Virginia DSS · Assisted Living Facility

The Residence at Colvin Run

📍 1131 Walker Road, Great Falls, VA, 22066

ID 48870One Year licenseActive
10
Inspections
On record
4
With violations
Visits that cited something
6
Clean visits
Nothing cited
16
Violations cited
Individual findings
11
Standards cited
Distinct rules
1
Complaint visits
Prompted by a complaint

The Residence at Colvin Run was inspected 10 times between August 24, 2022 and May 18, 2026 by the Virginia Department of Social Services. 4 of those visits ended with violations cited and 6 with none. Across that history VDSS cited 16 violations under 11 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
One Year
License expires
03/22/2027
Administrator
Seth Wirekoh
Licensing inspector
Marshall Massenberg
Inspector phone
(804) 543-5188
Approved for
Assisted Living · Non-Ambulatory · Special Care Unit

Inspection History

10

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

May 18, 2026Inspection0 violations
Inspection dates
05/18/2026
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUNDS63.2 GENERAL PROVISIONS63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS
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: 5/18/26 (4:50 PM - 5:40 PM). Self-Reported incidents were received by VDSS Division of Licensing on 5/5/26, 5/13/26, 5/15/26 regarding allegations in the area(s) of: Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 62 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: Three Number of staff records reviewed: None Number of interviews conducted with residents: None Number of interviews conducted with staff: Two Observations by licensing inspector: Building and Grounds Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (804) 543-5188 or by email at marshall.x.massenberg@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
April 29, 2026Complaint survey5 violations
Inspection dates
4/29/26, 5/18/26, 6/12/26
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUNDS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS63.2- (1) GENERAL PROVISIONS63.2- (17) LICENSURE AND REGISTRATION PROCEDURES63.2- (18) FACILITIES AND PROGRAMS22VAC40-80 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: 4/29/26 (2:45 PM - 6:30 PM), 5/18/26 (4:50PM - 5:40 PM), 6/12/26 (4:30 PM - 5:00 PM) The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by the Fairfax Licensing Office on 3/27/26 regarding allegations in the area(s) of: Resident Care and Related Services; Building and Grounds; Part X: Additional Requirements for Facilities that Care for Adults with Serious Cognitive Impairments. Number of residents present at the facility at the beginning of the inspection: 62 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: One Number of staff records reviewed: None Number of interviews conducted with residents: None Number of interviews conducted with staff: Two Observations by licensing inspector: N/A Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation(s) of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. 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 Marshall Massenberg, Licensing Inspector at (804) 543-5188 or by email at marshall.x.massenberg@dss.virginia.gov.
Violations
22VAC40-73-1020-A
Based on documentation, the facility did not ensure that there are at least two direct care staff members awake and on duty at all times in each building who shall be responsible for the care and supervision of the residents.
Evidence
  1. Facility schedules were observed during the inspection. On 9/21/25 (10 PM - 6 AM shift), only three staff members were included on the facility's schedule. The facility operates a memory care unit and a mixed population ALF. The three staff members did not meet the requirement for two staff members to be awake and on duty in both units of the facility.
Plan of correction
The facility immediately adjusted staffing schedules to ensure that a minimum of two direct care staff members are always awake and on duty in each building when residents are present. The Administrator, Resident Wellness Director and Wellness Coordinator reviewed staffing schedules, staffing assignments, and call-out procedures to ensure adequate coverage during all shifts, including weekends, holidays, and staff callouts. All supervisory staff and wellness coordinator (scheduler) were re-educated on the community's staffing requirements. Staffing Schedules will be audited weekly to ensure ongoing compliance, with corrective action taken immediately if deficiencies are identified.
22VAC40-73-930-D
Based on documentation, the facility failed to ensure that for each resident with an inability to use the signaling device, in addition to any other services, once the resident has gone to bed each evening until the resident has arisen each morning, at a minimum, direct care staff make rounds no less often than every two hours, except that rounds may be made on a different frequency if requested by the resident and agreed to by the facility.
Evidence
  1. Resident #1's ISP, dated 11/11/25, states that she cannot use a signaling device to summon assistance. The resident's ISP states that staff must anticipate all needs. Staff rounding logs were requested during the inspection. Staff #1 reported that rounding information was not available for Resident #1.
Plan of correction
Direct care staff have been re-educated on the requirements of rounding every two hours, including conducting and documenting safety rounds as outlined in residents' ISP. The Resident Wellness Director, or designee will audit rounding documentation weekly to ensure ongoing compliance.
22VAC40-73-680-D
Based on record review, the facility did not ensure that medications are administered in accordance with the physician’s or other prescriber’s instructions.
Evidence
  1. Resident #1's record contains an order, dated 1/12/26, for her to receive Carbidopa-Levodopa 25-100mg (1.5 tablets) three times per day. Resident #1's January 2026 MAR states that her Carbidopa-Levodopa was not administered during the 8 AM and noon administrations on 1/24/26. Resident #1's record contained an order for Midodrine, dated 2/9/26, that calls for the medication to be held if her systolic blood pressure is greater than 140. Resident #1's February 2026 MAR indicates that her Midodrine was administered on: 2/22/26 (noon administration) - SBP: 141; 2/25/26 (8 AM administration) - SBP: 150;
Plan of correction
Licensed staff and medication aides have been re-educated on the six rights of medication administration - right (resident, time, medication, dosage, route, and documentation) to ensure safe and accurate medication administration in accordance with 22VAC40-73-680-D. Licensed staff and medication aids have been re-educated to complete a reconciliation of the Medication Administration Record (MAR) at the end of each medication pass to ensure all medications administered, refused, or held are accurately documented and any discrepancies are immediately addressed. The Resident Wellness Director or designee will conduct routine audits of MARs and medication pass documentation to ensure compliance with medication administration procedures, with corrective action taken promptly when errors or omissions are identified.
22VAC40-73-650-A
Based on documentation, the facility did not ensure that no medication, dietary supplement, diet, medical procedure, or treatment is started, changed, or discontinued without a valid order from a physician or other prescriber.
Evidence
  1. Resident #1's record contains orders, dated 1/12/26, that call for the resident to receive Carbidopa-Levodopa 25-100mg (1.5 tablets) three times per day and Carbidopa-Levodopa 25-100mg (1 tablet) at bedtime. Resident #1's January MAR indicates that the resident’s order changed and that the Carbidopa-Levodopa that she receives three times per day had been discontinued on 1/25/26. No order was present, in Resident #1's record, to document that the Carbidopa-Levodopa that she received three times per day had been discontinued.
Plan of correction
The Administrator, Resident Wellness Director and Wellness nurses reviewed all physician orders to ensure that all medications were administered per physician order. Licensed Practical Nurses will conduct daily review/audits of all new physician orders during order confirmation process and medication records to ensure continued compliance. Any discrepancies identified will be corrected immediately and addressed through additional staff training as needed.
22VAC40-73-640-A
Based on documentation and interview, the facility did not ensure that the medication management plan includes all of the required information.
Evidence
  1. The facility's medication management plan was requested during the inspection. The provided medication management plan (Effective 1/1/24) did not include the methods for verifying that medication orders have been accurately transcribed to medication administration records (MARs) within 24 hours of receipt of a new order or change in order. Staff #1 confirmed that the plan did not include all of the required information.
Plan of correction
The facility immediately reviewed and revised its medication management plan to ensure a process is in place for verifying that all physician and prescriber medication orders are accurately transcribed to the Medication Administration Record (MAR) within 24 hours of receipt. Staff responsible for medication management were educated on the revised process and monitoring expectations. Licensed Practical Nurses will review all new physician orders within 24 hours of receipt during the order confirmation process and verify that all orders have been accurately transcribed to the Medication Administration Record (MAR) and Treatment Administration Record (TAR), as applicable. The Nurse in Charge will compare all pharmacy-transcribed orders with the original physician orders to ensure accuracy and completeness. Any discrepancies identified will be reported to the pharmacy immediately for correction, and corrective actions will be documented. The Resident Wellness Director and nursing leadership team will conduct ongoing audits of new orders to monitor compliance. A follow-up meeting will be held with the pharmacy to review the identified concern, reinforce expectations for accurate order transcription, and develop strategies to prevent future occurrences.
April 29, 2026Inspection0 violations
Inspection dates
04/29/2026
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: 4/29/26 (2:45 PM – 6:10 PM). Self-reported incidents were received by VDSS Division of Licensing regarding: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 62 Number of resident records reviewed: Three Number of interviews conducted with staff: Two Number of interviews conducted with residents: None Observations by licensing inspector: Building and Grounds Additional Comments/Discussion: N/A An exit meeting was conducted. 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 Marshall Massenberg, Licensing Inspector at (804) 543-5188 or by email at Marshall.x.massenberg@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
March 4, 2026Inspection5 violations
Inspection dates
03/04/2026
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS63.2 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
Technical assistance
Documentation was discussed with the provider.
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: 3/4/26 (8:15 AM - 5:00 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: 64 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: Six Number of staff records reviewed: Three Number of interviews conducted with residents: Two Number of interviews conducted with staff: Four Observations by licensing inspector: Meals, Medication Administration, Activities Additional Comments/Discussion: N/A 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 Marshall Massenberg, Licensing Inspector at (804) 543-5188 or by email at marshall.x.massenberg@dss.virginia.gov.
Violations
22VAC40-73-290-B
Based on observation, the facility did not ensure that the facility implement a procedure for posting the name of the current on-site person in charge.
Evidence
  1. Upon the licensing inspector's entrance at approximately 8:19 AM, no name was listed as the on-site person in charge. Staff #4's name was listed as the on-site person in charge at 9 AM, but no name was provided for the before 9 AM.
Plan of correction
Training Completed with concierge staff on 03/06/2026 of new policy/procedure for concierge staff to post the name of the onsite person in charge for the oncoming shift at the end of their shift to ensure clear communication and continuity of leadership.
22VAC40-73-660-A-1
Based on observation, the facility did not ensure that the medication cart, used for the storage of medication, remains locked.
Evidence
  1. Prior to the administration of Resident #1's medication at approximately 8:40 AM, the medication cart was not locked when the staff member entered Resident #1's room. Before his medication was administered, Resident #1's medication packages were left unattended in his room, while the staff member left the room to get water.
Plan of correction
Resident Wellness Director Completed an in-service to educate Registered medication aids and licensed practical nurses to never leave medication unattended and to lock the cart before always walking away from the cart to ensure safe medication administration practices An Audit was completed on 03/06/2026 Staff licensed practical nurses will review all physician orders and request prescriber orders for parameters on appropriate medications. Resident Wellness Director to provide in-service programs to educate registered medication aids and licensed practical nurses (med passers) to always administer medications per physician orders. Resident Wellness Director will train med passers to always contact the prescriber when medication administration related questions arise.
22VAC40-73-680-M
Based on record review and interview, the facility did not ensure that medications ordered for PRN administration are available and properly stored at the facility.
Evidence
  1. Resident #2's record contained PRN orders for Fluticasone (dated 3/27/25) and Pataday (dated 11/19/24). Resident #2's PRN Fluticasone and PRN Pataday were not present at the time of the medication cart inspection. Facility staff confirmed that the PRN Fluticasone and PRN Pataday were not present, at the time of the medication cart inspection.
Plan of correction
Medication carts to be audited by Registered Medication Aids-weekly on Tuesdays Medication carts to be audited by licensed practical nurses every other week on Thursdays Medication carts to be audited by Resident Wellness Director monthly Resident Wellness Director to provide training to all Medication Technicians and Licensed Practical Nurses to ensure they are educated on company policy and the importance of conducting thorough medication cart audits. Executive Operations Officer to review completion of all the medication cart audits with RWD EOO monthly. Executive Operations Officer will provide weekly reminders and encouragement for residents and family members to use community preferred pharmacy.
22VAC40-73-210-B
Based on record review, the facility did not ensure that all direct care staff attend at least 18 hours of training annually. EXCEPTION: Direct care staff who are licensed health care professionals or certified nurse aides shall attend at least 12 hours of annual training.
Evidence
  1. The record for Staff #1, hired 9/13/23, was reviewed during the inspection. Staff #1's record contained a certified nursing assistant license. Facility training documents indicate that Staff #1 did not attend any training hours within the annual review period of 9/13/24 through 9/13/25. The record for Staff #2, hired 8/23/22, was reviewed during the inspection. Facility training documents indicate that Staff #2 attended seven hours of training within the annual review period of 8/23/24 through 8/23/25.
Plan of correction
Staff training audit was completed on 03/04/2026. All staff with outstanding training requirements have been notified and instructed to complete their required training by March 31, 2026. Training being provided through Training Platform Care Academy with the oversight of the Executive Operations Officer and/Administrative Services Director Training Platform: Care Academy is scheduled to send automated weekly reports to Executive Operations Officer/Administrative Services Director. The Executive Operations Officer and/or Administrative Services Director will meet monthly to review training completion rate at the end of each month to ensure compliance with all training requirements.
22VAC40-73-680-D
Based on record review and interview, the facility did not ensure that medications are administered in accordance with the physician’s instructions.
Evidence
  1. Resident #1's February and March medication administration records (MARs) were reviewed during the inspection. Resident #1's MAR stated that he was administered Hydralazine on 3/3/26 (8 AM administration) when his systolic blood pressure reading was 109. Resident #1's record contained an order for Hydralazine, dated 9/5/24, that calls for his Hydralazine to be held when his systolic blood pressure is less than 110. Resident #2's February and March MARs were reviewed during the inspection. Resident #2's MAR states that her Carvedilol was held on 3/3/26 due to DR/RN orders, and that the resident’s blood pressure was measured twice to be 105/67. Resident #2's record contained an order for Carvedilol, dated 11/15/24, and the order did not contain administration parameters. No order was observed, in Resident #2's record, for her Carvedilol to be held on 3/3/26. Facility staff confirmed that no orders were present to hold Resident #2’s Carvedilol, on 3/3/26.
Plan of correction
An Audit was completed on 03/06/2026 Staff licensed practical nurses will review all physician orders and request prescriber orders for parameters on appropriate medications. Resident Wellness Director to provide in-service programs to educate registered medication aids and licensed practical nurses (med passers) to always administer medications per physician orders. Resident Wellness Director will train med passers to always contact the prescriber when medication administration related questions arise.
January 30, 2026Inspection0 violations
Inspection dates
01/30/2026
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUNDS
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: 1/30/26 (Noon – 1 PM). Self-reported incidents were received by VDSS Division of Licensing regarding: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 65 Number of resident records reviewed: Five Number of interviews conducted with staff: One Number of interviews conducted with residents: One Observations by licensing inspector: Building and Grounds Additional Comments/Discussion: N/A An exit meeting was conducted. 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 Marshall Massenberg, Licensing Inspector at (804) 543-5188 or by email at Marshall.x.massenberg@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 16, 2025Inspection5 violations
Inspection dates
05/16/2025
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 GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 - SUBJECTIVITY63.2 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 LICENSE
Technical assistance
Documentation was discussed with the provider.
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: 5/16/25 (8:30 AM - 5:20 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: 56 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: Six Number of interviews conducted with residents: Four Number of interviews conducted with staff: Four Observations by licensing inspector: Meals, Activities, Medication Administration An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (804) 543-5188 or by email at Marshall.x.massenberg@dss.virginia.gov.
Violations
22VAC40-73-640-A
Based on documentation and interview, the facility did not ensure that the medication management plan was implemented to ensure that each resident’s prescription medications are filled and refilled in a timely manner to avoid missed dosages.
Evidence
  1. Resident #7's morning medication administration was observed during the inspection. Resident #7's Prorenal tablet was not administered during the inspection. Facility staff reported that the Prorenal tablet was not present in the medication cart. Resident #7's May medication administration record (MAR) was also observed. The MAR documented that Resident #7's Alendronate was not administered on 5/3/25, as the medication was listed as "waiting on pharmacy delivery."
Plan of correction
The prescribing physician was notified, and a new prescription was obtained as pharmacy needed a new prescription to fill the medication. The medication was obtained and made available to the resident immediately upon receipt. The resident experienced no adverse effects. The medication administration record (MAR) was updated. The staff involved have been educated to monitor family supply medication, expiration dates and notify the prescribing physician in a timely manner- On 05/16/2025 RWD shall train all staff who are responsible for administering medications in the facility's medication management plan by 06/30/2025. Medication technicians shall audit medication carts weekly to ensure all prescribed medications are available. Nurses shall audit the medication carts/MARs bi-weekly to ensure that all medications are available and appropriately transcribed unto the MARs. RWD shall audit the medication carts at least monthly and as needed to verify that all medications are available.
22VAC40-90-40-B
Based on documentation, the facility did not ensure that the criminal history record report was obtained, on or prior to the 30th day of employment, for each employee.
Evidence
  1. Background checks for new employees, hired since 2/26/24, were reviewed during the inspection. Staff #2 was hired on 7/9/24 and her criminal background check was dated 10/16/24. Staff #5 was hired on 10/29/24 and her criminal background check was dated 3/21/25. Staff #6 was hired on 7/8/24 and his criminal background check was dated 10/16/24. Staff #7 was hired on 5/21/24 and her criminal background check was dated 10/16/24.
Plan of correction
The resident cited in the survey has since had a sex offender background check completed and documented in the resident's file. No match or concern was identified on 05/16/2025 The Community Relations Director shall ensure that all new resident admissions will have a sex offender background check completed prior to move-in or within the first 24 hours, to ensure compliance within the 30-day requirement. The Executive Operations Officer/ASD or designee shall verify the completion of sex offender background check for all new resident admissions prior to move-in or within the first 24 hours, to ensure compliance well within the 30-day requirement.
22VAC40-73-680-M
Based on observation and interview, the facility did not ensure that medications ordered for PRN administration are available and properly stored at the facility.
Evidence
  1. Resident #1's PRN Loperamide was not available for administration, at the time of the medication cart inspection. Facility staff confirmed that Resident #1's PRN Loperamide was not present, at the time of the medication cart inspection.
Plan of correction
The missing PRN medication was obtained and made available to the resident immediately upon discovery. The resident experienced no adverse effects. The medication administration record (MAR) was updated, and the staff involved were re-educated on timely PRN medication ordering and tracking on 05/16/2025. Effective immediately, medication inventory procedures have been updated to include routine verification of all PRN medications upon resident admission, monthly medication reviews, and prior to medication reorder dates. - -On going The Medication Technician or Nurse will now verify all PRN medications are present in the resident’s medication cart and in-date during admission and monthly medication audits. RWD will re-train staff on pharmacy communication protocols and the process for urgent medication delivery if a PRN medication is found to be missing - By May 31, 2025
22VAC40-73-680-D
Based on observation and documentation, the facility did not ensure that medications are administered in accordance with the physician’s instructions.
Evidence
  1. Resident #2's morning medication administration was observed during the inspection. The resident's medications were placed in a pill cup and the medication cart was locked. Before the medications were administered to Resident #2, the LI inquired about the resident's Torsemide. Two 20mg tablets of Torsemide were included in Resident #2’s pill cup. Resident #2’s record contained a physician’s order, signed 4/30/25, that called for the resident to receive two 10mg tablets (20mg) of Torsemide during the morning medication administration.
Plan of correction
The prescribing physician was notified, and a new corrected order was received and implemented on 05/16/2025. The medication administration record (MAR) was updated to reflect the correct dosage on 05/16/2025. The medication was administered per the updated physician order. Facility nurses shall match all new physician orders with pharmacy orders for accuracy prior to confirming all new orders. Effective immediately and moving forward. - On going
22VAC40-73-250-D
Based on documentation and interview, the facility did not ensure that each staff member submits the results of a tuberculosis risk assessment, documenting the absence of tuberculosis in a communicable form, on or within seven days prior to the first day of work at the facility.
Evidence
  1. Staff #2 was hired on 7/9/24 as a CNA. Staff #2's tuberculosis risk assessment was not completed until January 2025.
Plan of correction
The employee identified in the survey has now completed a TB risk assessment and screening in accordance with state requirements. No symptoms of TB were reported, and the employee was cleared for continued employment on 05/16/2025. Effective immediately, all new hires will be required to complete a TB risk assessment and screening within seven days prior to their first day of work- On going The ASD or designee shall ensure that no employee will be permitted to begin work until this assessment is completed and documented upon hire - On going The ASD/EOO shall audit all new hire files and verify that all new hires have completed a TB risk assessment and screening prior to or within seven days prior to their first day of work On going
February 26, 2024Inspection1 violation
Inspection dates
02/26/2024
Areas reviewed
Administration and Administrative ServicesPersonnelStaffing and SupervisionAdmission, Retention and Discharge of ResidentsResident Care and Related ServicesResident Accommodations and Related ProvisionsBuilding and GroundsEmergency PreparednessAdditional Requirements for Facilities that Care for Adults with Cognitive ImpairmentsBackground Checks for Assisted Living FacilitiesSworn Statement
Comments
Date of Inspection: February 26 and 27, 2024 Type of Inspection: Renewal inspection Census: 47 Number of records reviewed and interviews conducted- 8 records, 5 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. The Licensing Inspector observed residents participating in activity programs and eating lunch. This LI also observed medication administration and reviewed the following facility reports: health inspection reports, fire marshal reports, fire drills, emergency preparedness review with staff, medication review, dietary review, healthcare oversight and resident council. If you have any questions or email changes, please do not hesitate to contact me at sarah.pearson@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov. The Licensing Inspector and the Administrator discussed the risk assessment ratings for the violations for this inspection. Please complete the “plan of correction” and “date to be corrected” for each violation cited on the violation notice and returned it to the office. You will need to specify how the deficient practice will be or has been corrected. 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). Date of Inspection: February 26 and 27, 2024 Type of Inspection: Renewal inspection Census: 47 Number of records reviewed and interviews conducted- 8 records, 6 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. The Licensing Inspector observed residents participating in activity programs and eating lunch. This LI also observed medication administration and reviewed the following facility reports: health inspection reports, fire marshal reports, fire drills, emergency preparedness review with staff, medication review, dietary review, healthcare oversight and resident council. If you have any questions or email changes, please do not hesitate to contact me at sarah.pearson@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov. The Licensing Inspector and the Administrator discussed the risk assessment ratings for the violations for this inspection. Please complete the “plan of correction” and “date to be corrected” for each violation cited on the violation notice and returned it to the office. You will need to specify how the deficient practice will be or has been corrected. 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).
Violations
22VAC40-73-680-D
Based on resident record review and staff interview, it was determined that the facility failed to administer medications to the resident as prescribed by the physician.
Evidence
  1. The Medication Administration Record indicated that Acetaminophen was not available to be administered to Resident E on the following dates: 2/26/2024 and 2/27/2024.
Plan of correction
Medication for Resident E was filled by the pharmacy and is being administered per MD orders. Medication Management Plan will be reviewed with all nurses and registered medication technicians to include availability of all medications ordered by MD.
March 9, 2023Inspection0 violations
Inspection dates
03/09/2023
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 ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity32.1 Reported by persons other than physicians63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Comments
An unannounced renewal inspection was conducted on 3/9/2023. At the time of entrance 29 residents were in care. The sample size consisted of six resident records, three staff records and two individual interviews. Resident and staff records and other documentation were reviewed. Virginia State Police background checks reviewed for all new staff hired since the previous inspection conducted on 12/6/2022. Residents were observed eating breakfast. Residents were observed playing balloon volleyball and relaxing with nature television. Medication administration was reviewed. An exit meeting was 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 Lynette Storr, Licensing Inspector at (703) 479-4708 or by email at lynette.storr@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
December 6, 2022Inspection0 violations
Inspection dates
12/06/2022
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity32.1 Reported by persons other than physicians63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Comments
An unannounced mandated monitoring inspection was conducted on 12/6/2022. At the time of entrance 17 residents were in care. The sample size consisted of two resident records, two staff records and one individual interview. Resident and staff records and other documentation were reviewed. Virginia State Police background checks reviewed for all new staff hired since the previous inspection conducted on 8/24/2022. Residents were observed eating breakfast.. Medication administration was reviewed. An exit meeting was 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 Lynette Storr, Licensing Inspector at (703) 479-4708 or by email at lynette.storr@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
August 24, 2022Inspection0 violations
Inspection dates
08/24/2022
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 ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity32.1 Reported by persons other than physicians63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Comments
Licensing Inspector (LI) conducted an announced initial inspection on 8/24/2022. LI walked the physical plant, verified window and room measurements, reviewed policies and procedures and staff records and tested the call bell system. The following documents are required - Signed Building Inspection Report, Emergency Preparedness Local Contact and Fire Marshall Approval of the Emergency Prep Plan. No violations cited today and exit interview held. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Lynette Storr, Licensing Inspector at (703) 479-4708 or by email at lynette.storr@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.