11
Inspections
On record
3
With violations
Visits that cited something
8
Clean visits
Nothing cited
5
Violations cited
Individual findings
5
Standards cited
Distinct rules
1
Complaint visits
Prompted by a complaint

The Summit was inspected 11 times between September 13, 2021 and February 11, 2026 by the Virginia Department of Social Services. 3 of those visits ended with violations cited and 8 with none. Across that history VDSS cited 5 violations under 5 distinct standards. 1 inspection was 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.

Every inspection listed here is currently published on the VDSS site.

Provider Information

Facility type
Assisted Living Facility
License type
Three Year
License expires
03/31/2029
Administrator
Lisa Watson
Licensing inspector
Jennifer Stokes
Inspector phone
(540) 589-5216
Approved for
Assisted Living · Non-Ambulatory

Inspection History

11

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

February 11, 2026Inspection0 violations
Inspection dates
02/11/2026
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 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: 02/11/2026 7:48AM to 2:30PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 11/21/2025 regarding allegations in the areas of: resident care and related service & additional requirements for facilities that care for adults with serious cognitive impairments Number of residents present at the facility at the beginning of the inspection: 41 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of interviews conducted with staff: 4 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
February 11, 2026Inspection0 violations
Inspection dates
02/11/2026
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY32.1- (37) REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2- (1) GENERAL PROVISIONS63.2- (16) PROTECTION OF ADULTS AND REPORTING63.2- (17) LICENSURE AND REGISTRATION PROCEDURES63.2- (18) FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 02/11/2026 7:48AM to 2:30PM 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: 41 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 2 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 4 Observations by licensing inspector: breakfast & lunch, morning medication administration, medication cart audit An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
May 13, 2025Inspection0 violations
Inspection dates
05/13/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/13/2025 9:26AM to 10:30AM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 04/10/2025 regarding allegations in the area of: resident care and related services 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: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
May 13, 2025Complaint survey0 violations
Inspection dates
05/13/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/13/2025 9:26AM to 10:30AM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 03/07/2025 regarding allegations in the area of: resident care and related services 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: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov.
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
March 4, 2025Inspection0 violations
Inspection dates
03/04/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03/04/2025 8:20AM to 1:30PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 42 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 5 Observations by licensing inspector: breakfast, noon-time meal, medication cart audit, medication administration An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.stokes@dss.virginia.gov
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
February 15, 2024Inspection1 violation
Inspection dates
02/15/2024
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 IMPAIRMENTSARTICLE 1 – SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
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: 02/15/2024 8:30AM until 3:30PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 42 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 4 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: medication cart audit and medication administration An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-640-A
Based on an audit of medication carts, resident record review and staff interview, the facility failed to ensure to implement its medication management plan regarding methods to prevent the use of outdated, damaged, or contaminated medications.
Evidence
  1. The facility’s medication management plan provided to the licensing inspection during on-site inspection by staff person 5 indicates that medications that have been discontinued or found to be contaminated, damaged, and/or outdated should be disposed of properly.
  2. Manufacturer’s instructions for Latanoprost 0.005% eye drops indicate that once opened the medication is to be discarded after 6 weeks due to expiration of the eye drops.
  3. The first-floor medication cart contained an opened and used bottle of Latanoprost 0.005% eye drops for resident 9; however, neither the bottle of Latanoprost nor the orange bottle it was stored in contained the date in which the eye drops were opened. This was also observed and confirmed by staff person 2.
  4. The record for resident 9 contains a physician’s order, dated 11/14/2023, for Latanoprost 0.005% drops instill one drop to both eyes at bedtime for glaucoma. The January 2024 and February 2024 medication administration records (MARs) for resident 9 contain documentation that Latanoprost eye drops were administered to the resident every night at 8:00PM from 01/01/2024 through 02/14/2024.
  5. Interview with staff persons 5, 6 and 7 indicated that eye drops that have an expiration date once they are opened are to be dated by staff on the date they are opened to determine when they should be disposed of properly to ensure residents do not receive medication that is expired.
Plan of correction
Date of violation correction: 2/15/24 Medication cart audits will be conducted weekly to ensure open dates are on all required medications including eye drops. Latanoprost eye drops had already been ordered from the pharmacy and arrived before the Licensing Inspector departed. A sticker was applied with the open date. Education has been completed with all nurses and medication aides on writing open dates when eye drops are opened.
May 4, 2023Inspection0 violations
Inspection dates
05/04/2023
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/04/2023 9:35AM until 10:00AM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
March 20, 2023Inspection3 violations
Inspection dates
03/20/2023
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 IMPAIRMENTSARTICLE 1 – SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Comments
Type of inspection: Renewal Date of inspection and time the licensing inspectors were on-site at the facility for each day of the inspection: 03/20/2023 8:50AM until 2:15PM 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: 40 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 and 2 reviewed in regard to medication administration Number of staff records reviewed: 4 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 3 Observations by licensing inspector: observed a portion of morning medication pass, audit of medication carts, noon-time meal 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-680-D
Based on observation, document review, resident record review and resident and staff interview, the facility failed to ensure medications were administered consistent with the standards of practice outlined in the current medication aide curriculum approved by the Virginia Board of Nursing (VBON).
Evidence
  1. At approximately 9:56AM during on-site inspection on 03/20/2023, one licensing inspector (LI) observed a plastic, small pill cup that was sitting on a table beside a chair in resident 10’s living room with multiple medications inside of the cup. Interview with resident 10 revealed that the pills in the cup were her morning medications and had been left there by staff. The pills were also observed by staff 5. An interview between the LI and staff 2 and 5 revealed that staff 2, who is a registered medication aide (RMA), was the staff person who left the pills in the resident’s room and stated that she did not wait to ensure the resident had taken the medications. The uniform assessment instrument (UAI) for resident 10, dated 04/13/2022, indicates that the resident requires medications to be administered/monitored by an RMA and/or a nurse. The Medication Aide Curriculum for Registered Medication Aides by the VBON, revised in 2022, instructs RMAs on page 38 that RMAs are to stay with the client until medications have been consumed.
Plan of correction
One on one education conducted with RMA. All medication aides and nurses educated on medication administration curriculum and DSS standards. Clinical care manager and LPN to observe med passes on a weekly basis.
22VAC40-73-680-M
Based on observations made of the facility medications carts, the facility failed to ensure that medications ordered for PRN (as needed) use were available, properly labeled and properly stored at the facility.
Evidence
  1. The record for resident 11 has a physician’s order for Mucinex 600mg take two tablets by mouth every 12 hours as needed for cough/congestion. This medication was not available in the facility on the day of inspection. Staff 3 also conducted a search of the medication cart and was unable to locate this medication.
Plan of correction
Mucinex ordered and arrived by end of dayshift 3/20/2023. Staff education completed. Med cart audits will be done weekly by nurse.
22VAC40-73-100-C-2
Based on observations made of the facility medication carts, the facility failed to ensure implementation of their infection control policy regarding assisted blood glucose monitoring.
Evidence
  1. The first-floor medication cart was noted to have a glucometer bag labeled for resident 7 on the day of inspection; however, the meter inside of the bag did not contain the resident’s name. This was also observed by staff 3.
  2. The facility infection control manual policy 14.0 Cleaning and Maintenance of Equipment and Environment has documentation under K 1. That “Blood glucose monitoring practices will be consistent with CDC recommendations. Each resident who receives blood glucose checks will have their own glucometer, test strips, and safety lancets. Each individual glucometer will be properly labeled with resident’s name and stored properly. All medication Administration staff will be properly trained”.
Plan of correction
Blood glucometer storage bag was labeled upon inspection. Blood glucometer machine labeled immediately. Staff education completed.
March 3, 2022Inspection0 violations
Inspection dates
03/03/2022
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity32.1 Reported by persons other than physicians63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Comments
The licensing inspector (LI) for The Summit, along with another LI, conducted an unannounced mandated renewal inspection on 03/03/2022 from 8:35AM until 1:30PM, finding 41 residents in care. The inspection included a tour of the physical plant, observation of medication passes, review of the facility's two medication storage carts and resident interviews. Eight resident records were thoroughly reviewed. Sworn disclosure statements and criminal record checks were examined for all newly hired staff since 12/08/2021, and the records of four staff were thoroughly examined. Additional facility documentation was surveyed for compliance with the Standards for Assisted Living Facilities. There were no violations cited during the renewal inspection. An exit interview was conducted with the Administrator, Clinical Care Manager, and LPN Supervisor on 03/03/2022. If you have any questions, contact your licensing inspector at (540) 589-5216.
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
December 8, 2021Inspection1 violation
Inspection dates
12/08/2021
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity32.1 Reported by persons other than physicians63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Technical assistance
To ensure the facility had a thorough understanding of the standards, the LIs had a discussion with the Administrator regarding standard 1040-B and the regional licensing administrator in relation to resident rights information.
Comments
The licensing inspector (LI) for The Summit, along with another LI, conducted an unannounced mandated monitoring inspection on 12/08/2021 from 8:22AM until 4:00PM, finding 41 residents in care. The inspection included a tour of the physical plant, observation of medication passes, review of the facility's two medication storage carts and resident interviews. Eight resident records were thoroughly reviewed, and an additional two were partially reviewed in relation to the observation of the medication pass. Sworn disclosure statements and criminal record checks were examined for all newly hired staff since 10/01/2021, and the records of four staff were thoroughly examined. Additional facility documentation was surveyed for compliance with the Standards for Assisted Living Facilities. Findings were reviewed with facility staff during the inspection. An exit interview was conducted with the Administrator, Clinical Care Manager, and LPN Supervisor on 12/08/2021, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. Please complete the “plan of correction” and “date to be corrected” for each violation cited on the violation notice and return it to your licensing inspector within 10 calendar days from today. You will need to specify how the deficient practice will be or has been corrected. Just writing the word “corrected” is not acceptable. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). If you have any questions, contact your licensing inspector at (540) 589-5216.
Violations
22VAC40-73-450-C
Based on resident record review, the facility failed to ensure that the Individualized Service Plan (ISP) addressed all of the identified needs.
Evidence
  1. The record for resident 1 contains a physician's order, dated 09/15/2021, for "oxygen (O2) at 2 L/min per nasal cannula - oxygen at 2LPM via NC-continuous via concentrator/compressed oxygen". The ISP for resident 1, dated 06/10/2021, does not indicate the flow rate of the oxygen to be delivered to the resident.
  2. The ISP for resident 2, with an identified need date of 11/16/2021, and the most recent ISP for resident 4, dated 11/18/2021, shows for residents 2 and 4 the following: "Services to be provided - Physical therapy - coordinate services with Home Health agency of choice" and "When/Where services provided - As deemed appropriate by HH agency staff". The ISPs do not include a written description of what services are provided and who will provide the services for residents 2 and 4.
Plan of correction
1. The flow rate was added to the ISP of resident 1. 2. Resident 2 and 4 ISPs were updated to include a written description of what services are provided and the name of the home health agency providing the service.
September 13, 2021Inspection0 violations
Inspection dates
09/13/2021
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity32.1 Reported by persons other than physicians63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Comments
An announced mandated initial on-site inspection was initiated on 09/13/2021 and concluded on 09/13/2021. The Administrator reported that the current census was 45. The licensing inspector (LI) conducted a tour of the physical plant and observed the following: interior and exterior of the building, common areas, the facility's emergency food and water supply, required postings that included resident rights, activities schedule, oxygen in-use signs, current menu posted for meals, current first aid and CPR listings, viewed the facility's first aid kit to ensure all required components were included, residents' rooms to ensure all items/furnishings were available, and furnishings and fixtures were clean and in good repair. All policies and procedures submitted by the facility have been reviewed to ensure documentation was complete. The information gathered during the inspection determined no violations with applicable standards or law. No violations were issued.
Violations
No violations cited
The inspector documented no violation of standards at this inspection.