Virginia DSS · Assisted Living Facility

Chesapeake Place

📍 1500 & 1508 Volvo Parkway, Chesapeake, VA, 23320

ID 46997One Year licenseActive
34
Inspections
On record
32
With violations
Visits that cited something
2
Clean visits
Nothing cited
143
Violations cited
Individual findings
68
Standards cited
Distinct rules
24
Complaint visits
Prompted by a complaint

Chesapeake Place was inspected 34 times between March 23, 2021 and September 9, 2025 by the Virginia Department of Social Services. 32 of those visits ended with violations cited and 2 with none. Across that history VDSS cited 143 violations under 68 distinct standards. 24 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. 30 of these 34 are still on the state's site; the other 4 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
09/30/2026
Administrator
Ingrid Wilson-Brown
Licensing inspector
Lanesha Allen
Inspector phone
757-715-1499
Approved for
Special Care Unit · Assisted Living

Inspection History

34

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

September 9, 2025Inspection11 violations
Inspection dates
09/09/2025
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS
Technical assistance
22VAC40-73-860 Buildings And Ground 22VAC40-73-950 Emergency Preparedness
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: 09/09/2025 from 08:25am-05:00pm. 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: 74 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed:3 Number of interviews conducted with residents:5 Number of interviews conducted with staff: 5 Observations by licensing inspector: 3 Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. Breakfast, lunch and an activity were observed. A medication pass observation was completed for three residents. The following was reviewed: resident and staff records, medication carts, fire inspection report, health inspection report, and a staffing schedule. Water temperature was measured, and the call bell system was monitored. 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 Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at Lanesha.allen@dss.virginia.gov
Violations
22VAC40-73-640-A
Based on observation, a review of the facility’s medication plan and interview, it was determined that the facility shall have, keep current, and implement a written plan for medication management. The facility's medication plan shall address procedures for administering medication and shall include A plan for proper disposal of medication
Evidence
  1. During the medication cart inspection, Bayer 81mg tabs for resident #7 were found with an expiration date of 02/2025.
  2. During the medication cart inspection, Acetaminophen 500mg tabs for resident #7 were found with an expiration date of 06/2023.
  3. During the medication cart inspection, Ventolin HFA Aerosol inhaler for resident #8 were found with an expiration date of 04/30/2025.
  4. Staff #2 confirmed the medication for residents #7 and #8 were expired.
Plan of correction
What Has Been Done to Correct? Requested a formal med cart audit from our Pharmacy. Have started a weekly med cart audit with all Med Techs that includes discontinued orders, Sample Meds properly labeled and disposal of expired medication. How Will Recurrence Be Prevented? Resident Care Director, Memory Care Director or designee will review the weekly cart audit binder and inspect carts with any audit issues. Will continue to educate Med Techs on Medication procedures per / policy. Person Responsible: Resident Care Director, Memory Care Director or designee Due Date: Started on 10/8/2025- On going. Pharmacy cart audit to be completed by 11/7/2025
22VAC40-73-260-A
Based on a review of three staff records, it was determined that the facility did not ensure that each direct care staff member shall maintain 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. The record for Staff #1 contained a First Aid card that expired 7/20/25.
  2. Staff #5 reviewed the record for staff # 1 and was unable to provide documentation during the onsite inspection that the staff had a current first aid certification.
Plan of correction
What Has Been Done to Correct? Audit of all employees’ files has been done. CPR/ First Aid classes scheduled for Oct 7th and Oct 21st for compliance How Will Recurrence Be Prevented? The Executive Director, Business Office Manager or designee will review” Employee Training Template “monthly for compliance Person Responsible: Executive Director, Business Office Manager Due Date: Date of completion 10/21/2025
22VAC40-73-320-A
Based on the review of six resident records and interview, it was determined that the facility did not ensure that the physical contains a statement that specifies whether the individual is or is not capable of self- administering medication, and results of a risk assessment documenting the absence of tuberculosis in a communicable form as
Evidence
  1. d by the completion of the current screening form. Evidence:
  2. The record for resident #3 did not contain a statement that specifies whether the individual is or is not capable of self- administering medication.
  3. The record for resident #4 TB Assessment did not contain the signature of the examining physician or his designee.
  4. Staff #5 confirmed that the physical examination report for Resident #3 did not contain a statement that specifies whether the individual is or is not capable of self- administering medication during the onsite inspection for resident # 1 on 9/9/25.
  5. Staff #5 confirmed the TB assessment for Resident #4 did not contain the signature of the physician or his designee during the onsite inspection on 9/9/2025.
Plan of correction
What Has Been Done to Correct? An Audit of all residents’ records will be completed for accuracy and compliance. All files will be updated and place in residents file with new Physical forms signed by PCP if needed. How Will Recurrence Be Prevented? Executive Director and or Resident Care Director., Memory Care Director or Designee will review all new residents move in forms for accuracy and compliance. Person Responsible: Executive Director or Resident Care Director 11/7/2025 and on Going
22VAC40-73-440-A
Based on the review of six resident records and interview, it was determined that the facility did not ensure that the all residents of and applicants to assisted living facilities shall be assessed face to face using the uniform assessment instrument in accordance with Assessment in Assisted Living Facilities (22VAC30-110). The UAI shall be completed prior to admission, at least annually, and whenever there is a significant change in the resident's condition.
Evidence
  1. The record for Resident #1 did not contain a UAI.
  2. Staff #5 confirmed that UAI for resident #1, were not in the residents record.
Plan of correction
An audit of all residents’ files will be done for compliance. Will set up face to face meetings with residents and or families if needed and place the signed copies in the residents file. Executive Director Resident Care Director or Memory Care Director will review all UAI for completion on or before move in date. Will be placed in residents file Executive Director or designee 11/07/2025
22VAC40-73-450-A
Based on the review of six resident records, it was determined that the facility did not ensure that the Individualized Service Plan (ISP) shall be reviewed and updated at least once every 12 months and as needed for a significant change of a resident’s condition.
Evidence
  1. The record for Resident #6, date of admission 3/29/2021 did not contain an annual plan of care.
  2. Staff #5 reviewed the record for resident #6 and was unable to provide documentation during the onsite inspection.
Plan of correction
An audit of all residents’ files will be done for accuracy and compliance. All up dated ISPs will be signed and placed in residents file. Resident Care Director and or Memory Care Director will monitor AL Advantage care plan program weekly for up and coming assessments. All ISP will be completed and printed off for the Resident Care Director, Memory Care Director or Executive Directors review and signature. Resident Care Director, Memory Care Director, Executive Director or designee. 11/7/2025
22VAC40-73-990-C
Based on document reviewed and staff interviewed, the facility did not ensure at least every six months, all staff currently on duty on each shift participate in an exercise in which the procedures for resident emergencies are practiced.
Evidence
  1. On 9/9/25, the facility did not have documentation of staffs’ participation in an exercise in which the procedures for resident emergencies are practiced.
  2. Staff #5 acknowledged not having documentation of resident emergency practice during the onsite inspection 9/9/2025.
Plan of correction
What Has Been Done to Correct? An emergency exercise has been scheduled for 10/14/2025 How Will Recurrence Be Prevented? The Executive Director , Resident Care Director, Memory Care Director and Maintenance Director will schedule and monitor emergency drills every 2 months to cover all shifts to remain in compliance Person Responsible: Executive Director, Maintenance Director or designee Due Date: 11/7/2025- 1st one scheduled for 10/14/2025
22VAC40-73-1100-A
Based on a review of six resident records and interview, it was determined that prior to placing a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia in a safe, secure environment, the facility shall obtain the written approval of one of the following persons, a guardian or other legal representative of the resident if one has been appointed.
Evidence
  1. The record for resident #4 did not contain the signature of the legal guardian.
  2. Staff #5 reviewed the document and confirmed that the guardian did not sign the Written Approval for resident #4.
Plan of correction
What Has Been Done to Correct? An audit of all residents’ files will be done in Memory Care for compliance. The Memory Care Director or designee will contact the POA/ Guardian to review, sign and place in file. How Will Recurrence Be Prevented? The Memory Care Director or designee will review all new admissions for mandated paperwork that including written approval for a secured environment Person Responsible: Memory Care Director, Executive Director or designee Due Date: 11/7/2025
22VAC40-73-310-D
Based on the review of six resident records and interview, it was determined that the facility did not ensure the assisted living facility administrator shall provide written assurance to the resident that the facility has the appropriate license to meet his care needs at the time of admission.
Evidence
  1. The record for Resident #1, admission date 8/15/25 did not contain the Written Assurance.
  2. The record for Resident #3, admission date 3/27/25 did not contain the Written Assurance.
  3. The record for Resident #4, admission date2/10/25 did not contain the Written Assurance.
  4. The record for Resident #5, admission date11/1/24, did not contain the Written Assurance.
  5. Staff #5 reviewed the record for Residents #1, #3, #4, and #5 and was unable to provide documentation of the Written Assurance during the onsite inspection on 9/9/2025.
Plan of correction
What Has Been Done to Correct? An audit of all residents file will be done for compliance. All files will be updated and place in residents file. How Will Recurrence Be Prevented? Executive Director, designee will review all new Move in paperwork for completion and accuracy. Person Responsible: Executive Director or designee Due Date: 11/7/2025 and on Going
22VAC40-73-950-F
Based on the review of the Emergency Preparedness binder and interview, it was determined that the facility did not ensure to review the emergency preparedness plan annually or more often as needed, document the review by signing and dating the plan, and make necessary plan revisions. Such revisions shall be communicated to staff, residents, and volunteers and incorporated into the orientation and semi-annual review for staff, residents, and volunteers.
Evidence
  1. Evidence: 1. Staff #5 was unable to provide documentation of an annual review of the facility’s emergency preparedness plan during the onsite inspection on 9/9/2025.
  2. Staff #5 confirms an annual review of the Emergency Preparedness Plan was not completed for 2025.
Plan of correction
What Has Been Done to Correct? Review of the emergency preparedness plan has been completed to include signing and dating the plan, and necessary plan revisions have been included. The revisions will be communicated to staff, residents, and volunteers and incorporated into the orientation and semi-annual review for staff, residents, and volunteers. How Will Recurrence Be Prevented? Executive Director and Maintenance Director will review the Emergency Preparedness plan semi annually facility and monitor monthly for compliance Person Responsible: Executive Director, Maintenance Director or designee Due Date: 11/7/2025
22VAC40-73-970-A
Based document reviewed, the facility did not ensure that the fire and emergency evacuation drill frequency and participation was in accordance with the current edition of the Virginia Statewide Fire Prevention Code (13VAC5-51).
Evidence
  1. On 9/9/2025, a check of the facility’s fire drills log did not include documentation of a fire and emergency evacuation drill for the month of June 2025, July 2025 or August 2025.
  2. Staff #5 confirms Emergency drills were not conducted for the months of June 2025, July 2025 and August 2025.
Plan of correction
What Has Been Done to Correct? Emergency drill to be completed on 10/8/2025 and Fire drill on 10/10/2025 How Will Recurrence Be Prevented? Executive Director and Maintenance Director will schedule monthly drills for facility and monitor monthly for compliance Person Responsible: Executive Director, Maintenance Director or designee Due Date: 11/7/2025
22VAC40-73-550-G
Based on the review of six resident records and interview, it was determined that the facility did not ensure that the rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each resident, or his legal representative or responsible individual as stipulated in subsection H of this section and each staff person.
Evidence
  1. of this review shall be the resident's, his legal representative's or Evidence:
  2. The record for resident #2 record contained the rights and responsibilities of residents document that was dated 3/28/23.
  3. The record for resident #6 record contained the rights and responsibilities of residents document that was signed and dated 3/13/23.
  4. Staff #5 reviewed the records for residents #2 and #6 was unable to provide documentation during the onsite inspection that the resident rights and responsibilities were reviewed annually for each of the residents listed.
Plan of correction
An audit of all residents file will be done for accuracy. All documents deemed out of compliance will be updated and placed in residents file. A month to month binder will be started to be reviewed by the Resident Care Director or Memory Care Director monthly Resident Care Director, Activity Director Memory Care Director or designee 10/7/2025
July 21, 2025Complaint survey0 violations
Inspection dates
07/21/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/21/2025 15:10 pm to 17:00pm. 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 7/18/2025 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: 74 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: 1 Observations by licensing inspector: An observation of dinner and activity was completed in the assisted living facility. 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at Lanesha.allen@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
July 21, 2025Complaint survey2 violations
Inspection dates
07/21/2025
Areas reviewed
22VAC40-73 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 GROUND22VAC40-80 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: 07/21/2025 15:10 pm to 17:00pm. 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 7/17/2025 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: 74 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: 3 Number of interviews conducted with residents:5 Number of interviews conducted with staff: 2 Observations by licensing inspector: An observation of dinner and activity was completed in the assisted living facility. 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at Lanesha.allen@dss.virginia.gov
Violations
22VAC40-73-350-B
Based on a review of documentation and interviews, it was determined that the facility did not ensure that the assisted living facility shall ascertain, prior to admission, whether a potential resident is a registered sex offender.
Evidence
  1. A review of Resident #1’s record, admission date 11/21/2024 did not include a Sex Offender Registry check.
  2. Staff #1 confirmed there was no Sex Offender Registry check for Resident #1 prior to admission.
Plan of correction
Not published by VDSS.
22VAC40-73-460-A
Based on a review of documentation and interviews, it was determined that the facility did not ensure that the facility shall assume general responsibility for the health, safety, and well-being of the residents.
Evidence
  1. An APS report was received by the Office of Licensing regarding Resident #1 who was pushed by Resident #2 while exiting the dining hall.
  2. An interview with Resident #1 revealed she was pushed by Resident #2.
  3. Staff #1 reviewed the incident report and confirmed the incident did occur, and staff intervened to provide assistance once Resident #1 reported the incident.
Plan of correction
Not published by VDSS.
July 21, 2025Complaint survey1 violation
Inspection dates
07/21/2025
Areas reviewed
22VAC40-73 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 GROUND22VAC40-80 COMPLAINT INVESTIGATIONNone
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: 07/21/2025 15:10 pm to 17:00pm. 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 7/8/2025 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: 74 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: 3 Number of interviews conducted with residents:5 Number of interviews conducted with staff: 2 Observations by licensing inspector: An observation of dinner and activity was completed in the assisted living facility. 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at Lanesha.allen@dss.virginia.gov
Violations
22VAC40-73-320-B
Based on a review of documentation and interviews, it was determined that the facility did not ensure that a risk assessment for tuberculosis shall be completed annually on each resident
Evidence
  1. A review of Resident #3’s record, admission date 7/15/2024, did not include an annual tuberculosis evaluation. The record contained a tuberculosis evaluation dated 6/27/2024.
  2. Staff #1 confirmed the annual tuberculosis evaluation was not present in Resident #3’s record.
Plan of correction
Not published by VDSS.
July 21, 2025Complaint survey1 violation
Inspection dates
07/21/2025
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/21/2025 15:10 pm to 17:00pm. 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 7/17/2025 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: 74 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: 3 Number of interviews conducted with residents:5 Number of interviews conducted with staff: 2 Observations by licensing inspector: An observation of dinner and activity was completed in the assisted living facility. 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at Lanesha.allen@dss.virginia.gov
Violations
22VAC40-73-320-B
Based on a review of documentation and interviews, it was determined that the facility did not ensure that a risk assessment for tuberculosis shall be completed annually on each resident
Evidence
  1. A review of Resident #3’s record, admission date 7/15/2024, did not include an annual tuberculosis evaluation. The record contained a tuberculosis evaluation dated 6/27/2024.
  2. Staff #1 confirmed the annual tuberculosis evaluation was not present in Resident #3’s record.
Plan of correction
Not published by VDSS.
July 21, 2025Complaint survey2 violations
Inspection dates
07/21/2025
Areas reviewed
22VAC40-73 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: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/21/2025 15:10 pm to 17:00pm. 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 7/17/2025 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: 74 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: 3 Number of interviews conducted with residents:5 Number of interviews conducted with staff: 2 Observations by licensing inspector: An observation of dinner and activity was completed in the assisted living facility. 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at Lanesha.allen@dss.virginia.gov
Violations
22VAC40-73-460-A
Based on a review of documentation and interviews, it was determined that the facility did not ensure that the facility shall assume general responsibility for the health, safety, and well-being of the residents.
Evidence
  1. An APS report was received by the Office of Licensing regarding Resident #1 who was pushed by Resident #2 while exiting the dining hall.
  2. An interview with Resident #1 confirmed she was pushed by Resident #2.
  3. Staff #1 reviewed the incident report and confirmed the incident did occur, and staff intervened to provide assistance once Resident #1 reported the incident.
Plan of correction
What Has Been Done to Correct? The Residents Primary Care Physician (PCP) was notified of the behavioral event. A medication review was completed and medication have been adjusted. Waiting on results of Labs and U/A C&S r/o any infections or labs out of range. How Will Recurrence Be Prevented? The PCP and Facility Staff will monitor effectiveness of medication changes and PCP will adjust as needed . Staff is instructed to report any outbursts or behavioral event to Directors, Staff will assist residents in Dining room as needed. Will invite resident to activities to keep him engaged. Person Responsible: Resident Care Director or Designee Due Date: On Going.
22VAC40-73-350-B
Based on a review of documentation and interviews, it was determined that the facility did not ensure that the assisted living facility shall ascertain, prior to admission, whether a potential resident is a registered sex offender.
Evidence
  1. A review of Resident #1’s record, admission date 11/21/2024 did not include a Sex Offender Registry check.
  2. Staff #1 confirmed there was no Sex Offender Registry check for Resident #1 prior to admission.
Plan of correction
What Has Been Done to Correct? An audit of residents files will be done for accuracy and compliance. Resident #1 Sex Offender Registry has been checked and placed in her file. How Will Recurrence Be Prevented? The Executive Director and or the Marketing Director or designee will review all new resident’s paperwork for accuracy prior to moving in. Person Responsible: Executive Director and or Marketing Director or Designee Due Date: 11/7/2025
May 21, 2025Complaint survey1 violation
Inspection dates
05/21/2025
Areas reviewed
22VAC40-73 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 GROUND22VAC40-80 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: 05/21/2025 9:30 am to 12:00pm. 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 4/23/2025 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: 80 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents:1 Number of interviews conducted with staff: 2 Observations by licensing inspector: An observation of lunch and activity was completed in the assisted living facility. 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at Lanesha.allen@dss.virginia.gov.
Violations
22VAC40-73-460-E
Based on a review of documentation and interviews, it was determined that the facility did not ensure that the facility shall regularly observe each resident for changes in physical, mental, emotional, and social functioning. The facility shall provide appropriate assistance when observation reveals unmet needs.
Evidence
  1. The call bell logs for April 15 2025 for resident #1 shows assistance was requested at 9:02 am from the resident’s bedroom and went unanswered for 1 hour and 33 minutes.
  2. The call bell logs for April 15 2025 for resident #1 shows assistance was requested at 9:14 am from the resident’s bathroom and went unanswered for 1 hour and 22 minutes.
  3. Staff #1 reviewed documents and confirmed the assistance was requested from resident #1.
Plan of correction
Not published by VDSS.
January 31, 2025Complaint survey1 violation
Inspection dates
01/31/2025
Areas reviewed
22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-80 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: 1/31/25 from 4:00 pm to 4:30pm. A complaint was received by VDSS Division of Licensing on 1/22/2025 regarding allegations in the area(s) of: Heating, ventilation, and cooling 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: 74 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: Additional Comments/Discussion: none An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegations of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the (complaint(s)/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 Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at Lanesha.allen@dss.virginia.gov
Violations
22VAC40-73-880-B
Based on a complaint received, the heating system in the residents room malfunctioned in November. The resident was provided a space heater on 11/25/24 while heater repairs were in progress. The facility did not ensure that heat shall be supplied from a central heating plant or an electrical heating system in accordance with the Virginia Uniform Statewide Building Code (13VAC5-63).
Evidence
  1. 1: Facility placed a Space heater in resident #1’s room due to heater not working in residents’ room on 11/25/24.
  2. Local Fire Marshall removed space heater from resident #1s room on 01/22/25. The Fire Marshall did not approve the space heater for use.
  3. Staff #1 confirms the use of the space heater and delay of the heater repairs due to parts ordered not arriving.
Plan of correction
Resident’s PTAC unit was replaced on 1/22/25 and became fully operable. On 1/28/25, at the request of the resident’s family, the community installed a brand new PTAC unit and new operating system to minimize any future issues with the HVAC system in resident’s apartment. How Will Recurrence Be Prevented? Facility has ordered several back up units for quick change out in the event of HVAC failure. Person Responsible: Maintenance Director is responsible for repair/replacement of HVAC units. Due Date: 1/22/25
December 16, 2024Complaint survey1 violation
Inspection dates
12/16/2024
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/16/24 1:00pm to 1:40pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 11/18/24, 11/27/24, 12/4/24 regarding allegations in the area(s) of: Staffing And Supervision and Resident Care And Related Services, Admission, Retention And Discharge Of Residents, Buildings And Ground. Number of residents present at the facility at the beginning of the inspection: 80 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: 0 Observations by licensing inspector: none 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 complaints 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 Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at Lanesha.allen@dss.virginia.gov
Violations
22VAC40-73-150-B
Based on interview, the facility failed to immediately employ a new administrator or appoint a qualified acting administrator so that no lapse in administrator coverage occurs.
Evidence
  1. As of 12/16/2024, the facility has not employed a new administrator or appointed a qualified acting administrator causing a lapse in administrator coverage.
Plan of correction
22VAC40-73-150-B Administrator Provisions & Responsibilities. Based on interview, the facility failed to immediately employ a new administrator or appoint a qualified acting administrator so that no lapse in administrator coverage occurs. ___ Yes _X__ No What Has Been Done to Correct? A new licensed administrator was hired on 12/17/2024. _X__ Yes ___ No How Will Recurrence Be Prevented? The licensee or designee will notify the VBLTCA and the department’s regional licensing office within 14 days, in writing, if the facility’s administrator dies, resigns, is discharged, or becomes unable to perform duties and the appointment of a new or acting administrator. Person Responsible: Licensee or designee Due Date: 12/17/24
December 5, 2024Complaint survey5 violations
Inspection dates
12/05/2024
Areas reviewed
22VAC40-73 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 GROUND22VAC40-80 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: 12/05/24 12:00pm to 4:30pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 11/18/24, 11/27/24, 12/4/24 regarding allegations in the area(s) of: Staffing And Supervision and Resident Care And Related Services, Admission, Retention And Discharge Of Residents, Buildings And Ground. Number of residents present at the facility at the beginning of the inspection: 80 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 0 Number of interviews conducted with residents:2 Number of interviews conducted with staff: 1 Observations by licensing inspector: An observation of lunch and activity was completed in the assisted living facility. Water temperature check completed. 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at Lanesha.allen@dss.virginia.gov
Violations
22VAC40-73-440-B
Based on the record review the facility did not ensure for private pay individuals, the UAI shall be completed by one of the following qualified assessors: an assisted living facility staff person who has successfully completed state- approved training on the uniform assessment instrument and level of care criteria for either public or private pay assessments, provided the administrator or the administrator's designated representative has successfully completed such training and approves and then signs the completed UAI, and the facility maintains documentation of completed training.
Evidence
  1. Resident’s #1’s UAI was not signed or dated by the facility’s administrator or the administrator’s designated representative.
  2. Resident’s #2’s UAI was not signed or dated by the facility’s administrator or the administrator’s designated representative.
  3. Resident #3’s UAI was not signed or dated by the facility’s administrator or the administrator’s designated representative.
  4. Resident #4’s UAI was not signed or dated by the facility’s administrator or the administrator’s designated representative.
  5. Staff #3 confirmed the records for residents #1, #2 #3 and #4 did not did not contain signatures and date by the facility’s administrator or the administrator’s designated representative.
Plan of correction
22VAC40-73-440-B Uniform Assessment Instrument. Based on record review, the facility did not ensure for private pay individuals, the UAI was completed by a qualified assessor who has successfully completed state-approved training on the uniform assessment instrument and level of care criteria for either public or private pay assessments, and the administrator or administrator’s designee, who has successfully completed such training, approves and signs the completed UAI, and the facility maintains documentation of completed training. ___ Yes _X__ No What Has Been Done to Correct? All UAIs are now being completed by qualified UAI assessors, whom have completed state-approved training. Completed UAIs are being signed and reviewed by Administrator who has also completed approved training. Evidence of completed UAI training for qualified assessors is maintained in employee personnel record. _X__ Yes ___ No How Will Recurrence Be Prevented? Prior to being permitted to complete Uniform Assessment Instrument form, completion of state-approved training by evidence of completion certificate will be provided to the Executive Director and maintained in employee’s personnel record. Person Responsible: The Executive Director is responsible for ensuring UAIs are completed by a qualified assessor and evidence of completion of state-approved training is maintained on site. Due Date: 12/18/2024
22VAC40-73-860-G
Based on an observation of the facility, the facility did not ensure that hot water at taps available to residents shall be maintained within a range of 105°F to 120°F.
Evidence
  1. During a tour of the facility on 12/5/2024, the following hot water taps sampled were not within the required range in the following areas: Resident #1’s bathroom sink measured 96°F, Resident #5’s bathroom sink measured 94°F.
  2. Staff #3 confirms water temperature reading.
Plan of correction
22VAC40-73-860-G General Requirements. Based on observation, the facility did not ensure hot water at available taps to residents maintained at temperatures within range of 105°F to 120°F. ___ Yes __X_ No What Has Been Done to Correct? Facility has increased temperature at hot water heater to ensure consistent water temperature range of 105°F to 120°F. Weekly random water temperature checks and logs will be completed of at least 2 resident apartments and 1 common area to ensure water temperatures are maintained at appropriate temperatures. _X__ Yes ___ No How Will Recurrence Be Prevented? Weekly random water temperature checks and logs will be completed of at least 2 resident apartments and 1 common area to ensure water temperatures are maintained at appropriate temperatures. Person Responsible: The Maintenance Director is responsible for ensuring water temperatures are maintained within range of 105°F to 120°F as evidence by completion of weekly water temperature logs or documentation of repair by 3rd party vendor. The Executive Director is responsible for reviewing weekly water temperature logs each month. Due Date: 12/24/24
22VAC40-73-1110-B
Based on the record review the facility did not ensure Six months after placement of the resident in the safe, secure environment and annually thereafter, the licensee, administrator, or designee shall perform a review of the appropriateness of each resident's continued residence in the special care unit.
Evidence
  1. The record for resident #4, admission date of 12/28/22, did not contain a annual review of appropriateness for the resident's continued residence in the special care unit.
  2. Staff #3 confirmed the record for Resident #4 did not contain an annual review of appropriateness for the resident.
Plan of correction
22VAC40-73-1110-B Appropriateness of Placement and Continued Residence. Based on record review, the facility did not ensure that residents placed in a safe, secure environment received a 6-month review of appropriateness for continued residence in the special care unit. ___ Yes _X__ No What Has Been Done to Correct? A review of appropriateness for continued residence in facility’s special care unit has been completed on all current residents residing in facility’s special care unit. _X__ Yes ___ No How Will Recurrence Be Prevented? A tickler file with admission date, 6 month, and annual review date of all special care unit residents will be maintained to ensure that review of appropriateness is completed at required intervals. Person Responsible: The Executive Director is responsible for the completion of department’s REVIEW OF APPROPRIATENESS OF CONTINUED RESIDENCE IN SPECIAL CARE UNIT form or form consistent with it. Due Date: 12/18/24
22VAC40-73-450-E
Based on the record review the facility did not ensure the Individualized service plans shall 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’s #1 ISP dated 10/14/24 and was not signed and dated by the by the licensee, administrator, or designee and the resident or legal guardian.
  2. Resident’s #2 ISP dated 11/15/24 and was not signed and dated by the by the licensee, administrator, or designee and the resident or legal guardian.
  3. The record for resident #3 contains an ISP dated of 6/12/23. The was not updated annually.
  4. Resident’s #4 ISP dated 11/26/24 was not signed by the licensee, administrator, or designee and the resident or legal guardian.
  5. Staff #3 confirmed the records for residents #1, #2, #3, resident #4, did not contain signatures of the licensee, administrator, or designee and the resident or legal guardian.
Plan of correction
22VAC40-73-450-E Individualized Service Plan. Based on record review, the facility did not ensure the Individualized Service Plan (ISP) shall be reviewed and updated at least once every 12 months and as needed for a significant change of a resident’s condition. ___ Yes _X__ No What Has Been Done to Correct? Resident chart audits were initiated on 12/19/24. All resident ISPs will be reviewed/revised by facility staff who have successfully completed department-approved ISP training and signed by the resident and/or resident’s legal representative within 30 days of completion of this audit’s anticipated completion date of 1/31/2025. ___ Yes __X_ No How Will Recurrence Be Prevented? An ISP Binder has been created to maintain a copy of each resident’s comprehensive plan of care. Each comprehensive plan of care will be maintained in the monthly tab consistent with the month of admission. The comprehensive ISP will be reviewed and revised annually on or before the admission anniversary date. Person Responsible: The Director of Resident Services is responsible for ensuring ISPs are reviewed and revised at least once every 12 months and as needed for a significant change of a resident’s condition. The Executive Director is responsible for conducting quarterly audits of 10% of resident charts to ensure comprehensive ISPs are developed and maintained for each resident consisted with the department’s standards on Individualized Service Plans (ISPs) Due Date: 2/28/2025
22VAC40-73-320-B
Based on the record review the facility did not ensure to ensure a risk assessment for tuberculosis (TB) shall be completed annually on each resident as
Evidence
  1. d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence:
  2. The record for resident #1, admission date of 10/14/2023, did not contain evidence of an annual TB assessment.
  3. The record for resident #2, admission date of 11/15/2024, contains a risk assessment for TB that is blank.
  4. The record for resident #4, admission date of 12/28/2022, contains a risk assessment for TB dated 12/15/2022. There is no evidence of an annual TB assessment.
  5. Staff #3 confirmed the records for residents #1, #2 and #3 did not contain an annual risk assessment for TB.
Plan of correction
22VAC40-73-320-B Physical Examination & Report. Based on record review, the facility did not ensure a risk assessment for tuberculosis (TB) shall be completed annually on each resident as evidence by the completion of the current screening published by the Virginia Department of Health or a form consistent with it. ___ Yes _X__ No What Has Been Done to Correct? Resident chart audits were initiated on 12/19/24. All resident will have a TB risk evaluation and completed assessment form signed/dated by appropriate licensed health professional within 30 days of completion of this audit’s anticipated completion date of 1/31/2025. ___ Yes _X__ No How Will Recurrence Be Prevented? During annual resident plan of care meeting, all annually required evaluations, screenings and/or assessments will be completed in conjunction with annual ISP review and revisions. At the time of annual review, and electronic reminder is set to send notification to the Director of Resident Services for completion of annual TB evaluation. Person Responsible: The Director of Resident Services is responsible for ensuring all residents receive an annual TB evaluation and a completed risk assessment form. The Executive Director is responsible for conducting quarterly audits of 10% of resident charts to ensure annual TB risk assessments are completed annually, as required. Due Date: 2/28/25
September 11, 2024Complaint survey1 violation
Inspection dates
09/11/2024, 09/26/2024
Areas reviewed
22VAC40-73 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: 09/26/24 3:00pm to 4:45pm. 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 8/22/24 regarding allegations in the area(s) of: Staffing And Supervision and Resident Care And Related Services. Number of residents present at the facility at the beginning of the inspection: 72 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: 3 Number of interviews conducted with residents:0 Number of interviews conducted with staff: 2 Observations by licensing inspector: An observation of residents, and activity was completed in the assisted living facility. 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at Lanesha.allen@dss.virginia.gov
Violations
22VAC40-73-680-H
Based on a review of the medication administration records and interview, it was determined that the facility did not ensure that that the medication administration record (MAR) includes if the medication was administered or there was an omission.
Evidence
  1. The Medication Administration Record (MAR) for Resident #1 did not indicate whether the medication was administered for multiple medications, dates and times. A. The MAR for Donepezil 10mg tab did not indicate whether the medication was administered, or it was not administered for the following dates and times: 8/1/24 (7:00pm), 8/3/24(7:00pm) 8/5/24(7:00pm), 8/6/24(7:00pm),8/7/24(7:00pm), 8/8/24(7:00pm), 8/9/24(7:00pm), 8/10/24(7:00pm), 8/11/24(7:00pm), 8/12/24(7:00pm), 8/13/24(7:00pm), 8/14/24(7:00pm), 8/15/24(7:00pm), 8/16/24(9:00pm), 8/17/24(7:00pm), 8/18/24(7:00pm), 8/20/24(7:00pm), 8/23/24, (7:00pm), 8/24/24 (7:00pm), 8/25/24(7:00pm), 8/26/24(7:00pm), 8/27/24(7:00pm). B. The MAR for Gabapentin 300mg cap did not indicate whether the medication was administered, or it was not administered for the following dates and times: 8/1/24 (7:00 pm), 8/3/24(7:00 pm) 8/5/24(7:00 pm), 8/6/24(7:00 pm), 8/7/24 (7:00pm), 8/8/24(7:00 pm), 8/9/24(7:00 pm), 8/10/24(7:00 pm), 8/11/24(7:00 pm),8/12/24(7:00 pm),8/13/24(7:00 pm),8/15/24(7:00 pm),8/16/24(7:00 pm),8/17/24(7:00 pm),8/18/24(7:00 pm),8/20/24(7:00 pm),8/23/24(7:00 pm),8/24/24(7:00 pm),8/25/24(7:00 pm),8/26/24(7:00 pm),8/27/24(7:00 pm),8/31/24(7:00 pm). C. The MAR for Propranolol 20mg tab did not indicate whether the medication was administered, or it was not administered for the following dates and times: 8/12/24(2:00pm). D. The MAR for Tramadol 50mg tab did not indicate whether the medication was administered, or it was not administered for the following dates and times: 8/1/24 (6:00 am, 10:00pm), 8/3/24(10:00pm) 8/5/24(10:00pm), 8/6/24(10:00pm), 8/7/24(10:00pm),8/8/24(10:00pm),8/9/24(10:00pm),8/10/24(10:00pm),8/11/24(10:00pm),8/12/24(2:00 pm,10:00pm), 8/13/24(10:00pm),8/14/24(10:00pm),8/15/24(10:00pm),8/16/24(10:00pm),8/17/24(10:00pm),8/18/24(6:00am,10:00pm),8/20/24(10:00pm),8/22/24(6:00 am, 10:00pm), 8/23/24 (10:00 pm), 8/24/24 (10:00 pm), 8/25/24 (10:00 pm), 8/26/24 (10:00 pm).
  2. The Medication Administration Record (MAR) for Resident #2 did not indicate whether the medication was administered for multiple medications, dates and times. A. The MAR for Allergy Reli 10mg tab did not indicate whether the medication was administered, or it was not administered for the following dates and times: 8/6/24 (8:00am), 8/7/24 (8:00am), 8/25/24 (8:00am) B. The MAR for Lisinopril 10mg tab did not indicate whether the medication was administered, or it was not administered for the following dates and times: 8/6/24 (8:00am), 8/7/24 (8:00am), 8/25/24 (8:00am). C. The MAR for Memantine 10 mg tab did not indicate whether the medication was administered, or it was not administered for the following dates and times: 8/6/24 (8:00am), 8/7/24 (8:00am), 8/25/24 (8:00am). D. The MAR for Simvastatin 20mg tab did not indicate whether the medication was administered, or it was not administered for the following dates and times: 8/6/24 (8:00am), 8/7/24 (8:00am), 8/25/24 (8:00am).
  3. The Medication Administration Record (MAR) for Resident #3 did not indicate whether the medication was administered for multiple medications, dates and times. A. The MAR for Atorvastatin did not indicate whether the medication was administered, or it was not administered for the following dates and times:8/3/24(7:00pm) 8/6/24(7:00pm), 8/8/24(7:00pm), 8/9/24(7:00pm),8/12/24(7:00pm),8/13/24(7:00pm),8/15/24(7:00pm),8/16/24(7:00pm),8/17/24(7:00pm),8/18/24(7:00pm), 8/20/24 (7:00pm), 8/22/24(7:00pm), 8/23/24(7:00pm), 8/26/24(7:00pm), 8/27/24(7:00pm) 4, Staff #5 confirmed the medication administration records for residents #1, #2, and #3 did not include notation if the medications were administered or if there was an omission.
Plan of correction
What Has Been Done to Correct? Documented Training of all Med Tech on procedures to document on EMAR and change of shift procedures. How Will Recurrence Be Prevented? Outgoing Med Tech will review omission report on EMAR at end of shift and correct any violations. Incoming Med Tech will report any EMAR omissions to direct supervisor at beginning of shift. Person Responsible: Executive Director, Resident Services Director, Medication Tech or Designee 10/15/24 Re-Training.
September 11, 2024Inspection12 violations
Inspection dates
09/11/2024
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 COMPLAINT INVESTIGATION
Technical assistance
Buildings And Ground Emergency Preparedness
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: 09/11/24 from 08:50am-05:00pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 66 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed:3 Number of interviews conducted with residents:3 Number of interviews conducted with staff: 6 Observations by licensing inspector: 3 Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. Breakfast, lunch and an activity were observed. A medication pass observation was completed for three residents. The following was reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, medication carts, fire inspection report, health inspection report, and a staffing schedule. Water temperature was measured, and the call bell system was monitored. 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 Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at Lanesha.allen@dss.virginia.gov
Violations
22VAC40-73-950-F
Based on the review of the Emergency Preparedness binder and interview, it was determined that the facility did not ensure to review the emergency preparedness plan annually or more often as needed, document the review by signing and dating the plan, and make necessary plan revisions. Such revisions shall be communicated to staff, residents, and volunteers and incorporated into the orientation and semi-annual review for staff, residents, and volunteers.
Evidence
  1. The Emergency Preparedness binder contains the most recent review date as 1/1/2022.
  2. Staff #5 confirms an annual review of the Emergency Preparedness Pan was not completed annually.
Plan of correction
Emergency preparedness binder policy will be reviewed and revised if needed. A copy will be used for all orientations of staff, new residents and volunteers. Emergency preparedness copy of plan will be available at the front desk of the community and will be reviewed with all residents, staff, volunteers. Person Responsible: Maintenance Director, Executive Director or Designee. Plan review 10-1-24, front desk copy 10-1-24, Resident and staff review by 12/15/24
22VAC40-73-640-A
Based on observation, a review of the facility’s medication plan and interview, it was determined that the facility shall have, keep current, and implement a written plan for medication management. The facility's medication plan shall address procedures for administering medication and shall include A plan for proper disposal of medication
Evidence
  1. During the medication cart inspection, Atorvastatin 20mg tabs for resident #8 were found with an expiration date of 03/25/24.
  2. During the medication cart inspection, Allopurinol 100mg tabs for resident #8 were found with an expiration date of 07/31/23.
  3. During the medication cart inspection, Tylenol 650mg tabs for resident #7 were found with an expiration date of 04/2024.
  4. During the medication cart inspection, Centrium Silver tabs for resident #9 was found and it expired on 04/2024.
  6. Staff #2 confirmed the medication for residents #7, #8, and #9 was expired.
Plan of correction
The medication administration plan will be reviewed for administrative and medical disposal procedure for expired medications with all Med Techs. A cart audit will be scheduled with Pharmacy to review medication for compliance. All Med Techs will have the plan available in the medication room as reference. Executive Director, Pharmacy or RSD 11-15-24
22VAC40-73-670-2
Based on observation of the medication pass, a review of three staff records, and interview, it was determined that each staff person who administers medication to residents shall be authorized by § 54.1- 3408 of the Virginia Drug Control Act.
Evidence
  1. Staff #1 was observed administering medication to resident # 1 and resident #10 during the inspection.
  2. The record for staff #1 did not contain documentation to demonstrate that staff #1 was allowed to administer medication.
  3. The Licensing Inspector verified with the Board of Nursing that staff #1 has not been issued her provisional letter that allows her to administer medication.
Plan of correction
10% of Med Tech records will be audited for proper certification compliance and corrected. Executive Director or Resident Service Director will need to approve and review any new Med Techs state credentials prior to being scheduled to work on the medication cart. Business office manager will maintain the files. Executive Director and or Resident Services Director, Business Office Manager
22VAC40-73-1110-B
Based on a review of six resident records and interview, it was determined that six months after placement of the resident in the safe, secure environment and annually thereafter, the licensee, administrator, or designee shall perform a review of the appropriateness of each resident's continued residence in the special care unit.
Evidence
  1. The record for resident #2 did not contain the six-month review.
  2. Resident #2 started residing in the memory care unit on 12/29/22.
  3. Staff #5 confirmed that the six-month review was not completed for resident #2.
Plan of correction
10% of special care unit resident files will be reviewed for compliance of appropriateness. An electronic tickler will be created and reviewed for all special care unit residents to be reviewed bi-annually. Records will be updated and reviewed at this time on going. Person Responsible: Resident Services Director or Designee.
22VAC40-73-260-A
Based on a review of three staff records, it was determined that the facility did not ensure that each direct care staff member shall maintain 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. The record for Staff #2 did not contain a current first aid certification.
  2. Staff #5 reviewed the record for staff # 2 and was unable to provide documentation during the onsite inspection that the staff had a current first aid certification.
Plan of correction
10% of direct care staff will be audited for first Aide Training compliance and corrected. Scheduling trainings with Pharmacy provider to provide staff training. Reoccurring classes will be scheduled to remain compliant and employee tickler file will be created to track all expiration dates of First Aide Training. Person Responsible: Executive Director, Resident Services Director or designee.
22VAC40-73-440-A
Based on the review of six resident records and interview, it was determined that the facility did not ensure that the all residents of and applicants to assisted living facilities shall be assessed face to face using the uniform assessment instrument in accordance with Assessment in Assisted Living Facilities (22VAC30-110). The UAI shall be completed prior to admission, at least annually, and whenever there is a significant change in the resident's condition.
Evidence
  1. The record for Resident #1 contained an UAI dated 04/28/2022.
  2. The record for Resident #2 contained an UAI dated 12/09/2022.
  3. The record for Resident #6 contained an UAI dated 01/24/2022.
  4. Staff #5 confirmed that UAI for residents #1, #2 and #6 were not updated annually.
Plan of correction
10% of resident charts will be audited for UAI compliance and corrected if needed. UAI report will be pulled monthly and audited for compliance for three consecutive months after initial audit and corrections are complete. Person Responsible: Executive Director, Resident Services Director or Designee by 11/15/24 UAI Audit, February 28 additional three-month audit
22VAC40-73-550-G
Based on the review of six resident records and interview, it was determined that the facility did not ensure that the rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each resident, or his legal representative or responsible individual as stipulated in subsection H of this section and each staff person.
Evidence
  1. of this review shall be the resident's, his legal representative's or Evidence:
  2. The record for resident #1 record contained the rights and responsibilities of residents document that was dated 3/13/23.
  3. The record for resident #2 record contained the rights and responsibilities of residents document that was dated 12/29/22.
  4. The record for resident #3 record contained the rights and responsibilities of residents document that was signed and dated.
  5. The record for resident # record contained the rights and responsibilities of residents document that was not signed and dated.
  6. The record for resident #5 record contained the rights and responsibilities of residents document that was not signed and dated.
  7. The record for resident #6 record contained the rights and responsibilities of residents document that was dated 1/24/22
  8. Staff #5 reviewed the records for residents #1, #2, #3, #4, #5 and #6 was unable to provide documentation during the onsite inspection that the resident rights and responsibilities were reviewed annually for each of the residents listed
Plan of correction
A Resident Rights and Responsibilities Review with all residents will be scheduled and continued a minimum of annually thereafter. Annual calendar will be created each year to track compliance dates of Resident Right Review. Person Responsible: Executive Director, Resident Services Director or Designee
22VAC40-73-550-F
Based on the observation of facility postings and interview, it was determined that the facility did not ensure that the name and telephone number of the appropriate regional licensing supervisor of the department, the Adult Protective Services' toll-free telephone number, the toll-free telephone number of the Virginia Long-Term Care Ombudsman Program and any substate (i.e., local) ombudsman program serving the area, and the toll-free telephone number of the disAbility Law Center of Virginia.
Evidence
  1. The posted Rights and Responsibilities didn’t identify the current Licensing Administrator.
  2. The Rights and Responsibilities n the residents records didn’t identify the current Licensing Administrator
  3. Staff #5 confirmed that the posted Rights and Responsibilities and the Rights and Responsibilities in the resident records both did not contain the current Licensing Administrator.
Plan of correction
Executive Director will obtain correct names and phone numbers of agencies for compliance and post. Executive Director will be added to Resident Rights posted. Executive Director will make any changes to names or numbers given at the direction of the department of Social Services. Person Responsible: Executive Director or Designee.
22VAC40-73-320-B
Based on the review of six resident records and interview, it was determined that the facility did not ensure that subsequent tuberculosis evaluations for tuberculosis shall be completed annually on each resident as
Evidence
  1. d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: 1.The record for resident #1 contained tuberculosis screening that was dated 5/24/22.
  2. The record for resident #2 contained tuberculosis screening that was dated 12/15/22. 3.The record for resident #6 contained tuberculosis screening that was dated 1/21/22.
  3. Staff #5 confirmed that the annual TB Assessment was not in each resident’s record and available for viewing during the onsite inspection for resident # 1, resident #2, and resident #6.
Plan of correction
10% of Resident records will be audited for annual TB screening compliance and corrected. An electronic reminder will be set to review resident TB screening prior to each 12-month period. Person Responsible: Executive Director, Resident Services Director or Designee
22VAC40-73-100-B
Based on observation of medication administration and interview, it was determined that the facility did not ensure to implement the procedures for other infection prevention measures related to job duties include: the handling, storing, processing, and transporting of medical waste in accordance with applicable regulations were followed.
Evidence
  1. Staff # 1 passed medication to resident #10, it was observed that staff #1 dropped the medication on the floor and administered to the resident.
  2. Staff # 1 was observed passing medication to resident #1 without proper hand hygiene.
Plan of correction
All Med Techs will receive refresher training on proper medication administration hygiene Executive Director or Designee
22VAC40-73-450-C
Based on the review of six resident records and interview, it was determined that the facility did not ensure that the comprehensive individualized service plan (ISP) shall be completed within 30 days after admission.
Evidence
  1. The record for Resident #1 (date of admission 5/13/22) did not contain an individualized service plan (ISP).
  2. The record for Resident #2 (date of admission 12/28/22) did not contain an individualized service plan (ISP).
  3. The record for Resident #3 (date of admission 7/22/24) did not contain an individualized service plan (ISP).
  4. The record for Resident #5 (date of admission 8/7/24) did not contain an individualized service plan (ISP).
  5. The record for Resident #6 (date of admission 1/24/22) did not contain an individualized service plan (ISP).
  6. Staff #5 reviewed the records for residents #1, #2, #3, #5 and #6 was unable to provide documentation during the onsite inspection that the individualized service plan (ISP) had been completed for each of the residents listed.
Plan of correction
All staff accredited to complete ISPs will review the regulations for compliance. An electronic tickler will be created and set for 20 days from move in dates to review and complete comprehensive ISP. Resident Service Director or Designee will review monthly. Person Responsible: Executive Director, Resident Services Director or Designee
22VAC40-73-450-A
Based on the review of six resident records, it was determined that the facility did not ensure that on or within seven days prior to the day of admission, a preliminary plan of care shall be developed to address the basic needs of the resident hat adequately protects his health, safety, and welfare.
Evidence
  1. The record for Resident #4 (date of admission 8/29/24) did not contain a preliminary plan of care.
  2. Staff #5 reviewed the record for resident #4 and was unable to provide documentation during the onsite inspection that the preliminary plan of care was completed for resident #4.
Plan of correction
All initial move in charts will be reviewed by the Resident Services Director and reviewed and signed off by Executive Director for compliance. A file cover sheet will be signed off by the Executive Director in each new file to review compliance prior to move in. Person Responsible: Executive Director, Business Office Manager or Designee.
June 14, 2024Complaint survey0 violations
Inspection dates
06/14/2024
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: An unannounced complaint inspection took place on June 14, 2024 from 12:00pm- 1:00pm. 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 6/7/24 regarding allegations in the area(s) of: Staffing And Supervision And Resident Care And Related Services Number of residents present at the facility at the beginning of the inspection: 72 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed:0 Number of interviews conducted with residents:1 Number of interviews conducted with staff: 2 Observations by licensing inspector: Observed the Safe Secured unit Additional Comments/Discussion: none An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at lanesha.allen@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 24, 2024Complaint survey1 violation
Inspection dates
05/24/2024
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Complaint Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 5/24/2024 from 10:30am to 12:00pm. 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 5/20/24 regarding allegations in the area(s) of: Safe and Secure Environment. Number of residents present at the facility at the beginning of the inspection: 22 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:1 Number of interviews conducted with residents:0 Number of interviews conducted with staff: 4 Observations by licensing inspector: 3 Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation of non-compliance with standard or law. However, a violation not related to the complaint but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at Donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-250-D
Based on the onsite record review the facility did not ensure each staff person on or within seven days prior to the first day of work at the facility submit the results of a risk assessment, documenting that the individual is free of tuberculosis in a communicable form as
Evidence
  1. d by the completion of the current screening form. Evidence: 1.During the record review for staff #2, the record did not contain evidence of tuberculosis screening prior to the staff’s first day on direct care. 2.Staff #1 confirmed the TB Assessment/results were absent from the record.
Plan of correction
What Has Been Done to Correct? TB has been completed on employee #2. Executive Director, Business Office Manager, and or Designee will complete Employee File Audit . How Will Recurrence Be Prevented? ED, Business Office Manager, or Designee will review charts prior to Start Date and create a Tickler to ensure compliance. Person Responsible: ED or Designee
April 9, 2024Complaint survey5 violations
Inspection dates
04/09/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-80 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: An unannounced complaint inspection took place on 04/09/2024 from 12:10 p.m. to 4:48 p.m. A complaint was received by VDSS Division of Licensing on 03/22/2024 and 03/25/2024 regarding allegations in the area(s) of: Resident Care and Related Services, The Safe, Secure Environment, Buildings and Grounds, and Staffing and Supervision. 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: 73 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: An observation of the safe, secure environment was completed. Additional Comments/Discussion: None 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, The Safe Secure Environment, and Buildings and Grounds. 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 Donesia Peoples, Licensing Inspector at (757) 353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-440-A
Based on the onsite record review the facility failed to ensure the Uniform Assessment Instrument (UAI) shall be completed prior to admission, at least annually, and whenever there is a significant change in the resident’s condition.
Evidence
  1. The record for resident #1, admitted 05/15/23, did not contain a UAI. Staff #4 was unable to provide documentation during the onsite inspection of a completed UAI for resident #1.
Plan of correction
What Has Been Done to Correct? Executive Director, Resident Services Director, & Resident Services Coordinator are Certified UAI Assessors and are now in place and available for all assessments. How Will Recurrence Be Prevented? ED, RSD, or Designee will review charts prior to resident admission, after admission, annually and whenever there is a significant change in condition to ensure regulatory compliance. Person Responsible: ED, RSD, or Designee
22VAC40-73-450-E
Based on the record review the facility failed to ensure the individualized service plan (ISP) shall be signed and dated by the licensee, administrator, or his designee, and by the resident or his legal guardian.
Evidence
  1. Resident’s #1 ISP dated 09/14/23 was not signed and dated by the licensee, resident, or the legal guardian.
  2. Resident’s # 2 ISP dated 03/14/24 was not signed and dated by the licensee, resident, or the legal guardian.
Plan of correction
What Has Been Done to Correct? Chart Audits are in progress How Will Recurrence Be Prevented? All current resident charts will be audited for compliance with regards to required signatures and dates to ensure regulatory compliance. Person Responsible: ED, RSD, or Designee
22VAC40-73-440-B
Based on the record review the facility failed to ensure for private pay individual the UAI shall be completed by one of the qualified assessors: An assisted living facility staff person who has successfully completed state approved training on the UA1 and level of care criteria for either public or private pay assessments.
Evidence
  1. The record for resident #2 contains a UAI that documents the assessment was completed by staff #3. The record for staff #3 did not contain verification staff #3 completed a state approved training on the UAI. Staff #4 was unable to provide documentation staff #3 completed a state approved training on the UAI.
Plan of correction
What Has Been Done to Correct? Executive Director, Resident Services Director, & Resident Services Coordinator are Certified UAI Assessors and are now in place and available for all assessments. How Will Recurrence Be Prevented? Only staff who have successfully completed the state approved UAI course will conduct the UAI’s to ensure regulatory compliance. Person Responsible: ED, RSD, or Designee
22VAC40-73-930-B
Based on staff interviews the facility failed to ensure in buildings licensed to care for 20 or more residents under one roof, there shall be a signaling device that terminates at a central location that is continuously staffed and permits staff to determine the origin of the signal or is audible and visible in a manner that permits staff to determine the origin of the signal.
Evidence
  1. During an interview with staff #4 and staff #5, staff #4 and staff #5 confirmed in the month of March 2024 the signaling device/resident alert call system was not working in the assisted living, and safe, secure environment buildings. Staff #5 confirmed the signaling device/resident alert call system was not working the dates of 02/29/2024-03/25/2024.
Plan of correction
What Has Been Done to Correct? Signaling system has been serviced and upgraded. How Will Recurrence Be Prevented? Signaling system will be tested monthly/as needed by MD, ED, or Designee Person Responsible: ED, MD, or Designee
22VAC40-73-1130-A
Based on the onsite observation the facility failed to ensure except during night hours, when 20 or fewer resident are present, at least two direct care staff members shall be awake and on duty at all times in each special care unit who shall be responsible for the care and supervision of the residents. For every additional 10 residents, or portion thereof, at least one more direct care staff member shall be awake and on duty in the unit.
Evidence
  1. During the onsite observation of the safe, secure unit on 04/09/2024, the Licensing Inspector (LI) observed only two direct care staff members (staff #1 and staff #2) working in the safe, secure unit at the time of 12:25 p.m. Staff #1 and staff #2 confirmed to be the only direct care staff working in the safe, secure unit during the shift of 7am -3pm. During the observation the facility had a recorded census of 24 residents residing in the safe, secure environment.
Plan of correction
What Has Been Done to Correct? Additional staff members have been hired How Will Recurrence Be Prevented? ED, RSD, or Designee will monitor to ensure adequate staffing. <20 Residents but >31 there will be three direct care staff members for Memory Care. The schedule will be reviewed daily to ensure regulatory compliance. Person Responsible: ED, RSD, or Designee
February 1, 2024Complaint survey5 violations
Inspection dates
02/01/2024, 02/21/2024
Areas reviewed
¿ 22VAC40-73 GENERAL PROVISIONS¿ 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES¿ 22VAC40-73 PERSONNEL¿ 22VAC40-73 STAFFING AND SUPERVISION¿ 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS¿ 22VAC40-73 RESIDENT CARE AND RELATED SERVICES¿ 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS¿ 22VAC40-73 BUILDINGS AND GROUND¿ 22VAC40-73 EMERGENCY PREPAREDNESS¿ 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENT22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint An unannounced complaint inspection took place on 02/01/24 from 9:40 am to 2:30 pm and 02/21/24 from 1:37 pm to 2:30 pm. A complaint was received by the Division of Licensing on 01/17/24, 02/15/24, and 02/21/24 regarding allegations in the area(s) of: Resident Care and Related Services, Building and Grounds, and the Safe, Secure Environment. 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: 72 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: 2 Number of interviews conducted with staff: 6 Observations by licensing inspector: Lunch and an activity were observed. The staffing schedule was reviewed. Additional Comments/Discussion: None 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; area(s) of non-compliance with standard(s) or law were: Resident Care and Related Services, Buildings and Grounds, and The Safe Secure Environment. 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. 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 Donesia Peoples, Licensing Inspector at (757) 822-9957 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-450-H
Based on the record review the facility failed to ensure that personal assistance and care are provided to each resident as necessary so that the needs of the resident are met, including assistance or care with: The activities of daily living: Bathing at least twice a week, but more often if needed or desired.
Evidence
  1. Resident’s #2 Uniform Assessment Instrument (UAI) dated 07/28/23 documents the resident needs mechanical and human help (supervision) with bathing. Resident’s #2 ISP documents the following: “staff will provide verbal cues for use of handrails during transfers while resident bathes.” Resident’s #2 activities daily log for Jan. 2024 does not include documentation of the resident receiving assistance with bathing the dates of 01/06/24 through 01/31/24.
Plan of correction
Not published by VDSS.
22VAC40-73-1130-A
Based on the onsite observation the facility failed to ensure except during night hours, when 20 or fewer resident are present, at least two direct care staff members shall be awake and on duty at all times in each special care unit who shall be responsible for the care and supervision of the residents. For every additional 10 residents, or portion thereof, at least one more direct care staff member shall be awake and on duty in the unit.
Evidence
  1. During the onsite observation of the safe, secure unit on 02/21/24, the Licensing Inspector (LI) observed only one direct care staff member (staff #4) working in the safe, secure unit at the time of 1:38 p.m. Staff #4 confirmed to be the only direct care staff working in the safe, secure unit during the shift of 7am -3pm.
  2. The facility’s census list dated 02/21/24 documented a total of 20 residents on site in the safe, secure unit. Staff #4 confirmed a total of 20 residents were on site in the safe, secure unit on 02/21/24.
Plan of correction
Not published by VDSS.
22VAC40-73-450-E
Based on the record review the facility failed to ensure the individualized service plan (ISP) shall be signed and dated by the licensee, administrator, or his designee, and by the resident or his legal guardian.
Evidence
  1. Resident’s #1 ISPs dated 10/30/23 and 11/28/23 was not signed and dated by the resident or the legal guardian.
Plan of correction
Not published by VDSS.
22VAC40-73-320-A
Based on the record review the facility failed to ensure within the 30 days preceding admission, a person shall have a physical examination by an independent physician. The report of such examination shall be on file at the assisted living facility and shall contain the following: the signature of the examining physician or his designee.
Evidence
  1. Resident’s #1 physical exam dated as completed on 09/18/23 does not include a signature of the examining physician or his designee. Staff #2 confirmed resident’s #1 physician exam did not include signature of the examining physician or his designee.
Plan of correction
Not published by VDSS.
22VAC40-73-930-D
Based on the record review the facility failed to ensure for each resident with an inability to use the signaling device the following shall be met: once the resident has gone to bed each evening until the resident has arisen each morning, at a minimum direct care staff shall make rounds no less than every two hours; the facility shall document the rounds that were made, which shall include the name of the resident, the date and time of the rounds, and the staff member who made the rounds. The documentation shall be retained at the facility for two years.
Evidence
  1. Residents #1, and #2 ISPs documents the following: “Resident will be checked on every 2 hours, resident unable to acclimate to use of call bell.” The record for residents #1, #2, did not include documentation of the time rounds were made during the shifts of 3pm -11pm and 11pm and 7 am for the month of Jan. 2024.
Plan of correction
Not published by VDSS.
December 8, 2023Inspection5 violations
Inspection dates
12/08/2023
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
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: An unannounced monitoring inspection took place on 12/08/2023 from 8:50 am to 11:45 am. A self-reported incident was received by VDSS Division of Licensing on 11/06/23. 11/22/23, and 11/23/23 regarding allegations in the area(s) of: Resident Care and Related Services, and the Safe, Secure Environment. 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: 77 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: 6 Observations by licensing inspector: Lunch and an activity were observed. The staffing schedule was reviewed. Additional Comments/Discussion: None 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. A violation notice was 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. 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 Donesia Peoples, Licensing Inspector at (757) 353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-930-D
Based on the record review the facility failed to ensure for each resident with an inability to use the signaling device the following shall be met: once the resident has gone to bed each evening until the resident has arisen each morning, at a minimum direct care staff shall make rounds no less than every two hours; the facility shall document the rounds that were made, which shall include the name of the resident, the date and time of the rounds, and the staff member who made the rounds. The documentation shall be retained at the facility for two years.
Evidence
  1. Resident’s #1 Individualized Service Plan (ISP) dated 06/25/23 includes the “resident will be checked on every 2 hours. Resident is unable to acclimate to use of call bell.” Resident’s #1 record did not include documentation rounds were made for Nov. 2023 and Dec. 2023.
Plan of correction
All clinical staff will receive education/in service regarding 2 hour checks 2 hour check forms will be completed and turned in at the end of each shift. Resident services coordinator and/or designee will ensure 2 hour check forms are submitted. Resident services director will review forms for completion Executive Director and Resident Services Director or Resident Services Coordinator 1/31/2024
22VAC40-73-320-A
Based on the record review and staff interview the facility failed to ensure within the 30 days preceding admission, a person shall have a physical examination by an independent physician. The report of such examination shall be on file at the assisted living facility.
Evidence
  1. The record for resident #2, admission date 11/21/23, did not contain a physical examination.
  2. Staff #2 acknowledged the facility did not have a record of the resident’s physical examination.
Plan of correction
The physical exam was present in resident's chart. Resident services director and/or designee will continue to monitor all resident exams and pertinent paperwork for completion prior to resident's admission. Resident services director and/or designee will continue to monitor all resident exams and paperwork for completion prior to resident's admission. Executive Director will check resident charts for completion and accuracy monthly. Executive Director and Resident Services Director 12/08/2023
22VAC40-73-460-D
Based on the record review and staff interview the facility failed to ensure the facility shall provide supervision of resident schedules, care, and activities to include attention to specialized needs, such as wandering from the premises.
Evidence
  1. During an interview with staff #1, staff #1 stated during morning rounds on 11/22/23 at 7:30 am, resident #2 was not located in the safe secure unit. During an interview with staff #3, staff #3 discovered a broken window located in an unoccupied room and based on the facility’s internal investigation it was determined resident #2 exited the safe secure unit through the window.
  2. Resident’s #2 incident report dated 11/28/23 documents “resident #2 was last seen by facility staff on 11/22/23 at 5:30 a.m. Resident #2 was located by staff #5 and Staff #6 around 1:00 p.m.”
  3. During an interview with staff #5, and staff #6, staff #5 and staff #6 stated they located resident #2 off the premises of the facility on 11/22/23 in the city of Chesapeake. Staff #5 stated resident #2 was located in the afternoon around “lunchtime.”
  4. Resident’s #2 Assessment for Serious Cognitive Impairment dated 09/22/23 documents a diagnosis of Dementia.
Plan of correction
Resident was discharged from facility 11/23/2023. Staff received in service and education regarding memory care residents and safety. Executive Director, Resident services director and/or designee will assess and/or monitor resident behaviors to ensure resident safety and appropriateness. Service plans will be updated as needed and upon significant change. Executive Director, Resident Services Director and/or Resident services coordinator 1/31/2024
22VAC40-73-1150-B
Based on staff interview, and the record review the facility failed to ensure there shall be protective devices on windows in common areas accessible to residents to prevent windows from being opened wide enough for a resident to crawl through.
Evidence
  1. During an observation on 12/08/23, the Licensing Inspector (LI) observed a window located in the common area in the safe, secure unit to be missing the bottom frame window glass. The LI observed cardboard held in place by duct tape located in the area where the window glass was missing. The window did not contain a protective device to prevent the window from being opened.
  2. During an interview with staff #3, staff #3 stated on 11/23/23 resident #2 broke the window glass located in the common area/dining area, and staff #3 used cardboard and duct tape to cover the open area where the window glass was missing.
Plan of correction
The broken window was replaced 12/19/2023. Residents will be assessed for appropriate memory care placement. Staff will receive training regarding de-escalation and redirection of memory care residents. All memory care windows will be checked for safety and security, monthly Executive Director, Resident Services Director and Maintenance Director 1/31/2024
22VAC40-73-1150-A
Based on record review, and staff interview the facility failed to ensure doors that lead to unprotected areas be monitored or secured through devices that conform to applicable building and fire codes, including door alarms, cameras, constant staff oversight, security bracelets that are part of an alarm system, pressure pads at doorways, delayed egress mechanisms, locking devices, or perimeter fence gates for residents residing in a safe, secure environment.
Evidence
  1. Resident’s #1 incident report dated 11/09/23 documents “on 11/05/23 @ 12:40 pm, dietary staff entered the memory care unit, staff didn’t ensure the door was securely locked and resident #1 left the unit and sat on the front porch. 10 minutes later, resident #1 was discovered by dietary staff on the front porch.”
  2. During an interview with staff #1, staff #1 acknowledged on 11/05/23, resident #1 exited the safe secure unit through an unlocked front door leading to the facility’s parking lot. The front door leads to an unsecured parking lot area.
  3. Resident’s #1 assessment for serious cognitive impairment dated 05/16/23 documents the resident diagnosis as the following: severely impaired cognitive and memory due to Alzheimer’s Dementia.” Resident’s #1 physical examination dated 05/16/23 documents the resident diagnosis as “Alzheimer’s Dementia.”
Plan of correction
All staff will receive education and training regarding resident elopement. Maintenance Director and/or designee will perform elopement drills, monthly Maintenance Director and/or designee will perform exit door checks in memory care unit weekly Elopement drills and exit checks will be reviewed by Executive Director or designee monthly Executive Director and Maintenance Director 01/31/2024
September 8, 2023Inspection1 violation
Inspection dates
09/08/2023
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
e of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced monitoring inspection took place on 09/08/2023 from 8:16 am to 5:25 pm. A self-reported incident was received by VDSS Division of Licensing on 08/22/23 and 08/27/23 regarding allegations in the area(s) of: Personnel and Resident Care and Related Services The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 81 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 1 Observations by licensing inspector: Breakfast, lunch, and an activity were observed. A medication pass observation was completed for two residents. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the self-report area(s) of non-compliance with standard(s) or law were: Personnel A violation notice was 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. 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 Donesia Peoples, Licensing Inspector at (757) 353-0430 or by email at donesia.peoples@dss.virginia.gov 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: An unannounced monitoring inspection took place on 09/08/2023 from 8:16 am to 5:25 pm. A self-reported incident was received by VDSS Division of Licensing on 08/22/23 and 08/27/23 regarding allegations in the area(s) of: Personnel and Resident Care and Related Services The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 81 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 1 Observations by licensing inspector: Breakfast, lunch, and an activity were observed. A medication pass observation was completed for two residents. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the self-report area(s) of non-compliance with standard(s) or law were: Personnel A violation notice was 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. 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 Donesia Peoples, Licensing Inspector at (757) 822-9957 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-110-1
DESCRIPTION OF VIOLATION Based on the record review and resident interview the facility failed to ensure all staff shall be considerate and respectful of the rights, dignity, and sensitiveness of persons who are aged, infirm, or disabled.
Evidence
  1. The record for resident #2 contains a incident report dated 08/22/23 documenting the following: “resident #2 made allegations of staff speaking to the resident in an unpleasant manner as well as handling the resident rough during ADL care; both staff #1 and staff #2 have been terminated from their positions.”
  2. During an interview with resident #2, resident #2 confirmed staff #1 and staff #2, were “very rude” when communicating to the resident and staff #2 “refused to help and take the resident to the dining room.”
Plan of correction
All active employee records will be checked for resident abuse training. Employees that have not received training will receive formal training. Staff will be in serviced upon hire and annually about resident abuse. Records will be reviewed by HR or designee monthly Completion date 10/22/2023
September 8, 2023Complaint survey2 violations
Inspection dates
09/08/2023
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 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: An unannounced complaint inspection took place on 09/08/2023 from 8:16 am to 5:25 pm. A complaint was received by VDSS Division of Licensing on 09/01/23 regarding allegations in the area(s) of: Resident Care and Related Services The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 81 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 9 Number of staff records reviewed: 5 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 5 Observations by licensing inspector: Breakfast, lunch, and an activity were observed. A medication pass observation was completed for two residents. Additional Comments/Discussion: None 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 Donesia Peoples, Licensing Inspector at (757) 353-0430 or by email at donesia.peoples@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: An unannounced complaint inspection took place on 09/08/2023 from 8:16 am to 5:25 pm. A complaint was received by VDSS Division of Licensing on 09/01/23 regarding allegations in the area(s) of: Resident Care and Related Services The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 81 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 9 Number of staff records reviewed: 5 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 5 Observations by licensing inspector: Breakfast, lunch, and an activity were observed. A medication pass observation was completed for two residents. Additional Comments/Discussion: None 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 Donesia Peoples, Licensing Inspector at (757) 822-9957 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-450-F
The facility failed to ensure the Individualized Service Plan (ISP) shall be reviewed annually and updated at least once every 12 months.
Evidence
  1. The record for resident #6, contains an ISP completed 03/28/22. The resident’s record does not contain an ISP completed at least 12 months after 03/28/22.
Plan of correction
Not published by VDSS.
22VAC40-73-440-A
Based on the record review and staff interview the facility failed to ensure the Uniform Assessment Instrument (UAI) shall be completed prior to admission, and at least annually.
Evidence
  1. The record for resident #4, contains a UAI dated 10/18/21. The resident’s record does not contain a UAI completed annually after 10/18/21.
  2. The record for resident #6, contains a UAI dated 03/24/22. The resident’s record does not contain a UAI completed annually after 03/24/22.
  3. The record for resident #10, admission date 08/10/23, did not contain a UAI.
Plan of correction
Clinical staff will receive education/in-service regarding UAI regulations. All active resident charts will be reviewed for UAI’s dated within compliance All residents UAI’s, not within compliance date will be updated. Resident UAI’s will be reviewed by Nurse Manager or designee monthly Completion date 10/22/2023
September 8, 2023Inspection10 violations
Inspection dates
09/08/2023
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced renewal inspection took place on 09/08/2023 from 8:16 am to 5:25 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 81 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 9 Number of staff records reviewed: 5 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 5 Observations by licensing inspector: Breakfast, lunch, and an activity were observed. A medication pass observation was completed for two residents. Water temperatures were measured. Additional Comments/Discussion: None 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 Donesia Peoples, Licensing Inspector at (757) 822-9957 or by email at donesia.peoples@dss.virginia.gov The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 81 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 9 Number of staff records reviewed: 5 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 5 Observations by licensing inspector: Breakfast, lunch, and an activity were observed. A medication pass observation was completed for two residents. Water temperatures were measured. Additional Comments/Discussion: None 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 Donesia Peoples, Licensing Inspector at (757) 353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-990-C
Based on the onsite review the facility failed to ensure at least every six months, all staff currently on duty on each shift shall participate in an exercise in which the procedures for resident emergencies are practiced. Documentation of each exercise shall be maintained in the facility for at least two years.
Evidence
  1. The facility did not provide documentation of staff participation in an exercise in which the procedures for resident emergencies were practiced every 6 months.
Plan of correction
Maintenance Director was educated on regulations for fire and emergency evacuation drills Maintenance Director provided with adequate fire drill forms within regulations. Maintenance Director will conduct Fire and emergency evacuation drills on various shifts Fire and emergency evacuation drills will be reviewed by Executive Director monthly Completion date 10/22/2023
22VAC40-73-210-B
Based on the staff record review the facility failed to ensure in a facility licensed for both residential and assisted living care, all direct care staff shall attend at least 18 hours of training annually.
Evidence
  1. The record for staff #3, hired 10/31/16, did not include documentation of 18 hours of annual training.
  2. The record for staff #4, hired 12/14/21, did not include documentation of 18 hours of annual training.
Plan of correction
All active direct care employee records will be checked for continuing education. Employees that have not received training will receive formal training. Staff will receive education upon hire and annually. Records will be reviewed by HR or designee monthly. Completion date 10/22/2023
22VAC40-73-290-B
Based on observation the facility failed to develop and implement a procedure for posting the name of the current on-site person in charge.
Evidence
  1. Upon arrival at the facility on 9/08/23 at 8:16 a.m. the LI observed a posting that listed the manager on duty as staff #7. Staff #7 was not on site at the facility upon the LI arrival at the facility.
Plan of correction
Manager on Duty form was updated. Manager on duty form will be posted at entrances Record on manager on duty schedule will be kept in binder. Executive Director of designee will review binder monthly Completion date 10/22/2023
22VAC40-73-430-H-1
Based on the record review the facility failed to ensure at the time of discharge, the assisted living facility shall provide to the resident, and as appropriate, his legal representative and designated contact person a dated statement.
Evidence
  1. The record for resident #7, discharge date of 05/22/23, did not contain documentation of a dated discharge statement.
Plan of correction
Discharge documentation will be sent to resident/POA via certified mail. Staff will receive in service regarding resident discharge and documentation Residents discharged within the last 6 months will be reviewed for accurate discharge information. Records will be reviewed by Executive Director or designee monthly Completion date 10/22/2023
22VAC40-73-320-A
Based on the record review the facility failed to ensure within the 30 days preceding admission, a person shall have a physical examination by an independent physician and shall include the following: results of a risk assessment documenting the absence of tuberculosis (TB) in a communicable form.
Evidence
  1. The record for resident #1, admission date of 8/14/23, contains a TB risk assessment completed 1/13/23, which is more than 30 days prior to the resident’s admission date.
Plan of correction
All active resident records will be checked for active TB assessment. All residents, not within compliance date will be screened. Resident records will be updated pending screening. Records will be reviewed by Nurse Manager or designee monthly Completion date 10/22/2023
22VAC40-73-250-D
Based on the staff record review the facility failed to ensure each staff person required to be evaluated shall annually submit the results of a risk assessment, documenting that the individual is free of tuberculosis (TB) in a communicable form as
Evidence
  1. by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence:
  2. The record for staff # 3, contains a TB risk assessment completed 03/18/22. The staff record does not contain a TB risk assessment completed after 03/18/22.
  3. The record for staff # 4, contains a TB risk assessment completed 11/23/21. The staff record does not contain a TB risk assessment completed after 11/23/21.
Plan of correction
All active employee records will be checked for First Aid and CPR certification. Employees that have not received training will receive formal training. Staff will receive training annually. Records will be reviewed by HR or designee monthly. Completion date 10/22/2023
22VAC40-73-490-A
Based on the record review the facility failed to ensure for residents who meet the criteria for assisted living care, if the facility employs a licensed health care professional who is on site on a full-time basis, a licensed health care professional practicing within the scope of his profession, shall provide health care oversight at least every six months.
Evidence
  1. The facility record contains documentation of a health care oversight dated 02/07/23-02/09/23 and 02/14/23-02/16/23. The facility did not provide record of a health care oversight completed six months after the date of 02/16/23.
Plan of correction
Nurse Manager will complete healthcare oversight Nurse Manager will receive education on timeliness of healthcare oversight within regulations Consultation Company will review healthcare oversight for accuracy upon completion Completion date 10/22/2023
22VAC40-73-550-G
Based on the staff record review the facility failed to ensure the rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each staff person.
Evidence
  1. The record for staff #3 contains an annual review of rights and responsibilities dated 01/21/22. The staff record does not contain an annual review of rights and responsibilities of residents completed after the date of 01/21/22.
  2. The record for staff #4 contains an annual review of rights and responsibilities dated 12/24/21. The staff record does not contain an annual review of rights and responsibilities of residents completed after the date of 12/24/21.
Plan of correction
All active resident files will be reviewed for annual signature. All active Resident/POA will receive copy of resident rights once signed. Executive Director or designee will review monthly. Date of completion 10/22/2023
22VAC40-73-970-E
Based on the facility record review the facility failed to ensure a record of the required fire and emergency evacuation drills shall include: the method used for notification of the drill; any special conditions stimulated; weather conditions.
Evidence
  1. The facility’s fire dill records dated 06/09/23, 07/18/23, and 8/29/23 did not include the method used for notification, any special conditions stimulated, and the weather conditions.
Plan of correction
Maintenance Director was educated on regulations for fire and emergency evacuation drills Maintenance Director provided with adequate fire drill forms within regulations. Maintenance Director will conduct Fire and emergency evacuation drills on various shifts Fire and emergency evacuation drills will be reviewed by Executive Director monthly Completion date 10/22/2023
22VAC40-73-260-A
Based on the staff record review the facility failed to ensure each staff member shall maintain current certification in first aid.
Evidence
  1. The record for staff #3, hired 10/31/16, contains a first aid certification with an expiration date of 01/14/22. Staff # 3 record does not contain a current certification in first aid. 2.The record for staff #4, hired 12/14/21, did not contain documentation of certification in first aid.
Plan of correction
All active employee records will be checked for First Aid and CPR certification. Employees that have not received training will receive formal training. Staff will receive training annually. Records will be reviewed by HR or designee monthly. Completion date 10/22/2023
June 28, 2023Complaint survey5 violations
Inspection dates
06/28/2023
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-80 THE LICENSE22VAC40-80 COMPLAINT INVESTIGATION
Technical assistance
Weekly Breakfast Menu
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: An unannounced complaint inspection took place on 6/28/2023 from 11:19am to 5:00 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 06/22/2023 regarding allegations in the areas of: Personnel, Resident Care and Related Services, Staffing and Supervision, and the Safe, Secure Unit. Number of residents present at the facility at the beginning of the inspection: 95 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: An observation of lunch was completed and a review of the facility’s staffing schedule, and smoking policy was completed. Additional Comments/Discussion: None 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, Resident Care and Related Services, and Safe, Secure Unit. 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-1130-C
Based on staff interview and review of the staff schedule the facility failed to ensure during night hours, the following number of direct care staff members shall be awake and on duty at all times in each special care unit and responsible for the care and supervision of the residents: when 23 to 32 residents are present at least three direct care staff members.
Evidence
  1. The staffing schedule for the safe, secure unit for June 2023 documented only two direct care staff members scheduled for the shift of 11pm to 7am from 06/01/2023 through 06/26/2023. 2.During an interview with staff # 5, the staff confirmed only two direct care staff members were scheduled, and awake on duty in the safe, secure unit for the 11pm to 7 am shift from 06/01/2023 through 06/26/2023. The staff confirmed the facility census in the safe secure unit has been in the range of 23 to 32 residents for the month of June 2023, and the census as of 06/28/23 was 29 residents.
Plan of correction
Corrective action has been taken to help to enhance staffing and to ensure the deficient practice does not recur, multiple clinical staff were hired for all three shifts pending the completion their background checks, orientation, and training process.
22VAC40-73-40-B
Based on observation the licensee failed to ensure that the current license is posted in the facility in a place conspicuous to the residents and the public.
Evidence
  1. During a tour of the facility on 06/28/2023 the Licensing Inspector (LI) observed the previous license effective 10/01/2021-09/30/2022 to be posted in the facility. The current license, effective 10/01/2022-09/30/2023 was not posted in the facility.
Plan of correction
Current License Posted
22VAC40-73-70-A
Based on the record review the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident.
Evidence
  1. The record for resident #4 contains a progress note dated 06/09/2023 documenting “resident found coughing and admits to feeling short of breath, resident sent out via 911 for observation and treatment.” The facility did not notify the regional licensing office of the resident being sent to the hospital for observation and treatment.
  2. The record for residents #1 and #2 contains a progress noted dated 06/06/23 that documents “at approximately 6:30 pm resident was able to make it out of the Memory care building, the resident was found on the sidewalk by the Assisted Living facility.” The facility did not notify the regional licensing office within 24 hours of the incident of the residents exiting and wandering outside of the safe, secure unit.
  3. The record for resident #5 contains a progress note dated 06/10/23 documenting “resident was sent out to ER due to a fall, staff found resident on the floor in the dining room with a laceration in front of the resident’s head.” The facility did not notify the regional licensing office of the resident visit to the ER due to a fall, and laceration in front of the resident’s forehead.
Plan of correction
100% of Staff will be in serviced to inform Nursing Management of ALL residents sent out to the hospital. Nurse Management or designee will perform audit of all residents sent out for the month of July, moving forward, with notification to Licensing Office.
22VAC40-73-1150-A
Based on staff interview, the facility failed to ensure doors that lead to unprotected areas be monitored or secured through devices that conform to applicable building and fire codes, including door alarms, cameras, constant staff oversight, security bracelets that are part of an alarm system, pressure pads at doorways, delayed egress mechanisms, locking devices, or perimeter fence gates for residents residing in a safe, secure environment.
Evidence
  1. The record for residents #1 and #2 contains a progress noted dated 06/06/23 that documents “at approximately 6:30 pm resident was able to make it out of the Memory care building, the resident was found on the sidewalk by the Assisted Living facility.”
  2. During an interview with staff #5, the staff confirmed residents #1 and #2 exited the safe, secure unit building through the front door that leads to an unsecured parking lot, the door was opened and not locked when the residents exited the building.
Plan of correction
Maintenance fixed door and changed code All exits in memory care were checked for elopement risks Maintenance Director or designee will perform weekly checks on memory care exits. Executive Director or designee will sign off on audit tool weekly
22VAC40-73-130-A
Based on interviews and the staff record review the facility failed to ensure all staff who are mandated reporters under code 63.2-1606 of the Code of Virginia shall report suspected abuse, neglect, or exploitation of residents in accordance with that section.
Evidence
  1. The record for staff #1 contains documentation dated 03/19/2023 to include resident #6 complained of being verbally abused by staff #1. The documentation included “resident #6 stated that staff #1 talked to her very rude and disrespectful, wasn’t giving the resident, the resident’s medication, and was yelling at the resident.”
  2. During an interview with staff #4, #6, and #7, the staff did not confirm, and did not provide documentation to confirm the facility reported the suspected abuse to Adult Protective Services (APS).
  3. During an interview on 06/28/23 with resident #6, the resident informed the Licensing Inspector (LI) that during the weekend of March 17, and March 18 2023 staff #1 was “verbally disrespectful” to the resident, and staff #1 “refused” to give the resident, the resident’s eyedrops medication.
  4. During a call on 07/13/2023 with the City of Chesapeake APS Worker, the worker was not able to locate a report of suspected abuse made for resident #1.
Plan of correction
Affected resident interviewed regarding safety, employee removed from unit. All residents and/ or POA will be interviewed regarding abuse and safety of facility. 100% of Staff will be in serviced regarding abuse and reporting.
July 21, 2022Complaint survey3 violations
Inspection dates
07/21/2022,07/27/2022
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS
Comments
Type of inspection: Complaint An unannounced complaint inspection was conducted on 7-21-22 (AR 09:45 a.m./dep 1:30 p). The Acknowledgement of Inspection form was sent to the Administrator. A complaint was received by VDSS Division of Licensing on 6-6-22 regarding allegations in the area of administration and administrative services, resident care and related services. Preliminary Exit conducted on 7-27-2022. The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. The final exit was conducted on 8-8-2022. 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 (Willie Barnes), Licensing Inspector at 757-439-6815 or by email at willie.barnes@dss.virginia.gov
Violations
22VAC40-73-70-A
Based on record reviewed and staff interviewed the facility failed to report to the licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident.
Evidence
  1. On 7-21-22 during a complaint inspection, resident #1’s record documented incidents that were not reported to the licensing office. The facility charting notes document for resident #1 documented on 1-23-22, resident sent out via 911 due to fall and complain of right shoulder and back pain. On 2-5-22, resident was sent out via 911 after being found on the floor with blood on face and head/ update on 2-6-22 (late entry)- resident returned from ER with an eyebrow laceration. On 3-2-22, resident sent out ER following pulling out catheter, some bleeding and a lot of pain and agitation. On 3-19-22, resident sent out via 911, unwitnessed fall in dining room which resulted to abrasion to left side of head and left arm. On 4-5-22 resident sent out because of excessive bleeding from lower extremities.
  2. On 7-27-22, staff #2 acknowledged resident’s incidents as noted in resident’s record.
Plan of correction
• ED, RSC, RSD or designee will ensure that all major incidents that negatively affect or threaten the life, safety, or welfare of all residents are reported in an effective manner with the 24 hour notification template that the community has created. The ED, RSD, RSC or designee will keep a copy of the correspondence located in the DSS Incident binder. oDate to be completed Immediately and Ongoing as of 07-27-2022
22VAC40-73-325-A
Based on record reviewed and staff interviewed, the facility failed to ensure the resident’s fall risk rating shall be reviewed and updated when the condition of the resident changes and after a fall.
Evidence
  1. On 7-21-22 during a complaint inspection, the resident’s record did not included documentation of a risk rating following resident’s fall documented in resident’s charting notes. The fall risk rating in the record was dated 1-9-22. The record noted falls on 1-23-22, 2-5-22, 2-6-22, 2-7-22 and 3-9-22.
  2. Staff #1 acknowledged the fall risk rating was not completed for the aforementioned resident following each fall.
Plan of correction
• RSD, RSC, or designee will ensure that fall risk ratings are reviewed and updated when a resident has a change in condition or after a fall. Documentation of the review and any updates on the fall risk rating will be included in resident’s charts per state guidelines. o Date to be completed: Immediately and Ongoing as of 07-27-2022.
22VAC40-73-320-A
Based on record reviewed and staff interviewed, the facility failed to ensure prior to admission, the results of a risk-assessment documenting the absence of tuberculosis in a communicable form,
Evidence
  1. d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. The admitting physical should include all required information. Evidence:
  2. On 7-21-22 during a complaint inspection, resident #1’s record did not include documentation of the absence of tuberculosis (TB) prior to admission. Resident’s date of admission was documented as 1-9-22.
  3. The admitting physical dated 1-7-22 did not include the resident’s address, telephone number, height, weight and blood pressure.
  4. Staff #1 acknowledged the resident’s physical was not completed as required and the TB assessment was not in the aforementioned record.
Plan of correction
• ED, RSD, RSC, or designee will ensure that Virginia Department of Health forms are included and completed in entirety in the admission Health & Physical. Prior to move-in the community will have two individuals, either the ED, RSD, or RSC review the required admission paperwork via the Admission Checklist, to ensure that it is completed in entirety. Date to be completed Immediately and Ongoing as of 07-27-2022
July 15, 2022Inspection11 violations
Inspection dates
07/15/2022,07/21/2022,07/27/2022
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Renewal An unannounced renewal inspection was conducted by two inspectors (ERO and PLO) on 7-15-22, day one. (Ar 06:45/dep 17:10). Day 2 was conducted by one inspector on 7-21-22 (Ar 09:45/dep 13:30). The facility census on day 1 was 83. A medication pass observation was conducted, a tour of the facility was conducted, emergency preparedness items reviewed, signaling and water temperature observed. Staff and resident interviews and record reviews were conducted. The Acknowledgement of Inspection form was sent via email to the Administrator for both days of the inspection. The final exit meeting will be scheduled. 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 (Willie Barnes), Licensing Inspector at 757-439-6815 or by email at willie.barnes@dss.virginia.gov
Violations
22VAC40-73-710-B
Based on record reviewed and staff interviewed, the facility failed to ensure physical restraints was only used as a medical/orthopedic restraint for support, according to a physician’s written order and with the written consent of the resident or the legal representative.
Evidence
  1. On 7-21-22, resident #5’s individualized service plan (ISP) dated 5-10-22 documented resident bed contained half rails and was used for turning/positioning. The record did not include a physician’s order for the use of the bed rails for support.
  2. On 7-21-22, staff #1 and #2 acknowledged the aforementioned resident’s record did not have a physician’s order for the side rails for support/positioning.
Plan of correction
• ED, RSD, RSC or designee will ensure that all physical restraints including bedrails that are utilized for positioning or support are accompanied into the community with a written physicians order in addition to written consent of the resident or their POA. o Date to be completed Immediately and Ongoing as of 07-30-2022
22VAC40-73-280-A
Based on record reviewed and staff interviewed, the facility failed to ensure it had staff adequate in knowledge, skills and abilities and sufficient in numbers to provided services to attain and maintain the physical, mental, and psychosocial well-being of each resident as determined by resident assessments and individualized service plans, and to ensure compliance with the regulation.
Evidence
  1. On 7-15-22, the staff scheduled provided for the nursing department for the assisted living and the memory care did not have a medication staff on duty for the 3rd shift (11 p to 7a) on the following dates: 7-1-22; 7-4-22; 7-10-22; 7-15-22; 7-18-22 and 7-23-22.
  2. On 7-27-22, staff #1 acknowledged the staffing schedule did not have a medication administration staff on duty on the aforementioned dates.
Plan of correction
• ED, RSD, or designee will ensure that a Medication Aide is on duty for each shift. o Date to be completed: Immediately and Ongoing as of 07-27-2022. RCC has covered 11p – 7a as needed to ensure compliance as of 07-27-2022.
22VAC40-73-450-D
Based on record reviewed and staff interviewed, the facility failed to ensure when hospice care is provided to a resident, the assisted living facility and the licensed hospice organization shall communicate and establish an agreed upon coordinated plan of care for the resident. The services provided by each shall be included on the individualized service plan (ISP).
Evidence
  1. On 7-15-22, resident #4’s record documented resident receives hospice care services from a local agency. The services provided were not document on the ISP dated 7-1-21.
  2. On 7-15-22 and 7-27-22, staff #1 acknowledged, the aforementioned residents’ ISP did not include what services were provided and when services would be provided.
Plan of correction
• ED, RSD, RSC or designee will ensure that if Hospice care is provided to a resident that the ISP for said resident reflects the services provided by the Hospice Company. ED, RSD, RSC or designee will communicate with Hospice agency to ensure that open communication between community and Hospice Company is reflective to any changes, and said changes in care can be updated in ISP. o Date to be completed Immediately and Ongoing as of 07-30-2022
22VAC40-73-250-C
Based on record reviewed and staff interviewed, the facility failed to ensure a staff record included a copy of the sworn disclosure statement.
Evidence
  1. On 7-15-22, staff #11’s record did not have documentation of a sworn disclosure statement.
  2. On 7-15-22 and 7-27-22, staff #1 acknowledged the aforementioned staff did not have a signed sworn disclosure statement.
Plan of correction
• ED, BOM, or designee will ensure that staff members have a completed Sworn Disclosure Statement in their file prior to pulling their required background checks in order to remain compliant with the DSS Standard above. o Date to be completed Immediately and Ongoing as of 08-03-2022
22VAC40-73-320-A
Based on record reviewed and staff interview, the facility failed to ensure a resident’s record included the results of a risk assessment documenting the absence of tuberculosis in a communicable form as
Evidence
  1. d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence:
  2. On 7-15-22, resident #2’s record did not have documentation of the results of a risk assessment documenting the absence of tuberculosis prior to admission. The resident’s date of admission was documented as 1-4-22.
  3. On 7-15-22 and 7-27-22, staff #1 acknowledged the aforementioned resident’s record did not include a risk assessment.
Plan of correction
• ED, RSD, or designee will ensure that all residents have an TB risk assessment performed by an appropriate provider and that this assessment is placed in their file prior to admission. o Date to be completed Immediately and Ongoing as of 07-30-2022
22VAC40-73-440-D
Based on record reviewed and staff interviewed, the facility failed to ensure the uniformed assessment instrument (UAI) for private pay individuals, in an assisted living facility was completed as required.
Evidence
  1. On 7-15-22, resident #3’s uniformed assessment instrument (UAI) dated 1-28-22 was not signed by the administrator or another designee.
  2. On 7-21-22, resident #5’s UAI dated 3-29-22 was not signed by the administrator or another designee.
  3. On 7-21-22, staff #1 acknowledged the aforementioned residents’ UAI did not include all required signatures.
Plan of correction
• ED, RSD, RSC or designee will ensure that all UAI’s are signed by two designees to remain in compliance with the appropriate DSS Standard. The ED, RSD, RSC or designee will review at minimum 5 charts weekly to ensure that all UAI’s have dual signatures by appropriate designees. o Date to be completed Immediately and Ongoing as of 08-03-2022
22VAC40-73-450-C
Based on record reviewed and staff interviewed, the facility failed to ensure the comprehensive individualized service plan (ISP) was completed within 30 days and included all assessed needs for a resident.
Evidence
  1. On 7-15-22, resident 3’s record did not include an individualized service plan (ISP). The resident’s date of admission was documented as 2-3-22.
  2. On 7-21-22, resident #5’s ISP dated 5-10-22 did not include the resident’s physical therapy and occupational therapy services. The resident’s UAI dated 3-29-22 documented stairclimbing not performed. The ISP documented stairclimbing need as- human help and handrail assistance.
  3. On 7-17-21, resident #6’s record included a Do Not Resuscitate (DNR) document signed by a physician and dated 6-20-22. The ISP dated 6-17-22 documented the resident as a “Full Code”. The social data also documented resident as “Full Code”.
  4. On 7-21-22 staff #1 acknowledged the aforementioned residents’ record did not include an ISP and other resident’s record did not include all assessed needs on the ISP.
Plan of correction
• ED, RSD, RSC or designee will ensure that all ISP’s are completed within 30 days of admission and include an assessment of all the current needs and services provided to the resident both by community representatives and additional therapy agents. ED, RSD, and RSC or designee will also ensure that the appropriate end of life wishes are documented appropriately on the ISP. • ED, RSD, RSC or designee will review at minimum 5 charts weekly to ensure that all ISP’s are documented correctly to include all required information. o Date to be completed Immediately and Ongoing as of 07-30-2022
22VAC40-73-260-C
Based on record reviewed and staff interviewed, the facility failed a listing of all staff who have current certification in first aid or CPR, shall be posted in the facility so that the information is readily available to all staff at all times. The listing must indicate by staff person whether the certification is in first aid or CPR or both and must be kept up to date.
Evidence
  1. On 7-15-22 during a tour of the facility, the first aid or CPR listing was not posted and was not updated. The listing dated 4-14-2022 included the names of eight staff members with expired first aid and CPR dates ranging from 1-22-2021 through 3-31-2022.
  2. On 7-15-22 and 7-21-17 staff #1 and # 3 acknowledged the facility’s first aide/CPR listing was not posted and not updated.
Plan of correction
• ED, BOM, or designee will ensure that CPR & First Aide Current Staff list is posted in both buildings and maintained current. Will be updated with change in staff and/or at least monthly. • Updated list was posted in both buildings on 07-27-2022. o Date to be completed Immediately and Ongoing as of 08-03-2022
22VAC40-73-970-E
Based on documents reviewed and staff interviewed, the facility failed to ensure the fire and emergency evacuation drill frequency and participation shall be in accordance with the current edition of the Virginia Statewide Fire Prevention Code. The drills required for each shift in a quarter shall not be conducted in the same month.
Evidence
  1. On 7-21-22, the facility fire drills document for 5-23-22 was documented to have been completed on the 3rd shift. The fire drill for 6-6-22 was completed on the 3rd shift. The fire drill for 7-14-22 was completed on the 1st shift.
  2. The fire drill documents did not include the any special conditions simulated and the weather conditions.
  3. On 7-21-22, staff #1 acknowledged the fire drills for the facility was not conducted as required and did not include all required information.
Plan of correction
• ED, MD, or designee will ensure that Fire drills will be conducted on a rotating shift basis every quarter. They will not be conducted on the same shift during the same quarter. o Date to be completed Immediately and Ongoing as of 08-01-2022
22VAC40-90-40-B
Based on the employee record review, the facility failed to ensure the criminal history record report was obtained on or prior to the 30th day of employment for each employee.
Evidence
  1. On 7-15-22, staff 5’s record did not have documentation of a criminal record report within 30 days of the date of hire. Staff’s date hire was documented as 5-14-22.
  2. Staff #10’s record did not have documentation of a criminal record report. Staff’s date of hire was documented as 4-19-22.
  3. Staff #12’s criminal record report was dated 1-5-22. Staff’s date of hire was documented as 11-9-21.
  4. On 7-15-21 and 7-27-22 staff #1 acknowledged the aforementioned staffs criminal record report was not obtained within the required 30 days of hire.
Plan of correction
• ED, BOM, or designee will ensure that the prior to employment the DSS required background check will be present in their files to ensure that the candidates are cleared for employment in Senior Living. o Date to be completed Immediately and Ongoing as of 07-30-2022
22VAC40-73-450-E
Based on document reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) was signed and dated by the license, administrator, or his designee, (i.e. the person who has developed the plan), and by the resident or his legal representative. These requirements shall also apply to reviews and updates of the plan.
Evidence
  1. On 7-15-22, resident #2’s ISP dated 2-5-22 was not signed and dated by the resident and/or the resident’s legal representative.
  2. On 7-15-22 and 7-27-22, staff #1 acknowledged the aforementioned resident’s ISP was not sign and dated by the resident and/or resident’s legal representative.
Plan of correction
• ED, RSD, RSC or designee will ensure that all ISP’s are signed by two designees to remain in compliance with the appropriate DSS Standard. The ED, RSD, RSC or designee will review at minimum 5 charts weekly to ensure that all ISP’s have dual signatures by appropriate designees. o Date to be completed Immediately and Ongoing as of 08-03-2022
April 28, 2022Complaint survey1 violation
Inspection dates
04/28/2022.04/29/2022
Areas reviewed
22VAC40-73 BUILDINGS AND GROUND
Comments
Type of inspection: Complaint An on-site complaint inspection was conducted on 4/28/22 and 4/29/22 (ar 07:30 a.m./dep 10:00a.m). A tour of the kitchen was conducted, resident and staff interviews were conducted on 4-28-22 and 4-29-22. A review of the facility’s communication with a local repair vendor was reviewed with staff on 4-29-22. The Acknowledgement of Inspection form was signed and sent via email to the Administrator. A complaint was received by VDSS Division of Licensing on 4-27-22 regarding allegations in the building and grounds equipment as it related to food preparation and quality. Number of residents was 65. The licensing inspector completed a tour of kitchen area of the facility. Number of interviews conducted with residents- 8 who wanted to remain anonymous Number of interviews conducted with staff was 4 Observations by licensing inspector- the kitchen area Refrigerator was also reported but was repaired within a few days of it becoming non-operational. An exit meeting was 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. 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 Willie Barnes Licensing Inspector at 757-439-6815 or by email at willie.barnes@dss.virginia.gov
Violations
22VAC40-73-870-E
Based on document reviewed, staff and resident interviews, the facility failed to ensure all furnishings, fixtures, and equipment, including furniture, window coverings, sinks, toilets, bathtubs, and showers, shall be kept clean and in good repair and condition.
Evidence
  1. On 4-28-22 and 4-29-22, during a complaint inspection regarding the facility’s freezer and stove not working, interview with staff #1 and #2 stated, the facility freezer was not working but was repaired within two- three days. The facility stove was not working and was awaiting a part or replacement. Staff #2 stated using the top portion of the stove to cook and also the microwave.
  2. The facility administrator and dietary manager could not provide the date the stove became non-operational. An email dated March 18, 2022 provided documentation of the dietary manager and a local service company regarding the repair of the facility stove.
  3. Interviews with residents during the breakfast meal on 4-29-22 revealed the facility had been without an oven for a while. The subject of the oven not working was also stated as being discussed with the administrator during resident council meeting.
  4. Staff #1 and #2 acknowledged the facility stove/oven was not working and was not repaired as of 4-29-22 the second day of the inspector’s visit.
Plan of correction
On or approximately May 9, 2022 community received delivery of two new convection ovens. This fixed the issue with meal preparations for residents. In future will inform state and health department of non-operational kitchen equipment.
February 11, 2022Inspection1 violation
Inspection dates
02/11/2022; 03/03/2022; 03/17/2022
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDING AND GROUNDS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report
Comments
An unannounced monitoring- IPOC inspection was conducted on 2-11-22 (ar 06:45 a.m./dep 3:00 p.m). The facility census was 73. Resident and staff records were reviewed, background checks reviewed, medication pass observed, breakfast meal on safe, secure unit and assisted living units observed. An exit meeting was conducted with the administrator. The acknowledgement form was sent electronically. Please complete the columns for "description of action to be taken" and "date to be corrected" for each violation cited on the violation notice, and then return a signed and dated copy to the licensing office within 10 calendar days of receipt. You need to be specific with how the deficiencies either have been or will be corrected to bring you into compliance with the Standards. Your plan of correction must contain the following three points: 1. Steps to correct the noncompliance with the standard(s) 2. Measures to prevent the noncompliance from occurring again 3. Person(s) responsible for implementing each step and/or monitoring any preventive measure(s) Please provide your responses in a Word Document, if possible. POC due within 10 days.
Violations
22VAC40-73-450-F
Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) was updated as needed for a significant change of a resident’s condition.
Evidence
  1. Resident #5’s record documented Speech therapy, 2-15-21 through 3-16-21; Occupational therapy 3-3-21 through 4-1-21; 12-10-21 through 1-8-11; 2-4-22 through 3-5-22; Physical therapy, evaluation of left hand contracture, 8-27-21, 12-1-21 through 12-30-21; 2-15-21 through 3-16-21. These services were not documented on resident’s ISP dated 11-17-21.
  2. On 2-11-21, staff #2 acknowledged services were not on resident’s ISP.
Plan of correction
Resident Care Director reviewed ISP and added therapy notes to ISP. ED & RCD will add therapy notes upon receipt to ensure timely recording of progress of services
February 11, 2022Complaint survey3 violations
Inspection dates
02/11/2022; 03/03/2022; 03/17/2022
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDING AND GROUNDS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity
Comments
An unannounced complaint inspection was conducted on 2-11-22 regarding a complaint to the licensing office on 10-25-21, 12-10-21 and 1-20-22 regarding resident care and not being able to reach facility staff due to the telephone system not working on only able to leave a voice mail with the system. Resident records, staff and resident interviews were conducted regarding the allegation and the evidence gathered supported the allegations, therefore the complaint is "VALID". An exit meeting was conducted with the administrator on 2-11-22 and 3-17-22. The acknowledgement form was sent to the administrator electronically. Please complete the columns for "description of action to be taken" and "date to be corrected" for each violation cited on the violation notice, and then return a signed and dated copy to the licensing office within 10 calendar days of receipt. You need to be specific with how the deficiencies either have been or will be corrected to bring you into compliance with the Standards. Your plan of correction must contain the following three points: 1. Steps to correct the noncompliance with the standard(s) 2. Measures to prevent the noncompliance from occurring again 3. Person(s) responsible for implementing each step and/or monitoring any preventive measure(s) Please provide your responses in a Word Document, if possible. POC due within 10 days.
Violations
22VAC40-73-870-E
Based on staff interviewed and observation, the facility failed to ensure all furnishings and equipment are in good repair.
Evidence
  1. 1 The telephone to the facility does not ring to the staff person in charge and goes to a voicemail with a directory but not to the nursing station. The inspector call several times and did not receive a response on the early morning of 2-11-22. The inspector and staff #3 tried to determine why the phone was not ringing in the medication room. Several tries to dial the number provided, however, the phones in the medication room did not ring.
  2. Staff #1 acknowledged the telephone system was not working on the morning of 3-7-22 when the inspector arrived at the facility.
Plan of correction
Telephone service has been restored and phones are available at community 24/7. After hours, phones will be answered by care staff.
22VAC40-73-280-A
Based on resident interviewed, documented reviewed, staff interviewed and observation, the facility failed to ensure it had staff adequate in knowledge, skills and abilities and sufficient in numbers to provide services to attain and maintain the physical, mental and psychological well-being of each resident as determined by resident assessment and individualized service plan (ISP), and to ensure compliance with the regulation.
Evidence
  1. The nursing schedule for medication aide and direct care staff for February 6, 2022 through February 12, 2022 did not include a staff to administer medication on the 3rd shift (11 p.m. to 7 a.m.). When the inspector arrived at 06:45 a.m., the 3rd shift direct care staffs, # 6 and #7 were present on the safe, secure unit with 21 residents. In the assisted living building next door, no medication aide could be located. Interviews with various residents stated there was no staff to give medications at night. Staff #3, registered medication aide, was observed coming down the hall and going toward the staff breakroom area of the building at approximately 07:05 a.m. Another registered medication entered the medication room approximately 07:20 a.m.
  2. The facility have residents assessed as non-ambulatory requiring physical assistance to exit the assisted living building. There are residents who stated not being able to receive their prn pain medications at night due to no medication staff being available. One resident stated not receiving Synthyroid medication in the early morning and was voicing concern to the medication technicians on duty in the assisted living building on the morning of 2-11-22.
  3. The schedule noted that the medication staff for the 11 p.m. to 7 a.m. is on-call.
  4. Staff # 1 acknowledged on 2-11-22, staffing issues in the facility.
Plan of correction
ED and RSD will continue to solicited for third shift Med Tech/LPN. RSD will work with physician and pharmacy to ensure medications such as Synthyroid are provided on time as scheduled.
22VAC40-73-290-B
Based on observation and staff interviewed, the facility failed to ensure the posting of current on-site person in charge, per the regulation, in a place in the facility that is conspicuous to the residents and the public.
Evidence
  1. On 2-11-21, at 06:45 a.m. the name of the staff person in charge posted with staff #1. This person was not on-site and did not arrive until after 08:00. The staff schedule did not indicate the staff person in charge at any given time. The schedule also noted the name in bold serve as the manager on duty. However, there was no multiple shifts with no name highlighted on the schedule.
  2. The telephone to the facility does not ring to the staff person in charge and goes to a voicemail with a directory but not to the nursing station. The inspector call several times and did not receive a response on the early morning of 2-11-22. The inspector and staff #3 tried to determine why the phone was not ringing in the medication room. Several tries to dial the number provided, however, the phones in the medication room did not ring.
  3. Staff #1 acknowledged, the staff person in charge information was not updated.
Plan of correction
ED will instruct supervisors to update MOD staff member at every shift change.
February 11, 2022Complaint survey1 violation
Inspection dates
02/11/2022; 03/03/2022; 03/17/2022
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
The licensing inspectors conducted an unannounced complaint inspection in response to a complaint that was received by the licensing office on 10-25-21. Resident record was reviewed, interviews were conducted, and documents were reviewed. The information gathered during the investigation did not support the allegation for the resident being held without proper diagnosis and "prisoner" is determined to be "not valid". There were other violations cited during this investigation. Please review the document, provide the plan of correction for each violation cited, and then return a signed and dated copy to the licensing office within 10 calendar days of receipt. If you have any questions, contact your licensing inspector at (757) 439-6815. If possible, you may provide the plan of correction in a word document.
Violations
22VAC40-73-450-C
Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) included all assessed needs.
Evidence
  1. Resident #1’s uniformed assessment instrument (UAI) dated 9-24-21 documented bathing need assessed as mechanical help/ physical assistance. The individualized service plan (ISP) dated 9-24-21 documented bathing need as mechanical help/ supervision. Walking need assessed ad mechanical help, the ISP noted no help/ independent. Wheeling assessed as not performed, the ISP noted no help/ independent. Stairclimbing assessed as mechanical help/supervision, the ISP noted mechanical help only. Mobility assessed as human help supervision; ISP noted mechanical only- handrails.
  2. Resident #2’s UAI dated 10-3-21 documented dressing need assessed as physical assistance. The ISP dated 10-3-21 documented use of wheelchair and staff assistance.
  3. Staff #1 and #2 acknowledged the aforementioned residents’ ISP did not include the assessed needs.
Plan of correction
RCD and RCC reviewed ISPs and reassessed residents. The ISP and UAI are now reflecting the correct care requirement. ED & RCD will audit new assessments to ensure accuracy.
October 5, 2021Inspection21 violations
Inspection dates
10/5/2021; 10/6/2021; 10/26/2021
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity63.2 Protection of adults and reporting22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report
Comments
A renewal inspection was initiated on 10-5-21 and concluded on 10-29-21. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 70. The inspector emailed the administrator a list of items required to complete the remote documentation review portion of the inspection. The inspection reviewed four resident records and four staff records, health and fire inspection, healthcare oversight, nutrition and pharmacy report, fire and emergency drills, activity calendar and staff schedules. The inspector conducted the on-site portion of the inspection on 10-15-21 with an inspector from the Eastern Regional Office. An exit interview was conducted on 10-25-21 and 10-29-21 with the Administrator, Business office manager and Residential Services Coordinator, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. Information gathered during the inspection determined non compliances with applicable standards or law, and violations were documented on the violation notice issued to the facility.
Violations
22VAC40-73-310-H
Based on record review and staff interview, the facility failed to ensure it did not admit and or retain individuals with any prohibitive conditions or care needs per the regulations.
Evidence
  1. During the remote inspection, resident #1’s September medication administration record (MAR) submitted documented the following psychotropic medications, Paxil, Haloperidol and Lorazepam without a treatment plan.
  2. Resident #2’s September 2021 MAR documented the following psychotropic medications, Citalopram, Clonazepam and Sertraline without a treatment plan. A request for treatment plan was made on 10-25-21 during the exit meeting. Treatment plans dated 10-27-21 were received for the aforementioned psychotropic medications for resident #2.
  3. Resident #4’s September 2021 MAR documented Trazadone psychotropic medication without a treatment plan.
  4. During the exit on 10-25-21, staff $1 acknowledged the facility did not have treatment plans for psychotropic medication prior to and during admission. Resident #2’s treatment plans were obtained by the facility following the exit interview on 10-25-21.
Plan of correction
RSC or designee will obtain treatment plan for Resident #1 . Date of completion 14 days. RSC or designee will review current residents for compliance with treatment plans and update as needed. RSC or designee will obtain completed treatment plans for any new admissions with psychotropic medications at the time of physical move in Immediately and ongoing.
22VAC40-73-210-F
Based on record review and staff interview, the facility failed to ensure at least two of the required hours of training shall focus on infection control and prevention. When adults with mental impairment reside in the facility, at least four of the required hours shall focus on topics related to residents’ mental impairment.
Evidence
  1. Staff #4 record did not contain documentation of mental health and infection control and prevention training.
  2. Staff #6’s record documented 1.0 of the required 2.0 hours of infection control and prevention training.
  3. During exit on 10-25-21 documents were requested. However, there were not additional training records provided for staff #4 and #6’s.
  4. During exit on 10-29-21, staff #1 acknowledged staff #4 and #6 did not have documentation of the required mental health and infection control and prevention training.
Plan of correction
RCC and or designee will schedule additional training in infection control and mental impairment for staff #4 and #6 to meet training compliance. RCC and or designee will review infection control training and mental impairment topics are covered in the community training materials to meet state compliance going forward.
22VAC40-73-280-A
Based on document review and staff interview, the facility failed to ensure it had staff adequate in knowledge, skills, and abilities sufficient in numbers to provide services to attain and maintain the physical, mental, and psychosocial well-being of each resident as determined by resident assessments and individualized service plans, and to ensure compliance with the regulation.
Evidence
  1. The nursing schedule for medication aide and direct care staff for October 3 through October 16, 2021 did not include a medication aide for the following dates and shift: (a) 10-3-21, 11p- 7a; (b) 10-8-21, 11p—7a; and (c) 10-11-21, 11p—7a.
  2. The nursing schedule also documented one staff in the Assisted Living Building on the aforementioned dates and shift time. The facility census for the assisted living was documented as 58 on 10-31-21, and 57 on 10—8 and 10-11-21. The assisted living unit have residents on the unit who are two-person assist and non-ambulatory on those dates mentioned.
  3. During the exit on 10-25-21, staff #1 acknowledged the scheduled did not document a medication staff on the aforementioned shifts.
Plan of correction
Resident Services Coordinator and or designee shall create and publish the appropriate staffing schedule to meet current resident needs. Executive Director and or designee is to be notified immediately if needed levels of staffing are insufficient either in numbers or position. This allows the Facility to make contingent arrangements for staffing levels to meet the needs of the residents.
22VAC40-73-250-C
Based on record review and staff interview, the facility failed to ensure staff record included documentation of a sworn disclosure statement for two of the four sampled records.
Evidence
  1. Staff #6’s record did not contain documentation of a sworn disclosure statement, staff’s date of hire 9-8-20.
  2. During exit on 10-25-21 documents were requested and received on 10-26-21 and 10-27-21, however, staff #6’s sworn disclosure was not received.
  3. During exit on 10-29-21, staff #1 acknowledged staff #6’s sworn disclosure was not provided during renewal review.
Plan of correction
Business Office Manager or designee will obtain sworn disclosure from staff member #6. Business Office Manager or designee will include the sworn disclosure in the employee cover checklist in each employee file for compliance. Date of completion 7 days. Business Office Manager or designee will inform Executive Director or designee if a sworn disclosure is not obtained for each new hire so that it may be obtained prior Ito first day of employment. Date of completion is immediate and ongoing.
22VAC40-73-930-A
Based on observation and staff interview, the facility failed to ensure the signaling device was audible in a manner that permit staff to determine the origin of the signal.
Evidence
  1. During the tour of the facility on 10-15-21, the signaling cord was press by the resident in room #35 at 8:20 a.m. without a staff response. The signaling cord in the resident’s bathroom was pulled at 8:29 a.m. without a staff response. The administrator came to the hallway near room #35 at approximately 08:45 a.m. and was informed of the signaling device situation. The administrator was informed by staff that the pager was being charged, therefore staff did not know the signaling device was activated.
  2. Resident in room #35 is non-ambulatory and requires staff assistance to transfer from wheelchair.
  3. Staff #1, acknowledged on 10-15-21 that the signaling device was not audible to staff assigned to the hallway where room #35 was located.
Plan of correction
RSC or designee is to assign a pager to each shift supervisor to monitor for response. RSC or designee will conduct a documented training with all care staff on proper pager use and charging.
22VAC40-73-210-B
Based on record review and staff interview, the facility failed to ensure in a facility licensed for both residential and assisted living care, all direct care staff shall attend at least 18 hours of training annually. For direct care staff who are licensed health care professionals or certified nurse aides shall attend at least 12 hours of annual training.
Evidence
  1. Staff #4’s record did not contain documentation of the required 18 hours annual training. Staff’s date of hire documented as 6-18-19.
  2. Staff #6’s record documented 10.25 hours of the required 12 hours of annual training.
  3. During exit on 10-25-21 and 10-29-21 staff #1 acknowledged staff #4 and #6 did not have documentation of the required hours of annual training.
Plan of correction
Business Office Manager and or designee 1/15/22 will schedule, conduct and document the complete 12-18 hours of state required training for staff #4 and #6. Business Office Manager or designee will create a tickler for all care staff to monitor, record and ensure compliance in the required state training for each staff member. Business Office Manager or designee will inform Executive Director and or designee of any non-compliance of state required trainings so that the staff member can be removed from the schedule until training compliance is completed.
22VAC40-90-40-B
Based on documents reviewed and staff interview, the facility failed to ensure the criminal history record report shall be obtained on or prior to the 30th day employment for each employee.
Evidence
  1. On 10-6-21, the facility did not have documentation of the criminal history record report for fourteen new hires on or prior to the 30 th day of employment. The new hires dates ranged from May 6, 2021 to September 21, 2021
  2. During the exit on 10-25-21, staff #1 acknowledged the facility did not obtain on or prior to the 30th day of employment a criminal history record for new employees since the date of hire.
Plan of correction
Facility retained a new account with the Virginia State Police on 9/15/2021. Business Office Manager and or designee will audit current employee files to include the 14 employees listed and a review of the current staff records for compliance. A tickler will be created by Business Office Manager or designee to include all new hires and track compliance of requesting a state background check and other required documentation and obtain within 30 days.
22VAC40-73-290-B
Based on observation and staff interview, the facility failed to ensure the posting of the name of the current on-site person in charge, as required per the regulation, was in place in the facility that is conspicuous to the residents and the public.
Evidence
  1. During a tour of the facility on 10-15-21, the staff person in charge was not posted. According to the information posted at 7:50 a.m. the administrator, who was not on-site was posted as the staff person in charge.
  2. Staff #1 acknowledged the staff person in charge was not accurately posted.
Plan of correction
Concierge and or designee will post the staff person in charge on the entrance desk so that it is visible to everyone.
22VAC40-73-290-A
Based on record review and staff interview, the facility failed to ensure the facility written work schedule include the names and job classification of all staff working each shift, with an indication of whomever is in charge at any given time.
Evidence
  1. The facility’s written nursing department schedule for direct care staff and medication aides and the dietary department schedule documented only the first name of staff scheduled.
  2. The nursing department schedule documented “Med-Aides are in Charge of Shift”. However, there were shifts that document more than one medication aide, with no specific aide documented as the staff person in charge.
  3. On 10-15-21, during the on-site visit, two medication aides were present, but neither staff knew who was in charge.
  4. During exit on 10-25-21, staff #1 acknowledged the scheduled did not specify who was in charge.
Plan of correction
RSC or designee will create a schedule reflecting the first and last name of each staff member, the day, time and which scheduled position is the staff person in charge.
22VAC40-73-450-C
Based on record review and staff interview, the facility failed to ensure uniformed assessment (UAI) for private pay individuals in the assisted living facility is completed as required.
Evidence
  1. Resident #1’s uniformed assessment instrument (UAI) dated 10-4-21 documented resident need for eating/feeding assessed as human help/physical assistance (hh/pa). The individual service plan (ISP) dated 10-4-21 documented need as human help/supervision (hh/s); resident “will receive verbal cues and reminders to attend meals and to continue to feed self for the duration of the meal”. Interview with staff #1 on 10-25-21, staff stated resident did not require physical assistance.
  2. Resident #2’s UAI dated 9-17-21 documented medication is administered by registered medication aide (RMA) and licensed practical nurse (LPN). The individual service plan dated 9-17-21 documented resident “receives supplement nutritional drink as physician order. Resident able to self-manage. Resident has an order to keep at bedside”. Interview with staff #1 on 10-25-21, staff stated resident’s medication kept at bedside.
  3. Resident #3’s uniformed assessment and individualized service plan documents were requested on 10-6-21 as one of four sample records for review but documents were not received. On 10-25-21 during the exit with staff #1, records were requested. However, documents were not received for review during the renewal.
  4. Resident #4’s UAI dated 7-6-21 documented resident did not need assistance with money management. Resident’s ISP dated 7-6-21 documented, “POA will assist with financial management as needed”.
  5. During exit on 10-25-21 and 10-29-21, staff #1 acknowledged residents’ UAIs and ISPs did accurately reflect assessed needs and or care plan documented. Also, resident #3’s UAI and ISP were not provided for review.
Plan of correction
RSC or designee corrected Resident's #1, #2, #3 and #4's assessments. RSC or designee will audit of current resident ISP/UAl's for compliance. RCC or designee created a tickler for UAI/ISP compliance and monitoring which will be maintained daily. Executive Director and or designee will review tickler monthly for compliance.
22VAC40-73-970-A
Based on document review and staff interview, the facility failed to ensure fire and emergency drill frequency and participation shall be in accordance with the current edition of the Virginia Statewide Fire Prevention Code (13VAC5-51). The drills required for each shift in a quarter shall not be conducted in the same month.
Evidence
  1. The facility fire and emergency drill document for July, August and September 2021 did not include fire drills for the 11p---7a shift.
  2. During the exit on 10-25-21, staff #1 acknowledged the drills were not conducted for all three shifts, particularly the 11p—7a shift.
Plan of correction
Maintenance Director and or designee will create an annual fire drill calendar to include a rotation of a different shift each month in succession to be implemented, documented and monitored. The completed calendar will be shared with the Executive Director and or designee for compliance and monitoring.
22VAC40-73-1140-B
Based on record review and staff interview, the facility failed to ensure within four months of the starting date of employment in the safe, secure environment, direct care staff shall attend at least 10 hours of training in cognitive impairment that meets the requirements of 1140-C of the regulation.
Evidence
  1. Staff #6’s record did not document the required 10 hours of cognitive impairment training within 4 months of start of employment. Staff’s date of hire documented as 9-8-20; staff’s record documented 6 hours of training on 9-8-20.
  2. Staff #7’s record documented 6 hours of cognitive impairment training on 5-6-21; staff’s date of hire documented as 5-6-21.
  3. During exit on 10-25-21 and 10-29-21, staff #1 acknowledged staff #6 and #7 did not have the required hours of cognitive training.
Plan of correction
Staff #6 and #7 will complete the required 12/31/2021 10 hours of cognitive training. Business Office Manager and or designee will create a training tickler for all direct care staff employed and ensure that the required cognitive training is completed in the first four months of employ. Business Office Manager and or designee will notify the Executive Director and or designee of any staff that have not completed the cognitive training in the required four months, so that they can be removed from the schedule until time of completion.
22VAC40-73-320-B
Based on record review and staff interview, the facility failed to ensure a risk assessment shall be completed annually on each resident as
Evidence
  1. d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence:
  2. Resident #4’s record did not contain documentation of an annual risk assessment. Resident’s record document date of admission as 4-16-19.
  3. During exit on 10-25-21 documents were requested. However, resident #4’s TB was not included with documents provided on 10-26-21 and 10-27-21.
  4. During exit on 10-29-21, staff #1 acknowledged resident #4’s TB not provided during renewal review.
Plan of correction
RSC or designee will obtain an annual TB 12/5/2021 risk assessment for resident #4. RSC or designee will create a tickler for resident annual TB risk assessments and monitor for compliance.
22VAC40-73-550-G
Based on record review and staff interview, the facility failed to ensure the rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each resident or his legal representative and each staff person.
Evidence
  1. Staff #4’s record did not contain documentation of annual rights review, date of last review in record was documented 6-18-19.
  2. Staff #6’s record documented resident rights last review was dated 9-8-20.
  3. During exit on 10-25-21 documents were requested. However, staff #4 and #6’s resident’s rights were not included with documents provided on 10-26-21 and 10-27-21.
  4. During exit on 10-29-21, staff #1 acknowledged staff #4 and #5’s resident’s rights were not provided during renewal review.
Plan of correction
Business Office Manager or designee will review resident rights and responsibilities of residents in assisted living facilities with staff member #4 and #5 and document. Business Office Manager and or designee twill create a tickler for staff and a tickler for residents to monitor the rights and responsibility of residents in assisted living facilities is reviewed within the compliancetimeframes. Business Office Manager or designee will inform Executive Director and or designee of any staff or residents that are not in compliance so that it may be corrected. Executive Director and or designee will reach out to ombudsman to schedule a rights and responsibility of residents in assisted living facilities training. Date of completion 7 days to make request and 90 days to schedule training.
22VAC40-73-640-A
Based on record review and staff interview, the facility failed to ensure the medication management plan was followed. 640-A .4 (missed dosage) 1. Resident #1’a Tramadol medication which is administered three times a day, was not available to administer two times on 10-19-21 and three times on 9-20-21. Staff #1, stated facility was waiting for Hospice representative to re-order medication. Resident #1’s September 2021 medication administration record (MAR) documented the original date of medication was dated 4-21-21. Resident’s Amitiza, administered twice a day, not available three times 9:00 a.m. and three times 5:00 p.m. Resident’s September MAR documented the original date of 8-18-21 and discontinued 9-6-21. 640-A.5 (24 hour documentation) 2. Resident #2’s September 2021 medication administration record (MAR) did not document physician’s order dated 8-30-21 for Boost shakes. 3. Resident #3’s September 2021 MAR did not document physician’s order dated 9-2-21 for Nutritional Shake supplement. Resident #4s September 2021 MAR did not document physician’s order dated 5-4-21 for Tramadol PRN. 4. The facility’s “Med 01- Community Medication Management Plan, policy date 12-01-2020” -document medication would be transcribed on MARS within 24 hours of receipt of a new order or change in an order. The plan also documented plan shall address methods for filling and refilling prescriptions to avoid missed dosages. 5. During exit on 10-25-21, staff #1 acknowledged the MAR did not include medications for the physician’s orders.
Plan of correction
RSC and or designee will correct Resident #1, #2 and #3's MAR for compliance. RSC or designee will request pharmacy to conduct a documented training for the filling and refilling of medications for all staff assigned to medication administration to prevent missed doses and ensure timely refills. Date of Completion 60 days. Business Office Manager and or designee will document training of all staff that are assigned to medication administration to review Medication Management Plan for compliance.
22VAC40-73-250-D
Based on record review and staff interview, the facility failed to ensure the initial tuberculosis (TB) examination and report for a staff person was completed on or within seven days prior to the first day of work at the facility.
Evidence
  1. Staff #7’s initial documentation of tuberculosis (TB) was documented 5-29-21. Staff’s date of hire documented as 5-6-21.
  2. During exit on 10-29-21, staff #1 acknowledged staff #7’s TB date was after the required time. 250-D.2 Based on record review and staff interview, the facility failed to ensure a staff person was evaluated annually and submitted the results of a risk assessment, documenting that staff was free of tuberculosis (TB) in a communicable form as evidenced by the completion of a current screening form published by the Virginia Department of Health or a form consistent with it. Evidence:
  3. Staff #4’s record did not contain documentation of an annual risk assessment. Staff’s record documented a chest X-ray conducted on 2-12-20; date of hire documented as 6-18-19.
  4. Staff #6’s record did not contain documentation on an annual risk assessment. Staff’s dated of hire documented as 9-8-20.
  5. During exit on 10-25-21 documents were requested. However, staff #4 and #6’s TB were not included with documents provided on 10-26-21 and 10-27-21.
  6. During exit on 10-29-21, staff #1 acknowledged staff #4 and #5’s TB were not provided during renewal review.
Plan of correction
RSC or designee will obtain staff #4 and #6 annual TB risk assessment.. Business Office Manager and or designee will ensure TB results are obtained prior to the first day worked for new hires. Business Office Manager will notify Executive Director and or designee immediately of any results not received prior to first scheduled work day to ensure compliance. Business Office Manager or designee will create a tickler to include new hire TB compliance and current staff TB compliance dates. Business Office Manager or designee will inform Executive Director and or designee bf any staff member not in compliance so that they may be removed from the schedule until TB requirements are met.
22VAC40-73-870-A
Based on observation and staff interview, the facility failed to ensure the building was maintained in good repair and kept clean.
Evidence
  1. On 10-17-21 at 07:30 a.m. during a tour of the facility, the front porch was observed with building materiel left uncovered. Ladders of various sizes, a pallet of concrete mixtures, downspouts, caulking guns, moving dollies, piles of lumbers, paint scrapers, nails of various sizes in multiple containers, the base of a lamp, concrete hand tool, assorted ropes, old patio chairs and chair cushions, a shop vac equipment and metal rods along with other types of debris and equipment on the front porch/ entrance to the facility. The porch was not fully sectioned or roped off to keep the residents and others from entering the area being used as work area. The hallway to the left of room #35 and the activity room ceiling lights were dangling by the wire.
  2. Residents and others were observed entering and exiting the facility from the front porch entrance where the clutter and debris were observed by licensing.
  3. Staff #1 acknowledged the individuals who were completing the renovation in the assisted living unit did not leave the facility in a safe manner the previous evening.
Plan of correction
The storage of construction materials will 11/1/2021 be maintained and kept with physical barriers to prevent residents from entering. Any fixtures removed during repairs will be replaced properly when the work is completed or in a safe manner until repairs are complete. Maintenance Director and or designee will monitor all repairs during building walkthroughs for compliance to ensure resident safety
22VAC40-73-40-A
Based on record review, document review and staff interview, the facility failed to ensure it was in compliance with its own policies and procedures.
Evidence
  1. Resident #2's uniform assessment instrument (UAI) dated 9-17-21 documented medication administered by registered medication aide and licensed practical nurse. The resident's individualized service plan (ISP) dated 9-17-21 documented resident is able to self- administer supplement and keep at bedside. Resident is currently assessed and assigned to the facility's safe, secure unit.
  2. The facility medication administration policy document, Resident Self-Management/ Storage of Medication, "Residents with a diagnosis of memory impairment will not be permitted to self-manage their medication. 3.On 10-29-21, facility policy reviewed with staff #1.
Plan of correction
RSC or designee will correct resident #2's ISP for compliance in medication administration. RCC or designee will audit resident ISPs for compliance in medication administration with cognitive impairment. Business Office Manager or designee will document training with medication administration and cognitive impairment with all staff schedule in medication administration.
22VAC40-73-680-I
Based on record review and staff interview, the facility failed to ensure the medication administration record (MAR) included all of the required information.
Evidence
  1. Resident #1’s September 2021 medication administration record (MAR) did not include initials of direct care staff administering A & D ointment six times.
  2. Resident #4’s September 2021 MAR did not include a diagnosis. Condition, or specific indications for administering the drug Prilosec.
  3. During exit on 10-25-21, staff #1 acknowledged the MAR did not include all required information.
Plan of correction
Resident #1 and #4 were corrected on 10/31/2021. RSC and or designee will review all MARs on a monthly basis for compliance and thoroughness of information.
22VAC40-73-450-E
Based on record review and staff interview, the facility failed to ensure the individualized service plan (ISP) was signed and dated by the license, or this designee, and by the resident or his legal representative.
Evidence
  1. Resident #2's individualized service plan (ISP) dated 9-17-21 was not signed by the resident or his legal representative.
  2. Staff #1 acknowledged on 10-29-21 resident's ISP was not signed by the resident nor the legal representative.
Plan of correction
RCC or designee will obtain signatures on 1/15/2022 Resident #2's ISP for compliance. RCC or designee will audit ISPs for signature compliance.
22VAC40-73-450-F
Based on record review and staff interview, the facility failed to ensure a resident’s individualized service plan was updated as needed as the condition of the resident changed.
Evidence
  1. Resident #2’s individualized service plan (ISP) dated 91-17-21 was not updated to include the resident’s speech therapy services. Resident’s therapy notes documented Speech Therapy services was initiated on 9-9-21 and recertified on 10-10-21.
  2. Resident #1’s therapy notes documented occupational therapy initiated on 9-10-21 and discharged on 10-5-21.
  3. Resident #2 ISP was not updated to include the resident’s occupational and speech therapy services.
  4. During exit on 10-25-21, staff #1 acknowledged the aforementioned therapy services for resident #1 was not documented on the resident’s ISP.
Plan of correction
RCC and or designee will correct Resident #1 and #2's ISP for compliance. RCC or designee will audit of resident ISP's or compliance and correct. Executive Director and or designee will review all lSPs at the time of signature. Date of completion immediate and ongoing.
August 12, 2021Complaint survey3 violations
Inspection dates
Aug. 12, 2021 , Aug. 13, 2021 and Aug. 16, 2021
Areas reviewed
Staffing and SupervisionAdmission, Retention, and Discharge of ResidentsResident Care and Related ServicesBuildings and Grounds
Comments
A non-mandated complaint inspection was initiated on 08-12-2021 and concluded on 08-16-2021. A complaint was received by the department regarding allegations in the areas of Staffing and Supervision, Admission, Retention, and Discharge of Residents, Resident Care and Related Services, and Buildings and Grounds. The Administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the Administrator a list of documentation required to complete the investigation. The licensing inspector conducted an on-site observation at the facility on 08-13-2021. The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. Any violations not related to the complaints but identified during the course of the investigation can be found on the violation notice.
Violations
22VAC40-73-650-A
Based on record review and interview, the facility failed to ensure no medications are discontinued by the facility without a valid order from a physician.
Evidence
  1. Resident #3’s current signed physician’s orders dated 05-04-2020 documented, ?Aspirin 325mg- take 1 tablet by mouth once daily for Hypertension.?
  2. Resident #3’s May 2021 Medication Administration Record (MAR) documented the Aspirin 325mg was “DC’d” [discontinued]. The resident last received Aspirin 325mg on 05-21-2021. The May 2021 and June 2021 MAR’s did not include documentation that Aspirin 325mg was administered on 05-22-2021 through 06-30-2021.
  3. Staff #1 and staff #2 did not provide documentation verifying staff administered Aspirin 325mg to resident #3 during the aforementioned dates. Staff #1 and staff #2 acknowledged the facility did not have a valid physician’s order to discontinue resident #3’s Aspirin 325mg.
Plan of correction
RCD and RCC will review discharge summaries and/or new orders with PCP. We will get clarification any and all medication changes and make sure we have signed POS for each new medication, change and or discontinued medications.
22VAC40-73-680-D
Based on record review and interview, the facility failed to administer medications in accordance with the physician’s instructions.
Evidence
  1. Resident #1’s current signed physician’s orders dated 05-06-2021 documented, ?Cyclobenzapr 5mg- Take 1 tablet by mouth every 8 hours.?
  2. Resident #1’s May 2021 and June 2021 Medication Administration Records documented staff administered Cyclobenzapr 5mg at 8:00 AM, 2:00 PM, and 7:00 PM on 05-06-2021 through 06-04-2021.
  3. Staff #1 and staff #2 acknowledged resident #1’s Cyclobenzapr 5mg was not administered every 8 hours as instructed by the physician instructed by the physician.
Plan of correction
RCD and RCC has requested pharmacy to send daily MAR to RCD. RCD will in-service RMAs as to how to document MAR, if needed due to technical issues.
22VAC40-73-680-I
Based on record review and interview, the facility failed to ensure the Medication Administration Record (MAR) included the initials of direct care staff administering the medications.
Evidence
  1. May 2021 MAR’s did not include the initials of direct care staff administering the following scheduled medications: A. Resident #1’s 2:00 PM Cyclobenzapr 5mg on 05-06-2021, 05-12-2021, 05-13-2021, 05-19-2021, and 05-23-2021; B. Resident #3’s Furosemide 20mg on 05-08-2021, 05-14-2021, 05-18-2021, 05-22-2021, 05-24-2021, and 05-25-2021; Losartan 100mg on 05-14-2021 and 05-25-2021; Venlafaxine 150mg on 05-20-2021 and 05-25-2021; and Aspirin 81mg on 05-01-2021 through 05-21-2021.
  2. Staff #1 and staff #2 acknowledged the aforementioned dates did not include the initials of the direct care staff administering the medications.
Plan of correction
RCD and RCC will verify medication times entered by the pharmacy are correct prior to approving an order.
July 27, 2021Complaint survey6 violations
Inspection dates
7/27/2021;7/29/2021;8/4/2021;9/9/2021
Areas reviewed
22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
A non-mandated complaint inspection was initiated on 7-27-21 and concluded on 9-9-21. A complaint was received by the department regarding allegations in the areas of resident care and related services. The resident services director was contacted by telephone to conduct the investigation. The licensing inspector emailed the resident services director and administrator a list of documentation required to complete the investigation. The licensing inspector conducted an on-site observation at the facility on 7-29-21. The evidence gathered during the investigation supported the allegation of non-compliance with standards or law, and violations were issued. Any violations not related to the (complaint(s)/self-report) but identified during the course of the investigation can be found on the violation notice.
Violations
22VAC40-73-450-C
Based on record review and staff interview, the facility failed to ensure the resident’s individualized service plan (ISP) included all assessed needs.
Evidence
  1. Resident #1’s ISP documented resident is disoriented some spheres, all the time, however, the ISP documented the following intervention/ services to be provided: “Changes in orientation will be reported to MD as needed thru next review”. a. Resident‘s ISP document resident’s incontinent needs for bowel and bladder, however, the ISP did not document the use of incontinent products. Interview with collateral staff during on-site visit, staff stated resident use’s incontinent products. The inspectors also observed incontinent products in resident’s room. b. Bathing need is documented as mechanical help/ human help/ physical assistance, however, the intervention is documented as, “Report any changes in condition to physician and follow any orders”.
  2. Staff #1 acknowledged during the exit on 9-8-21, the aforementioned identified needs’ intervention/ what staff will do was not addressed on the ISP for resident #1.
Plan of correction
RSD and RCC will review all ISPs and UAI to ensure that they clearly indicate the resident's needs in all areas including ADL. ED will review and request any additional information needed to ensure complete picture of residents needs is noted on their ISP.
22VAC40-73-440-D
Based on record review and staff interview, for private pay individuals, the facility failed to ensure that the uniform assessment instrument (UAI) is completed as required by 22VAC30-110.
Evidence
  1. Resident #1’s uniformed assessment instrument dated 4-8-20, was completed by a designated facility staff, however, it was not signed by the administrator as required.
  2. Staff #1 acknowledged during the exit on 9-8-21, the aforementioned resident’s UAI was not completed as required.
Plan of correction
ED, RSD and RCC will audit all resident's charts to ensue that ll ISPs and UAI are up to date and fully executed.
22VAC40-73-450-D
Based on record review and staff interview, the facility failed to ensure when hospice care is provided to a resident, the assisted living facility and the licensed hospice organization shall communicate and establish an agreed upon coordinated plan of care for the resident. The services provided by each shall be included on the individualized service plan (ISP).
Evidence
  1. Resident #1’s record document resident is receiving hospice services, however, the resident’s ISP provided did not include the services provided by the hospice organization.
  2. Staff #1 acknowledged during the exit on 9-8-21 and 9-16-21 that the resident’s ISP did not document the hospice services.
Plan of correction
RSD will communicate with hospice services for resident to ensure that they are providing their full treatment plan of the resident. This information will be documented on ISP and updated as condition changes occur.
22VAC40-73-440-H
Based on record review, the facility failed to ensure an annual reassessment and reassessment due to significant change in the resident’s condition, using the UAI, shall be utilized to determine whether a resident’s needs can continue to be met by the facility and whether continued placement in the facility is in the best interest of the resident.
Evidence
  1. Resident #1’s uniform assessment instrument (UAI) was lasted completed, signed and dated on 4-8-20.
  2. Staff #1 acknowledged during the exit on 9-8-21, the aforementioned resident’s UAI was not updated since 4-8-20.
Plan of correction
ED, RSD and RCC will audit all residents charts to ensure that all ISPs and UAI are up to date. We will also update system to notify us prior to next due date.
22VAC40-73-310-H
Based on record review and staff interview, the facility failed to ensure it did not admit or retain individuals with psychotropic medications without a treatment plan.
Evidence
  1. Resident #1’s record did not have a treatment plan for Haloperidol and Lorazepam medications documented on resident’s unsigned and undated physician’s orders printed at 11:24 a.m.
  2. Staff #1 acknowledged on 9-8-21 during exit meeting, treatment plans were available for resident #1.
Plan of correction
ED, RDS will audit orders to ensure there are treatments plans and all orders are signed by physician.
22VAC40-73-700-1
Based on record review and staff interview, the facility failed to ensure when oxygen therapy is provided, all safety precautions shall be met and maintained.
Evidence
  1. Resident #1’s individualized service plan documented resident’s use of oxygen. However, the record did not have a valid physician’s or other prescriber’s order that included the following: (s) the oxygen source, (b) the delivery device and (c) the flow rate deemed therapeutic for the resident.
  2. Staff #1 acknowledged during the exit on 9-8-21 the aforementioned resident’s record did not have the required oxygen information.
Plan of correction
RSD will make sure that there is a signed physicians order for all residents on oxygen, and ensure that ISP lists all pertinent information such as delivery and flow rate.
July 27, 2021Inspection12 violations
Inspection dates
7/27/2021;7/28/2021;7/29/2021;8/23/2021; 9/8/2021; 9/9/2021
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report
Comments
A non-mandated monitoring inspection was initiated on 7-28-21 and concluded on 9-9-21. The administrator resident services director was contacted by telephone to conduct the investigation. The resident services coordinator reported that the census was 62. The inspector emailed the administrator and resident services director a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed seven resident records, four staff records, activities calendar, fire inspection, health inspection, pharmacy report and staff schedules submitted by the facility to ensure documentation was complete. The inspector conducted the on-site portion of the inspection on 7-29-21. An exit interview was conducted with the Administrator on 9-8-91 and 9-16-21, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations were documented on the violation notice issued to the facility.
Violations
22VAC40-73-210-B
Based on record review and staff interview, the facility failed to ensure staff attend at least 18 hours of training annually.
Evidence
  1. Staff #4’s record did not contain documentation of annual training. The staff roster provided and orientation training document noted staff’s date of hire as 12-31-19.
  2. Staff #5’s record did not contain documentation of annual training. The facility orientation training document noted staff’s date of hire as 2-1-17.
  3. Staff #1 acknowledged during exit on 9-8-21, staff did not have training hours. On 9-16-21, during final exit staff confirmed staff’s date of hire was the date noted in staff’s record and the staff roster.
Plan of correction
ED and BOM will audit staff training and keep log of all in-services to ensure staff of all departments are receiving required training
22VAC40-90-40-B
Based on documents reviewed and staff interview, the facility failed to ensure the criminal history record report shall be obtained on or prior to the 30th day employment for each employee .
Evidence
  1. On 7-28-21, the facility did not have documentation of the criminal history record report for fifteen new hires on or prior to the 30th day of employment. The new hire dates ranged from 4-1-21 through 7-12-21.
  2. Staff #1 acknowledged on 9-8-21 and 9-16-21, the facility did not obtain on or prior to the 30th day of employment a criminal history record for new employees since the date of hire.
Plan of correction
ED has secured an account with the Virginia 11/15/2021 !State Police to run background check for all new hires. IED and BOM will run background checks using new Virginia State Police account for all current employees hired on and after April 1,12021.
22VAC40-73-650-B
Based on record review and staff interview, the facility failed to ensure the physician and or prescriber’s orders, both written and oral, for administration of all prescription and over-the-counter medications and dietary supplements shall include all required information.
Evidence
  1. Resident #2’s physical examination with medication list/ physician’s orders dated 5-25-21 did not include diagnosis for the following: (a) Albuterol, (b) Aspirin, (c) Carvedilol and (d) Crestor.
  2. Staff #1 acknowledged during exit on 9-8-21 the aforementioned medications did not have diagnosis on the physician’s order/physical examination medication list.
Plan of correction
RCD and RCC will set system to require entry 10/15/2021 of diagnosis for all physicians orders prior to approving order. RCD and RCC are only staff members allowed to approve orders.
22VAC40-73-320-A
Based on record review and staff interview, the facility failed to ensure the physical examination document included all required information.
Evidence
  1. Resident #2’s physical examination dated 5-18-21 did not include resident’s blood pressure information.
  2. Staff #1 acknowledged on 9-8-21 during exit meeting, information was not on the physical examination form.
Plan of correction
ED and RCD will review all Health and Physical forms are fully completed prior to admission to ensure all required information is state on residents H&P forms.
22VAC40-73-310-H
Based on record review and staff interview, the facility failed to ensure it did not admit or retain individuals with psychotropic medications without a treatment plan.
Evidence
  1. Resident #4’s record did not have a treatment plan for Lorazepam, documented on resident’s physician order sheet dated 6-16-21 and June 2021 medication administration record.
  2. Resident #7’s record did not have a treatment plan for Clonazepam, documented on resident’s physician order sheet dated 4-27-21 and July 2021 medication administration record.
  3. Staff #1 acknowledged on 9-8-21 and 9-18-21 during exit meeting, treatment plans were available for residents #4 and #7.
Plan of correction
RCD and RCC will conduct weekly chart audits to ensure treatment plans are received from physician for all residents who are prescribed psychotropic medications.
22VAC40-73-700-1
Based on record review and staff interview, the facility failed to ensure when oxygen therapy is provided, all safety precautions shall be met and maintained.
Evidence
  1. Resident #4’s narrative/ clinical notes documented resident’s use of oxygen. Resident #6’s individualized service plan (ISP) documented oxygen use. However, resident #4 and #6’s record did not have a valid physician’s or other prescriber’s order that included the following: (s) the oxygen source, (b) the delivery device and (c) the flow rate deemed therapeutic for the resident.
  2. Staff #1 acknowledged during the exit on 9-8-21 the aforementioned resident’s record did not have the required oxygen information.
Plan of correction
RCD and RCC will obtain physician orders for every resident on 02. Order will be required Ito state full perimeter of usage for each resident. These perimeters will be listed on residents care plans (ISP).
22VAC40-73-450-C
Based on record review, the facility failed to ensure the individualized service plan (ISP) included all assessed needs for seven residents.
Evidence
  1. Resident #1’s uniformed assessment instrument (uai) dated 7-1-21 documented bathing, dressing, toileting and transferring as mechanical help/human help/ physical assistance. However, the individualized service plan (ISP) dated 7-1-21 documented direct care staff will provided the following: (a) bathing, “Give encouragement to resident to bath self with wash cloth to physical limitations. Allow resident sufficient time to bath without feelings of being rushed”. (b) dressing, “Allow sufficient time for dressing and undressing. Provide a consistent dressing routine to decrease confusion and encourage independence”. (c) toileting, “Remind resident to use the toilet regularly. Report any changes in condition to physician and follow any orders”. (d) transferring documented as “independent”. Resident’s uai also documented waling and stairclimbing as not performed, however, needs are not documented on the ISP. Mobility on the uai assessed as mechanical help; however, the ISP documented, “Human Help: Physical Assist, Assist client with transportation to appointments. Remain with client during all appointments, speak with responsible party to solicit their assistance”.
  2. Resident #2’s physical examination dated 5-18-21 documented resident allergic to Penicillin, this was not documented on resident’s ISP dated 6-3-21. Resident received physical therapy services from 6-17-21 through 7-14-21, this information was not documented on the ISP.
  3. Resident #3’s uai dated 6-21-21 documented mobility as mechanical help/human help/supervision; however, the ISP dated 7-29-21 documented, “Assist client with transportation to appointments”. Physical therapy and Occupational therapy documented did not include services provided.
  4. Resident #4’s uai dated 7-6-21 documented resident is disoriented all spheres, all the time, however, the ISP dated 7-6-21 did not include this need. The resident’s use of incontinent products is not included on the ISP; resident incontinent both bowel and bladder.
  5. Resident #5’s uai dated 7-1-21 documented resident’s behavior as appropriate, however, the ISP documented, “Behavior-Appropriate; exhibits appropriate behaviors: is independent with behavior management”.
  6. Resident #6’s record, clinical notes dated 6-29-21 documented resident receiving wound care, however, the ISP dated 7-1-21 did not include this service need.
  7. Resident #7’s uai dated 7-8-21 documented medication administration by layperson and professional, however, the resident’s ISP dated 7-8-21 documented medication administration, “Medication Administration: Administered by Professional Nursing Staff; RN, NP, PA, MD”. The resident was observed going the hallway in the facility with the following five medications in a soufflé cup on the seat of a rollator walkway: Clonazepam, Gabapentin, Atenlol, Aspirin and a multivitamin.
Plan of correction
ED and RCD will review each UAI and ISP to 11/15/2021 ensure that are complete and accurately noting specifics of care needs for residents after each assessment and upon condition changes. ED and RCD will in-service all Med Techs to ensure knowledgeable of proper procedures of administering medications.
22VAC40-73-650-A
Based on record review and staff interview, the facility failed to ensure no medication, dietary supplement, diet, medical procedure, or treatment shall be started, changed, or discontinued by the facility without a valid order from a physician or other prescriber. Medications include prescription, over-the-counter, and sample medications.
Evidence
  1. Resident #1’s records were requested as part of the sample review and received on 7-29-21 and 9-9-21. However, no signed and dated physician or prescriber’s orders were received.
  2. Resident #5’s June 2021 medication administration record (MAR) documented on 6-9-21, prn Imodium was administered. However, the facility did not have a physician or prescriber’s order for the medication.
  3. Resident #7’s July 2021 MAR documented Lidocaine patch to be placed on shoulder for 7 days, the MAR documented order 7-1-21 and stop 7-9-21.
  4. Staff #1 acknowledged during the exit on 9-8-21 and 9-16-21 physician’s orders were not provided.
Plan of correction
RCD and RCC will indicate on MAR when medications is received from pharmacy and document when medication is to be started and finished based on receipt of medication from pharmacy.
22VAC40-73-1140-B
Based on record review and staff interview, the facility failed to ensure within four months of the starting date of employment in the safe, secure environment, direct care staff shall attend at least 10 hours of training in cognitive impairment that meet the regulatory requirements.
Evidence
  1. Staff #6’s record did not contain documentation of at least 10 hours of cognitive training since employment date of 12-22-20.
  2. Staff #1 acknowledged during exit meeting on 9-8-21 and 9-16-21, staff’s record did not have documentation of required cognitive training.
Plan of correction
Not published by VDSS.
22VAC40-73-680-I
Based on record review and staff interview, the facility failed to ensure the facility’s medication administration record (MAR) included all required information .
Evidence
  1. Resident #3’s June 2021 medication administration record (MAR) did not include initials of the direct care staff administering the medication for following: (a) MetFormin, blank four times, (b) Paroxetine, two times and (c) Spironolactone, three times.
  2. Staff #1 acknowledged during exit on 9-8-21 the aforementioned blanks on the resident’s MAR.
Plan of correction
Med Tech will immediately notify RCD and or ED of missed medications along with explanation of why med was missed. System set to require explanation of missed medication to ensure RCD's and ED's knowledge of missed medication. Responsible party and physician will be informed of missed medication.
22VAC40-73-260-A
Based on record review and staff interview, the facility failed to ensure direct care staff maintain current certification in first aid.
Evidence
  1. Staff #5’s first aid card was not provided for review. Staff #6’s first aid and cardiopulmonary resuscitation (CPR) cared was expired on 6-11-21.
  2. Staff #1 started card needed to be printed. However, documents were not received with follow-up documents received on 9-9-21.
Plan of correction
RCC will conduct monthly CPR/First Aid certification classes for those staff members approaching expiration of their certification. Those without proper certification will be removed from schedule until time that their certification is up to date. BOM will track and notify staff member of mandatory upcoming classes and log participation. RCC will issue copy of certification to BOM and to staff member.
22VAC40-73-450-D
Based on record review and staff interview, the facility failed to ensure when hospice care is provided to a resident, the assisted living facility and the licensed hospice organization shall communicate and establish an agreed upon coordinated plan of care for the resident. The services provided by each shall be included on the individualized service plan (ISP).
Evidence
  1. Residents #4 and #6’ s record document residents are receiving hospice services, however, the resident #4’s individualized service plan (ISP) dated 7-6-21 and resident #6’s ISP dated 7-1-21 did not include the services provided by the hospice organization.
  2. Staff #1 acknowledged during the exit on 9-8-21 and 9-16-21 that the residents’ ISP did not document the hospice services.
Plan of correction
RCC will document ISP with all services provided by outside companies including Hospice and Therapy companies.
July 1, 2021Complaint survey4 violations
Inspection dates
July 1, 2021 , July 8, 2021 , July 19, 2021 , July 23, 2021 and July 30, 2021
Areas reviewed
Resident Care and Related ServicesStaffing and SupervisionBuildings and Grounds
Comments
A non-mandated complaint inspection was initiated on 07-01-2021 and concluded on 07-30-2021. A complaint was received by the department regarding allegations in the areas of Resident Care and Related Services, Staffing and Supervision, and Buildings and Grounds. The Administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the Administrator a list of documentation required to complete the investigation. The licensing inspector conducted an on-site observation at the facility on 07-02- 2021. The evidence gathered during the investigation supported the allegations of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.
Violations
22VAC40-73-460-E
Based on record review and interview, the facility failed to regularly observe and document in the resident’s record any changes in the resident’s condition to include injury, and any corresponding action taken. 1. Resident #1’s May 2021 Medication Administration Record (MAR) documented the resident received Hydroco/Apap 5- 325mg for pain on 05-19-2021 and 05-20-2021. The MAR also documented the resident was sent out to the hospital on 05-23-2021. 2. During interview, staff #1 stated the resident was sent out to the hospital due to “complaints of back pain.” 3. Resident #1’s skilled nursing facility (SNF) “History of Physical” form dated 06-01-2021 documented the resident was transferred to the SNF from the hospital after being admitted there for lumbar back pain. The resident was found to have an L3 compression fracture of the spine. 4. Staff #1 could not provide documentation regarding the resident’s complaints of back pain or the reason why the resident was sent out to the hospital.
Plan of correction
RCD and ED will insure that proper documentation is done when resident is admitted to SNF. Systems will list resident as on a "Leave of Absence." Upon readmission, new orders will be immediately send to pharmacy and RCD will verify new orders in system and medications upon delivery.
22VAC40-73-640-A
Based on record review and interview, the facility failed to implement their medication management plan to include, methods to ensure that each resident's prescription medications ordered for the resident are filled in a timely manner to avoid missed dosages.
Evidence
  1. Resident #1 admitted to the facility on 05-12-2021 (admission date confirmed by staff #1).
  2. Staff #1 provided a copy of the facility’s “Medication Refills” policy dated 12-01-2020, which documented ?Medication refills will be obtained in a timely manner to ensure residents have all physician ordered medication available.? Staff #1 could not provide a copy of the facility’s policy regarding filling new medications. 3 Resident #1’s physician’s orders dated 05-06-2021 documented ?Calcium 600mg daily; Lasix 20mg daily; Metoprolol
  3. Resident #1’s physician’s orders dated 05 06 2021 documented, ?Calcium 600mg daily; Lasix 20mg daily; Metoprolol 25mg BID [twice a day]; Sodium Chloride 1gm TID [Three times daily]; and Valsartan 160/25mg daily.
  4. Resident #1’s May 2021 Medication Administration Record (MAR) did not document staff administered the aforementioned medications on 05-13-2021 through 05-22-2021. The MAR documented the aforementioned medications were not administered due to “Med on order” Clarifying HOA- Waiting on MD Response??
  5. During interview, staff #2 stated she spoke with staff and could not confirm the aforementioned medications were administered; nor could staff #2 not provide documentation that the aforementioned medications were administered to resident #1 on 05-13-2021 through 05-22-2021.
  6. Staff #2 could not provide documentation confirming the pharmacy delivered resident # 1’s aforementioned medications to the facility at the time of admission; and acknowledged the aforementioned medications were not filled in a timely manner to avoid missed dosages.
Plan of correction
RCD, ED, and pharmacy conducted full audit to ensure that all resident's medications were in system after previous RCD deleted records. ED will ensure that any terminated employees access to QMar and AL Advantage at immediately deactivated. Cart audits are routinely conducted to ensure that alerts are set so medication can only be administered as directed by physician order.
22VAC40-73-680-D
Based on record review and interview, the facility failed to administer medications in accordance with the physician's instructions.
Evidence
  1. Resident #1’s signed physician’s order dated 05-17-2021 documented “Cephalexin 500mg PO Q12 hours x 5 days.”
  2. Resident #1’s June 2021 Medication Administration Record (MAR) documented staff administered the first does of Cephalexin 500mg on 05-19-2021 at 9:00 PM and the last dose was administered on 05-23-2021 at 9:00 AM. The resident did not receive the Cephalexin 500mg for 5 days as ordered by the physician.
  3. Resident #3’s current signed physician’s order dated 06-23-2021 (original order dated 04-17-2019) documented ? Methotrexate Tab 2.5mg- 4=10mg by mouth once a week on Friday.?
  4. Resident #3’s June 2021 MAR documented staff administered Methotrexate 2.5mg Wednesday, 06-02-2021 and Thursday, 06-03-2021.
  5. Staff #2 did not provide a physician’s order for Methotrexate 2.5mg to be administered daily, and acknowledged resident #3’s Methotrexate 2.5mg was not administered once a week as ordered by the physician.
Plan of correction
RCD and ED will insure that proper documentation is done when resident is admitted to SNF. Systems will list resident as on a "Leave of Absence." Upon readmission, new orders will be immediately sent to pharmacy and RCD will verify new orders in system and medications upon delivery.
22VAC40-73-680-I
Based on record review and interview, the facility failed to ensure the Medication Administration Record (MAR) included the initials of direct care staff administering the medications.
Evidence
  1. Resident #2’s May 2021 MAR did not include the initials of direct care staff administering the following scheduled medications: A. 8:00 AM Metoprolol 25mg on 05-21-2021; B. 9:00 AM Atorvastatin 20mg on 05-19-2021, 05-21-2021, and 05-24-2021; Eliquis 2.5mg on 05-14-2021, 05-22-2021, 05- 23-2021, and 05-27-2021; Furosemide 20mg on 05-16-2021, and 05-18-2021 through 05-25-2021; C. 2:00 PM Tramadol 50mg on 05-06-2021, 05-12-2021, 05-13-2021, 05-19-2021, and 05-23-2021; D. 5:00 PM Eliquis on 05-17-2021 and 05-23-2021; and E. 9:00 PM Furosemide 20mg on 05-17-2021, 05-21-2021, and 05-22-2021.
  2. Staff #2 acknowledged the aforementioned dates did not include the initials of the direct care staff administering the medications.
Plan of correction
RCD, ED, and pharmacy conducted full audit to ensure that all resident's medications were in system after previous RCD deleted records. ED will ensure that any terminated employees access to Qmar and AL Advantage are immediately deactivated. Cart audits are routinely conducted to ensure that alerts are set to medication can only be administered as directed by physician order.
June 14, 2021Complaint survey4 violations
Inspection dates
June 14, 2021 , June 16, 2021 , June 21, 2021 , June 30, 2021 and July 1, 2021
Comments
A non-mandated complaint inspection was initiated on 06-14-2021 and concluded on 07-01-2021. A complaint was received by the department regarding allegations in the areas of staffing, resident care, medication, and medication administration. The Administrator was contacted by telephone to conduct the investigation. The licensing inspectors emailed the Administrator a list of documentation required to complete the investigation. The licensing inspector conducted an on-site observation at the facility on 07-01-2021. The evidence gathered during the investigation supported the allegations of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.
Violations
22VAC40-73-290-A
Based on record review and discussion, the facility failed to maintain a copy of the schedule for two years.
Evidence
  1. Staff #1 was asked to provide a copy of the staff schedule for April 2021; however, the schedules for 04-01-2021 through 04-17-2021 could not be provided.
  2. Staff #1 and staff #2 acknowledged the facility did not have a copy of the aforementioned staff schedules.
Plan of correction
Not published by VDSS.
22VAC40-73-680-C
Based on record review and interview, the facility failed to ensure medications are administered no earlier than one hour before and no later than one hour after the scheduled administration time.
Evidence
  1. Staff #1 provided a copy of the facility’s standard dosing schedule labeled ?Routine Hours of Medication Administration“ which documented, ”The following times will be the routine hours of administration for the facility unless facility staff request an alternate schedule. Daily 8:00 AM; QAM 8:00 AM; QPM 4:00 PM; BID 8:00 AM, 4:00 PM, or 8:00 AM, 8:00 PM; TID 8:00 AM, Noon, 4:00 PM, or 8:00 AM, Noon, 8:00 PM? Routine medications may be administered one hour (before or after) the times indicated on the Medication Administration Record??
  2. May 2021 and June 2021 Medication Administration Records (MAR’s) documented the following scheduled administration times: A. Resident #1’s scheduled 9:00 AM medications to include Risperidone 0.5mg, Metformin 850mg, and Flovent 220mcg was administered at 11:28 AM on 05-25-2021, at 7:20 AM on 05-30-2021, and at 10:28 AM on 06-06-2021; Miconazole 2%, Lisinopril 5mg, Metoprolol Suc 25mg crea, and Buspirone 5mg scheduled at 8:00 AM was administered at 11:28 AM on 05-25-2021, at 10:10 AM on 05-26-2021, and at 10:21 AM on 06-03-2021, and scheduled 4:00 PM doses were administered at 5:58 PM on 05-27-2021; Metoprolol Suc 25mg scheduled at 8:00 AM was administered at 10:28 AM on 06-06-2021; Latanoprost 0.005% scheduled at 8:00 PM was administered at 11:17 PM on 05-19-2021 and at 9:29 PM on 05-24-2021. B. Resident #2’s scheduled 9:00 AM medications to include Furosemide 20mg, Escitalopram 20mg, Co Q-10 100mg, Certavite Tab, Aspirin 81mg, Vitamin D3, Vitamin B-1 100mg, Losartan 100mg, Isosorb Mono 60mg, Systane Complete 0.6%, and Diclofenac gel 1%, was administered at 7:27 AM on 05-24-2021, at 10:25 AM on 05-27-2021, at 10:49 AM on 06- 03-2021, and 1:11 PM on 06-05-2021; Diclofenac Gel 1% scheduled at 1:00 PM was administered at 2:55 PM on 05-26- 2021, and at 2:58 PM on 06-01-2021; Bystolic 5mg scheduled at 8:00 PM was administered at 12:20 AM on 06-01-2021, and at 9:40 on 06-14-2021; and Trazadone 50mg scheduled at 9:00 PM was administered at 11:24 PM on 05-19-2021, at 11:45 PM on 05-25-2021, at 11:37 PM on 05-28-2021, at 12:20 AM on 06-01-2021, and at 7:34 PM on 06-06-2021. t #3? l d Mid d i C. Resident #3’s scheduled 9:00 AM medications to include Midodrine 5mg, Certavite, Cholestryam 4mg, Mag Oxide 400mg, Pot Cl 20 MEQ, and Xarelto 20mg was administered at 10:37 AM on 05-21-2021, at 1:10 PM on 05-22-2021, at 11:49 AM on 05-25-2021, at 11:38 AM on 05-26-2021, at 12:54 PM on 05-27-2021, and at 7:12 AM on 05-30-2021.
  3. Staff #1 and staff #2 did not provide documentation of an alternate medication schedule and acknowledged the residents? aforementioned medications were not administered within the correct times.
Plan of correction
RCD & RCC will set up alerts to inform of late and missed meds, this will force MT to have to explain late or missed medication. MT to notify RCD, physician and POA immediately if medication is missed. In-services will be conducted with MTs to re-educate medication administration procedures. RCD & RCC will verify last orders received daily to ensure accuracy and that alert charting is correct and activated in system. They will indicate start and stop dates and times when required.
22VAC40-73-680-D
Based on record review and interview, the facility failed to ensure medications are administered in accordance with the physician's instructions.
Evidence
  1. Resident #1’s signed physician’s order dated 05-07-2021 documented, ?Clindamycin HCL- 150mg Oral Capsule (20 Capsules) [for 5 days] - Take 1 Capsule every 6 hours daily.?
  2. Resident #1’s May 2021 Medication Administration Record (MAR) documented: A. The first dose of Clindamycin 150mg was administered at 12:00 PM on 05-10-2021 and the last dose was administered at 6:00 PM on 05-12-2021. B. The resident only received Clindamycin 150mg for 2.5 days. C. The scheduled dosing times for Clindamycin 150mg were scheduled at 12:00 AM, 8:00 AM, 12:00 PM, and 6:00 PM, which was not every 6 hours as directed by the physician.
  3. Staff #2 and staff #3 did not provide a discontinued order for the Clindamycin 150mg, and acknowledged resident #1 did not receive the Clindamycin 150mg as directed by the physician.
  4. Resident #1’s signed physician’s order dated 05-01-2021 documented, ?Glucophage 850mg [Metformin] once a day. Increase to 850mg PO [by mouth] BID [twice a day] in 2 weeks [14 days].?
  5. Resident #1’s May 2021 MAR documented: A. The first dose of Metformin 850mg was administered on 05-04-2021. B. The resident received Metformin 850mg once a day from 05-04-2021 to 05-15-2021 [12 days]. C. The resident started receiving Metformin 850mg twice a day on 05-16-2021; instead of starting on 05-18-2021.
  6. Staff #1, staff #2, and staff #3 acknowledged resident #1 did not receive the Metformin as ordered by the physician.
  7. Resident #3’s signed physician’s order dated 04-27-2021 documented, ?Gabapentin Cap 100mg- Take 2 capsules = 200mg by mouth every 8 hours for Pain/Myeloma.“ The order also documented ”Midodrine Tab 5mg- Take 1 tablet by mouth every eight hours for Hypotension.?
  8. Resident #3’s May 2021 MAR documented: A. Staff administered Gabapentin 300mg- 1 capsule by mouth three times a day on 05-01-2021 through 05-31-2021. Staff administered Gabapentin 300mg at 9:00 AM, 1:00 PM, and 5:00 PM, which was not every 8 hours. B. Staff administered Midodrine 5mg at 9:00 AM, 1:00 PM, and 5:00 PM, which was not every 8 hours.
  9. Staff #1, staff #2, and staff #3 acknowledged resident #3’s Gabapentin and Midodrine were not administered every 8 hours as ordered by the physician.
Plan of correction
RCD & RCC will set up alerts to inform of late and missed meds, this will force MT to have to explain late or missed medication. MT to notify RCD, physician and POA immediaet ly if medication is missed. In-services will be conductedwith MTs to re-educate medication administration procedures. RCD & RCC will verify last orders received daily to ensure accuracy and that alert charting is correct and activated in system.They will indicate start and stop dates and times when required.
22VAC40-73-680-I
Based on record review and interview, the facility failed to ensure the Medication Administration Record (MAR) included the initials of direct care staff administering the medications.
Evidence
  1. May 2021 MAR’s did not include the initials of direct care staff administering the following scheduled medications: A. Resident #2’s 8:00 AM Hydralazine on 05-03-2021; 9:00 AM Ensure, Escitalopram 20mg, Furosemide 20mg, Isosorb 60mg, Losartan 100mg, Omeprazole 20mg, Pot Cl. 20 MEQ, Systane Complete, Vit D3, Vitamin B-1 100mg, and Diclofenac gel 1% on 05-03-2021; 9:00 AM Furosemide 20mg on 05-14-2021, 05-25-2021, and 05-26-2021; 10:00 PM Gabapentin 100mg on 05-11-2021 and 05-21-2021 and at 2:00 PM on 05-06-2021 through 05-08-2021, 05-12-2021 through 05-14- 2021, 05-16-2021, 05-22-2021 through 05-24-2021, 05-27-2021, and 05-31-2021; 12:00 PM Hydralazine 50mg on 05-08- 2021, 05-14-2021, 05-22-2021 and 05-23-2021; and Trazadone 50mg on 05-11-2021 and 05-21-2021. B. Resident #3’s 1:00 PM Gabapentin 300mg on 05-06-2021; 9:00 AM Midodrine 5mg on 05-17-2021 and at 1:00 PM on 05-06-2021, 05-22-2021, 05-23-2021, and 05-25-2021; 2:00 PM Oxycodone 5mg on 05-06-2021, 05-12-2021, 05-13-2021, 05-17-2021, 05-19-2021, and 05-23-2021; and 9:00 AM Xarelto 20mg on 05-20-2021, 05-22-2021, and 05-23-2021.
  2. Staff #1 and staff #2 acknowledged the aforementioned dates did not include the initials of the direct care staff administering the medications.
Plan of correction
RCD and ED to re-educate staff on using paper MARs in the event computer systems not available.
March 23, 2021Inspection1 violation
Comments
This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. An initial inspection was initiated on March 23, 2021 and concluded on March 23, 2021. The Executive Director as contacted by email to initiate the inspection. The inspector conducted a virtual tour of the Buildings and Grounds. 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.
Violations
22VAC40-73-870-A
Based on observation and discussion, the facility failed to ensure the interior of all buildings were kept clean.
Evidence
  1. During a virtual tour of the facility on 03-23-2021, the following areas were observed in the Assisted Living Building: a. Approximately four dark circular stains on the carpet in the Living Room to the right of the front entrance, b. Black horizontal scuffing on the door entrance to the Staff Lounge, c. Dark staining on the carpet in front of Room 16, d. Red circular staining in front of Rooms 25 and 36,
  2. During a virtual tour of the facility on 03-23-2021, the following areas were observed in the Special Care Unit Building: a. Bleach circular stain in front of Room 60, b. Two light colored circular stains in the Green Hall Living Room, and c. Black vertical scuffing on the Medication Room door.
  3. Staff #1 and staff #2 confirmed during the virtual tour that the aforementioned areas were not kept clean.
Plan of correction
1. Assisted living Building: a. Stains in carpet areas noted in violation will be cleaned by professional carpet cleaner by EOB Monday March 29, 2021. b. Scruff marks on the doors as noted in the violation will be cleaned and repainted by EOB Monday 29, 2021. 2. Special Care memory unit building: a. Stains in carpet areas noted in violations will be cleaned by professional carpet cleaner by EOB Monday March 29, 2021. b. Scruff marks on the doors as noted in the violation will be cleaned and repainted by EOB Monday 29, 2021.