances that may occur. Additionally, the ED or their designee is responsible for reviewing and discussing the status of this Plan of Correction during QAPI Meetings and initiating necessary actions.
22VAC40-73-450-F
Based on resident record review and staff interview, the facility failed to ensure that the individualized service plan (ISP) was reviewed and updated at least once every 12 months.
Evidence
  1. Resident 2’s (date of admission 01/28/2022) ISP was last updated on 03/16/2023.
  2. Staff 3 confirmed the ISP was not updated annually.
Plan of correction
Resident #2 was no longer in the community upon receiving this notice. The Director of Nursing or their designee will audit all resident Individual Service Plans (ISPs) for those who have lived in the community for a year or more. Any discrepancies will be documented and addressed. Additionally, a systemic quarterly review of ISPs will be conducted. The Executive Director (ED) or their designee is responsible for implementing and maintaining compliance with all components of this Plan of Correction, as well as addressing and resolving any variances that may occur. Additionally, the ED or their designee is responsible for reviewing and discussing the status of this Plan of Correction during QAPI Meetings and initiating necessary actions.
22VAC40-73-450-E
Based on resident record review and staff interview, the facility failed to ensure the individualized service plan (ISP) was signed and dated by the resident or the resident’s legal representative.
Evidence
  1. Resident 2’s ISP, dated 03/16/2023, was signed by the community staff on 03/16/2023. There was no signature by the resident or the resident’s legal representative.
  2. Staff 3 confirmed the ISP was not signed by the resident or the resident’s legal representative.
Plan of correction
Resident #2 was no longer in the community upon receiving this notice. The Director of Nursing or their designee will audit all Individual Service Plans (ISPs) to ensure they have proper signatures. Any discrepancies will be documented and addressed. Additionally, a systemic quarterly review of ISPs will be conducted. The Executive Director (ED) or their designee is responsible for implementing and maintaining compliance with all components of this Plan of Correction, as well as addressing and resolving any variances that may occur. Additionally, the ED or their designee is responsible for reviewing and discussing the status of this Plan of Correction during QAPI Meetings and initiating necessary actions.
22VAC40-73-280-B
Based on facility document review and staff interview, the facility failed to ensure a written staffing plan was maintained that specifies the number and type of direct care staff required to meet day to day, routine direct care needs.
Evidence
  1. Staff 1 provided the disclosure form to document their staffing needs.
  2. Staff 1 confirmed there was not a written staffing plan that documents the direct care staff required to meet day to day, routine direct care needs and any identified special needs for the residents in care that is directly related to the actual resident acuity levels.
Plan of correction
No immediate action was taken concerning any specific resident, as this is a general action applicable to the entire community. The community is staffed according to the resident's care needs. However, the community will develop and/or modify existing documentation to show direct care staffing requirements. The Executive Director (ED) or their designee is responsible for implementing and maintaining compliance with all components of this Plan of Correction, as well as addressing and resolving any variances that may occur. Additionally, the ED or their designee is responsible for reviewing and discussing the status of this Plan of Correction during QAPI Meetings and initiating necessary actions.
22VAC40-73-440-A
Based on record review and staff interview, the uniform assessment instrument (UAI) shall be completed annually.
Evidence
  1. Resident 1’s UAI was dated 03/16/2023 and has not been updated.
  2. Resident 2’s UAI was dated 03/16/2023 and has not been updated.
  3. Staff 3 confirmed the UAI was not updated annually.
Plan of correction
Resident #2 UAI was updated immediately. The Director of Nursing or their designee will audit all resident Uniform Assessment Instruments (UAIs) for those who have lived in the community for a year or more. Any discrepancies will be documented and addressed. Additionally, a systemic quarterly review of UAI records will be conducted. The Executive Director (ED) or their designee is responsible for implementing and maintaining compliance with all components of this Plan of Correction, as well as addressing and resolving any variances that may occur. Additionally, the ED or their designee is responsible for reviewing and discussing the status of this Plan of Correction during QAPI Meetings and initiating necessary actions.
22VAC40-73-220-A
Based on staff interview, the facility failed to obtain, in writing, information on the type and frequency of the services to be delivered to the resident by private duty personnel that before direct care staff or companion services were initiated, that the direct care or companion services provided by the private duty personnel were reflected on the residents individualized service plan (ISP), and that orientation and training was provided to private duty personnel regarding the facilities policies and procedures related to the duties of private duty personnel.
Evidence
  1. Resident 2 receives 24-hour private duty care.
  2. Staff 1 provided the private duty personnel records for Resident 2.
  3. Staff 1 confirmed that the facility does not have a copy, in writing or other, of the information on the type and frequency of the services to be delivered to the resident.
  4. Resident 2’s ISP does not list the private duty personnel services provided on the ISP.
  5. Staff 1 and 3 confirmed the private duty personnel were not listed on the ISP.
  6. Staff 1 provided the private duty personnel records.
  7. Staff 1 confirmed that a facility orientation and training regarding the facilities policies and procedures was not provided to private duty personnel.
Plan of correction
220-A.1 Resident #2 was no longer in the community upon receiving this notice. The Director of Nursing or their designee will audit the documentation of services for any resident assigned a Private Duty Aide (PDA) to verify proper records are maintained in the resident's chart. Additionally, a systemic quarterly review of PDA records will be conducted. The Executive Director (ED) or their designee is responsible for implementing and maintaining compliance with all components of this Plan of Correction, as well as addressing and resolving any variances that may occur. Additionally, the ED or their designee is responsible for reviewing and discussing the status of this Plan of Correction during QAPI Meetings and initiating necessary actions. 220- A.2 Resident #2 was no longer in the community upon receiving this notice. The Director of Nursing or their designee will audit the documentation of services for any resident assigned a Private Duty Aide (PDA) to verify proper records are maintained in the resident's chart. Additionally, a systemic quarterly review of PDA records will be conducted. The Executive Director (ED) or their designee is responsible for implementing and maintaining compliance with all components of this Plan of Correction, as well as addressing and resolving any variances that may occur. Additionally, the ED or their designee is responsible for reviewing and discussing the status of this Plan of Correction during QAPI Meetings and initiating necessary actions. 220 - A.4 No immediate action was taken concerning any specific resident, as this is a general action applicable to the entire community. The community will develop documentation for the use of agency/private duty aides, providing information regarding the community's policies, procedures, and orientation related to their assigned roles. Additionally, a systemic quarterly review of Private Duty Aide (PDA) records will be conducted. The Executive Director (ED) or their designee is responsible for implementing and maintaining compliance with all components of this Plan of Correction, as well as addressing and resolving any variances that may occur. Additionally, the ED or their designee is responsible for reviewing and discussing the status of this Plan of Correction during QAPI Meetings and initiating necessary actions. The Executive Director (ED) or their designee is responsible for implementing and maintaining compliance with all components of this Plan of Correction, as well as addressing and resolving any variances that may occur. Additionally, the ED or their designee is responsible for reviewing and discussing the status of this Plan of Correction during QAPI Meetings and initiating necessary actions.
22VAC40-73-460-B
Based on record review and staff interview, the facility failed to ensure care provision and service delivery was resident centered to the maximum extent possible and included prompt response by staff to resident needs as reasonable to the circumstances.
Evidence
  1. Resident 1’s call bell logs for the months of April 2024 and May 2024 showed frequent instances where the call bell was responded to 20 minutes or more after the initial call. The dates and duration of the call bells are as follows: 04/03/2024: 27.73 minutes 04/06/2024: 44.52 minutes 04/06/2024: 140.15 minutes 04/06/2024: 39.03 minutes 04/07/2024: 21.40 minutes 04/08/2024: 51.72 minutes 04/08/2024: 32.23 minutes 04/08/2024: 45.85 minutes 04/13/2024: 29.42 minutes 04/15/2024: 21.35 minutes 04/18/2024: 40.22 minutes 04/19/2024: 21.37 minutes 04/19/2024: 20.82 minutes 04/19/2024: 138.13 minutes 04/02/2024: 26.02 minutes 04/20/2024: 59.32 minutes 04/23/2024: 77.47 minutes 04/26/2024: 23.73 minutes 04/26/2024: 35.02 minutes 04/28/2024: 22.38 minutes 04/29/2024: 64.50 minutes 04/29/2024: 20.18 minutes 04/30/2024: 26.50 minutes 05/05/2024: 51.80 minutes 05/06/2024: 34.33 minutes 05/08/2024: 102.40 minutes
  2. Resident 2’s call bell logs for the months of April 2024 and May 2024 showed multiple instances where the call bell was responded to 20 minutes or more after the initial call. The dates and duration of the call bells are as follows: 04/06/2024: 39.27 minutes 04/13/2024: 24.55 minutes 04/14/2024: 41.98 minutes 05/11/2024: 40.42 minutes
  3. Staff 1 confirmed the call bells may seem long due to older devices being used by staff to answer.
Plan of correction
No immediate action was taken concerning any specific resident, as this is a general action applicable to the entire community. The Director of Nursing or their designee will review call response times daily during the morning meetings. The Front Desk staff will assist in monitoring calls on a daily basis. The community has upgraded the hardware to address any technology-related issues and has engaged the call systems support vendor to review the system for any abnormalities. Ongoing in-services and staff accountability measures are in place to address the needs of our residents. The Executive Director (ED) or their designee is responsible for implementing and maintaining compliance with all components of this Plan of Correction, as well as addressing and resolving any variances that may occur. Additionally, the ED or their designee is responsible for reviewing and discussing the status of this Plan of Correction during QAPI Meetings and initiating necessary actions.
January 19, 2023Complaint survey0 violations
Inspection dates
01/19/2023
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: LI entered the facility at 10:39 am on 1/19/2023 and exited at 12:10 pm on 1/19/2023 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 12/12/2022 regarding allegations in the area(s) of staffing quantity and resident care. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 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 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 Jamie Eddy, Licensing Inspector at (703) 479-5247 or by email at jamie.eddy@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
October 27, 2022Inspection3 violations
Inspection dates
10/27/2022,10/31/2022,02/01/2023,02/03/2023
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: LI entered the building on 10/27/2022 at 10:30 am and exited at 1:36 pm. LI entered the facility at 10:04 am on 10/31/2022 and exited at 12:20 pm. LI entered the facility at 9:28 am on 2/1/2023 and exited at 12:21 pm. LI entered the facility at 3:00pm and exited at 3:30pm on 2/3/2023. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 8/31/2022 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 staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 11 Observations by licensing inspector: LI walked the corridor on the memory care unit. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the self-report; area(s) of non-compliance with standard(s) or law were resident care and related services. A violation notice was issued; any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. 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 Jamie Eddy, Licensing Inspector at (703) 479-5247 or by email at jamie.eddy@dss.virginia.gov
Violations
22VAC40-73-70-A
Based upon a review of records, the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident:
Evidence
  1. Progress notes dated 2/22/2022 at approximately 4:34 pm documented an incident in which Resident 1 attacked staff. Staff called 911 to request assistance of 911 team members to “help de-escalate the situation.”
Plan of correction
1. Corrective actions and systemic changes • The management team has been educated on identifying state reportable and timeframes • ED or designated person will report any major incident that has the potential to or has negatively affected the health, safety, or welfare of any resident to the regional licensing office within 24 hours of observance. • All staff members will be educated on identifying aggressive behavior(s) and de-escalating techniques. 2. Monitoring corrective actions • The Resident Care Director, Memory Care Director, or designated person to completed random retention checks weekly and follow up on any subsequent findings. The results of this audit will be reported during the Safety Committee meeting monthly x 3 months for review and recommendations. 3. Date correction action completed • The community’s date of alleged compliance is September 5th, 2023
22VAC40-73-1110-B
Based upon a review of records, the facility failed to ensure that six months after placement of the resident in the safe, secure environment, and annually thereafter, the licensee, administrator, or designee shall perform a review of the appropriateness of each resident’s continued residence in the special care unit.
Evidence
  1. The record of Resident 1, reviewed on 10/27/22 did not include documentation that the review for appropriateness of placement and continued residence in the special care unit was completed within the required six- month time frame. Documentation in progress notes verified that Resident 1 was admitted to the special care unit on 10/26/21. The six-month review of Resident 1’s appropriateness of placement was required to have been completed by 4/26/22.
Plan of correction
1. Corrective action for resident • Point Click Care (PCC) glitch to auto-generate scheduled assessment identified. All continuous special unit assessments have been entered into PCC as a scheduled assessment. 2. Identifying other residents • An audit of all residents’ memory care residents completed. There were no additional findings related to this citation. 3. Systemic changes • An audit of all residents’ electronic charts will be conducted to ensure that a six-month safe placement review is assigned and completed timely. 4. Monitoring corrective actions • The Resident Care Director, or designated person will audit the Assessment History report monthly until compliance is met. The results of this audit will be reported during the Safety Committee meeting monthly x 3 months for review and recommendations. 3. Date correction action completed • The community’s date of alleged compliance is September 5th, 2023.
22VAC40-73-460-A
Based upon a review of records and interviews, the facility failed to ensure the health, safety, and well-being of the residents.
Evidence
  1. On 10/21/2022 LI interviewed a collateral #1 who stated that on 8/30/22 at approximately 4:00pm they had observed Resident #1 in the room of Resident #2 on multiple occasions. Collateral #1 stated that on 8/30/22, they observed the following: • Resident #1 enter the room of Resident #2. • Resident #1 wrestle for the cane from Resident. Resident #2 was thrown to the ground by Resident #1, then Collateral #1 heard Resident #2 scream. • Resident #1 take his left foot and hit Resident #2’s right leg, and then hitting Resident #2 with the cane five to seven times.
  2. Progress notes written on 8/30/2022 documented that after the incident between Resident #1 and Resident #2 staff assessed Resident #2 for injuries. Resident #2 complained of leg pain and was sent by the facility to Inova Fairfax Hospital. The progress notes written on 8/30/23 also documented that at approximately 11:00 pm on 8/30/2022, Resident #2’s responsible party notified the facility that Resident #2 had suffered a fractured hip.
  3. During an interview conducted on 2/1/2023 Staff #5 stated that: On 8/30/2022, she was assisting a resident with eating and observed Resident #1 walking around the unit. • At approximately 4 pm on 8/30/2022, she lost sight of Resident when she went to empty trash and then began searching resident rooms for Resident #1 “starting with room 2102.” • Resident #1 passed her in the hallway carrying a cane. • She then went to Resident #2’s room to check on her and found her “lying on the floor crying”. • She then called her co-worker for help and contacted the charge nurse. LI asked Staff #5 if she knew of any previous aggressive behaviors involving Resident #1. Staff #5 stated that Resident #1 “can be very, very aggressive, and you have to watch him when he is not in his room and that resident’s doors to their rooms are locked when he is walking around. “
  4. During an interview with Staff #1 they stated that the daughter of Resident #2 had previously reported her concerns to the facility regarding the fact that during previous video calls she was had with Resident #1 she observed Resident #1 wander into the room of Resident #2 and sit on the Resident #2’s bed.
  5. The Individualized Service Plan (ISP) for Resident #2 documented that on 8/31/22 focus of post-trauma care was added to the ISP with goals of “member will be able to express and discuss negative emotions, and member will exhibit reduced levels of fear and anxiety.” The intervention/tasks associated with the post-trauma care on the ISP are as follows: Caregivers will establish and sustain a trusting relationship with member by listening and demonstrating warmth and express understanding. Member has a private aid caregiver who comes in to accompany (provides emotional support) member in the afternoon daily. Staff will maintain a calm, non-threatening behavior and environment while working with member. Caregivers will assist member with reassurance and comfort as needed. Caregivers will conduct hourly checks for assurance and safety.
Plan of correction
This plan of correction is submitted as required under State and/or Federal law. The submission of this Plan of Correction does not constitute an admission on the part of the Community as to the accuracy of the surveyors’ findings or the conclusions drawn therefrom. Submission of this Plan of Correction also does not constitute an admission that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Community’s policies and procedures should be considered subsequent remedial measures as that concept is employed in Rule 407 of the Federal Rules of Evidence, corresponding state rules of civil procedure and should be inadmissible in any proceeding on that basis. The Community submits this plan of correction with the intention that it be inadmissible by any third party in any civil or criminal action against the Community or any employee, agent, officer, director, attorney, or shareholder of the Community or affiliated companies. 1. Corrective action for resident • Resident #1 and resident #2 no longer reside in the community. 2. Identifying other resident • Prior to admissions nursing manger(s) will review potential move in’s progress notes including physician notes, psychiatric notes (if applicable), UAIs and other clinical documents to determine appropriate placement and level of care. • All new move-ins will be observed for behavioral patterns every shift for the first 30-days. Any noted behaviors will be communicated to providers and care planned with recommended interventions. 3. Systemic changes • Clinical team will collaborate with member, RP/POA, and interdisciplinary team (s) to ensure safety and proper level of care is maintained for all residents throughout their stay. All correspondence will be recorded in resident’s charts accordingly. 4. Monitoring corrective changes • The Resident Care Director or designee will complete audits of all behavioral orders on all new admissions weekly x first 30 days and monthly thereafter on residents to assess compliance and follow up on any subsequent findings. The results of this audit will be reported during the Safety Committee meeting monthly x 3 months for review and recommendations. 5. Date correction action completed • The community’s date of alleged compliance is September 5th, 2023.
August 2, 2022Inspection0 violations
Inspection dates
08/02/2022
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 PROCESS
Technical assistance
A completed Renewal Application must be submitted prior to the expiration of the current license. The facility should receive an application in the mail, however if an application has not been received one can be obtained from the DSS web site or by calling the main office at (276) 206-0492.
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: LI entered the facility on 8/2/2022 at 8:48 am and exited on 8/2/2022 at 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: 42 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: 0 Number of interviews conducted with staff: 0 Observations by licensing inspector: LI observed medication administration. LI observed residents eating breakfast and lunch. Additional Comments/Discussion: 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 Jamie Eddy, Licensing Inspector at (703) 479-5247 or by email at jamie.eddy@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
August 17, 2021Inspection0 violations
Inspection dates
Aug. 17, 2021
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 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
A renewal inspection was initiated on 8/16/2021 and concluded on 8/17/2021. The Administrator was contacted by telephone to initiate the inspection and reported that the current census was 15. The Licensing Inspector (LI) emailed the Administrator a list of items required to complete the remote documentation review portion of the inspection. The LI reviewed two resident records, two staff records, staff schedules, health care oversight, fire and emergency drills, Fire Inspection, Health Inspection, activity calendar, menu and the most recent dietary oversight submitted by the facility to ensure documentation was complete. Background Checks of all staff hired since the previous inspection were reviewed. The LI conducted the on-site portion of the inspection on 8/17/2021. An exit interview was conducted with the Administrator on the date of inspection, where findings were reviewed and an opportunity was given for questions. The information gathered during the inspection determined no violations with applicable standards or law. No violations were issued. Thank you for your cooperation and if you have any questions please call 703-479-4708 or contact me via e-mail at lynette.storr@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
June 7, 2021Inspection0 violations
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY 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 mandated monitoring inspection was initiated on 6/3/2021 and concluded on 6/7/2021. The Administrator was contacted by email to initiate the inspection. The Administrator reported that the current census is nine. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed two resident records, two staff records, medication administration records and other documentation submitted by the facility to ensure documentation was complete. All background checks of staff hired after the most recent inspection were reviewed. The information gathered during the inspection determined no violations with applicable standards or law. No violations were issued. Thank you for your cooperation and if you have any questions please call 703-479-4708 or contact me via e-mail at lynette.storr@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
February 9, 2021Inspection0 violations
Inspection dates
Feb. 9, 2021
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT 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
Technical assistance
Please provide final test documentation for the call system. Please ensure that all staff are aware that resident room doors leading to the Juliet balconies remain secure until the residents occupying that room are assessed to ensure the residents' safety.
Comments
Licensing Inspector (LI) conducted an announced initial inspection on 2/9/2021. LI walked the physical plant, verified window and room measurements, reviewed policies and procedures and staff background checks and tested the call bell system. All inspections have been completed. Evacuation and Resident Rights Postings will be updated. No violations cited today and exit interview held. Thank you for your cooperation and if you have any questions please call 703-479-4708 or contact me via e-mail at lynette.storr@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.