Virginia DSS · Assisted Living Facility

Karolwood Gardens at Portsmouth

📍 1 Bon Secours Way, Portsmouth, VA, 23703

ID 47483One Year licenseClosed
24
Inspections
On record
19
With violations
Visits that cited something
5
Clean visits
Nothing cited
100
Violations cited
Individual findings
60
Standards cited
Distinct rules
11
Complaint visits
Prompted by a complaint

Karolwood Gardens at Portsmouth was inspected 24 times between November 18, 2021 and October 6, 2025 by the Virginia Department of Social Services. 19 of those visits ended with violations cited and 5 with none. Across that history VDSS cited 100 violations under 60 distinct standards. 11 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 and no longer serves any of these on its site. All 24 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
05/31/2026
Administrator
Rachel Ford
Licensing inspector
Darunda Flint
Inspector phone
(757) 807-9731
Approved for
Special Care Unit · Non-Ambulatory · Residential and Assisted Living Care

Inspection History

24

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

October 6, 2025Complaint survey0 violations
Inspection dates
Oct. 6, 2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 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: 10/06/2025 (arrival 12:10 p.m. / departure 3:08 p.m.) 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 07/27/2025 and 08/10/2025 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: 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 interviews conducted with residents: 2 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 allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Darunda Flint, Licensing Inspector at (757)807-9731 or by email at darunda.a.flint@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
October 6, 2025Complaint survey1 violation
Inspection dates
Oct. 6, 2025
Areas reviewed
22VAC40-90 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: 10/06/2025 (arrival 12:10 p.m. / departure 3:08 p.m.) 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 07/23/2025 regarding allegations in the area(s) of: The Criminal History Record Report 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: 0 Number of interviews conducted with residents:0 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s); area(s) of non-compliance with standard(s) or law were: Criminal History Record Report A violation notice was issued; any violation(s) not related to the complaint(s) 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 Darunda Flint, Licensing Inspector at (757)807-9731 or by email at darunda.a.flint@dss.virginia.gov
Violations
22VAC40-90-40-B
Based on record review, the facility failed to obtain a criminal history record report on or prior to the 30th day of employment for each employee.
Evidence
  1. The following staff did not have a completed history record report completed on or prior to the 30th day of employment: Staff #2 (hired 06/01/2023) completed 10/06/2025.
  2. Staff #1 acknowledged the aforementioned staff’s record did not have documentation of a criminal background record check completed prior to the 30th day of employment.
Plan of correction
Not published by VDSS.
July 2, 2025Complaint survey5 violations
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 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: 07/03/2025 ( arrival 10:06 am / departure 1:20 pm) The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 06/23/2025 regarding allegations in the area(s) of: 1) Resident Care and Related Services 2) Building and Grounds The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of residents present at the facility at the beginning of the inspection: 46 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s) area(s) of non-compliance with standard(s) or law were: 1) Resident Care and Related Services 2) Building and Grounds A violation notice was issued; any violation(s) not related to the complaint(s) 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Darunda Flint, Licensing Inspector at (757)807-9731 or by email at Darunda.a.flint@dss.virginia.gov
Violations
22VAC40-73-610-B
Based on observation and staff interviews, the facility failed to ensure the menus and snacks for the current week were b tit ti dditi dated and posted in an area conspicuous to residents: Any menu substitutions or additions shall be recorded on the posted menu.
Evidence
  1. During the tour of the facility with staff #1, the lunch menu for 07/03/2025 listed ham salad with crackers for lunch. The posted menu did not document the substitution of hot dogs for ham salad for the observed lunch meal.
  2. Staff # 1 acknowledged the menu substitution was not documented.
Plan of correction
Meal substitution has been updated on the menu. All cooks educated to update menu with any substitutions or changes to the menu immediately, to ensure future compliance.
22VAC40-73-870-A
Based upon observation, the facility failed to ensure that the interior and exterior of all buildings shall be maintained in good repair and kept clean and free of rubbish.
Evidence
  1. The first-floor front lobby had dog feces on the carpet.
  2. The resident courtyard was noted to have the following: a blue plastic container laying on the ground with debris in and around it, iron yard chairs with no cushions and brown stained fabrics draped on them, air conditioner vent covers laying against the building and laying on the ground.
  3. The carpet in front of the elevator on the second floor had brown stains.
  4. The hallway next to the kitchen has a brown substance on the floor.
Plan of correction
1. Dog feces from visiting pet cleaned up immediately and shortly after area was sanitized and carpet spot cleaned. Education provided for all to staff to clean and sanitize any and all spills immediately. 2. Courtyard debris cleaned up, fabric cleared, and vent covers replaced. Administrator and maintenance director or their designee will inspect courtyards and grounds together monthly to ensure future compliance. 3. Carpet stains were treated and cleaned. Housekeeping supervisor or their designee to inspect all common areas daily to ensure future compliance. 4. Service hallway cleaned and sanitized. Housekeeping supervisor or their designee will clean and mop service hallway daily to ensure future compliance.
22VAC40-73-870-C
Based on observations made during the tour of the building, the facility failed to have adequate provisions for the collection of garbage and waste material.
Evidence
  1. During a tour of the facility with staff #1, the inspector observed in the rear of the facility a furniture cabinet, dresser, toilet, multiple mattresses and box springs, multiple recliner chairs, and multiple plastic containers that need to be collected.
  2. Staff #1 acknowledge the items needed to be removed from the rear area of the facility.
Plan of correction
All bulk trash will be removed. To ensure future compliance, all bulk trash removal will be arranged with in a week from the time it is discarded.
22VAC40-73-870-E
Based on observation, 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, except that furnishings and equipment owned by a resident shall be, at a minimum, in safe condition and not soiled in a manner that presents a health hazard.
Evidence
  1. Multiple chairs were noted to not be in good repair.
Plan of correction
All chairs will be inspected and repaired, replaced, or removed as needed. All staff educated to report any furniture that is not in good repair via work order to help ensure future compliance.
22VAC40-73-870-G
Based on observation, the facility failed to ensure the grounds shall be properly maintained to include mowing of grass and removal of snow and ice.
Evidence
  1. The grass in the courtyard was not mowed and multiple bushes needed to be trimmed.
Plan of correction
Contracted landscaping company notified to mow and trim bushes in the courtyard. Maintenance director will check courtyards every two weeks during the growing season to ensure landscaping contract is being adhered to.
May 7, 2025Inspection12 violations
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT 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 REPORT
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: 05/07/2025 from 8:45 am to 1:45 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: 44 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: 3 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 4 Observations by licensing inspector: Breakfast and an activity were observed. A medication pass observation was completed for 3 residents. The following were reviewed: resident and staff records, medication carts, call bells, and water temperatures. 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Violations
22VAC40-73-1140-B
Based on record review, the facility failed to ensure within four months of the starting date of employment in the safe, secure environment, direct care staff attend at least 10 hours of training in cognitive impairment that meets the requirements of subsection C of this section.
Evidence
  1. Staff #3 (hired 07/31/2024) did not have at least 10 hours of training in cognitive impairment within four months of their hire date.
Plan of correction
Staff #3 to complete additional hours of training to bring into compliance. Additional training in cognitive impairment will be added to the orientation process for all staff working or could work in our safe and secure unit. Administrator or designee to ensure all required training hours are completed at new employee 90-day check in.
22VAC40-73-45-A
Based on interview, the facility failed to provide
Evidence
  1. of liability insurance coverage according to their licensed capacity tier. Evidence:
  2. Staff #1 was unable to provide evidence of liability insurance coverage for the facility.
Plan of correction
Copy of proof of liability insurance coverage has been requested, once received will maintain copy on site.
22VAC40-73-50-B
Based on record review, the facility failed to retain written acknowledgment of the receipt of the disclosure by the resident or his legal representative.
Evidence
  1. For Resident #1 and Resident #3, there was no written acknowledgment of the receipt of the full disclosure by the residents or their legal representatives.
Plan of correction
Acknowledgement of disclosure statements will be obtained from the residents #1 and #3 or their representatives. Double check of all admission paperwork to be completed with each new admission by Sales and Marketing Director and Administrator.
22VAC40-73-325-B
Based on record review, the facility failed to ensure a fall risk rating is completed after a fall.
Evidence
  1. Resident #3 fell per nursing notes on 02/26/2025 and 04/16/2025; however, Resident #3’s record included only 1 undated fall risk rating.
Plan of correction
Resident #3 fall risk rating update has been completed. Resident Care Coordinator and Administrator or their designee will ensure a new fall risk rating is completed following every resident fall.
22VAC40-73-390-A
Based on record review, the facility failed to ensure at or prior to the time of admission, there be a written agreement/acknowledgment of notification dated and signed by the resident or applicant for admission or the appropriate legal representative, and by the licensee or administrator.
Evidence
  1. The facility was unable to provide documentation a written agreement/acknowledgment of notification dated and signed by Resident #1 (admitted 06/08/2024) or their appropriate legal representative.
Plan of correction
Written agreement to be obtained from resident #1s representative. Double check of all admission paperwork to be completed with each new admission by Sales and Marketing Director and Administrator.
22VAC40-73-410-A
Based on record review, the facility failed to ensure upon admission, the assisted living facility provide an orientation for new residents and their legal representatives, including emergency response procedures, mealtimes, and use of the call system. Acknowledgment of having received the orientation shall be signed and dated by the resident and, as appropriate, his legal representative, and such documentation shall be kept in the resident's record.
Evidence
  1. Resident #1 (admitted 06/08/2024) did not have evidence of receiving orientation in their resident records.
Plan of correction
Acknowledgement of resident orientation will be completed. Double check of all admission paperwork to be completed with each new admission by Sales and Marketing Director and Administrator.
22VAC40-73-640-A
Based on observation, the facility failed to implement their written plan for medication management which includes methods to prevent the use of outdated medications and plan for proper disposal of medication.
Evidence
  1. The following expired medications were observed in the medication carts at the facility: 2 cards of PRN Meclizine 12.5mg tablets expired 02/28/2025 and 11/15/2024 for Resident #6, PRN Docusate 100mg capsule expired 03/04/2025 for Resident #7, and PRN Acetaminophen 325mg tablets expired 02/17/2025 for Resident #8.
Plan of correction
Expired medications removed from cart and reordered as appropriate. Monthly cart audits will be completed by RCC or designee.
22VAC40-73-870-A
Based on observation, the facility failed to ensure the interior and exterior of all buildings be maintained in good repair and kept clean and free of rubbish.
Evidence
  1. The screened-in porch of the safe, secure environment had debris throughout the area.
  2. On the second floor in one of the kitchenette areas, there were areas of missing flooring.
Plan of correction
Debris cleared and porch area cleaned. Administrator or designee to inspect area weekly to ensure build up debris is removed promptly. Maintenance director to replace missing flooring and complete weekly inspections of all areas of the building and complete any required repairs immediately.
22VAC40-73-990-C
Based on interview, the facility failed to document staff participation in practice exercises for resident emergencies at least once every six months.
Evidence
  1. Staff #1 confirmed the last documented staff participation in practice exercises for resident emergencies was completed on 09/26/2024.
Plan of correction
Staff practice of resident emergencies will be completed by Administrator at a minimum of every six months.
22VAC40-90-40-B
Based on record review and interview, the facility failed to ensure the criminal history record report be obtained on or prior to the 30th day of employment for each employee.
Evidence
  1. Staff #7 was hired on 03/31/2025; however, there was not a completed criminal history record report for Staff #7.
  2. Staff #1 confirmed there is not a completed criminal history record report for Staff #7.
Plan of correction
Staff #7’s criminal history record has been requested again. Staff member removed from schedule pending return of criminal history report. Going forward, no new hire will start work until criminal history report is obtained and reviewed by Administrator or designee.
22VAC40-90-40-H
Based on record review, the facility failed ensure any person employed does not have a conviction of any of the barrier crimes.
Evidence
  1. Evidence:
  2. Staff #6 was hired on 04/22/2024. The criminal history record report (completed 04/23/2024) indicates Staff #6 was convicted of a felony barrier crime in 2006.
Plan of correction
Staff #6’s employment was terminated on 5/7/2025. Administrator and HR director to both review all criminal background reports for all new hires.
22VAC40-90-60-A
Based on record review, the facility failed to ensure the original report be maintained at the facility where the person is employed.
Evidence
  1. Staff #5 was hired on 12/01/2021 upon new ownership/licensure of the facility; however, their staff record did not include their original criminal history record report.
Plan of correction
Staff #5’s criminal background report has been requested and will be maintained in staff’s file. All staff records will be audited to ensure all original criminal background checks are in place.
February 18, 2025Inspection1 violation
Inspection dates
Feb. 18, 2025
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Technical assistance
22VAC40-73-210 22VAC40-73-460
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: 02/18/2025 from 11:05 am to 12:11 pm. 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 02/11/2025 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: 50 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: 4 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions please contact M Tess Pittman Licensing Inspector at (757) 641 0984 or by email at Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Violations
22VAC40-73-710-B
Based on record review and discussion, the facility failed to ensure physical restraints shall not be used for purposes of discipline or convenience.
Evidence
  1. On the morning of 02/11/2025, Staff #3 reported Resident #1 was found in bed with their sheets/blanket tucked tightly into the mattress in a manner that restricted the resident’s movement.
  2. Staff #4 worked the night prior and acknowledged tucking Resident #1 into bed in such a manner to prevent the resident from falling out of bed.
  3. Based on Staff #3’s observation and admission of actions by Staff #4, Staff #4 was terminated due to physically restraining Resident #1.
Plan of correction
All current employees required to attend educational session on abuse, neglect, and mandated reporting. Emphasizing appropriate interventions and what constitutes a restraint.
February 18, 2025Complaint survey2 violations
Inspection dates
Feb. 18, 2025
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 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: 02/18/2025 from 11:05 am to 12:12 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Three complaints were received by VDSS Division of Licensing on 02/05/2025 (2) and 02/06/2025 regarding allegations in the area(s) of: Admission, Retention, and Discharge of Residents and Buildings and Grounds. Number of residents present at the facility at the beginning of the inspection: 50 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s); area(s) of non-compliance with standard(s) or law were: Buildings and Grounds. A violation notice was issued; any violation(s) not related to the complaint(s) 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Violations
22VAC40-73-870-A
Based on observation, the facility failed to ensure the interior and exterior of all buildings be maintained in good repair and kept clean and free of rubbish.
Evidence
  1. Outside the back entrance of the facility, various pieces of furniture, toilets, equipment, and trash were piled beside the dumpsters.
Plan of correction
Not published by VDSS.
22VAC40-73-870-D
Based on interview, the facility failed to keep free of infestations of insects and vermin.
Evidence
  1. On 02/18/2025, 5 rooms were identified as having live bed bugs.
Plan of correction
Not published by VDSS.
December 10, 2024Complaint survey3 violations
Inspection dates
Dec. 10, 2024
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 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: 12/10/2024 from 10:30 am to 10:45 am. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Two complaints were received by VDSS Division of Licensing on 10/29/2024 and 11/06/2024 regarding allegations in the area(s) of: Buildings and Grounds. Number of residents present at the facility at the beginning of the inspection: 52 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 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation(s) 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Violations
22VAC40-73-150-B
Based on interview, the facility failed to ensure if an administrator resigns or is discharged, to immediately employ a new administrator or appoint a qualified acting administrator so that no lapse in administrator coverage occurs.
Evidence
  1. The facility did not employ a new administrator or appoint a qualified acting administrator from 11/15/2024- 12/08/2024.
Plan of correction
Not published by VDSS.
22VAC40-73-870-D
Based on interview, the facility failed to keep free of infestations of insects and vermin.
Evidence
  1. On 11/20/2024, 7 rooms were identified as having live bed bugs.
Plan of correction
Not published by VDSS.
22VAC40-73-870-I
Based on observation, the facility failed to ensure elevators, where used, be kept in good running condition, and be inspected at least annually. Elevators shall be inspected in accordance with the Virginia Uniform Statewide Building Code (13VAC5-63). The signed and dated certificate of inspection issued by the local authority shall be
Evidence
  1. of such inspection. Evidence:
  2. The certification of inspection for the elevator that is utilized by residents, visitors, and staff expired 05/25/2024.
Plan of correction
Not published by VDSS.
September 12, 2024Complaint survey0 violations
Inspection dates
Sept. 12, 2024
Areas reviewed
22VAC40-73 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: 09/12/2024 from 12:50 pm to 2:10 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 09/12/2024 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: 55 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: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
September 12, 2024Inspection3 violations
Inspection dates
Sept. 12, 2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 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: 09/12/2024 from 12:50 pm to 2:10 pm. 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 09/02/2024 regarding allegations in the area(s) of: Additional Requirements for Facilities that Care for Adults for Serious Cognitive Impairments. Number of residents present at the facility at the beginning of the inspection: 55 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 staff: 2 Observations by licensing inspector: All exits within the safe, secure environment observed. Additional Comments/Discussion: Inspection focused on submitted self-reported incident. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Violations
22VAC40-73-1150-A
Based on discussion, 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.
Evidence
  1. On 09/02/2024, Resident #1 exited the safe, secure environment through an emergency exit door where the alarm was deactivated.
Plan of correction
Frequency of checking the door alarm is armed increased to every 30 min. All staff reeducated on how to verify door alarms are armed. Executive Director or designee ensure training of all new staff on verifying door alarms are armed properly.
22VAC40-73-460-D
Based on record review and discussion, the facility failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs, such as wandering from the premises.
Evidence
  1. Resident #1 eloped from the safe, secure environment on 09/02/2024.
  2. Resident #1 was found off the premises approximately 0.4 miles away.
Plan of correction
Frequency of checking the door alarm is armed increased to every 30 min. All staff reeducated on how to verity door alarms are armed. Education provided to all staff to verify location of all residents on the secured unit.
22VAC40-73-990-C
Based on interview, the facility failed to document staff participation in practice exercises for resident emergencies at least once every six months.
Evidence
  1. The facility was unable to provide documentation that staff had participated in an exercise in which the procedures for resident emergencies were practiced at least every six months.
Plan of correction
Executive Director or designee will conduct emergency procedure practice now and every 6 months with all staff, as well as for any new staff upon hire.
August 22, 2024Complaint survey0 violations
Inspection dates
Aug. 22, 2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 08/22/2024 from 10:00 am to 10:50 am. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 08/20/2024 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: 55 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: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
August 12, 2024Complaint survey1 violation
Inspection dates
Aug. 12, 2024
Areas reviewed
22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 08/12/2024 from 1:10 pm to 1:20 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 08/09/2024 regarding allegations in the area(s) of: 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: 57 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: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation(s) 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Violations
22VAC40-73-1120-F
Based on interview, the facility failed to ensure the designated staff person responsible for managing or coordinating the structured activities program be on site in the special care unit at least 20 hours a week.
Evidence
  1. Floor staff within the special care unit and Staff #2 verified Staff #2 is not on site in the special care unit at least 20 hours a week.
Plan of correction
Director of Activities will coordinate, conduct, and/or oversee at least 20 hours of activities per week in the special care unit. The Director of Activities will utilize office on special care unit to be more present and available to the residents on special care unit.
April 23, 2024Inspection15 violations
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT 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 REPORT
Technical assistance
22VAC40-73-670
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: 04/23/2024 from 8:30 am to 3:06 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: 49 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 5 Number of staff records reviewed: 4 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 4 Observations by licensing inspector: Breakfast and an activity were observed. A medication pass observation was completed for 3 residents. The following were reviewed: resident and staff records, medication carts, call bells, and water temperatures. 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Violations
22VAC40-73-1090-A
Based on record review and interview, the facility failed to ensure prior to admission to a safe, secure environment, residents have been assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare.
Evidence
  1. Resident #1 (admitted 4/10/2024) and Resident #3 (admitted 10/27/2023) did not have a completed assessment of serious cognitive impairment in their records.
Plan of correction
New admission packets updated to have complete serious cognitive impairment assessment forms. Executive Director, Resident Care Coordinator, or designee to review all new admission to secure environment has all required documentation prior to moving into the community.
22VAC40-73-1110-A
Based on record review, the facility failed to ensure the licensee, administrator, or designee determine whether placement in the special care unit is appropriate for a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia to a safe, secure environment.
Evidence
  1. Resident #1 (admitted 4/10/2024) and Resident #3 (admitted 10/27/2023) did not have documentation of the determination and justification on whether placement in the special care unit is appropriate by the licensee, administrator, or designee in their record.
Plan of correction
Documentation of approval for placement in special care unit to be completed for residents #1 and #3. Executive Director or Resident Care Coordinator to ensure form is completed and in file of any resident moving into community’s special care unit.
22VAC40-73-50-B
Based on record review, the facility failed to retain written acknowledgment of the receipt of the disclosure by the resident or his legal representative.
Evidence
  1. Upon review of Resident #1’s record, there was no written acknowledgment of the receipt of the full disclosure by the resident or their legal representative.
Plan of correction
Disclosure will be resent to resident #1’s legal representative for initials and signatures. All new admission packets will be reviewed for all required admission documents by the Executive Director or designee.
22VAC40-73-200-D
Based on record review and interview, the facility failed to obtain a copy of the certificate issued or other documentation indicating that the person has met one of the requirements of subsection C of this section, which shall be part of the staff member's record in accordance with 22VAC40-73-250.
Evidence
  1. Staff #5 works at the facility as direct care staff; however, their record did not include a copy of the certificate issued or other documentation indicating that the person has met one of the requirements of subsection C of this section.
Plan of correction
Audit of all current staff files to ensure requirements to provide care are present in the file. Any staff member missing documentation will be removed from the schedule until appropriate documentation is provided. Executive Director or designee to review all new hire documentation prior to the first day working with residents to ensure appropriate training has been completed.
22VAC40-73-210-B
Based on record review and interview, the facility failed to ensure all direct care staff attend at least 18 hours of training annually with the exception of direct care staff who are licensed health care professionals or certified nurse aides attend annually with the exception of direct care staff who are licensed health care professionals or certified nurse aides attend at least 12 hours of annual training. Training also should include at least two of the required hours on infection control and prevention and when adults with mental impairments reside in the facility, at least four of the required hours on topics related to residents' impairments.
Evidence
  1. Staff #1 was unable to provide documentation of 2023 annual training for Staff #5.
Plan of correction
Audit to ensure that all current staff members have the required annual training going forward. Executive Director, Resident Care Coordinator, or designee to conduct monthly audits of staff education to ensure compliance.
22VAC40-73-250-D
Evidence
  1. Staff #2 was rehired on 05/23/2023; however, the only TB risk assessment for Staff #2 was completed on 03/17/2024.
  2. Staff #3 was hired on 08/14/2023; however, the initial TB risk assessment in the record for Staff #3 was completed on 02/21/2023.
  3. Staff #4 was hired on 01/08/2024; however, the initial TB risk assessment in the record for Staff #4 was completed on 03/17/2024.
Plan of correction
Executive Director, Resident Care Coordinator, or designee to review all new hire documentation prior to first day working with residents to ensure TB risk assessment has been completed.
22VAC40-73-260-A
Based on record review, the facility failed to ensure each direct care staff member 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. Staff #5 works as direct care staff and does not have documentation of a current certification in first aid in their staff record.
Plan of correction
Audit to ensure that all current staff members have the required first aid training. Any staff member with missing or expired first aid training will be removed from the schedule until they have appropriate training completed. Executive Director, Resident Care Coordinator, or designee to conduct monthly audits of staff education to ensure ongoing compliance.
22VAC40-73-320-A
Based on record review, the facility failed to ensure within the 30 days preceding admission, a person have a physical examination by an independent physician.
Evidence
  1. Resident #1 admitted to the facility on 04/10/2024; however, their record did not include a completed physical examination.
Plan of correction
Executive Director, Resident Care Coordinator, or designee to review physical examination paperwork prior to admission of any new residents, to ensure that exam paperwork is completed in its entirety.
22VAC40-73-390-A
Based on record review, the facility failed to ensure at or prior to the time of admission, there be a written agreement/acknowledgment of notification dated and signed by the resident or applicant for admission or the appropriate legal representative, and by the licensee or administrator.
Evidence
  1. The facility was unable to provide documentation there was a written agreement/acknowledgment of notification dated and signed by the appropriate legal representative for Resident #1 (admitted 04/10/2024).
Plan of correction
All admission packets will be reviewed for all required admission documents by the Executive Director or designee.
22VAC40-73-620-A
Based on record review the facility failed to ensure dietary oversight was conducted every six months for specials diets Description: Based on record review, the facility failed to ensure dietary oversight was conducted every six months for specials diets by a dietitian or nutritionist.
Evidence
  1. The last dietary oversight completed was completed on 2/20/2023.
Plan of correction
Executive Director to coordinate with a registered dietician to conduct dietary oversight for the community every six months.
22VAC40-73-680-C
Based on observation and interview, the facility failed to ensure medications be administered not earlier than one hour before and not later than one hour after the facility's standard dosing schedule, except those drugs that are ordered for specific times, such as before, after, or with meals.
Evidence
  1. Resident #1 admitted to the facility on 4/10/2024; however, the April 2024 MAR for Resident #1 does not document medication administration until 4/12/2024. Additionally, the 8:00 am and 9:00 am medications (total of 6 medications) for Resident #1 were not documented as administered on 4/21/2024.
  2. The April 2024 MAR for Resident #2 shows the following medications were not administered on the following days: Atorvastatin 40 mg tablets from 4/15/24-4/17/24 (3 doses), Buspirone 5 mg tablet on 4/7/24, Clopidogrel 75 mg tablet from 4/20/24-4/22/24 (3 doses), Diclofenac gel on 4/4/24, 4/14/24, and 4/15/24, Gabapentin 600 mg tablet on 4/4/24, 4/9/24, 4/14/24, and 4/15/24 (4 doses), Mirtazapine 7.5 mg tablet from 4/1/24, 4/2/24, and 4/4/24 (3 doses), Omeprazole 20 mg tablet on 4/9/24, Sertraline 100 mg tablet on 4/18/24-4/19/24 (2 doses), and Vitamin B-12 1000 mcg tablet on 4/19/24.
  3. During a medication observation on 4/23/2024 with Staff #2, the following medications were not available for administration for Resident #3: Memantine 10 mg tablet, Atenolol 50 mg tablet, and Hydroxyz 25 mg tablet. Additionally, the April 2024 MAR for Resident #3 shows the following medications were not administered on the following days: Atenolol 50 mg tablet on 4/21/24, Gabapentin 100 mg capsule on 4/13/24, Hydroxyz on 4/17/24 and 4/19/24-4/21/24 (4 doses), and Memantine 10 mg tablet 4/16/24-4/22/24 (10 doses).
  4. Resident #5 has an order to check blood sugar three times a day before meals; however, the April 2024 MAR for Resident #5 indicates the machine has not worked since at least 4/1/24 and does not document Resident #5’s blood sugars.
Plan of correction
Education will be provided to all RMA and LPNs on obtaining and reporting any missing medications for residents. Family education will be provided to ensure that all prescribed medications and supplies are available to staff or will be ordered through contracted pharmacy to ensure that residents are receiving all prescribed medications and treatments. New blood sugar machine was ordered and received for resident #5 on 5/1/2024. Resident Care Coordinator or designee to conduct weekly audits of MAR/TAR to ensure compliance with medication administration plan.
22VAC40-73-690-B
Based on record review, the facility failed to ensure for each resident assessed for assisted living care, except for those who self- administer all of their medications, a licensed health care professional, practicing within the scope of his profession, perform a review every six months of all the medications of the resident.
Evidence
  1. Staff #1 was unable to provide documentation of a medication review within the last 12 months.
Plan of correction
Executive Director to coordinate medication review by licensed health care professional for all current residents and every six months going forward.
22VAC40-73-980-C
Based on record review, the facility failed to ensure first aid kits be checked at least monthly to ensure that all items are present and items with expiration dates are not past their expiration date.
Evidence
  1. There was no documentation of the monthly checks of the first aid kit from April 2023-February 2024.
Plan of correction
Monthly first aid kit checks are currently being performed. Executive Director, Resident Care Coordinator, or designee to audit compliance with completion of monthly checks.
22VAC40-73-990-C
Based on interview, the facility failed to document staff participation in practice exercises for resident emergencies at least once every six months.
Evidence
  1. Staff #1 was unable to provide documentation that staff had participated in an exercise in which the procedures for resident emergencies were practiced at least every six months.
Plan of correction
Executive Director to develop documentation staff practice of resident emergencies and ensure practice is completed at least every six months.
22VAC40-90-40-B
Based on record review, the facility failed to ensure the criminal history record report be obtained on or prior to the 30th day of employment for each employee.
Evidence
  1. Staff #6 was hired on 09/25/2023; however, their criminal history record report was obtained on 11/01/2023.
  2. Staff #7 was hired on 09/18/2023; however, their criminal history record report was obtained on 11/06/2023.
  3. Staff #8 was hired on 03/08/2024; however, there was not a completed criminal history record report for Staff #8.
Plan of correction
Staff #8 criminal history has been obtained and has cleared criminal history. Executive Director or designee to ensure criminal history reports are received by the 30th day of employment or staff member will be removed from the scheduled until report is obtained. Executive Director or designee to audit all pending criminal history records for new employees weekly.
January 25, 2024Complaint survey0 violations
Inspection dates
Jan. 25, 2024
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 01/25/2024 from 2:35 pm to 3:00 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 01/19/2024 regarding allegations in the area(s) of: Admission, Retention, and Discharge. Number of residents present at the facility at the beginning of the inspection: 52 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
November 21, 2023Inspection6 violations
Inspection dates
Nov. 21, 2023
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 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: 11/21/2023. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 11/16/2023 regarding allegations in the area(s) of: Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 49 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: All medication carts reviewed. Additional Comments/Discussion: Inspection focused on submitted self-reported incident. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Violations
22VAC40-73-120-A
Based on record review, the facility failed to ensure the orientation and training required in subsections B and C of this section occur within the first seven working days of employment.
Evidence
  1. The record of Staff #2 (hired 7/11/23) does not include documentation of their staff orientation and initial training.
Plan of correction
Audit of all staff records will be done to identify any other missing orientation and initial training. Any identified missing items will be completed and placed in the employee’s file. All new employees starting after audit is completed will be double checked by the executive director or their designee for completion.
22VAC40-73-250-C
Based on record review, the facility failed to maintain personal and social data on staff to include verification that the staff person has received a copy of his current job description.
Evidence
  1. Staff #2’s record does not include verification that the staff person has received a copy of their current job description.
Plan of correction
Audit of all staff records will be done to identify any other missing signed job descriptions. Any identified missing items will be completed and placed in the employee’s file. All new employees starting after audit is completed will be double checked by the executive director or their designee for completion.
22VAC40-73-250-D
Evidence
  1. Staff #1 was unable to provide the results of a TB risk assessment for Staff #2 (hired 7/11/23).
Plan of correction
Audit of all staff records will be done to identify any other missing TB screenings. Any identified missing items will be completed and placed in the employee’s file. All new employees starting after audit is completed will be double checked by the executive director or their designee for completion.
22VAC40-73-260-A
Based on record review, the facility failed to ensure each direct care staff member 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. Staff #2 (hired 7/11/23) worked as direct care staff and does not have a current certification in first aid.
Plan of correction
Audit of all staff records will be done to identify any other staff members missing current first aid. Any identified missing items will be given the opportunity to complete and update their first aid and proof of completion placed in their file. All new employees starting after audit is completed will be double checked by the executive director or their designee for completion.
22VAC40-73-640-A
Based on record review, the facility failed to ensure methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes.
Evidence
  1. Two count sheets and cards of Hydrocodone 5-325 mg tablets (approximately 40 tablets) for Resident #1 were unable to be located and accounted for on 11/15/2023.
Plan of correction
100% education to all med techs and LPNs to complete the “Shift Change Verification” form and to ensure they are counting all cards and sheets to make sure they match and to report any discrepancies immediately to the RCC or Executive Director. RCC or designee will conduct weekly audits to ensure compliance.
22VAC40-73-680-C
Based on record review, the facility failed to ensure medications be administered not earlier than one hour before and not later than one hour after the facility's standard dosing schedule, except those drugs that are ordered for specific times, such as before, after, or with meals.
Evidence
  1. The following medications were not documented as administered on the November MAR for Resident #1: Desonide Cream on 11/01/2023, 11/02/2023, 11/05/2023, 11/07/2023, 11/08/2023, 11/11/2023-11/14/2023, 11/16/2023, 11/17/2023, and 11/20/2023, Estradiol Cream on 11/01/2023, 11/02/2023, 11/05/2023-11/09/2023, 11/11/2023- 11/13/2023, 11/15/2023-11/17/2023, and 11/20/2023, Gabapentin 300 mg tab on 11/14/2023 and 11/20/2023, Gemtesa 75 mg tab on 11/13/2023 and 11/16/2023, Hydrocodone 5-325 mg tab on 11/05/2023, 11/14/2023, and 11/17/2023, Omeprazole 20 mg capsule on 11/01/2023-11/04/2023 and 11/06/2023-11/21/2023, and Stioloto Respimat on 11/02/2023 and 11/07/2023.
Plan of correction
RCC or designee will do daily audits x4 weeks of MAR to ensure proper documentation of medication administration. 100% education for all LPN and med techs will be completed on ensuring proper documentation of medication administration.
July 20, 2023Inspection1 violation
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 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: 07/20/2023. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 07/11/2023 regarding allegations in the area(s) of: Part V Admission, Retention and Discharge of Residents. Number of residents present at the facility at the beginning of the inspection: 53 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 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. However, violation(s) not related to the self-report 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Violations
22VAC40-73-560-C
Based on record review and interview, the facility failed to ensure any physician's notes and progress reports in the possession of the facility be retained in the resident's record.
Evidence
  1. There were no physician’s notes or progress notes/information pertaining to Resident #1’s wounds in their record.
  2. Staff #1 acknowledged the facility had additional information; however, it was not provided during the inspection nor within the resident’s record for review.
Plan of correction
1. The needed documentation was obtained and entered into the medical record. 2. The Administrator, AIT, or designee will complete an audit on all current resident charts to ensure compliance with 22VAC40-73-560-C. 3. The Administrator, AIT, or designee will routinely audit resident charts to ensure ongoing compliance. 4. Audits will be reviewed in QAPI with any trends reported and a POC initiated as indicated.
July 20, 2023Complaint survey6 violations
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS
Technical assistance
22VAC40-73-870 22VAC40-73-930
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: 07/20/2023 and 07/25/2023. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Three complaints were received by VDSS Division of Licensing on 07/10/2023 (2) and 07/21/2023 (1) regarding allegations in the area(s) of: Part VI Resident Care and Related Services, Part VII Resident Accommodations and Related Provisions, Part VIII Buildings and Grounds, Part IX Emergency Preparedness, and Part X 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: 53 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 5 Observations by licensing inspector: Lunch was observed. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s); area(s) of non-compliance with standard(s) or law were: Part VI Resident Care and Related Services and Part VIII Buildings and Grounds. A violation notice was issued; any violation(s) not related to the complaint(s) 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 For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Violations
22VAC40-73-440-A
Based on record review, the facility failed to complete a resident’s UAI at least annually.
Evidence
  1. The last UAI for Resident #1 was completed on 05/16/2022.
  2. The last UAI for Resident #2 was completed on 04/11/2022.
Plan of correction
1. The UAIs for Resident #1 and Resident #2 were updated. 2. The Administrator, AIT, or designee will complete a 100% audit on UAIs to ensure all current residents UAIs are up to date. 3. Moving forward Administrator, AIT, or designee will complete a 100% audit once a month to ensure that all UAIs are up to date. 4. Audits will be reviewed in QAPI with any trends reported and a POC initiated as indicated.
22VAC40-73-460-H
Based on 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.
Evidence
  1. The documentation provided by Staff #1 does not indicate the residents reviewed are receiving bathing at least twice a week. The following are the documented completion or attempts of bathing on the records reviewed from 7/1/23 to 7/25/23: Resident #1 – 7/8/23, 7/14/23, 7/18/23, and 7/21/23, Resident #2 – 7/12/23, 7/19/23, 7/22/23, and 7/26/23, Resident #3 – 7/8/23, 7/12/23, and 7/14/23, Resident #4 – 7/25/23, and Resident #5 – 7/4/23. Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5 require physical assistance with bathing per the resident’s UAIs.
Plan of correction
1. Resident #1, Resident #2, Resident #3, Resident #4 and Resident #5 were bathed. a UAIs were updated to reflect assistance was needed for bathing. 2. AIT has made a new shower schedule that ensures that residents receive a shower at least twice a week. 3. AIT created a new shower documentation sheet for all residents. Staff will document on residents set shower days. 4. Administrator, AIT, or designee will complete a weekly 100% audit on shower sheet documentation at the end of each week for 1 month. These audits will be completed on the shower documentation audit sheet. The audit will be reviewed in QAPI. Any trends will be reported and a POC will be initiated as indicated.
22VAC40-73-660-A-1
Based on observation, the facility failed to ensure the medication cart be locked.
Evidence
  1. During a tour of the facility on 07/25/2023, the medication cart on the Cedar Point unit was observed to be unlocked and unattended.
Plan of correction
1. The medication cart was immediately locked. 2. Administrator, AIT, or designee will educate all Registered Medication Aides and LPNs on the violation. 3. RMAs and LPNs will be re-educated on 22VAC40-73-660A. 4. Administrator, AIT, or designee will complete rounds throughout the day to make sure that all medication carts are locked on daily rounds. Daily rounds will be reported in QAPI. Any trends will be discussed and POC initiated as indicated.
22VAC40-73-680-C
Based on record review, the facility failed to ensure medications be administered not earlier than one hour before and not later than one hour after the facility's standard dosing schedule, except those drugs that are ordered for specific times, such as before, after, or with meals.
Evidence
  1. The July MAR for Resident #5 indicates Uribel 118 mg capsule to be administered four times every Monday, Wednesday, and Friday was not available or administered on 7/7/2023 and 7/10/2023.
Plan of correction
1. Resident #5 had no adverse reactions. The medication is available for resident #5. The medication is being administered per M.D. order. 2. The Administrator, AIT, or designee will complete training with all Registered Medication Aids and LPNs on the medication times and procedure if a medication is not available. 3. Administrator, AIT, or designee will audit 100% of resident’s MAR for medications not administered or medications not available 3xper week for 30 days. This audit will be completed on the newly created MAR audit sheet. 4. Any medication that is not available will be discussed in the daily stand-up meeting. Any trends will be reported to QAPI and a POC will be initiated as indicated.
22VAC40-73-870-A
Based on observation, the facility failed to ensure the interior of the building be maintained in good repair and kept clean and free of rubbish.
Evidence
  1. During a tour of the facility on 07/20/2023, a vent in the dining room of the safe, secure environment was observed to have grey colored substance. Additionally, there was flooring within the hallway of the unit that was buckled and a potential trip hazard to residents.
Plan of correction
1. The vent in the dining room was cleaned. The flooring was adjusted and re-glued to the floor. 2. Maintenance Director or designee will audit all vents in the building during daily rounds. If a vent is observed to need cleaning housekeeping or designee will clean the vent. 3. Maintenance Director or designee will observe flooring on daily rounds. If any issues arise, they will be addressed accordingly. 4. Maintenance or designee will make rounds daily to ensure they are complying with 22VAC40-73-870-A. Any issues or trends will be reported to QAPI and a POC will be initiated as indicated.
22VAC40-73-880-C
Based on observation, the facility failed to provide in all buildings an air conditioning system for all areas used by residents, including residents' bedrooms and common areas. Temperatures in all areas used by residents shall not exceed 80°F.
Evidence
  1. During a tour of the facility on 07/20/2023 and 07/25/2023, portable AC units were observed within the common areas (two living room areas and the dining room) of the safe, secure environment.
  2. On 07/25/2023 around 2:00pm, the dining room area temperature measured 81°F.
Plan of correction
1. A portable AC was installed in the dining room. 2. Maintenance Director or designee will make daily rounds of the building to check temperatures of building. If temperature is above 80 degrees. 3. AC Vendor will be notified of any temperature issue. Designee will ensure that AC Vendor addresses the issue in a timely manner. If there is an issue with the vendor, the Designee will notify AIT or Administrator immediately. 4. 22VAC40-73-880-C will be discussed in QAPI. Any issues or trends will be discussed and POC initiated as indicated.
June 15, 2023Complaint survey6 violations
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 GROUND22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Technical assistance
22VAC40-73-460-H
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/15/2023 from 9:45 am to 1:15 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Three complaints were received by VDSS Division of Licensing on 06/01/2023 and 06/05/2023 regarding allegations in the area(s) of: Part IV Staffing and Supervision, Part V Admission, Retention and Discharge of Residents, Part VI Resident Care and Related Services, Part VII Resident Accommodations and Related Provisions, and Part VIII Buildings and Grounds. Number of residents present at the facility at the beginning of the inspection: 50 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Observations by licensing inspector: Lunch was observed. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s); area(s) of non-compliance with standard(s) or law were: Part VI Resident Care and Related Services and Part VIII Buildings and Grounds. A violation notice was issued; any violation(s) not related to the complaint(s) 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Violations
22VAC40-73-580-B
Based on record review, the facility failed to ensure if the facility, through its policies and procedures, offers routine or regular room service, residents be given the option of having meals in the dining area or in their rooms, provided that there is a written agreement to this effect, signed and dated by both the resident and the licensee or administrator and filed in the resident's record.
Evidence
  1. Resident #6 indicated they eat all their meals in their apartment which was confirmed with Staff #3; however, the resident’s record does not include a written agreement between the resident and the licensee or administrator of this arrangement.
Plan of correction
1. Resident #6 will be provided a written agreement to give the option of having meals in the dining area or in her room. 2. A written agreement to give the option of having meals in the dining area or in resident’s room will be provided to those who prefers to have the meals in their rooms. 3. Director of Resident Care or designee will monitor and audit the practice. 4. The result of audit will be reported to facility QAPI committee for review and recommendations.
22VAC40-73-680-C
Based on record review, the facility failed to ensure medications be administered not earlier than one hour before and not later than one hour after the facility's standard dosing schedule, except those drugs that are ordered for specific times, such as before, after, or with meals.
Evidence
  1. The June MAR for Resident #2 indicates the following medications were not administered on the following days: Clopidogrel 75mg tablet from 6/9/23-6/12/23 and Atorvastatin 40mg tablet on 6/13/23.
  2. The June MAR for Resident #3 indicates the following medications were not administered on the following days: Buspirone 10mg tablet from 6/1/23-6/14/23 and Fluticasone 50mg spray from 6/1/23-6/14/23.
  3. The June MAR for Resident #6 indicates the following medications were not administered on the following days: Lidocaine Pain Relief on 6/13/23 and Melatonin 3mg tablet on 6/6/23.
  4. The June MAR for Resident #7 indicates the following medications were not administered on the following days: Carvedilol 3.125mg tablet on 6/6/23 and 6/8/23 and Venlafaxine 75mg capsule from 6/1/23-6/15/23.
Plan of correction
1. There are no adverse effects noted from resident #2, #3, #6 and #7. 2. There are no effects on other residents. 3. Director of Resident Care or designee will conduct random audit during medication passing time weekly to assure the compliance. 4. The result of audit will be reported to facility QAPI committee for review and recommendations.
22VAC40-73-680-H
Based on record review, the facility failed to ensure the MAR contain the items identified in the standard.
Evidence
  1. The MARs of Resident #1, Resident #2, Resident #3, Resident #4, Resident #6, and Resident #7 did not include the name, signature, and initials of all staff administering medications.
Plan of correction
1. A master signature form includes name, signature and initials of all staff administering medications will be put in place for each MAR book. All RMA or LPN will fill out the form. 2. New hires or Agency staff will complete the master signature form upon the starting date. 3. Director of Resident Care will audit the Master Signature Form is completed per standard. 4. The result of audit will be reported to facility QAPI committee for review and recommendations.
22VAC40-73-720-A
Based on record review, the facility failed to ensure a valid written Do Not Resuscitate (DNR) order has been issued by the resident's attending physician; and that the written order is included in the individualized service plan.
Evidence
  1. Evidence:
  2. Upon review of Resident #1’s record, their ISP (dated 5/11/23) indicates the resident as a DNR; however, the resident does not have a signed DNR order or Durable DNR in their record.
Plan of correction
1. Resident #1 has been hospitalized since June 14, 2023. 2. Resident #1 POA was reminded to provide the facility the signed DNR form. They were also informed resident will be treated as FULL code till signed DNR form is received. ISP is updated to reflect the code status. 3. Director of Resident Care or designee will audit the resident’s ISP to assure the signed DNRs on of file. 4. The result of audit will be reported to facility QAPI committee for review and recommendations.
22VAC40-73-870-A
Based on observation, the facility failed to ensure the interior of the building be maintained in good repair and kept clean and free of rubbish.
Evidence
  1. During a tour of the facility, a vent in the dining room of the safe, secure environment was observed to have grey colored substance. Additionally, a fan was noted in a common area and is a potential trip hazard.
Plan of correction
1. Staff will clean the identified vent in the dinning room on MCU. The fan has been removed from the common area. 2. Housekeeping staff will check all vent in the dining rooms to assure they are clean. 3. Administrator or designee will audit the vent cleanness and monitor for any trip hazard during rounds. 4. The results of audit will be presented to facility QAPI committee for review and or recommendations.
22VAC40-73-930-B
Based on record review, the facility failed to ensure there is 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. On 6/15/2023 around 10:32 am, the call bell of Resident #6 was pressed. After 10 minutes past, no staff were observed to respond. Around 10:45 am, the call bell of Resident #7 was pressed. After 10 minutes past, no staff were observed to respond.
  2. Staff #3, Staff #4, and Staff #5 indicated they were unaware of the call bells as there were no pagers available on the first floor for notification.
Plan of correction
1. Facility maintenance coordinator placed order for six beepers immediately. Director of Resident Care provide her beeper to 1st floor staff. The beeper for 2nd floor was located the same day of survey. 2. Additionally, we have ordered the table bells for the residents. 3. Director of Resident Care or designee will in service residents and staff to use table bell as call bell for assistance. Director of Resident Care or designee will audit the beepers and table bells usage during rounds. 4. The result of audit will be reported to facility QAPI committee for review and recommendations.
May 23, 2023Inspection1 violation
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: 05/23/2023 from 2:45 pm to 3:35 pm. 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 05/04/2023 regarding allegations in the area(s) of: Resident Care and Related Services. Number of resident records reviewed: 1 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Violations
22VAC40-73-680-C
Based on record review, the facility failed to ensure medications be administered not earlier than one hour before and not later than one hour after the facility's standard dosing schedule, except those drugs that are ordered for specific times, such as before, after, or with meals.
Evidence
  1. The May MAR for Resident #1 indicates the following medications were not administered on the following days: Alprazolam 1mg tab on 5/8/23 (two doses), 5/10/23, 5/13/23, and 5/21/23, Clomipramine 50mg capsule on 5/8/23, 5/10/23, and 5/19/23, Famotidine 20mg tab on 5/1/23, 5/8/23, 5/10/23, and 5/13/23, Olanzapine 10mg tab on 5/10/23, 5/16/23, and 5/18/23, Trospium CL 20mg tab on 5/7/23, 5/10/23, and 5/21/23, Valacyclovir 1gm tab on 5/3/23 and 5/21/23, Azo Urinary 99.5 tab on 5/1/23, 5/2/23 (two doses), and 5/3/23 (two doses), Cefdinir 300mg capsule on 5/1/23 and 5/2/23, and Roflumilast 250mg tab on 5/1/23, 5/2/23, 5/3/23, 5/10/23, 5/12/23, and 5/16/23, Nitrofurantoin 100mg capsule on 5/10/23.
Plan of correction
Resident #1 has completed the oral antibiotic medication on the extended days. There are missing signatures on the MARs noticed. Staff assessed resident and there are no adverse effects noticed. We have been aggressively hiring for RMA, LPNs. And we have been using agency staff to assist the medication administration. Director of Resident Care or designee will re-educate the RMA, Licensed Nurses on P/P of the Medication Administration Director of Resident Care or designee will make random rounds during medication passing to assure that RMA/LPN follow the nursing practice standard to administer medication timely and document on MAR. The result of audit will be presented to facility QAPI committee for review and recommendations.
April 24, 2023Inspection12 violations
Inspection dates
April 24, 2023 and April 25, 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 REPORT
Technical assistance
22VAC40-73-450-E
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: 04/24/2023 from 8:50 am to 3:50 pm and 04/25/2023 from 8:40 am to 11:15 am. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 48 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 4 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 The departments 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Violations
22VAC40-73-40-B
Based on record review, the facility failed to ensure the criminal history record report be obtained on or prior to the 30th day of employment for each employee.
Evidence
  1. The criminal history record report was obtained on 12/22/2022 for Staff #6 (hired 8/30/2022), Staff #7 (hired 11/8/2022) and Staff #8 (hired 11/8/2022).
Plan of correction
1. Staff #6, 7 and 8 all have clear criminal history records. 2. Business Office Coordinator will audit all current staff to make sure all criminal history records are obtained within the 30 days of hire. 3. We have started a new practice that all CRC must be obtained before the orientation day. 4. The result of audit will be presented to facility QAPI committee for review and recommendations.
22VAC40-73-120-A
Based on record review, the facility failed to ensure the orientation and training required in subsections B and C of this section occur within the first seven working days of employment.
Evidence
  1. Staff #5 was hired on 6/20/2022; however, their staff record does not include documentation of their staff orientation and initial training.
Plan of correction
1. Staff #5 has received some orientation on the date of hiring. She will receive all the intimal training and orientation. 2. Business office coordinator or designee will audit all recent new hires to make sure the staff orientations and initial training are complete per DSS regulation. 3. Administrator or designee will audit the new hire files weekly. 4. The result of audit will be presented to facility QAPI committee for reviewing and recommendations.
22VAC40-73-210-G
Based on record review, the facility failed to ensure there is documentation of the type of training received, the entity that provided the training, number of hours of training, and dates of the training kept by the facility in a manner that allows for identification by individual staff person and is considered part of the staff member's record.
Evidence
  1. The records for Staff #1, Staff #2, Staff #3, and Staff #4 indicate they have completed 18 hours of annual in-services; however, the documentation did not include the dates the types of training were individually completed.
Plan of correction
1. Staff #1, 2, 3 and 4 have completed 18 hours of annual in-services. 2. Facility will implement a new annual in-service form to indicate the dates, the types of training we individually completed. 3. Business office coordinator or designee will keep track of each staff's annual in-service requirement. 4. Annual in-service completion status will be presented to facility QAPI committee for reviewing and recommendations.
22VAC40-73-250-C
Based on record review, the facility failed to ensure personal and social data be maintained on staff and included in the staff record.
Evidence
  1. Staff #5's record did not include verification that the staff person has received a copy of their current job description and name and telephone number of person to contact in an emergency.
Plan of correction
1. Staff #5 will receive a copy the current job description. and name and telephone number of person to contact in an emergency will be kept on file. 2. Business office coordinator or designee will audit all current new hires to make sure the staff has received a copy of job description. And the emergency contact person's name and phone number are on file. 3. Move forward, administrator or designee will review each new hires file to make sure all required documents are in the file. 4. The result of audit will be presented to facility QAPI committee for reviewing and recommendations.
22VAC40-73-260-A
Based on record review, the facility failed to ensure each direct care staff member 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. Staff #2 works as direct care staff and does not have documentation of a current certification in first aid in their staff record.
Plan of correction
1. Staff #2 has obtained a new first aid certificate on May 5, 2023. 2. Business office coordinator or designee will audit all current direct care staff''s fille to make sure all required certificates are in file. 3. Administrator or designee will conduct random audit of personal files to make sure the required certificates are on current on file. 4. The results of audit will be presented to facility QAPI committee for reviewing and recommendations.
22VAC40-73-320-A
Based on record review, the facility failed to ensure within the 30 days preceding admission, a person have a physical examination by an independent physician.
Evidence
  1. Resident #6 admitted to the facility on 3/17/2023; however, their admitting physical examination was completed on 12/22/2022.
Plan of correction
1. Resident has been seen by the same physician in February 2023, she gave the verbal approve to our staff to use December's physical examination since there is no changes. 2. Director of Resident Care (DRC) will review all upcoming new admission to make sure the physical examination is within 30 days of the admission. 3. Administrator or designee will audit the new admissions to make sure the physical examinations are within 30 days of admission date. 4. The result of audit will be presented to facility QAPI committee for viewing and recommendations.
22VAC40-73-450-C
Based on record review, the facility failed to ensure the comprehensive ISP be completed within 30 days after admission and include a description of current identified needs and written description of what services will be provided to address identified needs based upon the UAI.
Evidence
  1. Resident #4's record did not include a comprehensive ISP.
  2. Resident #1's UAI (dated 5/16/2022) indicates the resident is incontinent of bowel and bladder weekly or more; however, Resident #1's ISP (dated 6/20/2022) does not address the resident’s incontinence needs.
  3. Resident #6's UAI (dated 3/15/2023) indicates the resident requires supervision with bathing, dressing, toileting, transferring and is incontinent of bowel and bladder weekly or more; however, Resident #6's ISP (dated 3/17/2023) indicates the resident does not require any assistance for bathing, dressing, toileting, transferring or note any assistance needed for incontinence.
Plan of correction
1. Resident #4 will have the comprehensive ISP. Resident #1 ISP will address the incontinence care needs. Resident #6's UAI and ISP will be updated regarding her ADLs needs. 2. Director of resident care will audit current residents UAI and ISP to make sure the care needs are matched. 3. Administrator will randomly audit 5 charts monthly to make sure the UAI and ISP are accurately reflect resident’s care needs. 4. The result of audit will be presented to the facility QAPI committee for review and recommendations.
22VAC40-73-640-A
Based on observation, the facility failed to implement their written plan for medication management which includes methods to prevent the use of outdated medications and plan for proper disposal of medication.
Evidence
  1. The following expired medications were observed in the medication carts at the facility: PRN Acetaminophe 325 mg tablets expired 12/15/2022 for Resident #1, PRN Ondansetron 4 mg tablets expired 7/29/2022 and Multaq 400 mg tablets expired 10/28/2022 for Resident #10, two cards of PRN Acetaminophe 325 mg tablets expired 12/15/2022 and 12/16/2022 for Resident #11, two cards of PRN Acetaminophe 325 mg tablets expired 12/15/2022 for resident #12, One A Day Multivitamin tablets expired 01/2022 for Resident #13, PRN Benzonatate 100 mg capsules expired 1/19/2023 for Resident #14, PRN Benzonatate 200 mg capsules expired 1/7/2023 for Resident #15, and Acetamin 500 mg tablets expired 12/15/2022 for Resident #7.
Plan of correction
1. All identified expired medication of the residents are removed from the medication carts. 2. Director of Resident Care or designee will conduct medication carts audit to assure no expired medications would stay in the carts. MD will be notified for reordering the meds or to DC meds. 3. DRC or designee will re-educate the RMAs and or LPNs on medication storage policy. 4. The result of audit will be presented to facility QAPI committee for review and recommendations.
22VAC40-73-680-C
Based on observation and interview, the facility failed to ensure medications be administered not earlier than one hour before and not later than one hour after the facility's standard dosing schedule, except those drugs that are ordered for specific times, such as before, after, or with meals.
Evidence
  1. At 10:00 am on 4/24/2023, Staff #2 was observed administering 9:00 am scheduled medications on the 3rd floor, and indicated two residents, Resident #6 (7 medications) and Resident #10 (4 medications), had not received their 9:00 am scheduled medications. The following residents in the safe, secure environment also had not received their 9:00 am scheduled medications by 10:00 am on 4/24/2023: Resident #4 (3 medications), Resident #7 (6 medications), Resident #16 (8 medications), Resident #17 (9 medications), Resident #18 (9 medications), and Resident #19 (5 medications).
Plan of correction
1. The identified residents received their medication a little bit late than the scheduled hours. There is no adverse effects noticed. 2. We have been aggressively hiring for RMA LPNs. And we have been use agency staff to assit the medication administration. 3. Director of Resident Care will make rondom rounds during medication passing time to make sure RMA/LPN administer medication timely per nursing practice standard. 4. The result of audit will be presented to facility QAPI committee for review and recommendations.
22VAC40-73-680-I
Based on record review, the facility failed to ensure the MAR include the identified items in the standard.
Evidence
  1. The following medications on Resident #1's April MAR 2023 did not include the diagnosis, condition, or specific indications for administering the drug or supplement: Aspirin 81 mg tablet, Metoprol Sub 100 mg tablet, Paroxetine 10 mg tablet, and Amlodipine 5 mg tablet.
  2. The following medications on Resident #2's April MAR 2023 did not include the diagnosis, condition, or specific indications for administering the drug or supplement: Ensure.
  3. The following medications on Resident #5's April MAR 2023 did not include the diagnosis, condition, or specific indications for administering the drug or supplement: Amlodipine 10 mg tablet, Aspirin 81 mg tablet, Melatonin 10 mg capsule, Olanzapine 5 mg tablet, Polyeth Glyc Powder, Vitamin D 3 tablet, and Vitamin E capsule.
  4. The following medications on Resident #6's April MAR 2023 did not include the diagnosis, condition, or specific indications for administering the drug or supplement: Ferosol 325 mg tablet and Colestipol 1 mg tablet. Additionally, the facility obtained a list of medication orders from the resident's physician to include the name of the resident, the date of the order, the name of the drug, route, dosage, strength, how often medication is to be given, and identify the diagnosis, condition, or specific indications for administering each drug on 3/22/2023 for Resident #6; however, the April MAR 2023 did not include the orders for Aricept and Glucosamine.
  5. The following medications on Resident #7's April MAR 2023did not include the diagnosis, condition, or specific indications for administering the drug or supplement: Ensure
  6. The following medications on Resident #9's April MAR 2023 did not include the diagnosis, condition, or specific indications for administering the drug or supplement: Amiodarone 200 mg tablet, Eliquis 2.5 mg tablet, Ferosul 325 mg tablet, and Trazodone 50 mg tablet.
Plan of correction
1. All needed diagnoses are added to MARs and POS for identified residents in survey samples. 2. Director of Resident Care and Administrator have reviewed all current resident's POS and MARs for May, any missing diagnoses are added accordingly. All medications have matching diagnoses in May's MARs and POS. 3. Director of Resident Care or designee will audit all new medications orders received to have matching diagnoses. 4. The result of audit will be presented to facility QAPI committee for review and recommendations.
22VAC40-73-690-G
Based on record review, the facility failed to act in response to the recommendations noted in subsection F of this section.
Evidence
  1. A pharmacy medication review was conducted on 1/31/2023. Resident #5's review included a recommendation for physician review and response; however, there was no documentation that the recommendation was sent for physician review and response at the time of inspection.
Plan of correction
1. Physician review has been completed, all needed diagnosis are added to MAR/POS accordingly for resident #5. 2. There is no other recommendations from pharmacy review. 3. Move forward, Director of Resident Care make sure all pharmacy review recommendations are followed up timely. 4. The result of pharmacy review recommendations will be presented to facility QAPI Committee for review and recommendations.
22VAC40-90-30-B
Based on record review, the facility failed to ensure a sworn statement or affirmation be completed for all applicants for employment.
Evidence
  1. There is no sworn disclosure in Staff #5's record.
Plan of correction
1. Facility will receive the sworn statement from staff #5. 2. Business office Coordinator or designee will review the current staff's file to make sure all sworn statement are in the staff's records. 3. Business office coordinator will review each new hire to make sure all required documents are obtained and kept in the file. 4. The result of audit will be presented to the facility QAPI committee for review and recommendations.
April 28, 2022Inspection8 violations
Inspection dates
April 28, 2022 and April 29, 2022
Areas reviewed
Part I General ProvisionsPart II Administration and Administrative ServicesPart III PersonnelPart IV Staffing and SupervisionPart V Admission, Retention and Discharge of ResidentsPart VI Resident Care and Related ServicesPart VII Resident Accommodations and Related ProvisionsPart VIII Buildings and GroundsPart IX Emergency PreparednessPart X Additional Requirements for Facilities that Care For Adults with Serious Cognitive Impairments
Comments
An unannounced renewal inspection was initiated by two Licensing Inspectors (LI) on 04-28-2022 and concluded on 04-29-2022. There were 30 residents in care at the time of the inspection. A tour of the facility was conducted, medication carts were inspected, and the first aid kit reviewed. LIs reviewed 4 staff records and 8 resident records. 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. The areas of noncompliance were discussed with the Administrator throughout the inspection and during the exit interview.
Violations
22VAC40-73-1090-A
Based on record review and interview, the facility failed to ensure prior to admission to a safe, secure environment, residents have been assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare.
Evidence
  1. Resident #1 resides in the safe, secure environment; however, the Assessment of Serious Cognitive Impairment forms documenting the assessment of Resident #1 indicate that Resident #1 is able to recognize danger or protect his/her own safety and welfare.
Plan of correction
Facility psychiatric PA will re-assess resident #1 to determine whether he/her is able to recognize danger or protect his/her own. There is no adverse effect on this resident. All other residents at special care unit have appropriate documents. Administrator or designee will review each resident on special care unit every 6 month for appropriate continuous placement. The resident of review will be presented to facility QAPI committee for review or recommendations.
22VAC40-73-1110-A
Based on record review, the facility failed to ensure that prior to admitting a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia to a safe, secure environment, the licensee, administrator, or designee due ato , o des g ee determine whether placement in the special care unit is appropriate. The determination and justification for the decision shall be in writing and shall be retained in the resident's file.
Evidence
  1. Resident #1 did not have documentation of the determination and justification on whether placement in the special care unit is appropriate by the licensee, administrator, or designee in the resident’s record.
Plan of correction
The documentation of the determination and justification on whether placement in the special care unit is appropriated for resident #1 by the administrator is placed in the resident’s record. Administrator will audit all residents on special care unit to assure each resident has the documentation of the determination and justification on whether placement in the special care unit is appropriated on their records. Administrator or designee will review resident pre-admission document to assure that appropriate documentation for special care unit is in place. Administrator or designee will review each resident on special care unit every 6 month for appropriate continuous placement. The results of review will be presented to facility QAPI committee for review or recommendations.
22VAC40-73-250-C
Based on record review, the facility failed to ensure personal and social data be maintained on staff and include verification that the staff person has received a copy of their current job description.
Evidence
  1. The record of Staff #2 did not contain verification that Staff #2 received a copy of their current job description.
Plan of correction
Staff #2 will receive the current job description. The varication of that will be placed in staff #2’s file. Business Office Coordinator or designee will audit all staffs? personnel files to assure that all staff have received current job descriptions from Karolwood Gardens at Portsmouth. Moving forward, Business Office Coordinator or designee will make sure that new hires receive the current Job Description during the orientation. Business Office Coordinator or designee will audit new hire files twice a month to assure that the verification of staff received a copy of their current job description. The results of audit will be presented to facility QAPI committee for review or recommendations.
22VAC40-73-325-A
Based on record review, the facility failed to ensure that a fall risk rating was completed by the time the comprehensive ISP was completed for residents who meet the criteria for assisted living care.
Evidence
  1. Resident #1 met the criteria for assisted living care upon admission on 2/23/2022; however, there was not documentation of a fall risk rating being completed by the time the comprehensive ISP was completed. The only fall risk rating in the record of Resident #1 was after a fall on 4/22/22.
Plan of correction
An updated fall assessment for resident #1 is completed There is no adverse effect on the resident Director of Resident Care or designee will audit residents record to assess the admission fall risk assessment is in place. Director of Resident Care or designee will audit new resident file monthly to assure the admission fall risk assessment are in place.
22VAC40-73-430-H-1
Based on record review and interview, the facility failed to ensure a dated discharge statement signed by the licensee or administrator that contains the information listed in the standard to be provided to the resident and, as appropriate, his legal representative and designated contact person at the time of discharge.
Evidence
  1. The records for Resident #5 and Resident #6 did not contain a written discharge statement.
Plan of correction
Administrator will complete the Discharge Notification and Statement for resident #5 and #6. A facility wide audit for discharge statement will be conducted to assure the compliance. Administrator or designee will establish a weekly Discharge Notification and Statement calendar. Business Office Coordinator or designee will audit for discharge statement completion weekly. The result of audit will be presented to facility QAPI Committee for review or recommendations presented to facility QAPI Committee for review or recommendations.
22VAC40-73-450-C
Based on record review, the facility failed to ensure the Individualized Service Plan (ISP) included a description of the resident’s identified needs based on the Uniform Assessment Instrument (UAI).
Evidence
  1. Resident #1’s UAI (dated 2/10/22) states the resident is incontinent with bowel weekly or more; however, Resident #1? s ISP (dated 3/22/22) does not address a need for bowel incontinence. The UAI for Resident #1 also states the resident requires mechanical and physical assistance with walking and mobility; however, the ISP for Resident #1 states the resident needs supervision with walking and does not indicate a need for mobility. Additionally, the ISP indicated Resident #1 has a DNR; however, there is not one in the record as the resident is a full code.
  2. Resident #2’s ISP (dated 4/18/22) indicates the resident has a no concentrated sweet diet; however, the physician order sheet for Resident #2 signed on 4/26/22 states the resident’s diet is NCS, NAS, mechanical soft texture, thin consistency.
  3. Resident #3’s UAI (dated 4/21/22) states the resident needs only physical assistance with bathing and dressing; however, Resident #3’s ISP (dated 4/21/22) indicates the resident needs physical and mechanical assistance with bathing. The UAI for Resident #3 also indicates the resident requires supervision with dressing; however, the ISP states the resident requires physical assistance with dressing.
  4. Resident #4’s UAI (dated 4/21/22) states the resident needs only physical assistance with bathing and dressing; however, Resident #4’s ISP (dated 4/21/22) indicates the resident needs physical and mechanical assistance with bathing and supervision with dressing. The UAI for Resident #4 indicates the resident requires physical assistance with transfers; however, the ISP states the resident does not require assistance. The ISP for Resident #4 also indicates the resident utilizes a walker; however, both the UAI and ISP for Resident #4 state the resident does not need assistance with walking or mobility.
  5. Resident #7’s UAI (dated 3/29/22) states the resident requires mechanical assistance with bathing; however, Resident #7’s ISP (dated 3/29/22) indicates Resident #7 requires mechanical and supervision with bathing.
Plan of correction
The UAI and ISP for resident #1, #2, #3, #4 and #7 will be updated accordingly. There is no adverse effect on the residents. Director of Resident Care and LPN supervisor will conduct on site health care oversight to review all UAI and ISP for accuracy. Director of Resident Care or LPN Supervisor will audit UAI/ISP monthly for accuracy. The result of audit will be presented to facility QAPI committee for review or recommendations.
22VAC40-73-640-A
Based on observation, the facility failed to ensure their written plan for medication management includes methods to prevent the use of outdated medications.
Evidence
  1. The following expired medications were observed in the medication carts at the facility: Montelukast 10 mg tablets expired 2/23/22 for Resident #4 and Allergy Relief 180mg tablets expired 4/8/22 for Resident #9.
Plan of correction
Resident #4 and #9: Nursing staff have discarded the expired medications identified. There is no adverse side effect on both residents. Nursing staff will audit all medications to assure that current medications are not expired. Director of Resident Care (DRC) or designee will re-educate nurses/RMAs on Medication administration policy and procedures. DRC or designee will conduct random medication expiration audit weekly. The result of audit will be presented to facility QAPI Committee for review or recommendation.
22VAC40-73-870-A
Based on observation, the facility failed to ensure the interior of the building be maintained in good repair and kept clean and free of rubbish.
Evidence
  1. During a tour of the facility, a vent in the common area of the safe, secure environment was observed to have grey colored substance. Additionally, in the courtyard of the safe, secure environment, the screening of the porch was ripped. In the Cedar Point neighborhood, the wallpaper in the living room/common area was noted to be lifted in pealing in various sections. A refrigerator in the kitchenette areas in one of the units on the first floor was noted to have brown substance inside.
  2. Two stairwells were also observed throughout the inspection. One stairwell was noted to have debris which could pose as a tripping hazard if the stairwell is needed for an emergency Additionally a ladder was noted in a vertical position in an as a tripping hazard if the stairwell is needed for an emergency. Additionally, a ladder was noted in a vertical position in an alcove of a stairwell.
Plan of correction
Maintenance Coordinator cleaned the vent and placed a new filter. A new screen for the porch at special care unit is installed. Peeling wallpaper in the living room on Cedar Point neighborhood has been taken care. Staff also cleaned the refrigerator on the first-floor kitchenette area. Maintenance coordinator had removed the debris and ladder during the survey. Maintenance Coordinator or designee will audit the vents to assure the cleanness. Nursing staff have cleaned all refrigerators in kitchenette areas. Maintenance Coordinator or designee will make environment rounds weekly. Any identified area will be taken care of timely. Certified Dietary Manager will audit refrigerators at each neighborhood kitchenette area for cleanness. The results of the rounds and audits will be presented to facility QAPI committee for review and recommendations.
March 28, 2022Inspection0 violations
Comments
A non-mandated self-report inspection was conducted on 03-24-2022 from 1:38 PM to 2:58 PM. A self-reported incident was received by the department regarding the areas of Part VI Resident Care and Related Services. The resident involved in the self-report was interviewed. The records in regards to the self-reported incident were reviewed. The evidence gathered during the investigation did not support non-compliance with standards or law.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
March 24, 2022Inspection1 violation
Areas reviewed
22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity
Comments
A non-mandated self-report inspection was conducted on 03-24-2022 from 1:38 PM to 2:58 PM. A self-reported incident was received by the department regarding the areas of Additional Requirements for Facilities that Care For Adults with Serious Cognitive Impairments. A tour of the safe, secure environment was conducted. The resident involved in the self-report was observed as well as their record. The evidence gathered during the investigation supported the self-report of non-compliance with standards or law, and violations were issued. Any violations not related to the self-report but identified during the course of the investigation can be found on the violation notice.
Violations
22VAC40-73-1150-A
Based on observation, record review and 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. On 3/17/22, Resident #1 who resides in a safe, secure environment was observed at the front entrance area of the facility. The March MAR for Resident #1 indicates the two following orders; ?Monitor left leg every shift for redness and remove wander guard if redness develops“ and ”Apply secure care bracelet, check for placement every shift. Check for functioning once per week every shift “ diagnosis: elopement risk.” These two items on the MAR were not signed as completed on various shifts throughout 3/1/22-3/23/22.
  2. After the incident occurred, it was identified the secure care bracelet was on the left leg of Resident #1’s walker and not physically on the resident. Resident #1 was ambulating without the use of their walker, therefore able to exit the safe, secure environment.
  3. Resident #1’s record does not document redness from the secure bracelet or when the secure bracelet was removed from the resident’s body and put onto their walker.
  4. Resident #1 was observed on 3/24/22 at the time of inspection to have a secure bracelet on their right leg and on the left leg of their walker.
  5. Staff #1 acknowledged the inconsistency of the monitoring of the secure care bracelet of the resident and the discrepancy of the current placement of the secure care bracelet on Resident #1.
Plan of correction
Staff has placed the wonder guard to resident #1’s left ankle area on 3/24/2022. All residents at Memory Care unit were audit for wonder guard placement and its working condition on 3/17/2022. A new wonder guard was placed on #1 resident’s right ankle in addition to the one on her walker. Director of Resident Care has completed the in-service on wonder guard placement check and monitor to Memory Care unit staff unit staff. Director of Resident Care or designee will monitor the practice weekly to assure the compliance. The result of the audit will be presented to facility QAPI committee for review and recommendations.
February 10, 2022Inspection12 violations
Inspection dates
Feb. 10, 2022
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDING AND GROUNDS22VAC40-90 The Criminal History Record Report
Comments
An unannounced monitoring inspection was conducted by a Licensing Inspector (LI) from the Eastern Regional Office on 02-10-2022 from 11:10 AM to 4:30 PM. There were 25 residents in care at the time of the inspection. Water temperatures were sampled, staff and resident interviews held, and lunch meal observed. LI reviewed also reviewed 3 staff records, 5 resident records, emergency supply, and conducted a medication pass observation. LI followed up on violations received from the initial inspection. 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. The areas of noncompliance were discussed with the Administrator throughout the inspection and during the exit interview.
Violations
22VAC40-73-40-B-6
Based on record review, the facility failed to exercise general supervision over the affairs of the licensed facility and establish policies and procedures concerning its operation in conformance with applicable law, this chapter, and the welfare of the residents.
Evidence
  1. The new ownership attained responsibility on 12-01-2022; however, at the time of inspection, resident records were without the following current documents: Disclosure Statement, Resident Agreements, written assurance, and documents pertaining to residents residing in a safe, secure environment.
Plan of correction
Facility staff will provide current residents with Disclosure Statement, Resident Agreements, writing assurance and documents pertaining to resident residing in a safe, secure environment. There is no resident that is affected by this practice. When new resident moves in or should the ownership change, facility staff shall provide residents with Disclosure Statement, Resident Agreements, writing assurance and documents pertaining to resident residing in a safe, secure environment per VA Standards for Licensed Assisted Living Facilities. Administrator or designee will monitor for the compliance. The result of audit will be presented to facility’s QAPI committee for review and/or recommendations.
22VAC40-73-260-A
Based on record review and interview, the facility failed to ensure each direct care staff member 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. Staff #4 works as a Certified Nursing Assistant and does not have a current certification in first aid.
  2. Staff #1 acknowledged that Staff #4 does not have a current first aid certification on record.
Plan of correction
Staff #1 has obtained their new first aid certificate. Business Office Coordinator will audit other C.N.A.s to assure they have current first aid certificate. Director of Resident Care or designee will re-educate nursing staff on P/P and regulations on First Aid certificate and CPR. Business Office Coordinator will audit monthly for First Aid Certificate and CPR compliance. The results of audit will be presented to facility QAPI committee for review and or recommendations.
22VAC40-73-320-A
Evidence
  1. The Report of Resident Physical Examination for Resident #5 dated the examination as 11-05-2021; however, the physician signed and dated the report on 02-01-2022.
  2. Resident #1, Resident #3, and Resident #4 did not have current risk assessments for tuberculosis in their resident record.
Plan of correction
A qualified staff will complete the annual risk assessment for tuberculosis for resident #1, #3 and #4. Nursing staff will audit other resident’s charts to assure the annual risk assessments for tuberculosis are completed. Director of Resident or designee will re-educate nursing staff of P/P annual risk assessment for TB for resident. Director of Resident Care or designee will audit monthly for risk assessment for TB for resident. The results of audit will be presented to facility QAPI committee for review and or recommendations.
22VAC40-73-325-B
Based on record review, the facility to ensure that a fall risk rating was completed at least annually and/or after a fall.
Evidence
  1. Resident #1 had documentation of a fall on 12-27-2021; however there was not documentation of a fall risk rating being completed after this fall.
  2. Resident #3 had documentation of a fall on 02-05-2022; however, there was not documentation of a fall risk rating being completed after this fall.
  3. Resident #2 and Resident #4 meet the criteria for assisted living care; however, there was not documentation of a fall risk rating being completed in their records.
Plan of correction
Nursing staff will complete the fall risk rating for resident #1, #3, #2 and #4. Director of Resident Care or designee will audit other resident’s chart to assure the appropriated fall risk rating are completed. Director of Resident Care or designee will re-educate nursing staff on P/P fall risk rating. Director of Resident Care or designee will audit the chart for new resident and resident that had fall to assure the fall risk rating is completed accordingly. The results of audit will be presented to facility QAPI committee for review and or recommendations.
22VAC40-73-350-B
Based on record review, the facility failed to ascertain, prior to admission, whether a potential resident was a registered sex offender and failed to document that this was ascertained and the date the information was obtained.
Evidence
  1. Resident #2 admitted to the facility on 01-11-2022; however, there was no sex offender screening documented in the resident’s record.
  2. Resident #3 also did not have a sex offender screening documented in the resident’s record.
Plan of correction
Resident #2 and #3 sex offender screening documentations are located from the “Sex Offender Check” binder Plan of Correction: Resident #2 and #3 sex offender screening documentations are located from the “Sex Offender Check” binder. There is no affect for other residents. Facility staff will make the “Sex Offender Check” documentation binder available to licensure staff at all times. Business Office Coordinator or designee will audit all new admission to assure the Sex Offender screening is completed prior to admission. The results of audit will be presented to facility QAPI for review and or recommendations.
22VAC40-73-380-A
Based on record review, the facility failed to ensure prior to or at the time of admission to an assisted living facility, all required documentation was included in the residents personal and social information.
Evidence
  1. Resident #5’s record does not include the following: birthplace; marital status; service in the armed forces, if applicable; lifetime vocation, career, or primary role; special interests and hobbies; information concerning advance directives, Do Not Resuscitate (DNR) Orders, or organ donation, if applicable; previous mental health or intellectual disability services history, if any, and if applicable for care or services; current behavioral and social functioning including strengths and problems; and any substance abuse history if applicable for care or services.
Plan of correction
Resident #5’s Resident Personal and Social Information form will be updated on March 14, 2022. Business Office Coordinator or designee will audit the new moved-in residents from 12/01/2022 to assure all required documentation is included in the Resident Personal and Social Information Form. Administrator will re-educate marketing director on: ALF regulation on: Prior to or at the time of admission, all required documentation should be included in the resident's personal and social information. Business Office Coordinator will audit the compliance. The results of the audit will be presented to facility QAPI committee for review and or recommendations.
22VAC40-73-440-A
Based on record review and interview, the facility failed to complete a UAI for residents prior to admission, at least annually, and whenever there is a significant change in the resident's condition.
Evidence
  1. Two of the five residents reviewed did not have a current UAI: Resident #1’s last UAI dated 09/02/2019 and Resident #4’s last UAI dated 1/19/2019.
  2. Resident #5 was admitted on 02-01-2022. The Report of Resident Physical Examination signed by the physician on 02- 01-2022 indicates the resident is not capable of self-administering medication; however, the UAI completed 01-31-2022 states the resident will take their medication without assistance. The Individualized Service Plan for Resident #5 dated 01-31-2022 also states the “resident can self-administer medications.”
  3. Staff #1 acknowledged the discrepancy between Resident #5’s Report of Resident Physical Examination and the UAI. Staff #1 confirmed since admission on 02-01-2022, Resident #5 has self-administered their medications.
Plan of correction
A: The qualified staff will complete the UAIs for resident #1 and #4. Resident #5 has been capable of self-administer the medications. Their physician will re-evaluate him when visits him. Resident #5 is planned to return home on March 15, 2022. B: Nursing staff will audit all resident charts to assure the annual UAIs are completed. There is no affect on resident #5 or any other residents. C: Administrator will create a calendar schedule to remind qualified staff to conduct Annual UAIs for residents. Administrator will re-educate Director of Resident Care and licensed nurse on UAI related regulations. Director of Resident Care or designed will audit residents that are self-administer medications to assure the MD order, UAI and ISP all indicate resident is able to self-administer the medications. D: Administrator or designee will audit UAI monthly. The results of audit will be presented to facility QAPI for review and or recommendations. Director of Resident Care or designee will audit the residents that are self-administer medications to make sure the MD order, UAI and ISP all match. The results of audit will be presented to facility QAPI committee for review and or recommendations.
22VAC40-73-450-A
Based on record review, the facility failed to ensure on or within seven days prior to the day of admission a preliminary plan of care be developed. The facility also failed to ensure a comprehensive individualized service plan be completed within 30 days after admission and reviewed and updated at least once every 12 months and as needed for a significant change of a resident’s condition.
Evidence
  1. Resident #4 did not have an individualized service plan (ISP) in their resident record. Additionally, Resident #1 did not have a current ISP in the record as the last dated ISP was 09/02/2019.
Plan of correction
Qualified staff will complete ISP for resident #4 and #1. Nursing staff will audit resident charts to assure all residents have current ISP. Administrator will create a calendar schedule to remind qualified staff to conduct Annual ISP for residents. Administrator will re-educate Director of Resident Care and licensed nurse on ISP related regulations. Administrator or designee will audit resident charts monthly to assure the ISP are completed accordingly. The results of the audit will be presented to facility QAPI committee for review and or recommendations.
22VAC40-73-550-G
Based on record review, the facility failed to obtain written acknowledgment of the receipt and review of the rights and responsibilities of residents in assisted living facilities with the resident's, his legal representative's or responsible individual.
Evidence
  1. Three of the five residents reviewed did not have current written acknowledgment of the receipt and review of the rights and responsibilities of residents in assisted living facilities with the resident's, their legal representative's or responsible individual: Resident #1’s last review dated 09/02/2019, Resident #3’s last review dated 06/18/2020, and Resident #4’s last review dated 07/09/2019.
Plan of correction
Facility staff will review the rights and responsibilities of residents in ALF with the POAs for resident #1, #3 and #4, and receive the written acknowledgement. Facility staff has started the annual review of the residents? rights and responsibilities with residents or POAs. The written acknowledgement will be received afterwards. January of each year is dedicated for annual resident rights and responsibilities of residents in ALF review. Business office Coordinator or designee will monitor for the compliance in January of each year. The results of the audit will be presented to facility QAPI committee for review and or recommendations.
22VAC40-73-680-C
Based on record review, the facility failed to ensure medications be administered not earlier than one hour before and not later than one hour after the facility's standard dosing schedule, except those drugs that are ordered for specific times, such as before, after, or with meals.
Evidence
  1. From 02/01/2022-02/09/2022, there were occasions residents did not receive their medication as they were not notated as administered on the resident’s MAR. Resident #1 missed 5 doses of Aquaphor Ointment (2/2/22, 2/4/22, 2/8/22, 2/9/22, and 2/10/22), 1 dose of Carvedilol 3.125 mg tablet (2/4/22), 1 dose of Calcium/D3 600 mg-400u tablet (2/4/22), and 1 dose of Eliquis 2.5 mg tablet (2/4/22). Resident #2 missed 1 dose of Acetaminophen 325mg tablet (2/2/22), 3 doses of Amlodipine 10 mg tablet (2/2/22, 2/3/22, and 2/9/22), and 1 dose of CO Q-10100mg capsule (2/10/22). Resident #3 missed 1 dose of Vitamin D3 tablet (2/4/22). Resident #4 missed 1 does of Donepezil 5mg tablet (2/2/22) and 1 does of Montelukast 10 mg tablet.
  2. Resident #1’s order for Carvedilol 3.125mg tablet has a parameter that reads hold for SBP less than 105, or DBP less than 45, or Pulse less than 60; however, the MAR for Resident #1 documents the medication as administered and does not include documentation of the resident’s blood pressure and pulse at 1700 to ensure it is within the parameters for administration.
  3. The MAR for Resident #3 includes a PRN order for Acetaminophe 325 mg tablet and Bengay vansh gel; however, these two items were not on the medication cart.
Plan of correction
A: There are no adverse effects on resident #1, #2, #3 and #4. Director of Resident Care or designee will review the MARs to identify if there is missing signatures holes on MARs. Director of Resident Care or designee will re-educate the RMA/Nurses on P/P Medication administer and documentation. A new shift to shift report including the audit of signatures to indicate the medications are administered will be initiated. Director of Resident Care or designee will monitor weekly, then twice a month to assure the compliance. The results of audit will be presented to facility QAPI committee for review and or recommendations. B: There was no adverse effect on resident #1. Director of Resident Care or designee will audit other residents that have BP and Pulse parameters for medications orders are followed accordingly. Director of Resident Care or designee will re-educate RMAs/Nurse on P/P medication administration. Director of Resident Care or designee will monitor weekly, then twice a month to assure the compliance. The results of audit will be presented to facility QAPI committee for review and or recommendations. C: Resident #3 has received her Tylenol and Bengay vansh gel from pharmacy. No other resident is affected. Director of Resident Care or designee will re-educate RMAs/Nurse to reorder resident medications timely. Director of Resident Care or designee will monitor medication carts monthly to assure residents have medications available. The results of audits will be presented to facility QAPI committee for review and or recommendations.
22VAC40-73-870-A
Based on observation and interview, the facility failed to ensure the interior of the building be maintained in good repair and kept clean and free of rubbish.
Evidence
  1. During a tour of the facility, a vent in the common area of the safe, secure environment was observed to have grey colored substance. The bathroom of Resident #3 was also observed to have a broken light above the sink and missing cabinet in vanity. A threshold on the first floor in the Cedar Point neighborhood was noted as being held down by black tape which could pose as a tripping hazard.
  2. Staff #1 acknowledged the aforementioned areas in need of repair.
Plan of correction
Maintenance Coordinator has repaired the aforementioned areas on February 15, 2022. No resident is affected. Staff are reminded to report any needed repair to maintenance staff timely. Maintenance Coordinator or designee will make weekly rounds to assure any broken items are repaired timely. The results of the audit will be presented to facility QAPI committee for review and or recommendations.
22VAC40-90-40-B
Based on record review and interview, the facility failed to obtain a criminal history record report on or prior to the 30th day of employment for each employee.
Evidence
  1. At the time of the inspection on 02-10-2022, Staff #1 (hired 12-01-2021) did not have a completed criminal history record report.
  2. Staff #1 acknowledged the facility did not obtain a criminal history record reports within the required timeframe.
Plan of correction
Staff #1’s criminal history record report request has been sent to Virginia State Police. All new hires since 12/01/2021 either have criminal history records in the file or the results are pending from Virginia State Police. Business office Manager or designee will obtain a criminal history record report from Virginia State Police for new hires on or prior to the 30th day of employment. Administrator or designee will audit new hire’s personnel record to assure the CRR is obtained on or prior to the 30th day of employment for each employee. The results of audit will be presented to facility QAPI committee for review and or recommendations.
November 18, 2021Inspection4 violations
Inspection dates
Nov. 18, 2021
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS
Comments
An initial inspection was initiated on 11-18-2021 and concluded on 11-19-2021. The Administrator contacted by telephone to initiate the inspection. The Administrator reported that the current census was 28. A Licensing Administrator and a Licensing Inspector conducted the on-site portion of the inspection on 11-19-2021. An exit interview was conducted with the Administrator on the date of inspection, 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(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility.
Violations
22VAC40-73-290-B
Based on observation and interview, the facility failed to develop and implement a procedure for posting the name of the current on-site person in charge in a place in the facility that is conspicuous to the residents and the public.
Evidence
  1. On 11-19-2021, during a tour of the facility, the current on-site person in charge was not posted in the facility.
  2. Staff #1 and Staff #2 acknowledged the name of the current on-site person in charge was not posted in the facility.
Plan of correction
1. Facility started to post the name of the current on-site person in charge at the front lobby area that is conspicuous to the residents and the public on 01/13/2022. 2. No resident is affected. 3. A new procedure has been developed to ensure the compliance: Resident Care Coordinator or designee will post the name of the current on-site person in charge daily. 4. Administrator or designee will audit daily to ensure the compliance. Any non-compliance will be corrected immediately. The results of audit will be presented to facility QAPI committee quarterly for review and recommendations.
22VAC40-73-610-B
Based on observation, the facility failed to ensure menus for meals and snacks for the current week are dated and posted in an area conspicuous to residents.
Evidence
  1. On 11-19-2021, during a tour of the facility with Staff #1 and Staff #2, a posted menu for meals and snacks for the current week was not observed in an area conspicuous to residents in the facility.
  2. Staff #2 acknowledge a current menu for meals and snacks was not posted in an area conspicuous to residents in the facility.
Plan of correction
1. Menus for meals and snacks for the current week are dated and posted on each neighborhood Dining Room entrance area. 2. No resident is affected. 3. Dietary manager or designee will make sure the weekly menus are dated and posted to each neighborhood entrance area. 4. Administrator or designee will monitor weekly to ensure the menus are dated and posted. Any non-compliance will be corrected immediately. The results of audit will be presented to facility QAPI committee quarterly for review and recommendations.
22VAC40-73-610-E
Based on observation, the facility failed to ensure a copy of a diet manual containing acceptable practices and standards for nutrition is kept current and readily available to personnel responsible for food preparation.
Evidence
  1. On 11-19-2021, during a tour of the facility with Staff #1 and Staff #2, the facility was not able to provide a copy of a diet manual containing acceptable practices and standards for nutrition readily available to personnel responsible for food preparation.
Plan of correction
1. A Diet and Nutrition Care Manual by Becky Dorner & Associates, Inc. is kept current and readily available to personnel responsible for food preparation in the kitchen. 2. No resident is affected. 3. Dietary manager or lead cook is responsible to ensure the diet manual is available for dietary staff. 4. Administrator or designee will audit monthly to ensure the dietary manual is current and readily available to dietary staff. Any non-compliance will be corrected immediately. The results of audit will be presented to facility QAPI committee quarterly for review and recommendations.
22VAC40-73-870-A
Based on observation, the facility failed to the interior and exterior of all buildings are maintained in good repair and kept clean and free of rubbish.
Evidence
  1. On 11-19-2021, during a tour of the facility, vegetation growing both in and over the gutters at the front of the facility and in the assisted living courtyard was observed.
  2. On 11-19-2021, during a tour of the facility, four of a ten bed unit were observed to be unable to be occupied by residents due to various states of repair. Units 207 and 208 had disconnected AC units and uninstalled bathroom sinks. Unit 203 also had a disconnected AC unit on the floor of the apartment. Unit 210 was being utilized for facility storage.
  3. Staff #1 and Staff #2 acknowledged the condition of the units observed.
Plan of correction
1. Maintenance Coordinator has removed/cleaned the vegetation growing in and over the gutters at the front of the facility and in the assisted living courtyard in December 2021. Facility will order new P-tanks for suite 203, 207 and 208 and install them. A new bathroom sink will be installed to suite 207. All supplies stored in suite 210 have been removed. This suite has been cleaned and is ready for admission. 2. Maintenance Coordinator will assess all gutters to ensure they are free from vegetation growing. No resident is affected as this neighborhood has not been occupied after COVID-19 pandemic. 3. Maintenance Coordinator or designee will assess the facility gutters monthly to ensure they are free from vegetation growing or blockage. Maintenance Coordinator will repair or replace suite P-Tanks timely. 4. Administrator or designee will audit the gutters quarterly. Any identified issue will be corrected timely. Administrator or designee also will audit suite P-tanks randomly to ensure they are in working condition. The results of audits will be presented to facility QAPI committee quarterly for review and recommendations.