Sunrise of Falls Church — Virginia Inspection Report

Inspections

On record

With violations

Visits that cited something

Clean visits

Nothing cited

Violations cited

Individual findings

Standards cited

Distinct rules

Complaint visits

Prompted by a complaint

Sunrise of Falls Church was inspected 15 times between February 18, 2021 and November 24, 2025 by the Virginia Department of Social Services. 5 of those visits ended with violations cited and 10 with none. Across that history VDSS cited 11 violations under 10 distinct standards. 5 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. 14 of these 15 are still on the state's site; the other 1 has since dropped off it and is 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

12/31/2026

Administrator

Stephen Cuthbertson

Licensing inspector

Marshall Massenberg

Inspector phone

(804) 543-5188

Approved for

Assisted Living · Non-Ambulatory · Special Care Unit

Inspection History

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

November 24, 2025Inspection2 violations

Inspection dates

11/24/2025

Areas reviewed

22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND 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

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: 11/24/25 (8:30 AM - 2:50 PM) Number of residents present at the facility at the beginning of the inspection: 49 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: Four Number of interviews conducted with residents: Three Number of interviews conducted with staff: Four Observations by licensing inspector: Meals, Activities, Medication Administration 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

22VAC40-73-640-A

Based on documentation and interview, the facility did not implement a medication management plan to prevent the use of outdated medications and ensure that medications are filled and refilled in a timely manner to avoid missed dosages.

Evidence

Resident #1's October and November medication administration records (MAR) were reviewed during the inspection. Resident #1's MAR states that her Lidocaine patch, ordered 9/29/25, was pending delivery on 11/21/25, 11/22/25 and 11/23/25. Resident #1's Lidocaine patch was not present at the time of the medication cart inspection. The facility's medication management policy states that medications must be delivered to the community at least five days prior to the end of the current supply. Facility staff confirmed that Resident #1's Lidocaine patch was not present, at the time of the inspection.

Plan of correction

A. With respect to the specific resident cited: Resident #1 did not have any negative outcome and medication available for administration. The resident physician was informed, and no new directions were provided. B. With respect to how the facility will identify residents with the potential for the identified concerns: The Resident Care Director (RCD) and the clinical team audited the medication orders and medication carts to confirm that medications prescribed were available per doctor's orders. Issues identified were resolved. The Wellness Nurses and Medication Care Managers (MCMs) were re-educated by the RCD regarding the process on reordering medication and what to do when a medication isn't available from the pharmacy. C. With respect to what systemic measures have been put into place to address the stated concern: The RCD or designee will continue to audit physician orders for 3 months to confirm orders are present in the medication cart. Issues that may be identified will be addressed and resolved and refresher training as needed. The results of the audits will be presented by the RCD or wellness designee at Quality Assurance and Performance Improvement (QAPI) meeting for 3 months. During and at the end of the 3 months, the QAPI Committee will evaluate the results of the medication orders and determine if additional focus or action is warranted. D. With respect to how the plan of correction will be monitored: The Executive Director, or designee is responsible for confirming implementation and ongoing compliance components of this Plan of Correction and addressing and resolving variances that may occur.

22VAC40-73-680-M

Based on record review and interview, the facility did not ensure that medications ordered for PRN administration are available and properly stored at the facility.

Evidence

Resident #1's record contained a PRN order, dated 8/20/25, for Albulterol Sulfate Nebulization solution. Resident #1's PRN Albuterol Sulfate Nebulization Solution was not present at the time of the medication cart inspection. Facility staff confirmed that Resident #1's Albuterol Sulfate Nebulization Solution was not present at the time of the medication cart inspection.

Plan of correction

A.) With respect to the specific resident/situation cited: Resident #1 did not have any negative outcome and medication available for administration. The resident physician was informed, and no new directions was provided B. With respect to how the facility will identify residents with the potential for the identified concerns: The Resident Care Director (RCD) and the clinical team audited the medication orders and medication carts to confirm that medications prescribed were available per doctor's orders. Issues identified were resolved. The Wellness Nurses and Medication Care Managers (MCMs) were re-educated by the RCD regarding the process on reordering medication and what to do when a medication isn't available from the pharmacy. C. With respect to what systemic measures have been put into place to address the stated concern: The RCD or designee will continue to audit physician orders for 3 months to confirm orders are present in the medication cart. Issues that may be identified will be addressed and resolved and refresher training initiated as needed. The results of the audits will be presented by the RCD or wellness designee at Quality Assurance and Performance Improvement (QAPI) meeting for 3 months. During and at the end of the 3 months, the QAPI Committee will evaluate the results of the medication orders and determine if additional focus or action is warranted. D. With respect to how the plan of correction will be monitored: The Executive Director or designee is responsible for confirming implementation and ongoing compliance components of this Plan of Correction and addressing and resolving variances that may occur.

May 28, 2025Inspection5 violations

Inspection dates

05/28/2025, 06/03/2025

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 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: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 5/28/25 (9:40 AM - 4:50 PM), 6/3/25 (12:00 PM - 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: 47 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: Four Number of interviews conducted with residents: Three Number of interviews conducted with staff: Four Observations by licensing inspector: Meals, Activities, Medication Administration 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 Marshall Massenberg, Licensing Inspector at (804) 543-5188 or by email at Marshall.x.massenberg@dss.virginia.gov.

Violations

22VAC40-90-60-B

Based on record review and interview, the facility did not ensure that the criminal background check, for terminated staff members, remains in the facility fles for a year after the staff member's termination.

Evidence

Background checks of new staff, hired since April 2024, were reviewed during the inspection. Background checks for Staff #'s 4-10 were not available for review, during the inspection. Facility documentation indicated that Staff #'s 4-10 had been terminated after May 2024. Facility staff confirmed that the background checks for Staff #'s 4-10 were not present at the facility, during the inspection.

Plan of correction

Executive Director submitted formal request for Staff #4-10 employee files be returned to community immediately. The Human Resource Coordinator will complete an audit of terminated staff files from the past 12 months to verify that Criminal Background Checks were completed and on file at the time of their employment. This review will help identify any gaps or trends in compliance related to staff who are no longer part of the community. Any areas identified will be addressed through corrective action or process improvement as appropriate. The Human Resource Coordinator and/or designee will audit terminated staff files on a monthly basis for three months, focusing on individuals who remained in the community for at least one year after termination, to confirm that Criminal Background Checks were completed and on file during their employment. Any gaps identified will prompt a review of hiring and recordkeeping practices, and corrective action will be implemented to ensure that Criminal Background Checks are consistently obtained and documented for all applicable staff. During the Quality Assurance and Performance Improvement (QAPI) meeting and up to 3 months following the implementation of the Plan of Correction (POC), the Executive Director will review the POC and the results of the audit with the HRC. The Executive Director or designee is responsible for implementation and ongoing compliance with the components of this Plan of Correction and for addressing and resolving variances that may occur.

22VAC40-73-410-A

Based on record review, the facility did not ensure that each resident record contained a signed acknowledgment of the resident's orientation to the facility.

Evidence

Three out of four resident records (Residents #1, #3, and #4) did not contain a signed acknowledgment that the resident received an orientation to the facility.

Plan of correction

Residents #1, #3 and #4 received immediate orientation to the building checking off and signing appropriate acknowledgement of orientation with Resident Care Coordinator. The Residential Care Coordinator conducted immediate audit of Administration Record for all current residents confirm record of signed acknowledgement of the resident's orientation to the facility. The Resident Care Coordinator or designee will continue to conduct Resident Admin file audits for any new move in residents each month, every month, for 3 months to verify that Orientation Acknowledgement Forms were completed within the correct timeframe. Issues that may be identified during these audits will be addressed and resolved when possible. At the end of the 3 months, the QAPI committee will evaluate the results of the resident file audits to determine if additional focus or action is warranted. The Executive Director is responsible for implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving and variances that may occur.

22VAC40-73-680-D

Based on observation and documentation, the facility did not ensure that medications were administered in accordance with the physician’s instructions.

Evidence

Resident #5's morning medication administration was observed during the inspection. The resident's medications were placed in a pill cup and the medication cart was locked. Before the medications were administered to Resident #5, the LI inquired about the resident's Quetiapine and Trazodone. Two 150mg tablets of Quetiapine and one 50mg tablet of Trazodone were included in Resident #5's pill cup. Resident #5's medication administration record (MAR) called for him to receive one 150mg tablet of Quetiapine and two 50mg tablets of Trazodone, during the morning medication administration.

Plan of correction

Resident #5 did not have any negative outcomes and both medications, Trazadone and Quetiapine, are available for administration. The Resident Care Director conducted eMAR to medication cart audit to confirm medications were available per physician's order. Refresher training with medication care managers and nurses was conducted by the Resident Care Coordinator regarding procedures to follow in order to administer medications in accordance with the physician's order. The Resident Care Director or Designee conducted an audit of residents with specific order parameter to verify the medication are administered according to MD orders. The Resident Care Director or designee will continue to conduct unannounced medication pass observations weekly for 3 months to confirm medications are given within the prescribed orders. Issues that may be identified will be addressed. During the Quality Assurance and Performance Improvement (QAPI) meeting and up to 3 months following the implementation of the Plan of Correction (POC), the Executive Director will review the POC and the results of the audit with the Department Heads. Additional improvement plans will be developed and implemented as necessary, including training to correct any deficient practices.

22VAC40-73-260-A

Based on record review, the facility did not ensure that each direct care staff member maintains current certification in first aid.

Evidence

Staff #2's record was reviewed during the inspection. Staff #2 was hired in December 2014 as a care manager. Staff #2's record contained first aid certification that expired in February 2025, at the time of the record review.

Plan of correction

Staff #2 completed first aid training, on 5/30/2025, the certificate was provided to Surveyor on day of training completion. The Human Resource Coordinator will complete an audit of First Aid training records for staff member hired in the past 12 month to verify that staff have a current first aid certification. Any areas identified will be corrected. The HRC and/or designee will audit new team members files monthly for three months to confirm that new team members have a current first aid certification, for staff identified first aid certification will be completed within 60 days of employment and required documentation placed in file. During the Quality Assurance and Performance Improvement (QAPI) meeting and up to 3 months following the implementation of the Plan of Correction (POC), the Executive Director will review the POC and the results of the audit with the Department Heads. Additional improvement plans will be developed and implemented as necessary, including training in order to correct any deficient practices. The Executive Director or designee is responsible for implementation and ongoing compliance with the components of this Plan of Correction and for addressing and resolving variances that may occur.

22VAC40-73-250-D

Based on record review, the facility did not ensure that each staff member annually submits the results of a tuberculosis risk assessment, documenting that the individual is free of tuberculosis in a communicable form.

Evidence

Staff #2's record was reviewed during the inspection. The most recent tuberculosis risk assessment, included in Staff #2's record, was completed in April 2024. Facility staff confirmed that the most recent tuberculosis risk assessment, included in Staff #2's record, was more than a year old.

Plan of correction

Staff member #2 completed annual tuberculosis risk assessment and documentation are in employees' file. Human Resource Coordinator completed an audit of TM files not surveyed, to verify compliance of initial and annual Tuberculosis risk assessment are completed within the required timeframe. HRC to complete a quarterly audit of TM files for TB risk assessments for 6 months. Issues identified will be resolved. The Executive Director or designee is responsible for confirming implementation and ongoing compliance components of this Plan of Correction and addressing and resolving variances that may occur.

April 17, 2024Inspection0 violations

Inspection dates

04/17/2024

Areas reviewed

Administration and Administrative ServicesPersonnelStaffing and SupervisionAdmission, Retention and Discharge of ResidentsResident Care and Related ServicesResident Accommodations and Related ProvisionsBuilding and GroundsEmergency PreparednessAdditional Requirements for Facilities that Care for Adults with Cognitive ImpairmentsBackground Checks for Assisted Living FacilitiesSworn Statement

Comments

Type of inspection: Monitoring Inspection Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 04/17/2024 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: 48 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 4 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 4 Observations by licensing inspector: LI observed residents participating in activity programs and eating lunch. This LI also observed a medication administration pass. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact 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.

January 4, 2024Complaint survey0 violations

Inspection dates

01/04/2024

Areas reviewed

Admission, Retention and Discharge of ResidentsResident Care and Related Services

Comments

Date of Inspection: January 5, 2024 Type of Inspection: Complaint inspection Standards Investigated: As stated above Complaint was determined not valid If you have any questions, please do not hesitate to contact me at (540) 680-9469 or sarah.pearson@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection, you can find the information on the internet: www.dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

July 13, 2023Inspection0 violations

Inspection dates

07/13/2023

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: LI entered the facility at 9:40 am on 7/13/2023 and exited at 1:05 pm on s7/13/2023. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 3/14/2023, 3/19/2023,4/18/2023, 4/25/2023,5/5/2023, and 6/14/2023 regarding allegations in the area(s) of resident care and related services. Number of residents present at the facility at the beginning of the inspection: 50 Number of resident records reviewed: 6 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the 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 Jamie Eddy, Licensing Inspector at (703) 479-5247 or by email at jamie.eddy@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

December 7, 2022Complaint survey0 violations

Inspection dates

12/07/2022

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: LI entered the facility at 10:13 am on 12/7/2022 and exited at 2:40 pm on 12/7/2022. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 11/28/2022 and 11/30/2022, regarding allegations in the area(s) of resident care, staffing quantity, and admission, retention, and discharge of residents. Number of residents present at the facility at the beginning of the inspection: 41 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: 4 Number of interviews conducted with staff: 1 Observations by licensing inspector: LI observed residents eating lunch. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jamie Eddy, Licensing Inspector at (703) 479-5247 or by email at jamie.eddy@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

December 7, 2022Complaint survey0 violations

Inspection dates

12/07/2022

Areas reviewed

22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICESS

Comments

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

November 17, 2022Inspection0 violations

Inspection dates

11/17/2022,11/18/2022

Areas reviewed

22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE 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: LI entered the facility at 8:45 am on 11/17/2022 and exited at 3:30 pm on 11/17/2022. LI entered the facility at 10:15 am on 11/18/2022 and exited at 1:05 pm on 11/18/2022. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 42 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 4 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 0 Observations by licensing inspector: LI observed medication administration. LI observed residents engaging in activities and eating lunch. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jamie Eddy, Licensing Inspector at (703) 479-5247 or by email at jamie.eddy@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

December 8, 2021Inspection0 violations

Inspection dates

12/08/2021,12/20/2021

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

Licensing Inspector (LI) conducted unannounced inspection that began on 12/8/2021 and ended on 12/20/2021, in response to a self-reported incident. LI reviewed resident records and conducted interview with administration. No violations were cited.

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

December 8, 2021Complaint survey0 violations

Inspection dates

12/08/2021,12/14/2021

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

Licensing Inspector (LI) conducted unannounced complaint investigation that began on 12/8/2021 and concluded on 12/14/2021 regarding resident care. LI reviewed resident record, interviewed staff and resident. Complaint regarding resident care is deemed not valid as a preponderance of evidence gathered during the investigation did not support the allegations. Thank you for your cooperation and if you have any questions please call 703-479-5247 or contact me via email at jamie.eddy@dss.virginia.gov.

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

December 2, 2021Inspection2 violations

Inspection dates

12/02/2021,12/08/2021

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

On 12/2/2021 Licensing Inspector (LI) conducted unannounced focused monitoring visit to ensure correction of violations cited during 10/26/2021 renewal study. Medication observation was conducted, six resident records were reviewed and interviews with staff were conducted. . All previous violations were found to have been corrected. Violations of other standards were cited and reviewed with the administrator. 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 standard(s), 2) measures to prevent the non-compliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s). Thank you for your cooperation and if you have any questions please call 703-479-5247 or contact me via e-mail at jamie.eddy@dss.virginia.gov.

Violations

22VAC40-73-650-C

Based upon a review of records and interviews, the facility failed to ensure that physician's or other prescriber's oral orders shall: be reviewed and signed by a physician or other prescriber within 14 days.

Evidence

According to the electronic chart for Resident #2, a verbal physician's order for Ipratropium-Albuterol Solution 0.5-2.5 (3) mg/3mL: 3ml inhale orally every six hours as needed for shortness of breath or wheezing via nebulizer was received on 11/03/2021. A signed physician's order was not found in the record of Resident #1. Interview with Staff #2 revealed that the written physician's order was still waiting for the physician to review and sign as of 12/2/2021 at approximately 1:00pm.

Plan of correction

A verbal physician order for Ipratropium-Albuterol Solution for Resident #2 was signed and received on 12/3/2021. The Resident Care Director (RCD), Wellness Nurse (WN) or designee audited resident records to confirm residents have verbal orders signed within 14 days of being taken. The RCD will conduct refresher training with the Wellness Nurses (WNs) regarding the process for obtaining a signature from a physician on a verbal order within the appropriate time frame. The RCD or designee will continue to audit verbal physician orders for 3 month to confirm signatures are received within the correct time frame. Issues that may be identified will be addressed and resolved and refresher training initiated as needed. The RCD or designee will present the results of the verbal order audit to the Quality Assurance and Performance Improvement Committee (AQPI) monthly for 3 months. During and at the end of the 3 months, the QAPI Committee will evaluate the results and determine if additional focus or action is warranted. The Executive Director (ED) or designee is responsible for confirming the implementation and ongoing compliance components of this Plan of Correction and addressing and resolving variances that may occur.

22VAC40-73-650-A

Based upon a review of documents and interviews the facility failed to ensure that no medication, dietary supplement, diet, medical procedure, or treatment shall be started, changed, or discontinued by the facility without a valid order from a physician or other prescriber. Medications include prescription, over-the-counter, and sample medications.

Evidence

According to the Medication Administration Record (MAR) and observation made by Licensing Inspector, Resident #1 was administered nasal spray at approximately 9:42 am on 12/2/2021. The MAR indicates that the start date for the nasal spray was 10/05/2021. The date of admission to the facility for Resident #1 is documented in the resident's record as 10/05/2021. A physician's order for the nasal spray was not located in the record of Resident #1. Interview with Staff #2 confirmed that the facility does not have a valid physician's order for the nasal spray.

Plan of correction

Resident #1 experienced no negative outcomes as a result of nasal spray medication administered on 12/2/2021. A valid signed order for nasal spray for Resident #1 was received on 12/2/2021. The Resident Care Director (RCD), Wellness Nurse (WN) or designee audited resident records to confirm residents have valid signed orders for medications. The RCD conducted refresher training with the Wellness Nurses (WNs) regarding the importance of valid signed medication orders and reporting issues with orders to the RCD so that they can be addressed timely by the clinical team, pharmacy, and physician. The RCD or designee will continue to audit physician orders for 3 months to confirm orders are present in the resident's chart. Issues that may be identified will be addressed and resolved and refresher training initiated as needed. The results of the audits will be presented by the RCD or wellness designee at Quality Assurance and Performance Improvement (QAPI) meeting for 3 months. During and at the end of the 3 months the QAPI Committee will evaluate the results of the medication orders and determine if additional focus or action is warranted. The Executive Director (ED) or designated coordinator is responsible for implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur.

December 2, 2021Complaint survey0 violations

Inspection dates

12/02/2021,12/14/2021

Areas reviewed

22VAC40-73 BUILDING AND GROUNDS

Comments

Licensing Inspector (LI) conducted unannounced complaint investigation that began on 12/02/2021 and concluded on 12/14/2021 regarding buildings and grounds. LI interviewed staff and residents, walked the physical plant, and reviewed documents of work orders for repairs to heating system. Complaint regarding resident medication and staff qualifications is deemed not valid as a preponderance of evidence gathered during the investigation did not support the allegations. Thank you for your cooperation and if you have any questions please call 703-479-5247 or contact me via email at jamie.eddy@dss.virginia.gov.

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

October 25, 2021Inspection1 violation

Inspection dates

10/25/2021,10/29/2021

Areas reviewed

22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity32.1 Reported by persons other than physicians63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE

Technical assistance

A completed Renewal Application must be submitted prior to the expiration of the current license. The facility should receive an application in the mail, however if an application has not been received one can be obtained from the DSS web site or by calling the main office at (276) 206-0492.

Comments

A renewal inspection was initiated on 10/25/2021 and concluded on 10/29/2021. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 48. 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, monthly menu, fire drill reports, healthcare and dietary oversight reports, annual health and fire inspection reports submitted by the facility to ensure documentation was complete. Criminal Background Checks of all staff hired since the previous inspection conducted on 9/3/2021, were reviewed. The inspector conducted the on-site portion of the inspection on 10/28/2021. An exit interview, was conducted with the Administrator on 10/29/2021, 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. 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 standard(s), 2) measures to prevent the non-compliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s). Thank you for your cooperation and if you have any questions please call 703-479-5247 or contact me via e-mail at jamie.eddy@dss.virginia.gov.

Violations

22VAC40-73-680-D

Based upon a review of records, the facility failed to ensure that medications shall be 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. According to the physician's order written 6/30/2021, Resident #3 is to receive Senna-Docusate Sodium Tablet 8.6-50mg, 2 tablets every 24 hours as needed for bowel regimen, if not effective, may offer PRN (as needed) Miralax. The Medication Administration Record (MAR) for 10/15/2021 indicates that Resident #3 was administered Senna-Docusate Sodium Tablet at approximately 11:32 am and on 10/16/2021 the medication was administered at approximately 7:53 am, which is 20 hours and 22 minutes after the previous dosage was administered. . The MAR documents that on 10/21/2021, Resident #3 was administered a dosage of Senna Docusate Sodium Tablet at approximately 19:04 (7:04 pm) and again at approximately 7:54 am, which is 12 hours and 54 minutes after the previous dosage was administered.

Plan of correction

Resident #3 experienced no negative outcomes as a result of medication administration on 10/15/2021 and 10/21/2021. The Resident Care Director (RCD) conducted a refresher training with medication care manager regarding the importance of and process for adhering to medication administration in accordance with the physician's orders. The RCD conducted unannounced medication pass observations of medication care managers to confirm medications are being administered in accordance with physician orders. Any concerns identified are addressed, resolved and a refresher training provided as needed. The RCD conducted refresher training with the specific medication care manager regarding the importance of and process for adhering to medication administration in accordance with the physician's orders and to report issues with order clarification to the RCD so that they can be addressed timely by the clinical team, pharmacy, and physician. The Wellness Nurses and Med Care Managers (MCMs) were re-educated by the RCD regarding the process to confirm medications prior to administration and to report issues with order clarification to the RCD so that they can be addressed timely by the clinical team, pharmacy, and physician. The RCD or wellness designee conducts weekly audits for 1 month, and monthly audits for 2 months, to confirm accuracy between physician orders, and the EMAR. Issues that may be identified will be addressed and resolved and refresher training initiated as needed. The results of the audits will be presented by the RCD or wellness designee at Quality Assurance and Performance Improvement (QAPI) meeting for 3 months. During and at the end of 3 months, the QAPI Committee will evaluate the results of the medication care audits and determine if additional focus or action is warranted. The Executive Director (ED) or designated coordinator is responsible for implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur.

August 31, 2021Inspection1 violation

Inspection dates

08/31/2021,09/03/2021

Areas reviewed

22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity32.1 Reported by persons other than physicians63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS

Comments

A monitoring inspection was initiated on 8/31/2021 and concluded on 9/3/2021. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 49. 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, annual fire and health inspection reports, dietary and healthcare oversight reports, staff work schedule, activity calendar, monthly menu submitted by the facility to ensure documentation was completed. Criminal Background Checks of all staff hired since the previous inspection conducted on 2/18/2021 were reviewed. The inspector conducted the on-site inspection on 9/2/2021. An exit interview was conducted with the administrator on 9/3/2021 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. 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 standard(s), 2) measures to prevent the non-compliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s). Thank you for your cooperation and if you have any questions please call 703-479-5247 or contact me via e-mail at jamie.eddy@dss.virginia.gov.

Violations

22VAC40-73-680-C

Based upon a review of records and interview, the facility failed to ensure that medications shall be administered not earlier than one hour before and not later than one hour after the facility's standard dosing schedule, except those drugs that are ordered for specific times, such as before, after, or with meals.

Evidence

According to the Medication Administration Record (MAR) and the Location of Administration Report, on 8/24/2021 the 8 am dosage of Resident #2's Rivastigmine Patch and the 8 am dosage of Resident #2's Insulin Aspart Solution was administered at approximately 10:24 am. An interview with Staff #4 confirmed that the above listed medications were administered at approximately 10:24 am, 2 hours and 24 minutes past the schedule dosing time of 8 am.

Plan of correction

A. With respect to the specific resident cited: Resident # 2 experienced no negative outcomes as a result of not administering within the standard during schedule. PCP was notified of late administration and no adverse reaction being noted. The Resident Care Director conducted refresher training with the specific medication care manager regarding the importance of and process for adhering to medication administration timeframes. B. With respect to how the facility will identify residents with the potential for the identified concerns: The Resident Care Director is conducting unannounced medication administration pass observations to confirm that medications are administered within the correct time frame.Issues that may be identified will be addressed and resolved and refresher training initiated as needed. C. With respect to what systemic measures have been put into place to address the stated concern: The Resident Care Director will conduct refresher training with the medication care managers and nurses regarding the process for administering medications within the appropriate time frame. D. With respect to how the plan of correction will be monitored: The Resident Care Director or designee will continue to conduct unannounced medication pass observations weekly for 3 months to confirm medications are given within the correct time frame as well as a review will take place during the morning community meeting to identify any med pass discrepancies from the previous day. Issues that may be identified will be addressed and resolved and refresher training initiated as needed.The Resident Care Director or designee will present the results of the medication-pass observations to the Quality Assurance and Performance Improvement Committee (QAPI) committee monthly for three months. During and at the end of 3 months, the QAPI committee will evaluate the results and determine if additional focus or action is warranted. The Executive Director or designee is responsible for confirming implementation and ongoing compliance components of this Plan of Correction and addressing and resolving variances that may occur.

February 18, 2021Inspection0 violations

Inspection dates

Feb. 18, 2021 and March 2, 2021

Areas reviewed

22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity32.1 Reported by persons other than physicians63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS

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. Licensing Inspector (LI) conducted announced initial inspection on 2/18/2021,3/2/2021. The inspection was necessary due to a change in ownership. LI reviewed policies and procedures. The Fire and Health Inspections and Elevator Inspection have been completed. The exit interview took place on 3/2/2021 via telephone with the administrator. No violations were cited. Thank you for your cooperation and if you have any questions please call 703-479-5247 or contact me via e-mail at jamie.eddy@dss.virginia.gov.

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.