16
Inspections
On record
6
With violations
Visits that cited something
10
Clean visits
Nothing cited
16
Violations cited
Individual findings
15
Standards cited
Distinct rules
2
Complaint visits
Prompted by a complaint
Kensington Reston Owner LLC was inspected 16 times between January 13, 2021 and December 11, 2025 by the Virginia Department of Social Services. 6 of those visits ended with violations cited and 10 with none. Across that history VDSS cited 16 violations under 15 distinct standards. 2 inspections were prompted by a complaint.
A violation is a licensing standard - a rule in the Virginia Administrative Code - that the inspector found the facility was not meeting. Each is shown with the evidence the inspector recorded and, where VDSS publishes it, the facility's own plan of correction.
VDSS publishes inspections on a rolling window. 13 of these 16 are still on the state's site; the other 3 have since dropped off it and are reproduced from Assisted Living Magazine's archive of the original VDSS reports.
Provider Information
Facility type
Assisted Living Facility
License type
One Year
License expires
08/14/2026
Administrator
Llena Sta.Ana
Licensing inspector
Ishmel Paige
Inspector phone
(804) 963-0360
Approved for
Assisted Living · Non-Ambulatory · Special Care Unit
Inspection History
16Select an inspection to read the areas reviewed, the inspector's comments and any violations cited.
December 11, 2025Inspection
Inspection dates
12/11/2025, 12/17/2025
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY63.2 FACILITIES AND PROGRAMS
Technical assistance
Documentation was discussed with the provider.
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: 12/11/25 (Noon - 2:00 PM), 12/17/25 (4:40 PM - 5:30 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: 81
The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility.
Number of resident records reviewed: Six
Number of interviews conducted with residents: One
Number of interviews conducted with staff: Two
Observations by licensing inspector: Building and Grounds, Facility Documents
Additional Comments/Discussion:
An exit meeting was conducted.
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 Marshall Massenberg, Licensing Inspector at (804) 543-5188 or by email at Marshall.x.massenberg@dss.virginia.gov
Violations
22VAC40-73-460-D
Based on documentation, the facility did not ensure that supervision of resident schedules, care, and activities, including attention to specialized needs, such as prevention of falls and wandering from the premises.
Evidence
- Facility documentation indicated that Resident #1 eloped from the facility's special care unit on 11/28/25. Resident #1 was reported to have gotten on the elevator and exited the building. Resident #1 told Staff #1 that she wanted to go downstairs. Staff #1 reported that she believed that Resident #1 was a visitor. Staff #1 then provided access to the elevator and assistance with the facility's front door, both of which require a key fob or door code to operate. A facility picture shows Resident #1 leaving the building at approximately 4:02 PM. Facility documentation indicated that Resident #1 walked to a nearby store after leaving the facility. Collateral #1 reported speaking with Resident #1 and Collateral #2, after Resident #1 asked for assistance in making a telephone call. Collateral #2 informed Collateral #1 that the resident lives at the nearby assisted living facility. Collateral #2 reported receiving the phone call at approximately 4:08 PM. Collateral #2 then contacted the facility to provide information about Resident #1's whereabouts. Collateral #1 escorted Resident #1 back to the facility and they were observed on a facility camera at approximately 4:15 PM. Resident #1's record contained an assessment of serious cognitive impairment form, dated 10/16/25, that states that she has a serious cognitive impairment and that she is unable to recognize danger or protect her own safety and welfare. Resident #1's individualized service plan (ISP), dated 10/20/25, states that she has a "current or history of occasional disorientation to person, place, time or situation even in familiar surroundings and requires supervision and oversight for safety." The ISP goes on to state that Resident #1 has "poor short term memory," and that the "care team will provide direction and supervise behaviors to ensure safe decisions are being made."
Plan of correction
Immediate Actions Taken:
Resident was safely returned to the community and assessed for any injury or distress. No injuries or signs of distress were noted.
POA was notified immediately.
The Executive Director and nursing leadership were notified.
Care Partner was re-educated that the service elevator is for employee use only and that residents must always be supervised when outside secured areas.
The Elopement Prevention Bracelet (EPB) system was initiated; PCP was notified.
An investigation of the incident was initiated, including staff interviews.
Follow-Up Actions
The resident's safety check was increased from every 2 hours to hourly.
Conducted staff re-education on elopement prevention procedures, supervision expectations, and door security protocols.
Ongoing re-education will continue for all Care and Clinical staff to ensure consistent adherence to safety and supervision protocols.
Resident’s service plan will be updated to reflect current elopement risk, interventions and supervision needs.
For all new admissions, a "Move-In at a Glance" sheet will be prepared to ensure all team members are promptly informed and aligned on the new resident's profile and care needs.
The Move-In at a Glance sheet will include resident's photo. This document will be visibly posted in designated staff communication areas to ensure awareness across all shifts:
Care Partner (CP) Office
Staff Lounge
Crossover/Communication Board for the entire community.
Tips for Identifying Wandering Behavior will be posted inside the service elevator as a visual reminder for staff. These reminders will include signs such as restlessness, repeated attempts to leave, talking about "going home," and pacing near exits.
All neighborhood residents will be assessed by the Neighborhood Manager for elopement risk, and the elopement protocol will be initiated as needed.
Cameras will be place in every elevator.
Ongoing monitoring for compliance through spot checks and shift debriefs for the next 30 days.
Upon completion of the investigation, one team member was separated from employment, and the remaining team members were re-educated and counseled on elopement prevention procedures, supervision protocols, and adherence to community safety policies.
Resident will be encouraged to engage in jewelry-making crafts or watch jewelry-related TV programs to support interest, engagement, and individualized leisure opportunities.
The resident was assessed by the psychiatric provider following the incident. No new recommendations or medication changes were made. The POA was notified of the investigation findings, corrective actions, and outcomes. The resident remains stable, with no changes noted in physical or emotional condition following the incident.
The community will continue to provide ongoing staff education focused on recognizing wandering behaviors and applying timely, effective interventions during new hire orientation and annually thereafter.
July 15, 2025Inspection
Inspection dates
07/15/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE
Comments
Type of inspection: Renewal
Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7/15/25 (9:40 AM - 6:15 PM)
Number of residents present at the facility at the beginning of the inspection: 87
The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility.
Number of resident records reviewed: Six
Number of interviews conducted with residents: Three
Number of interviews conducted with staff: Four
Observations by licensing inspector: Meals, Activities, Medication Administration
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 Marshall Massenberg, Licensing Inspector at (804) 543-5188 or by email at Marshall.x.massenberg@dss.virginia.gov.
Violations
22VAC40-73-1090-A
Based on record review and interview, the facility did not ensure that prior to each resident's admission to the safe, secure environment, that the resident is assessed by an independent clinical psychologist as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare.
Evidence
- Resident #3's record was reviewed during the inspection. Resident #3 was admitted into the facility's safe, secure, environment on 4/11/25. Resident #3's record contained an Assessment of Serious Cognitive Impairment form, dated 4/9/25. The form indicates that Resident #3 does not have a serious cognitive impairment due to a primary psychiatric diagnosis of dementia. Facility staff confirmed that no other Assessments of Serious Cognitive impairment, for Resident #3, were present at the time of the record review.
Plan of correction
The Primary Care Provider was notified of the discrepancy. The resident's medical record was reviewed, and the "Assessment of Serious Cognitive Impairment" form was updated to accurately reflect the resident’s current diagnosis. A corrected and signed form has been placed in the resident’s chart.
A complete audit of all residents with a serious cognitive impairment diagnosis will be conducted to verify the accuracy of all corresponding assessment forms.
Any forms found to be inaccurate will be corrected in collaboration with the appropriate providers.
Re-education will be provided to the Memory Care Managers and the Admissions Department to ensure that the form is completed accurately.
Memory Care Managers will review all newly completed "Assessment of Serious Cognitive Impairment" forms for accuracy prior to filing them in the resident record.
Memory Care Managers will perform monthly audits to ensure that the Assessment of Serious Cognitive Impairment form has been completed accurately and in a timely manner.
The results of these audits will be submitted to the Executive Director (ED) and Assistant Executive Director (AED). Any discrepancies will be addressed immediately through follow-up with the provider.
Memory Care Managers will report audit outcomes and trends on the facility's monthly Quality Assurance Performance Improvement (QAPI) Program.
22VAC40-73-250-C
Based on record review, the facility did not ensure that each staff record contained documentation of qualifications for employment related to the staff person's
position, including any specified relevant information.
Evidence
- Staff #3 was observed administering medication during the inspection. Facility documents indicate that Staff #3 is a nurse that was hired on 10/8/24. Staff #3's nursing license was not present in the staff record, at the time of the inspection. Facility staff confirmed that Staff #3's nursing license was not in the staff member’s record, at the time of the inspection.
Plan of correction
The involved nurse will be terminated due to non-responsiveness. Multiple attempts were made to contact the nurse via text messages and phone calls; however, no responses were received.
A full audit of all licensed staff files was conducted to verify the presence of current licenses for all RNs, LPNs, and CNAs. All other licensed team members have a valid license on file.
The onboarding checklist and ongoing compliance process were updated to include mandatory verification and filing of current licenses before starting dates and upon renewal.
HR staff were re-educated on license verification procedures.
A license tracker has been implemented to monitor the receipt and expiration dates of all required licenses, ensuring they remain current. Ongoing monitoring and follow-up will be conducted by the Executive Director (ED) and Assistant Executive Director (AED).
The Human Resources Manager will conduct monthly audits of licensed staff.
Any discrepancies identified during the audit will be corrected immediately and reviewed with the personnel involved to prevent recurrence and reinforce accountability.
Any discrepancies identified during the audit will be corrected immediately and reviewed with the personnel involved.
Audit results and compliance status will be reported during monthly QAPI meetings.
22VAC40-73-680-M
Based on documentation and interview, the facility did not ensure that medications ordered for PRN administration were available and properly stored at the facility.
Evidence
- PRN Hydrocortisone Suppository and PRN Procto cream, ordered for Resident #8, were expired at the time of the medication cart inspection. The Hydrocortisone suppository package indicated that the medication expired in December 2024. The PRN Procto cream package indicated that it expired in June 2025. Facility staff confirmed that the medications were expired, at the time of the medication cart inspection. PRN Mupirocin ointment, ordered for Resident #8, was not present at the time of the medication cart inspection. Facility staff confirmed that the PRN Mupirocin ointment was not present, at the time of the medication cart inspection.
Plan of correction
1.The PRN medication was not reordered because the resident's biopsy site had already healed. The temporary unavailability of the medication did not result in any adverse effects to the resident.
2. A comprehensive review of all residents' current PRN medication orders will be conducted by DON/ADON. This review will include a comparison of prescribed PRN medications with those currently available to ensure that:
All active PRN orders are up-to-date and clinically appropriate;
and Medications are available and accessible for all active PRN orders.
3. Re-education has been provided to all licensed staff on the importance of:
- PRN medication availability
- Verifying medication availability upon receipt of new orders.
- Reporting any medication shortages immediately to DON, ADON and pharmacy.
4. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) will perform:
- Weekly audits of PRN medication availability on all medication carts for 90 days.
- Biweekly audits for the following 90 days, and
- Monthly audits thereafter to ensure sustained compliance.
5. Results of these audits will be submitted to the Executive Director (ED) and Assistant Executive Director (AED) for ongoing oversight.
6. Any discrepancies or non-compliance will be addressed immediately through staff re-education and corrective coaching. Additional training will be conducted as needed to reinforce proper procedures for PRN medication management.
7. The DON or ADON will report audit outcomes and trends on the facility’s monthly Quality Assurance Performance Improvement (QAPI) Program.
22VAC40-73-640-A
Based on documentation and interview, the facility did not ensure that the medication management plan was implemented to ensure that each resident’s prescription medications
are filled and refilled in a timely manner to avoid missed dosages.
Evidence
- Resident #7's July medication administration record (MAR) was observed during the inspection. Resident #7's Clonidine patch (ordered 2/17/25) was documented as not administered on 7/7/25. The MAR stated that the drug/item was not administered because it was "unavailable."
Plan of correction
1. The resident's physician was notified of the missed dose, and no adverse effects were observed. The missed dose of the medication did not have any adverse effect on the resident involved.
2. The missed dose was documented in the resident’s chart, and appropriate follow-up was conducted.
3. All medication carts and storage areas were audited to ensure that all ordered routine medications were present and in stock.
4. Nursing staff received re-education on the importance of:
- Verifying medication availability upon receipt of new orders.
- Reporting any medication shortages immediately to the DON, ADON and pharmacy.
5. The Director of Nursing (DON) or designee will perform:
- Weekly audits of MARs and medication availability for the next 90 days
- Biweekly audits for the following 90 days, and
- Monthly audits thereafter to ensure sustained compliance.
6. Results of these audits will be submitted to the Executive Director (ED) and Assistant Executive Director (AED) for ongoing oversight.
7. Any discrepancies or non-compliance will be addressed immediately through staff re-education and corrective coaching.
8. The DON or ADON will report audit outcomes and trends on the facility's monthly Quality Assurance Performance Improvement (QAPI) Program.
May 14, 2025Inspection
Inspection dates
05/14/2025, 06/30/2025
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring
Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 5/14/25, 6/30/25
Self-reported incidents were received by VDSS Division of Licensing on 4/3/25, 4/6/25, 4/19/25, 4/25/25, 5/2/25 regarding allegations in the areas(s) of: Resident Care and Related Services
The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility.
Number of resident records reviewed: Six
Number of interviews conducted with residents: One
Number of interviews conducted with staff: Two
Observations by licensing inspector: Meal, Activity
An exit meeting was conducted
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 Marshall Massenberg, Licensing Inspector at (804) 543-5188 or by email at Marshall.x.massenberg@dss.virginia.gov
Violations
22VAC40-73-550-G
Based on record review, the facility did not ensure that the written acknowledgement of an annual review of resident rights is retained in each staff person's record.
Evidence
- The record for Staff #1, hired on 3/4/24, was observed during the inspection. Staff #1's record contained documentation of an initial review of resident rights in March 2024. No documentation was provided, during the inspection, to indicate that Staff #1 has completed a review of resident rights since March 2024. Facility staff confirmed that additional resident rights training, was not present in the record for Staff #1.
Plan of correction
The employee who missed the training has completed the Resident Rights in-service on July 1st. The training was conducted one-on-one and documented in the employee's training file.
A comprehensive audit of staff training records has been completed to identify any team members who may have missed the required Resident Rights in-service. All individuals found to be non-compliant will be notified and are required to complete the training no later than July 29th.
Monthly audits of training records will be conducted by the HR Coordinator for a period of 4 quarters. If full compliance is consistently achieved throughout this period, the audits will be discontinued thereafter.
Audit results will be submitted to department leaders for review and appropriate follow-up. Any instance of missed or overdue training will be reported to the Executive Director, along with a documented make-up plan.
Training compliance trends and outcomes will be reviewed quarterly during QAPI (Quality Assurance/Performance Improvement) meetings to support continuous improvement.
December 18, 2024Inspection
Inspection dates
12/18/2024; 02/25/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Technical assistance
Documentation was discussed with the provider.
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: 12/18/2024 (4:40 PM - 5:50 PM), 2/25/2025 (2:20 PM - 3:00 PM)
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
Self-reported incidents were received by the VDSS Division of Licensing in the area(s) of: Resident Care and Related Services.
Number of resident records reviewed: Three
Number of interviews conducted with residents: One
Number of interviews conducted with staff: Two
The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary.
The department's inspection findings are subject to public disclosure.
Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility.
For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov
Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (804) 543-5188 or by email at marshall.x.massenberg@dss.virginia.gov.
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
November 18, 2024Inspection
Inspection dates
11/18/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Technical assistance
Documentation was discussed with the provider.
Comments
Type of inspection: Monitoring
Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/18/2024 (3:10 PM - 4:10 PM)
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
Self-reported incidents were received by the VDSS Division of Licensing on 9/14/24 and 10/10/24 in the area(s) of: Resident Care and Related Services.
Number of resident records reviewed: Two
Number of interviews conducted with residents: None
Number of interviews conducted with staff: One
The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary.
The department's inspection findings are subject to public disclosure.
Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility.
For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov
Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (804) 543-5188 or by email at marshall.x.massenberg@dss.virginia.gov.
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
November 18, 2024Complaint survey
Inspection dates
11/18/2024
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES
Comments
Type of inspection: Complaint
Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/18/2024 (3:10 PM - 4:10 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 10/09/2024 regarding allegations in the area(s) of: Administration and Administrative Services
Number of residents present at the facility at the beginning of the inspection: 91
Number of resident records reviewed: None
Number of interviews conducted with residents: None
Number of interviews conducted with staff: One
Observations by licensing inspector: Staff Records, Infection Control Policy, Facility supplies
An exit meeting was conducted to review the inspection findings.
The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary.
The department's inspection findings are subject to public disclosure.
Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility.
For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov
Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (804) 543-5188 or by email at marshall.x.massenberg@dss.virginia.gov.
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
August 23, 2024Inspection
Inspection dates
08/23/2024
Areas reviewed
22VAC40-73 BUILDING AND GROUNDS
Technical assistance
Documentation was discussed with the provider.
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: 8/23/24 (9:00 AM - 10:55 AM)
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
An unannounced other inspection was conducted on 8/23/24. Resident rooms were observed and measurements obtained. No violations were cited during the inspection.
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 (804) 543-5188 or by email at marshall.x.massenberg@dss.virginia.gov.
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
August 23, 2024Inspection
Inspection dates
08/23/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring
Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 08/23/2024 (9:00 AM - 10:55 AM)
The Acknowledgement of inspection form was signed and left at the facility for each date of the inspection.
A self-reported incident was received by VDSS Division of Licensing on 8/10/24 regarding an allegation in the area of: Resident Care and Related Services
The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility.
Number of resident records reviewed: one
Number of interviews conducted with residents: none
Number of interviews with staff: Two
Observations by licensing inspector: Facility documentation, training information
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 (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 at the facility.
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 (804) 543-5188 or by email at marshall.x.massenberg@dss.virginia.gov.
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
August 5, 2024Inspection
Inspection dates
08/05/2024, 08/06/2024
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 ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULT63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS
Technical assistance
Documentation was discussed with the provider.
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: 8/5/24 (8:14 AM - 6:15 PM), 8/6/24 (8:45 AM - 6:40 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: 88
The licensing inspector completed a tour of the physical plant that included the building and grounds at the facility.
Number of resident records reviewed: 10
Number of staff records reviewed: 5
Number of interviews conducted with residents 4
Observations by licensing inspector: Building and grounds, meals, medication administration, activities, background checks of new staff (hired since the last inspection)
Additional Comments/Discussion:
An exit meeting was 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 to the facility to compliance and maintain future compliance with 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 (804) 543-5188 or by email at marshall.x.massenberg@dss.virginia.gov.
Violations
22VAC40-73-310-M
Based on a review ten resident records, it was determined that the facility did not ensure that the hospice provider agreement includes all of the required information.
Evidence
- The record for Resident #9 contained a hospice agreement between the facility and Company A that was not signed by a facility representative, or a representative of Company A.
Plan of correction
1. Hospice contract will be corrected and/or amended to include the required information and will be properly executed and signed by 10/31/2024.
2. Additional/other hospice contracts will be reviewed to ensure all the required information is included.
3. Corrective action will be initiated for any variance, and findings will be reported to the Executive Director.
4. Subsequently executed hospice contracts implemented will be double-checked by company partners to ensure they include all required elements.
5. Person Responsible: Executive Director or designee
22VAC40-73-220-B
Based on a review of documentation, it was determined that the facility did not ensure that
all of the required information is present for private duty personnel, who are not employees of a licensed home care organization.
Evidence
- Private duty aide documentation was reviewed during the inspection. No criminal history record report or qualifications were included in the files for the private duty aides for Resident #12 or Resident #13.
Plan of correction
1. Files will be reviewed for two private duty personnel who are not employees of licensed home care organizations to ensure required information is on file. Corrective action to ensure required information is present and on-file will be completed by 09/30/24.
2. A 100% audit of files for private duty personnel who are not employees of a licensed home care organization will be completed to ensure the required information is present and on-file. Corrective action will be initiated for any variances, and findings will be reported to the Executive Director.
3. Subsequently executed private duty personnel agreements with those not employed by a licensed home care organization will be double-checked by Executive Director or designee to ensure the required information is present and on-file.
4. Person Responsible: Executive Director or designee
22VAC40-73-660-A-1
Based on observation and a resident record review, it was determined by that the facility did
not ensure that the medication storage area remains locked.
Evidence
- The facility's second-floor treatment cart was observed to be unlocked and unattended, during a facility tour at approximately 8:58 AM on 8/5/24.
- The second-floor treatment cart contained Resident #10's Ketoconazole cream (ordered 7/11/24).
- Staff #6 conducted the tour, and locked the cart after being informed that the cart was unlocked.
Plan of correction
1. Medication storage cart (treatment cart) was locked during inspection on 8.5.24.
2. Additional treatment carts inspected on 8.5.24 were deemed to be locked.
3. Education to be provided to nursing team members on protocols for locking treatment carts.
4. A 100% audit of treatment carts to ensure proper locking will be completed by a licensed nurse or designee, daily for 4 weeks. Corrective action will be initiated for any variance, and findings will be reported to the Executive Director.
5. Person Responsible: Executive Director or designee
22VAC40-73-680-E
Based on a review of ten resident records, it was determined that the facility did not ensure
that medical procedures ordered by a physician shall be provided according to his instructions and documented.
Evidence
- Resident #4's record contained an order for Metoprolol Succinate 50mg to be administered daily. The order states "hold for systolic blood pressure <110 or Heart Rate <55."
- Resident #4's July and August MARs only contained documentation of the resident's vital signs on the first day of the month. No records were provided, during the inspection, to verify that Resident #4's blood pressure was taken before each administration of her Metoprolol Succinate.
Plan of correction
1. The data entry field for the vital sign data to be noted in the electronic medication administration record was corrected for Resident #4 on 8/5/24.
2. A 100% audit of residents with orders for blood pressure medication with parameters was completed to ensure that the data entry field for the vital sign data was visible in the electronic medication record. Corrective actions have been initiated for any variances, and findings were reported to the Executive Director.
3. Education will be provided to the nursing team regarding required steps for medication order approvals for residents with medications with parameters.
4. A 100% audit of residents with orders for blood pressure medication with parameters will be completed monthly for 3 months to ensure that the data entry field for the vital sign data is visible in the electronic medication record.
5. Person Responsible: Executive Director or designee
22VAC40-73-830-E
Based on a review of documentation and interview, it was determined that the facility did not ensure that a written response is provided to the resident council regarding recommendations about problems/concerns.
Evidence
- The facility's resident council binder was observed during the inspection. Notes from the 6/25/24 resident council meeting indicated that resident recommendations were provided regarding staff entry into resident rooms, and for regular visual sweeps of the dining room.
- The most recent resident council meeting occurred on 7/30/24. No written response to the resident recommendations from the previous meeting on 6/25/24 had been provided to the council, before the 7/30/24 meeting.
- Staff #6 confirmed that a written response had not been provided to the council regarding the resident recommendations.
Plan of correction
1. Written response to problems/concerns raised during the last resident council meeting (July) will be provided to the council prior to the next Resident Council meeting (Aug).
2. Education to be provided to appropriate team members on the protocol for resident council communication by 08/31/24.
3. Process changes include completion of Resident Council Minutes within one week of the meeting; Minutes to be reviewed by the Executive Director to ensure resolutions are documented; Assisted Living Manager or designee to ensure written responses are provided to residents prior to the following months’ meeting.
4. A monthly audit will be conducted by Executive Director or designee to ensure resolutions are provided to residents in advance of each meeting. Corrective action will be initiated for any variance and findings will be reported to the Executive Director.
5. Person Responsible: Executive Director or designee
22VAC40-73-430-H-1
Based on a review of ten resident records and interview, it was determined that the facility did
not ensure that a discharge statement is provided to the resident, at the time of discharge.
Evidence
- Resident #11's discharge documentation was reviewed during the inspection. Resident notes indicate that Resident #11 never returned to the facility after a hospitalization on 3/16/24.
- Resident #11's discharge statement indicates the resident’s contact person was notified about the discharge verbally on 3/16/24. No information was included on the discharge form, to indicate when and to whom the discharge statement was provided.
- Staff #6 confirmed that discharge notification was only provided verbally.
Plan of correction
1. No current residents are being actively discharged at this time.
2. Education to be provided on the protocol for ensuring discharge statements are provided, in writing, to resident responsible parties, within the required timeframe
3. Discharge statements from the past three months to be audited to ensure protocol was followed for residents who may have been discharged from the community due to a circumstance or condition necessitating a discharge. Corrective action will be initiated for any variance, and findings will be reported to the Executive Director.
4. Future discharge statements relating to emergency discharges will be double-checked by company partners or designee to ensure they are provided to residents’ responsible parties within the required timeframe.
5. Person Responsible: Executive Director or designee
22VAC40-73-450-C
Based on a review of ten resident records, it was determined that the facility did not ensure
that the comprehensive individualized service plan (ISP) includes identified needs and dates
based upon the uniform assessment instrument (UAI).
Evidence
- Resident #1's UAI, dated 2/4/24, states hat she needs mechanical assistance and supervision for bathing. Resident #1's ISP, dated 3/2/24, states that she needs physical assistance for bathing.
- Resident #6's UAI, dated 6/6/24, states that he needs mechanical and physical assistance for toileting. Resident #6's ISP, dated 6/6/24, states that the resident requires one person assistance in managing bowel and/or bladder care.
- Resident #7's UAI, dated 4/16/24, states that the resident needs no assistance for bathing, dressing, toileting, or transferring. Resident #7's ISP, dated 4/16/24, states that the resident needs physical assistance for bathing, dressing, toileting, and transferring.
Plan of correction
1. A review of resident #1, #6, and #7's Individualized Service Plans took place. Corrections have been made to ensure identified needs are based upon the Uniform Assessment Instrument.
2. A 10% audit of residents' Individualized Service Plans and UAIs will be conducted by the Executive Director or designee, monthly for three months, to ensure identified needs are based upon the Uniform Assessment Instrument. Corrective action will be initiated for any variances and findings will be reported to the Executive Director.
3. Executive Director or designee to educate designated team members on practices related to ensuring the identified needs on the Individualized Service Plan are based upon the Uniform Assessment Instrument.
4. Person Responsible: Executive Director or designee
22VAC40-73-210-B
Based on a review of six staff records, it was determined that the facility did not ensure that
all direct care staff attend at least 18 hours of training annually. EXCEPTION: Direct care staff who are licensed health care professionals orcertified nurse aides shall attend at least 12
hours of annual training.
Evidence
- The record for Staff #2, hired 8/24/15 as a LPN. Staff #6 reported that Staff #2 was originally hired at a sister facility, and that Staff #2 transferred to this facility on 10/25/22.
- Facility training documents indicate that Staff #2 attended 5.5 hours of training within the annual review period of 10/25/22 through 10/25/23.
Plan of correction
1. Staff #2 has completed all required training for the current year.
2. Education to be provided to Staff #2 on expectations related to the completion of annual training.
3. A 100% audit of annual training for team members will be completed to ensure completion of training modules for the current year. Corrective action will be initiated for any variances and findings will be reported to the Executive Director.
4. Person Responsible: Executive Director or designee
May 2, 2024Complaint survey
Inspection dates
05/02/2024
Areas reviewed
Building and GroundsEmergency PreparednessAdditional Requirements for Facilities that Care for Adults with Cognitive Impairments
Comments
Type of inspection: Complaint
Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/02/2024
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: 88
The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility.
Number of resident records reviewed: 0
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 1
Observations by licensing inspector: Licensing Inspector observed residents congregating throughout the facility and participating in activity programs.
Additional Comments/Discussion:
An exit meeting will be conducted to review the inspection findings.
The evidence gathered during the investigation did not support the allegation 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 Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov
Violations
No violations cited
The inspector documented no violation of standards at this inspection.