Virginia DSS · Assisted Living Facility

Morningside House of Leesburg, LLC

📍 316 Harrison Street, SE, Leesburg, VA, 20175

ID 46870One Year licenseActive
24
Inspections
On record
20
With violations
Visits that cited something
4
Clean visits
Nothing cited
82
Violations cited
Individual findings
59
Standards cited
Distinct rules
14
Complaint visits
Prompted by a complaint

Morningside House of Leesburg, LLC was inspected 24 times between February 24, 2021 and March 4, 2026 by the Virginia Department of Social Services. 20 of those visits ended with violations cited and 4 with none. Across that history VDSS cited 82 violations under 59 distinct standards. 14 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. 22 of these 24 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
11/26/2026
Administrator
Susan Ackman
Licensing inspector
Amanda Velasco
Inspector phone
(703) 397-4587
Approved for
Assisted Living · Non-Ambulatory

Inspection History

24

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

March 4, 2026Inspection4 violations
Inspection dates
03/04/2026
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-80 SANCTIONS
Technical assistance
Reviewed Intensive Plan of Correction.
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: 03/04/2026 9:35 AM to 10:45 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: 67 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 (Selective) Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 5 Observations by licensing inspector: Medication Cart Audit – 1st, 2nd, and 3rd Floor 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. 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-H
Based on resident record review and staff interview, the facility failed to ensure all medications administrations to residents were documented on the medication administration record (MAR) at the time of administration.
Evidence
  1. Resident 2’s chart contained an order for Bacitracin 500- Unit/ GM Ointment that states to clean the right second toe with NSS, then apply a quarter size amount with gauze and cover with foam dressing.
  2. Resident 1’s Medication Administration Record (MAR) for January 2026 and February 2026 contains indications that Bacitracin was not administered on the following dates with additional notes that state a variation of ‘nurse will do”: a. January 3rd, 2026 b. January 6th – 9th, 2026 c. January 11th – 13th, 2026 d. January 15th, 2026 e. January 17th, 2026 f. January 19th-20th, 2026 g. January 22nd, 2026 h. January 24th – 25th, 2026 i. January 31st, 2026 j. February 04th, 2026 k. February 05th, 2026 l. February 9th, 2026 m. February 11th, 2026 n. February 13th, 2026
  3. In an interview with two LI’s on 02/04/2026, Staff 2 confirmed that while the medication was administered, the nurses were not going back into the MAR to document administration of the medication. There was no documentation provided to support that the medication was administered.
Plan of correction
An in-service was conducted with wellness staff for proper process for documenting treatments completed by licensed staff to ensure that treatments performed by nurses are documented in the MAR prior to end of shift. Will continue to monitor MAR audits currently being conducted with additional focus in this area.
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. Resident 1’s chart contained an order for Vitamin C 250 MG Gummy that states to chew and swallow two gummies by mouth every day for supplement.
  2. Resident 1’s Medication Administration Record (MAR) for January 2026 and February 2026 states that the medication was not administered on the following dates because it was not available: a. January 1st – 4th, 2026 b. January 09th, 2026 c. January 15th – 17th, 2026 d. January 20th – 21st, 2026 e. January 23rd - 24th, 2026 f. January 26th – 28th, 2026 g. February 1st – 3rd, 2026
  3. Resident 1’s MAR for January of 2026 indicates that it was still marked as administered on the following dates in between not being administered: a. January 6th – 8th, 2026 b. January 10th – 14th, 2026 c. January 18th – 19th, 2026 d. January 22nd, 2026 e. January 25th, 2026 f. January 29th – 31st, 2026
  4. In an interview with two LI’s on 03/04/2026, Staff 2 confirmed that they were not available which is why they were not administered and stated that Resident 1’s POA who provided the medication was aware it was not being administered. There was no documentation provided regarding the discrepancy between when it was available or not available and when it was administered.
Plan of correction
The medication not administered is provided by the family. The facility acknowledges that medications were not consistently available for administration and that the Medication Administration Record (MAR) contained discrepancies regarding administration documentation when the medication was not available. An in-service was conducted with all wellness staff to re-educate on medication refills from outside normal pharmacy parameters. Will continue to monitor MAR audits currently being conducted with additional focus in this area.
22VAC40-73-680-M
Based on resident record review and staff interview, the facility failed to ensure medications ordered for [as needed] PRN administration was available, properly labeled, and properly stored at the facility.
Evidence
  1. During a medication cart audit on 1st floor with Staff 3, two LI’s observed Resident 4’s PRN medication as expired. The medication “Bisacodyl” expired on 03/02/2026.
  2. Resident 4’s record contains an order for Bisacodyl that states take one tablet by mouth every day as needed.
  3. In an interview with two LI’s on 03/04/2026, Staff 1 confirmed that Resident 4’s PRN medication was expired and therefore not available as needed.
  4. Photo evidence obtained.
Plan of correction
PRN medication was immediately removed and properly disposed of per facility policy. A med cart audit was completed to ensure all PRN medications were present, properly labeled and stored appropriately. DHW or designee will perform random cart audits to ensure compliance.
22VAC40-73-640-A
Based on facility document review and interview, resident record review, direct observation and staff interview, the facility failed to ensure a written plan for medication management was kept current, implemented, and addressed procedures for administering medication including required components.
Evidence
  1. The Medication Management Plan was submitted via email by Staff 2 on 02/02/2026 and approved by the department on 02/06/2026.
  2. Resident 1’s Medication Administration Record (MAR) for January 2026 and February 2026 indicate that there were 18 doses of medication not administered due to the medication not being available on site.
  3. Page 2 of the Medication Management Plan states, “Refills are initiated at seven days remaining by MT/Nurse. Escalation occurs at 72 hours remaining by DHW/Nurse.”
  4. Resident 2’s MAR for January 2026 and February 2026 indicates that there 20 doses of medication not documented at time of administration.
  5. Page 3 of the Medication Management Plan states, “Late entries and corrections to be completed following audit standards by DHW/Nurse/MT
  6. In an interview with two LI’s on 03/04/2026, Staff 1 confirmed that the Medication Management Plan was not implemented for Resident 1 and Resident 2’s medication administration.
Plan of correction
DHW and ADHW conducted MAR and medication cart audits in accordance with the adopted MMP. Results were reviewed with ED to ensure ongoing compliance. DHW or designee will conduct audits of medication administration records, medication carts and compliance with medication management procedures. The written medication managements plan will be reviewed quarterly and updated as needed. Audit results will be discussed during QA meetings and corrective action will be taken as necessary.
March 4, 2026Complaint survey3 violations
Inspection dates
03/04/2026
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03/04/2026 11:30 AM to 1:00 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 01/31/2026 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: 68 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed:0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Resident Records Additional Comments/Discussion: N/A 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
22VAC40-73-70-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 record contains discharge paperwork from the emergency department dated 01/04/2026, that indicates Resident 1 was seen for a fall resulting in a head injury.
  2. Resident 1’s record contains discharge paperwork from the emergency department dated 01/31/2026, that indicates that Resident 1 was seen for a fall resulting in a head injury, traumatic hematoma, shoulder injury, and multiple abrasions/lacerations.
  3. In an interview with two LI’s on 03/04/2026, Staff 1 confirmed that the reports for Resident 1 were not submitted within 24 hours.
Plan of correction
Not published by VDSS.
22VAC40-73-460-D
Based on resident record review and staff interview, the facility failed to ensure supervision of resident schedules, care, and activities included attention to specialized needs, such as prevention of falls and wandering from the premises.
Evidence
  1. Resident 1’s UAI, dated 07/27/2025, assessed Resident 1 as needing physical and mechanical assistance with wheeling.
  2. Resident 1’s progress notes contain a note dated 01/04/2026 that states Resident 1 slid out of Resident 1 wheelchair while being transferred to the apartment by a staff member. The note states that Resident 1 fell face forward, landed on Resident 1’s right shoulder, and hit Resident ‘s head. The following note, dated 01/05/2026, states that Resident 1 reported mild head discomfort and limited right shoulder mobility due to discomfort.
  3. Resident 1’s record contains discharge paperwork from the emergency department dated 01/04/2026, that indicates Resident 1 was seen for a fall resulting in a head injury.
  4. Resident 1’s progress notes contain an entry dated 02/02/2026, that states Resident 1 fell out of the wheelchair while being by a staff member on 01/31/2026. The progress note states that Resident 1’s foot was caught between the wheelchair wheels, result in Resident 1 tipping forward and landing face down on the floor. The note states that bumps, bruising, and blood were seen on the face The note indicates Resident 1 was sent to the emergency room.
  5. Resident 1’s record contains discharge paperwork from the emergency department dated 01/31/2026, that indicates that Resident 1 was seen for a fall resulting in a closed head injury, traumatic hematoma to the forehead, left shoulder injury, and multiple abrasions to the forehead, face, and nose.
  6. In an interview with two LI’s on 03/04/2026, Staff 1 confirmed that the facility failed to ensure supervision of Resident 1’s care including prevention of falls.
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’s UAI, dated 07/27/2025, assessed Resident 1 as needing physical and mechanical assistance with wheeling.
  2. Resident 1’s ISP, dated 07/27/2025, did not include services related to using a wheelchair.
  3. In an interview with two LI’s on 03/04/2026, Staff 2 confirmed that the wheelchair use was not included on the ISP dated 07/27/2025.
Plan of correction
Not published by VDSS.
March 4, 2026Complaint survey0 violations
Inspection dates
03/04/2026
Areas reviewed
22VAC40-73 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 Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03/04/2026 10:45 AM to 11:30 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 03/02/2026 regarding allegations in the area(s) of: 1. Admission, Retention, and Discharge of Residents Number of residents present at the facility at the beginning of the inspection: 67 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents:0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Resident record. Additional Comments/Discussion: Resident was unavailable for interview at time of inspection. 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. The evidence gathered during the investigation did not support the allegation 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 “AJ” 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.
October 17, 2025Inspection9 violations
Inspection dates
10/17/2025
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 IMPAIRMENTS22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Technical assistance
Standards Reviewed: 550, 450, 210
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: 10/17/2025 8:30 AM to 4:06 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 67 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 7 Observations by licensing inspector: Activities, Meals, and Medication Pass/Medication cart audits on all three floors. 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
22VAC40-73-860-D
Based on direct observation and staff interview, the facility failed to ensure that all operable windows were screened.
Evidence
  1. During a tour of the facility, the LI observed the following windows without screens: a. 3rd floor hallway near room 324 b. 3rd floor lobby c. 1st floor, stairs to dining area d. Various unidentified windows on the outside of the building
  2. In an interview with the LI on 10/17/2025, Staff 1 confirmed that the windows did not have screens.
  3. Photo evidence obtained.
Plan of correction
The screens identified as missing were replaced. A quarterly building safety audit checklist was updated to include screen verification. ED and or Designee will monitor monthly and address any missing or damaged screens will be replaced within 48 hours of discovery.
22VAC40-73-680-H
Based on resident records and staff interviews, the facility failed to ensure that medication administration was documented on the medication administration record (MAR) at the time medication is administered.
Evidence
  1. Resident 1’s MAR for August 2025 has a blank box next to the following administrations: a. 08/03/2025 6:30 AM Levothyroxine b. 08/03/2025, 08/07/2025, 08/09/2025 2:00 PM Sodium Bicarb c. 08/23/2025 6:00 AM Alendronate
  2. Resident 1’s MAR for September 2025 has a blank box next to the following administrations: a. 09/06/2025 6:30 AM Levothyroxine b. 09/06/2025 6:00 AM Alendronate
  3. Resident 2’s MAR for August 2025 has a blank box next to the following administrations a. 08/18/2025, 08/20/2025 2PM Gabapentin and Furosemide
  4. Resident 2’s MAR for September 2025 has a blank box next to the following administrations: a. 09/08/2025 3PM Gabapentin and Furosemide
  5. Resident 8’s MAR for August 2025 has a blank box on 08/10/2025 for a 2PM scheduled dose of Gabapentin.
  6. Resident 8’s MAR for September 2025 has a blank box on 09/05/2025, 09/11/2025, and 09/16/2025 for a 2PM scheduled dose of Gabapentin.
  7. Signed physician and prescriber orders for the medications of Resident 1, Resident 2, and Resident 8 were reviewed.
  8. In an interview with the LI on 10/17/2025, Staff 11 stated that the medication must not have been documented at the time of administration.
  9. On 10/17/2025, Staff 1 provided Narcotic Count Sheets via email for Resident 2 and Resident 8 confirming that the Gabapentin had been administered but not documented on the MAR at the time of administration.
Plan of correction
Reviewed MARs for Residents 1, 2, and 8. Confirmed all medications were administered but not timely documented. Med techs re-trained on immediate documentation. MAR reviews conducted weekly by the Wellness Director or designee to ensure compliance with documentation timing.
22VAC40-73-970-A
Based on facility document review and staff interview, the facility failed to ensure the drills were conducted on each shift in a quarter.
Evidence
  1. The Record of Required Fire and Emergency Evacuation Drills stated that the following drills were all conducted at 2:00 PM: a. 05/29/2025 b. 06/26/2025 c. 07/31/2025 d. 08/28/2025 e. 10/01/2025
  2. In an interview with the LI on 10/17/2025, Staff 1 confirmed that the drills were not being conducted on different shifts throughout each quarter.
Plan of correction
Drill schedule was revised to include all three shifts. Night and evening drills are now scheduled for November and December 2025. Administrator/designee will maintain a quarterly fire drill log showing at least one drill per shift per quarter. Review will occur monthly in Safety Committee meetings.
22VAC40-73-50-A
Based on resident records and staff interview, the facility failed to ensure the disclosure statement was on the form developed by the department.
Evidence
  1. The following resident records contained disclosure statements on outdated disclosure statement forms: a. Resident 3, admitted 07/25/2025 b. Resident 4, admitted 03/06/2025 c. Resident 6, admitted 02/14/2025 d. Resident 7, admitted 10/06/2025
  2. In an interview with the LI on 10/17/2025, Staff 1 confirmed that Resident 3, Resident 4, Resident 6, and Resident 7’s records contained outdated disclosure forms.
Plan of correction
The Administrator has updated the disclosure form to meet regulations. The Administrator or designee will verify quarterly that the disclosure form matches the most recent VDSS version posted on the DSS website.
22VAC40-73-680-B
Based on resident records and staff interview, the facility failed to ensure that medication shall remain in the pharmacy issued container with the prescription label or direction label attached until administered to the resident.
Evidence
  1. During a medication cart audit on the 1st floor with Staff 3, the LI observed a pill pack containing Resident 9’s prescribed Gabapentin. The medication pack, containing 31 pills, had two pill slots that had been popped out, replaced with two visually different pills, and then taped shut.
  2. The Narcotic Count sheet provided to the LI indicated that two pills were removed in error, initialed by an unidentified staff member.
  3. On 10/17/2025, Staff 1 and Staff 11 could not determine who or why the pills had been removed from the pharmacy issued container and replaced.
  4. In a follow-up email to the LI on 10/20/2025, Staff 1 stated that Staff 11 initialed the correction solely looking at the total number of pills and not realizing that the two pills had been replaced and taped over.
  5. Photo evidence obtained.
Plan of correction
The affected medication pack was destroyed per policy. All med techs were re-educated on pharmacy-issued container requirements. New audits of medication carts were implemented. An in-service training was conducted for all Med Techs on 10.29.25 to review and reinforce proper procedures for medication replacement, handling, and documentation. Weekly audits of med carts will be conducted for the next ninety (90) days to ensure narcotic counts are being performed and documented accurately and consistently.
22VAC40-90-40-B
Based on staff record review and staff interview, the facility failed to ensure that the criminal record report was obtained on or prior to the 30th day of employment.
Evidence
  1. The following staff records contained documentation that the Criminal Record Report was completed more than 30 days after hiring: a. Staff 12, hired on 01/01/2025, Criminal Record Report obtained on 03/10/2025 b. Staff 13, hired on 01/27/2025, Criminal Record Report obtained on 03/10/2025 c. Staff 14, hired on 01/30/2025, Criminal Record Report obtained on 03/10/2025
  2. In an interview with the LI on 10/17/2025, Staff 1 confirmed the criminal record reports for Staff 12, Staff 13, and Staff 14 were not obtained on or prior to the 30th day of employment.
Plan of correction
Administrator will audit new hire files biweekly for 90 days, then monthly. Staff cannot be scheduled for independent work until background results are received.
22VAC40-73-490-A-3
Based on resident records and staff interviews, the facility failed to ensure all residents were included annually in the health care oversight.
Evidence
  1. The Record of On-Site Health Care Oversight was reviewed for the last year. The form dated 07/18/2025 contained a list of 13 residents. The form dated 01/24/2025 contained a list of 11 residents.
  2. In an interview with the LI on 10/22/2025, Staff 1 stated that a random selection of residents was chosen during each oversight period. Staff 1 confirmed that not all residents were included annually in the healthcare oversight.
Plan of correction
A master tracking log created with records completion dates for each resident. The Administrator, Wellness Director or Designee will cross-check semi-annually to ensure 100% inclusion.
22VAC40-73-640-A
Based on resident records and staff interview, the facility failed to ensure that the medication management plan was implemented.
Evidence
  1. While on site at the facility, a pack of Gabapentin was observed with two visually different pills taped into the back of the bubble pack.
  2. Staff 1 provided a copy of the medication management plan to the LI on 10/17/2025.
  3. Page 09 of the medication management plan states the following, “Controlled medications are destroyed by medications by disposing in a contained labeled specifically for medication distribution…” The medication management plan later states that a report sheet is used to document the destruction of controlled substances, which is then signed by multiple leadership positions, and faxed to drug control.
  4. In an interview with the LI on 10/17/2025, Staff 1 confirmed that nothing had been reported regarding the two pills being removed, and additional pills being taped into the pack.
  5. In an interview with the LI on 10/17/2025, Staff 1 confirmed the medication plan was not followed.
Plan of correction
Medication error was reviewed, and Gabapentin pack removed from use. Re-education provided to medication staff on controlled substance handling and destruction per facility policy. Medication Management Plan was updated to include step-by-step verification before medication destruction or correction. Quarterly audits by RN will ensure compliance.
22VAC40-73-860-I
Based on direct observation and staff interview, the facility failed to ensure cleaning supplies and hazardous materials were stored in a locked area.
Evidence
  1. During a tour of the facility, the LI observed that the employee lounge door was propped open and accessible to residents. Inside the lounge, both the cleaning supply closet and laundry room doors were also propped open. Multiple cleaning products were observed including laundry detergent, room sprays, wipes, and spray bottles. No staff were present in the employee lounge, closet, or laundry room.
  2. In an interview with the LI on 10/17/2025, Staff 1 confirmed that the cleaning supplies were not stored in a locked area.
  3. Photo evidence obtained.
Plan of correction
ED or designee will monitor the cleaning supply closets daily to ensure they remain locked when not in use. ED and DPO will check lock integrity weekly. Supervisors will verify compliance during daily rounds. Non-compliance will be addressed via staff coaching or disciplinary action.
May 15, 2025Complaint survey1 violation
Inspection dates
05/15/2025
Areas reviewed
22VAC40-80 COMPLAINT INVESTIGATION22VAC40-73 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: Complaint A complaint was received by VDSS Division of Licensing on 03/10/2025 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: 05/15/2025 9:15 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: 67 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 5 Observations by licensing inspector: Resident Room 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. However, violation(s) not related to the complaint but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Violations
22VAC40-73-70-A
Based on staff interview, the facility failed to ensure that any incident that has negatively affected or that threatens the life, health, safety or welfare of any resident as reported to the regional licensing office within 24 hours.
Evidence
  1. On 03/10/2025, a complaint was received by the regional licensing office regarding an incident that occurred between Staff 6 and Resident 1.
  2. In an interview with the LI on 05/15/2025, Staff 1 stated that Resident 2 had concerns about the attitude of Staff 1 affecting the care of Resident 1. Staff 1 confirmed that an incident report was not submitted regarding the incident between Staff 6 and Resident 1.
Plan of correction
Facility will ensure that communication is sent to the regional licensing office in the event of major incident within 24 hours.
February 3, 2025Complaint survey1 violation
Inspection dates
02/03/2025
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
Comments
Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 01/09/2025 regarding allegations in the area(s) of: medication administration. Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 02/03/2025 11:00 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: 67 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 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 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
22VAC40-73-640-A
Based on resident record review, facility document review, and staff interview, the facility failed to ensure that the medication management plan was implemented.
Evidence
  1. On 01/09/2025, Staff 1 notified the LI via email of a self-reported incident. The email stated, “We have a resident, [Resident 1], who missed an evening and morning dose of BP medication due to waiting on pharmacy for refill.”
  2. On 02/03/2025, Staff 2 provided the LI with a copy of the facility’s medication management plan. The medication management plan states the following: a. “Medication errors will be immediately reported to the DHW [Director of Health and Wellness] or ED [Executive Director] via phone. Resident’s physician and family member/responsible party shall be notified as soon as possible. Action shall be taken as directed by a physician, pharmacist, or poison control center. Actions taken will be documented by a nurse or medication aide. The ED or DHW will complete appropriate follow-up.”
  3. Resident 1’s, admitted 12/09/2024, scheduled medications for December 2024 contain the following prescriber order: Eliquis 5 MG Tablet. The directions state “Take one tablet by mouth every 12 hours for [Diagnosis].”
  4. Resident 1’s Medication Administration Record (MAR) states that a dose was administered by Staff 3 on 12/10/2024 at 8:00 PM. Resident 1’s MAR states a “1” on 12/11/2024 at 8:00 AM by Staff 4. The key listed on the MAR states 1 as “Other.” On the notations of the MAR, the 12/11/2024 dose lists the notation as “on order.”
  5. In an interview with the LI on 02/03/2025, Staff 5 confirmed that scheduled medications with multiple doses will come in individual bubble packs. Staff 5 stated that if a morning dose of the same medication for the same resident was not available, an evening dose of the same medication for the same resident should have been used as a substitution.
  6. In an interview the with the LI on 03/07/2024, Staff 4 stated that they cannot recall if on 12/11/2024 whether they contacted the physician, the executive director, the director of health and wellness, or the legal representative/family of the resident. Staff 4 stated that typically, if a resident’s medication is unavailable, they will notify the pharmacy and/or search the nurse’s station to see if it arrived with the pharmacy order. Staff 4 confirmed that they will additionally check for scheduled dose of the same medication for the same resident to administer; however, sometimes they will just wait for the pharmacy to send over the additional bubble pack.
  7. In an interview the LI on 03/07/2025, Staff 2 stated they were unsure if there was any communication between the physician, legal representative, and the director of health and wellness. Staff 2 could not recall if they notified the executive director or the director of health and wellness.
  8. Resident 1’s progress notes for December 2024 and January 2025 were reviewed. They did not contain documentation of notification to the family, physician, executive director, or director of health and wellness when the medication dose was missed.
  9. In an email exchange with the LI on 03/07/2025, Staff 2 confirmed that no notification had been made to the physician, family, the executive director or director of health and wellness.
Plan of correction
Resident missed one dose of medication due to refill not being available at the pharmacy. ED reviewed Policy and standards of practices with HWD, AHWD and Wellness Team. HWD will ensure proper notification is sent to all applicable parties when a medication dose is missed.
November 8, 2024Complaint survey1 violation
Inspection dates
11/08/2024
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 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-80 COMPLAINT INVESTIGATION
Technical assistance
Discharge notification discussed per resident refusal.
Comments
Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 11/07/2024 regarding allegations in the area(s) of: resident care & related services, admission, retention, and discharge of residents, and 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: 11/08/2024 9:15 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: 67 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 4 Observations by licensing inspector: resident room. Additional Comments/Discussion: This inspection was a joint inspection with Adult Protective Services. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. However, violation(s) not related to the complaint but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Violations
22VAC40-73-70-A
Based on resident record review, staff interview, and resident interview, the facility failed to ensure a report was given 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. Resident 1’s, admitted 07/12/2023, record contains a progress note written by Staff 1 that states the following: a. On 11/01/2024, “Resident notified writer that [Resident 1] was “assaulted” by [Resident 2]. Interviewed staff members [Initials of Staff 2 and 3] in dining. [Resident 2] did shake table but did not come in contact with resident. Resident 1 contacted 911 to file report on [Resident 2]; [Resident 2] interviewed with [Staff 1] and information taken. No action taken by LCPD.”
  2. In an interview with the LI on 11/08/2024, Resident 1 confirmed that Resident 2 shook the table and was yelling in the resident’s face. Resident 1 stated that they reported to both Staff 1 and the police.
  3. In an interview with the LI on 11/08/2024, both Staff 2 and 3 confirmed that Resident 2 yelled at and shook the table near Resident 1. Staff 2 stated that they overheard Resident 1 say they were going to police as they were leaving the dining area.
  4. An initial report of the incident was not sent to the licensing office.
  5. In an interview with the LI on 11/08/2024, Staff 1 acknowledged that a report should have been sent to the licensing office.
Plan of correction
Facility will ensure that communication is sent to the regional licensing office in the event of major incident.
October 10, 2024Inspection7 violations
Inspection dates
10/10/2024
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 PREPAREDNESS63.2- (1) GENERAL PROVISIONS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION
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: 10/10/2024 9:40 AM to 5:05 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: 66 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: 2 Number of interviews conducted with staff: 2 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
22VAC40-73-620-B
Based on facility document review and staff interview, the facility failed to ensure that certification that the requirements of this subsection were met was included in the oversight of special diets.
Evidence
  1. Staff 1 provided the special diets oversight for 04/30/2024, 01/30/2024, and 10/31/2023.
  2. The dietician oversight for all three (3) dates did not include certification that requirements of the standards were reviewed and included in the oversight.
  3. In an interview with the LI, Staff 1 acknowledged that the certification statement was not included on the special diet oversight.
Plan of correction
Certification Statement has been added to dietician oversight “I have reviewed the described facility and resident diets and certify them in accordance with the Virginia Assisted Living Regulations 22VAC40-73-620 Oversight of Special Diets” ED or designee will review dietician oversight documents quarterly to ensure all future oversight documents include the Certification Statement.
22VAC40-73-260-C
Based on direct observation and staff interview, the facility failed to ensure a listing of all staff who have current certification in first aid or CPR, was posted in the facility so that the information is always readily available to all staff.
Evidence
  1. During the onsite tour of the building to include all floors, common areas, the nurse’s station and the staff break area, the LI did not observe a posted list of all staff certified in CPR/First Aid.
  2. In an interview with the LI on 10/10/2024, Staff 1 stated that they were unsure if they needed to post the list as all direct care staff are certified.
Plan of correction
All wellness staff is certified in CPR/FA. Signs stating that all wellness staff are CPR/FA Certified has been posted in Wellness Office, Staff Break Room and Dining Room to ensure all team members know who is certified in case of emergency. ED or designee will monitor these spaces monthly to ensure signage is present.
22VAC40-73-980-H
Based on direct observation and staff interview, the facility failed to ensure 48 hours of the 96 hour emergency water supply was on site at any given time.
Evidence
  1. The census for 10/10/2024 was 67.
  2. During a tour of the kitchen storage and staff areas, the LI observed approximately 15 gallons of emergency water.
  3. In an interview with the LI on 10/10/2024, Staff 1 confirmed there was no additional water on site.
  4. Photo evidence obtained.
Plan of correction
Emergency water was ordered and obtained by facility and kept on site. ED and/or DPO will monitor water bottle inventory to ensure required amount of water is available based on census
22VAC40-73-550-G
Based on resident record review and staff interview, the facility failed to ensure that written acknowledgment of the review of the rights and responsibilities was filed in the resident’s record.
Evidence
  1. Resident 1’s, admitted 02/09/2023, record did not contain an annual acknowledgment of the Resident Rights and Responsibilities.
  2. Resident 2’s, admitted 03/04/2023, record did not contain an annual acknowledgment of the Resident Rights and Responsibilities.
  3. Resident 5’s, admitted 05/13/2023, record did not contain an annual acknowledgment of the Resident Rights and Responsibilities.
  4. In an interview with the LI on 10/10/2024, Staff 1 stated that the Resident Rights are discussed during resident council and emailed to all legal reps, as well as shared in resident mailboxes. Staff 1 confirmed that there was not acknowledgement of receipt in the resident records.
Plan of correction
Audit was completed to ensure all resident records include acknowledgement of receiving Resident Rights & Responsibilities ED and/or designee will continue to audit records on a new resident move in and bi-annual basis to ensure Resident Rights and acknowledgement of receipt has been obtained.
22VAC40-73-610-B
Based on direct observation and staff interview, the facility failed to ensure menus for meals and snacks for the current week were posted in an area conspicuous to residents.
Evidence
  1. During a tour of the facility including all floors and common areas, the LI observed a daily menu that stated, “assorted snacks always available.”
  2. In an interview with the LI on 10/10/2024, Staff 1 confirmed that there not a snack menu or weekly menu posted elsewhere in the facility.
  3. Photo evidence obtained.
Plan of correction
Weekly menu has been posted outside of the dining room entrance. Clarification was added to daily menu for elevator that Assorted Snacks (Chips, Candy and Fruit) are available at the 1st Floor Lobby Bistro. DDS or designee will ensure weekly menu is always posted outside of dining room.
22VAC40-73-980-A
Based on direct observation and staff interview, the facility failed to ensure items in the first aid kit with expiration dates did not have dates that have already passed.
Evidence
  1. During a tour of the wellness room and offices, the LI observed a first aid kit.
  2. The first aid kit contained antiseptic ointment that expired 09/2023 and First Aid Wound Saline Wash that expired 06/25/2024.
  3. In an interview with the LI, Staff 3 confirmed the first aid kit contained expired items.
  4. Photo evidence obtained.
Plan of correction
First Aid kit replaced ED and or DWH will audit all first aid kits monthly to ensure nothing has expired.
22VAC40-73-220-A
Based on facility document review and staff interview, the facility failed to ensure that when private duty personnel from licensed home care organizations provide direct care or companion services, the facility will maintain proper documentation including written information on the type and frequency of services listed, required tuberculosis (TB) reports, orientation and training regarding the facility’s policies and procedures, and documentation of resident care.
Evidence
  1. In an interview with the LI on 10/10/2024, Staff 1 stated that Resident 1 has a private duty aide through an agency. Staff 1 confirmed the facility does not have a file including a written copy of the type and frequency of services that will be provided, a tuberculosis screening, record of facility orientation and training, or documentation of resident care on either private duty companion
Plan of correction
Background check and TB chest x-ray and screening were obtained. ED and or BOM will ensure all records necessary for private duty have been obtained and are present in resident record.
September 27, 2024Complaint survey3 violations
Inspection dates
09/27/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS63.2- (1) GENERAL PROVISIONS22VAC40-80 COMPLAINT INVESTIGATION
Technical assistance
Aggressive Behavior Training for Staff
Comments
Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 09/23/2024 regarding allegations in the area(s) of: resident care and related services and 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: 09/27/2024 10:30 AM to 12:45 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: 68 Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: Meals (Lunch), Activities. 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: resident care and related services, and resident accommodations and related provisions. 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
22VAC40-73-440-A
Based on resident record review and staff interview, the facility failed to ensure that the Uniform Assessment Instrument (UAI) was completed for all residents at least annually.
Evidence
  1. Resident 1’s record contains a UAI that is dated as completed and signed on 07/12/2023.
  2. Staff 4 confirmed that an updated UAI was not completed for Resident 1.
Plan of correction
Resident 1's UAI was not updated annually per the regulation. UAI was updated immediately to reflect the correct assessment. All resident files were audited by DHW and any outdated UAIs were corrected. DHW or designee will update UAIs when care level changes or annually whichever is sooner to ensure all records are up to date.
22VAC40-73-450-F
Based on resident record review, resident interview, and staff interview, the facility failed to ensure that the Individualized Service Plan (ISP) was reviewed and updated in conjunction with the resident.
Evidence
  1. On 08/20/2024, Staff 3 emailed Resident 1 and Staff 1 a copy of the Level of Care (LOC) Assessment and Individualized Service Plan (ISP) with the message “I hope you are doing well, attached to this email is a copy of the most recent Assisted Living Resident Level of Care Plan Assessment and/or the Individualized Service Plan. We would appreciate your assistance by reviewing and signing the signature pages for the assessment and/or service plan and returning them to the community. No changes have been made to the level of care.”
  2. Resident 1’s ISP, dated 08/19/2024, states that Resident 1’s mental health functions include “Attitude” and “Interaction with Others”. Both functions include a section titled “Resident’s needs/preferences.” The “Resident’s Needs/Preferences” section for “Attitude” states “Requires staff assistance and encouragement maintaining appropriate/positive attitudes.” The “Resident’s Needs/Preferences” section for “Interaction with Others” states “Requires staff assistance and encouragement maintaining positive/appropriate interactions with others.”
  3. In an interview the with LI on 09/27/2024, Staff 3 and 4 confirmed that Resident 1 did not contribute to making her goals in the ISP. Staff 3 and 4 stated this information is from the assessment. Staff 3 and 4 confirmed that once the plan was created, they emailed the plan to the resident for signature.
Plan of correction
Resident #1 required a change in their ISP based on an addition to their care plan. Resident #1, who is own POA, received document but was not included in discussion leading up to the change. The ISP was emailed to the resident without acknowledgement. ISP was discussed with resident during inspection. DHW or designee will ensure resident and/or POA are consulted during changes in care needs/ISPs and work to obtain documentation of the discussions either through signature or response to email.
63.2-1606-A
Based on resident record review, resident interview, and staff interview, the facility failed to ensure matters giving reason to suspect the abuse, neglect or exploitation of were reported immediately to Adult Protective Services (APS) upon the reporting person's determination that there is such reason to suspect.
Evidence
  1. In an interview with the LI on 09/27/2024, Resident 1 stated that at dinner they were trying to take a photo of themselves using their phone to show the green drainage they were having to a doctor. Resident 1 stated that Staff 1 jumped up, started yelling at her and saying, “Why are you taking my picture?” and knocked the phone to the ground. Resident 1 stated that a scratch gave them pain her left arm. Resident 1 stated that Staff 1 picked up the phone, held it above their head, and started saying “[Resident 1] took my picture – I got [Resident 1’s] phone.”
  2. In an interview with the LI on 09/27/2024, Staff 3 and 4 stated that they interviewed Staff 1 who confirmed that they had concerns about Resident 1 taking pictures. Staff 3 and 4 stated that Resident 1 threatened to call the police and Staff 1 stated that they didn’t touch the resident.
  3. In Resident 1’s progress notes, Staff 3 wrote “Resident complained of aide (Staff 1) grabbing phone, aide stated resident had taken a picture of him while in dining room. Spoke with resident regarding not taking pictures of residents and staff members. [Staff Titles] had a conversation with aide, aide apologized to resident and resident accepted apology and is satisfied.”
  4. In an interview with Staff 1, Staff 1 stated that Resident 1 stated they wanted to talk through the situation with APS but didn’t realize they were making a report; however, the facility did not call. Staff 1 stated that Resident 1 can overreact, make reports, and then want to rescind the reports. Staff 1 encouraged Resident 1 to come to Staff 1 first and provided their personal contact number to monitor reporting.
Plan of correction
Facility did not contact APS or DSS to report suspected abuse. Resident 1 reported an incident with a caregiver in the dining room involving retrieval of resident 1s phone for taking unauthorized pictures of residents and staff. A thorough investigation was conducted by ED with care team, dining staff, Resident 1 and other residents. No abuse, neglect or exploitation of Resident 1 was found and matter was documented. ED or DHW will contact APS and/or DSS in the future for any incident of suspected abuse regardless of outcome. Ongoing.
August 5, 2024Complaint survey0 violations
Inspection dates
08/05/2024
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 GENERAL PROVISIONS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 07/26/2024 regarding allegations in the area(s) of: resident care and related services and admission, 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: 08/05/2024, 8:35 AM to 9:45 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: 66 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: 3 Observations by licensing inspector: Residents preparing for field trip pick-up, meal delivery to room. 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 9, 2024Complaint survey5 violations
Inspection dates
07/09/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 06/17/2024 regarding allegations in the area(s) of physical abuse and neglect. Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/09/2024: 1:10 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: 69 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 2 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 4 Observations by licensing inspector: Activities. Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. However, violation(s) not related to the complaint but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Violations
22VAC40-73-210-G
Based on staff record review and staff interview, the facility failed to ensure documentation of the type of training received, the entity that provided the training, number of hours of training, and dates of the training were kept by the facility.
Evidence
  1. Staff 4’s record contains a document titled “Employee Annual Training- Mandatory” that is signed on 09/20/2023 and states “I have been in serviced in the training topics below I have received handouts for each topic so that I may refer to the topic if I need to at a later date and completed the testing packet associated with each.”
  2. The document lists the following topics as in-serviced: Abuse and Neglect, basic CPR, Basic First Aid, Basic Food Safety, Bloodborne Pathogens, Fire Safety, Disaster Preparation/Planning, Infection Control and Precautions, and Resident Rights.
  3. The annual training log has “post test” questionnaires attached for each topic.
  4. Staff 5’s record contains the same “Employee Annual Training – Mandatory” document and was signed on 09/24/2024.
  5. The “Employee Annual Training – Mandatory” document t does not include the type of training received, the number of training hours, or the date of each training.
  6. Staff 2 confirmed that this is the only documentation provided for annual training, and that it does not contain specific information about the training including the type of training, number of training hours, or the date of each training.
Plan of correction
All Staff receive annual training compliance hours in topics required by State regulations. The facility did not total the number of hours received on the packet provided to staff. The facility has revised the packet to include the number of hours credited for the continuing education provided.
63.2-1808-A-10
Based on resident interview and staff interview, the facility failed to ensure that each resident is free from mental, emotional, physical, sexual, and economic abuse or exploitation; is free from forced isolation, threats or other degrading or demeaning acts against him; and his known needs are not neglected or ignored by personnel of the facility.
Evidence
  1. Resident 1 stated that they had made 4 or 5 complaints to the facility regarding Resident 2 bothering her.
  2. Resident 1 stated that this resident has been both verbally and physically aggressive.
  3. Resident 1 stated that they have told Staff 3; however, they don’t do anything about it. Resident 1 has said that Staff 3 will “sidestep” around the issue and that the facility (both staff and residents) are a “great big club against me.”
  4. Resident 1 documented phone calls to Leesburg Police on February 01st, 2024 and March 28th, 2024, regarding the incidents that have occurred with Resident 2.
  5. Resident 1 stated that most incidents happen in the club room during bingo which has resulted in not participating in activities and/or having to sit alone during meals.
  6. Staff 1, 2, and 3 verified that there has been a history of altercations between Resident 1 and 2; however, it has not escalated physically.
  7. Staff 1, 2, and 3 stated that police have not been on site regarding these incident(s).
  8. Staff 2 and 3 said that the current intervention in place is that Resident 2 has agreed to stay away from Resident 1.
  9. When asked about attending activities, Staff 2 verified that Resident 1 has stopped coming to activities and stated that she understands why the Resident 1 doesn’t come because the other residents in the facility “don’t like her.”
  10. Staff 2 and 3 stated that Resident 1’s decision to avoid activities was supported by the staff to help avoid altercations between Resident 1 and 2.
Plan of correction
Resident #1 has known behavioral issues and difficulty interacting with residents and staff in the community. ED has met with Resident #1 as well as multiple residents and staff members to facilitate a community approach that addresses the concerns while meeting the needs of all residents in the community. Resident #1 has been encouraged to attend group activities and has received guidance and assistance in setting up activities led by Resident #1 with residents they are comfortable with; Resident #1 will also be provided opportunities outside of group activities to ensure they don’t feel isolated and are contributing to the community. ED has assisted Resident #1 in identifying residents in the dining room with like interests to sit with at mealtime.
22VAC40-73-830-E
Based on facility document review and staff interview, the facility shall provide a written response to the council prior to the next meeting regarding any recommendations made by the council for resolution of problems or concerns.
Evidence
  1. Staff 2 provided the resident council notes to review regarding resident concerns.
  2. In discussion of the resident council notes, Staff 2 confirmed the facility does not provide a written response to residents prior to council.
  3. Staff 2 stated the current method is reviewing the response during the resident council meeting.
Plan of correction
Facility holds Resident Council every month for resident feedback. Facility provided verbal responses to resident council concerns but did not provide the response in writing. Facility will provide residents with written response to each Resident Council meeting at the next scheduled Resident Council meeting the following month.
22VAC40-73-130-B
Based on staff interview, the facility failed to ensure the resident's contact person or legal representative was notified when a report is made relating to the resident.
Evidence
  1. An APS report was referred on 06/14/2024 regarding the care of Resident 1.
  2. Staff 1 and 2 were unsure if a report had been submitted to Resident 1’s contact person when notified of the report.
  3. Staff 3 confirmed via phone interview that Resident 1’s contact person was not notified because the resident is their own representative and has requested that nobody contact Resident 1’s relations.
  4. No documentation was provided to verify this information.
Plan of correction
Reporting resident is own POA and facility inadvertently mistook this to mean that the emergency contact did not need to be contacted. Facility will contact resident contact person or emergency contact for any future reports made to state or local agencies regarding resident welfare.
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 was provided.
Evidence
  1. Resident 1 ‘s Uniform Assessment Instrument, completed 07/12/2023, lists her behavior as “appropriate” with no notes of inappropriate behavior.
  2. Staff 1, 2, and 3 all confirmed that Resident 1 has behavioral concerns with refusal of care, intervening in care of other residents, and being verbally aggressive with staff.
  3. Staff 1 and 2 stated that Resident 1 had been discharged from the facility at one time and was previously re-admitted on 07/12/2023.
  4. Staff 1 and 2 stated that these concerns were present in both her previous and current admissions in the facility.
  5. Staff 1 and 2 confirmed that this is not documented in the resident record through progress notes, incident reports, or on the most recent Individualized Service Plan (ISP) and the interventions currently in place are using a preferred caregiver whenever possible.
Plan of correction
Facility did not indicate on UAI, ISP or progress notes that resident #1 exhibited behavioral issues and additional care intervention was in place when caring for this resident. Facility has added these notations to resident #1’s UAI, ISP and progress notes.
June 6, 2024Inspection2 violations
Inspection dates
06/06/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 EMERGENCY PREPAREDNESS
Technical assistance
Reviewed Incident Report Guidelines
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: 06/06/2024, 1:25 PM 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: 64. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 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
22VAC40-73-950-B
Based on facility document review, the facility failed to ensure a description of the generator's capacity to provide sufficient power for the operation of lighting, ventilation, temperature control, supplied oxygen, and refrigeration was included in it’s emergency preparedness and response plan.
Evidence
  1. Staff 1 provided a copy of the emergency response plan and the emergency generator policy.
  2. The policy stated “Areas serviced by this generator during times of main power outage include elevator(s), hallway lighting, limited kitchen equipment, resident emergency call system, facility office phone system, and designated wall receptacles (identified with a sticker)”
  3. Staff 1, 2, and 3 confirmed that the generators serviced all of the areas described in the plan but did not service the temperature control and supplied oxygen.
Plan of correction
Emergency Preparedness and Response Plan did not include a description of the generator’s capacity and areas that it services when in use. The generator services elevator, hallway lighting, ventilation, heating and cooling systems, limited kitchen equipment, resident emergency call system, facility office phone system and designated common area wall receptacles (identified with a sticker) to be used in powering supplied oxygen as needed. Residents on oxygen (2) were switched over to tank operation for resident comfort in their apartments in lieu of relocating resident and oxygen concentrator to common areas. Generator vendor has been scheduled to verify equipment to ensure all areas of the Emergency Plan are serviced by the generator. Emergency Plan has been updated to include the power capacity of the generator and all areas it services in the event of an outage.
22VAC40-73-950-H
Based on staff interview, the facility failed to notify family members and legal representatives after the emergency was stabilized and reported to the regional licensing office by the next day.
Evidence
  1. Staff 1 stated that there was a town-wide power outage on Monday, May 27th, 2024 that lasted from 6:30 AM to roughly 3:30 PM where emergency generators were in use.
  2. Staff 1 stated that there was no notification to families at any point during the power outage or after.
  3. Staff 1 stated that there was a town-wide power outage on Monday, May 27th, 2024, that lasted from 6:30 AM to roughly 3:30 PM where emergency generators were in use.
  4. Staff 1 confirmed that the incident was not reported to the regional licensing office.
Plan of correction
There was a town wide power outage at 6:30 am on May 27, 2024 that lasted for approximately 3 hours at which time the community generator provided power to the community. When the main power was restored at 9:30 am, the generator continued to provide power to the community rather than switching back to main power. The generator vendor was notified immediately and dispatched to switch back to main power. Main power source was restored at 3:30 pm. Residents were safe and virtually unaffected by outage and resident families were not notified. Community will notify resident families in the future in the event of a power outage or other emergency. Residents were safe and virtually unaffected by outage and regional licensing office was not notified. Community will notify regional licensing office in the future in the event of a power outage or other emergency.
October 5, 2023Inspection4 violations
Inspection dates
10/05/2023
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS
Comments
Type of Inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/5/23 (9:00 AM – 6:00 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: 69 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of interviews conducted with resident: 4 Number of interviews conducted with staff: 2 Observations by licensing inspector: Meals, medication administration, activities An exit meeting was held. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (703) 431-4247 or by email at m.massenberg@dss.virginia.gov.
Violations
22VAC40-73-710-B
Based on observation and documentation, the facility failed to ensure that physical restraints are used as a medical/orthopedic restraint for support, according to a physician's written order and with the written consent of the resident or his legal representative or (ii) in an emergency situation after less intrusive interventions have proven insufficient to prevent imminent threat of death or serious physical injury to the resident or others.
Evidence
  1. Bed rails were observed on the bed of Resident #4. Resident #4’s record contained a physical examination form, dated 7/26/23, indicating that she has a cognitive impairment and that she is non-ambulatory. Resident #4’s ISP, dated 7/31/23, does not include information about her use of the bed rail. No physician’s orders were observed, in Resident #4’s record, to indicate the rails were necessary as a medical/orthopedic restraint for support.
Plan of correction
Resident #4 does have a bed rail in place per the family's request for support not restraint. Facility will obtain documentation from the resident's legal representative as well as an order from the physician to document the necessity of the rails currently in place for support. ED or Designee will ensure any future use of bed rails for support will be documented and signed off by legal representative and physician.
22VAC40-73-260-A
Based on record review, the facility failed to ensure that each direct care staff member maintains current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. The certification must either be in adult first aid or include adult first aid. Each direct care staff member who does not have current certification in first aid, shall receive certification in first aid within 60 days of employment.
Evidence
  1. No documentation was provided, during the inspection, to confirm that Staff #1 (hired 6/12/23) or Staff #2 (hired 6/6/23) had current certification in first aid.
Plan of correction
Staff #1 and Staff #2 did not have current First Aid Certification. Staff #1 had First Aid Certification that was expired and had already taken the class for both CPR and First Aid prior to inspection but not within the 60 days of new hire. Staff #1 is not compliant. Staff #2 had current CPR and BLS/AED certification provided at hire but did not have First Aid. Staff #2 will obtain First Aid Certification to meet requirements within 30 days. ED or Designee will audit personnel records to ensure all clinical staff members are current with CPR and First Aid certifications and monitor monthly moving forward to ensure compliance.
22VAC40-73-720-A
Based on documentation, the facility failed to ensure that Do Not Resuscitate (DNR) Orders for withholding cardiopulmonary resuscitation are included in the individualized service plan.
Evidence
  1. Resident #1’s record contained a DNR, dated 12/11/20. Resident #1’s DNR was not documented on his ISP, dated 9/5/23. Resident #2’s record contained a DNR, dated 4/18/23. Resident #2’s DNR was not documented on his ISP, dated 9/6/23.
Plan of correction
DNR orders were not listed on Resident #1 and #2 individualized service plans. The Facility maintains records for all residents for DNR status and advises of status to staff in the medication management system and the resident chart but did not indicate the DNR status on the individualized service plan per the regulation. Facility has audited all resident charts and noted on each individualized service plan the DNR status. ED or Designee will ensure the DNR status is on all future ISP's created.
22VAC40-73-450-C
Based on documentation, the facility failed to ensure that the comprehensive individualized service plan (ISP) is based upon the uniform assessment instrument (UAI).
Evidence
  1. Resident #1’s UAI, dated 9/1/23, states that he needs no assistance for eating. Resident #1’s ISP, dated 9/5/23, states that assistance is required for the resident to eat meals. Resident #5’s UAI, dated 7/26/23, states that he needs no assistance for dressing. Resident #5’s ISP, dated 8/10/23, states that he requires monitoring, verbal prompts and cues for dressing.
Plan of correction
Resident #1 and Resident #5 UAIs did not match the current ISPs. Current ISPs were created for each resident and the corresponding UAIs were not updated to reflect the current service plan. HWD or Designee will audit resident UAIs and ISPs to ensure they match and make any necessary corrections. HWD will ensure both the UAI and ISP are reviewed for any future care changes and updated accordingly. ED or Designee will spot audit monthly to ensure compliance.
February 17, 2023Complaint survey9 violations
Inspection dates
02/17/2023, 3/17/2023, 04/04/2023
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 BUILDINGS AND GROUNDS63.2 FACILITIES AND PROGRAMS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Unannounced complaint inspection visits were conducted on 2/17/23, 3/17/23, and 4/4/23 in response to complaints received by the licensing office on 1/17/23 and 1/25/23 regarding: Personnel; Staffing and Supervision; Admission, Retention and Discharge of Residents; Resident Care and Related Services; Building and Grounds. Medication administration, staff documentation, resident records, and facility grounds were observed. The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint, but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (703) 431-4247 or by email at m.massenberg@dss.virginia.gov.
Violations
22VAC40-73-460-H
Based on documentation, the facility failed to ensure that personal assistance and care is provided to each resident as necessary so that the needs of the resident are met, including assistance or care with: Bathing - at least twice a week, but more often if needed or desired.
Evidence
  1. The facility's February shower logs (2/1/23 – 2/16/23) were observed during the inspection. Resident #3's ISP, dated 11/16/22, states that he needs staff assistance for bathing. Resident #3's only documented shower, during the review period, was completed on 2/15/23. The shower log documented that Resident #3 refused showers on two occasions (2/1/23 and 2/3/23), during the review period. Resident #5's ISP, dated 1/10/23, states that she needs staff assistance for bathing. Resident #5's only documented shower, during the review period, was completed on 2/7/23.
Plan of correction
Residents are scheduled to receive two or more showers per week and a log is kept by staff members to record whether the shower was given or refused by the resident. Staff members failed to document the outcome of the scheduled showers for Resident #3 and Resident #5. Staff members have been in serviced on the importance of documenting outcomes of resident care provided. HWD or designee will review shower logs weekly to ensure accurate documentation is kept for resident showers.
22VAC40-73-680-D
Based on documentation, the facility failed to ensure that medications are administered in accordance with the physician's or other prescriber's instructions and consistent with the standards of practice outlined in the current medication aide curriculum approved by the Virginia Board of Nursing.
Evidence
  1. The morning medication administration, for Resident #3, was observed during the inspection. Resident #3's insulin order calls for him to receive the medication before meals. Resident #3 was observed receiving insulin, after he began eating breakfast.
Plan of correction
Medication administration for Resident #3, wasnot administered as prescribed by the physician and consistent with the standards of practice. All RMA associates have been in-serviced on the importance of standards of practice of medication administration, administering medication in accordance with physician orders and including proper documentation to ensure physicians orders are being followed as prescribed and recorded in the medication records. ED, HWD or designee will conduct audit weekly of insulin administration to ensure medication is administered per physician orders.
22VAC40-73-680-C
Based on documentation, the facility failed to ensure that medications are administered within one hour of the facility’s standard dosing schedule,Based on documentation, the facility failed to ensure that medications are administered within one hour of the facility’s standard dosing schedule, except those drugs that are ordered for specific times, such as before, after, or with meals.
Evidence
  1. Resident #1's January MAR was reviewed, during the inspection. Resident #1's Digoxin was scheduled to be administered by 9 AM daily. Resident #1's Digoxin was administered at 10 AM on 1/26/23 and at 10:25 AM on 1/29/23. Resident #1's Gabapentin (administered 3 times per day) was scheduled to be given by 10 AM, 3 PM, and 9 PM. Resident #1's Gabapentin was administered at: 4:03 PM on 1/20/23, 10:46 PM on 1/22/23, and 10:12 on 1/24/23. Resident #1's Montelukast Sodium was scheduled to be given by 8 PM daily. Resident #1's Montelukast Sodium was administered at: 10:17 PM on 1/21/23, 10:47 PM on 1/22/23, 10:14 PM on 1/24/23, and 9:39 PM on 1/28/23. Resident #1’s Quetiapine was scheduled to be given by 5 PM daily. Resident #1's Quetiapine was administered at: 6:29 PM on 1/21/23, 6:18 PM on 1/22/23, and 8:02 PM on 1/27/23. Resident #6's MAR indicates that she had evening administrations of Eliquis and Metoprolol Succinate that are scheduled to be given by 9:00 PM. Resident #6’s Eliquis and Metoprolol were administered after 10:20 PM on 1/21/23 and 1/22/23.
Plan of correction
Medication administration for Resident #1 and Resident #6, was not administered timely as prescribed by the physician and consistent with the standards of practice. All RMA associates have been in-serviced on the importance of administering medication timely in accordance with standards of practice of medication administration, administering medications in accordance with physician orders and will include proper documentation to ensure physicians orders are being followed as prescribed and recorded in the medication records.
22VAC40-73-650-A
Based on record review, the facility failed to ensure that no medications, dietary supplement or treatment is started, changed, or discontinued without a valid order from a physician or other prescriber.
Evidence
  1. Resident #1's record contained orders, dated 1/4/23, that called for the resident's Metformin, Ferrous Sulfate, and Vitamin C to be discontinued. The orders also called for Resident #1's Rosuvastatin to be changed from 40mg to 20mg. Resident #1's medication administration record (MAR) indicates that his Metformin, Ferrous Sulfate, and Vitamin C were not discontinued until February 2023. Resident #1's Rosuvastatin was not changed from 40mg to 20mg, until February 2023. Resident #1's record contained an order, dated 1/4/23, for Vitron-C to be administered daily. No administrations of Vitron-C were included on Resident #1's MAR. Resident #2 was admitted to the facility on 11/17/22. Resident #2's admission medication list included Eucerin topical cream, and it was to be administered to a rash on the resident's back. Resident #2's November treatment administration record (TAR) did not include documentation of Eucerin administration/application.
Plan of correction
Medication administration for Resident #1 and Resident #2 were not administered as prescribed by the physician and consistent with the standards of practice. Policy and standards of practice were reviewed with HWD and changes to MAR/TAR based on inspection findings were implemented immediately. HWD performed audit of MAR and resident orders to ensure medications matched physician orders and any medications that should be discontinued were correctly reflected in both the MAR/TAR and the resident chart. Regional HWD, ED or designee to perform random audit monthly on resident files and MAR/TAR to ensure quality control.
22VAC40-73-470-B
Based on record review, the facility failed to ensure that a resident’s need for skilled nursing treatment is met by a licensed nurse.
Evidence
  1. Staff #1 documented changing Resident #2's dressing in December 2022. Staff #1 is a registered medication aide. No training records or health care license, was provided during the inspection, to indicate that Staff #1 had the appropriate training or licensure to complete dressing changes. Resident #2 was noted to have stage 1 pressure sores on her heels and redness on her buttocks, upon her admission in November 2022. On 12/12/22, Resident #2's progress notes state that the resident’s coccyx has a stage 2 wound that is increasing in size. The notes, completed by a home health provider, states that the dressing should be changed when soiled. Progress notes indicated that Staff #1 changed Resident #2’s dressing in December 2022. No training records or nursing licensure was provided, during the inspection, to document that Staff #1 had the appropriate training or licensure to perform wound care/dressing changes.
Plan of correction
Staff #1 holds a current First Aide certification, is a Registered Medication Aide and is studying to be an LPN at Standard Healthcare College of Nursing. Staff #1 has completed coursework in Foundations of Nursing Skills/Concepts; Geriatric Nursing Skills and Concepts; Sterile Dressing Change Training and has completed over 50 hours of direct patient care in long term care setting. Staff #1 was providing dressing changes and wound care based on regular assessments and direction from skilled nursing licensed professionals on how to care for the resident between assessments. Facility was not aware that RMA's were qualified to change some butnot all wound dressings. Facility will ensure moving forward that only a LPN/RN will provide wound care to any resident with an advanced staged wound.
22VAC40-73-470-C
Based on record review, the facility failed to ensure that services are provided to prevent clinically avoidable complications, including: pressure ulcer development or worsening of an ulcer.
Evidence
  1. Resident #2's record contains a progress note, dated 12/12/22, that states that the resident's stage 2 wound is increasing in size and that the resident must be repositioned every two hours. Resident #2's ISP, dated 11/10/22, states that she needs maximum assistance for transfers and a Hoyer lift to be transferred into a wheelchair. Resident #2's ISP did not include documentation that she needed to be turned and repositioned every two hours. Resident #2's MAR included documentation that the resident was turned and repositioned, every two hours, beginning 12/28/22. No information was provided, during the inspection, to document that Resident #2 was turned and repositioned (every two hours) from 12/12/22 until 12/28/22.
Plan of correction
Resident #2 was admitted to the facility on 11.16.23 and an ISP was created on 11.10.23 in accordance with ALF Regulations. Following the addition of documentation to the MAR that the resident should be turned and repositioned every two hours, a revision to the ISP of record was not made. HWD has been inserviced on the importance of ensuring continuity throughout all documentation when a change in care services is implemented. Regional HWD, ED or designee will conduct a random audit monthly of resident e-charts to ensure documentation is accurate and consistent with standards of practice.
22VAC40-73-460-B
Based on documentation, the facility failed to ensure a prompt response by staff to resident needs as reasonable to the circumstances.
Evidence
  1. Call bell reports for January were reviewed during the inspection. Resident # 3's call bell report indicated that there were 155 occasions when it took staff 30 minutes to respond to the resident's call bell (out of 230 call alarms). Resident #4's call bell report indicated that there were 215 occasions when it took staff 30 minutes to respond to the resident's call bell (out of 409 call alarms). Resident #5's call bell report indicated that there were 57 occasions when it took staff 30 minutes to respond to the resident's call bell (out of 111 call alarms).
Plan of correction
Residents #3, #4 and #5 did not receive aprompt response by staff to resident needs. Upon review of the documents provided, Resident #3, Resident #4 and Resident #5 exceeded maximum response time for call bells on 34, 58 and 24 unique occasions, respectively, during the time period reviewed. None of the requests resulted in staff finding an “emergency” when the call was answered. On 4.12.23, facility has implemented a new call bell system that provides additional tools for identifying resident call bells and promotes better response times. ED and HWD have provided in-service to staff on importance of answering call bells in a timely manner in conjunction with the training of the new call bell system. ED and HWD will monitor through email notification when a call bell goes unanswered for ten minutes and meet to review the response times on a weekly basis for the next 60 days to ensure improvements are made.
22VAC40-73-430-H-1
Based on record review, the facility failed to ensure that a discharge statement is provided to the resident (or their legal representative), at the time of discharge.
Evidence
  1. Resident #6's discharge record was observed during the inspection. No documentation was provided, during the inspection, to indicate that Resident #6 was provided with a discharge statement at the time of discharge.
Plan of correction
Resident #6 was discharged from the facility and was not provided a discharge statement. Resident #6 received various correspondence regarding discharge via email but was not provided a formal discharge statement after exiting the facility. A discharge statement was emailed to the resident on the date of the inspection. ED will ensure all residents discharging from the facility moving forward will be provided with a discharge statement.
22VAC40-73-660-A-1
Based on observation and documentation, the facility failed to ensure that a medicine cabinet is used for the storage of medications and that the storage area is locked.
Evidence
  1. At approximately 8:30 AM on 2/17/23, the first-floor medication cart was observed to be unlocked and unattended.
Plan of correction
Medication should be kept in a medicine cabinet and this area should be locked when not in use or unattended. All RMA associates have been in-serviced on the importance of ensuring this standard of practice is maintained for the integrity of the contents and the safety of all residents and staff. ED, HWD or designee will do random spot checks of medication carts to ensure this practice is maintained.
January 6, 2023Complaint survey2 violations
Inspection dates
01/06/2023
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
An unannounced complaint inspection was conducted on 1/6/23 in response to a complaint received by the licensing office on 12/9/22 regarding: Administration and Administrative Services, Admission, Retention, and Discharge of Residents, and Resident Care and Related Services. Resident records were observed. Violations were discussed and an exit meeting was held. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (703) 431-4247 or by email at m.massenberg@dss.virginia.gov.
Violations
22VAC40-73-390-A
Based on documentation, the facility failed to ensure that the resident agreement includes a description of all accommodations, services, and care that the facility offers and any related charges.
Evidence
  1. Resident agreements were observed during the inspection. The resident agreements; for Residents #1, #2, and #4; listed the care levels provided by the facility, but the care levels were not described. A signed level of care worksheet, that indicates the care necessary to meet each level, was not included in the records of Residents #1, #2, or #4 at the time of their admission.
Plan of correction
Residents #1, #2, and #4 had completed level of care worksheets that were reviewed and agreed to prior to admission by each resident with the lease agreements. The worksheets completed were not signed in addition to the lease agreement. Facility was not aware that the lease agreement itself did not fulfill the admission requirement for the description of services to be provided. ED, HWD or designee will audit all resident records to ensure that level of care worksheet is signed by the resident or resident representative along with the lease agreement. Facility will ensure the level of care worksheet is signed for future residents at the time of admission.
22VAC40-73-450-E
Based on record review, the facility failed to ensure that each individualized service plan (ISP) is signed by the resident or their legal representative.
Evidence
  1. Resident # 1's ISP, dated 11/7/22, was signed by the Director of Health and Wellness. The ISP was not signed by the resident or her legal representative. Resident #4’s record contained two ISPs, dated 2/8/22 and 3/4/22, but the ISPs were not signed by the resident or his legal representative.
Plan of correction
Residents #4's ISP was not signed by the resident or resident's legal representative. Facility will have the resident or resident representative sign this document for the resident record. ED, HWD or designee will audit all resident records to ensure resident current ISPs are signed by the appropriate resident or resident representative.
November 18, 2022Complaint survey2 violations
Inspection dates
11/18/2022
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION
Comments
An unannounced complaint inspection was conducted on 11/18/22 in response to complaints received by the licensing office on 10/31/22 and 11/7/22 regarding Staffing and Supervision, and Resident Care and Related Services. Facility documentation and resident records were observed. The complaint was determined to be 'valid,' as a preponderance of evidence supported the allegations. Violations were discussed and an exit meeting was held. Areas of non-compliance are identified on the violation notice. Please complete the 'plan of correction' and 'date to be corrected' for each violation cited on the violation notice and return to the licensing office within five business days. Please specify how the deficient practice will be or has been corrected. Just writing the word 'corrected' is not acceptable. The 'plan of correction' must contain: 1) Steps to correct the non-compliance with the standards, 2) Measures to prevent the non-compliance from occurring again, and 3) Person responsible for implementing each step and/or monitoring any preventative measures. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (703) 431-4247 or by email at m.massenberg@dss.virginia.gov
Violations
22VAC40-73-290-A
Based on documentation, the facility failed to maintain a written work schedule that includes the names and job classifications of all staff working each shift, with an indication of whomever is in charge at any given time. Any absences, substitutions, or other changes shall be noted on the schedule.
Evidence
  1. Facility schedules for October and November were observed. The facility schedules were not updated to include all substitutions involving Staff #1 and Staff #2.
Plan of correction
Staff schedule was not completely updated to reflect staff coverage made for absences. Wellness Coordinator has been counseled as to the importance of having correct documentation regarding schedule changes as they occur. Wellness Coordinator will make all corrections to the posted schedule in a timely manner so the schedule is available to the licensing agency at any time it is requested. HWD or designee will review staff schedule bi-weekly to ensure schedule reflects staff members that were on duty for each shift.
22VAC40-73-280-A
Based on documentation and interview, the facility failed to have staff adequate in knowledge, skills, and abilities and sufficient in numbers to provide services to attain and maintain the physical, mental, and psychosocial well-being of each resident as determined by resident assessments and individualized service plans, and to ensure compliance with this chapter.
Evidence
  1. On 34 occasions, there were two staff members that worked during the 10PM - 6 AM shift (10/15/22 - 11/17/22). Facility staff reported that there was no documentation of staff members refusing a break period during that timeframe. Resident documentation, reviewed during the inspection, indicated that there are at least two residents (Resident #1 and Resident #2) that require two staff members for ADL assistance. During staff member break periods, the facility would not have a sufficient amount of staff members to provide resident assistance when only two staff members are on duty. Facility punch detail reports were observed and only one staff member was documented as being present on 10/30/22 (from 4:45 AM until 6 AM) and 11/6/22 (from 10 PM until 11:15 PM).
Plan of correction
Two staff members are on duty from 10p-6a nightly. Resident #1 and Resident #2 require two staff members to assist with ADLs. The number of staff members present during this time would not allow for staff to take a break during their shift and still have the number of required staff members to assist with the level of care needed. Facility will immediately implement a change to the start time of a day shift staff member to allow for an additional staff member to be on site during the 10p-6a shift for coverage during a 30-minute break during this time period. Staff members have been counseled as to the requirement to remain on duty until additional staff members are on duty. ED and HWD will review census and acuity levels monthly and facility will add additional staff members to shift as needed to ensure all resident care needs are met.
November 18, 2022Inspection3 violations
Inspection dates
11/18/2022
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND
Comments
An unannounced focused monitoring inspection was conducted on 11/18/22 to follow-up on a high-risk violation that was cited on 10/6/22. Medication administration and resident records were observed. Violations were discussed and an exit meeting was held. Areas of non-compliance are identified on the violation notice. Please complete the 'plan of correction' and 'date to be corrected' for each violation cited on the violation notice and return to the licensing office within five business days. Please specify how the deficient practice will be or has been corrected. Just writing the word 'corrected' is not acceptable. The 'plan of correction' must contain: 1) Steps to correct the non-compliance with the standards, 2) Measures to prevent the non-compliance from occurring again, and 3) Person responsible for implementing each step and/or monitoring any preventative measures. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (703) 431-4247 or by email at m.massenberg@dss.virginia.gov
Violations
22VAC40-73-660-A
Based on observation, the facility failed to ensure that the medication storage area is locked.
Evidence
  1. Amoxicillin, probiotic pills and ointments were observed to be unlocked and unattended in the closet of the therapy room shortly after 8:20 AM.
Plan of correction
Medications were found in an unlocked area of the therapy room. The area where the unlocked medications were observed was an area that was previously but not currently used for medication storage. The observed medications were discontinued medications for residents no longer residing in the facility and were stated to have been removed and destroyed by a staff member no longer employed. ED has confirmed that medications have now been removed and destroyed. HWD and RMA staff have been counseled on the importance of storing and destroying medications properly and ED, HWD or Designee will monitor facility for medications improperly stored on ongoing basis.
22VAC40-73-870-E
Based on observation, the facility failed to ensure that all furnishings, fixtures, and equipment are kept clean and in good repair.
Evidence
  1. Several ceiling access panels/covers were missing on the third floor. Closet doors were not installed and three light switch covers were missing in the room of Resident #3.
Plan of correction
Ceiling access panels in common hallway and light switch covers were missing and closet doors were not installed in Resident #3's room. The access panels in the common hallway had been removed during a maintenance repair and not replaced because a different size was needed. The correct sized access panels have been received and replaced. The closet doors found in Resident #3's room have been removed. The light switch covers had been removed during a repair and have been replaced. The DPO has been counseled on the importance of restoring items that are being maintained to their original or better condition and to ensure that they are in good repair. ED, DPO and/or designee will monitor facility on ongoing basis for areas in need of future repair.
22VAC40-73-680-D
Based on documentation, the facility failed to ensure that medications are administered in accordance with the physician's or other prescriber's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing.
Evidence
  1. Resident #1's October and November MARs (medication administration records) were reviewed during the inspection. Resident #1 has his blood sugar (BS) checked three times per day, and the MAR calls for him to receive Novolog units (U) based on a sliding scale. Resident #1's MAR included the following sliding scale for Novolog administration: 0U (BS= 0-150), 2U (BS= 151-200), 4U (BS= 201-250), 6U (BS= 251-300), 8U (BS= 301-350), 12U (BS= 351-400), Call MD (BS > 400) The MAR included the following administration of Novolog for Resident #1: 0U (BS= 158) on 11/8/22 (4:30 PM administration) 4U (BS= 267) on 11/16/22 (4:30 PM administration) Resident #1's blood sugar was documented as being 526 on 11/6/22 (4:30 PM administration), but no documentation of physician contact was included in the resident record. Resident #2's November MAR was reviewed during the inspection. Resident #2 has her blood sugar checked three times per day, and the MAR calls for her to receive Insulin units based on a sliding scale. Resident #2's MAR included the following sliding scale for insulin administration: 0U (BS < 150), 2U (BS= 151-200), 4U (BS= 201-250), 6U (BS= 251-300), 8U (301-350), 10U (351-400), Call MD for BS > 401 The MAR included the following administration of Insulin for Resident #2: 6U (BS= 233) on 11/1/22 (12:00 PM administration) 8U (BS= 265) on 11/1/22 (5:00 PM administration) 8U (BS= 260) on 11/2/22 (8:00 AM administration) 4U (BS= 151) on 11/2/22 (5:00 PM administration) 2U (BS= 222) on 11/4/22 (8:00 AM administration) 4U (BS= 175) on 11/4/22 (5:00 PM administration) 8U (BS= 241) on 11/5/22 (5:00 PM administration) 8U (BS= 227) on 11/6/22 (5:00 PM administration) 4U (BS= 265) on 11/8/22 (12:00 PM administration) 8U (BS= 287) on 11/8/22 (5:00 PM administration) 8U (BS= 250) on 11/9/22 (5:00 PM administration) 6U (BS= 234) on 11/10/22 (8:00 AM administration) 6U (BS= 234) on 11/10/22 (12:00 PM administration) 8U (BS= 275) on 11/10/22 (5:00 PM administration) 6U (BS= 182) on 11/11/22 (8:00 AM administration) 4U (BS= 145) on 11/11/22 (12:00 PM administration) 8U (BS= 169) on 11/11/22 (5:00 PM administration) 10U (BS= 283) on 11/12/22 (5:00 PM administration) 6U (BS= 230) on 11/13/22 (5:00 PM administration) 8U (BS= 171) on 11/14/22 (12:00 PM administration) 8U (BS= 281) on 11/14/22 (5:00 PM administration) 6U (BS=180) on 11/15/22 (8:00 AM administration) 8U (BS= 283) on 11/15/22 (12:00 PM administration) 8U (BS= 199) on 11/15/22 (5:00 PM administration) 4U (BS= 134) on 11/16/22 (8:00 AM administration) 4U (BS= 158) on 11/16/22 (12:00 PM administration) 8U (BS= 274) on 11/16/22 (5:00 PM administration) 8U (BS= 371) on 11/17/22 (5:00 PM administration)
Plan of correction
Medication administration for Resident #1 and Resident #2 were not administered as prescribed by the physician. HWD to discuss Resident #2's order with physician to ensure it is written in a clear and concise manner for the resident's medication needs. All RMA associates will be in-serviced on administering medications in accordance with physician orders and will include documentation to ensure physicians orders are being followed as prescribed and recorded in the medication records. ED, HWD or designee will audit MAR weekly to ensure physician's orders are being followed for medication administration.
October 6, 2022Inspection13 violations
Inspection dates
10/06/2022
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 PREPAREDNESS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS
Comments
An unannounced renewal inspection was conducted on 10/6/22 (8:35 AM – 6:45 PM). At the time of entrance, 43 residents were in care. Meals, medication administration, and an activity were observed. Building and grounds were inspected and records were reviewed. The sample size consisted of eight resident records and four staff records. Violations were discussed and an exit meeting was held. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (703) 431-4247 or by email at m.massenberg@dss.virginia.gov
Violations
22VAC40-73-450-E
Based on record review, the facility failed to ensure that each ISP is signed by the resident or their legal representative.
Evidence
  1. The ISPs for Residents #2 (9/29/22), #3 (11/6/21), #6 (1/27/22), #7 (9/29/22), and #8 (4/5/22) were not signed by the resident nor their legal representative.
Plan of correction
Resident #2, #3, #6, #7 and #8's ISPs were not signed by the resident or their legal representative. Facility will have these documents signed by the resident or legal representative by 11.1.2022. HWD or designee will audit all resident records to ensure resident ISPs are signed by the appropriate resident representative.
22VAC40-73-450-C
Based on documentation, the facility failed to ensure that the comprehensive individualized service plan (ISP) is completed within 30 days after admission.
Evidence
  1. Resident #2 was admitted to the facility in March 2022, but the first ISP included in her record was dated 9/29/22. Resident #7 was admitted to the facility in April 2022, but the first ISP included in her record was dated 9/29/22. No additional documentation was provided during the inspection.
Plan of correction
Resident #2 and Resident #7's ISPs were not completed and made as part of the resident's records within 30 days of admission. Prior to the inspection, all resident records were audited to ensure an ISP was included for all residents and documentation was placed in the record with the current date by the HWD. HWD or Designee will audit resident records on a monthly basis to ensure proper documentation is completed in a timely manner. The ED or designee will ensure compliance with quarterly QA meetings with the management team.
22VAC40-73-680-D
Based on documentation and observation, the facility failed to ensure that medications are administered in accordance with physician's or other prescriber’s instructions and consistent with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing.
Evidence
  1. Medication administration for Resident #1 was observed during the inspection. Resident #1’s record contained a PRN order for Gas Relief 80mg, dated 3/10/22, to be given after meals and at bedtime. During the inspection, Resident #1 was given PRN Gas Relief before she ate lunch. Medication administration for Resident #2 was observed during the inspection. After Resident #2 was given a pill cup containing her medication, she dropped a Furosemide tablet on the floor. The medication aide retrieved the Furosemide tablet and gave it back to the Resident to take. Resident #9’s September MAR (medication administration record) was reviewed during the inspection. Resident #9 has his blood sugar (BS) checked three times per day, and the MAR calls for him to receive Novolog units (U) based on a sliding scale. Resident #9’s MAR included the following sliding scale for insulin administration: 2U (BS= 151-200), 4U (BS= 201-250), 6U (BS= 251-300), 8U (BS= 301-350), 12U (BS= 351-400) The MAR included the following administration of Novolog for Resident #9: 0U (BS= 155) on 9/12/22 at 4:30 PM 0U (BS= 154) on 9/15/22 at 4:30 PM 0U (BS= 168) on 9/23/22 at 4:30 PM 0U (BS= 157) on 9/29/22 at 4:30 PM
Plan of correction
Medication administration for Resident #1, Resident #2, and Resident #9 were not administered as prescribed by the physician and consistent with the standards of practice. All RMA associates will be in-serviced on standards of practice of medication administration, administering medications in accordance with physician orders and will include proper documentation to ensure physicians orders are being followed as prescribed and recorded in the medication records.
22VAC40-73-320-B
Based on documentation, the facility failed to ensure that a risk assessment for tuberculosis is completed annually for each resident.
Evidence
  1. The tuberculosis risk assessments for Residents #3 (September 2021), #5 (June 2021), and #6 (July 2021) were more than a year old, at the time of the inspection.
Plan of correction
Residents #3, #5, and #6 did not obtain a new tuberculosis assessment on an annual basis as required. HWD or Designee will audit all resident records to ensure all residents have an annual tuberculosis assessment. HWD or designee will maintain a list of the residents and their due date for their annual TB screening and review the list monthly to ensure completion of those assessments due. The Executive Director or designee will ensure compliance with quarterly QA meetings with the management team.
22VAC40-73-970-E
Based on record review, the facility failed to ensure that emergency evacuation drill records include all of the required information.
Evidence
  1. The facility’s fire drills were reviewed during the inspection. The fire drill reporting forms (7/19/22, 8/25/22, 9/14/22) did not include: the time of drill, method used for notification of the drill, the time it took to complete the drill, and weather conditions.
Plan of correction
Emergency drills did not include all required details of the drills. The emergency evaluation drills were facilitated monthly as required but did not include documentation of the time of the drill, method of notification, length of time to complete and weather conditions. Facility acknowledges the requirement for missing information and will ensure proper documentation using VA DSS form 032-05-0059-03-ENG for future emergency drills.
22VAC40-73-260-A
Based on record review, the facility failed to ensure that each direct care staff member receives certification in first aid within 60 days of employment.
Evidence
  1. The record for Staff #4, hired 5/24/22, was reviewed during the inspection. Staff #4’s record contained documentation of CPR certification, but it did not contain documentation of first aid certification. No documentation was provided, during the inspection to indicate that Staff #4 received first aid certification within 60 days of his employment.
Plan of correction
Direct Care staff are required to have First Aid certification within 60 days of employment. Staff #4 was hired on 5/24/22 and presented documentation of CPR, AED and BLS training. This training does not include the required certification of First Aid. Staff #4 will complete the required First Aid training by 11.1.22. ED or designee will audit staff records on a monthly basis to ensure First Aid certification is obtained and maintained per state regulations.
22VAC40-73-720-A
Based on documentation, the facility failed to ensure that each Do Not Resuscitate (DNR) Order is included in the resident’s ISP.
Evidence
  1. Resident #3’s record contained a DNR order, dated 5/24/22. Resident #3’s ISP, dated 11/6/21, was not updated to include the DNR order.
Plan of correction
Resident #3's ISP did not contain the change to information regarding the residents' DNR status. HWD or designee has audited all resident records to ensure the current ISP reflects the most recent DNR status for all residents.
22VAC40-90-40-C
Based on documentation, the facility failed to ensure that any individual is ineligible for employment if their criminal history record report contains barrier crime convictions.
Evidence
  1. The criminal history record reports for new employees were observed during the inspection. The criminal history record report for Staff #7, hired 3/17/22, contained felony convictions for barrier crimes (18.2-57 and 18.2-58).
Plan of correction
Staff #7 criminal history contains a barrier crime. Staff #7 was hired and the criminal history record report was reviewed prior to employment. The record contained a conviction for a barrier crime dated 24 years prior and the regulation for the statute of past history was misinterpreted by the facility. Based on the clarification, the staff member has been released from employment by the facility.
22VAC40-73-950-E
Based on documentation, the facility failed to implement a semi-annual review on the emergency preparedness and response plan for all staff.
Evidence
  1. Staff records were reviewed during the inspection. The most recent review on the emergency preparedness and response plan was completed in November 2021.
Plan of correction
Staff members should review the emergency preparedness plan bi-annually. Staff members have been assigned to review emergency preparedness and response plan training documents upon date of hire and annually. Facility had already assigned all staff members with emergency preparedness and response plan training documents dated 9.16.22 based on an incorrect interpretation of the requirement. ED or designee will ensure all staff members complete the training document on a bi-annual basis.
22VAC40-90-40-B
Based on documentation, the facility failed to obtain a criminal history record report within 30 days of each employee’s hire date.
Evidence
  1. The records for Staff #5 (hired 2/27/22) and Staff #6 (hired 5/1/22) did not contain a criminal history record report within 30 days of their hire dates.
Plan of correction
Criminal background checks were not obtained for Staff #5 and Staff #6. Staff #5 and Staff #6 were re-hired to the facility following a brief period of non-employment at the facility but longer than 30 days. The facility failed to obtain new criminal history reports on these staff members at the time of re-hire. New criminal history reports were obtained on the day of inspection and no criminal history was on record. ED or designee will ensure all staff members, including re-hired staff members, will have a criminal history report reviewed prior to employment.
22VAC40-73-460-B
Based on documentation, the facility failed to ensure a prompt response by staff to resident needs as reasonable to the circumstances.
Evidence
  1. Call bell reports for August and September were reviewed during the inspection. Resident #4’s call bell report indicated that the maximum response time (30 minutes) was reached on 15 occasions for the resident’s call bell. Resident #7’s call bell report indicated that the maximum response time (30 minutes) was reached on 31 occasions for the resident’s call bell.
Plan of correction
Residents #4 and #7 did not receive a prompt response by staff to resident needs. Resident #4 and Resident #7 received maximum response time for call bells on 15 and 31 occasions, respectively, during the time period reviewed. During this time period, Resident #4 used the call bell system 280 times and Resident #7 used the call bell system 743 times for requests; none of the requests resulted in staff finding an "emergency" when the call was answered. HWD will provide an in-service to staff on importance of answering call bells in a timely manner. ED and HWD will monitor through email notification when a call bell goes unanswered for ten minutes and meet to review the response times on a weekly basis for the next 60 days to ensure improvements are made.
22VAC40-73-660-B
Based on observation, the facility failed to limit medication storage to an out-of-sight place in the rooms of residents whose UAIs have indicated that the residents are capable of self-administering their medication.
Evidence
  1. Antacid tablets, Bayer, and Mucus D-M were observed in the room of Resident #2. Resident #2’s UAI, dated 9/26/22, states that the resident needs her medication administered/monitored by professional nursing staff.
Plan of correction
Medications were observed in Resident #2's room. The medications observed in the resident's room were over-the-counter medications brought into the facility without facility consent by the resident's family. The medications were removed from the resident's room and the resident and family were notified and counseled regarding policy of having non-physician ordered medications available for the resident's use. An inspection of all resident rooms was conducted and any medications observed for non-self-administering residents were removed. HWD and RMA staff members have been in-serviced on the importance of monitoring rooms for unauthorized medications.
22VAC40-73-660-A-1
Based on observation, the facility failed to ensure that the medication storage area is locked.
Evidence
  1. Amoxicillin, probiotic pills, and ointments were observed to be unlocked and unattended in the closet of the therapy room shortly after 8:40 AM.
Plan of correction
Medications were found in an unlocked area of the therapy room. The area where the unlocked medications were observed was an area that was previously but not currently used for medication storage. The observed medications were discontinued medications for residents no longer residing in the facility and were destroyed. HWD and RMA staff have been in-serviced on the importance of storing and destroying medications properly.
August 11, 2022Complaint survey0 violations
Inspection dates
08/11/2022
Areas reviewed
22VAC40-73 BUILDINGS AND GROUNDS
Comments
An unannounced complaint inspection was conducted on 8/11/22 in response to a complaint received by the licensing office on 7/11/22, regarding Building and Grounds. Facility walkthrough was completed, building and grounds were inspected. No violations were cited during the inspection. Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (703) 431-4247 or by email at m.massenberg@dss.virginia.gov For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
June 2, 2022Complaint survey2 violations
Inspection dates
06/02/2022
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
An unannounced complaint inspection was conducted on 6/2/22 (1:30 PM – 4:20 PM) in response to a complaint received by the licensing office on 5/5/22 regarding: Resident Care and Related Services. A preponderance of evidence was found to support the allegation and the complaint is considered to be "valid." Violations were discussed and an exit meeting was held. Areas of non-compliance are identified on the violation notice. Please complete the 'plan of correction' and 'date to be corrected' for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word 'corrected' is not acceptable. The 'plan of correction' must contain: 1) Steps to correct the non-compliance with the standards, 2) Measures to prevent the non-compliance from occurring again, and 3) Person responsible for implementing each step and/or monitoring any preventative measures. Thank you for your cooperation and if you have any questions, please call (703) 431-4247 or contact me via email at M.Massenberg@dss.virginia.gov 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
Violations
22VAC40-73-680-E
Based on documentation, the facility failed to ensure that medical procedures or treatments are provided and documented.
Evidence
  1. Resident #2’s record contained an order, dated 2/2/22, that called for the resident to be turned in bed every two hours. Resident #2’s treatment administration record (TAR) was observed during the inspection. There was no documentation of Resident #2 being turned on the following dates/times in May 2022: 5/4/22 (10 PM), 5/9/22 (10PM), 5/11/22 (8AM), 5/14/22 (10PM), 5/23/22 (10PM), 5/24/22 (Noon), 5/25/22 (10PM), 5/26/22 (Noon), 5/26/22 (10PM), and 5/28/22 (10PM).
Plan of correction
Resident #2 physician order for resident to be turned every two hours. The TAR indicated missing documentation of resident being turned. RMA's counseled by HWD 6.23.22 to educate current staff on medication administration/treatments and proper documentation to ensure physicians orders are being followed as prescribed and recorded in the medication records. A daily audit of the TAR will be conducted for 14 days then a random monthly audit will be conducted and results presented at quarterly QA meeting.
22VAC40-73-450-G
Based on record review, the facility failed to ensure that the service plan is filed in the resident record.
Evidence
  1. The record for Resident #1, admitted 3/31/22, was observed during the inspection. Resident #1’s individualized service plan (ISP) was not in the resident record, at the time of the inspection.
Plan of correction
Resident #1 was admitted on 3.31.22. The ISP was not in the resident record. The ISP was filed in the resident record on 6.3.22. HWD or designee will audit 100% of resident records for ISP. Random monthly audit of resident records will be conducted to ensure updated ISPs in resident record and discussed at quarterly QA meetings.
November 4, 2021Complaint survey3 violations
Inspection dates
11/04/2021, 11/23/2021, 11/29/2021
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDING AND GROUNDS
Comments
A non-mandated complaint inspection was initiated on 11/4/21 and concluded on 12/3/21. A complaint was received by the department regarding allegations in the areas of: Resident Care and Related Services, and Building and Grounds. The administrator's designee was contacted by telephone to conduct the investigation. The licensing inspector conducted on-site observations at the facility on 11/4/21, 11/23/21, and 11/29/21. The evidence gathered during the investigation supported the allegation of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.
Violations
22VAC40-73-680-D
Based on record review, the facility failed to ensure that medications are administered in accordance with the physician’s or other prescriber's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing.
Evidence
  1. Resident #1’s May and June 2021 medication administration records (MARs) were reviewed during the inspection. Resident #1’s MAR calls for a blood pressure check three times per day. The MAR also calls for the staff to see Resident #1’s PRN order for Hydralazine, if Resident #1’s Systolic Blood Pressure (SBP) is greater than 160, or the resident’s Diastolic Blood Pressure (DBP) is greater than 100. The PRN Hydralazine order calls for Resident #1 to receive 25mg of Hydralazine three times a day as needed for SBP greater than 160 or DBP greater than 100. Resident #1’s DBP was 104 on 5/2/21 (6 AM), but there is no documentation of Hydralazine administration on that date. Resident #1’s SBP was 171 on 6/22/21 (6 AM), but there is no documentation of Hydralazine administration on that date. Resident #2’s MAR states that her Acetaminophen was not administered on 6/10/21 (2 PM administration), because the facility was “waiting for pharmacy.” Resident #2’s MAR states that her Gabapentin was not administered on 6/21/21 (8 PM administration), because the facility was “unable to provide medication.” Resident #3’s MAR states that the resident’s Eliquis, Levemir, and Melatonin were not administered on 6/11/21 (8 PM administration), as the medications were “not available.”
Plan of correction
Resident #1 did not receive PRN medication on 5.02.21 and 6.22.21 at 6am as ordered. Resident #2 did not receive medication on 6.10.21 (2pm) and 6.21.21 (8pm) as ordered by physician. Resident #3 did not receive medication on 6.11.21 at 8pm as ordered by physician. RMA documented medication not available. RMA counseled by Health and Wellness Director. Health and Wellness Director or designee to educate current staff who administer medication on the Medication Policy to include medications being ordered in a timely manner and administered in accordance with physician orders. Health and Wellness Director or designee to conduct random monthly Medication Administration observations on current staff administering medication to verify that medications are being administered according to physician orders. Health and Wellness Director or designee to discuss results of the random audits at the quarterly QA meetings until compliance is established.
22VAC40-73-460-B
Based on documentation, the facility failed to ensure a prompt response by staff to resident needs as reasonable to the circumstances.
Evidence
  1. Resident #3’s May 2021 call bell reports were reviewed. The report indicates that Resident #3 pressed the call pendant 16 times during the month. The report indicated that there were 12 instances when staff members took 30 minutes to acknowledge the call bell, or the maximum alarm time was exceeded.
Plan of correction
Implemented a call bell escalation process to include call bells being sent to the HWD and ED's cell phones and emails if the call bell is active for 7 minutes. Daily call bell response report will be reviewed weekly by the HWD and ED to show effectiveness. An outlook calendar invite will be utilized to schedule this meeting. ED or designee to discuss results effectiveness at the quarterly QA meetings until compliance is established.
22VAC40-73-650-B
Based on record review, the facility failed to ensure that physician or other prescriber orders include how often a medication is to be given.
Evidence
  1. Resident #2's record included a prescription for elimite cream, dated 5/20/21. The order did not include how often the cream is to be applied.
Plan of correction
Resident #2 discharged on 8.19.21. HWD or designee will audit 100% of residents current physician orders for cream to ensure the order includes how often to apply. Health and Wellness Director or designee to discuss results of the random audits at the quarterly QA meetings until compliance is established.
October 19, 2021Inspection7 violations
Inspection dates
10/19/2021
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 PREPAREDNESS63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS
Comments
A renewal inspection was initiated on 10/19/21 and concluded on 10/22/21. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 44. The inspector emailed the administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed three resident records, three staff records, activity calendar, and other facility documentation to ensure documentation was complete. The inspector conducted the on-site portion of the inspection on 10/22/21. An exit interview was conducted with the administrator on the date of inspection, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations were documented on the violation notice issued to the facility.
Violations
22VAC40-73-320-A
Based on record review, the facility failed to ensure that the physical examination, completed Within the 30 days preceding admission, includes all of the required information.
Evidence
  1. Resident #1’s physical examination form, dated 8/24/21, includes a list of the resident’s allergies. The examination form did not include Resident #1’s reactions to the allergens. Resident #3's physical examination form, dated 6/2/21, states that the resident is allergic to sulfa. The examination form did not include information about Resident #3's reaction to the allergen.
Plan of correction
Addendums were added to Resident #1 and #3 history and physical forms to include reactions to allergens. Current H&P form was revised to include reactions to allergens. HWD or designee to audit 100% of all new move-ins to ensure compliance in reactions to allergens are included. HWD or designee will report results at the quarterly QA meeting until compliance is established
22VAC40-73-870-A
Based on observation, the facility failed to ensure that all furnishings, fixtures, and equipment, including furniture, window coverings, sinks, toilets, bathtubs, and showers, are kept clean and in good repair and condition.
Evidence
  1. Ceiling vent covers were observed to be missing for several vents on the hallway of the second floor. Electrical wiring was also observed hanging from the ceiling, near a missing ceiling vent cover.
Plan of correction
Immediate correction was taken at the time of the survey. Ceiling vents on the second floor were covered on 10.26.2021. Electrical wiring was covered by new vent coverings. Maintenance Director to conduct random rounds on the second floor hallway to ensure all vents are covered and no electrical wiring is exposed. Maintenance Director or designee to report results of random audits at the quarterly QA meeting.
22VAC40-73-860-I
Based on observation, the facility failed to store cleaning supplies and other hazardous materials in a locked area.
Evidence
  1. A spray can of "Belt Dressing" was found unlocked and unattended in third floor stairwell. The warning on the can's label states that the contents are extremely flammable and harmful or fatal if swallowed.
Plan of correction
Immediate correction was taken at the time of the survey. Spray can of "Belt Dressing" found in third floor stairwell was removed and placed in a secure area. Maintenance Director to conduct random rounds of third floor stairwell to ensure all cleaning supplies and other hazardous materials are in locked areas. Maintenance Director or designee to report results of random audits at the quarterly QA meeting.
22VAC40-80-120-E-2
Based on observation and interview, the facility failed to ensure that the findings of the most recent inspection of the facility were posted.
Evidence
  1. The licensing inspector was unable to locate the findings of the most recent inspection posted at the facility. Facility staff confirmed that the inspection findings were not posted.
Plan of correction
Immediate correction was taken at the time of the survey. ED posted finding of most recent inspection at concierge desk. Concierge was reeducated on need to keep most recent inspection results posted at the concierge desk. ED or designee will conduct weekly audits to ensure compliance in most recent survey results being posted. ED or designee to report findings at the Quarterly QA meeting until compliance is established.
22VAC40-73-680-I
Based on record review, the facility failed to ensure that the medication administration record (MAR) includes all of the required information.
Evidence
  1. Administration information was not present for Resident #1’s Amiodarone from 9/2/21 through 9/4/21. Resident #1’s record included an order, dated 9/15/21, that calls for the resident’s blood pressure medications to be held, if the resident’s Systolic Blood Pressure (SBP) is less than 100. Blood pressure readings were not present for the administration of Resident #1’s Amlodipine Besylate and Lisinopril from 9/16/21 through 9/27/21. No information was documented on the MAR for the application of Resident #1’s Diclofenac patch on 9/8/21 (9 AM). No information was documented on the MAR for the administration of Resident #1’s Ertapenem on 9/25/21. No information was documented on the MAR for the administration of Resident #1’s Gabapentin on 9/1/21 (5:30 AM administration), 9/3/21 (1:30 PM administration), and 9/4/21 (1:30 PM administration). No information was documented on the MAR for the administration of Resident #2’s Atorvastatin or Carvedilol on 9/27/21 (8 PM administration).
Plan of correction
RMA's were reeducated on needed documentation for medication administration. HWD or designee to conduct random audits on medication administration records for appropriate documentation for medication administration. HWD or designee will report results at the quarterly QA meeting until compliance is established.
22VAC40-73-680-D
Based on record review, the facility failed to ensure that medications are administered in accordance with the physician’s or other prescriber's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing.
Evidence
  1. Resident #1’s September MAR was observed during the inspection. Resident #1’s PRN Acetaminophen order, dated 8/25/21, calls for the resident to receive two 325mg tablets every four hours as needed for pain or temperature. The MAR documents that Resident #1 was administered PRN Acetaminophen on 9/7/21 at 1:35 PM and 3:26 PM. Four hours did not elapse between the two administrations of Acetaminophen.
Plan of correction
Resident #1 had PRN order to receive two Acetaminophen 325mg tablets every four hours as needed for pain or temperature. On 09.07.2021 resident was administered PRN Acetaminophen at 1:35 PM and 3:26 PM. Four hours did not elapse between the two administrations of Acetaminophen. RMA's will receive remediation/refresher training on PRN order frequency. Health and Wellness Director or designee to conduct random audits of residents Medication Administration Records to ensure compliance in administration times of PRN medications. Health and Wellness Director or designee to discuss results of the random audits at the quarterly QA meetings until compliance is established.
22VAC40-73-680-B
Based on observation, the facility failed to ensure that medications remain in the pharmacy issued container, with the prescription label or direction label attached, until administered to the resident.
Evidence
  1. The first floor medication cart was observed during the inspection. An unlabeled insulin pen was observed in the medication cart. No information was attached to the pen to indicate which resident was to receive the medication or directions for its use.
Plan of correction
Immediate correction was taken at the time of the survey. Unlabeled insulin pen was identified as belonging to resident in apartment 101. Insulin pen was labeled accordingly on 10.22.2021. Health and Wellness Director or designee will conduct monthly random audits of first floor med cart to ensure compliance in medication labeling. Results of the audits will be reported at the quarterly QA meetings until compliance is established.
July 15, 2021Inspection1 violation
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS
Comments
A monitoring inspection was initiated on 7/15/21 and concluded on 7/27/21. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 40. The inspector emailed the administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed three resident records, three staff records, activities calendar, fire inspection, and health inspection submitted by the facility to ensure documentation was complete. The inspector conducted the on-site portion of the inspection on 7/21/21. An exit interview was conducted with the administrator on the date of inspection where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations were documented on the violation notice issued to the facility.
Violations
22VAC40-73-680-D
Based on record review, the facility failed to ensure that medications are administered in accordance with the physician's or other prescriber's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing.
Evidence
  1. Resident #1's June Medication Administration Record (MAR) was reviewed during the inspection. The MAR indicated that Resident #1's Acetaminophen 500mg wasn't administered on 6/9/21 (9 AM administration) or 6/10/21 (2 PM administration), as the facility was waiting for the pharmacy to deliver the medication. The MAR indicated that Resident #1's Gabapentin wasn't administered on 6/21/21 (8 PM administration), as the facility was unable to provide the medication. The MAR indicated that Resident #2's Med Pass 2.0 Supplement Drink was not available for administration on: 6/22/21 (8 PM administration), 6/23/21 (8 PM administration), 6/24/21 (8 AM administration and 8 PM administration), 6/25/21 (8 AM administration), 6/26/21 (8 PM administration), 6/28/21 (8 PM administration), 6/30/21 (8 PM administration). The MAR indicated that Resident #3's Visine wasn't administered on 6/3/21 (8 AM administration), as the facility was waiting for pharmacy to deliver the medication.
Plan of correction
Not published by VDSS.
February 24, 2021Inspection0 violations
Inspection dates
Feb. 24, 2021
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS63.2 General Provisions
Technical assistance
Documentation was discussed with the provider.
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 2/25/21 and concluded on 3/5/21. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 38. The inspector emailed the administrator a list of required items to complete the inspection. Facility reports, policies and inspections were reviewed. 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.