The Blake at Charlottesville — Virginia Inspection Report

Inspections

On record

With violations

Visits that cited something

Clean visits

Nothing cited

Violations cited

Individual findings

Standards cited

Distinct rules

Complaint visits

Prompted by a complaint

The Blake at Charlottesville was inspected 25 times between June 23, 2023 and April 2, 2026 by the Virginia Department of Social Services. 20 of those visits ended with violations cited and 5 with none. Across that history VDSS cited 54 violations under 36 distinct standards. 14 inspections were prompted by a complaint.

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

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

Provider Information

Facility type

Assisted Living Facility

License type

One Year

License expires

12/31/2026

Administrator

Russell Williams

Licensing inspector

Kimberly Davis

Inspector phone

(804) 356-3572

Approved for

Special Care Unit · Assisted Living

Inspection History

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

April 2, 2026Complaint survey1 violation

Inspection dates

04/02/2026

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE 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: 4-2-26 from 10: 46 a.m.- 12:05 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 2-19-26 regarding allegations in the area(s) of: infection control Number of residents present at the facility at the beginning of the inspection: 121 Number of interviews conducted with staff: 5 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. However, violation(s) not related to the complaint(s) but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. 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 Kimberly Davis, Licensing Inspector at (804) 356-3572 or by email at Kimberly.M.Davis@dss.virginia.gov

Violations

22VAC40-73-100-E

Based on staff interviews and a review of facility documentation the facility did not ensure that the facility administrator shall immediately make or cause to be made a report of an outbreak of disease as defined by the State Board of Health. Such report shall be made by rapid means to the local health director or to the Commissioner of the Virginia Department of Health and to the licensing representative of the Department of Social Services in the regional licensing office.

Evidence

The facility reported an outbreak of a gastro-intestinal virus of 14 residents to the Health Department on 2-18-26, but failed to report the outbreak to the licensing representative of the Department of Social Services in the regional licensing office. This was confirmed by Staff # 1.

Plan of correction

Not published by VDSS.

February 9, 2026Inspection2 violations

Inspection dates

02/09/2026

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: 02/09/2026 from 10:45 a.m.- 12:30 p.m. A self-reported incident was received by VDSS Division of Licensing on 12/19/2025 regarding allegations in the area(s) of: resident care Number of residents present at the facility at the beginning of the inspection: 122 Number of resident records reviewed: 2 Number of interviews conducted with staff: 2 An exit meeting was 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. 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 Kimberly Davis, Licensing Inspector at (804) 356-3572 or by email at Kimberly.M.Davis@dss.virginia.gov

Violations

22VAC40-73-460-A

Based on a self-report received from the facility as well as staff interviews and a review of facility documentation, the facility failed to ensure that it shall assume general responsibility for the health, safety, and well-being of the residents.

Evidence

Based on an incident report and interviews, Resident # 1 was pushed by Resident # 2 in the dining area of the facility on 12-19-2025. Resident #1 was injured in the fall and required transport to a local hospital.
Staff #2 confirmed that Resident #1 was injured in a fall at the facility on 12-19-2025.

Plan of correction

Based on the community inquiry to the incident (that same day of the incident) a staff member observed the event unfolding, yet did not intervene quickly enough to prevent further escalation. The Staff member was immediately In serviced (within 24 hours) as to how better they could have handled the situation. Employee file was updated with that counseling.

22VAC40-73-460-F

Based on a review of facilitydocumentation the facility failed to ensurethat it shall notify the next of kin, legalrepresentative, designated contactperson, or, if applicable, any responsible social agency of any incident of aresident falling or wandering from thepremises, whether or not it results ininjury. This notification shall occur assoon as possible but no later than 24 hours from the time of initial discovery orknowledge of the incident. Theresident's record shall includedocumentation of the notification,including date, time, caller, and person or agency notified.

Evidence

According to a review of the record of Resident # 1, Resident # 1 fell on 12-19-25 as a result of being pushed by another resident and had to be transported to a local hospital.
The facility was unable to provide documentation during the onsite inspection that indicated that facility staff notified the next of kin of Resident # 1.

Plan of correction

The DOW & ADOW were both present when the overseeing Hospice nurse called and informed the Family member about the incident via telephone. A " Late Entry'' was added to the resident chart to document that this did in fact occur and staff was present when notification took place.

December 17, 2025Complaint survey0 violations

Inspection dates

12/17/2025

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: 12-17-25 from 10:20 a.m.-11:55 a.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 12-5-25 regarding allegations in the area(s) of: resident care. Number of residents present at the facility at the beginning of the inspection: 123 Number of resident records reviewed: 1 Number of interviews conducted with staff: 3 An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Kimberly Davis, Licensing Inspector at (804) 356-3572 or by email at Kimberly.M.Davis@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

December 4, 2025Inspection3 violations

Inspection dates

12/04/2025

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 PROCESS

Comments

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12-4-25 from 9:15 a.m.- 4:45 p.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: 113 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:4 Number of interviews conducted with staff: 5 Additional Comments/Discussion: The following items were reviewed/observed during the inspection- facility documentation, facility postings, first aid kit, medication pass, physician’s orders, and medication administration records. An exit meeting was 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 Kimberly Davis, Licensing Inspector at (804) 356-3572 or by email at Kimberly.M.Davis@dss.virginia.gov

Violations

22VAC40-73-1110-B

Based on a review of resident records the facility failed to ensure that six months after placement of the resident in the safe, secure environment and annually thereafter, the licensee, administrator, or designee shall perform a review of the appropriateness of each resident's continued residence in the special care unit.

Evidence

The record for memory care Resident # 8 (admit date: 7-7-23) only contained a Review of Appropriateness of Continued Residence in Special Care Unit form dated 2-5-25. This was confirmed by staff.

Plan of correction

Resident Record #8 updated and completed on day of inspection (12/4/25). DOW, ADOW, MCD and/or Designee will conduct a full audit of all memory care resident records to ensure all current residents have this document in their records. DOW, ADOW, MCD and/or Designee will schedule quarterly audits to keep in compliance going forward. To be completed by 12/10/2025. This is an ongoing process.

22VAC40-73-310-D

Based on a review of resident records the facility failed to ensure that a copy of the written assurance was signed by the resident or his/her legal representative.

Evidence

The record for Resident # 8 (admit date: 7-7-23) contained a written assurance that was not signed by the resident or his/her legal representative. This was confirmed by staff.

Plan of correction

ED, BOM and/or Designee will audit all resident records to ensure that this document is (1) in the records and (2) that it has been signed by the Resident, Legal Guardian, POA or other Designee for current residents. All incoming residents’ records (files) will be reviewed by two administration staff to ensure all required admission documents have been attained before filed for record keeping. To be completed by 12/19/2025.

22VAC40-73-260-A

Based on a review of staff records the facility failed to ensure that each direct care staff member shall maintain current certification in first aid.

Evidence

-The record for Staff # 1 (date of hire: 7-30-25) did not contain first aid certification. -The record for Staff # 4 (date of hire: 2-28-24) did not contain first aid certification. This was confirmed by staff.

Plan of correction

Community will schedule several Basic First Aid classes for remaining Direct Care Staff that have not had or not renewed their certificate, to obtain it in a timely manner. This will be supervised by the BOM and DOW to ensure compliance and completion. To be Completed by January 15, 2026. Community will have bi-monthly training scheduled throughout the year to ensure compliance with new hires starting January 2026.

November 20, 2025Inspection1 violation

Inspection dates

11/20/2025

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: 11-20-25 from 1:30 p.m.-2:25 p.m. 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 10-31-25 regarding allegations in the area(s) of: resident care. Number of residents present at the facility at the beginning of the inspection: 114 Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with staff: 1 An exit meeting was 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 Kimberly Davis, Licensing Inspector at (804) 356-3572 or by email at Kimberly.M.Davis@dss.virginia.gov

Violations

22VAC40-73-680-D

Based on a self-report received from the facility regarding a medication error, the facility failed to ensure that medications shall be administered in accordance with the physician's or other prescriber’s instructions.

Evidence

-According to the self-report received as well as facility documentation and a staff interview, a medication error occurred on 10-28-25 in which Resident # 1 was given a Fentanyl 50 mcg patch at 9:00 a.m., when the resident’s physician’s order and Medication Administration Record indicated a Fentanyl 12 mcg patch at 9:00 a.m. -Progress notes for Resident # 1 dated 10-29-25 indicated that the wrong dosage patch was observed/removed by staff, the resident’s family and physician were notified, and the resident’s vitals were observed with no adverse effects noted to the resident.

Plan of correction

The Nursing staff was counseled and in serviced on this incident and the DOW and ADOW have been following up with the nursing staff member to ensure proper steps are being taken. The DOW, ADOW and/or other designated staff are monitoring and auditing Medication administration monthly.

November 20, 2025Complaint survey1 violation

Inspection dates

11/20/2025

Areas reviewed

22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Comments

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11-20-25 from 10:30 a.m.-1:25 p.m. 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 9-29-25 regarding allegations in the area(s) of: safe,secure unit staffing Number of residents present at the facility at the beginning of the inspection: 114 Number of interviews conducted with staff: 2 An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation(s) of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint(s) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Kimberly Davis, Licensing Inspector at (804) 356-3572 or by email at Kimberly.M.Davis@dss.virginia.gov

Violations

22VAC40-73-1130-A

Based on a review of facility documentation as well as an interview with staff the facility failed to ensure that when 20 or fewer residents are present, at least two direct care staff members shall be awake and on duty at all times in each special care unit who shall be responsible for the care and supervision of the residents. For every additional 10 residents, or portion thereof, at least one more direct care staff member shall be awake and on duty in the unit.

Evidence

-A review of the facility’s census on the memory care unit for the month of September 2025 noted a census of 40-43 residents daily, indicating the need for 4 direct care staff on duty at all times on the unit when there were 40 residents and the need for 5 direct care staff on duty at all times on the unit when there were 41-43 residents. -Per a review of the memory care staff schedule for the month of September 2025 as well as an interview with staff, the facility did not ensure that there were 4-5 direct care staff on duty at all times on the memory care unit when the census was 40-43 residents.

Plan of correction

DOW, ADOW, MCD and/or Designee will ensure that All Staff assigned to the Memory Care neighborhood are accounted for Daily on the Daily Nursing Schedule Assignment sheet for (1) Daily Staffing levels within the Memory Care neighborhood on all shifts and (2) that it correctly reflected on the Daily Nursing Schedule Assignment sheet for future review(s). This will be ongoing.

January 17, 2025Inspection2 violations

Inspection dates

01/17/2025

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: 1-17-25 from 11:00 a.m.- 12:00 p.m. 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 regarding allegations in the area(s) of: resident care Number of residents present at the facility at the beginning of the inspection: 101 Number of resident records reviewed: 1 Number of interviews conducted with staff: 2 An exit meeting was 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 Kimberly Davis, Licensing Inspector at (804) 662-7578or by email at Kimberly.M.Davis@dss.virginia.gov

Violations

22VAC40-73-680-I

Based on a review of the resident record as well as staff interviews, the facility failed to ensure that the Medication Administration Record (MAR) shall include the initials of direct care staff administering the medication.

Evidence

The first staff who administered the 8:00 p.m. dosage of Gabapentin to Resident # 1 did not document it on the MAR and the medication was administered to the resident a second time by the evening nurse.

Plan of correction

The facility will re-educate the nurses on medication administration and documentation. The facility Wellness Director (and/or appropriate designee) will ensure that the re-education is conducted monthly for three consecutive months. The Executive Director (and/or appropriate designee) will schedule the re-education on monthly basis and ensure the re-education is completed for three consecutive months.

22VAC40-73-680-D

Based on a self-report received from the facility as well staff interviews, the facility failed to ensure that medications shall be administered in accordance with the physician's or other prescriber’s instructions.

Evidence

Per the facility’s self-report and staff interviews, on 1-12-25 the nurse administered Gabapentin 300 mg to Resident # 1 prior to 8:00 p.m. The physician’s order for Resident # 1 as of 11-7-24 states: “Gabapentin 300 mg Take 1 capsule by mouth twice daily for pain 8:00 a.m. and 8:00 p.m. However, the Medication Administration Record (MAR) for January 2025 did not match the physician’s order as the MAR states, “Gabapentin 300 mg Take 2 capsules (600 mg) by mouth twice daily for pain.” The staff member did not document that the medication was administered on the electronic MAR and another nurse therefore administered the same medication to the resident and documented it on the MAR for the 8:00 p.m dosage.

Plan of correction

The facility re-educated the staff on medication administration and medication rights. The facility Wellness Director (and/or appropriate designee) will ensure that the re-education is conducted monthly for three consecutive months. The Executive Director (and/or appropriate designee) will schedule the re-education on monthly basis and ensure the re-education is completed for three consecutive months.

December 16, 2024Inspection6 violations

Inspection dates

12/16/2024,1/17/2025

Areas reviewed

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: 12-16-24 from 9:46 a.m.-3:00 p.m. and 1-17-25 from 10:00 a.m.-3:00 p.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: 108 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 interviews conducted with residents: 3 Number of staff records reviewed: 4 Number of interviews conducted with staff: 2 Additional Comments/Discussion: The following items were also reviewed/observed- facility documentation, facility postings, first aid kit, lunch meal/menu, medication pass, physician’s orders, and medication administration records. An exit meeting was 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 Kimberly Davis, Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov

Violations

22VAC40-73-450-E

Based on a review of resident records the facility failed to ensure that the individualized service plan (ISP) shall be signed and dated by the licensee, administrator, or his designee, (i.e., the person who has developed the plan), and by the resident or his legal representative.

Evidence

The record for Resident # 4 contained an ISP signed and dated by staff on 4-14-24 and 4-15-24, but was not signed or dated by the resident or his/her legal representative.

Plan of correction

The facility will complete an audit for all Individualized Care Plan (ISP) . Each Individualized Service Plan (ISP) will be signed and dated by the licensee, administrator, or designee and by the resident or their legal representative. The facility will schedule care plan meetings with families to discuss care provided and obtain a signature on the Individualized Service Plan (ISP). The Wellness Director (and/or appropriate designee) will be responsible for scheduling and obtaining signatures on the ISP. The Executive Director (and/or appropriate designee) will spot check five ISP a month for compliance for three consecutive months.

22VAC40-90-30-B

Based on a review of staff records the facility failed to ensure that the sworn statement or affirmation shall be completed for all applicants for employment.

Evidence

-The record for Staff # 3 (date of hire:10-4-24) did not contain a sworn statement or affirmation. -The record for Staff # 27 (date of hire: 2-13-24) did not contain a sworn statement or affirmation. -The record for Staff # 30 (date of hire: 1-11-24) did not contain a sworn statement or affirmation. -The record for Staff # 31 (date of hire: 4-29-24) did not contain a sworn statement or affirmation. -The record for Staff # 54 (date of hire: 1-3-24) did not contain a sworn statement or affirmation.

Plan of correction

The facility completed an audit for all employees to ensure all sworn statements are present in the employee record. The Director of Business office (and/or appropriate designee) will audit all employees records and rectify. The Executive Director (and/or appropriate designee) will audit 5 employees record a month for three consecutive months for compliance.

22VAC40-73-980-A

Based on a review of the facility’s first aid kit, the facility failed to ensure that the first aid kit contained all required items.

Evidence

The first aid kit did not contain adhesive tape, antiseptic ointment, or band aids.

Plan of correction

The Facility will have the first aid kit inspected monthly to ensue all content are in place. The Wellness Director (and/or appropriate designee) will check the first aid kit and sign off monthly. The Executive Director (and/or appropriate designee) will verify that the inspection is completed.

22VAC40-90-40-B

Based on a review of staff records the facility failed to ensure that the criminal history record report shall be obtained on or prior to the 30th day of employment for each employee.

Evidence

-The record for Staff # 33 (date of hire 1-23-24) contained a criminal record report that was dated 3-21-24. -The record for Staff # 35 (date of hire: 6-6-24) contained a criminal record report dated 9-12-24. -The record for Staff # 39 (date of hire: 6-26-24) did not contain a criminal record report.

Plan of correction

The facility completed an audit for all employees’ criminal background. The facility will ensure that all employees background checks are completed prior or within 30 days of the hire date. The Director of Business office (and/or appropriate designee) will audit all employees records and rectify. The Executive Director (and/or appropriate designee) will audit 5 employees a month for three consecutive months for compliance.

22VAC40-73-1110-B

Evidence

The record for Resident # 8 (admit date: 12-16-22), who resides on the secure unit, did not contain a six month review of appropriateness of continued placement on the special care unit.

Plan of correction

The facility will ensure that the six-month appropriateness placement form is completed and filed in the record for all residents residing in our secure neighborhood. The Wellness Director (and/or appropriate designee) will complete the form. The Executive Director will (and/or appropriate designee) will audit all the residents’ records weekly for compliance for three consecutive months.

22VAC40-73-550-G

Based on a review of resident records the facility failed to ensure that the rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each resident or his legal representative or responsible individual and each staff person.

Evidence

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: The record for Resident # 7 (admit date: 5-25-23) and Resident # 8 (admit date: 12-16-22) did not contain written acknowledgement of an annual review of the rights and responsibilities of residents in assisted living facilities.

Plan of correction

The facility will review residents’ rights annually with each resident or his/her legal representative. Evidence of this review will be maintained in the resident business record. The annual review will take place at the beginning of the month of November of each year. The Business office (and/or appropriate designee) will complete the annual requirement. The Executive Director (and/or appropriate designee) will verify that all residents have signed the residents’ rights for compliance.

December 14, 2024Complaint survey2 violations

Inspection dates

12/14/2024

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUNDS

Comments

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12-14-23 from 9:45 a.m.-12:10 p.m. 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 11-30-23 regarding allegations in the area(s) of: resident care Number of residents present at the facility at the beginning of the inspection: 118 Number of resident records reviewed: 1 Number of interviews conducted with staff: 2 Additional Comments/Discussion: An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the (allegation(s); area(s) of non-compliance with standard(s) or law were: resident care and building and grounds. A violation notice was issued; any violation(s) not related to the (complaint(s)/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 Kimberly Davis, Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov

Violations

22VAC40-73-930-D

Based on a review of the facility 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 shall 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

There was no documentation in the 2 Hour Rounds log for Resident # 1 for November 2023 from 11-18-23 until 11-20-23 and from 11-21-23 until 11-26-23 and no documentation for 11-27-23.

Plan of correction

The Facility will re-educate all direct care staff on rounding and care documentation. The Director of Wellness (and/or a designee) will ensure that rounding documentation is reviewed daily and prior to care staff shift changes. For a period of 90 days, the Executive Director will also make a monthly review of rounding documentation of at least five (5) residents to ensure compliance.

22VAC40-73-530-C

Based on a complaint received, as well as interviews with facility staff, the facility failed to ensure that they provide freedom of movement for the residents to their personal spaces. The facility shall not lock residents out of or inside their rooms.

Evidence

Staff #1 and Staff #2 stated that the rooms of some memory care residents are locked to prevent residents from wandering into other residents’ rooms on the unit. Staff #1 and Staff #2 stated that staff open the residents’ room doors with keys when they observe the residents returning to their room doors. Staff #1 and Staff #2 stated that many of the residents’ family members request that their loved ones door be locked to prevent other residents from wandering into their rooms.

Plan of correction

The charge nurse (and/or a designee) will ensure that all doors are unlocked and remain unlocked in Memory Care. The Director of Wellness (and/or a designee) will re-educate all care staff on keeping resident doors unlocked in Memory Care. The Executive Director (and/or a designee) will monitor the adherence to this requirement. Families of Memory Care residents will be notified of the Department’s decision.

October 24, 2024Inspection1 violation

Inspection dates

10/24/2024

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

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: 10-24-24 from 10:20 a.m.- 11:15 a.m. 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 regarding allegations in the area(s) of: resident care Number of residents present at the facility at the beginning of the inspection: 113 Number of resident records reviewed: 1 Number of interviews conducted with staff: 1 An exit meeting was 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 Kimberly Davis, Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov

Violations

22VAC40-73-460-D

Based on a self-report of a resident elopement received from the facility, the facility failed to ensure that it shall provide supervision of resident schedules, care, and activities, including attention to specialized needs, such as prevention of falls and wandering from the premises.

Evidence

-Per the self-report received from the facility on 6-24-24 as well as an interview with the facility administrator and staff documentation, Resident # 1, who resides in the memory care unit, was observed on 6-23-24 to be “highly agitated, banging on doors, trying to get out. Staff was unable to redirect.” -Per facility documentation, resident was last seen at 7:30 a.m. on 6-23-24. Staff observed at 9:20 a.m. that the window in Resident # 1’s room was completely open and the window screen was bent out, indicating that the resident had eloped from the facility. -The resident was located on 6-23-24 at 11:55 a.m. at his home, approximately 20 miles from the facility, without incident.

Plan of correction

The Facility re-educated all the direct care staff on residents’ elopement and protocols. The facility moved the resident to an interior window room as an intervention. The Facility Window Stop apparatus was augmented so the stopping mechanism is more secure, preventing the resident from manipulating the window stop and/or removing it from its attachment point. The resident had 1:1 care provided by a sitter for a period of two weeks. The attending physician is monitoring the resident closely for any change of condition.

October 24, 2024Inspection1 violation

Inspection dates

10/24/2024

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: 10-24-24 from 11:15 a.m.- 11:40 a.m. 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 regarding allegations in the area(s) of: resident care Number of residents present at the facility at the beginning of the inspection: 113 Number of resident records reviewed: 1 Number of interviews conducted with staff: 1 An exit meeting was 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 Kimberly Davis, Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov

Violations

22VAC40-73-680-D

Evidence

Per the facility’s self-report, as well as a review of facility documentation and an interview with the facility administrator, on 7-7-24 at approximately 9:30 a.m., the medication aide administered 2.5mL of morphine instead of 2.5mg/0.125mL to Resident # 1 as prescribed. According to facility documentation, no adverse reactions were observed by the resident’s hospice nurse or facility staff as a result of the medication error.

Plan of correction

The Facility will re-educate all nurses and medication technicians on medication administration and physicians' orders. The Director of Wellness (and/or an appropriate designee) will re- educate nurses and medication technicians monthly for three consecutive months. The Executive Director (and/or an appropriate designee) will follow up to ensure compliance.

October 24, 2024Complaint survey0 violations

Inspection dates

10/24/2024

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10-24-24 from 9:10 a.m.- 10:20 a.m. 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 regarding allegations in the area(s) of: resident care Number of residents present at the facility at the beginning of the inspection: 113 Number of resident records reviewed: 1 Number of interviews conducted with staff: 1 An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Kimberly Davis, Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

August 23, 2024Complaint survey0 violations

Inspection dates

08/23/2024

Areas reviewed

22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS

Comments

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 8-23-24 from 9:45 a.m.-2:45 p.m. 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 July 5, 2024 regarding allegations in the area(s) of: resident discharges. Number of residents present at the facility at the beginning of the inspection: 107 Number of resident records reviewed: 2 Number of interviews conducted with staff: 2 An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Kimberly Davis, Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

August 22, 2024Complaint survey2 violations

Inspection dates

08/22/2024,08/23/2024

Areas reviewed

22VAC40-73 PERSONNEL22VAC40-73 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: 8-22-24 from 12:20 p.m.-2:20 p.m. and 8-23-24 from 1:00 p.m.- 2:00 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 6-28-24 regarding allegations in the area(s) of: personnel and resident care. Number of residents present at the facility at the beginning of the inspection: 107 Number of resident records reviewed: 1 Number of interviews conducted with staff: 2 An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s); area(s) of non-compliance with standard(s) or law were: resident care and personnel. A violation notice was issued; any violation(s) not related to the complaint(s) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Kimberly Davis, Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov

Violations

22VAC40-73-220-B

Based on a review of resident records and staff interviews, the facility failed to ensure that when private duty personnel who are not employees of a licensed home care organization provide direct care or companion services to residents in an assisted living facility, the requirements listed under subdivisions A 2 through A 6 of this section apply. In addition, before direct care or companion services are initiated, the facility shall: 1. Obtain, in writing, information on the type and frequency of the services to be delivered to the resident by private duty personnel, review the information to determine if it is acceptable, and provide notification to whomever has hired the private duty personnel regarding any needed changes. 2. Ensure that private duty personnel are qualified for the types of direct care or companion services they are responsible for providing to residents and maintain documentation of the qualifications. 3. Review an original criminal history record report issued by the Virginia Department of State Police, Central Criminal Records Exchange, for each private duty personnel. a. The report must be reviewed prior to initiation of services. b. The date of the report must be no more than 90 days prior to the date of initiation of services, except that if private duty personnel change clients in the same facility with a lapse in service of not more than 60 days, a new criminal history record report shall not be required. c. The administrator shall determine conformance to facility policy regarding private duty personnel and criminal history to protect the welfare of residents. The policy must be in writing. If private duty personnel are denied the ability to provide direct care or companion services due to convictions appearing on their criminal history record report, a copy of the report shall be provided to the private duty personnel. d. The report and documentation that it was reviewed shall be maintained at the facility while the private duty person is at the facility and for one year after the last date of work. e. Criminal history reports shall be maintained in locked files accessible only to the licensee, administrator, board president, or the respective designee. f. Further dissemination of the criminal history record report information is prohibited other than to the commissioner's representative or a federal or state authority or court as may be required to comply with an express requirement of law for such further dissemination.

Evidence

The record for Resident # 1, who staff confirmed had a private duty sitter as a condition of her readmittance to the facility after her hospitalization in June 2024, did not contain the documentation required for private duty personnel. Staff confirmed that the facility did not have such documentation.

Plan of correction

The facility will re-evaluate services provided by all private sitters and companions currently with residents at the facility by 8/29/2024. The facility will review frequency of services, review criminal history prior of initiation of services and conformance to facility policies by 8/29/2024. The Wellness Director (and/or an appropriate designee) will ensure that the qualifications are reviewed and documented by 8/29/2024. The Director of Business office (and/or an appropriate designee) will review all private sitters and companions background checks by 8/29/2024. The Executive Director will maintain documentation for compliance by 11/29/2024.

22VAC40-73-680-D

Based on a review of resident records the facility failed to ensure that medications shall be administered in accordance with the physician's or other prescriber’s instructions.

Evidence

-The record for Resident # 1 contained a Physician’s Order and Status Update Form dated 6-21-24 that noted the following: Quetiapine (Seroquel) 50 mg tab q a.m., Quetiapine 50 mg tab q p.m. However, the Physician’s Progress Notes for Resident # 1 dated 6-24-24 stated, “she has been getting her 100mg Seroquel scheduled at nighttime, but still not her 50 mg BID (8 am and 2pm as scheduled. -The Medication Administration Record (MAR) for Resident # 1 for June 2024 lists Quetiapine (Seroquel) 25 mg tablet, take ½ tab by mouth twice daily at 8:00 a.m. and 2:00 p.m. and the MAR also lists Quetiapine 50mg tablet at 8:00 p.m. three different times as medication # 13, # 14, and # 16. -LI provided facility staff an opportunity to review the MAR and physician’s orders for Quetiapine (Seroquel) for Resident # 1. Facility staff confirmed that the MAR did not match the physician’s orders.

Plan of correction

The Facility will re-educate all nurses and medication technicians on medication administration and physicians’ orders by 8/29/2024. The Director of Wellness (and/or an appropriate designee) will re-educate nurses and medication technicians monthly for three consecutive months by 11/29/2024. The Executive Director (and/or an appropriate designee) will follow up to ensure compliance by 11/29/2024.

August 22, 2024Complaint survey1 violation

Inspection dates

08/22/2024

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 8-22-24 from 9:40 a.m.-12:20 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 6-26-24 regarding allegations in the area(s) of: resident care Number of residents present at the facility at the beginning of the inspection: 107 Number of resident records reviewed: 1 Number of interviews conducted with staff: 2 An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s); area(s) of non-compliance with standard(s) or law were: resident care A violation notice was issued; any violation(s) not related to the complaint(s) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. 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 Kimberly Davis, Licensing Inspector at (804) 662-7578 or by email at Kimberly@dss.virginia.gov

Violations

22VAC40-73-460-H

Based on a review of resident records the facility failed to ensure that personal assistance and care are provided to each resident as necessary so that the needs of the resident are met, including assistance or care with: 1.The activities of daily living: a. Bathing - at least twice a week, but more often if needed or desired; b. Dressing; c. Toileting; d. Transferring; e. Bowel control; f. Bladder control; and g. Eating/feeding; as well as instrumental activities of daily living to include hygiene and grooming.

Evidence

The record for Resident # 1 contained a Task Administration Record for June 2024 which documented daily care provided, but did not contain staff initials to indicate care was provided for the following dates: June 1-3, 6, 8-9, 11, 14-16,18, 21-23, 26-30 for Safety Checks for Meals, Dining Intake Documentation, Dressing Assistance, Grooming Assistance, and Toileting/Incontinence Care. Bathing Assistance was only documented with staff initials on the following dates: June 4, 13, 17, 20, 24, and 25.

Plan of correction

The Facility will ensure that the care is provided to each resident as necessary so that their needs are met by 8/29/2024. The Charge Nurse will ensure that care is provided to the residents and documented by 8/29/2024. The Director of Wellness (and/or an appropriate designee) will ensure that all residents’ care is documented daily by 8/29/2024. The Executive Director (and/or an appropriate designee) will review a sample of 5 residents weekly to ensure compliance for three consecutive months by 11/29/2024.

July 29, 2024Complaint survey3 violations

Inspection dates

07/29/2024

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND

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: 7-29-24 from 10:10 a.m.- 3:00 p.m. 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 regarding allegations in the area(s) of: resident care. Number of residents present at the facility at the beginning of the inspection: 117 Number of resident records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s); area(s) of non-compliance with standard(s) or law were: resident care and buildings and grounds. A violation notice was issued; any violation(s) not related to the complaint(s) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Kimberly Davis, Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov

Violations

22VAC40-73-650-A

Based on a review of resident records the facility failed to ensure that no medication, dietary supplement, diet, medical procedure, or treatment shall be started, changed, or discontinued by the facility without a valid order from a physician or other prescriber.

Evidence

-The physician’s order sheet for Resident # 1 for the month of July 2024 indicated “Diet Texture- Pureed”. However, licensing staff observed Resident # 1 in the dining area during the lunch meal eating a sandwich and mixed vegetables were on the resident’s plate. -Hospice notes dated 4-19-24 documented, “Med Tech requested for patient diet to be switched from a soft regular diet to a pureed diet due to increase tendency to pocket food.”

Plan of correction

The Facility will ensure that no medication, dietary supplement, diet, medical procedure or treatment shall be started or changed or discontinued without a valid order from a physician or a medical provider. The Director of Wellness (and/or an appropriate designee) will re- educate staff on medical providers orders process. The Director of Wellness (and/or an appropriate designee) will monitor orders for three consecutive months.

22VAC40-73-860-I

Based on observation by licensing staff the facility failed to ensure that it shall store cleaning supplies and other hazardous materials in a locked area.

Evidence

Licensing staff observed a male resident walking on the memory care unit carrying a bottle of Downy liquid laundry detergent in his hand. (Photographic evidence was taken). Staff removed the bottle of laundry detergent from the resident when advised to do so by licensing staff.

Plan of correction

The Facility will ensure that all cleaning and laundry supplies are stored in a secure and locked area. The Director of Wellness (and/or an appropriate designee) will be re- educated the staff on storing cleaning supplies. The Memory Care Director (and/or an appropriate designee) will monitor compliance. The Executive Director will round memory care to ensure compliance.

22VAC40-73-650-E

Based on a review of resident records the facility failed to ensure that the resident's record shall contain the physician's or other prescriber's signed written order.

Evidence

The record for Resident # 1 contained a physician’s order sheet for the month of July 2024 that was not signed by the physician or other prescriber and facility staff confirmed.

Plan of correction

The Facility will ensure that all orders received from a medical provider are signed. The Director of Wellness (and/or an appropriate designee) will re- educate staff on medical providers orders process. The Director of Wellness (and/or an appropriate designee) will monitor orders for three consecutive months.

June 17, 2024Complaint survey3 violations

Inspection dates

06/17/2024

Areas reviewed

22VAC40-73 PERSONNEL22VAC40-73 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: 6-17-24 from 1:55 p.m.- 3:05 p.m. 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 3-19-24 regarding allegations in the area(s) of: personnel and resident care. Number of residents present at the facility at the beginning of the inspection: 119 Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with staff: 1 An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s); area(s) of non-compliance with standard(s) or law were: resident care. A violation notice was issued; any violation(s) not related to the complaint(s) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. 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 Kimberly Davis, Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov

Violations

22VAC40-73-450-C

Based on a review of resident records the facility failed to ensure that the resident’s Individualized Service Plan (ISP) contained the date of the identified need and a written description of what services will be provided to address identified needs.

Evidence

The ISP for Resident # 1 (with a report date of 6-17-24) did not contain the written description of the need for the facility’s use of a zippered jumpsuit for the resident or the date of the identified need and facility staff confirmed.

Plan of correction

The Facility will update each resident's individualized service plan {ISP) as frequent as needed based on residents' needs. The Director of Wellness (and/or an appropriate designee) will be responsible for reviewing and completing all such ISPs. The Executive Director will spot check five ISPs each month for compliance for three consecutive months.

22VAC40-73-710-C

Based on a complaint received as well as an interview with staff, the facility failed to ensure that if a restraint is used, it is imposed in accordance with a physician’s written order that specifies the condition, circumstances, and duration under which the restraint is to be used.

Evidence

Per an interview with Staff # 1, the facility purchased a jumpsuit that zipped in the back for Resident # 1 because resident would take her clothes off and use the bathroom in the hallway. -Staff # 1 acknowledged that the facility did not have a physician’s written order for the zippered jumpsuit for Resident # 1.

Plan of correction

The Facility will not utilize any perceived restrainT without a physician order that specify condition, circumstances, and duration. The Director of Wellness (and/or an appropriate designee) will be educated on restrained use. The Executive Director will also be re-educated on use of restraint to ensure compliance.

22VAC40-73-450-E

Based on a review of resident records the facility failed to ensure that the individualized service plan shall be signed and dated by the licensee, administrator, or his designee, (i.e., the person who has developed the plan), and by the resident or his legal representative.

Evidence

The ISP for Resident # 1 (with a report date of 6-17-24) was not signed or dated at all and facility staff confirmed.

Plan of correction

The Facility will complete each Individualized Service Plan (ISP) as required and on time. Each ISP will be signed and dated by the Facility's Executive Director or Director of Wellness or an appropriate designee and by the resident or their legal representative. The Director of Wellness (and/or an appropriate designee) will be responsible for reviewing and completing all such ISPs. The Executive Director will spot check five ISPs each month for compliance for three consecutive months.

June 17, 2024Complaint survey3 violations

Inspection dates

06/17/2024

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 6-17-24 from 12:35 p.m. – 1:55 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 2-16-24 regarding allegations in the area(s) of: resident care Number of residents present at the facility at the beginning of the inspection: 119 Number of resident records reviewed: 1 Number of interviews conducted with staff: 1 Additional Comments/Discussion: An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation(s)of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint(s) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Kimberly Davis, Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov

Violations

22VAC40-73-325-B

Based on a review of the resident’s record the facility failed to ensure that the fall risk rating shall be reviewed and updated under each of the following circumstances: 1. At least annually; 2. When the condition of the resident changes; and 3. After a fall.

Evidence

The record for Resident # 1 contained charting notes indicating that the resident had two falls in January 2023 on the following dates : 1-17-23 and 1-30-23. However, the resident’s record only contained one fall risk assessment updated 2-12-23.

Plan of correction

The Facility will ensure that all fall risk ratings are completed after each fall and at least annually. The Director of Wellness (and/or designee) will verify that the fall risk ratings are completed in a timely manner. The Executive Director will spot check during the monthly safety meetings to ensure compliance for three consecutive months.

22VAC40-73-470-F

Based on a review of the resident’s record the facility failed to ensure that when the resident suffers serious accident, injury, illness, or medical condition, or there is reason to suspect that such has occurred, medical attention from a licensed health care professional shall be secured immediately. The circumstances involved and the medical attention received or refused shall be documented in the resident's record. The date and time of occurrence, as well as the personnel involved shall be included in the documentation. 1. The resident's physician, if not already involved, next of kin, legal representative, designated contact person, case manager, and any responsible social agency, as appropriate, shall be notified as soon as possible but no later than 24 hours from the situation and action taken, or if applicable, the resident's refusal of medical attention. If a resident refuses medical attention, the resident's physician shall be notified immediately. 2. A notation shall be made in the resident's record of such notice, including the date, time, caller, and person notified.

Evidence

Facility progress notes for Resident # 1 for February 2024 noted that the resident tested positive for COVID-19 on 2-10-24. However, there was no documentation in the resident’s record to indicate that the facility had notified the resident’s next of kin of the resident testing positive for COVID, as there was no notation of the date, time, caller, and person notified by the facility.

Plan of correction

The Facility will reeducate staff to ensure that the attending medical provider, next of kin, legal representative, and designated contact person are notified of any change of condition and/or illness. In addition, the Facility will reeducate staff to ensure that such notification is documented. The Director of Wellness (and/or an appropriate designee) will complete the reeducation and monitor notification. The Executive Director will review each change of condition incident to ensure compliance for three consecutive months.

22VAC40-73-450-E

Based on a review of the resident’s record the facility failed to ensure that the individualized service plan shall be signed and dated by the licensee, administrator, or his designee, (i.e., the person who has developed the plan), and by the resident or his legal representative.

Evidence

The ISP dated 2-1-24 for Resident # 1 was not signed or dated at all.

Plan of correction

The Facility will complete each Individualized Service Plan (ISP) as required and on time. Each ISP will be signed and dated by the Facility’s Executive Director or Director of Wellness or an appropriate designee and by the resident or their legal representative. The Director of Wellness (and/or an appropriate designee) will be responsible for reviewing and completing all such ISPs. The Executive Director will spot check five ISPs each month for compliance for three consecutive months.

June 17, 2024Complaint survey1 violation

Inspection dates

06/17/2024

Areas reviewed

22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Comments

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 6-17-24 from 9:45 a.m. -12:35 p.m. 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 regarding allegations in the area(s) of: staffing on the memory care unit. Number of residents present at the facility at the beginning of the inspection: 119 Number of interviews conducted with staff: 1 An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation(s) of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint(s) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Kimberly Davis, Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov

Violations

22VAC40-73-1130-A

Based on a review of the facility’s memory care staff schedules, the facility failed to ensure that except during night hours, when 20 or fewer residents are present, at least two direct care staff members shall be awake and on duty at all times in each special care unit who shall be responsible for the care and supervision of the residents. For every additional 10 residents, or portion thereof, at least one more direct care staff member shall be awake and on duty in the unit.

Evidence

-The staff schedule for memory care on 1-13-24 indicated that there were 3 staff on the memory care unit with a census of 32 residents. -The staff schedule for memory care on 2-3-24 indicated that there were 3 staff on the memory care unit with a census of 32 residents.

Plan of correction

The Facility will ensure that staffing requirements are met for the Memory Care unit. The Director of Wellness (and/or a designee) will ensure that every attempt is made to replace a staff “call off.” The Director of Wellness (and/or a designee) will document on the schedule the replacement for the staff “call off.” For a period of 90 days, the Executive Director will ensure compliance with the above-described correction measures.

March 20, 2024Complaint survey6 violations

Inspection dates

03/20/2024

Areas reviewed

22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND

Comments

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 3-20-24 from 9:05 a.m.-12:30 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 3-7-24 regarding allegations in the area(s) of: resident care. Number of residents present at the facility at the beginning of the inspection: 115 Number of resident records reviewed: 1 Number of interviews conducted with staff: 1 An exit meeting was 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. 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 Kimberly Davis, Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov

Violations

22VAC40-73-325-B

Evidence

The record for Resident #1 contained charting notes that documented that the resident went to the ER due to a fall on February 10, 2024. However, the resident’s record did not contain a fall risk assessment/rating after that fall.

Plan of correction

The Facility will ensure that all fall risk ratings are completed after each fall and at least annually. The Director of Wellness (and/or designee) will verify that the fall risk ratings are completed in a timely manner. The Executive Director will spot check during the monthly safety meeting to ensure compliance for three consecutive months.

22VAC40-73-460-H

Based on a review of the resident’s record the facility failed to ensure that personal assistance and care are provided to each resident as necessary so that the needs of the resident are met, including assistance or care with: 1.The activities of daily living, to include Bathing - at least twice a week, but more often if needed or desired, Toileting, Eating/feeding 2. The instrumental activities of daily living, to include Meal Preparation, Housekeeping/Laundry 3.Ambulation, 4. Hygiene and grooming.

Evidence

-The facility’s Shower Form for Resident # 1 only contained documentation with staff initials for resident shower dates for January 2024 for January 24 and 30 and for February 2024 for February 1, 8, 14, and 21. - There was no documentation/staff initials on the facility’s Task Administration Record for Resident # 1 for Bathing Assistance for January 2024 except for the following dates: January 15,18, and 25. - There was no documentation/staff initials on the facility’s Task Administration Record for Resident # 1 for Bathing Assistance for February 2024 except for the following dates: February 1 and 22. - There was no documentation/staff initials on the facility’s Task Administration Record for Resident # 1 for Dressing Assistance for “Wake Up” except for the following dates in February 2024: February 1,5, 7,17. -There was no documentation/staff initials on the facility’s Task Administration Record for Resident # 1 for Dressing Assistance for “Bed Time” except for the following dates in February 2024: February 6 and 14. - There was no documentation/staff initials on the facility’s Task Administration Record for Resident # 1 for Toileting/Incontinence Care Assistance except for the following dates in January 2024: January 1,7-9,13,14,18, 20, 21, 22, 24-26, and 29. - There was no documentation/staff initials on the facility’s Task Administration Record for Resident # 1 for Toileting/Incontinence Care Assistance except for the following dates in February 2024: February 1,4-9, 12,14,17,24, and 27. - There was no documentation/staff initials on the facility’s Task Administration Record for Resident # 1 for Meal Escort Assistance except for the following dates in January 2024: Breakfast-January 3, 9,15,18,19, 21,24, 25, 27, and 30. Lunch- January 2, 9,15, 21,24, and 25. Dinner-January 2, 9, 14, 24-26, and 30.

Plan of correction

The Facility shall ensure that personal assistance and care are provided to each resident as necessary, so the needs of the resident are met, all per the ISPs. All direct care staff are being reeducated on daily charting of each resident’s ADL’s tasks. The Charge Nurse will ensure that care is provided to the residents and documented per ISPs. The Director of Wellness (and / or an appropriate designee) will monitor daily charting and follow up as necessary. The Executive Director will spot check the above-described efforts and tasks daily for three consecutive months.

22VAC40-73-450-H

Based on a review of the resident’s record the facility failed to ensure that the facility shall ensure that the care and services specified in the individualized service plan (ISP) are provided to each resident.

Evidence

-The ISP for Resident # 1 dated 12-8-23 listed Bathing and Showering Assistance frequency as “Once every Monday, Thursday, and as needed.” However, the facility’s Task Administration Record for January 2024 and February 2024 failed to document this frequency for resident’s bathing and showering. -The ISP for Resident # 1 dated 12-8-23 listed Toileting and Incontinence Care Assistance frequency as “3 x every day and as needed.” However, the facility’s Task Administration Record for January 2024 and February 2024 failed to document this frequency for resident’s toileting and incontinence care. - The ISP for Resident # 1 dated 12-8-23 listed Dressing Assistance frequency as “2 x every day”. However, the facility’s Task Administration Record for January 2024 and February 2024 failed to document this frequency for resident’s dressing assistance. - The ISP for Resident # 1 dated 12-8-23 listed Diet and Dietary Assistance frequency as “As Needed Every Day.” However, the facility’s Task Administration Record for January 2024 and February 2024 failed to document this frequency for resident’s Diet and Dietary Assistance. - The ISP for Resident # 1 dated 12-8-23 listed Housekeeping and Laundry frequency as “Once Every Monday And As Needed.” However, the facility’s Task Administration Record for January 2024 and February 2024 contained no documentation at all to indicate Housekeeping and Laundry for resident.

Plan of correction

The Facility shall ensure that personal assistance and care are provided to each resident as necessary and documented appropriately. All direct care staff are being reeducated on daily charting of each resident’s ADL’s tasks. However, housekeeping does not document in the Electronic Health Record tasks. They maintain their own tracking system. The Charge Nurse will ensure that care is provided to the residents and documented as per the above. The Director of Wellness (and / or an appropriate designee) will monitor daily charting and follow up as necessary. The Executive Director will spot check the above-described efforts and tasks daily for three consecutive months. The Executive Director will also verity that all housekeeping tasks are completed and documented for three consecutive months

22VAC40-73-590-A

Based on a review of the resident’s record the facility failed to ensure that at least three well-balanced meals, served at regular intervals, shall be provided daily to each resident, unless contraindicated as documented by the attending physician in the resident's record or as provided for in 22VAC40-73-580 G.

Evidence

-There was no documentation/staff initials on the facility’s Task Administration Record for Resident # 1 for meal intake for Breakfast in February 2024, except on February 7,17, and 18. - There was no documentation/staff initials on the facility’s Task Administration Record for Resident # 1 for meal intake for Lunch in February 2024, except on February 7 and 17. - There was no documentation/staff initials on the facility’s Task Administration Record for Resident # 1 for meal intake for Dinner in February 2024, except on February 6, 14, and 22. - There was no documentation/staff initials on the facility’s Task Administration Record for Resident # 1 for meal intake for Breakfast in January 2024, except on January 3, 9,15,18,19, 21, 24 ,25, 27, and 30. - There was no documentation/staff initials on the facility’s Task Administration Record for Resident # 1 for meal intake for Lunch in January 2024, except on January 2, 9,15, 21, 24, and 25. - There was no documentation/staff initials on the facility’s Task Administration Record for Resident # 1 for meal intake for Dinner in January 2024, except on January 2,9,14, 24-26, and 30.

Plan of correction

The Facility will continue to provide three nutritional meals for all residents. Direct care staff to round and ensure all residents are escorted (as needed) to the dining room and that meal attendance is documented, as appropriate. Charge nurses to ensure that residents have had their meals and care staff have documented meal attendance as required by individual service plans. The Wellness Director (and/or designee) will review on daily basis to ensure compliance. The Executive Director will sample five (5) resident charts to ensure documentation is completed per above. Will repeat for 90 days.

22VAC40-73-930-D

Based on a review of the resident record the facility failed to ensure that for each resident with an inability to use the signaling device, in addition to any other services, the following shall be met: The facility shall document the rounds that were made, which shall include the name of the resident, the date and time of the rounds, and the staff member who made the rounds. The documentation shall be retained for two years.

Evidence

The record for Resident # 1 did not contain documentation of rounds. Staff # 1 was unable to locate rounds documentation for Resident # 1.

Plan of correction

22VAC40-73-460-F

Based on a review of the resident’s record the facility failed to ensure that the facility shall notify the next of kin, legal representative, designated contact person, or, if applicable, any responsible social agency of any incident of a resident falling or wandering from the premises, whether or not it results in injury. This notification shall occur as soon as possible but no later than 24 hours from the time of initial discovery or knowledge of the incident. The resident's record shall include documentation of the notification, including date, time, caller, and person or agency notified.

Evidence

The record for Resident # 1 contained charting notes dated February 10, 2024 stating, “Resident returned from ED at UVA...no injuries found from fall.” However, the resident’s record contained no documentation of notification to the resident’s next of kin, legal representative, or designated contact person regarding the resident’s fall.

Plan of correction

The Facility will re-educate all nurses on family notification after an adverse incident and documentation. The Director of Wellness (and/or designee) will ensure that all nurses are educated and monitor to ensure adherence to said requirement. The Executive Director will spot check to ensure compliance.

March 20, 2024Complaint survey3 violations

Inspection dates

03/20/2024

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 3-20-24 from 12:30 p.m.-2:20 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 1-19-24 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: 115 Number of resident records reviewed: 1 Number of interviews conducted with staff: 1 An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s); area(s) of non-compliance with standard(s) or law were: resident care. A violation notice was issued; any violation(s) not related to the complaint 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 Kimberly Davis, Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov

Violations

22VAC40-73-440-A

Based on a review of resident records the facility failed to ensure that all residents of and applicants to assisted living facilities shall be assessed face to face using the uniform assessment instrument in accordance with Assessment in Assisted Living Facilities. The UAI shall be completed prior to admission, at least annually, and whenever there is a significant change in the resident's condition.

Evidence

The record for Resident # 1 did not contain a UAI and Staff # 1 was unable to locate the resident’s UAI.

Plan of correction

The Facility will reeducate staff to ensure that Uniform Assessment Instruments (UAI) are completed prior to admission, annually, and whenever there is a significant change in the resident’s condition. UAIswill be updated as they mature. The Facility is in the process of auditing UAIs and will create a tracker to properly identify necessary UAI updates/revisions. The tracker will review the UAIs monthly. The Director of Wellness (and/or an appropriate designee) will retrieve data from the tracker and complete the UAIs as needed per the above. The Executive Director will spot check the Director of Wellness’s above-described efforts monthly for three consecutive months.

22VAC40-73-460-H

Based on a review of resident records the facility failed to ensure that personal assistance and care are provided to each resident as necessary so that the needs of the resident are met, including assistance or care with: bathing - at least twice a week, but more often if needed or desired; trimming fingernails and toenails (certain medical conditions necessitate that this be done by a licensed health care professional).

Evidence

- The facility’s Task Administration Record for Resident # 1 for Bathing Assistance for the month of December 2023 only contained documentation of staff initials on 12-21-23 and 12-28-23. -The facility’s Task Administration Record for Resident # 1 for the month of December 2023 contained no documentation of staff initials at all for Nail Care Assistance. - The facility’s Task Administration Record for Resident # 1 for the month of December 2023 contained no documentation of staff initials at all from December 1-13, 2023 for 19 of 20 daily tasks identified, except CPAP or BIPAP machine assistance.

Plan of correction

The Facility shall ensure that personal assistance and care are provided to each resident as necessary, so the needs of the resident are met, all per the ISPs. All direct care staff are being reeducated on daily charting of each resident’s ADL’s tasks. The Director of Wellness (and / or an appropriate designee) will monitor daily charting and follow up as necessary. The Executive Director will spot check the above-described efforts and tasks daily for three consecutive months.

22VAC40-73-450-E

Based on a review of resident records the facility failed to ensure the individualized service plan (ISP) shall be signed and dated by the licensee, administrator, or his designee, (i.e., the person who has developed the plan), and by the resident or his legal representative.

Evidence

The record for Resident # 1 contained an ISP that was not signed or dated at all.

Plan of correction

The Facility will complete each Individualized Service Plan (ISP) as required and on time. Each ISP will be signed and dated by the Facility’s Executive Director or Director of Wellness or an appropriate designee and by the resident or their legal representative. NOTE: The Facility is in the process of identifying residents in need of an updated ISP. The Director of Wellness (and/or an appropriate designee) will be responsible for reviewing and completing all such ISPs. The Executive Director will spot check five ISPs each month for compliance for three consecutive months.

December 14, 2023Inspection3 violations

Inspection dates

12/14/2023

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND

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: 12-14-23 from 12:10 p.m.- 1:45 p.m. 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 11-27-23 regarding allegations in the area(s) of: resident care and building and grounds. Number of residents present at the facility at the beginning of the inspection: 118 Number of resident records reviewed: 1 Number of interviews conducted with staff: 2 An exit meeting was 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 Kimberly Davis, Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov

Violations

22VAC40-73-460-H

Based on a self-report from the facility dated 11-25-23, the facility failed to ensure that personal assistance and care are provided to each resident as necessary so that the needs of the resident are met, including assistance or care with: The activities of daily living to include bowel control, bladder control; and eating/feeding.

Evidence

-A self-report received from the facility dated 11-25-23 stated, “Personal Assistant (PA) failed to complete morning ADLs as well as failure to provide care set forth in the resident’s care plan of care, causing the resident to miss a meal and go an extended period without incontinent care.” -The facility’s administrator and director of wellness confirmed that the agency personal assistant who was assigned to Resident # 1 was relieved of her duties, removed from the facility, and placed on a do not return status due to failure to provide care to the resident according to resident’s plan of care.

Plan of correction

The Facility will ensure that care is provided to each resident as necessary so that their needs are met pursuant to individual service plans. The Charge Nurse will ensure that care is provided to the residents and documented pursuant to individual service plans. The Wellness Director will ensure that all residents’ care is documented daily. The Executive Director will sample five (5) residents’ charts to ensure documentation is completed per above. Will repeat for 90 days.

22VAC40-73-450-H

Based on a review of the identified resident’s Individualized Service Plan (ISP), the facility failed to ensure that the care and services specified in the individualized service plan are provided to each resident.

Evidence

Resident #1’s ISP dated 12-8-23 indicates that the resident needs assistance with “toileting and incontinence care 3 x every day and as needed” as well as “meal escort assistance 3 x every day-PA to assist resident with escorts to meals by reminding her of the time for meals.” However, based on the facility’s self-report and statements from the administrator and director of wellness, the PA failed to provide assistance such that the resident missed a meal and did not receive incontinent care for an extended period on 11-25-23.

Plan of correction

The facility will continue to provide three nutritional meals for all residents. Direct care staff to round and ensure all residents are escorted to the dining room if such service is required in the resident’s individual service plan. Charge nurses to ensure that residents have had their meals and care staff has documented meal attendance as required by individual service plans. The Wellness Director (and/or designee) will review on daily basis to ensure compliance. The Executive Director will sample five (5) residents’ charts to ensure documentation is completed per above. Will repeat for 90 days.

22VAC40-73-460-B

Based on a review of the facility’s call bell history for Resident # 1 for the month of November 2023, the facility failed to provide prompt response by staff to the residents' needs to ensure that care provision and service delivery were resident care centered to the maximum extent.

Evidence

-The facility’s Call History Log for Resident # 1 indicates wait times for staff response for the following: 10-20 minutes on six instances on 11-25-23. -On 11-24-23 the call history log for Resident # 1 indicates three instances of wait times of 10-20 minutes, four instances of 21-30 minutes, and two instances of a 3 hr. wait time.

Plan of correction

Charge nurses to ensure that residents have had their meals and care staff has documented meal attendance as required by individual service plans. The Wellness Director (and/or designee) will review on daily basis to ensure compliance. The Executive Director will sample five (5) residents’ charts to ensure documentation is completed per above. Will repeat for 90 days.

November 27, 2023Inspection9 violations

Inspection dates

11/27/2023,01/03/2024

Areas reviewed

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: 11-27-23 from 10:10 a.m.- 2:45 p.m. and 1-3-24 from 10:05 a.m.-3:30 p.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: 122 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: 4 Number of interviews conducted with staff: 4 Additional Comments/Discussion: The following items were also reviewed/observed during the inspection-facility documentation, facility postings, first aid kit, medication pass, physician’s orders, Medication Administration Records (MARs), and lunch meal/menu. An exit meeting was 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 Kimberly Davis, Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov

Violations

22VAC40-73-980-C

Based on a review of the facility’s first aid kit the facility failed to ensure that first aid kits shall be checked at least monthly to ensure that all items are present and items with expiration dates are not past their expiration date.

Evidence

The facility did not have documentation of when the first aid kit was last checked.

Plan of correction

The Facility will have a first aid inspected monthly to ensure that all items are present and content is not expired. The Wellness Director (and/or designee) will check the first aid kit and sign off monthly. The Executive Director will verify that the inspection is completed.

22VAC40-73-950-E

Based on a review of facility documentation the facility failed to ensure a semi-annual review on the emergency preparedness and response plan for all staff, residents, and volunteers, with emphasis placed on an individual's respective responsibilities. The review shall be documented by signing and dating. The orientation and review shall cover responsibilities for: 1. Alerting emergency personnel and sounding alarms; 2. Implementing evacuation, shelter in place, and relocation procedures; 3. Using, maintaining, and operating emergency equipment; 4. Accessing emergency medical information, equipment, and medications for residents; 5. Locating and shutting off utilities; and 6. Utilizing community support services.

Evidence

The facility was unable to provide documentation of a semi-annual review on the emergency preparedness and response plan for all staff, residents, and volunteers.

Plan of correction

All direct staff personnel will have proof of tuberculosis screening in their records. All direct staff personnel records will be audited for compliance. The Director of Business Operations (and/or designee) will track and coordinate the completion of TB screening as needed. The Executive Director (and/or designee) will oversee said annual audit to ensure compliance.

22VAC40-73-440-A

Based on a review of resident records the facility failed to ensure that each resident’s UAI shall be completed prior to admission, at least annually, and whenever there is a significant change in the resident's condition.

Evidence

-The record for Resident # 6 (admit date:8-31-22) contained a UAI last dated 9-22-22. -The record for Resident # 7 (admit date: 9-23-19) contained a UAI last dated 9-10-22.

Plan of correction

The Facility will ensure that the Uniform Assessment Instrument (UAI) is completed prior to admission, annually and whenever there is a significant change in the resident’s condition. UAI will be completed as they mature. The Wellness Director (and/or designee) will track and complete the UAI. The Wellness Director (and/or designee) will spot check monthly for three consecutive months.

22VAC40-73-520-I

Based on observation of facility postings the facility failed to ensure that the current month's activity schedule shall be posted in a conspicuous location in the facility or otherwise be made available to residents and their families.

Evidence

During a tour of the facility on 1-3-24, the licensing inspector observed that the activity schedule posted in the hallway on the first floor was for the month of December.

Plan of correction

The Facility will ensure that the activities calendar is updated in the middle of the current month and posted by the first day of each month. The Activity Director (and/or designee) will complete and post the calendar the first day of the month. The Executive Director (and/or designee) will monitor for compliance.

22VAC40-73-610-B

Based on observation of facility postings the facility failed to ensure that menus for meals and snacks for the current week shall be dated and posted in an area conspicuous to residents.

Evidence

During a tour of the facility on 1-3-24, the licensing inspector observed that the menu posted in the main dining room was dated for the week of 12-17-23 through 12-23-23.

Plan of correction

22VAC40-73-250-D

Based on a review of staff records the facility failed to ensure each staff person shall annually submit the results of a risk assessment, documenting that the individual is free of tuberculosis (TB) in a communicable form as

Evidence

d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: -The record for Staff # 3 (date of hire: 9-27-22) contained a TB screening last dated 11-21-22. -The record for Staff # 4 (date of hire:4-7-21) contained a TB screening last dated 11-10-22. -The record for Staff # 5 (date of hire: 10-12-21) contained a TB screening last dated 11-11-22.

Plan of correction

22VAC40-73-550-G

Evidence

of this review shall be the resident's, his legal representative's or responsible individual's, written acknowledgment of having been so informed, which shall include the date of the review and shall be filed in the resident's record. Evidence: The record for Resident # 6 (admit date: 8-31-22) and Resident # 8 (admit date: 9-28-22) did not contain written acknowledgment of an annual review of the rights and responsibilities of residents in assisted living facilities.

Plan of correction

The Facility will review residents’ rights annually with each resident or his/her legal representative. Evidence of this review will be maintained in the resident business records. The annual review will take place at the beginning of the month of November of each year. The Business office (and/or designee) will complete the annual requirement. The Executive Director will verify that all residents have signed the residents’ rights for compliance.

22VAC40-73-450-E

Evidence

-The ISP for Resident # 4 (admit date: 9-5-23) was not signed or dated at all. -The ISP for Resident # 5 (admit date: 5-15-23) was not signed or dated at all. -The ISP for Resident # 9 (admit date: 9-5-19) was not signed or dated by the resident or his/her legal representative.

Plan of correction

The Facility will timely complete each Individualized Service Plan (ISP). 01/02/2024 Each ISP will be signed and dated by the licensee, administrator, or designee and by the resident or their legal representative. Director of Wellness and/or Assistant Director of Wellness will be responsible for reviewing and completing each ISP. The Executive Director will spot check five ISPs per month for compliance for three consecutive months.

22VAC40-73-450-F

Based on a review of resident records the facility failed to ensure that Individualized service plans shall be reviewed and updated at least once every 12 months and as needed for a significant change of a resident’s condition.

Evidence

-The record for Resident # 6 (admit date: 8-31-22) contained an ISP last dated 10-31-22. -The record for Resident # 7 (admit date: 9-23-19) contained an ISP last dated 11-5-22. -The ISP for Resident # 9 (admit date: 9-5-19) was last dated 8-3-22.

Plan of correction

The Facility will timely complete each Individualized Service Plan (ISP). Each ISP will be signed and dated by the licensee, administrator, or designee and by the resident or their legal representative at least every 12 months. Director of Wellness and/or Assistant Director of Wellness will be responsible for reviewing and completing each ISP. The Executive Director will spot check five ISPs per month for compliance for three consecutive months.

September 8, 2023Inspection0 violations

Inspection dates

09/08/2023,09/19/2023

Areas reviewed

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: 9-8-23 from 10:00 a.m.- 3:53 p.m. and 9-19-23 from 9:37 a.m.-2:30 p.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: 125 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: 4 Number of interviews conducted with staff: 5 Additional Comments/Discussion: The following items were also reviewed/observed: facility postings, facility documentation, lunch meal/menu, emergency food and water, first aid kit supplies, medication pass, physician’s orders, and Medication Administration Records. 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 Kimberly Davis, Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

June 23, 2023Inspection0 violations

Inspection dates

06/23/2023

Areas reviewed

22VAC40-73 BUILDINGS AND GROUNDS22VAC40-80 THE LICENSING PROCESS

Technical assistance

Technical assistance was provided regarding updated resident agreements and new criminal background checks for staff.

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: 6-23-23 from 11:03 a.m.- 12:35 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Additional Comments/Discussion: An initial inspection was conducted by licensing staff due to a change of ownership. In addition to observing the physical plant, facility documentation and facility postings were also reviewed. No violations were cited. A conditional license will be recommended. An exit meeting was conducted to review the inspection findings. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Kimberly Davis, Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.