7
Inspections
On record
5
With violations
Visits that cited something
2
Clean visits
Nothing cited
13
Violations cited
Individual findings
11
Standards cited
Distinct rules
1
Complaint visits
Prompted by a complaint

Morningside House of Spotsylvania was inspected 7 times between January 22, 2021 and May 13, 2026 by the Virginia Department of Social Services. 5 of those visits ended with violations cited and 2 with none. Across that history VDSS cited 13 violations under 11 distinct standards. 1 inspection was 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. 5 of these 7 are still on the state's site; the other 2 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
07/31/2026
Administrator
Joy Mcgee
Licensing inspector
Patricia Koval
Inspector phone
(804) 621-6046
Approved for
Special Care Unit · Non-Ambulatory · Assisted Living

Inspection History

7

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

May 13, 2026Complaint survey3 violations
Inspection dates
05/13/2026
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/13/2026 Time in: 10:30 AM Time out: 1:03 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 01/28/2026 regarding allegations in the area(s) of: Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 37 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Licensing inspector observed residents entering and exiting the facility for community outings. Additional Comments/Discussion: Nina Wilson, Licensing Inspector and Tess Pittman, Licensing Administrator were present during this inspection. 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(s) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of these inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov
Violations
22VAC40-73-680-D
Based on resident record review and staff interview, the facility failed to ensure that medications were administered in accordance with the physician’s or other prescriber’s instructions.
Evidence
  1. September 2025 MAR indicated that resident 1 was not administered their prescribed medication, Gabapentin CV 100 MG (take 1 capsule by mouth every 12 hours) at 8:00 am on 09/15/2025, 09/17/2025, 09/21-22/2025, and 09/29/2025; or 8:00 pm on 09/14-19/2025, 09/21/2025, 09/23-24/2025, 09/26/2025, and 09/28-29/2025.
  2. During the onsite inspection, 05/13/2026, staff 1 confirmed that resident 1’s Gabapentin CV 100 MG was not administered in accordance with the physician’s or other prescriber’s instructions on the identified dates.
Plan of correction
1. The Executive Director and Director of Health and Wellness conducted a root-cause review on 06/02/2026 through 06/03/2026. The review examined staffing assignments, shift-handoff practices, and MAR documentation habits. 2. A MAR accuracy in-service training for all medication aides, nurses, and shift supervisors. Training to cover: the significance of MAR accuracy, how to document a missed dose correctly versus leaving it blank, the shift-handoff MAR review requirement, and the process for notifying a physician following a missed scheduled dose. Training to be led was led by the Director of Health and Wellness or designee. Attendance to be documented on a sign-in sheet retained in the staff training binder.
22VAC40-73-460-D
Based on resident record review and staff interview, the facility failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs, such as prevention of falls.
Evidence
  1. Post Fall Incident Reports, (02/10/2025, 04/06/2025, 07/04/2025, 08/17/2025, 09/20/2025, 09/24/2025, 10/09/2025, 01/25/2026, and 01/19/2026) indicated that resident 1 sustained multiple witnessed and unwitnessed falls; however, the response to the incidents stated that “no” treatment was provided and/or “no” questions were asked about pain level.
  2. Resident 1’s individualized service plan (ISP, 01/09/2026) stated, “requires human help with mobility” and “is a fall risk due to cognitive decline and Parkinson’s disease.”
  3. During the onsite inspection, 05/13/2026, staff 1 acknowledged that resident 1’s documentation indicated a lack of response to falls.
Plan of correction
1. Inservice to be conducted on 06/17/2026, all direct care staff and supervisory staff to complete a mandatory in-service training on post-fall response protocol, proper incident documentation, and recognition of pain in residents with cognitive impairment. Training will be conducted by the Director of Care. Attendance and will be documented on a sign-in sheet maintained in the Director's office training binder. 2. The Executive Director and Director of Care or designee will review 100% of post-fall incident reports within 24 hours of completion to verify that all mandatory fields are completed, the pain assessment is documented, and the ISP was reviewed. Any incomplete reports will be returned to the staff member responsible for correction before end of the following shift. 3. The fall prevention protocol and incident report compliance will be a standing agenda item at the morning standup department head meeting, in addition to weekly risk review, and identifying trends within the monthly QA.
22VAC40-73-640-A
Based on resident record review and staff interview, the facility failed to have, kept current, and implement a written plan for medication management. The facility’s medication plan should address procedures for administering medication and should include methods to ensure that each resident’s prescription medications and any over-the-counter drugs and supplements ordered for the resident were filled and refilled in a timely manner to avoid missed dosages.
Evidence
  1. Resident 1 was prescribed Gabapentin CV 100 MG (take 1 capsule by mouth every 12 hours for pain and neuropathy), 8:00 am and 8:00 pm. September 2025’s Medication Administration Record (MAR) indicated that resident 1 was not administered Gabapentin CV 100 MG at 8:00 am on 09/15/2025, 09/17/2025, 09/21-22/2025, and 09/29/2025; or 8:00 pm on 09/14-19/2025, 09/21/2025, 09/23-24/2025, 09/26/2025, and 09/28-29/2025.
  2. Medication Management Plan stated, “community will have a Medication Procurement Binder which stores a sheet for each resident who needs to have their outside provider medications managed by our staff. Each shift the Nurse/Medication Aides will review the binder for any outstanding needs or calls to follow up and document as such.”
  3. During the onsite inspection, 05/13/2026, staff 1 confirmed methods to ensure that resident 1’s Gabapentin CV 100 MG were not followed, which resulted in missed dosages.
Plan of correction
1.) Executive Director and Director of Health and Wellness will review Medication Management Plan and Medication Procurement Binder Process with Corporate Clinical Director of Operations for best practices. All medication aides, nurses, and shift supervisors to complete mandatory in-service training covering: the Medication Management Procedure, how to identify and escalate a low-supply situation, and the staff member's responsibility for MAR accuracy and same-shift follow-through. Training to be conducted by Director of Health and Wellness. A sign-in sheet documenting attendance is maintained in the staff training binder in the Director's office. 2.) The Director of Health and wellness or designee will conduct a daily audit to review the MAR for the first 30 days following submission of this POC to verify that each shift has completed its required review, signature, and documentation, and that no resident's supply has fallen below the 7-day refill threshold without a documented action taken. 3.) The Executive Director will conduct weekly MAR audits for all residents outside provider medications for the first 90 days, reviewing for any missed doses, documentation completeness, and timely refill procurement. Findings will be recorded in the facility's QA log.
May 13, 2026Inspection1 violation
Inspection dates
05/13/2026
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Technical assistance
The Licensing Administrator reviewed the following standards with the facility: 22VAC40-73-460.
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/13/2026 Time in: 10:30 AM Time out: 1:00 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 01/05/2026 regarding allegations in the area(s) of: Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 37 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: Licensing inspector observed residents entering and exiting the facility for community outings. Additional Comments/Discussion: Nina Wilson, Licensing Inspector and Tess Pittman, Licensing Administrator were present at this inspection. 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. 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 Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov
Violations
22VAC40-73-450-E
Based on record review and interview, the facility failed to ensure the individualized service plan be signed and dated by the resident or their legal representative when reviews and updates of the plan have been made.
Evidence
  1. During the onsite inspection conducted on May 13, 2026, Staff 1 provided Resident 1’s current Individualized Service Plan (ISP), dated June 6, 2025; however, the ISP did not include the signature of the resident’s legal representative.
  2. Staff 1 confirmed that Resident 1’s current ISP, dated June 6, 2025, had not been signed by the resident’s legal representative.
Plan of correction
1. The Executive Director and the Director of Care will conduct a community-wide audit of all current residents' ISPs to verify that each plan has been signed and dated by the resident or their legal representative. 2. Community will utilize an ISP Completion Checklist that includes, a line confirming that the resident's or legal representative's signature was obtained, the date, and date of next scheduled review. 3. Executive Director and Director of Health and wellness will conduct ongoing ISP signature audits weekly and will continue permanently as part of the communities QA program.
May 13, 2026Inspection2 violations
Inspection dates
05/13/2026
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/21/2026 Time in: 1:00 PM Time out: 1:30 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 03/07/2026 regarding allegations in the area(s) of: Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 37 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Licensing inspector observed residents entering and exiting the facility for community outings. Additional Comments/Discussion: Nina Wilson, Licensing Inspector and Tess Pittman, Licensing Administrator were present at this 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 Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov
Violations
22VAC40-73-640-A
Based on record review and interview, the facility failed to implement their written plan for medication management which includes methods to ensure that each resident's prescription medications and any over-the- counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages.
Evidence
  1. On March 7, 2026, Staff 1 self-reported to Licensing that Resident 1 missed their prescribed daily dose of Gabapentin 100 mg from February 22, 2026, through March 4, 2026.
  2. During the onsite inspection conducted on May 13, 2026, a review of Resident 1’s February and March 2026 Medication Administration Records (MAR) indicated that the prescribed Gabapentin 100 mg capsule, ordered to be administered nightly at bedtime, was unavailable for administration from February 15, 2026, through March 4, 2026.
  3. During the same onsite inspection, Staff 1 provided the facility’s medication management plan, which states: “Community will have a Medication Procurement Binder which stores a sheet for each resident who needs to have their outside provider medications managed by our staff. Each shift the Nurse/Medication Aides will review the binder for any outstanding needs or calls to follow up on and document as such.”
  4. Staff 1 confirmed that Resident 1 did not receive Gabapentin 100 mg from February 15, 2026, through March 4, 2026, due to staff not adhering to the facility’s medication management plan to ensure timely ordering of the medication, resulting in missed doses for this resident.
Plan of correction
1.) Executive Director and Director of Health and Wellness will review Medication Management Plan and Medication Procurement Binder Process with Corporate Clinical Director of Operations for best practices. All medication aides, nurses, and shift supervisors to complete mandatory in-service training covering: the Medication Management Procedure, how to identify and escalate a low-supply situation, and the staff member's responsibility for MAR accuracy and same-shift follow-through. Training to be conducted by Director of Health and Wellness. A sign-in sheet documenting attendance is maintained in the staff training binder in the Director's office. 2.) The Director of Health and wellness or designee will conduct a daily audit to review the MAR for the first 30 days following submission of this POC to verify that each shift has completed its required review, signature, and documentation, and that no resident's supply has fallen below the 7-day refill threshold without a documented action taken. 3.) The Executive Director will conduct weekly MAR audits for all residents outside provider medications for the first 90 days, reviewing for any missed doses, documentation completeness, and timely refill procurement. Findings will be recorded in the facility's QA log.
22VAC40-73-680-D
Based on record review and interview, the facility failed to ensure medications be administered in accordance with the physician's or other prescriber’s instructions.
Evidence
  1. During the onsite inspection conducted on May 13, 2026, a review of Resident 1’s February and March 2026 Medication Administration Records (MAR) indicated that the prescribed Gabapentin 100 mg capsule, ordered to be administered nightly at bedtime, was unavailable for administration from February 15, 2026, through March 4, 2026.
  2. Resident 1’s Individualized Service Plan (ISP), dated July 22, 2025, and Uniform Assessment Instrument (UAI), dated July 22, 2025, document the resident’s need for assistance with medication administration by facility Licensed Practical Nurse (LPN) or Registered Medication Aide (RMA).
  3. Staff 1 confirmed that Resident 1’s order for Gabapentin 100 mg to be administered nightly at bedtime was not followed from February 15, 2026, through March 4, 2026, due to the medication being unavailable for administration, resulting in missed doses for the resident.
Plan of correction
1. The Executive Director and Director of Health and Wellness conducted a root-cause review on 06/02/2026 through 06/03/2026. The review examined staffing assignments, shift-handoff practices, and MAR documentation habits. 2. A MAR accuracy in-service training for all medication aides, nurses, and shift supervisors. Training to cover: the significance of MAR accuracy, how to document a missed dose correctly versus leaving it blank, the shift-handoff MAR review requirement, and the process for notifying a physician following a missed scheduled dose. Training to be led was led by the Director of Health and Wellness or designee. Attendance to be documented on a sign-in sheet retained in the staff training binder.
July 1, 2025Inspection5 violations
Inspection dates
07/01/2025, 07/02/2025
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSING PROCESS
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: 7/1/2025 11:00 A.M. – 5:00 P.M., 7/2/2025 9:00 A.M. – 3:15 P.M. 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: 37 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: Building and grounds, activities, dining services, and medication pass. Additional Comments/Discussion: 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 Jeff Marnien, Licensing Inspector at (540) 571-0189 or by email at Jeffrey.marnien@dss.virginia.gov
Violations
22VAC40-73-680-M
Based on record review, observation and staff interview, the facility failed to ensure that as needed (PRN) medications were properly stored at the facility.
Evidence
  1. During a medication cart audit with staff 2 on 7/2/2025, the LI observed that resident 5’s PRN medication Iprat-Albut .5-3(2.5) MG was not in the medication cart.
  2. Staff 2 confirmed that Iprat-Albut .5-3(2.5) MG for resident 5 was not in the medication cart.
Plan of correction
1.) Director of Health and Wellness will conduct routine. audits of the Medication Carts to ensure that all PRN medications are available for resident use and properly stored at facility.
22VAC40-73-930-D
Based on record review and staff interviews, the facility failed to document rounds that were made for residents with an inability to use the signaling device.
Evidence
  1. During an interview on 7/1/2025, the Licensing Inspector (LI) requested staff 2 provide documentation of completed rounds for any of the 37 residents in care unable to use their signaling device.
  2. Staff 2 confirmed documentation of rounding for residents with an inability to use the signaling device was not being completed.
Plan of correction
1.) Community will create a rounding log which shall include the name of the resident, the date and time of rounds, and the staff member who made the rounds. 2.) Once the res1dent has gone to bed, until the resident has arisen each morning, at minimum, direct care staff will make rounds no less than every two hours. 3.) If there Is a change in residents condition or care needs the frequency of rounds will tie adjusted to reflect the residents needs and documented in the plan of care.
22VAC40-73-50-A
Based on record review and staff interview, the facility failed to ensure they provided a statement prepared by the department, to the prospective residents that disclosed information about the facility.
Evidence
  1. The LI observed during record review on 7/2/2025, that resident 4’s, admitted 6/6/2025, disclosure form was not on the updated form prepared by the department.
  2. Staff 1 confirmed the disclosure statement in resident 4’s chart was not on the current form prepared by the department.
Plan of correction
1.) Executive Director updated the facilities sworn disclosure statement to ensure it was on the updated VOSS form prepared by the department. 2.) Executive Director submitted the updated form to inspector for review on 7.21.2025 3.) Executive Director has retired previous form and will ensure updated form will be used for all new admissions.
22VAC40-73-1140-B
Based on record review and staff interview, the facility failed to ensure that direct care staff working in the safe, secure environment received at least 10 hours of training in cognitive impairment within four months of their start date.
Evidence
  1. During a record review on 7/1/2025 the LI requested a training log for staff 3, hired 2/24/2025, showing completion of 10 hours of training in cognitive impairment.
  2. Staff 1 confirmed the required documents were not completed and available for review.
Plan of correction
1) Executive Director will audit all Employee Flies to ensure compliance with 1140-B. 2.) Any team team members who do not have documentation of at least 10 hours of training in cognitive impairment will be required to complete training immediately. 3.) Executive Director will ensure required documents are completed and available for review. 1.) Audit to be completed by 8.11.25 2.) Staff training to be completed by 8.25.25
22VAC40-73-310-D
Based on record review and staff interview, the facility failed to ensure, based on a review of the UAI prior to admission of a resident, the assisted living facility administrator had provided written assurance to the resident that the facility had the appropriate license to meet their care needs at the time of admission. The written assurance was to be kept in the resident’s record.
Evidence
  1. During a record review, on 7/2/2025, the LI requested resident 3’s, admitted 11/7/2024, written assurance.
  2. Staff 1 confirmed resident 3 did not have the required written assurance available for review.
Plan of correction
1.) Executive Director will ensure that all new residents and/or POA will be provided with a written assurance that the facility has the appropriate license to meet their care needs at time of admission.
July 11, 2022Inspection2 violations
Inspection dates
07/11/2022,07/12/2022
Areas reviewed
Administration and Administrative ServicesPersonnelStaffing and SupervisionAdmission, Retention and Discharge of ResidentsResident Care and Related ServicesBuildings and GroundsEmergency PreparednessSafe, Secure Environment
Comments
Date of Inspection: July 11 and 12, 2022 Type of Inspection: Renewal Inspection If you have any questions or email changes, please do not hesitate to contact me at laura.lunceford@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov. Census 34 Number of records reviewed and interviews conducted- 4 resident records and 7 staff records, 8 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. The Licensing Inspector observed the residents during activities and care. The Licensing Inspector reviewed the following documentation during the inspection: resident council minutes, dietician report, activity schedules, healthcare oversight, menus and fire drills. The Licensing Inspector and the Administrator discussed the risk assessment ratings for the violations for this inspection. Please complete the “plan of correction” and “date to be corrected” for each violation cited on the violation notice and returned it to the office. You will need to specify how the deficient practice will be or has been corrected. 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).
Violations
22VAC40-73-250-D
Based on staff record review and staff interview, it was determined that staff records failed to have documentation of subsequent risk assessment for tuberculosis.
Evidence
  1. Staff F and G had no documentation in the record of a current tuberculosis risk assessment screening. Staff F's last screening was dated April 20, 2020. Staff G's last screening was July 27, 2020.
Plan of correction
All staff records will have the current risk assessment for tuberculosis as required. The Administrative staff will audit all records to ensure compliance.
22VAC40-73-250-C
Based on staff record review and staff interview, it was determined that staff records failed to have documentation of required reports.
Evidence
  1. Staff C, D and E had no documentation of the original criminal record report.
Plan of correction
All staff records will have original criminal record reports as required. The Administrative staff will audit all staff records to ensure compliance.
July 22, 2021Inspection0 violations
Inspection dates
July 22, 2021 and July 27, 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 July 22, 2021 and concluded on July 27, 2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 33. The inspector emailed the Administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed 3 resident records, 3 staff records, activities calendar, staff schedules, healthcare oversight, fire drills, emergency drills and training submitted by the facility to ensure documentation was complete. The inspector conducted the on-site portion of the inspection on July 27, 2021. An exit interview was conducted with the Administrator and Director of Nursing on the date of inspection, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. The information gathered during the inspection determined no violations with applicable standards or law. No violations were issued.
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
January 22, 2021Inspection0 violations
Inspection dates
Jan. 22, 2021 and Jan. 25, 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
This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. An initial inspection was initiated on January 22, 20201 and concluded on January 25. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 30. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 4 resident records, 4 staff records, policies and staff schedules submitted by the facility to ensure documentation was complete. The information gathered during the inspection determined no violations with applicable standards or law. No violations were issued. Not all of the Standards were reviewed during this inspection. A recommendation for licensure will be made for February 1, 2021.
Violations
No violations cited
The inspector documented no violation of standards at this inspection.