Virginia DSS · Assisted Living Facility

Living Well Assisted Living

📍 2600 Shorehaven Drive, Virginia Beach, VA, 23454

ID 48858Two Year licenseActive
9
Inspections
On record
8
With violations
Visits that cited something
1
Clean visits
Nothing cited
60
Violations cited
Individual findings
48
Standards cited
Distinct rules
1
Complaint visits
Prompted by a complaint

Living Well Assisted Living was inspected 9 times between November 2, 2022 and April 13, 2026 by the Virginia Department of Social Services. 8 of those visits ended with violations cited and 1 with none. Across that history VDSS cited 60 violations under 48 distinct standards. 1 inspection was prompted by a complaint.

A violation is a licensing standard - a rule in the Virginia Administrative Code - that the inspector found the facility was not meeting. Each is shown with the evidence the inspector recorded and, where VDSS publishes it, the facility's own plan of correction.

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

Provider Information

Facility type
Assisted Living Facility
License type
Two Year
License expires
05/08/2027
Administrator
Tina Waring
Licensing inspector
Lanesha Allen
Inspector phone
757-715-1499
Approved for
Assisted Living · Non-Ambulatory

Inspection History

9

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

April 13, 2026Inspection1 violation
Inspection dates
04/13/2026
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION
Technical assistance
22VAC40-73-380 22VAC40-73-440
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: 04/13/2026 from 7:45 a.m. until 10:49 a.m. 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: 7 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: 2 Number of interviews conducted with residents:3 Number of interviews conducted with staff: 2 Observations by licensing inspector: Morning ADLs, Breakfast and an activity were observed. The temperature was checked and Emergency Preparedness were completed. A tour of the buildings and grounds occurred during this inspection. Additional Comments/Discussion: 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. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). 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 these 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. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at Lanesha.allen@dss.virginia.gov.
Violations
22VAC40-73-50-B
Based on the onsite record review and interview, it was determined that the facility did not ensure to obtain written acknowledgment of the receipt of the disclosure by the resident or their legal representative.
Evidence
  1. Resident #1 (admitted 11/16/25) did not have written acknowledgement of the receipt of the disclosure statement by the resident or their legal representative in their record.
  2. Staff #2 was unable to provide documentation during the onsite inspection 4/13/2026 that the written acknowledgement of the receipt of the disclosure statement by the resident or their legal guardian was retained in the record for the resident.
Plan of correction
Resident signed disclosure statement was placed in resident business folder. Check list for a new admissions updated audited to make sure that disclosure statement is included. Conducted audit of all residents to insure disclosure statement is completed.
March 28, 2025Inspection3 violations
Inspection dates
03/28/2025
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 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS
Technical assistance
22VAC40-73-350 22VAC40-73-440 22VAC40-73-450
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced renewal inspection took place on 03/27/2025 at 9:00 am until 01:00 pm. and 03/28/2025 from 07:20am until 08:20 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: 6 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 2 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: 2 Additional Comments/Discussion: Breakfast, lunch and an activity were observed. A medication pass observation was completed for two residents. The following was reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, medication carts, fire inspection report, health inspection report, and a staffing schedule. Water temperature was measured. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at lanesha.allen@dss.virginia.gov
Violations
22VAC40-73-310-D
Based upon review of the UAI prior to admission of a resident, the assisted living facility administrator did not ensure to provide written assurance to the resident that the facility has the appropriate license to meet his care needs at the time of admission. Copies of the written assurance shall be given to the legal representative and case manager, if any, and a copy signed by the resident or his legal representative shall be kept in the resident's record.
Evidence
  1. The record for Resident #3 did not contain the signed Written Assurance in the resident’s record during inspection on 3/28/25.
  2. Staff #2 confirms the Written Assurance was not present in the Resident’s record during inspection on 3/28/25.
Plan of correction
Resident written assurance was placed in resident business folder. Check list for a new admissions updated to ensure written assurance is collected at time of admission.
22VAC40-73-550-G
Based on record review, the facility did not ensure the rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each resident or his legal representative or responsible individual as stipulated in subsection H of this section and each staff person.
Evidence
  1. of this review shall be the resident's, his legal representative's or responsible individual's, or staff person's written acknowledgment of having been so informed, which shall include the date of the review and shall be filed in the resident's or staff person's record. Evidence:
  2. The record for Resident #3 did not contain the signed Rights and Responsibilities for 2025 (last 1/31/24) in the resident’s record during inspection on 3/28/25.
  3. Staff #2 confirms the Rights and Responsibilities was not present in the Resident’s record during inspection on 3/28/25.
Plan of correction
Executive Director updated annual resident rights review to be updated in December for all residents so that new year documents are all within the annual requirement.
22VAC40-73-320-A
Based on record review, the facility did not ensure a physical examination by an independent physician be completed within 30 days preceding admission and contain the items identified in the standard.
Evidence
  1. The physical examination for Resident #3 (completed 01/31/2024) was missing page 2 which reviews if Resident #3 has any of the conditions or care needs prohibited by 22VAC40-73-310 H.
  2. Staff #2 confirms page 2 of the ISP was not in the record during inspection on 3/28/25.
Plan of correction
Resident page 2 of physical exam was obtained from provider for resident file. Check list for a new admissions updated to ensure all three pages of physical exam is collected at time of admission.
October 29, 2024Complaint survey3 violations
Inspection dates
10/29/2024
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection. 10/29/2024 at 9:45 am until 11:30 am. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 10/25/2024 regarding allegations in the area(s) of: Admission, Retention And Discharge Of Residents, Resident Accommodations And Related Provisions Number of residents present at the facility at the beginning of the inspection: 5 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: 1 Observations by licensing inspector: 1 Additional Comments/Discussion: The evidence gathered during the investigation supported the allegations of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaints but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at lanesha.allen@dss.virginia.gov
Violations
22VAC40-73-410-A
Based on a review of two resident records, it was determined that the facility did not ensure Upon admission, the assisted living facility shall provide an orientation for new residents and their legal representatives, including emergency response procedures, mealtimes, and use of the call system. If needed, the orientation shall be modified as appropriate for residents with cognitive impairments. Acknowledgment of having received the orientation shall be signed and dated by the resident and, as appropriate, his legal representative, and such documentation shall be kept in the resident's record. 1. The record for Resident #2 did not contain an orientation form with signatures from the resident or their legal representative. 2. Staff #1 reviewed the record for resident #2 and acknowledged the absence of the orientation form with signatures.
Plan of correction
100% audit of all resident files for signed New Admission orientation form and corrected any discrepancies.
22VAC40-73-460-E
Based on a review of two resident records, the facility did not ensure to regularly observe each resident for changes in physical, mental, emotional, and social functioning. The facility shall provide appropriate assistance when observation reveals unmet needs. 1. The record for resident #2 contained information identifying Heartland Home Hospice as the hospice provider, however there was no plan of care for the resident at admission. 2. The record for resident #2 identified the resident as a falls risk, however the plan did not contain falls risk. 3. The record for resident #2 identified the residents need for oxygen therapy, however the plan did not contain an outcome for oxygen therapy. 4. Staff #1 reviewed the records for Resident #2, acknowledged the residents record did not contain a hospice care plan. 5. Staff #1 reviewed the records for Resident #2, acknowledged the residents record did not contain falls risk. 6. Staff #1 reviewed the records for Resident #2, acknowledged the residents record did not contain an outcome related to oxygen therapy.
Plan of correction
1) 100% Audit of all current residents who upon admission were receiving contracted outside services from Hospice agencies for a Hospice care plan upon admission and recv’d updated care plans for anyone with those orders. 2) 100% audit of all residents that have been identified as fall risk to ensure careplan reflects fall risk and outcomes. 3) 100% audit of all current residents that have orders for oxygen therapy that the careplan reflects oxygen therapy outcomes.
22VAC40-73-310-D
Based on a review of two resident records, it was determined the facility did not ensure the UAI prior to admission of a resident, the assisted living facility administrator shall provide written assurance to the resident that the facility has the appropriate license to meet his care needs at the time of admission. Copies of the written assurance shall be given to the legal representative and case manager, if any, and a copy signed by the resident or his legal representative shall be kept in the resident's record.
Evidence
  1. The record for Resident #2 contained a Written Assurance document dated for 9/25/24, but it did not contain signatures from the resident or their legal representative.
  2. Staff 1 reviewed the record for resident #2 and acknowledged the Written Assurance document in the file dated for 9/25/24, but it did not contain signatures from the resident or their legal representative.
Plan of correction
100% audit of all resident files for signed Written Assurance document and corrected any discrepancies.
March 19, 2024Inspection14 violations
Inspection dates
03/19/2024, 03/20/2024
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 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Technical assistance
22VAC40-73-450 22VAC40-73-650 22VAC40-73-1030
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: 03/19/2024 from 9:00 am to 1:35 pm and on 03/20/2024 from 7:30 am to 8:30 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: 6 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: 4 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: Breakfast, lunch, and an activity were observed. A medication pass observation was completed for 2 residents. The following were reviewed: resident and staff records, medication cart, and water temperatures. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Violations
22VAC40-73-980-C
Based on record review, the facility failed to ensure first aid kits be checked at least monthly to ensure that all items are present and items with expiration dates are not past their expiration date.
Evidence
  1. Staff #1 was unable to provide documentation of the monthly checks of the first aid kit from June 2023-January 2024.
Plan of correction
Monthly First Aid kit schedule created for third shift to audit monthly. February and March 2024 complete. All staff educated.
22VAC40-73-990-C
Based on interview, the facility failed to document staff participation in practice exercises for resident emergencies at least once every six months.
Evidence
  1. Staff #2 was unable to provide documentation that staff had participated in an exercise in which the procedures for resident emergencies were practiced at least every six months.
Plan of correction
The administrator created a schedule for resident emergency exercises and documentation. All staff educated. Staff had a documented emergency exercise 3/21/2024.
22VAC40-73-660-A
Based on observation, the facility failed to ensure the medication cart be locked and the individual responsible for medication administration keep the keys to the storage area on their person.
Evidence
  1. During a tour of the facility on 03/19/2024, the medication cart was observed to be unattended with the keys noted in the cart and not on the individual responsible for medication administration.
Plan of correction
Staff member was immediately educated and keys were kept on person once corrected. All other staff RMA’s were educated.
22VAC40-73-700-3
Based on observation, the facility failed to ensure that only oxygen from a portable source be used by residents when they are outside their rooms. The use of long plastic tether lines to the source of oxygen outside their rooms is not permitted.
Evidence
  1. During a tour of the facility, Resident #1 was noted in a common dining area with an oxygen concentrator with a long plastic tether line.
Plan of correction
Staff immediately removed the concentrator and brought out the portable for the resident. All staff educated and Hospice team notified of need for more portable oxygen that was delivered 3/21/2024.
22VAC40-73-690-B
Based on record review and interview, the facility failed to ensure for each resident assessed for assisted living care, except for those who self- administer all of their medications, a licensed health care professional, practicing within the scope of his profession, perform a review every six months of all the medications of the resident.
Evidence
  1. Staff #1 confirmed the last medication review was conducted on 08/17/2023.
Plan of correction
Pharmacist conducted onsite pharmacy review on 3/21/2024. Administrator set a schedule with pharmacy for every Jan and July going forward.
22VAC40-73-320-A
Based on record review, the facility failed to ensure a physical examination by an independent physician be completed within 30 days preceding admission and contain the items identified in the standard.
Evidence
  1. The physical examination for Resident #2 (completed 01/31/2024) was missing page 2 which reviews if Resident #2 has any of the conditions or care needs prohibited by 22VAC40-73-310 H.
Plan of correction
Implemented a signature process at the bottom of each page of the H&P to ensure total count of pages available. All other resident H&P audited and found to be compliant.
22VAC40-73-520-I
Based on observation, the facility failed to ensure the current month's schedule of activities include the type and hour of the activity.
Evidence
  1. During the tour of the facility on 03/19/2024, the current month’s activity calendar posted did not include the type and hour of the activity.
Plan of correction
Administrator immediately hand wrote times on current posted activity schedule and updated future calendars with times.
22VAC40-73-490-A
Based on record review, the facility failed to retain a licensed health care professional who has at least two years of experience as a health care professional in an adult residential facility, adult day care center, acute care facility, nursing home, or licensed home care or hospice organization, either by direct employment or on a contractual basis, to provide on-site health care oversight within compliance to the standard.
Evidence
  1. There was not a health care oversight completed from 02/08/2023 to 01/19/2024.
Plan of correction
Facility contracted with an RN in February 2024 RN to conduct quarterly oversite reviews. Next review scheduled for May 2024. Administrator created a schedule for the following quarters as well. Additionally, fulltime LPN position is posted on job boards.
22VAC40-73-440-B
Based on record review, the facility failed to ensure for private pay individuals, the administrator or the administrator's designated representative approves and then signs the completed UAI.
Evidence
  1. The UAI completed on 12/21/2023 for Resident #3 was not approved and signed by the administrator or the administrator’s designated representative.
Plan of correction
Administrator reviewed UAI from 12/21/2023 and signed document. Administrator audited all other resident UAI’s for signature and found all compliant.
22VAC40-73-970-A
Based on record review and interview, the facility failed to ensure fire and emergency evacuation drill frequency and participation be in accordance with the current edition of the Virginia Statewide Fire Prevention Code (13VAC5-51). The drills required for each shift in a quarter shall not be conducted in the same month.
Evidence
  1. There was no documentation of a fire and emergency evacuation drill conducted from 05/31/2023-1/25/2024.
Plan of correction
Created current schedule for fire drills monthly rotating shifts. (Jan, Feb, Mar 2024 complete to date)
22VAC40-73-670-3
Based on interview, the facility failed to ensure medication aides are supervised by one of the following individuals listed in the standard.
Evidence
  1. Staff #1 confirmed the facility does not currently employ a qualified individual to supervise medication aides.
Plan of correction
Administrator taking the 68 hour Medication Aide course to commence 3/25/2025. Fulltime LPN posted on job board.
22VAC40-73-620-A
Based on record review, the facility failed to ensure dietary oversight was conducted every six months for specials diets by a dietitian or nutritionist.
Evidence
  1. There was not a dietary oversight completed from 03/29/2023 to 11/01/2023.
Plan of correction
Dietician was contacted on March 25, 2024 and is scheduled for oversite visit on April 18, 2024. Ongoing annually will be July and Jan.
22VAC40-90-40-F
Based on record review, the facility failed to ensure a criminal history record report issued by the State Police shall not be accepted by the facility if the report is dated more than 90 days prior to the date of employment.
Evidence
  1. Staff #3 was hired on 02/01/2024; however, the criminal history record report for Staff #3 was completed 08/28/2023.
Plan of correction
Staff member has since been terminated. All other current staff members were audited and have up to date required Background check. All individuals hired, regardless if they prior agency working in building will have a new, current Background check pulled.
22VAC40-73-610-D
Based on record review, observation, and interview, the facility failed to ensure when a diet is prescribed for a resident by his physician or other prescriber, it be prepared and served according to the physician's or other prescriber's orders.
Evidence
  1. Resident #1 admitted to the facility on 12/21/2023 with an order for a puree diet with nectar thickened liquids; however, the order is not reflected in the resident’s record.
  2. The resident was not served food pureed at lunch while onsite on 03/19/2024.
  3. Staff confirmed there were no residents with a special diet.
Plan of correction
Resident #1 regular diet order was recv’d by MD on 3/20/2024. All diet orders were audited to ensure correct orders in place. All others found to be compliant.
December 28, 2023Inspection4 violations
Inspection dates
12/28/2023
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Technical assistance
22VAC40-73-200 22VAC40-73-450
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: 12/28/2023. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 12/19/2023 regarding allegations in the area(s) of: Personnel and Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 6 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: 1 Observations by licensing inspector: Exit and entry doors reviewed. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Violations
22VAC40-73-460-A
Based on record review, the facility failed to assume general responsibility for the health, safety, and well-being of the residents.
Evidence
  1. On 12/18/2023, Resident #1 wheeled themselves out of the front door and fell. The resident sustained a bruise and contusion to forehead with 5 stitches.
  2. Staff #2 was the designated person in charge at the time of the incident.
  3. Staff #3 reported Staff #2 was “inattentive” to the resident.
Plan of correction
Staff #2 (Agency staff) was removed from schedule permanently. All current staff were in-serviced on the topic of personal care services, customer service, compassion and general supervision of residents.
22VAC40-73-325-B
Based on record review, the facility failed to ensure the fall risk rating be reviewed and updated at least annually, when the condition of the resident changes, and after a fall.
Evidence
  1. Resident #1 meets the criteria for assisted living care and fell on 12/18/2023. The last fall risk rating completed for Resident #1 was 12/5/2022.
Plan of correction
Fall risk was completed for Resident #1 on December 28, 2023. An audit of all residents was completed on December 28, 2023 and all fall risk assessments are up to date as of Jan 10, 2024 and ISPs updated if needed.
22VAC40-73-530-B
Based on observation and discussion, the facility failed to ensure doors leading to the outside not be locked from the inside or secured from the inside in any manner that amounts to a lock.
Evidence
  1. Based on observation and discussion with Staff #1, all facility doors are secured upon entering and exiting the facility and only accessible via an access card.
Plan of correction
New door system was installed in all doors that includes a) alarm when anyone enters or exits the doors to the outside; b) a hand wave system in front of door that will unlock the door for exit available for anyone to utilize including staff, residents, visitors or vendors.
22VAC40-73-150-B
Based on interview, the facility failed to immediately employ a new administrator or appoint a qualified acting administrator so that no lapse in administrator coverage occurs.
Evidence
  1. As of 12/13/2023, the facility has not employed a new administrator or appointed a qualified acting administrator causing a lapse in administrator coverage.
Plan of correction
A licensed nursing home administrator started Jan 2, 2024.
July 7, 2023Inspection3 violations
Inspection dates
07/07/2023
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/07/2023. 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: 4 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: 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Violations
22VAC40-90-50-A
Based on record review, the facility failed to ensure when the facility utilizes temporary agencies for the provision of substitute staff to maintain a letter from the agency containing information listed in the standard.
Evidence
  1. Staff #4, Staff #5, and Staff #6 did not have a statement verifying that the criminal history record report by the Virginia State Police has been obtained within 30 days of employment, is on file at the temporary agency, and does not contain barrier crimes.
Plan of correction
KARE staff will not be allowed to work unless another staff member who has a completed a background check is available to supervise them. The first time a KARE staff member comes to work, an online background check will be done.
22VAC40-73-680-D
Based on record review, the facility failed to ensure medications be administered in accordance with the physician's or other prescriber’s instructions.
Evidence
  1. Resident #2’s blood pressure check order reads the following: “check blood pressure while seated 3 times daily with meals for monitoring. If Blood Pressure <105/70, see as needed Midodrine Order.” Upon review of the June 2023 MAR, Resident #2 received 1 dose of Midodrine on 6/15/23, 6/17/23, 6/22/23, and 6/29/23. However, Resident #2’s BP met the parameters of <105/70 to receive Midodrine on the following days: 1 dose on 6/15/23, 1 dose on 6/23/23, 1 dose on 6/26/23, 2 doses on 6/29/23, and 1 dose on 6/30/23.
Plan of correction
Owner will have NP clarify the order when Midrodine is to be administered. An in-service for all RMAs will occur after the order is changed.
22VAC40-73-680-C
Based on record review, the facility failed to ensure medications be administered not earlier than one hour before and not later than one hour after the facility's standard dosing schedule, except those drugs that are ordered for specific times, such as before, after, or with meals.
Evidence
  1. The June 2023 MAR for Resident #1 indicates the resident was not administered their 8:00 PM medications (7 total) on 06/18/2023.
Plan of correction
All RMAs will receive an in-service on recording medication passes. The owner or designee will do a regular audit to insure medications are recorded.
March 23, 2023Inspection20 violations
Inspection dates
03/23/2023, 03/30/2023
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
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: 3/22/2023 from 8:55 am to 3:30 pm. A second day of inspection was attempted on 03/30/2023. 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: 5 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: 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Violations
22VAC40-73-660-A-3
Based on observation, the facility failed to ensure the medication cart be locked and the individual responsible for medication administration keep the keys to the storage area on their person.
Evidence
  1. During a tour of the facility, the medication cart was observed to be unlocked and unattended with the keys noted on the cart and not on the individual responsible for medication administration.
Plan of correction
The facility failed to ensure the medication cart be locked and the individual responsible for the keys to the storage area be on their person. All residents have the ability to be affected. The owner and program director will conduct a training with all RMAs for compliance to this standard.
22VAC40-73-550-G
Based on record review, the facility failed to annually review the rights and responsibilities of residents with each staff person.
Evidence
  1. Staff #5’s record did not include written acknowledgement of having been so informed of the review of the rights and responsibilities of residents within the last year as the last review was completed on 12/23/2021.
Plan of correction
Staff #5’s record did not include written acknowledgement of having been informed of the review of the rights and responsibilities of the residents within the last year. All residents and staff have the ability to be affected. Owner and Program Director will schedule and execute training on Resident Rights for all employees.
22VAC40-73-640-A
Based on observation, record review, and interview, the facility failed to implement their written plan for medication management to include methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes.
Evidence
  1. While ensuring accurate counts of all controlled substances with Staff #6, it was discovered that the count indicated on the Controlled Drug Record was not consistent with the amount of medication for Resident #3’s Lorazepam .5 mg tablets with 11 noted on the record as available with 10 tablets on the medication cart and Resident #4’s Gabapentin 100 mg capsule with 47 noted on the record as available with 46 capsules on the medication cart.
  2. Staff #1 and Staff #6 acknowledged the Controlled Drug Record was not consistent with the amount of two medications identified on the medication cart.
Plan of correction
Facility failed to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes occur. All residents have the ability to be affected. Owner will institute new eMar software that includes electronic controlled substance count to ensure an accurate count whenever assigned medication administration staff changes occur. Owner or designee will do a check for accuracy of controlled substance count for 3 months.
22VAC40-73-440-B
Based on record review, the facility failed to ensure for private pay individuals, the administrator or the administrator's designated representative approves and then signs the completed UAI.
Evidence
  1. Based on record review, the UAI completed on 3/15/23 for Resident #1 was not approved and signed by the administrator or the administrator’s designated representative.
Plan of correction
UAI for Resident #1 has been approved and signed by Executive Director. All residents have the ability to be affected. Owner and Program Director will be in-serviced on the admission process and UAI standards. 100% audit will be completed on all UAI. Program Director will audit UAIs weekly for 3 months. Results will be discussed at risk management meeting.
22VAC40-73-260-A
Based on record review, the facility failed to ensure each direct care staff member maintain current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department.
Evidence
  1. Staff #3 (hire date 11/17/22) works as direct care staff and does not have documentation of a current certification in first aid in their staff record.
Plan of correction
Staff#3 has been scheduled to attend a first aid class. All staff have the ability to be affected. 100% audit of all personnel files will be completed. Any staff not having first aid will be asked to attend first aid class. Executive Director will manage new hire log for all new employees. Owner or designee will audit log for 3 months. Results discussed during risk management meeting.
22VAC40-73-250-D
Based on record review, the facility failed to ensure health information required by these standards be maintained at the facility and be included in the staff record for each staff person, and shall be maintained at the facility for each household member who comes in contact with residents.
Evidence
  1. Staff #1 was unable to provide the results of a TB risk assessment for Staff #6.
Plan of correction
TB Risk assessment has been received for staff #6. All staff have the ability to be affected. 100% audit will be completed on tb skin test/ risk assessment compliance. TB skin test or risk assessment will be obtained for any staff that does not have tb skin test/risk assessment on file. All new employees will be audited for compliance by Executive Director or designee for 3 months . Results will be given to Owner and discussed during risk management meeting.
22VAC40-73-680-I
Based on record review and interview, the facility failed to ensure the MAR include the items required in the standard.
Evidence
  1. The MAR did not include the following for Resident #1: date prescribed, diagnosis, condition, or specific indications for administering the drug or supplement, and name, signature, and initials of all staff administering medications.
  2. During a medication observation with Staff #6, the document that was being utilized as the MAR for Resident #1 were the physician order sheets for Resident #2 (one sheet) and Resident #3 (one sheet). The medications, date of birth, and names of Resident #2 and Resident #3 were marked thru, but still legible. The physician orders sheets included all other personal information of Resident #2 and Resident #3 to include their allergies, diagnoses, room number, and Medicare Number, and not information pertaining to Resident #1.
  3. Staff #1 and Staff #6 acknowledged the MAR being utilized to document medication administration of Resident #1 contained other resident information and did not include all of the required MAR items in the standard.
Plan of correction
The facility failed to have the correct MAR for resident #1. All residents have the ability to be affected. Owner will ensure that medication record is sent to the pharmacy in advance of admission and that the record is in the eMar before any new resident moves in.
22VAC40-73-70-A
Based on record review, the facility failed to ensure any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident to the regional licensing office within 24 hours.
Evidence
  1. During a review of Resident #2’s record, it was noted that on 2/1/23 Resident #2 fell out of bed, sustained a laceration to the back of the head, and was sent to the ER. The resident received stitches to the back of the head and returned to the facility. The assigned licensing inspector did not receive a notification of the incident.
Plan of correction
All residents have the ability to be affected. All staff (including temporary staff) will be in-serviced on incident reporting expectations-including to notify Executive Director of falls and transfers to the ER. All incident reports will be reviewed timely. Incident log will be created and audited. Owner or designee will audit log for mandatory reporting compliance. Log will be monitored for 3 months for compliance and discussed during risk management meeting.
22VAC40-73-450-A
Based on record review and discussion, the facility failed to ensure on or within seven days prior to the day of admission, a preliminary plan of care be developed to address the basic needs of the resident that adequately protects his health, safety, and welfare.
Evidence
  1. During the onsite inspection, Resident #1’s record did not contain a preliminary plan of care.
  2. Staff #1 acknowledged Resident #1 (admitted 3/21/23) did not have a preliminary plan of care.
Plan of correction
Resident #1’s record did not contain a preliminary plan of care. All residents have the ability to be affected. Owner and Program Director will be in-serviced on Admission Process and importance of ISPs. Owner and Executive Director will ensure ISPs are completed and signed before each new resident moves into the facility.
22VAC40-73-300-B
Based on interview, the facility failed to ensure a method of written communication be utilized as a means of keeping direct care staff on all shifts informed of significant happenings or problems experienced by residents, including complaints and incidents or injuries related to physical or mental conditions.
Evidence
  1. During the onsite inspection, Staff #1, Staff #5, and Staff #6 were unable to provide a method of written communication as a means of keeping direct care staff on all shifts informed of significant happenings or problems experienced by residents, including complaints and incidents or injuries related to physical or mental conditions.
Plan of correction
A 24 hour communication book will be implemented. All employees have the ability to be affected. All staff will be in-serviced on the communication book. Communication book expectations and use will be added to new employee orientation. Communication book will be reviewed by management and audited at least 3 times a week. Results will be discussed among management, variances will be discussed at risk management meeting.
22VAC40-73-250-C
Based on record review, the facility failed to maintain personal and social data on staff to include verification that the staff person has received a copy of his current job description.
Evidence
  1. Staff #3’s record does not include verification that the staff person has received a copy of their current job description.
Plan of correction
Staff #3 has reviewed and signed job description with Owner. All staff have the ability to be affected. All employee personnel files will be audited signed job descriptions. Executive Director will submit results to Owner. Owner or designee will audit all new employee files for compliance for 3 months. Results will be discussed during risk management meeting.
22VAC40-73-1030-B
Based on record review, the facility failed to ensure within four months of the starting date of employment, direct care staff attend six hours of training in working with individuals who have a cognitive impairment, and the training shall meet the requirements of subsection C of this section.
Evidence
  1. During the onsite inspection, Staff #1 and Staff #2 were unable to provide evidence of the required six hours of training in working with individuals who have a cognitive impairment within four months of the starting date of employment and licensure (11/9/2023) for Staff #3 (hired 11/17/2022) and Staff #5 (hired prior to licensure).
Plan of correction
There was no proof of the required 6 hours of training for Staff #3 and Staff #5. All staff have the ability to be affected. The Executive Director and the Program Director will ensure all staff have the required 6 hours of training within four months of their start date. The Executive Director will audit staff records for 3 months to ensure compliance.
22VAC40-73-1070-B
Based on observation and interview, the facility failed to ensure ordinary materials or objects that may be harmful to a resident with a serious cognitive impairment, these materials or objects be inaccessible to the resident except under staff supervision.
Evidence
  1. During the onsite inspection, shelves were noted outside the kitchen area in a resident hallway and contained a jug of vegetable oil and the staff member’s personal belongings (purse, water bottle, lunch, etc.).
  2. Staff #1 and Staff #2 acknowledged the potential of these ordinary materials or objects may be harmful to a resident with a serious cognitive impairment and were accessible to residents without staff supervision.
Plan of correction
Shelves outside the kitchen door contained objects possibly harmful to a resident with serious cognitive impairment. The Executive Director and the owner will ensure the shelves are not used to hold harmful materials. Checks of the contents of the shelves will be checked at least 3 times a week by program director and owner.
22VAC40-73-650-B
Based on record review and discussion, the facility failed to ensure physician or other prescriber orders, both written and oral, for administration of all prescription and over-the-counter medications and dietary supplements identify the diagnosis, condition, or specific indications for administering each drug.
Evidence
  1. Resident #1 admitted on 3/21/23, and their admitting physician orders (11 total) did not identify the diagnosis, condition, or specific indications for administering each drug.
Plan of correction
Resident #1, admitted on 3/21/23 and their admitting physician orders did not identify the diagnosis, condition or specific indications for administration of each drug. All residents have the ability to be affected. Owner will ensure orders are reviewed before admittance of any new residents to ensure the diagnosis, condition or specific indications are evident for administering each drug.
22VAC40-90-40-E
Based on record review and interview, the facility failed to ensure criminal history record reports be kept confidential. Reports on employees shall only be received by the facility administrator, licensee, board president, or their designee.
Evidence
  1. The records of Staff #3 and Staff #4 indicate the criminal history record reports were not completed by the facility administrator or licensee.
  2. Staff #1 acknowledged the criminal history record reports were completed by a separate organization/entity that is not owned nor operated by the facility.
Plan of correction
The facility failed to ensure criminal history record reports be kept confidential. Staff #3 and Staff #4 criminal history record reports were not completed by the facility administrator or licensee. All staff have the ability to be affected. The owner or Executive Director will send criminal history checks directly to the Virginia State Police.
22VAC40-73-310-D
Based on record review, the facility failed to provide written assurance to a resident or the legal representative documenting that the facility has the appropriate license to meet their care needs at the time of admission.
Evidence
  1. During the onsite inspection, there was no evidence of written assurance for Resident #1 (admitted 3/21/2023) or their legal representatives documenting that the facility has the appropriate license to meet their care needs at the time of admission.
Plan of correction
Written assurance for resident #1 has been completed. All new admissions have the ability to affected. Owner and Program Director will be in-serviced on Admission Process and importance of written assurance. 100% audit will be completed on all resident files. New admissions will be audited by Program Director. Results will be given to Executive Director and discussed during risk management meeting.
22VAC40-73-290-B
Based on observation and discussion, the facility failed to develop and implement a procedure for posting the name of the current on-site person in charge, as provided for in this chapter, in a place in the facility that is conspicuous to the residents and the public.
Evidence
  1. Upon entry on 03/23/2023, the signage of the manager on duty was blank and did not indicate the designated person in charge. Staff #4, Staff #5, and Staff #6 verbally stated Staff #6 was the designated person in charge; however, later Staff #1 stated Staff #4 was the designated person in charge at the time of the initiation of the inspection.
  2. On 03/23/2023, Staff #1 acknowledged the current on-site person in charge was no posted in a place in the facility that is conspicuous to the residents and the public.
  3. On the follow-up visit on 03/30/2023, the signage of the manager on duty was blank and did not indicate the designated person in charge.
Plan of correction
Posting of person in charge has been posted. In-service with staff and management will be completed concerning posting and who is in charge. Executive Director or designee will randomly audit posting for placement at least twice a week. Results will be given to owner and discussed at risk management meeting for 3 months.
22VAC40-73-560-I
Based on record review, the facility failed to ensure a current picture of each resident be readily available for identification purposes or, if the resident refuses to consent to a picture, there be a narrative physical description, which is annually updated, maintained in his file.
Evidence
  1. Resident #1’s record did not include a current picture or a narrative physical description in their resident record.
Plan of correction
The facility failed to ensure a current picture of each resident to be readily available for identification purposes. All residents have the ability to be affected. Owner will ensure all resident records include a picture before or day of move-in of a new resident.
22VAC40-73-560-E
Based on observation, the facility failed to ensure all resident records be kept in a locked area.
Evidence
  1. Upon entry and during the tour of the facility, the area where resident records are stored was open, unlocked, unattended, and accessible.
Plan of correction
The facility failed to ensure resident records be kept in a locked area. The owner, Executive Director and Program Director will lock the office door when stepping away from their desk.
22VAC40-90-50-A
Based on record review, the facility failed to ensure when the facility utilizes temporary agencies for the provision of substitute staff to maintain a letter from the agency contain information listed in the standard.
Evidence
  1. The records of Staff #6 and Staff #7 indicate the background checks are not completed by the Virginia State Police.
Plan of correction
The records of Staff #6 and Staff #7 background checks were not completed by the Virginia State Police. All staff have the ability to be affected. The owner or the Executive Director will send agency staff background checks to the Virginia State Police.
December 29, 2022Inspection12 violations
Inspection dates
12/29/2022
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
Technical assistance
22VAC40-73-560
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: 12/29/2022 from 9:00 am to 4:00 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: 4 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: 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Violations
22VAC40-73-925-B
Based on observation, the facility failed to ensure common face/hand washing sinks have paper towels or an air dryer for hand washing.
Evidence
  1. During the onsite inspection on 12/29/2022, the Licensing Inspector did not observe paper towels or an air dryer for hand washing in a hall bathroom used for resident use. The hall bathroom had a hand towel available for use.
Plan of correction
Paper towels were replenished. All other areas checked to ensure compliance. Staff were re-inserviced on replenishing supplies and completing supply requests. Administrator or designee will round in the community a minimum of 3 times per week ensure continued compliance.
22VAC40-73-310-D
Based on record review, the facility failed to provide written assurance to a resident or the legal representative documenting that the facility has the appropriate license to meet their care needs upon receiving licensure.
Evidence
  1. During the onsite inspection on 12/29/2022, there was no evidence of written assurance to Resident #2, Resident #3 or their legal representatives documenting that the facility has the appropriate license to meet their care needs upon receiving licensure.
Plan of correction
Resident #2 and 3 written assurance was placed in the residents file. The files for all other residents were checked to ensure compliance. Administrator or designee will check the resident file at time of admission to ensure compliance. Administrator or designee will review a minimum of 3 resident files per month to ensure ongoing compliance.
22VAC40-73-410-A
Based on record review, the facility failed to ensure upon receiving licensure and admission, the assisted living facility provide an orientation for new residents and their legal representatives, including emergency response procedures, mealtimes, and use of the call system. Acknowledgment of having received the orientation shall be signed and dated by the resident and, as appropriate, his legal representative, and such documentation shall be kept in the resident's record.
Evidence
  1. During the onsite inspection on 12/29/2022, Resident #1 (admitted 11/26/2022) and Resident #3 did not have evidence of receiving orientation.
Plan of correction
Resident #1 documentation of orientation was placed in the residents file. The files for all other residents were checked to ensure compliance. Administrator or designee will check the resident file at time of admission to ensure compliance. Administrator or designee will review a minimum of 3 resident files per month to ensure ongoing compliance.
22VAC40-73-50-B
Based on record review and interview, the facility failed to obtain written acknowledgment of the receipt of the disclosure by the resident or their legal representative.
Evidence
  1. During the onsite inspection on 12/29/2022, Resident #4 (admitted 12/02/2022) did not have written acknowledgement of the receipt of the disclosure statement by the resident or their legal representative in their resident record.
  2. During the onsite inspection on 12/29/2022, Staff #4 acknowledged Resident #4 did not have written acknowledgement of receiving the facility’s disclosure statement in their resident record.
Plan of correction
Resident #4 disclosure statement receipt was placed in the residents file. The files for all other residents were checked to ensure compliance. Administrator or designee will check the resident file at time of admission to ensure compliance. Administrator or designee will review a minimum of 3 resident files per month to ensure ongoing compliance.
22VAC40-90-40-B
Based on staff record review, the facility failed to obtain a criminal history record report on or prior to the 30th day of hire for each employee.
Evidence
  1. The facility did not obtain a completed criminal history record reports for Staff #2 and Staff #6 (both hired 11/17/2022) on or prior to the 30th day of hire.
Plan of correction
Staff #2 and 6 were removed from the schedule. All other employee files were checked to ensure compliance. Administrator or designee will review the file of all new hires monthly to ensure compliance.
22VAC40-73-450-E
Based on record review, the facility failed to ensure the individualized service plan is signed and dated by the resident or their legal representative.
Evidence
  1. During the onsite inspection on 12/29/2022, Staff #4 was unable to provide documentation indicating Resident #1, Resident #2, Resident #3, or Resident #4 have signed and dated their individualized service plan.
Plan of correction
Signatures were obtained for the ISP for Resident #1-4. ISPs for all other residents were checked to ensure compliance. Administrator or designee will check the resident file at time of admission to ensure compliance. Administrator or designee will review a minimum of 3 resident files per month to ensure ongoing compliance.
22VAC40-73-680-D
Based on record review and observation, the facility failed to ensure medications be administered in accordance with the physician's or other prescriber’s instructions.
Evidence
  1. On the admitting orders for Resident #1, there is an order for Flomax .4 mg tablet to be administered at night; however, the MAR and medication in the medication in the medication cart is in capsule form.
  2. The December MAR for Resident #2 indicates the resident received a multivitamin tab on the following days: 12/02/22-12/06/22, 12/08/22-12/10/22, 12/15/22, 12/16/22, 12/19/22-12/21/22, 12/26/22, and 12/27/22. However, during the onsite inspection on 12/29/22, Staff #5 presented a signed discontinued order for the medication dated 11/21/2022.
Plan of correction
Prescriber and Responsible Parties were notified. There were no adverse effects. All nurses and RMAs re-educated on the medication management policy and to specifically administer and document administration of medications in accordance with prescriber orders. Administrator or designee will ensure adherence to the medication management policy with annual review and training of all staff and observation a medication pass weekly to ensure continued compliance.
22VAC40-73-640-A
Based on observation, the facility failed to implement their written plan for medication management to include methods to prevent the use of outdated medications.
Evidence
  1. A expired medication, Pantoprazole Sod DR 40 mg tablets expired 03/2022, for Resident #2 was observed in the medication cart for administration.
Plan of correction
Prescriber and responsible party for resident #2 were notified and the resident had no adverse effects. All other medication and treatments were inspected with no additional concerns. All nurses and RMAs were re-educated on the medication management policy and to specifically dispose of any expired medications and do not administer.
22VAC40-73-330-A
Based on record review and interview, the facility failed to ensure a mental health screening be conducted prior to admission if behaviors or patterns of behavior occurred within the previous six months that were indicative of mental illness, intellectual disability, substance abuse, or behavioral disorders and that caused, or continue to cause, concern for the health, safety, or welfare either of that individual or others who could be placed at risk of harm by that individual.
Evidence
  1. Resident #4 admitted to the facility on 12/02/2022. A progress note dated 12/06/2022 indicates resident is diagnosed with advanced dementia, was physically aggressive with a family member, and admitted to an ALF due to the inability to manage the resident in the home setting.
  2. During the onsite inspection on 12/29/2022, Staff #4 acknowledged Resident #4 did not have a mental health screen completed in their resident record.
Plan of correction
Resident #4 mental health screening was added to resident chart. The files for all other residents were checked to ensure compliance. Administrator or designee will check the resident file at time of admission to ensure compliance. Administrator or designee will review a minimum of 3 resident files per month to ensure ongoing compliance.
22VAC40-73-680-C
Based on record review, the facility failed to ensure medications be administered not earlier than one hour before and not later than one hour after the facility's standard dosing schedule, except those drugs that are ordered for specific times, such as before, after, or with meals. 1. The December MAR for Resident #1 indicates the following medications were administered late on the following days: Prosource Neutral on 12/28/22, Ferrous Sulfate 325 mg tab on 12/28/22, Aspirin 81 mg tab on 12/28/22, Ensure Liquid on 12/26/22 and 12/28/22, Vitamin B-12 5000 mcg tab on 12/28/22, Vitamin D3 1000 unit tab on 12/28/22, Methenamine Hipp 1 gm tab on 12/26/22 and 12/28/22, Furosemide 20 mg tab on 12/28/22, Fluticasone-Vilanterol 100-25 on 12/28/22, Finasteride 5 mg tab on 12/28/22, DOK 100 mg Softgel on 12/28/22, and Tamsulosin HCL .4mg capsule on 12/26/22. 2. The December MAR for Resident #2 indicates the following medications were administered late or not documented as administered on the following days: Duloxetine LCI 20 mg capsule on 12/09/22, 12/13/22, 12/14/22, 12/19/22, 12/20/22, 12/21/22, and 12/25/22, Melatonin 3 mg tab on 12/11/22, Diclofenac Sodium 1% gel on 12/11/22, 12/23/22, 12/24/22, 12/25/22, and 12/27/22, and Pantoprazole Sod 40 mg tab on 12/24/22, 12/25/22, 12/28/22, and 12/29/22. 3. The December MAR for Resident #4 indicates the following medications were administered late or not documented as administered on the following days: Risperidone 1mg tab on 12/25/22, 12/26/22, 12/27/22 and 12/28/22, Eliquis 5 mg tab on 12/21/22, 12/24/22, 12/25/22 (two doses on 12/25/22) and 12/26/22, Carvedilol 12.5 mg tab on 12/21/22, 12/24/22, 12/25/22 (two doses on 12/25/22) and 12/26/22, Ramipril 5 mg capsule on 12/25/22, Memantine HCL 10 mg tab on 12/25/22, Donepezil HCL 10 mg tab on 12/25/22, and Trazodone 50 mg tab on 12/21/22.
Plan of correction
Prescriber and Responsible Parties were notified. There were no adverse effects. All nurses and RMAs re-educated on the medication management policy and to specifically administer and document administration of medications within the identified time frame. Administrator or designee will ensure adherence to the medication management policy with annual review and training of all staff and observation a medication pass weekly to ensure continued compliance.
22VAC40-73-350-B
Based on record review, the facility failed to ascertain, prior to admission, whether a potential resident was a registered sex offender and failed to document that this was ascertained and the date the information was obtained.
Evidence
  1. During the onsite inspection on 12/29/2022, Resident #2 did not have a completed sex offender screening in their record.
Plan of correction
Resident #2 sex offender screening was placed in the residents file. The files for all other residents were checked to ensure compliance. Administrator or designee will check the resident file at time of admission to ensure compliance. Administrator or designee will review a minimum of 3 resident files per month to ensure ongoing compliance.
22VAC40-73-650-A
Based on record review and discussion, the facility failed to ensure no medication, dietary supplement, diet, medical procedure, or treatment be started, changed, or discontinued by the facility without a valid order from a physician or other prescriber. Medications include prescription, over-the-counter, and sample medications.
Evidence
  1. Staff #5 was unable to provide the physician’s order for Mucinex Fast-Max DM Max Liquid as shown on Resident #4’s MAR.
Plan of correction
Prescriber order was placed in the resident file. All nurses and RMAs re-educated on the medication management policy and to specifically place the written prescriber order in the resident file to ensure compliance. All other resident files were reviewed and there were no concerns. Administrator or designee will ensure adherence to the medication management policy with annual review and training of all staff and observation a medication pass weekly to ensure continued compliance.
November 2, 2022Inspection0 violations
Inspection dates
11/02/2022
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
Type of inspection: Initial Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/02/2022 from 12:54 pm to 1:32 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: 3 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Additional Comments/Discussion: The first aid kit, emergency food and water, menu, and activity calendar were reviewed along with samples of the water temperature taken. 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 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.