12
Inspections
On record
6
With violations
Visits that cited something
6
Clean visits
Nothing cited
19
Violations cited
Individual findings
16
Standards cited
Distinct rules
6
Complaint visits
Prompted by a complaint
Watercrest Richmond Assisted Living and Memory Care was inspected 12 times between March 8, 2023 and January 6, 2026 by the Virginia Department of Social Services. 6 of those visits ended with violations cited and 6 with none. Across that history VDSS cited 19 violations under 16 distinct standards. 6 inspections were prompted by a complaint.
A violation is a licensing standard - a rule in the Virginia Administrative Code - that the inspector found the facility was not meeting. Each is shown with the evidence the inspector recorded and, where VDSS publishes it, the facility's own plan of correction.
Every inspection listed here is currently published on the VDSS site.
Provider Information
Facility type
Assisted Living Facility
License type
Two Year
License expires
09/07/2027
Administrator
Kyle Satterwhite
Licensing inspector
Tamara Watkins
Inspector phone
(804) 840-3710
Approved for
Assisted Living · Special Care Unit
Inspection History
12Select an inspection to read the areas reviewed, the inspector's comments and any violations cited.
January 6, 2026Complaint survey
Inspection dates
01/06/2026
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Complaint
Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 1/6/2026 12:45 – 3:30p
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
A complaint was received by VDSS Division of Licensing on 11/24/2025 regarding allegations in 22VAC40-73-(6)
RESIDENT CARE AND RELATED SERVICES 22VAC40-680 Administration of medications and related provisions
The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility.
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of interviews conducted with staff: 1
Observations by licensing inspector: Medication Administration Records
Additional Comments/Discussion:
The investigation did not support the allegation of non-compliance with standard(s) or law. However, violation(s) identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law.
If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview.
Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected.
Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area.
Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice.
The department's inspection findings are subject to public disclosure.
Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility.
The evidence gathered during the investigation did not support the allegation 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 Tamara Watkins, Licensing Inspector at (804) 840-3710 or by email at tamara.g.watkins@dss.virginia.gov
Violation Notice Issued: Yes
Violations
22VAC40-73-680-D
Based on a review of medication administration records medication was not administered in accordance with physician's instructions.
Evidence
- Resident 1 - is prescribed Ozempic to be administer by injection, weekly. A review of his MAR medication administration records shows he did not receive his prescribed medication on: 10/2/2026 reason - "out of facility" 10/16/2026 "not administered" 11/6/2026 "med not administered" "resident not in room" 11/13/2026 " resident was not in his apartment" "did not receive"
Plan of correction
Not published by VDSS.
October 30, 2025Complaint survey
Inspection dates
10/30/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Complaint
Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/30/2025 1:00p – 2:00p
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 regarding allegations in the area of: Resident Care and Related Services
Number of resident records reviewed: 1
Number of interviews conducted with staff: 2
Additional Comments/Discussion:
The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law.
If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview.
Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected.
Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area.
Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice.
The department's inspection findings are subject to public disclosure.
Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility.
For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov
Should you have any questions, please contact Tamara Watkins, Licensing Inspector at (804) 840-3710 or by email at tamara.g.watkins@dss.virginia.gov
Violation Notice Issued: Yes
Violations
22VAC40-73-460-A
Based on resident records and staff interviews the facility failed to protect the health, safety and well-being of the residents.
Evidence
- Resident #1 a resident in the memory care unit was punched in the face resulting in facial and jaw redness by Resident #2 a new resident in the memory care unit. EMS was called and a police report made. Resident #2 was discharged.
Plan of correction
Not published by VDSS.
October 30, 2025Complaint survey
Inspection dates
10/30/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Complaint
Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/30/2025 12:00p – 2:05p
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 9/4/2025 regarding allegations in the area of Resident Care and Related Services (RB & MW)
Number of resident records reviewed: 2
Number of interviews conducted with residents: 2
Number of interviews conducted with staff: 2
Additional Comments/Discussion:
The evidence gathered during the investigation did not support the allegation 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 Tamara Watkins, Licensing Inspector at (804) 840-3710 or by email at tamara.g.watkins@dss.virginia.gov
Violation Notice Issued: No
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
October 30, 2025Inspection
Inspection dates
10/30/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring
Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/30/2025 12:00pm – 2:00pm
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 10/30/2025 regarding allegations in the area of: Resident Care and Related Services
Number of resident records reviewed: 1
Number of interviews conducted with staff: 3
Additional Comments/Discussion:
The evidence gathered during the investigation did not support the allegations 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 Tamara Watkins, Licensing Inspector at (804) 840-3710 or by email at tamara.g.watkins@dss.virginia.gov
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
July 24, 2025Complaint survey
Inspection dates
07/24/2025
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION
Comments
Type of inspection: Complaint
Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7/24/2025 1:00p – 2:00p
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
A complaint was received by VDSS Division of Licensing on 3/6/2025 regarding allegations in the area of Staffing
Number of residents present at the facility at the beginning of the inspection: 78
The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility.
Number of interviews conducted with staff: 2
Observations by licensing inspector: Staffing schedules
Additional Comments/Discussion:
The evidence gathered during the investigation did not support the allegations 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 Tamara Watkins, Licensing Inspector at (804) 840-3710 or by email at tamara.g.watkins@dss.virginia.gov
Violation Notice Issued: No
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
July 23, 2025Complaint survey
Inspection dates
07/23/2025
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 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS63.2 PROTECTION OF ADULTS AND REPORTING22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint
Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7/23/2025
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
A complaint was received by VDSS Division of Licensing on 7/23/2025 regarding allegations in the area(s): Resident Care and Related Services.
Number of residents present at the facility at the beginning of the inspection: 78
The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility.
Number of resident records reviewed: 1
Number of interviews conducted with staff: 2
Additional Comments/Discussion:
The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the allegation 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 Tamara Watkins, Licensing Inspector at (804) 840-3710 or by email at tamara.g.watkins@dss.virginia.gov
Violation Notice Issued: Yes
Violations
22VAC40-73-70-A
Based on a review of documentation and interview, the facility failed to report to the regional licensing office within 24 hours of any major incident that has negatively affected or that threatens the life, health, safety or welfare of any resident.
Evidence
- Based on a report received from the local agency on 1/31/25, an incident of inappropriate sexual contact occurred at the facility on 1/18/25 involving resident 1 and resident 2.
- No notification was received by the regional licensing office from the facility within 24 hours.
Plan of correction
Not published by VDSS.
22VAC40-73-70-C
Based on a review of documentation and interviews, the facility failed to submit a written incident report to the regional licensing office within seven days of the date of the incident.
Evidence
- A written incident report about the inappropriate sexual contact between resident 1 and resident 2 on 1/18/25 was not submitted to the regional licensing office within seven days of the date of the incident.
- Staff at the facility could not provide proof that a written report of the incident was submitted to the regional licensing office.
Plan of correction
Not published by VDSS.
22VAC40-73-130-A
Based on a review of documentation and interviews. It was determined that the facility did not ensure that all staff who are mandated reporters under § 63.2-1606 of the Code of Virginia shall report suspected abuse, neglect, or exploitation of residents in accordance with that section.
Evidence
- The facility made a report to the local agency on 1/21/25 about an incident of inappropriate sexual contact between residents 1 and resident 2 on 1/18/25.
- 63.2-1606 of the Code of Virginia requires that staff shall immediately report suspected abuse, neglect or exploitation of residents, but the facility did not make the report until three days after the incident.
Plan of correction
Not published by VDSS.
22VAC40-73-460-A
Based on a review of documentation and interviews, the facility failed to assume general responsibility for the health, safety, and well-being of the residents.
Evidence
- On 1/18/2025 at approximately 10:00am staff 3 were making rounds in the memory care unit and entered the room for resident 1. Staff 3 observed Resident 2 (male) making inappropriate sexual contact with resident 1(female). Resident 2 was removed from the room of resident 1.
- The incident report provided by the facility confirmed the incident of inappropriate sexual contact between resident 1 and resident 2 occurred on 1/18/2025.
Plan of correction
Not published by VDSS.
July 23, 2025Complaint survey
Inspection dates
07/23/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Complaint
Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7/23/2025 2:15p – 3:15p.
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
A complaint was received by VDSS Division of Licensing on 7/23/2025 regarding allegations in the area(s) of: Resident Care and Related Services.
Number of residents present at the facility at the beginning of the inspection: 78
The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility.
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of interviews conducted with staff: 3
Additional Comments/Discussion:
The evidence gathered during the investigation did not support the allegations 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 Tamara Watkins, Licensing Inspector at (804) 840-3710 or by email at tamara.g.watkins@dss.virginia.gov
Violation Notice Issued: No
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
July 23, 2025Inspection
Inspection dates
07/23/2025
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 PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Comments
Type of inspection: Renewal
Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7/23/2025 1:00 pm – 6:00pm
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
Number of residents present at the facility at the beginning of the inspection: 113 (78+35)
The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility.
Number of resident records reviewed: 8
Number of staff records reviewed: 4
Number of interviews conducted with residents: 2
Number of interviews conducted with staff: 2
Observations by licensing inspector: required postings, menus, activities, staffing schedules, medication administration, staff resident interaction
Additional Comments/Discussion:
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 Tamara Watkins, Licensing Inspector at (804) 840-3710 or by email at tamara.g.watkins@dss.virginia.gov
Violation Notice Issued: No
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
July 15, 2024Inspection
Inspection dates
07/15/2024
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 IMPAIRMENTSARTICLE 1 – SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Comments
Type of inspection: Monitoring
Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7/15/2024 11:50a – 4:45p
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: 114
The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility.
Number of resident records reviewed: 10
Number of staff records reviewed: 5
Number of interviews conducted with residents: 3
Number of interviews conducted with staff: 2
Additional Comments/Discussion:
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 Tamara Watkins, Licensing Inspector at (804) 662-7422 or by email at tamara.g.watkins@dss.virginia.gov
Violations
22VAC40-73-250-D
Based on a review of staff records the facility failed to ensure that each staff person shall be evaluated annually and submit the results of a risk assessment documenting that the individual is free from tuberculosis in the communicable form.
Evidence
- Staff 2 - Date of hire 12/12/23. No risk assessment was completed and retained in the staff record. There was a blank form in the staff record. Staff 3 - Date of hire 5/3/24. No risk assessment was completed and retained in the staff record. There was a blank form in the staff record. Staff 4 - Date of hire 3/20/24. No risk assessment was completed and retained in the staff record. There was a blank form in the staff record. Staff 5 - Date of hire 5/3/24. No risk assessment was completed and retained in the staff record.
Plan of correction
Not published by VDSS.
22VAC40-73-320-B
Based on a review of the resident records the facility failed to complete a risk assessment for tuberculosis annually on each resident as
Evidence
- d by the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: Resident 6 - The last tuberculosis screening in the resident’s record was completed on 3-22-23.
Plan of correction
Not published by VDSS.
22VAC40-73-1110-B
Based on a review of resident records the facility six months after placement in the safe, secure environment and annually thereafter failed to perform a review of the appropriateness of each resident’s continued residence in the special care unit.
Evidence
- Resident 3 - Date of admission is 7/6/23 and a six-month and annual review of appropriateness of placement in the special care unit was not completed. Resident 7 - Date of admission is 5/11/23 and a six-month and annual review of appropriateness of placement in the special care unit was not completed.
Plan of correction
Not published by VDSS.
22VAC40-73-390-B
Based on a review of resident records the facility failed to retain in the resident record copies of the signed agreement/acknowledgment and any updates.
Evidence
- Resident 4 - A signed resident agreement was not retained in the resident record.
Plan of correction
Not published by VDSS.
22VAC40-73-720-A
Based on a review of resident records the facility failed to include written Do Not Resuscitate Orders included in the resident’s individualized service plan.
Evidence
- Resident 1 - A DNR on file in the resident record for this resident dated 12/28/23 is not included in the resident’s service plan. Resident 2 - A DNR on file in the resident record for this resident dated 2-6-23 is not included in the resident’s service plan. Resident 5 - A DNR on file in the resident record for this resident dated 9-27-23 is not included in the resident’s service plan. Resident 6 - A DNR on file in the resident record for this resident dated 2-22-23 is not included in the resident’s service plan.
Plan of correction
Not published by VDSS.
22VAC40-73-260-A
Based on a review of staff records the facility failed to ensure that each staff member receive first aid certification in the first 60 days of employment.
Evidence
- Staff 1 - The date of hire for this CNA is 2/12/24. There is no certification in the staff record documenting first aid certification.
Plan of correction
Not published by VDSS.
22VAC40-73-50-B
Based on a review of resident records the facility failed to document written acknowledgment of the receipt of the disclosure statement by the resident or his legal representative retained in the resident record.
Evidence
- Resident 2 - No disclosure statement was in the resident record.
Plan of correction
Not published by VDSS.
August 11, 2023Inspection
Inspection dates
08/11/2023
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Comments
Type of inspection: Renewal
Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 8/11/2023 1:00p – 5:45p
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: 82
The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility.
Number of resident records reviewed: 8
Number of staff records reviewed: 4
Number of interviews conducted with residents: 2
Number of interviews conducted with staff: 2
Observations by licensing inspector: Resident Care and related Services, posting, meals, activity
Additional Comments/Discussion:
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 Tamara Watkins, Licensing Inspector at (804) 662-7422 or by email at tamara.g.watkins@dss.virginia.gov
Violation Notice Issued: Yes
Violations
22VAC40-73-450-A
Based on a review of resident records a preliminary plan of care was not developed on or within seven days prior to admission.
Evidence
- Resident #1 was admitted to the facility on 5/11/2023. An individualized service plan was not developed until 5/24/2023.
Plan of correction
Not published by VDSS.
22VAC40-73-990-A
Based on a review of facility records the facility failed to develop a plan for resident emergencies and practice exercises.
Evidence
- The facility was unable to provide documentation of a written plan or procedures for review of practice exercises for resident emergencies as described in this standard.
Plan of correction
Not published by VDSS.