Virginia DSS · Assisted Living Facility

Pinecrest Assisted Living Facility, LLC

📍 709 River Ridge Road, Danville, VA, 24541

ID 48840One Year licenseActive
13
Inspections
On record
7
With violations
Visits that cited something
6
Clean visits
Nothing cited
37
Violations cited
Individual findings
27
Standards cited
Distinct rules
6
Complaint visits
Prompted by a complaint

Pinecrest Assisted Living Facility, LLC was inspected 13 times between September 19, 2022 and December 11, 2025 by the Virginia Department of Social Services. 7 of those visits ended with violations cited and 6 with none. Across that history VDSS cited 37 violations under 27 distinct standards. 6 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
08/21/2026
Administrator
Camilla Mccoy
Licensing inspector
Angela Swink
Inspector phone
(276) 623-6575
Approved for
Assisted Living · Ambulatory Only

Inspection History

13

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

December 11, 2025Complaint survey0 violations
Inspection dates
12/11/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/11/2025 10:20 to 11:20 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 11/15/2025 regarding allegations in the area(s) of: Resident Care and Related Services Number of resident records reviewed: 3 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 A Marie Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
November 6, 2025Complaint survey2 violations
Inspection dates
11/06/2025
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: 11/6/2025 09:15 to 11:35 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 10/21/2025 regarding allegations in the area(s) of: Admission, Retention, and Discharge of Residents 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 did not support the allegation of non-compliance with standard(s) or law. However, violation(s) not related to the complaint but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact A Marie Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov
Violations
22VAC40-73-430-J
Based on facility record review and staff interview, the facility failed to ensure within 60 days of the date of discharge, each resident or his legal representative shall be given a final statement of account, any refunds due, and return of any money, property, or things of value held in trust or custody by the facility.
Evidence
  1. Facility communication with their contracted pharmacy, dated 11/6/2025, contained documentation that Resident 1 medications, Glipizide 10mg Tab #60, Trazodone 100mg Tab #60, Venlafaxine ER 150mg Cap #30, Lisinopril 30mg Tab #30, Eliquis 5mg tab #60, Metoprolol Tartrate 25mg Tab #60, Atorvastatin 10mg Tab #30, Meclizine 25mg Tab #30, Spironolactone 25mg Tab #30, Levothyroxine 100mcg tab #30, and Jardiance 10mg Tab 30#, were returned to the pharmacy.
  2. Interview with Staff 1 confirmed that the facility had returned all of Resident 1 medications at their facility to the pharmacy after Resident 1 was discharged therefore the facility did not return the property or things of value held in trust and custody by the facility to Resident 1 or their legal representative.
Plan of correction
Not published by VDSS.
22VAC40-73-430-H-2
Based on resident record review and staff interview, the facility failed to ensure that a copy of the written discharge statement shall be retained in the resident's record.
Evidence
  1. Resident 1 record did not contain the discharge statement, dated 10/18/2025, at the time of the request to be reviewed by the licensing inspector (LI).
  2. Interview with Staff 1 confirmed that the discharge statement, dated 10/18/2025, was not retained in Resident 1 record.
Plan of correction
Not published by VDSS.
July 8, 2025Inspection8 violations
Inspection dates
07/08/2025
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 PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS
Comments
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: 7/8/2025 08:00 to 15:00 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: 38 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: 2 Number of interviews conducted with staff: 7 Observations by licensing inspector: Medication Pass, Breakfast and Lunch meals, 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 A Marie Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov
Violations
22VAC40-73-930-D
Based on resident record review and staff interviews, the facility failed to ensure that for each resident with an inability to use the signaling device, in addition to any other services, it shall be included in the resident's individualized service plan.
Evidence
  1. During an interview with the Licensing Inspector and Staff 3, Staff 3 revealed that Resident 1 was not able to use their signaling device due to their memory loss.
  2. Resident 1 record contained an Individualized Service Plan (ISP), dated 8/19/2024, which did not contain documentation that the resident was not able to use the signaling device.
  3. During an interview with the LI and Staff 1 and Staff 2, Staff 1 and Staff 2 confirmed the resident was not able to use their signaling device due to their memory loss.
Plan of correction
1. On 7.10.25, Staff #6 advised Staff #3 to update Resident #1’s ISP by 7.16.25 to reflect his cognitive limitation regarding the use of the signaling device (call bell system) and including his need for increased/enhanced supervision. 2. On 7.10.25 Staff #6 discussed with Staff #1 and Staff #3 about documenting any changes in Resident #1’s ability to use assistive or safety equipment and Staff #6 advised Staff #3 to update Resident #1’s ISP by 7.16.25 to reflect his cognitive limitation regarding the use of the signaling device (call bell system) and including his need for increased/enhanced supervision. 3. On 7.10.25 Staff #6 discussed with Staff #1 and Staff #3 about documenting any changes in Resident #1’s ability to use assistive or safety equipment. In the August All Staff Meeting Staff #6 & Staff #3 will re-educated Direct Care Staff & Staff #2 on the importance of reporting and documenting any changes in a resident’s ability to use assistive or safety equipment.
22VAC40-73-680-M
Based on medication cart audit, resident record review, and staff interviews, the facility failed to ensure that medications ordered for PRN administration shall be available, properly labeled for the specific resident, and properly stored at the facility.
Evidence
  1. Resident 1 record contained signed physicians orders dated 5/21/2025 with documentation of Senna Plus 50/8.6mg Tab, Take 2 tablets by mouth every evening before bed as needed for constipation *do not crush* and Diphenhydramine 25mg capsule, take 2 capsules (50mg) by mouth as needed x1 for bee stings.
  2. During a medication cart audit, the two medications were not observed or located on the medication cart.
  3. During an interview with the licensing inspector and Staff 2 and Staff 3, Staff 2 and Staff 3 confirmed that the medications were not available to the resident at the facility.
Plan of correction
1. On 7.8.25, Staff #3 verified that these medications were still active and the orders were not discontinued. 2. On 7.10.25, Staff #6 requested Staff #3 complete a full audit of Resident #1’s PRN and standing medications by 7.18.25, to ensure availability and proper storage. On 7.10.25, Staff #6 requested Staff #3 to complete a full audit for all residents' PRN and standing medications by 9.30.25 to ensure availability and proper storage. 3. On 7.10.25, Staff #6 rediscussed with Staff #3 that all ordered medications must be available on-site at all times, including PRNs. Moving forward, Staff #3 will ensure all order medications, including PRNs are available on-site.
22VAC40-73-250-D
Based on staff record review and staff interview, the facility failed to ensure that each staff person, on or within seven days prior to the first day of work at the facility and each household member prior to coming in contact with residents, shall submit the results of a risk assessment that is no older than 30 days, documenting the absence of tuberculosis (TB) in a communicable form as
Evidence
  1. d by the Virginia Department of Health or a form consistent with it. EVIDENCE:
  2. Staff 4 record, date of hire 4/8/2025, contained documentation of a TB risk assessment dated 12/2/2024. This is the only TB assessment on record.
  3. During an interview with the licensing inspector and Staff 1, Staff 1 revealed that it was the most current TB risk assessment for Staff 4.
Plan of correction
1. PineCrest Assisted Living Facility (PALF) will obtain a new TB risk assessment for Staff #4 by 7.18.25. Staff #3 will review and secure in Staff #4’s file. 2. The new hire onboarding checklist was updated on 7.14.25 by Staff #1, to include a TB assessment date verification, with a reminder that the results of a TB risk assessment is to be no older than 30 days.
22VAC40-73-870-A
Based on physical plant observation and staff interviews, 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. During the physical plant observation on the day of inspection, the Licensing Inspector (LI) observed black tape holding the seams of the floor together transitioning from the dining room to the hallway for rooms 14-19 and the hallway into Wing B. The LI observed black tape holding the seams together for approximately 4 of the vinyl planks in the dining room and approximately 3 of the vinyl planks in Wing B.
  2. During an interview on the day of the inspection with the licensing inspector and Staff 1 and Staff 5, Staff 1 revealed that the floor had been in the current condition for approximately 60 days due to a water issue. Staff 5 revealed that the facility would fix the flooring in the Fall of 2025.
Plan of correction
1. On 7.10.25, Staff #6 discussed with Staff #5 installing transition strips at the identified areas by October 2025. 2. On 7.9.25, Staff #6 inquired with the Licensing Inspector about potential grants or funding assistance available through the Virginia Department of Social Services to support timely repair of the facility flooring. Once resources are made available, PALF will repair the facility flooring.
22VAC40-73-520-I
Based on physical plant observation, the facility failed to ensure that the current month's schedule shall be posted in a conspicuous location in the facility or otherwise be made available to residents and their families.
Evidence
  1. During the physical plant observation on the day of inspection, the licensing inspector (LI) observed the posted activity calendar to be dated June 2025 on the bulletin board in the dining room.
  2. During an interview with the licensing inspector and Staff 1, Staff 1 revealed that the July 2025 calendar had not been posted until the day of the inspection, and it was located in a binder prior to the day of inspection that was not available to the residents and their families.
Plan of correction
1. The July activity calendar was posted on 7.8.25 on the bulletin board in the dining room by Staff #1. 2. Staff #6 re-instructed Staff #1 on 7.8.25, to ensure timely posting of activity schedules in compliance with 22VAC40-73-520I.
22VAC40-73-720-A
Based on resident record review and staff interview, the facility failed to ensure that Do Not Resuscitate (DNR) Orders for withholding cardiopulmonary resuscitation from a resident in the event of cardiac or respiratory arrest may only be carried out in a licensed assisted living facility when all requirements are met.
Evidence
  1. Resident 1 record contained a DNR order dated 3/7/2024.
  2. Resident 1 record contained an Individualized Service Plan (ISP) dated 8/19/2024 which did not contain the written DNR order.
  3. During an interview with the licensing inspector and Staff 1, Staff 1 confirmed the DNR written order is not on the ISP.
Plan of correction
1. On 7.8.25, the DNR order was verified. 2. On 7.10.25, Staff #6 advised Staff #3 to update Resident #1’s ISP by 7.16.25 to include the DNR order. Staff #6 advised Staff #3 to ensure the DNR order is also reflected in Residex by 7.14.25. 3. On 7.10.25, Staff #6 advised Staff #3 to update Resident #1’s ISP by 7.16.25 to include the DNR order. In the August All Staff Meeting Staff #6 & Staff #3 will provide a refresher on DNR documentation requirements, including the need to reflect DNR status clearly in the ISP.
22VAC40-73-680-D
Based on resident record review and staff interview, the facility failed to ensure that medications shall be administered in accordance with the physician's or other prescriber’s instructions.
Evidence
  1. Resident 2 record contained a signed physician’s order dated 6/12/2025 with documentation for Acetaminophen 325mg Tablet, Take 2 tablets (650mg) by mouth three times daily for pain. The frequency on the order notes 2x a day.
  2. Resident 2 record contained a June 2025 Medication Administration Record (MAR) with documentation that Acetaminophen 325mg Tablets, was scheduled only for 4:00pm and 8:00pm daily.
  3. During the morning medication pass observation on the day of inspection, the licensing inspector did not observe Resident 2 receive Acetaminophen 325mg Tablets.
  4. During an interview with the licensing inspector and staff 3, staff 3 stated that the morning dose of Acetaminophen had been discontinued by the physician in May 2024, and the pharmacy never updated the specific indications for administering the drug, however the physician continued to sign the orders submitted by pharmacy.
Plan of correction
1. Staff #3 immediately clarified with the prescribing physician, and a corrected order reflecting the accurate dosage and frequency was obtained and documented on 7.8.25. Going forward, any physician orders received with internal discrepancies will be flagged and verified by Staff #3 before being processed or entered into the MAR via pharmacy connect. 2. Staff #3 obtained a verbal order and the MAR was promptly updated on 7.8.25 to match the clarified physician’s order. Moving forward, Staff #6 has implemented a monthly MAR audit process for Staff #3 to ensure that all orders are accurately transcribed and scheduled according to physician directives. 3. By 7.18.25, Staff #2 will receive immediate re-training from Staff #3 on verifying MARs and scheduled doses during medication administration. Direct Care Staff will receive this retraining in the August departmental meeting conducted by Staff #3. 4. On 7.13.25, Staff #6 contacted Katherine Zammit, Consultant Pharmacist, via email to request a meeting to address ongoing issues with the pharmacy’s handling of physician order updates and discontinuations. The purpose of the meeting is to seek her support in ensuring timely and accurate updates on the pharmacy’s end. Katherine confirmed her availability to meet the week of 7.14.25. Additionally, on 7.8.25, Staff #6 reviewed with Staff #3 the use of the edit functions in Residex, reinforcing the importance of manually verifying and adjusting physician orders prior to processing them through Pharmacy Connect to ensure consistency with the written medical orders.
22VAC40-73-310-A
Based on resident record review, resident interview, and staff interviews, the facility failed to ensure that no resident shall be admitted or retained who requires a level of care or service or type of service for which the facility is not licensed or which the facility does not provide.
Evidence
  1. The facility has a stipulation on the facility license that indicates that all residents must be ambulatory.
  2. During an interview with the licensing inspector and staff 2 on the day of inspection, staff 2 revealed that Resident 1 had a diagnosis of dementia. Staff 2 also revealed that Resident 1 was not able to use their signaling device due to their cognition and not being able to remember to use it.
  3. During an interview with the licensing inspector and Staff 1, Staff 1 revealed that Resident 1 had a Serious Cognitive Impairment. Staff 1 confirmed that the resident was not able to use their signaling device due to their memory.
  4. During an interview with the Licensing Inspector and Staff 2, Staff 2 revealed that the resident may or may not acknowledge a fire alarm when they heard it and exit the facility.
  5. During an interview with the Licensing Inspector, Resident 1, and Staff 2, Resident 1 was not able to recall the month, year, the season, their current location, or the president. Resident 1 reported they did not know what they would do if they needed help or their roommate needed help. Resident 1 was not able to recall the purpose of the signaling device.
  6. Resident 1 record contained a Uniform Assessment Instrument, dated 8/13/2024, with documentation that the resident is Disorientated, some spheres, all of the time and has a diagnosis of Dementia.
  7. Resident 1 record contained a physician’s progress note, dated 5/21/2025, with documentation that the resident has a diagnosis of dementia and confusion was noted.
Plan of correction
1. PALF will operate in full accordance with the ambulatory-only stipulation on its license by ensuring that all current and prospective residents are physically and cognitively capable of self-preservation and safe evacuation. 2. While awaiting his re-assessment, Resident #1 is receiving enhanced supervision to ensure increased monitoring and support. These updates will be documented in his Individualized Service Plan (ISP) and reflected within the Residex system on 7.16.25. 3. While awaiting his re-assessment, Resident #1 is receiving enhanced supervision to ensure increased monitoring and support. These updates will be documented in his Individualized Service Plan (ISP) and reflected within the Residex system on 7.16.25. 4. To support Resident #1’s ongoing safety and compliance with licensure requirements, PALF will continue to conduct regularly scheduled fire drills, providing opportunities for Resident #1 to practice self-preservation responses in the event of an emergency. While Resident #1 is unable to verbally articulate the appropriate steps, he is physically ambulatory and able to respond to verbal cues and prompts from staff. These drills will serve as reinforcement and allow staff to continuously assess and document his ability to evacuate independently with minimal assistance. 5. PALF will conduct regularly scheduled safety drills focused specifically on the use of the call bell system. These sessions will be conducted with Resident #1 to reinforce the purpose and proper use of the signaling device. Although Resident #1 has demonstrated difficulty in recalling the function of the device due to cognitive impairment, Staff 1, Staff 2, Staff 3 (and other Direct Care Staff) will provide verbal prompts and one-on-one guidance to support memory reinforcement. These drills will be documented while PALF is awaiting the results of Resident #1’s reassessment. The next specific safety drill will be conducted on 7.23.25 by Staff 1& Staff 3. 6. On 7.10.25, Staff #6 contacted Pernita Echols of Pittsylvania County Department of Social Services, via email, who had previously assessed Resident #1 to request an urgent reassessment of his level of care. 7. On 7.14.25, Resident #1’s physician was notified by Staff #3 of the recent inspection and respective concerns, so the physician could also do an urgent reassessment of his level of care.
May 13, 2025Complaint survey2 violations
Inspection dates
05/13/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 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: 05/13/2025 9am until 12;30pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 05/07/2025 regarding allegations in the area(s) of: General provisions, admission, retention and discharge of residents and resident care and related services. 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 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 some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: admission, retention and discharge or residents. 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Violations
22VAC40-73-400
Based on resident record review and staff interview, the facility failed to ensure that residents monthly statements of charges and payments only contained itemized charges made by the facility.
Evidence
  1. The Personal Funds Tracking Sheet from 01/01/2025 through 05/13/2025 for resident 2 has documentation of a charge for $5.00 dollars for a missed appointment fee-PALF Group on 01/09/2025, 01/23/2025 and 04/14/2025.
  2. The Personal Funds Tracking Sheet from 01/01/2025 through 05/13/2025 for resident 3 has documentation of a charge for $5.00 dollars for a missed appointment fee-PALF Group on 01/08/2025. 3.The Personal Funds Tracking Sheet from 01/01/2025 through 05/13/2025 for resident 4 has documentation of a charge for $5.00 dollars for a missed appointment fee-PALF Group on 04/03/2025.
  3. The Personal Funds Tracking Sheet from 01/01/2025 through 05/13/2025 for resident 5 has documentation of a charge for $5.00 dollars for a missed appointment fee-PALF Group on 02/13/2025.
  4. In an interview with staff persons 1 and 2 on the day of the on-site inspection it was expressed that these fees are for a group counseling service that is provided at the facility by an outside 3rd party vendor. Staff person 2 also confirmed that residents 2, 3, 4 and 5 manage their own personal funds or have a legal representative who manages their personal funds, and that the facility does not handle personal funds for these residents.
Plan of correction
1. Third-party vendor fees will not be included in the personal funds tracking sheet for Resident 2. These fees have been, and will continue to be, directly billed to the family by the vendor. 2. Third-party vendor fees will not be included in the personal funds tracking sheet for Resident 3. These fees have been, and will continue to be, directly billed to the family by the vendor. 3. Third-party vendor fees will not be included in the personal funds tracking sheet for Resident 4. These fees have been, and will continue to be, directly billed to the family by the vendor. 4. Third-party vendor fees will not be included in the personal funds tracking sheet for Resident 5. These fees have been, and will continue to be, directly billed to the family by the vendor. 5. PALF will support the residents or legal representatives in managing such counseling service fees with the third party vendor since PALF is not the payee representative to manage their personal funds. A plan of correction date was not provided by the facility for this violation. The date included on the violation notice is the date that the licensing inspector received the plan of correction from the facility.
22VAC40-73-390-A
Based on resident record review and staff interview, the facility failed to ensure that all requirements or rules to be imposed regarding resident conduct and other restrictions or special conditions were included in the facility agreement.
Evidence
  1. The Personal Funds Tracking Sheet for resident 1 has documentation that a fee of $60.00 dollars was charged to resident 1 on 02/04/2025 for Contraband (Cigarette)-1st offense. In an interview with staff persons 1 and 2 it was expressed that the facility is no smoking on the entire premises and that smoking supplies (cigarettes/lighters) are also not allowed.
  2. The facility agreement dated and signed by the resident and facility Administrator on 01/02/2025 contains the facility policy for no smoking in the facility or on the premises but does not include information that smoking supplies (cigarettes/lighters) are not allowed on the facility premises.
Plan of correction
1.Resident 1 has been notified on multiple occasions, since the facility implemented its smoke-free policy in 2024 about the prohibition of cigarettes and related supplies on the premises. However, on 2.4.25, she was informed again when observed with a lighter. She will be informed again at the 6.11.25 Resident Meeting. 2. A Resident Meeting is scheduled for 6.11.25, to discuss the facility's non-smoking policy and to emphasize that smoking supplies are prohibited on the premises. The Resident Agreement will be updated to include this language for all new residents and will also be amended for existing residents during the annual renewal period in December 2025/January 2026.
September 23, 2024Inspection0 violations
Inspection dates
09/23/2024
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS
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: 09/23/2024 11:40am to 12:10pm 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: 36 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: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact A Marie Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
July 17, 2024Inspection3 violations
Inspection dates
07/17/2024
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 PREPAREDNESS32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE 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: 7/17/2024 08:25 to 13:45 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: 38 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: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 5 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 A Marie Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov
Violations
22VAC40-73-190-C
Based on staff record review and staff interview, the facility failed to ensure that prior to being placed in charge, the staff member was informed of and received training on their duties and responsibilities and provided written documentation of such duties and responsibilities.
Evidence
  1. Staff 6 record did not contain written documentation of duties and responsibilities prior to being placed in charge.
  2. On the day of inspection during an interview with the licensing inspector and staff 2, staff 2 confirmed staff 6 has been the staff in charge at times at the facility. Staff 2 confirmed staff 6 record to be current.
Plan of correction
Staff 2 developed a policy on 7.18.24, Designated Staff Persons in Charge. This policy was provided to and signed by Staff 6 on 7.18.24. The Administrator also shared this policy with all employees, so they are aware of the Designated Staff Persons in Charge Policy & Procedure. Moving forward, this policy will be provided in Orientation and discussed periodically in All Staff Meetings.
22VAC40-73-320-A
Based on resident record review and staff interview, the facility failed to ensure that a physical examination with all required information was obtained within 30 days preceding admission for a resident.
Evidence
  1. Resident 3 record, admitted to the facility on 6/20/2024, has documentation of a physical examination dated for 6/13/2024. The physical examination does not have documentation of the required information that includes a statement that the individual does not have any conditions or care needs prohibited by 22VAC40-73-310H and a statement that specifies whether the individual is or is not capable of self-administering medication.
  2. On the day of inspection during an interview with the licensing inspector and staff 2, staff 2 confirmed resident 3 record to be current.
Plan of correction
Staff 2 notified Resident 3’s PCP, via email on 7.18.24 that his current H&P lacked the VDSS standards regarding prohibitive conditions and capacity (or not) to self-administer medications. Staff 2 requested the provider complete a new H&P for Resident 3 using the VDSS Physical Examination Form. Provider completed the VDSS Physical Examination Form and returned it to Staff 2 on 7.22.24. Moving forward, PineCrest Assisted Living will only accept the VDSS Physical Examination Form for prospects and residents.
22VAC40-73-270-1
Based on resident record review, staff record review and staff interview, the facility failed for direct care staff to be trained in methods of dealing with residents who have a history of aggressive behavior prior to being involved in the care of such residents.
Evidence
  1. Resident 5 record contained documentation from Resident Notes of the resident being aggressive as documented by the resident attempting to push and hit staff, and spitting on staff on 5/28/2024. 2.Staff 3 record, date of hire 2/5/2024, did not contain documentation of training in methods of dealing with residents who have a history of aggressive behavior.
  2. On the day of inspection, during an interview with the licensing inspector and staff 2, staff 2 confirmed staff 3 record was current. Staff 2 confirmed that staff 3 did provide care for resident 5.
Plan of correction
Staff 2 informed Staff 3 on 7.17.24 that he needed to complete the Aggressive Behavior Training. Staff 2 advised Staff 3 on 7.17.24 not to work with Resident 5 until the training is completed. Staff 2 scheduled the training with Staff 3 for 8.7.24. Moving forward, the Aggressive Behavior Training will be provided in Orientation.
June 12, 2024Complaint survey0 violations
Inspection dates
06/12/2024
Areas reviewed
22VAC40-73 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: 6/12/2024 10:15am to 11:15am 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 6/5/2024 regarding allegations in the area(s) of: Buildings and Grounds Number of residents present at the facility at the beginning of the inspection: 40 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 6 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 complaint 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 A Marie Swink, Licensing Inspector 276-635-6575 or by email at angela.swink@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
March 6, 2024Complaint survey0 violations
Inspection dates
03/06/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 3.6.2024 08:40am to 10:45am 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 1.31.2024 regarding allegations in the area of: Resident Care and Related Services 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: 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 did not support the allegation of non-compliance with standards 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 A Marie Swink, Licensing Inspector at 276-635-6575 or by email at angela.swink@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
March 6, 2024Inspection0 violations
Inspection dates
03/06/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 3.6.2024 08:40am to 10:35am 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 2.23.2024 regarding allegations in the area of: Resident Care and Related Services 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: 1 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 did not support the self- report of non-compliance with standard 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 A Marie Swink, Licensing Inspector at 276-635-6575 or by email at angela.swink@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
July 26, 2023Inspection10 violations
Inspection dates
07/26/2023
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 PREPAREDNESSARTICLE 1 – SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Comments
Type of inspection: Renewal Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/26/2023 9:10am until 5:00pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 36 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 Number of staff records reviewed: 4 Number of interviews conducted with residents: 3 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Violations
22VAC40-73-100-C-1
Based on observations of the facility medication carts and review of facility policies, the facility failed to implement its infection control policy regarding CDC recommendations for blood glucose monitoring practices.
Evidence
  1. The facility’s infection control policy, effective June 2023, states the following regarding Point-of-Care Blood Glucose Testing: “Glucose meters are not to be shared between residents, and should be dedicated for single-resident use – Glucose meters must be labeled with resident information.”
  2. While performing an audit of the facility’s medication carts, it was observed that the individual glucometers for resident 6 and resident 7 were not labeled with each resident’s name.
Plan of correction
Residents 6 & 7 names were written on their individual glucometers with a black sharpie on 7.26.23 following the inspection. The Administrator discussed this violation with the Nursing and RMA staff during the 8.9.23 staff meeting. The Administrator also added a weekly chore (Tuesday for day shift & Saturday for evening shift) in RTasks for Nursing/RMA Department to check the glucometers to ensure the individual meters and bags are appropriately labeled. The Administrator contacted the pharmacy on 8.9.23 to have them send sticker labels to be used on the glucometers. The sticker labels arrived on 8.10.23.
22VAC40-73-520-I
Based on observations of the facility physical plant and staff interview, the facility failed to post a monthly activity schedule.
Evidence
  1. A monthly activity for July 2023 was not posted in the facility on the day of inspection. Staff 6 expressed in an interview that the facility is working on their activities and the monthly schedule.
Plan of correction
On 7.28.23 the Administrator created the Activity Calendar for August. The activities calendar was posted on 8.1.23 by Staff 6. Staff 6 and the Administrator met with Staff 1 and the two other hired staff that are responsible for specific activities to review the Activities Calendar. The Administrator discussed The Activities Calendar with all staff during the 8.9.23 All Staff Meeting.
22VAC40-73-650-E
Based on resident record review, the facility failed to ensure that signed physicians orders were maintained in resident records.
Evidence
  1. The record for residents 1, 2 and 3 did not contained signed physicians orders for all medications prescribed to the residents.
Plan of correction
The Administrator confirmed with the pharmacy on 7.28.23 that all signed physician orders are faxed to the facility. The Administrator discussed in the staff meeting on 8.9.23 the missing signed physician orders and reminded Nurse/RMA/DCS to scan and save all signed physician orders sent via fax from the pharmacy and/or provider, to the residents file in RTasks. Residents 2 and 3 signed physician orders were saved in their files on 8.9.23. The Administrator created an MD order from RTasks for Resident 1 and sent it to his provider on 8.11.23, via email, for the provider to review, sign, and return. The provider is scheduled to be onsite 8.17.23 and the Administrator will request the signed order if it has not been provided prior to the onsite visit. The Administrator will show the Nurse/RMA/DCS staff in the Departmental Meeting on 8.14.23, how to create an MD Order in RTasks for the orders to be sent with the residents on future doctor appointments, so the orders can be signed.
22VAC40-73-440-A
Based on resident record review, the facility failed to ensure that uniform assessment instruments (UAIs) were completed as required.
Evidence
  1. The public pay UAI dated 07/05/2023 in the record for resident 1 is incomplete as it has documentation that the resident requires ADL assistance with bathing, dressing and transferring but the UAI does not identify what type of assistance is needed.
Plan of correction
The Administrator notified Case Manager & Assessor that completed Resident 1’s UAI, via email on 7.26.23, of the incomplete sections on his UAI. The Administrator requested that the Case Manager/Assessor include the type of ADL assistance Resident 1 needs. Case Manager/Assessor completed an addendum to address the incomplete sections on 8.11.23, during scheduled site visit.
22VAC40-73-320-A
Based on resident record review, the facility failed to ensure that a resident’s report of physical examination form contained all required information.
Evidence
  1. The report of physical examination form for resident 5, dated 06/05/2023, was incomplete in the following areas: address, telephone number, height, weight, blood pressure, and resident’s ability to self-administer medications.
Plan of correction
The Administrator notified Resident 5’s provider, via email on 7.27.23, of the incomplete sections on resident 5’s H&P and requested the incomplete sections be completed and the H&P returned. Provider returned Resident 5’s completed H&P on 8.2.23. Administrator discussed this with Nursing/RMA/DCS Department during the 8.9.23 staff meeting and informed them to return any incomplete H&P’s to the provider for the provider to complete. Moving forward, Staff 6 and the Administrator will do fidelity checks of all admission documents to ensure they are completed. A chart audit was completed by the Administrator and Staff 6 on 8.2.23.
22VAC40-73-450-F
Based on resident record review, the facility failed to ensure that all required information was included when individualized service plans (ISPs) are reviewed and updated.
Evidence
  1. The record for resident 5, admitted to the facility on 06/05/2023, has documentation of home health plan of care, effective 06/28/2023 – 08/26/2023, which indicates that this resident will be receiving physical therapy 1 time per week for 1 week, 2 times per week for 2 weeks, and 1 time per week for 5 weeks; and speech therapy 1 time per week for 1 week. The ISP for resident 5, dated 06/07/2023, did not contain documentation that physical therapy and speech therapy services are being provided.
  2. The ISPs dated 07/09/2023 in the records for residents 1 and 3 are incomplete as they lacks documentation of the dates of identified needs, where services will be provided, the expected outcome/goal and date of expected outcome/goal.
Plan of correction
On 7.26.23 the Administrator contacted the home health care provider and requested Resident 5’s care plan. The care plan was added to Resident 5’s file. The Administrator added home health care as a service and need to Resident 5’s ISP. The Administrator and Staff 6 will retrain Nurse/RMA/DCS on how to add this service and need in RTasks and to a resident’s ISP in the Departmental meeting on 8.14.23. On 7.27.23 the Administrator emailed the development team with RTasks regarding the existing ISPs lacking the following information: dates of identified needs, where services will be provided, the expected outcome/goal and date of expected outcome/goal, and requested they customize the ISPs to mirror the VDSS Model Form. RTasks confirmed via email on 7.28.23 that they were working on the changes. The Administrator and Staff 6 met with the RTasks team on 8.2.23 to review the customized changes. Resident 1 and 3 ISP will be updated/amended on 8.15.23. The customize version mirrors the VDSS Model Form, so the ISP’s should be in compliance moving forward.
22VAC40-73-250-D
Based on staff record review, the facility failed to ensure that on or within seven days prior to the first day of work at the facility all staff submitted the results of a risk assessment, documenting the absence of tuberculosis.
Evidence
  1. The record for staff 2, hired on 02/22/2023, contained a most recent tuberculosis risk assessment form which was dated 03/11/2022.
Plan of correction
Staff 6 informed Staff 2 of expired TB and requested Staff 2 get a new one. Staff 2 provided negative TB on 7.31.23. To ensure this does not occur again, Staff 6 and Administrator have started adding TB dates to RTasks so RTasks will provide an alert when a TB test is about to expire. Staff 6 & Administrator will then notify the appropriate staff.
22VAC40-73-870-A
Based on observations of the facility physical plant, the facility failed to maintain the interior of the building in good repair and keep clean.
Evidence
  1. The carpets in rooms 12, 28 and 31 were observed to have heavy stains on the day of inspection.
Plan of correction
The Administrator informed the outsourced cleaning service, on 8.9.23, of the heavy stains in room 12, 28, and 31. The Administrator requested the cleaning service to audit and inspect all rooms to determine the conditions of the carpet. We discussed keeping the carpet routinely cleaned (Mon – Fri). The Administrator discussed with Staff 6 and The Director of Maintenance replacing all carpet in residents rooms throughout the next year, beginning with rooms 12, 28, and 31.
22VAC40-73-640-A
Based on observations of the facility medication carts, review of facility policies and staff interview, the facility failed to implement its medication management plan specifically regarding its methods to prevent the use of outdated, damaged, or contaminated medications, and its methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes.
Evidence
  1. The facility’s current medication management plan states “Each oncoming shift must count controlled pills with the outgoing shift and both must sign off on the control sign log and the oncoming staff must sign off as a “Witness” in RTasks. The administrator can also serve as a “Witness” in RTasks of this process.”
  2. The Control Sign Sheet for medication cart A, which became effective on July 5 per staff 2, was not completed by the following shifts on the following dates: On 07/05/2023, the outgoing evening shift and oncoming day shift did not sign; on 07/06, the oncoming evening shift did not sign; on 07/07, the outgoing evening shift and the oncoming evening shift did not sign; on 07/08, the outgoing evening shift did not sign; and on 07/26, the outgoing evening shift did not sign.
  3. The facility’s current medication management plan states “2.) The assigned RMA and/or Nurse will check medications on a weekly basis for outdated medications. 3.) Use Cheat Sheet for open and close dates for insulin. 4.) All outdated medications will be disposed of by the facility and new ones will be ordered to ensure that the resident will have his medications and the date will be current.”
  4. A Novolog FlexPen prefilled syringe 100 units/mL with an open date of 06/07/2023 and a label to discard the medication after 28 days with an expiration date of 07/04/2023 was noted in the medication cart on the day of inspection.
Plan of correction
On 7.26.23 the Administrator informed Nurse/RMA’s of the Control Sign Sheet missing signatures. Nurse acknowledged it being her oversight. On 7.26.23 the Administrator added the daily chore (confirm signature for controlled sign sheet) to RTasks with detailed instructions for oncoming and outgoing shifts to remember to sign. On 7.26.23 the Administrator added a every other day chore (discard expired medications) to RTasks with detailed instructions for Nurse/RMA’s to safely discard/dispose of expired medications. The Administrator requested sticker labels from the pharmacy on 8.9.23 that include date open and date expired. The sticker labels were received on 8.10.23. The Nurse/RMA Department will have an in-service on 8.14.23 with Nurse Carrie Turner for retraining. The Medication Management Plan was reviewed in the staff meeting on 8.9.23.
22VAC40-73-860-I
Based on observations of the facility physical plant, the facility failed to ensure that cleaning supplies were stored in a locked area.
Evidence
  1. At 9:39am on the day of inspection a container of Sani Professional Disinfecting Multi-Surface wipes was observed sitting in an unlocked, bottom cabinet near the refrigerator in the dining room.
  2. At 9:53am on the day of inspection a can of Champion Stainless Steel Cleaner was observed sitting out on the top of the cabinet next to the refrigerator in the dining room. No staff were present in the dining room at the time this cleaning agent was observed.
Plan of correction
Staff 6 secured the Sani Professional Disinfecting Multi-Surface wipes following the sate inspection on 7.26.23. Staff 6 discussed the violation with the Director of Dietary & Environmental Services on 7.26.23. The Administrator reviewed this violation and the standards of regulations during the All Staff meeting on 8.9.23. Staff 6 and The Administrator retrained on the Daily Facility Walk-Thru and reiterated the importance of cleaning supplies being attended to and then locked and secured. The Administrator reviewed the chore and detailed instructions on this task on 8.9.23.
May 3, 2023Complaint survey0 violations
Inspection dates
05/03/2023
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND
Comments
Type of inspection: Complaint Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/03/2023 9am until 2:30pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 3/20/2023 regarding allegations in the area of: resident care and related services and personnel. Number of residents present at the facility at the beginning of the inspection: 37 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: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. he evidence gathered during the investigation did not support the (allegation(s)/self-report) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 3, 2023Inspection11 violations
Inspection dates
05/03/2023
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Comments
Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/03/2023 9am until 2:30pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 37 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 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Violations
22VAC40-73-640-A
Based on observation, policy review, and staff interview, the facility failed to implement parts of its medication management plan specifically regarding methods to prevent the use of outdated, damaged, or contaminated medications and methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes.
Evidence
  1. Regarding insulin pens, the facility’s current medication management plan states, “Make sure when opening a new pen, the open and expiration dates are written on the pen”. While performing an audit of medication cart #2, the LI observed a opened Lantus Solostar Insulin pen for resident 5. The label on the pen stated, “Discard after 28 days”; however, the pen did not contain an open date in order to determine the date that the pen is to be discarded. The LI interviewed staff 1 regarding the pen’s expiration date and she could not determine when the pen had been opened.
  2. Regarding accurate counts of controlled medications, the facility’s current medication management plan states, “Each oncoming shift must count controlled pills with the outgoing shift and both must sign off on the control sign log”. Resident 6 has physician’s orders for Lorazepam 0.5mg, take 1.5 tablets by mouth twice daily for anxiety. While performing an audit of medication cart #1, the LI observed that the morning Lorazepam 0.5mg pill card for resident 5 contained 27 doses of the prescribed medication; however, the corresponding controlled drug log for this medication indicated that there should be 28 doses in the pill card. An interview with staff 1 could not reconcile the count discrepancy between the pill card and the corresponding controlled drug log despite staff 5and staff 1 signing that the counts were correct on the morning of the inspection. Resident 7 has physician’s orders for Clonazepam ODT 1mg tablet, Dissolve 1 tablet by mouth at bedtime. While performing an audit of medication cart #2, the LI observed that the Clonazepam ODT 1mg tablet pill packs for resident 7 contained 17 pills; however, the corresponding controlled drug log for this medication indicated that there should be 29 pills in the pill packs. An interview with staff 1could not reconcile the count discrepancy between the pill packs and the corresponding controlled drug log despite staff 6 and staff 7 signing that the counts were correct on the morning of the inspection.
  3. The April 2023 Control Sign Sheet for medication cart #1 was not signed on the following dates: on 4/25 by 2nd shift off-going staff and 3rd shift oncoming staff; on 4/26 by 3rd shift off-going staff; on 4/28 by 3rd shift oncoming staff; and on 4/29 by the 3rd shift off-going staff. The April 2023 Control Sign Sheet for medication cart #2 was not signed on the following dates: on 4/22 by the 1st shift off-going staff and on 4/27 by the 1st shift oncoming staff.
Plan of correction
Staff 4 reviewed the Medication Management Plan with Staff 1 and Staff 7 on 5.3.23 following state inspection. On 5.3.23, Staff 4 also observed the off-going & oncoming staff during shift exchange to ensure compliance with the Medication Management Plan. Staff 4 reviewed the Medication Management Plan again on 5.10.23 with Staff 1, Staff 2, Staff 5, Staff 6 and the other RMA staff. Staff 4 consulted with the Pharmacy about observing medication passes and retraining RMA staff. The training is scheduled for 6.5.23. Staff 4 has also randomly observed ongoing medication passes to ensure compliance with the Medication Management Plan. Staff 4 contacted the local sheriff’s department on 5.3.23 to report the drug diversion. Staff 4 spoke with Deputy. Staff 4 contacted Pharmacy on 5.5.23 to discuss the drug diversion and process for re-ordering the missing medications for Resident 7. Staff 4 reached out to Resident 7’s prescribing provider on 5.5.23. Prescribing provider contacted Staff 4 on 5.8.23 and confirmed she would refill her script. Resident 7’s new script arrived on 5.10.23. Staff 4 discussed and reviewed with Staff 1 Resident 5’s insulin pen. Staff 1 discussed with other RMA staff and reviewed records to determine when the pen was opened. Staff 1 wrote when the pen is to be discarded, 6.1.23. Staff 1 addressed this on 5.5.23. Staff 4 addressed with Staff 1 the medication audit performed on cart #1 and her oversight in counting and documenting the appropriate medication count after she administered medication to Resident 6. Staff 4 addressed the counting error on the eMar. Staff 4 documented on the eMAR the counting errors and the new medication count for Resident 6 & Resident 7. Staff 4 hired an LPN and a National Pharmacist Technician. Both started on 5.15.23, to help ensure best practices with medication management.
22VAC40-73-360-A
Based on resident record review, the facility failed to ensure that an emergency placement occurred only when the emergency is documented and approved by an adult protective services worker for public pay individuals or an independent physician or an adult protective services worker for private pay individuals.
Evidence
  1. The record for resident 3 has documentation that the resident was admitted to the facility on 03/15/2023. A letter documenting the residents emergency placement was not obtained by an adult protective services worker for public pay individuals until 04/14/2023.
Plan of correction
Staff 4 created an admission checklist to ensure PineCrest obtains required documentation within the regulations specified time-frames. The check list also indicates that an Emergency Placement Letter is to be provided before or on the day of the emergency placement or otherwise the resident will not be able to be placed at PALF.
22VAC40-73-860-I
Based on observations of the facility physical plant, the facility failed to store cleaning supplies in a locked area.
Evidence
  1. Room 28 was observed to have a container of Chases Clean Home Spray Disinfectant sitting out on the bed side table of the first bed.
  2. Room 31 was noted to contain a container of Sani Cloth Disinfectant Wipes and a can of SC Johnson Scrubbing Bubbles sitting out on the sink cabinet by the first bed in the room.
  3. A bottle of Glass Cleaner was observed sitting out on the fireplace mantle by the kitchen.
  4. The cabinet under the kitchen sink was noted to be unlocked and multiple cleaning supplies were observed in the cabinet. The kitchen was unattended at the time the LI made these observations.
Plan of correction
On 5.3.23 Staff 4 did a walk-through of the Facility and locked the cleaning supplies up in the locked supply closet. Staff 4 discussed with Resident in Room28 keeping all cleaning supplies in inconspicuous locations like his closet or under his sink. Resident in Room 28 put the disinfectant spray on the top shelf in his closet. On 5.24.23 Staff 4 discussed this with all residents in the Resident Meeting. On 5.4.23 Staff 4 sent out a memo to all PALF staff reminding all staff that cleaning supplies are to be locked up. Staff 4 communicated that the cleaning supplies under the kitchen have also been relocated to locked supply closet until a lock is provided for the kitchen sink. Staff 4 educated staff on capable residents having access to cleaning supplies but such supplies needing to be out of sight for residents that are not capable to have access. On 5.10.23, Staff 4 addressed these issues again with All Staff and the contracted Cleaning Services in the All Staff Meeting. Staff 4 implemented a procedure for Environmental Services and the contracted Cleaning Services to do daily sweeps to ensure all cleaning supplies are safely locked up.
22VAC40-73-250-D
Based on staff record review, the facility failed to ensure that a screening for tuberculosis was completed on or within seven days prior to the first day of work at the facility for all employees.
Evidence
  1. The records for staff 1 and 2, hire date of 02/28/2023, doe not have documentation that a screening for tuberculosis was completed prior to their first day of work.
  2. The record for staff 3, hired on 04/10/2023, has documentation that a screening for tuberculosis was not completed until 04/16/2023.
Plan of correction
Staff 4 scheduled for Staff 1, Staff 2, and Staff 3 to have TB test completed onsite by contracted provider, GoDocs, on 5.16.23. GoDocs, reported that TB test should only be completed annually and that she would not be able to do new ones for staff whose TBs were within the year.
22VAC40-73-120-A
Based on staff record review, the facility failed to ensure that orientation and initial training for employees occurred within the first seven working days.
Evidence
  1. The records for staff 1 and 2, hired on 02/28/2023 and staff 3, hired on 04/10/2023, do not contain documentation that these employees have received an orientation and initial training.
Plan of correction
Staff Orientation has been developed by Staff 4 for all future hires. The orientation covers the initial ALF training items and will be completed within the first 7 days of employment. Staff 1, Staff 2, and Staff 3 completed the Initial ALF Training/Orientation on 5.24.23 with Staff 4.
22VAC40-73-450-C
Based on record review and staff interview, the facility failed to ensure that the comprehensive individualized service plan (ISP) included all requirements.
Evidence
  1. The ISP for resident 4 dated 05/18/2023, did not address the resident’s walking and mobility needs; however, the public pay UAI for the same resident, dated 07/19/2022, indicates that the resident requires the mechanical assistance of a walker for walking and mobility. Interview with staff 4 revealed that resident 4 uses a walker for his walking and mobility needs.
Plan of correction
Staff 4 contacted the local DSS regarding resident 4 on 5.8.23. His UAI was updated 5.10.23 but Staff 4 noticed an oversight regarding Ambulation that was not corrected. Staff 4 reached out to local DSS on 5.23.23 to have this oversight addressed, so the updated ISP & UAI will be congruent. Local DSS communicated to Staff 4 that the UAI has been corrected and placed in the mail to the facility on 5.25.23
22VAC40-73-360-B
Based on resident record reviews, the facility failed to ensure that all required information was obtained within 7 days of admission for an emergency placement.
Evidence
  1. 1, The record for resident 3 has documentation that the resident was admitted on 03/15/2023 as an emergency placement. The history and physical in the record for resident 3 was not completed until 03/27/2023 and the sex offender screening was not completed until 04/14/2023.
Plan of correction
Staff 4 created an admission checklist to ensure PineCrest obtain required documentation within the regulations specified time-frames. The admission check list also indicates that an Emergency Placement Letter is to be provided before or on the day of the emergency placement or otherwise the resident will not be able to be placed at PALF.
22VAC40-73-440-A
Based on resident record review and staff interview, the facility failed to ensure that uniform assessment instruments (UAI) for public pay individuals were completed as required.
Evidence
  1. The public pay UAI dated 07/19/2022 in the record for resident 4 indicates that the resident requires supervision with bathing; however, the individualized service plan (ISP) for the same resident, dated 05/18/2022, does not address bathing needs. Interview with staff 4 revealed that resident 4 does not require any assistance with bathing and that the public pay UAI is incorrect.
Plan of correction
Staff 4 contacted local DSS regarding resident 4 on 5.8.23. His UAI was updated 5.10.23 and provided to the Facility on 5.22.23. Resident 4’s ISP was updated on 5.23.23 by Staff 6. Both documents are now congruent and reflect that Resident 4 does not require assistance with bathing.
22VAC40-90-40-B
Based on staff record reviews, the facility failed to ensure that a criminal history record review was completed prior to the 30th day of employment for new employees.
Evidence
  1. The record for staff person 1, hired on 02/28/2023, has a criminal record check that was not completed until 04/25/2023.
  2. The record for staff person 2, hired on 02/28/2023, did not have documentation that a criminal record check has been completed for this employee.
Plan of correction
Staff 4 established a new check list to ensure background checks are completed and sent off within 30 days of employment. Staff 4 completed the process to become a notary and had a designee also complete the process to become a notary, to ensure background checks are notarized and sent off timely.
22VAC40-73-750-E
Based on observations of the facility physical plant, the facility failed to ensure that the sheets on resident beds were clean.
Evidence
  1. The bed linens on the bed in room 12 were noted to be soiled/stained on the day of inspection.
Plan of correction
Staff 4 had housekeeping clean and replace soiled/stained linens in Room 12 on 5.3.23. Staff 4 has added Room 12 to the housekeeping daily list for ensuring clean linens. Staff 4 discussed with resident in Room 12 on 5.3.23 making his cigarettes outside instead of on his bed. Staff 4 has continued to randomly check in with resident in Room 12 to make sure he remembers to make his cigarettes outside.
22VAC40-73-270-1
Based on staff record review, the facility failed to ensure that direct care staff received training in methods of dealing with residents who have a history of aggressive behavior or of dangerously agitated states prior to being involved in the care of such residents.
Evidence
  1. The record for staff 1 and 2, hired on 02/28/2023 do not have documentation of current training in methods of dealing with residents who have a history of aggressive behavior or of dangerously agitated states. The facility houses a mental health population including resident 3, who has a history of aggressive behaviors.
Plan of correction
Aggressive Behavior Training will be provided to all PineCrest employees on 6.28.23 by Staff 4. After this facility-wide training, the Aggressive Behavior Training will be part of the Initial Orientation Training to ensure staff have completed this training requirement moving forward. Staff 4 will ensure Staff 1 & Staff 2 are in this training. Staff 4 will discuss Resident 3’s history of aggressive behavior for training purposes.
September 19, 2022Inspection1 violation
Inspection dates
09/19/2022
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 BUILDINGS AND GROUND63.2 GENERAL PROVISIONS63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS
Comments
Type of inspection: Initial Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 9/19/2022, 11:30 am to 2:24 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: 40 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Additional Comments/Discussion: This is an existing facility being purchased by the applicant licensee. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the initial inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The applicant has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to maintain future compliance with applicable standard(s) or law. If the applicant 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 should the facility be issued a license to operate. 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 a licensed facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Susan Mallory Licensing Inspector at (540) 309-3043 or by email at susan.mallory@dss.virginia.gov
Violations
22VAC40-73-870-A
Based on observation, the facility failed to be maintained in clean and good repair.
Evidence
  1. The bathroom next to room 13 has an inoperable shower with exposed insulation.
  2. The edges of floors in some halls have a build-up of a dark substance.
  3. There are a few areas where the paint is scuffed throughout the facility.
Plan of correction
1. The exposed installation will be appropriately reinstalled & covered. A direct-to-stud shower enclosure will be installed so the shower is fully operable. The work will be completed by a contractor. 2. A deep cleaning of all of the floors, with targeted focus on the areas with the dark substance build-up, will be performed by a commercial cleaning service. The licensee will identify a vendor that can provide this service to address the current need and to provide ongoing cleaning services at a monthly frequency. 3. The facility will receive a fresh paint of coat to address the areas that are scuffed and to spruce up the facility. Camilla McCoy will have this work contracted out & completed by a home improvement company.