Virginia DSS · Assisted Living Facility

Edgeworth Park at New Town

📍 5501 Discovery Park Boulevard, Williamsburg, VA, 23188

ID 47486One Year licenseActive
18
Inspections
On record
11
With violations
Visits that cited something
7
Clean visits
Nothing cited
34
Violations cited
Individual findings
20
Standards cited
Distinct rules
12
Complaint visits
Prompted by a complaint

Edgeworth Park at New Town was inspected 18 times between October 28, 2021 and May 13, 2026 by the Virginia Department of Social Services. 11 of those visits ended with violations cited and 7 with none. Across that history VDSS cited 34 violations under 20 distinct standards. 12 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.

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

Provider Information

Facility type
Assisted Living Facility
License type
One Year
License expires
04/30/2026
Administrator
Taylor Montgomery
Licensing inspector
Alyshia Walker
Inspector phone
(757) 670-0504
Approved for
Non-Ambulatory · Assisted Living · Special Care Unit

Inspection History

18

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

May 13, 2026Complaint survey0 violations
Inspection dates
05/13/2026
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 5/13/2026 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 12/30/2025 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: 83 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: n/a Additional Comments/Discussion: n/a 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 Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 13, 2026Complaint survey0 violations
Inspection dates
05/13/2026
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-80 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: 5/13/2026 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 3/31/2026 regarding allegations in the area(s) of: Discharge Number of residents present at the facility at the beginning of the inspection: 83 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: n/a Additional Comments/Discussion: n/a 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 Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
August 14, 2025Complaint survey0 violations
Inspection dates
08/14/2025
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 8/14/2025 10:23 am- 12:45 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 7/18/20025 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: 64 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 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 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 Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
August 14, 2025Complaint survey0 violations
Inspection dates
08/14/2025
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 8/14/2025 10:23 am- 12:45 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 7/18/20025 regarding allegations in the area(s) of: Personnel Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 64 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 1 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 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 Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
July 16, 2025Inspection1 violation
Inspection dates
07/16/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7/16/2025 11:55 am- 2:22 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 5/9/2025 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: 76 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: 2 Number of interviews conducted with residents:1 Number of interviews conducted with staff: 3 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 Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Violations
22VAC40-73-460-D
Based on record review and staff interviews 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’ s Individualized Service Plan (ISP) documents the resident requires a safe, secure, unit due to the diagnosis of dementia with serious cognitive impairments.
  2. The Division received a self-report on 5/9/2025, which indicated Resident #1 exited the emergency exit door in the sunroom of the safe, secure unit. Staff members were alerted by the door’s alarm and implemented the elopement protocol. Staff #1 saw Resident #1 outside their office window and the resident was redirected back into the building.
  3. Staff #3 acknowledged Resident #1 exited the safe secure unit. The staff member was alerted by the door’s alarm and observed the resident on the sidewalk walking towards the front of the facility. Staff #3 initiated the elopement protocol.
Plan of correction
On 5/9/25, a resident pushed the emergency exit door in the secure neighborhood, which immediately triggered the door alarm. Staff responded right away according to our company’s elopement procedures. One team member went directly to the door where the alarm had sounded, while other team members immediately accounted for all residents in the neighborhood. The resident was never out of sight and was continuously followed by staff to ensure their safety. A staff member who observed the resident outside promptly went out to assist and successfully redirected the resident back into the secure neighborhood. Once safely returned, staff followed state regulations and company protocol by assessing the resident for safety, notifying the family and physician, and completing all required documentation. To prevent recurrence, all staff assigned to the secure neighborhood were re-educated on elopement procedures and response protocols on 5/9/25. Exit doors and alarms were checked for proper function and continue to be monitored daily. Elopement drills will continue to be conducted regularly to ensure staff remain prepared to respond quickly and effectively.
July 16, 2025Complaint survey0 violations
Inspection dates
07/16/2025
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7/16/2025 11:55 am- 2:22 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 5/8/2025 regarding allegations in the area(s) of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 79 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 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 Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
April 21, 2025Inspection1 violation
Inspection dates
04/21/2025, 05/08/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISION22VAC40-73 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 AFFIRMATION22VAC40-80 THE LICENSE
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 4/21/2025 (8:30 am- 1:40 pm) and 5/2/2025 (10:40 am- 2:50 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: 73 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 5 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 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. I f 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 Alyshia Walker, Licensing Inspector at 757-650-0507 or by email at Alyshia.Walker@dss.virginia.gov
Violations
22VAC40-73-680-C
Based on observation, the facility failed to ensure medications to be administered no earlier than one hour before and no later than one hour after the facility’s standard dosing schedule, except for those drugs that are ordered for specific times.
Evidence
  1. During the on-site inspection of Resident #5’s resident record, the Licensing Inspector reviewed documentation that medication for Resident #5 was administered outside the standard dosing schedule.
  2. Staff # 1 and #2 acknowledged Resident #5 did not receive their prescribed 9:00 am medication (Aspirin 81 mg, Desitin 13%, Diclofenac Gel 1%, Duloxetine 60 mg, Ipratropium/ Sol Albuterol, Lidocaine Patch 4%, Tamsulosin 0.4 mg, Ult Lub Eye drop 0.4-0.3 %) within the facility’s standard dosing time.
Plan of correction
After investigation, the Facility terminated the medication technician involved in the medication pass. Facility communicated with resident’s physician, and received authorization to give the medications outside of the standard dosing schedule. Facility had the physician see the resident two days after the incident as a follow-up. Facility communicated with the resident’s responsible party. WD/Designee will complete a review of medication times to ensure that residents medication times are appropriate. Any changes needed will be completed per PCP approval. WD/Designee will complete in-service on medication administration and administering within the two hour window that is allotted. WD/Designee will monitor any late/early meds that are administered and address as they arise.
March 7, 2025Complaint survey2 violations
Inspection dates
03/07/2025
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 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: 3/7/2025 9:00 am - 2:40 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 10/28/2024 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: 72 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff/private duty records reviewed: 8 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. However, violation(s) not related to the complaint(s) 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 Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Violations
22VAC40-73-450-F
Based on record review and interview with staff, the facility failed to ensure individualized service plans (ISPs) were reviewed and updated as needed for a significant change of a resident’s condition.
Evidence
  1. Resident #1 received wound care services, foot care due to diabetes, and had a prescribed mechanical soft diet. These services/needs were not documented on the ISP dated 9/16/2024.
Plan of correction
ISP's will be updated and reviewed to reflect significant changes of resident conditions. Staff will review 3rd party visit note and recommendations will be updated on the ISP as needed. Executive Director will audit 3 outside provider notes each week for 90 days to ensure compliance.
22VAC40-73-220-A
Based on staff interview, the facility failed to obtain proper documentation for private duty personnel from a licensed home care organization.
Evidence
  1. During the on-site inspection on 3/7/2025, the licensing inspector reviewed files for private duty personnel currently providing services in the facility. Private duty providers # 2, #3, #4, #5, #7, and #8, did not have current TB screenings or evidence the private duty personnel had been provided a facility orientation.
Plan of correction
Upon shift, private duty personnel must attend orientation with Executive Director. Private duty providers #2, #3, #4, #5 #7 will receive TB screening prior to coming to work at the community. Private duty company will maintain records for annual TB screenings on their employees and submit to the community as needed. Executive Director will audit monthly to ensure compliance.
March 7, 2025Complaint survey0 violations
Inspection dates
03/07/2025
Areas reviewed
22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 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: 3/7/2025 9:00 am- 2:40 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 6/26/2024 and 7/1/2024 regarding allegations in the area(s) of: Resident Care and Related Service 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: 2 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 Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
June 28, 2024Complaint survey1 violation
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 3/26/2024 11:12am- 3:08 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 3/7/2024 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: 69 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: 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 allegation(s) of non-compliance with standard(s) or law, and violation(s) were 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 Alyshia Walker Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Violations
22VAC40-73-460-D
Based on staff interview and resident record review, the facility failed to provide supervision of the resident schedule and specialized needs.
Evidence
  1. Resident #1 was receiving treatment for Moderate Obstructive Sleep Apnea. On 1/11/2024, the resident’s physician provided a statement to the facility explaining the resident would be under a one month trial using APAP therapy nightly. The statement further expressed, “I would appreciate your assistance in ensuring 100% compliance with APA use during the next 30 days.” Staff was to ensure the device was on and properly fitted.
  2. The facility observation notes dated 1/11/2024, “Assistance with APAP therapy for next 30 days added to care plan. Provider wants to ensure compliance with therapy during one month trial. Med tech made aware.”
  3. The Charted Care Report for Resident #1 documented the resident received assistance 14 out of 25 days.
Plan of correction
Not published by VDSS.
May 2, 2024Inspection6 violations
Inspection dates
05/02/2024, 05/09/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 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: 5/2/24 8:00 am- 5:00 pm, 5/9/2024 10:47 am - 4:15 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: 71 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 16 Number of staff records reviewed: 6 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 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. Please Note: A copy of the findings of the most recent inspection are 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 Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Violations
22VAC40-73-680-C
Based on documents reviewed and staff interviewed, the facility to ensure medications shall be administered not earlier than one hour before and not later than on 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. During the on-site inspection, Staff #5 was observed administering 8am medications at 9:50 am. A further review of the electronic medication administration record verified an additional 15 residents still needed to be administered 8 am and 9 am medication.
Plan of correction
Not published by VDSS.
22VAC40-73-450-C
Based on records reviewed and staff interviews, the facility failed to develop Individualized Service Plans (ISPs) which contains all of the elements in 22VAC40-73-450-C.
Evidence
  1. The ISPs for Residents #8, #7, #16, #11, #13, #14, and #15 do not contain all of required elements of the ISP as listed in 22VAC40-73-450-C.
Plan of correction
Not published by VDSS.
22VAC40-73-680-D
Based on a review of resident and facility records, the facility failed to administer medications in accordance with the physician’s or other prescriber’s instructions.
Evidence
  1. During the observation of the medication pass, the licensing inspector observed Staff # 5 administer Risperidone 0.25 mg in a medication cup with the resident’s other 8am medication. The physician’s orders for the Risperidone state the medication is to be dissolved on top of the tongue. The licensing inspector observed the resident swallow the pill.
Plan of correction
Not published by VDSS.
22VAC40-73-440-B
Based on record review, the facility failed to ensure the uniform assessment instrument (UAI) was completed by one of the following qualified assessors: An assisted living facility staff person who has successfully completed state- approved training on the uniform assessment instrument and level of care criteria for either public or private pay assessments, provided the administrator or the administrator's designated representative has successfully completed such training and approves and then signs the completed UAI.
Evidence
  1. The UAIs for Resident #7 (dated 4/23/2024), Resident # 16 (dated 3/7/2024), Resident #14 (dated 4/23/2024) did not contain the administrator’s nor administrator’s designee signature.
Plan of correction
Not published by VDSS.
22VAC40-73-450-E
Based on resident record review and interview with staff, the facility failed to have the ISP signed and dated by the licensee, administrator, or designee and by the resident or his legal representative.
Evidence
  1. The ISPs for Residents #13 (dated 4/29/2024), Resident #11 (dated 11/10/2023), Resident #8 (dated 4/10/2024), and Resident #15 (dated 4/23/2024) did not contain a signature resident of the resident or his legal representative.
Plan of correction
Not published by VDSS.
22VAC40-73-450-F
Based on a review of resident records the facility failed to ensure that each resident's individualized service plan (ISP) contained a description of all needs/services identified.
Evidence
  1. Resident # 14 is receiving hospice services. Those services are not on the resident’s ISP dated 4/23/2024.
  2. Resident #13 is receiving podiatry services. Those services are not on the resident’s ISP dated 4/29/2024.
  3. Resident #11 is receiving hospice and podiatry services. Those services are not on the resident’s ISP dated 11/10/2023.
  4. Resident #8 is receiving hospice services. Those services are not on the ISP dated 4/10/2024.
Plan of correction
Not published by VDSS.
March 26, 2024Complaint survey1 violation
Inspection dates
03/26/2024
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: 3/26/2024 11:12am- 3:08 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 2/12/2024 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: 69 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: 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 allegation(s) of non-compliance with standard(s) or law, and violation(s) were 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 Alyshia Walker Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Violations
22VAC40-73-640-A
Based on resident record review, the facility failed to follow their medication management plan in regard to ensuring each resident’s prescription medication and any over the counter drugs for the resident are filled and refilled in a timely manner to avoid missed dosages.
Evidence
  1. A review of the Medication Exception Report for Resident #3 documented the resident’s medications (Latanoprost 0.005% eye drop, Xarelto, Midodrine, Melatonin, Metoprolol Tartrate) were not available/needs a refill 81 times in the December 1, 2023 through February 9, 2024 timeframe.
Plan of correction
Not published by VDSS.
December 6, 2023Complaint survey4 violations
Inspection dates
12/06/2023
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/6/2023 9:21am- 1:50 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 11/25/2023 regarding allegations in the area(s) of: Personnel Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 78 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 9 Number of staff records reviewed: 4 Number of interviews conducted with residents: Number of interviews conducted with staff: 5 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(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 Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Violations
22VAC40-73-660-A
Based on observation and staff interview, the facility failed to ensure that all medications and dietary supplements were stored in a manner consistent with the current standards of practice.
Evidence
  1. During the on-site inspection on 12/6/2023, Licensing Inspectors observed a bottle of Boost unsecured and unattended on the shelf of a table outside of the nurses’ station near the first-floor medication cart.
  2. Staff #3 acknowledged the Boost was unsecured.
Plan of correction
Executive Director, Director of Health Services performing routine audits during walk of building to ensure boost is stored properly. By 3/8/24, medication aids will receive an in-service to ensure that all medications and dietary supplements are stored in a manner consistent with the current standards of practice. Staff number 3 addressed on day of inspection to ensure boost is not left unattended in the community.
22VAC40-73-660-A-7
Based on observations made during the medication cart audit, the facility failed to properly label single-use and dedicated medical supplies.
Evidence
  1. The glucometer for Resident #9 was not labeled and the bag for the glucometer was present but the resident’s name could not be clearly read as the bag was black and the name was written with a black marker.
Plan of correction
Executive Director provided medication aid with metallic sharpie on day of inspection to clearly label resident #9’s glucometer bag and labeled the glucometer. Weekly, medication aids will perform cart audits to ensure single-use and dedicated medical supplies are labeled properly.
22VAC40-73-640-A
Based on the audit of the medication cart, review of facility records, and interviews conducted the facility failed to implement a written plan that ensured that each resident's prescription medications and any over- the- counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages.
Evidence
  1. On 12/6/23, during the on-site inspection, Resident #5’s PRN Ondansetron 4 mg tablets were not present. Resident #6’s PRN Flonase was not present. Resident # 7’s PRN Acetaminophen 325 mg, Meloxican 7.5 mg, and Polyethylene Glycol were all not present.
  2. A review of the Medication Administration Record (MAR) for November 2023 documented the following residents’ medications were not able to be administered because the medications were not available. Resident #5’s Advair was not available to be administered on 11/11/23, 11/12/23/, and 11/16/23. Resident #6’s Lidocaine Pain Relief patch was not available to be administered on 12/3/23. Resident # 7’s Fluticasone nasal spray was not available to be administered on 11/4/23 and 11/23/2023. Resident #9’s Humalog Kwik Pen was not available to be administered on 11/27/23, 11/28/23, and 11/29/23.
Plan of correction
On 12/27/23, all medication aids received an in-service on re-ordering medications to avoid missed dosages. Medication aids will reach out to dispensing pharmacy at least 7 days prior to medications running out. Implemented a medication tech to medication tech binder for communication regarding reminder and follow up calls/faxes to pharmacy. Medication aids gained access in our electronic medical record system to request refills from pharmacy. On 2/7/24, medication aids received another in-service on medication refill policy. During this in-service, the community also implemented a procedure for medication aids who are unable to find a medication during their shift. All medication aids must call either the Resident Care Coordinator or Memory Care Director to avoid missed dosages. Every morning, the clinical team, Executive Director, and Director of Operations review the previous day medication pass to follow up on any outstanding refills and missed medications.
22VAC40-73-680-I
Based on resident record review and review of the Medication Administration Record (MAR), the facility failed to have all items required by standards on the MAR.
Evidence
  1. Resident #3’s November 2023 MAR did not contain the diagnosis, condition, or specific indications for Furosemide 20 mg, Loratadine 10 mg, and the Serevent Diskus inhaler. Resident #4’s November 2023 MAR did not contain the diagnosis, condition, or specific indications for the Carvedilol 12.5 mg or the Albuterol solution. Resident #7’s November 2023 MAR did not contain the diagnosis, condition, or specific indication for the Ipratropium Brom 0.03% nasal spray, Latanoprost 0.005% eye drop, or the Vitamin D2 2,000 Unit soft gel. Resident #8’s November 2023 MAR did not contain the diagnosis, condition, or specific indication for the Lidocaine pain relief patch, Potassium 2o MEQ, Pro-stat Liquid, and Loperamide HCL 2mg capsule.
  2. Resident #2 was administered PRN Claritin on 11/2/23, 11/10/23, 11/18/23, and 12/4/23. There was no documentation of the medication’s effectiveness on the MAR. Resident #7 was administered PRN Tramadol 50 mg on 12/1/23, 12/2/23, 12/3/23, 12/4/23, and 12/6/23. There was no documentation of the medication’s effectiveness on the MAR.
  3. Resident #4’s November 2023 MAR did not record if the resident’s prescribed Gabapentin 300 mg was administered on11/22/23. There was no response recorded on the electronic MAR to explain the missing initials. Resident #7’s November 2023 MAR did not record if the resident’s prescribed Amlodipine 5 mg was administered on 11/5/23. There was no response recorded on the electronic MAR.
Plan of correction
Director of Health Services and/or designee will not approve medications in the electronic record system from pharmacy unless medication has a diagnosis, condition, or specific indication. All medication aids are to document effectiveness of PRN medications on the MAR. Community worked with electronic record system to enable an alert to remind staff to document on the effectiveness. Going forward, the clinical team, Executive Director and Director of Operations audit the electronic MAR to ensure medication aids are documenting the effectiveness of PRN’s. In addition, every day the clinical team, Executive Director and Director of Operations review the previous day medication pass to ensure if medication aids are unable to pass a medication, that they are documenting the reason. To avoid missed medications, if a medication aid is unable to find a medication on the cart, they must call the Resident Care Coordinator, Memory Care Director or Director of Health Services. On 2/7/24, medication aids received an in-service on this process and there are notes on every med cart to remind staff.
April 12, 2023Complaint survey1 violation
Inspection dates
04/12/2023, 04/24/2023
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
Type of inspection: self-report Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 4/12/23 9:44 am - 4:30 pm and 4/24/23 9:50 am - 1:04 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: 73 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 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. 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 Alyshia E. Walker, Licensing Inspector at (757) 670-0504 or by email at Alyshia.Walker@dss.virginia.gov Type of inspection: Self-Report Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 4/12/23 9:44 am - 4:30 pm and 4/24/23 9:50 am - 1:04pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 73 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 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 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 Alyshia E. Walker, Licensing Inspector at (757) 670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Violations
22VAC40-73-460-D
Based on staff interviews and documentation review, the facility failed to provide supervision of resident schedules, care, and activities including attention to the specialized need of wandering from the premises for one resident in care.
Evidence
  1. Facility provided an Incident Report on 2/6/23 acknowledging that Resident #1 eloped from the safe, secure, unit at approximately 4:30 pm on 2/6/23. Resident #1 was found in the parking lot the facility shares with an adjacent business. The Individual Service Plan for Resident #1 identified the resident’s need to be reoriented to time and place as the ISP stated the resident was prone to confusion and forgetfulness. This need was identified on 12/30/22. The ISP further stated the resident would remain supervised at all time effective 12/30/22. Resident #1 was identified as an elopement risk on 1/3/23 as the ISP stated, “the resident exhibits wandering with exit seeking behavior, staff will monitor whereabouts of and report to supervisor if unsafe wandering or exit seeking occurs”.
  2. The facility did not follow its Missing Resident Policy as the policy states, “An incident report will be completed providing detailed accounting of the incident in its entirety.” The incident report written on 2/6/23 did not contain a complete detailed account of the incident based upon follow up documentation that was provided during the time of the inspection and a subsequent email.
Plan of correction
Residents will be screened prior to admission for significant elopement risk. Upon admission, a clear frontal photograph will be obtained and kept in an elopement binder at front desk. Should an elopement occur, the facility will notify next of kin, legal representative, or designated contact person of any incident of a resident wandering from the premises, whether or not it results in injury. Following the incident, the resident’s record will be updated with documentation of the notification, including date, time, caller and person or agency notified. In addition, facility will report to the regional licensing office within 24 hours with the following information: Name and address of the facility, name of the resident or residents involved in the incident, date and time of the incident, description of the incident, the circumstances under which it happened, and when applicable, extent of injury or damage, location of the incident, actions taken in response to the incident, actions to prevent recurrence of the incident (if applicable), name of staff person in charge at the time of the incident, names, telephone numbers and addresses of witnesses to the incident if any. Following the self-report elopement, signs were placed upon entry and exit of Memory Care neighborhood to remind visitors to be aware when exiting the neighborhood not to allow residents to leave behind them. In Service for staff was held 5/30/23 and 6/27/23 to ensure staff is trained on proper protocol for an elopement.
April 12, 2023Inspection9 violations
Inspection dates
04/12/2023, 04/13/2023, 04/21/2023
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-80 THE LICENSE
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 4/12/23 9:44 am - 4:30 pm, 4/13/23 9:41 am - 6:10 pm, 4/24/23 9:50 am - 1:04 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: 73 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 11 Number of staff records reviewed:5 Number of interviews conducted with residents:4 Number of interviews conducted with staff: 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. 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 Alyshia E. Walker, Licensing Inspector at (757) 670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Violations
22VAC40-73-450-F
Based on a review of resident records the facility failed to ensure that each resident's individualized service plan (ISP) contained a description of all needs/services identified.
Evidence
  1. The ISP for Resident #4 did not contain the resident’s identified allergies.
Plan of correction
Resident #4’s ISP was corrected immediately. Following inspection, Director of Health Services and Resident Care Coordinator audited every resident’s ISP to ensure allergies were listed appropriately. Director of Health Services or designee will audit 3 ISP/UAI’s a day at Clinical Review Meeting to ensure all ISP’s reflect resident care needs. Furthermore, every month the Director of Health Services will pull monthly report from MARS to audit ISP’s and ensure their allergies are reflected within.
22VAC40-73-1110-B
Based on record review and staff interview, the facility failed to ensure six months after placement of the resident in the safe, secure environment and annually thereafter, the licensee, administrator, or designee shall perform a review of the appropriateness of the resident’s continued residence in the special care unit.
Evidence
  1. Resident #4’s resident record did not contain a six-month continued need for placement in the special care unit.
  2. Resident #10’s resident file did not contain an annual review of continued need for placement in the special care unit.
  3. Staff #1 acknowledged the aforementioned documents were not present at the time of inspection for the licensing inspector to review.
Plan of correction
On June 25, 2023, Executive Director performed an audit to ensure that six months after placement of the resident in the safe, secure environment, the licensee administrator or designee performed a review of the appropriateness of the resident’s continued residence in the special care unit. Executive Director also audited to ensure annually thereafter, the licensee, administrator, or designee performed a review of the appropriateness of the resident’s continued residence in the special care unit. All memory care residents have received a review of appropriateness to date. Going Forward, licensee, administrator, or designee should review appropriateness of placement when UAI and ISP is updated at 6-month mark and every 6 months thereafter.
22VAC40-73-440-B
Based on record reviewed, the facility failed to ensure that uniform assessment instrument (UAI) forms were approved and signed by the administrator or the administrator's designee.
Evidence
  1. The UAI for Resident #1 dated 7/7/2022 did not contain an administrator or administrator’s designee signature.
Plan of correction
Based on record reviewed, the facility failed to ensure that uniform assessment instrument (UAI) forms were approved and signed by the administrator or the administrator's designee Administrator and/or the Administrator’s designee are signing immediately after care plan meetings with the family to ensure all UAI’s are approved and signed by the administrator and/or administrator’s designee. Director of Health Services and/or designee will audit all UAI’s by 7/7/23 to ensure that all are signed by Administrator or designee and brought current by 7/7/2023.
22VAC40-73-680-C
Based on observation, the facility failed to ensure medications be administered no earlier than one hour before and no later than one hour after the facility’s standard dosing schedule, except for those drugs that are ordered for specific times.
Evidence
  1. On 4/12/23, during medication observation pass with Staff #1, Staff #3 was observed administering the following 9:00am medications to Resident #1 at 10:31am: Cranberry 425mg, Ezetimibe 10mg, Fenofibrate 54mg, Fexofenadine 180mg, Preservision soft Gel, and Vitamin D3 1000IU.
  2. On 4/12/23, during medication observation pass with Staff #1, Staff #3 was observed administering the following 8:00am medications to Resident #11 at 10:42am: Acetaminophen 325 mg, Aspercrm/Lido 4% patch, Atorvastatin 20mg, Docusate SOD/Senna, Folic Acid 1 mg, Midodrine HCL 5mg, and Vitamin B-12 1,000 mcg.
Plan of correction
Every day, Director of Health Services, Memory Care Director, Executive Director, and Director of Operations review the previous day med pass to ensure every medication is administered within the communities dosing schedule, except for the drugs that are ordered for specific times. By 6/28/23, all Memory Care medications will be scheduled for 8:30,12:30,4:30pm,9pm unless drugs are ordered for specific times, to ensure medications are administered no earlier than one hour before and no later than one hour after the facilities dosing standards. By 6/31/23, all Assisted Living medications will be scheduled for 8:30,12:30,4:30pm,9pm unless drugs are ordered for specific times, to ensure medications are administered no earlier than one hour before and no later than one hour after the facilities dosing standards. This will be monitored on an ongoing basis by the DHS, MCD and ED.
22VAC40-73-320-B
Based on records reviewed and staff interviewed, the facility failed to ensure a risk assessment for tuberculosis was completed annually on each resident as
Evidence
  1. d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence:
  2. Resident files provided for Residents #5, #6, and #7 did not contain TB assessment forms which were completed annually.
  3. Staff #1 acknowledged updated TB assessment forms were not available for licensing inspector to review at the time of the inspection.
Plan of correction
For resident #6, we completed a T.B. risk assessment 6/27/23. By the time we received the inspection summary, resident #5 and #7 had been discharged. Going forward every month, my Director of Health Services and/or designee will confirm upcoming annual TB dates by the resident’s respective yearly date due. Either the Resident’s doctor and/or Director of Health Services (L.P.N.) and/or Licensed Designee will perform the annual T.B risk assessment to ensure compliance.
22VAC40-73-430-H-1
Based on review of resident record, the facility failed to ensure that a discharge statement included all the required information listed in the standards to be provided to the resident and as appropriate, his legal representative and designated contact person at the time of discharge.
Evidence
  1. Resident # 9’s discharge statement dated 8/8/22 was blank in the following area: date discharge statement provided to legal representative/designated contact person.
  2. Resident #8’s file did not contain a discharge statement.
Plan of correction
Executive Director provided the date that the discharge statement was provided to legal representative/contact person for resident #9 on 6/27/23. Executive Director completed resident #8’s discharge summary 6/27/23. Going forward, prior to discharge, Executive Director and/ or designee will document conversations, interactions, statements, and documentation with legal representatives/designated contact persons on the required discharge statement. Executive Director and/or designee will complete form (with signature) in its entirety.
22VAC40-73-660-A-1
Based on observation and interview, the facility failed to ensure the medicine cabinet or compartment used for storage of medications is locked.
Evidence
  1. During the medication cart audit on 4/12/2023 with Staff#1, the medication cart on the memory care unit was unattended and unlocked.
  2. Staff #1 acknowledged the medication cart was unlocked and unattended.
Plan of correction
Following the Med Cart Audit by licensing inspector, the employee was addressed immediately. Starting 6/12/23, Assisted Living and Memory Care have random daily cart audits to ensure carts are locked when unattended and keys are on person administering the medications. Furthermore, Director of Health Services and Memory Care Director conduct weekly med cart audits, in addition to quarterly med cart audits conducted by community pharmacy. This will be a weekly process.
22VAC40-73-325-B
Based on records reviewed and staff interviewed, the facility failed to ensure that a fall risk assessment was reviewed and updated after every fall.
Evidence
  1. Resident #4 had documented falls on 6/27/22, 9/10/22, 8/12/22, 8/29/22, 9/25/22, 9/28/22 and there were no corresponding fall risk assessments completed in the resident’s file.
  2. Staff #6 acknowledged there were no fall risk assessments for the documented falls in the resident file which was provided to the licensing inspector to review
Plan of correction
Fall risk assessments shall be completed after every fall. We have implemented a fall risk assessment into our electronic MARS system. Going forward, with every documented fall, Director of Health Services and/or designee will be alerted to complete a fall risk assessment to ensure compliance. Every week, the Director of Health Services will audit all falls at the weekly Quality Assurance Meeting to make sure fall risk assessments are complete in the MARS. This is ongoing.
22VAC40-73-580-A
Based on a review of facility documentation the facility failed to ensure that it obtained an annual inspection report from the Virginia Department of Health.
Evidence
  1. The facility provided documentation of a health inspection report from the Virginia Department of Health last dated 12/12/2021.
Plan of correction
The previous Administrator contacted the Department of Health on 2/20/23 and provided documentation that we have one but until they inspect, they will not send the new permit. The Department of Health stated that we are on the list, and they will get to us when they can. The previous Executive Director noted that there were follow-ups on multiple occasions. On 6/21/23 and 6/27/23, Executive Director reached out to multiple contact numbers. ED was able to leave a message on 6/27/23 at 11:44am at contact number listed on the last health department permit and also left message for Business Office. On 6/27/23, Executive Director spoke with ******** at 2:30pm. He stated he needed to go through the database and would call back. He acknowledged they were very backed up and it was not our fault. At 3:27 pm on 6/27/23, the Health Inspector arrived to perform his inspection. Please see attached permit.
October 2, 2022Complaint survey6 violations
Inspection dates
10/02/2022
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS
Comments
Type of inspection: Complaintx Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/03/2022 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Complaints were received by VDSS Division of Licensing on 9/14/2022 & 9/22/2022 regarding allegations in the area(s) of: Staffing and Supervision Resident Care Buildings and Grounds Number of residents present at the facility at the beginning of the inspection: 18 Memory Care Unit 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: 0 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: Licensing Inspector observed activities, toured several resident rooms, took water temperature, and observed breakfast. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the (allegation(s); area(s) of non-compliance with standard(s) or law were: Resident Care 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alyshia E. Walker, Licensing Inspector at (757)670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Violations
22VAC40-73-450-E
Based on resident record review, the facility failed to have the ISP (Individualized Service Plan) signed by the resident or his/her legal representative.
Evidence
  1. Resident #5 has an ISP dated 12/31/2021. There was no signature of the resident or the resident’s legal representative.
Plan of correction
Audit all ISPs by March 5th to ensure that all parties have signed the ISP At care plan meetings all ISP need to be signed by resident and responsible party
22VAC40-73-450-F
Based on a review of resident records the facility failed to ensure that each resident's individualized service plan (ISP) contained a description of all needs/services identified.
Evidence
  1. Resident #5’s ISP dated 12/31/2021 did not document the resident’s physical therapy services.
  2. Resident #5’s Uniform Assessment Instrument (UAI) assessed the resident as needing mechanical and human assistance in bathing. The ISP does not indicate what type of mechanical assistance the resident requires.
  3. Resident #5’s UAI assessed the resident as needing mechanical and human assistance with toileting. The ISP does not indicate what type of mechanical assistance the resident requires.
Plan of correction
Ensure all ISP’s have been updated as required to reflect resident needs. DON or designee will audit 4 ISP/UAI weekly for 3 months and report all findings to QA meeting weekly. Ensure any resident with COC has an update ISP/UAI
22VAC40-73-325-B
Based on resident records reviewed, the facility failed to ensure a fall risk rating was updated after a fall.
Evidence
  1. Resident #2 had a documented fall on 7/28/22 and there was no updated fall risk assessment completed.
  2. Resident #1 had a documented fall on 9/28/22 and there was no updated fall risk assessment completed.
  3. Resident #5 had documented falls on 7/19/2022, 8/2/2022, and 8/29/2022. There were no updated fall risk assessments completed.
Plan of correction
DON to audit all falls at weekly Quality Assurance meeting for the next 3 months to ensure fall risk assessments are completed. Fall risk assessment to be completed after every fall. DON or designee to audit full month of FEB 2023 to ensure all Fall risk assessments are completed.
22VAC40-73-550-G
Based on record review, the facility failed to ensure that the annual review of resident rights and responsibilities is filed in the resident’s record.
Evidence
  1. The record for Resident #4 contained a most recent resident rights review signed 9/28/2021.
Plan of correction
All resident charts to be audited for completed resident rights by 2-24-23. All residents will have a completed and signed Resident Rights BY March 1st follow up to be reported at weekly QA meeting. Life Enrichment Director will create a tickler file to ensure resident’s rights are updated monthly.
22VAC40-73-640-A
Based on record review and staff interview, the facility failed to implement a written plan for medication management.
Evidence
  1. Resident #2 refused 135 medications in September 2022.
  2. Resident #4 refused 50 medications/treatments in September 2022.
Plan of correction
All medication techs and nurses must be trained on notifying families and doctors of refusals of medications, and it must be documented that the notifications were completed- training by March 1st for all medication staff / nurses Don or designee shall audit MARS weekly at the QA meeting to ensure families and doctors have been notified of refusals this shall be done for a period of three months with all findings documented in the quality assurance meeting minutes
22VAC40-73-320-B
Based on record reviewed and staff interviewed, the facility failed to ensure a risk assessment for tuberculosis (TB) was completed annually for a resident.
Evidence
  1. Resident #4’s most recent TB assessment was dated 9/30/2021, and Resident #5’s most recent TB assessment was dated 7/01/2021.
Plan of correction
All charts have been audited and tickler file created with due for TB risk assessment dates as of 2/8/23 Set up a plan with NP who visits to get all TB risk assessment completed. DON or designee to audit 3 charts week to ensure all TB assessments are updated for period of 3 months with finds reported at weekly quality assurance meeting.
June 7, 2022Inspection2 violations
Inspection dates
06/07/2022, 06/10/2022
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE 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: 06/07/2022 from 8:30 am to 2:20 pm and 06/10/2022 from 8:51 am to 10:13 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: 87 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 5 Observations by licensing inspector: First aid kit inspected, medication pass observed, and required postings reviewed. 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
22VAC40-73-640-A
Based on observation, the facility failed to implement methods to prevent the use of outdated, damaged, or contaminated medications.
Evidence
  1. During a medication pass observation with Staff #4 for Resident #4 on 06-07-2022, one of the medications, Probiotic Pearl 1B capsule, fell on the floor of the resident’s apartment. Staff #4 was observed to pick it off of the floor and place it back into the cup with the remaining medications for Resident #4 to take.
Plan of correction
The protocol for the destruction of a contaminated medication has been reviewed with staff #4. In order to ensure compliance with the regulation, an in-service on proper medication pass will be performed by Director of Health Services by 7/22/2022 for all nurses and medication technicians to ensure compliance. Director of Health service will do 2 random monthly medication pass audits for the next 3 months to ensure compliance and report findings at the monthly Quality Assurance meeting.
22VAC40-73-260-C
Based on observation and discussion, the facility failed to ensure a listing of all staff who have current certification in first aid or CPR is be posted in the facility.
Evidence
  1. On 06-10-2022, Staff #8 acknowledged a listing of all staff who have current certification in first aid or CPR is not posted in the facility.
Plan of correction
On 6-10-2022 staff member #8 corrected on site. Posted a list of all staff who are CPR and First Aid certified. Executive Director educated staff about the regulation at staff meeting held on 6/22/2022. Educated staff of the importance and where it is posted. Monthly the Director of Health Services will audit the CPR and first aid is posted. This will be reviewed monthly at Quality Assurance meting for next 4 months.
October 28, 2021Inspection0 violations
Inspection dates
10/28/2021
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS
Comments
A initial inspection was initiated on 10/28/2021 and concluded on 10/28/2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported the current census. The inspector conducted the on-site portion of the inspection on 10/28/2021. An exit interview was conducted with Administrator on 10/28/2021 Information gathered during the inspection determined compliance(s) with applicable standards or law, and no=violations were documented.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.