Virginia DSS · Assisted Living Facility

Sunrise at Bluemont Park

📍 5910 Wilson Boulevard, Arlington, VA, 22205

ID 46974One Year licenseActive
15
Inspections
On record
10
With violations
Visits that cited something
5
Clean visits
Nothing cited
28
Violations cited
Individual findings
22
Standards cited
Distinct rules
8
Complaint visits
Prompted by a complaint

Sunrise at Bluemont Park was inspected 15 times between February 19, 2021 and March 18, 2026 by the Virginia Department of Social Services. 10 of those visits ended with violations cited and 5 with none. Across that history VDSS cited 28 violations under 22 distinct standards. 8 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 15 are still on the state's site; the other 2 have since dropped off it and are reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type
Assisted Living Facility
License type
One Year
License expires
09/21/2026
Administrator
Brian Williams
Licensing inspector
Nina Wilson
Inspector phone
(703) 635-6074
Approved for
Assisted Living · Non-Ambulatory · Special Care Unit

Inspection History

15

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

March 18, 2026Complaint survey6 violations
Inspection dates
03/18/2026, 04/22/2026
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03/18/2026 Time in: 1:41 PM Time out: 3:10 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 03/11/2026 regarding allegations in the area(s) of: General Provisions, Resident Care and Related Services, Buildings and Ground, and Complaint Investigation Number of residents present at the facility at the beginning of the inspection: 155 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: Licensing inspector (LI) observed residents participating in scheduled activities. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s); area(s) of non-compliance with standard(s) or law were: Resident Care and Related Services and Complaint Investigation A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of these inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov
Violations
22VAC40-73-450-E
Based on resident record review and staff interview, the facility failed to ensure that the individualized service plan should be signed and dated by the licensee, administrator, or his designee, (i.e., the person who developed the plan), and by the resident or his legal representative.
Evidence
  1. Resident 2’s ISP (dated, 02/18/2026) was not signed by the resident or his legal representative.
  2. During the onsite inspection, 04/22/2026, staff 2 and staff 4 acknowledged that resident 2’s ISP was not signed by the resident or his legal representative.
Plan of correction
A. With respect to the specific resident/situation cited: Resident #2 experienced no negative outcomes as a result of missing signed ISP B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: The Care Coordinator conducted an audit of current resident record to confirm Individualized Service plan are signed. issues identified were resolved. Associate Executive Director (AED) conducted a refresher training with the Care Coordinators regarding the importance of having a signed individualized service plan by the community team and resident/responsible party. C. With respect to what systemic measures have been put into place to address the stated concern: The Care Coordinator or designee will continue to audit Individualized service plans (ISP) for 3 months to confirm resident have a signed ISP on record. Issues that may be identified will be addressed and resolved and refresher training is initiated as needed. The results of the audits will be presented by the Care Coordinator or designee at Quality Assurance and Performance Improvement (QAPI) meeting for 3 months. D. With respect to how the plan of correction will be monitored: The Executive Director or designee is responsible for implementation and ongoing compliance with all components of this Plan of Correction and address/resolve any variance that may occur. The Executive Director or designee will verify the status of this Plan of Correction is reviewed and discussed at Quality Assurance/Improvement Meetings and action initiated when/if necessary.
22VAC40-73-530-C
Based on record review and staff interview, the facility failed to provide freedom of movement for the residents to common areas and to their personal spaces. The facility should not lock residents out of or inside their rooms.
Evidence
  1. During the onsite inspection, 03/18/2026, staff 1 confirmed the Potomac elevators have been offline since 12/03/2025 to present. Staff 1 confirmed the facility provided two evacuation (evac) chairs for those residents on upper floors.
  2. During the onsite inspection, 04/22/2026, staff 1 confirmed that maintenance is responsible for operating the evac chairs; and a reservation is recommended if the evac chair is needed after business hours of 8am to 5pm. Staff 1 confirmed that overnight staff are not trained to use the evac chairs, resulting in the evac chair deemed inaccessible from 5pm-8am.
  3. During the onsite inspection, 04/22/2026, staff 1 and staff 2 acknowledged that the Potomac building, approximately over 20 residents have experienced a restriction of movement to common areas and to their personal spaces without the use of an operable elevator.
Plan of correction
A. With respect to the specific resident/situation cited: Residents did not experience any negative outcomes as a result of the elevators being offline. B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: are following all required tasks during medication administration in accordance with Virginia Board or Nursing and Sunrise Medication Management Plan C. With respect to what systemic measures have been put into place to address the stated concern: Established vendor accountability protocols, including escalation procedures and routine follow-up timelines, to ensure timely completion of critical repairs. Cross-trained team members, including non-maintenance staff, on the safe operation of evacuation equipment to ensure 24/7 accessibility if needed. D. With respect to how the plan of correction will be monitored: The Executive Director or designee is responsible for implementation and ongoing compliance with all components of this Plan of Correction and address/resolve any variance that may occur The Executive Director or designee will verify the status of this Plan of Correction is reviewed and discussed at Quality Assurance/Improvement Meetings and action initiated when/if necessary.
22VAC40-73-460-B
Based on staff interviews, the facility failed to ensure care provision and service delivery should be resident-centered to the maximum extent possible and include prompt response by staff to resident needs as reasonable to the circumstances.
Evidence
  1. During the onsite inspection, 04/22/2026, staff 1 confirmed that Potomac building elevator continues to be offline, 12/03/2025 to present, affecting over 20 residents and services to those residents to include meals.
  2. During the onsite inspection, 03/18/2026, staff 3 confirmed that breakfast, lunch, and dinner was provided to residents who required tray service in their unit. Staff 3 confirmed that residents wait approximately thirty to forty-five minutes to receive their pre-ordered meal(s), which may result in food at times being cold.
  3. During the onsite inspection, 04/22/2026, staff 1 and staff 2 acknowledged that residents in the Potomac building affected by the elevator closure may receive cold food and at times require staff to microwave their meal(s), which is not a prompt response or reasonable to the circumstances.
Plan of correction
A. With respect to the specific resident/situation cited: Residents did not experience any negative outcomes as a result of the elevators being offline. B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: Elevator vendor to perform monthly elevator inspections C. With respect to what systemic measures have been put into place to address the stated concern: In compliance with regulations, the revamped Health Care Oversight (HCO) will continue to be conducted/documented semi-annually. After revamping semi-annual HCO, the Executive Director and/or designee will file sign document and review document at the Quarterly QAPI meeting. D. With respect to how the plan of correction will be monitored: The Executive Director or designee is responsible for implementation and ongoing compliance with all components of this Plan of Correction and address/resolve any variance that may occur The Executive Director or designee will verify the status of this Plan of Correction is reviewed and discussed at Quality Assurance/Improvement Meetings and action initiated when/if necessary.
22VAC40-73-400
Based on resident record review and staff interview, the facility failed to provide to each resident or the resident’s legal representative, if one has been appointed, a monthly statement that itemizes any charges made by the facility and any payments received from the resident or on behalf of the resident during the previous calendar month and should show the balance due or any credits for overpayment. The facility should also place a copy of the monthly statement in the resident’s record.
Evidence
  1. On 01/10/2026, the facility sent notification to residents and legal representatives residing in the Potomac building that stated, “monthly credit: a $500 credit will be applied to your bill for every month the elevator remains offline, retroactive to December.”
  2. Resident 1’s, who resides in the Potomac building, December 2025 through March 2026 monthly statement of charges did not reflect the $500 credit.
  3. During the onsite inspection, 03/18/2026, staff 1 acknowledged that resident 1’s December 2025 through March 2026 monthly statement of charges did not reflect the $500 credit applied to those residents residing in Potomac building.
Plan of correction
A. With respect to the specific resident/situation cited: There was no negative outcome as a result of missed credit. Resident #1 has received the agreed upon credits. B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: Executive Director conducted an audit of current residents to ensure identified credits were appropriately applied. C. With respect to what systemic measures have been put into place to address the stated concern: Implemented a secondary review process for all account adjustments and monthly statements prior to distribution. D. With respect to how the plan of correction will be monitored: The Executive Director or designee is responsible for implementation and ongoing compliance with all components of this Plan of Correction and address/resolve any variance that may occur. The Executive Director or designee will verify the status of this Plan of Correction is reviewed and discussed at quarterly Quality Assurance/Improvement Meetings and action initiated when/if necessary.
22VAC40-73-870-I
Based on video recordings and staff interview, the facility failed to ensure elevators, where used, should be kept in good running condition.
Evidence
  1. There are over 20 residents that reside in the Potomac building, and the elevator has been offline since 12/03/2025. The elevator was on track to be repaired by 03/30/2026, which did not occur.
  2. During the onsite inspection, 04/22/2026, staff 1 confirmed that the elevator was not repaired on 03/30/2026 to present. Staff 1 stated that there was a delay in the delivery of the “jack,” but the elevator would be repaired on 04/24/2026 and online by 04/28/2026, following an inspection by the building official.
Plan of correction
A. With respect to the specific resident/situation cited: Resident was not known to experience a negative outcome due to a cup of morning medications not administered according to proper procedure B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: Email to families and residents as a reminder to keep Team informed of anything noted with elevator swiftly. C. With respect to what systemic measures have been put into place to address the stated concern: Ensure Maintenance Chief are supervising 3rd Party Vendor and holding accountable for routine maintenance and inspections D. With respect to how the plan of correction will be monitored: Lerchbates Company contracted to serve with community as advocate and Third Party Consulting. The Executive Director or designee is responsible for implementation and ongoing compliance with all components of this Plan of Correction and address/resolve any variance that may occur. The Executive Director or designee will verify the status of this Plan of Correction is reviewed and discussed at Quality Assurance/Improvement Meetings and action initiated when/if necessary.
22VAC40-73-450-F
Based on resident record review and staff interview, the facility failed to ensure that individualized service plans should be reviewed and updated at least once every 12 months and as needed for a significant change of a resident’s condition.
Evidence
  1. Resident 2’s record included a change of condition assessment that occurred on 02/18/2026; however, the ISP (dated 02/18/2026) for Resident 2 was not updated to reflect the change.
  2. Resident 2’s UAI (dated, 02/18/2026) reflected support was required with dressing; however, the ISP (dated, 02/18/2026) did not include assistance with dressing.
  3. During the onsite inspection, 03/18/2026, staff 2 acknowledged that resident 2’s ISP (dated 02/18/2026) was not updated to include dressing support.
  4. Resident 2’s ISP (dated, 02/18/2026) stated, “I need a walker to assist with mobility/transferring.”; however, during the onsite inspection, 04/22/2026, staff 4 stated, “no, resident 2 does not use a walker; never had to use a walker.”
Plan of correction
A. With respect to the specific resident/situation cited: Residents did not experience any negative outcomes for Resident #2 due to ISP and UAI not being updated. B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: The Resident Care Director (RCD) or designee conducted an audit of current resident record to confirm Individualized Service plan (ISP) and Uniform Assessment Instrument (UAI) are updated to reflect current resident needs. issues identified were resolved. C. With respect to what systemic measures have been put into place to address the stated concern: Resident Care Director or designee will continue to audit Individualized service plans (ISP) and Uniform Assessment Instrument (UAI) for 3 months to confirm identified resident need are updated. 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 Care Coordinator or designee at Quality Assurance and Performance Improvement (QAPI) meeting for 3 months D. With respect to how the plan of correction will be monitored: The Executive Director or designee is responsible for implementation and ongoing compliance with all components of this Plan of Correction and address/resolve any variance that may occur. The Executive Director or designee will verify the status of this Plan of Correction is reviewed and discussed at Quality Assurance/Improvement Meetings and action initiated when/if necessary.
March 18, 2026Complaint survey0 violations
Inspection dates
03/18/2026
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03/18/2026 Time in: 12:13 PM Time out: 1:40 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A (complaint/self-reported incident) was received by VDSS Division of Licensing on 03/03/2026 regarding allegations in the area(s) of: Staffing and Supervision, Resident Care and Related Services, and Complaint Investigation Number of residents present at the facility at the beginning of the inspection: 155 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Licensing inspector (LI) observed residents participating in scheduled activities. Additional Comments/Discussion: The evidence gathered during the investigation did not support the allegation(s) 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 Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
January 23, 2026Complaint survey2 violations
Inspection dates
01/23/2026
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-80 COMPLAINT INVESTIGATION
Technical assistance
Licensing inspector (LI) reviewed the following standards with the facility: 22VAC40-73-280.
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: 01/23/2026 Time in: 11:19 AM Time out: 12:49 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 12/18/2025 regarding allegations in the area(s) of: Staffing and Supervision, Resident Care and Related Services, Buildings and Ground, and Complaint Investigation Number of residents present at the facility at the beginning of the inspection: 157 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: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: Licensing inspector observed residents sitting in common areas interacting with staff and peers. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegations of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. 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
Violations
22VAC40-73-870-I
Based on record review and staff interview, the facility failed to ensure that elevators, where used, should be kept in good running condition and should be inspected at least annually.
Evidence
  1. Potomac building’s elevator has not been functioning, 12/03/2025 to present. There are over forty residents that reside in the Potomac building.
  2. During the onsite inspection, 01/23/2026, staff 1 confirmed that Potomac building’s elevator was not online, 12/03/2025 to present. Staff 1 stated that the elevator requires a “jack,” that must be manufactured, which takes about six to eight weeks. Staff 1 confirmed that the elevator should be in working order by mid- March 2026.
Plan of correction
a. Corrective Action Taken to Address the Specific Violation Upon confirmation that the Potomac building elevator was non-operational as of December 3, 2025, the facility immediately contacted TK Elevator to diagnose the issue. The failure was determined to be caused by a damaged hydraulic elevator jack requiring full replacement. The replacement jack was ordered promptly following diagnosis, and residents were notified of the outage and alternative options for mobility and access, including use of the evac chair with staff assistance as needed. ________________________________________ b. Steps to Be Implemented to Ensure Future Compliance To ensure the elevator is restored to proper working condition and remains compliant going forward: • The required elevator jack was ordered, with a manufacturer estimated timeline of 6–8 weeks for fabrication. • Once delivered, installation and testing are scheduled to take place within two weeks by TK Elevator, the licensed contractor. • Annual state required elevator inspections will continue to be scheduled and documented, and additional preventive maintenance will be added to the quarterly facility safety review. • The facility will maintain direct oversight of all elevator service intervals, repair requests, and weekly status updates until the elevator is fully functional. ________________________________________ c. Measures to Monitor and Maintain Compliance To strengthen long-term monitoring and ensure elevator reliability: • A third party elevator consulting and management company has been hired to oversee TK Elevator’s repair timelines, service quality, maintenance documentation, and overall compliance. • This third party firm will audit all elevator service records, ensuring timely response and verifying all work meets regulatory standards. • The facility’s Executive Director and Environmental Services leadership will review elevator performance reports monthly and maintain written documentation for VDSS review. • Future service needs or outages will be communicated to residents immediately, with documentation in resident communication logs. ________________________________________ d. Completion Date The elevator jack is currently in the manufacturing process. Based on the repair timeline provided by TK Elevator, final installation, inspection, and return to service are expected to be completed by March 31, 2026. All corrective actions will be completed within 60 days of the exit interview, in accordance with VDSS requirements.
22VAC40-73-460-B
Based on resident and staff interviews, the facility failed to make care provision and service delivery should be resident-centered to the maximum extent possible and include resident participation in decisions regarding the care and services provided to him; personalization of care and services tailored to the resident’s circumstances and preferences; and prompt response by staff to resident needs as reasonable to the circumstances.
Evidence
  1. During the onsite inspection, 01/23/2026, licensing inspector (LI) interviewed collateral contact 1 who stated, “I have not seen anyone use the electric evac chairs. I didn’t know that we had those, but I think that people are afraid to use the stairs. They don’t want to fall.”
  2. During the onsite inspection, 01/23/2026, LI interviewed collateral contact 2 who stated, “I think it stinks. I live on the terrace level – people on higher levels are missing relationships with others. People have to move out.” LI asked collateral contact 2 if they used the evac chair to visit their friend(s). Collateral contact 2 stated that they were unaware of the option and “did not know” about the evac chair.
  3. During the onsite inspection, 01/23/2026, staff 1 confirmed that the residents were not formally informed that evac chairs were available for use. Staff 1 stated that legal representatives, family members, residents with email addresses, and power of attorneys (POA’s) were advised via email but could not be sure if that information was passed along to the residents.
Plan of correction
a. Corrective Action Taken to Address the Specific Violation To immediately correct the identified communication failure regarding the availability and use of the evacuation (evac) chair, the facility issued a building-wide communication on January 24, 2026, to all residents, legal representatives, families, POAs, and staff. This communication included: • Notification that the evac chair is available as an alternative mobility option during elevator downtime. • Instructions on how to request and schedule use of the evac chair. • Assurance that trained staff are available to assist residents with the chair. This information was delivered via email to all contacts on file and verbally distributed to residents by department directors to ensure all residents—not just those with email—were informed. ________________________________________ b. Steps to Be Implemented to Ensure Future Compliance To ensure ongoing resident-centered care and clear communication regarding mobility options: • A replacement elevator part has been ordered, with an estimated arrival date of 6-8 weeks from order placement. • Following delivery, the part will require an additional two weeks for installation by the licensed elevator contractor. • Until the elevator is fully restored, the facility will continue to communicate updates regularly via email and in-person resident meetings. • Evac chair information will be added to new resident orientation and the resident handbook to ensure clear, ongoing communication going forward. • Unit managers will review mobility resources weekly with their residents to ensure continued awareness. ________________________________________ c. Measures to Monitor and Maintain Compliance To ensure long-term compliance and oversight of elevator functionality and emergency mobility resources: • A third party elevator consulting and management firm has been hired to oversee TK Elevator’s service, repair, maintenance records, and performance. • This firm will monitor all elevator system updates, document service history, and ensure timely repairs. • Documentation of all resident communications related to mobility options—including evac-chair availability—will be maintained and reviewed monthly by the Executive Director and the management team. • Quarterly audits will be conducted to confirm evacuation equipment is accessible, staff are trained, and residents are aware of available resources. ________________________________________ d. Completion Date Email notifications to residents, families, and representatives are ongoing and will continue until the elevator is fully operational. The anticipated completion date for elevator repair, inspection, and return to full service is March 31, 2026. All corrective actions will be completed within 60 days of the exit interview, in accordance with VDSS requirements
July 18, 2025Inspection6 violations
Inspection dates
07/18/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS
Technical assistance
Licensing inspector reviewed the following standards with the facility: 22VAC40-73-200, 22VAC40-73-210, 22VAC40-73-250, and 22VAC40-73-1110.
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: 07/18/2025 Time in: 10:40 AM Time out: 4:19 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: 143 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 4 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: Licensing inspector (LI) observed residents waiting for transportation services, dining for lunch, and engaging in scheduled activities. Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov.
Violations
22VAC40-73-680-K
Based on resident record review, the facility failed to ensure that the use of PRN medications was prohibited, unless the order included directions as to what to do if symptoms persisted.
Evidence
  1. Resident 2 was prescribed Tylenol Extra Strength Oral Tablet 500 MG (start date, 06/09/2025) to be administered 1 tablet by mouth every 6 hours as needed for pain – moderate. The Tylenol order did not include directions as to what to do if symptoms persisted.
  2. Resident 5 was prescribed Ondansetron HCI Tablet 4 MG (start date, 04/04/2025) to be administered 1 tablet by mouth every 6 hours as needed for nausea and vomiting. The Ondansetron order did not include directions as to what to do if symptoms persisted.
Plan of correction
A. With respect to the specific situation cited: Residents did not experience any negative outcomes. Residents (2&5) PRN medication orders were updated to include directions as to what to do if symptoms persisted. B. With respect to how the facility will identify situations with the potential for the identified concerns: The Resident Care Director (RCD), and/or designee are conducting audits of the electronic medical record - 15% of current residents weekly for 1 month - and then 15% of current residents twice monthly for 2 months to confirm that PRN medications orders include directions as to what to do if symptoms persisted. 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 citation: Refresher training regarding medication administration procedure- including PRN medications - was conducted for current team members by the RCD, and/ or designee. This training is incorporated into new team member orientation and on-boarding for team members assigned roles involving medication administration. In addition, The RCD conducts a formal medication pass observations annually and as needed for Medication Care Managers to verify the team member's competency. In order to confirm that the processes outlined above are sustained: The Resident Care Director and/or Designee will report results of the observational audits and the audits from the electronic Medical Record at Quarterly QAPI meeting. Issues that may be identified will be addressed and resolved and refresher training initiated as needed. D. With respect to how the plan of correction will be monitored: The Executive Director or designee is responsible for implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur. Tracking and trending will take place during Quarterly QAPI meeting for the next 2 QAPI committee meetings.
22VAC40-90-40-B
Based on staff record review and staff interview, the facility failed to ensure that the criminal history report was obtained on or prior to the 30th day of employment for each employee.
Evidence
  1. Upon request, the facility did not provide criminal history reports for staff 7 (hire date, 09/09/2024), staff 8 (hire date, 08/09/2024), and staff 9’s (hire date, 10/21/2024).
  2. During the onsite inspection on 07/18/2025, staff 6 confirmed that staff 7 and staff 8’s criminal history report results had not been received. Staff 6 also did not provide documentation of staff 9’s criminal history report.
Plan of correction
A. With respect to the specific situation cited: Background checks were completed on all staff members identified. B. With respect to how the facility will identify situations with the potential for the identified concerns: The Human Resource Coordinator(HRC) and/or designee are conducting audit of criminal history report records for current staff members to verify staff member's file includes criminal history report. Issues that may be identified, will be addressed and resolved. The Human Resource Coordinator(HRC) and/or designee are conducting audit of new staff members records monthly for three months to confirm that new staff members have criminal history report in record on or prior to the 30thday of employment. C. With respect to what systemic measures have been put into place to address the citation: In order to confirm that the processes outlined above are sustained: The Human Resource Coordinator and/or Designee will report results of the audits at Quarter! QAPI meetin . Issues that may be identified will be addressed and resolved and refresher training initiated as needed. D. With respect to how the plan of correction will be monitored: The Executive Director or designee is responsible for implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur. Tracking and trending will take place during Quarterly QAPI meeting for the next 2 QAPI committee meetings.
22VAC40-73-950-E
Based on record review and staff interview, the facility failed to develop and implement a semi-annual review on the emergency preparedness and response plan for all staff, residents, and volunteers. The review was documented by signing and dating.
Evidence
  1. Upon request, the facility did not provide a semi-annual review of the emergency preparedness and response plan.
  2. During the onsite inspection on 07/18/2025, staff 6 confirmed that the emergency preparedness and response plan was not documented as reviewed semi-annually with all staff, residents, and volunteers.
Plan of correction
A. With respect to the specific situation cited: Residents had no adverse outcomes due to failing to document semi-annual review of emergency preparedness plan. B. With respect to how the facility will identify situations with the potential for the identified concerns: Following inspection, a review of emergency preparedness plan has been conducted and documented with current staff. C. With respect to what systemic measures have been put into place to address the citation: In order to confirm that the processes outlined above are sustained: Review of emergency preparedness plan (EPP) has been added semi-annually to community's annual training calendar. After conducting EPP semi-annual reviews, the Executive Director and/or designee will file sign document and review document at the Quarterly QAPI meeting. D. With respect to how the plan of correction will be monitored: The Executive Director or designee is responsible for implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur. Tracking and trending will take place during Quarterly QAPI meeting for the next 2 QAPI committee meetings.
22VAC40-73-490-A-2
Based on record review and staff interview, the facility failed to ensure that all residents who met the criteria for assisted living care, a licensed health care professional, provided health care oversight at least every six months, or more often if indicated.
Evidence
  1. Upon request, the facility did not provide a healthcare oversight that was completed at least every six months.
  2. During the onsite inspection on 07/18/2025, staff 6 confirmed that the healthcare oversight was not completed at least every 6 months.
Plan of correction
A. With respect to the specific situation cited: Residents had no adverse outcomes due to failing to document semi-annual Health Care Oversight. B. With respect to how the facility will identify situations with the potential for the identified concerns: Following inspection, the Health Care Oversight was completed at the community. C. With respect to what systemic measures have been put into place to address the citation: In order to confirm that the processes outlined above are sustained: The Health Care Oversight (HCO) has been added semi-annually to community's annual training calendar. After conducting semi-annual HCO, the Executive Director and/or designee will file sign document and review document at the Quarterly QAPI meeting. D. With respect to how the plan of correction will be monitored: The Executive Director or designee is responsible for implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur. Tracking and trending will take place during Quarterly QAPI meeting for the next 2 QAPI committee meetings.
22VAC40-73-680-D
Based on resident record review, the facility failed to ensure that medications were administered in accordance with the physician’s or other prescriber’s instructions.
Evidence
  1. Resident 3 was prescribed ClonazePAM Oral Tablet 1 MG (start date, 03/28/2025), give 1 tablet by mouth three times a day related to essential tremor (7 AM, 1 PM, and 7 PM).
  2. Per resident 3’s June medication administration record (MAR), CLonazePAM Oral Tablet 1 MG was not administered at 1 PM on 06/18/2025.
Plan of correction
A. With respect to the specific situation cited: Resident 3 did not experience any negative outcomes due to the missed medication administration. B. With respect to how the facility will identify situations with the potential for the identified concerns: The Resident Care Director (RCD), and/or designee are conducting audits of the electronic medical record - 15% of current residents weekly for 1 month - and then 15% of current residents twice monthly for 2 months to confirm that medication administration is in accordance with the physician's or prescriber's instructions. 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 citation: Refresher training regarding medication administration procedure- including medication administration based on physician orders and proper documentation of medication administration - was conducted for current team members by the RCD, and/ or designee. This training is incorporated into new team member orientation and on-boarding for team members assigned roles involving medication administration. In addition, The RCD conducts a formal medication pass observations annually and as needed for Medication Care Managers to verify the team member's competency. In order to confirm that the processes outlined above are sustained: The Resident Care Director and/or Designee will report results of the observational audits and the audits from the electronic Medical Record at Quarterly QAPI meeting. Issues that may be identified will be addressed and resolved and refresher training initiated as needed. D. With respect to how the plan of correction will be monitored: The Executive Director or designee is responsible for implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur. Tracking and trending will take place during Quarterly QAPI meeting for the next 2 QAPI committee meetings.
22VAC40-73-260-A
Based on staff record review and staff interview, the facility failed to ensure that each direct care staff member maintained current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer, rescue squad, or fire department.
Evidence
  1. Staff 1’s current certification in first aid was issued by NationalCPRFoundation, expiration 10/30/2025. 2.During the onsite inspection on 07/18/2025, staff 6 confirmed that staff 1’s current certification in first aid was not from any of the required organizations.
Plan of correction
A With respect to the specific situation cited: Staff #1 is scheduled to complete required first aid training. The Certificate will be provided to Surveyor once received. B. With respect to how the facility will identify situations with the potential for the identified concerns: The Human Resource Coordinator(HRC) and/or designee are conducting audit of First Aid training records for current staff members to verify staff members have current first aid certification from the approved agencies. Issues that may be identified, will be addressed and resolved. The Human Resource Coordinator(HRC) and/or designee are conducting audit of new staff members First Aid training records monthly for three months to confirm that new staff members have current First Aid Certification, for staff identified out of compliance­ First Aid training will be completed within 60 days of employment and certification placed in file. C. With respect to what systemic measures have been put into place to address the citation: In order to confirm that the processes outlined above are sustained: The Human Resource Coordinator and/or Designee will report results of the audits at Quarterly QAPI meeting. Issues that may be identified will be addressed and resolved and refresher training initiated as needed. D. With respect to how the plan of correction will be monitored: The Executive Director or designee is responsible for implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur. Tracking and trending will take place during Quarterly QAPI meeting for the next 2 QAPI committee meetings.
June 16, 2025Complaint survey1 violation
Inspection dates
06/16/2025
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/16/2025 Time in: 12:54 PM Time out: 2:06 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 06/02/2025 regarding allegations in the area(s) of: Administration and Administrative Services, Staffing and Supervision, and Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 149 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Licensing inspector (LI) observed residents participating in scheduled activities and dining for lunch. Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: Administration and Administrative Services, Staffing and Supervision, and Resident Care and Related Services A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov. Should you have any questions, please contact Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov.
Violations
22VAC40-73-70-A
Based on record review, the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatened the life, health, safety, or welfare of any resident.
Evidence
  1. The facility did not report Resident 2’s hospitalization for a heart attack on 05/30/2025 or their unexpected death on 06/05/2025.
  2. On 06/16/2025, staff 1 confirmed that the regional licensing office was not contacted within 24 hours of resident 2’s hospitalization.
Plan of correction
Not published by VDSS.
June 16, 2025Inspection2 violations
Inspection dates
06/16/2025
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 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: 06/16/2025 Time in: 2:07 PM Time out: 2:40 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-report was received by VDSS Division of Licensing on 02/28/2025 regarding allegations in the area(s) of: Buildings and Grounds. Number of residents present at the facility at the beginning of the inspection: 149 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: 2 Observations by licensing inspector: Licensing inspector (LI) observed residents participating in scheduled activities, entering and exiting the community for outings, and dining for lunch. Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. 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 Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov.
Violations
22VAC40-73-950-A
Based on record review and resident interview, the facility failed to ensure the written emergency preparedness and response plan addressed and analyzed potential hazards of the facility that disrupted normal operation of the facility.
Evidence
  1. The facility reported on 02/28/2025 that building 2’s elevator was offline for approximately 3 weeks. The same elevator was previously offline in 10/2024.
  2. On 06/16/2025, staff 2 indicated residents were escorted from their respective floors to the main floor by calling the concierge desk for medical and/or community appointments.
  3. On 06/16/2025, two collateral contacts confirmed that the elevators were offline for an extended period and that the plan for staff to assist residents to other floors not consistent or followed.
Plan of correction
Not published by VDSS.
22VAC40-73-870-I
Based on record review, the facility failed to ensure that elevators were kept in good running condition.
Evidence
  1. The only elevator in building 2 was offline for approximately 3 weeks.
Plan of correction
Not published by VDSS.
June 16, 2025Complaint survey2 violations
Inspection dates
06/16/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/16/2025 Time in: 2:41 PM Time out: 6:05 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 06/16/2025 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: 149 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: 3 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Licensing inspector (LI) observed residents engaging in scheduled activities and dining for lunch. Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: Resident Care and Related Services. A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov. Should you have any questions, please contact Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov. 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: 06/16/2025 Time in: 2:41 PM Time out: 6:05 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 06/16/2025 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: 149 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: 3 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Licensing inspector (LI) observed residents engaging in scheduled activities and dining for lunch. Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: Resident Care and Related Services. A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov. Should you have any questions, please contact Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov.
Violations
22VAC40-73-680-D
Based on resident review, the facility failed to administer medications in accordance with the physician’s or other prescriber’s instructions.
Evidence
  1. Resident 3’s Cambigan Ophthalmic Solution 0.2-0.5% and Carbidopa-Levodopa Oral Tablet 25-100 MG were scheduled for administration at 1:00 pm. Cambigan Ophthalmic Solution 0.2-0.5% and Carbidopa-Levodopa Oral Tablet 25-100 MG was not documented as administered at 1:00 pm on 04/08/2025 and 04/10/2025, per resident 3’s April 2025 MAR.
  2. Resident 3’s Apixaban Oral Tablet 5 MG was scheduled for administration at 4:00 pm on 06/06/2025 and 7:00 am on 06/07/2025; however, resident 3’s June 2025 MAR indicated the medication was held for twice on 06/06/2025 and for the 7:00 am dose on 06/07/2025.
Plan of correction
Not published by VDSS.
22VAC40-73-680-C
Based on resident record, the facility failed to ensure that medications were administered not earlier than one hour before and not later than one hour after the facility's standard dosing schedule, except those drugs that are ordered for specific times, such as before, after, or with meals.
Evidence
  1. Resident 3 was prescribed Carbidopa-Levodopa Oral Tablet 25-100 MG and Combigan Ophthalmic Solution 0.2-0.5%, which were scheduled to be administered at 1:00 pm. The medications were administered at 5:03 pm on 05/30/2025 per resident 3’s May 2025 MAR.
  2. Resident 3 was prescribed Carbidopa-Levodopa Oral Tablet 25-100 MG and Combigan Ophthalmic Solution 0.2-0.5%, which were scheduled to be administered at 4:00 pm. The medications were administered at 7:37 pm on 06/06/2025, per resident 3’s June 2025 MAR.
Plan of correction
Not published by VDSS.
October 7, 2024Complaint survey0 violations
Inspection dates
10/07/2024
Areas reviewed
22VAC40-73 BUILDINGS AND GROUND
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: 10/07/2024 Time In: 6:06 PM Time Out: 6:20 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 10/07/2024 regarding allegations in the area(s) of: Buildings and Grounds Number of residents present at the facility at the beginning of the inspection: 145 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: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: LI observed the physical plant of the facility. LI observed residents waiting for staff to assist with utilizing the stairs. LI observed residents interacting with peers and staff. 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 Nina Wilson Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
August 21, 2024Complaint survey2 violations
Inspection dates
08/21/2024, 08/22/2024
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 08/21/2024 Time In: 10:10 AM Time Out: 4:11 PM 08/22/2024 Time In: 11:54 Time Out: 3:13 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 08/12/2024 regarding allegations in the area(s) of: Personnel, Staffing and Supervision, Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 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: 3 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 8 Observations by licensing inspector: LI observed the physical plant of the facility. LI observed residents engaging in activities, sitting on the porch with peers and staff, participating in community outings, and eating lunch in the dining area. Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: Personnel, Staffing and Supervision, Resident Care and Related Services A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov
Violations
22VAC40-73-280-C
Based on facility record review, the facility failed to ensure that an adequate number of staff persons shall be on the premises at all times to implement the approved fire and emergency evacuation plan.
Evidence
  1. The facility has three assisted living facilities (ALF) and one memory care unit on the campus: Shenandoah (staff ratio: 1st shift, 3 employees; 2nd shift, 3 employees, and 3rd shift, 2 employees), Potomac (staff ratio: 1st shift, 3 employees; 2nd shift, 3 employees, and 3rd shift, 2 employees), and James (ALF and Memory Care - staff ratio: 1st shift, 2 employees, 2nd shift, 2 employees, and 3rd shift, 2 employees).
  2. June - August 2024’s Shenandoah staff schedule states that 2 employees were scheduled for the 2nd shift on 06/28/2024, 06/30/2024, and 07/01/2024, 07/05/2024, 07/07/2024, 07/08/2024, 07/09/2024, 07/12/2024, 07/14/2024, 07/15/2024, 07/16/2024, 07/18/2024, 07/19/2024, 07/21/2024, 07/25/2024, 07/26/2024, 07/28/2024, 07/29/2024, 07/30/2024, 08/01/2024, 08/02/2024, 08/04/2024, 08/05/2024, 08/06/2024, 08/08/2024, 08/09/2024, 08/11/2024, 08/12/2024, 08/13/2024 and 08/15/2024.
  3. June – August 2024’s Shenandoah staff schedule states that 1 employee was scheduled for the 2nd shift on 07/22/2024, 08/09/2024 and 08/18/2024.
  4. June – August 2024’s Shenandoah staff schedule states that 1 employee was scheduled for the 3rd shift on 08/15/2024, 08/17/2024, and 08/18/2024.
  5. June – August 2024’s Potomac staff schedule states that 2 employees was scheduled for the 1st shift on 07/30/2024.
  6. May – July 2024’s James (Memory Care) staff schedule states that 1 employee was scheduled for the 3rd shift on 05/25/2024 and 07/27/2024.
  7. May – July 2024’s James (Memory Care) staff schedule states that 1 employee was scheduled for the 2nd shift on 05/31/2024.
  8. May – July 2024’s James (Memory Care) staff schedule states that 1 employee was scheduled for the 1st shift on 06/14/2024 and 06/17/2024.
  9. May – July 2024’s James (ALF) staff schedule states that 1 employee was scheduled for the 2nd shift on 05/19/2024, 06/08/2024, 07/04/2024, 07/26/2024, 08/02/2024.
  10. May – July 2024’s James (ALF) staff schedule states that 1 employee was scheduled for the 3rd shift on 05/28/2024, 06/09/2024, 06/10/2024, 06/11/2024, 06/15/2024, 06/18/2024, 06/19/2024, 06/24/2024, 06/29/2024, 06/30/2024, 07/06/2024, 07/21/2024, 07/28/2024, 08/03/2024, 08/04/2024, 08/08/2024.
  11. May – July 2024’s James (Memory Care) staff schedule states that 1 employee was scheduled for the 1st shift on 06/18/2024.
  12. On 08/21/2024 LI interviewed Staff 9 who explained the staffing plan. Staff 9 stated that there are holes in the schedule that were filled but not updated in the system.
Plan of correction
A. With respect to the specific situation cited: Residents did not experience any negative outcomes due to posted staffing schedule. Provided staffing schedule were inaccurate based on actual staffing numbers. Staffing was aligned with requirements outlined in the approved fire and emergency evacuation plan. B. With respect to how the facility will identify situations with the potential for the identified concerns: Refresher training regarding scheduling and staffing - including required staffing based on approved fire and emergency evacuation plan, current resident occupancy and needs of residents, procedure or updating and posting staffing schedule to reflect accurate daily staffing conducted for current Assisted Living Coordinators, Resident Care Coordinator, Resident Care Director, and Associate Executive Director. The Executive Director, and/or designee are conducting twice weekly random schedule reviews for posted schedule for 30 days and then weekly thereafter to confirm compliance with daily posted schedule requirements based on the approved fire and emergency evacuation plan and needs of current residents. Issues that may be identified will be addressed and resolves and refresher training initiated as needed. C. With respect to what systemic measures have been put into place to address the citation: In order to confirm that the processed outlined above are sustained: The Assisted Living Coordinator, Resident Care Coordinator and/or Designee will report audits of the accuracy for the daily posted staffing schedule for the previous 90-days at the Quarterly QAPI meeting for 2 QAPI meetings. After concluding the 90-day reviews, the QAPI committee will re-evaluate and initiate the necessary action needed at that time. D. With respect to how the plan of correction will be monitored: The Executive Director or designee is responsible for implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur. Tracking and trending will take place during Quarterly QAPI meeting for the next 2 QAPI committee meetings.
22VAC40-73-680-C
Based on facility record review, the facility failed to ensure that medications were administered not earlier than one hour before and not later than one hour after the facility’s standard dosing schedule, except those drugs that are ordered for specific times, such as before, after, or with meals.
Evidence
  1. Medication Admin Audit Report, 07/21/2024 – 08/21/2024 stated that there were 41 late medication administrations recorded for the Assisted Living Facility.
  2. Medication Admin Audit Report, 07/25/2024 states that there were 14 instances where medications were scheduled for 7 PM one day but were not documented as administered until 10 AM the next day, 14 hours past the scheduled administration time.
  3. Medication Admin Audit Report, 07/25/2024 states that there was 1 instance where medications were scheduled for 9 PM one day but was not documented as administered until10 AM the next day, 12 hours past the scheduled administration time.
  4. Medication Admin Audit Report, 08/11/2024 and 08/17/2024 states that there were 2 instances where medications were scheduled for 4 PM one day but were not documented as administered until 9 PM the next day, 4 hours past the scheduled administration time.
  5. Medication Admin Audit Report, 08/17/2024 states that there were 9 instances where medications were scheduled for 7 PM and were documented as administered at 11 PM, 3 hours past the scheduled administration time.
  6. Medication Admin Audit Report, 08/17/2024 states that there was 1 instance where medications were scheduled for 9 PM and were documented as administered at 11 PM, 2 hours past the scheduled administration time.
  7. Medication Admin Audit Report, 08/11/2024 states that there was 1 instance where medications were scheduled for 7 AM and were documented as administered at 10 AM, 2 hours past the scheduled administration time.
  8. Medication Admin Audit Report, 07/21/2024 – 08/21/2024 states that there were 2 instances where medications were scheduled for 4 PM and were documented as administered at 6 PM, 1 hour past the scheduled administration time.
  9. Medication Admin Audit Report, 07/21/2024 – 08/21/2024 states that there were 7 instances where medications were documented as administered between 40 minutes and 1 minute past the scheduled administration time.
  10. On 08/22/2024, LI interviewed Staff 9 who stated that counseling was conducted with one employee who documented administering medications late on 17 separate instances.
Plan of correction
A. With respect to the specific situation cited: Residents did not experience any negative outcomes due to the timing of medication administration and/or due to late documentation of medication administration. B. With respect to how the facility will identify situations with the potential for the identified concerns: The Resident Care Director (RCD), and/or designee are conducting audits of the electronic medical record - 15% of current residents weekly for 1 month - and then 15% of current residents twice monthly for 2 months to confirm that medication administration is accurate within standard dosing schedule and documented as medication is being administered. Issues that may be identified will be addressed and resolved and refresher training initiated as needed. The Resident Care Director (RCD), and/or designee are conducting weekly walking rounds of community observing medication administration and reviewing documented medication administration for 30 days and then twice monthly thereafter for 2 months to confirm compliance with medication administration procedures. 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 citation: Refresher training regarding medication administration procedure - including appropriate time window for medication administration based on physician orders and proper timely documentation of medication administration was conducted for current team members by the RCD, and/or designee. This training is incorporated into new team member orientation and on-boarding for team members assigned roles involving medication administration. In addition, the RCD conducts a formal medication pass observations annually and as needed for Medication Care Managers to verify the team member's competency. In order to confirm that the processes outlined above are sustained: the RCD and/or Designee will report results of the observational audits and audits from the electronic Medical Record at Quarterly QAPI meeting. Issues that may be identified will be addressed and resolved and refresher training initiated as needed. D. With respect to how the plan of correction will be monitored: the Executive Director or designee is responsible for implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur. Tracking and trending will take place during Quarterly QAPI meeting for the next 2 QAPI committee meetings.
June 20, 2024Inspection3 violations
Inspection dates
06/20/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND
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: 06/20/2024 Time In: 10:58 AM Time Out: 3:00 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 Nina Wilson, Licensing Inspector at (703) 635-6075 or by email at nina.wilson@dss.virginia.gov.
Violations
22VAC40-73-940-A
Based on facility records review and staff interview, the facility failed to ensure that at least an annual inspection by an appropriate fire official and reports of the inspection shall be retained at the facility for at least two years.
Evidence
  1. The most recent inspection completed by a fire official was 10/18/2022.
  2. On 06/20/2024, Staff 5 stated that “there was a COVID outbreak in 2023. The fire marshal came out but when they were told about the outbreak, they turned around immediately.” Staff 5 further stated, “I typically email or call Summit, who schedules the inspection for September or October. There’s nothing scheduled for this year, but I will call while you’re here.”
Plan of correction
A. With respect to the specific situation cited: Community received annual fire Marshal inspection with a passing inspection. B. With respect to how the facility will identify 1ations with the potential for the identified concerns: Maintenance Coordinator and Executive Director will ntain record of annual inspection. Maintenance Coordinator will contact Arlington County Fire Marshal's office 1 month prior to expiration to confirm scheduled inspection date C. With respect to what systemic measures have been put into place to address the citation: Maintenance Coordinator will schedule annual inspection for the coming year with fire Marshal as fire Marshal is present in community for the current year's annual inspection D. With respect to how the plan of correction will be monitored: During the Quality Assurance and Performance Improvement (QAPI) meeting and up to 3 months following the implementation of the POC, the Executive Director will review the POC and the results of the audit with the Department Coordinators. Additional improvement plans will be developed and implemented as necessary, including training to correct any deficient practices.
22VAC40-73-870-I
Based on facility record review, the facility failed to ensure that elevators, where used, shall be kept in good running condition, and shall be inspected at least annually. The signed and dated certificate of inspection issued by the local authority shall be
Evidence
  1. of such inspection. Evidence:
  2. During a tour of the building and grounds, it was observed that the most recent inspection was not posted in the elevator. Staff 4 stated that the elevator inspection is housed at the front desk. On the way to the way to the front desk, Staff 4 advised that the elevator certificate would be expired but she was unsure of the reasoning.
  3. The most recent inspection completed by a fire official was 05/28/2023.
Plan of correction
A. With respect to the specific situation cited: Community has all 3 elevators up-to-date with passing inspections. B. With respect to how the facility will identify situations with the potential for the identified concerns: Community will maintain the Certificate of Compliance and record of elevator Inspections at the front desk and Executive director's Office. Community will replace record of certification annually following inspection. C. With respect to what systematic measures have been put into place to address the citation: Certificate of Compliance and Record of Elevator Inspection has been placed at the front desk of each building & copy of each has been filed in the Executive Director's office. Community will maintain certificates at all locations to provide proof of compliance when requested. D. With respect to how the plan of correction will be monitored: During the Quality Assurance and Performance Improvement (QAPI) meeting and up to 3 months following the implementation of the POC, the Executive Director will review the POC and the results of the audit with the Department Coordinators. Additional improvement plans will be developed and implemented as necessary, including training to correct any deficient practices.
22VAC40-73-990-B
Based on facility records review, the facility failed to ensure that the procedures in the plan for resident emergencies shall be reviewed by the facility at least every six months with all staff. Documentation of the review shall be signed and dated by each staff person.
Evidence
  1. On 06/20/2024, LI requested the resident emergency drills, but they were not provided. LI requested the drills at the start of the inspection, during the inspection, and prior to the tour, which occurred at the end of the inspection.
Plan of correction
A With respect to the specific situation cited: Community will host mandatory in-service & review of resident emergency plan every 6- months. 8. With respect to how the facility will identify situations with the potential for the identified concerns: Community will maintain record of resident emergency plan. Community will maintain record of resident emergency drills conducted. Maintenance Coordinator and Executive director will maintain record of resident emergency drills conducted. C. With respect to what systemic measures have been put into place to address the citation: Maintenance Coordinator and Executive director will schedule resident emergency drills very 6- months at community. Maintenance CoordinatL and Executive director will ensure participation of team members with drills and record participation with dated sign-in sheet. D. With respect to how the plan of correction will be monitored: During the Quality Assurance and Performance Improvement (QAPI) meeting and up to 3 months following the implementation of the POC, the Executive Director will review the POC and the results of the audit with the Department Coordinators. Additional improvement plans will be developed and implemented as necessary, including training to correct any deficient practices.
September 19, 2023Complaint survey0 violations
Inspection dates
09/19/2023
Areas reviewed
Staffing and SupervisionResident Care and Related ServicesBuilding and Grounds
Comments
Date of Inspection: September 19,2023 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.
August 30, 2022Inspection1 violation
Inspection dates
08/30/2022
Areas reviewed
Administrative 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 Serious Cognitive Impairments
Comments
Date of Inspection: August 30 and 31, 2022, 10:15am-3:30pm Type of Inspection: Renewal Inspection If you have any questions or email changes, please do not hesitate to contact me at sarah.pearson@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov. Census 115 Number of records reviewed and interviews conducted- 8 records, 8 interviews. All facility self-reported incidents since the last inspection were reviewed on this date.
Violations
22VAC40-73-650-B
Facility staff failed to administer medications as prescribed by her physician.
Evidence
  1. Resident C's Medication Administration Record indicated that Eliquis Tablet on 8/9/23, Cozar Tablet on 8/9/23 and Protonix Tablet on 8/8/23 and 8/9/23 were not administered due to not being available.
Plan of correction
A. With respect to the specific resident/situation cited: Resident C did not experience any negative effect due to missing Eliquis. Eliquis was ordered and administered on 8/10/23. Resident C did not experience any negative effect due to missing Cozar. Cozar Tablet was ordered and administered for the next does on 8/10/23. Resident C did not experience any negative effect due to missing Protonix. Protonix Tablet was ordered and administered on 8/10/23. B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: RCD or Designee completed an audit of residents' medications administration and current supply. No other negative findings. 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 is not provided by family in a timely fashion. Medication will be ordered from our contract pharmacy to ensure the availability for administration.
September 23, 2021Inspection0 violations
Inspection dates
09/23/2021, 09/24/2021
Areas reviewed
22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS
Comments
This inspection was conducted by licensing staff using an alternate remote protocol necessary due to DOLP COVID-19 questions answered on 9/23/2021. A renewal inspection was initiated on 9/23/2021 and concluded on 9/25/2021. The administrator was contacted by telephone and email for an entrance interview to initiate screening questions and the inspection. The administrator reported that the current census was 106. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed five resident records and five staff records. Criminal record checks and sworn statements of one staff hired since last inspection and other documentation submitted by the facility was reviewed to ensure documentation was complete. The information gathered during the inspection determined no violations with applicable standards or law. No violations were issued. Thank you for your cooperation and if you have any questions please call (703) 895-5627 or contact me via e-mail at jeannette.zaykowski@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 28, 2021Inspection3 violations
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity63.2 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
This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A monitoring inspection was initiated on 5/28/2021 and concluded on 5/28/2021. The administrator was contacted by telephone for an entrance interview to initiate the inspection. The administrator reported that the current census was 105. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed five resident records and five staff records. Criminal record checks and sworn statements of all staff hired since issuance of license and other documentation submitted by the facility was reviewed to ensure documentation was complete. Exit interview was conducted with the administrator on 6/07/2021. Information gathered during the inspection determined non-compliance(s) 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, 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s), and 4) date that that plan of correction will be completed. Thank you for your cooperation and if you have any questions please call (703) 895-5627 or contact me via e-mail at jeannette.zaykowski@dss.virginia.gov.
Violations
22VAC40-73-450-C
Based on record review, facility failed to ensure that a written description of what services will be provided to address identified needs, and if applicable, other services, and who will provide them shall be included on the comprehensive Individualized Service Plan (ISP).
Evidence
  1. Resident #1's ISP dated 5/05/2021 does not document the resident's Physical Therapy Services ordered 5/07/2021.
Plan of correction
A.) With respect to the specific resident/situation cited: The ISP for resident #1 was updated to include services to be provided, who will provide the services, and the frequency of those services. B.) With respect to how the facility will identify residents/situations with the potential for the identified concerns: The Resident Care Director (RCD) or designee completed an audit of all residents? ISPs who are currently receiving outpatient rehabilitation services. ISPs updated as needed. C.) With respect to what systemic measures have been put into place to address the stated concern The RDC completed training with the Wellness Nurses, the Assisted Living Coordinator and the Resident care Coordinator on ISP requirements and compliance. The RCD/Designee will monitor ISP’s for residents with new/continuing orders for outpatient rehabilitation services for 3 months and report outcome to QAPI committee. D. With respect to how the plan of correction will be monitored: During the Quality Assurance and Performance Improvement (QAPI) meeting and up to 3 months following the implementation of the Plan of Correction (POC), the ED 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. The ED 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.
22VAC40-90-30-B
Based on record review, facility failed to ensure that the sworn statement or affirmation shall be completed for all applicants for employment.
Evidence
  1. 8/105 Staff records documented Sworn Statements that were not completed. Sworn Statements signed by the applicants for Staff #3 dated 3/31/2021, Staff #27 dated 4/05/2021, Staff #65 dated 4/05/2021, Staff #68 dated 3/30/2021, Staff #76 dated 4/08/2021 and Staff #87 dated 4/01/2021 did not document an answer to the question "have you ever been convicted of a law violation"; and Staff #101's SS was not signed and dated by the applicant; and Staff #28's SS was dated 6/25/2021 after the date of this inspection.
Plan of correction
A.) With respect to the specific resident/situation cited: Team members #3, #27, #65, #68, #76 and #87 answered the overlooked question, ?have you ever been convicted of a law violation?, on their sworn statement. Team member #101 signed and dated their sworn statement. Team member #28 completed a new sworn statement and dated accordingly. Corrections that were completed on existing sworn statement forms were initialed by the team member. B.) With respect to how the facility will identify residents/situations with the potential for the identified concerns: The Executive Director (ED) or designee to conduct an audit of all current team member sworn statements to validate that they have been filled out completely, signed and dated appropriately. Any sworn statements found that are not completed appropriately will be addressed and corrected. C.) With respect to what systemic measures have been put into place to address the stated concern: Retraining completed with the HR Representative over what must be filled out on the sworn statement. Going forward, prior to a new team member’s first day, the Human Resource Representative or designee reviews the required new hire paperwork, including the sworn statement. The sworn statement will be reviewed to verify that it has been completed correctly, signed, and dated. For the next 3 months all new team members that are hired for the community, the Executive Director (ED/Administrator) or designee will review the required new hire documents, including the sworn statements. The sworn statements will be reviewed to verify that the form was fully completed with all questions answered, signed, and dated appropriately. D.) With respect to how the plan of correction will be monitored: During the Quality Assurance and Performance Improvement (QAPI) meeting and up to 3 months following the implementation of the Plan of Correction (POC), the ED 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. The ED 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.
22VAC40-90-30-C
Based on record review, facility failed to ensure that any person making a maerially false statement on the sworn statement or affirmation shall be guilty of a Class 1 misdemeanor.
Evidence
  1. 4/105 employees documented on their Sworn Statements an answer of "no" to the question "have you ever been convicted of a law violation(s)" and their Criminal History Record (CHR) documented a conviction for each staff: Staff #41's SS dated 3/22/2021 and CHR dated 3/22/2021, Staff #77's SS dated 3/23/2021 and CHR dated 3/22/2021, Staff #79's SS dated 3/23/2021 and CHR dated 3/22/2021 and Staff #85's SS dated 3/26/2021 and CHR dated 3/22/2021 document conflicting information.
Plan of correction
A.) With respect to the specific resident/situation cited: Team members #41, #77, #79 and #85 completed new sworn statement forms and completely and correctly answered the question “have you ever been convicted of a law violation”. Answers no longer conflict with the results on their Criminal History Record. B.) With respect to how the facility will identify residents/situations with the potential for the identified concerns: The Executive Director (ED) or designee to conduct an audit of all current team member sworn statements to validate that they have been filled out correctly and do not conflict with results on the Criminal History Record. Any sworn statements found that are not correct will be addressed and corrected. C.) With respect to what systemic measures have been put into place to address the stated concern: Retraining completed with the HR Representative over what must be filled out on the sworn statement. Going forward, prior to a new team member’s first day, the Human Resource Representative or designee reviews the required new hire paperwork, including the sworn statement. The sworn statement will be reviewed to validate that it has been filled out correctly and does not conflict with results on the Criminal History Record. For the next 3 months all new team members that are hired for the community, the Executive Director (ED/Administrator) designee will review the required new hire documents, including the sworn statements. The sworn statements will be reviewed to verify that the form was fully completed and that the answers do not conflict with the Criminal History Record. D. With respect to how the plan of correction will be monitored: During the Quality Assurance and Performance Improvement (QAPI) meeting and up to 3 months following the implementation of the Plan of Correction (POC), the ED 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. The ED 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.
February 19, 2021Inspection0 violations
Inspection dates
Feb. 19, 2021
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY 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. An initial inspection was initiated with a virtual tour of the facility on 2/19/2021 with the administrator. The inspection was necessary due to a change of ownership. Management will continue under current company. Policies and procedures were reviewed. The most recent health and fire inspections were provided with a leniency noted due to the state of emergency; LI confirmed that both inspections are currently scheduled dependent on county availability. An exit interview was conducted with the Administrator on 3/15/2021. No violations were cited. Thank you for your cooperation and if you have any questions please call (703) 895-5627 or contact me via e-mail at jeannette.zaykowski@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.