Virginia DSS · Assisted Living Facility

Lakeside ALF Operations, LLC

📍 2125 Hilliard Road, Henrico, VA, 23228

ID 49207Two Year licenseActive
8
Inspections
On record
4
With violations
Visits that cited something
4
Clean visits
Nothing cited
11
Violations cited
Individual findings
11
Standards cited
Distinct rules
2
Complaint visits
Prompted by a complaint

Lakeside ALF Operations, LLC was inspected 8 times between January 27, 2023 and June 4, 2025 by the Virginia Department of Social Services. 4 of those visits ended with violations cited and 4 with none. Across that history VDSS cited 11 violations under 11 distinct standards. 2 inspections were prompted by a complaint.

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

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

Provider Information

Facility type
Assisted Living Facility
License type
Two Year
License expires
07/31/2027
Administrator
Sarah Blackard
Licensing inspector
Coy Stevenson
Inspector phone
(804) 972-4700
Approved for
Assisted Living

Inspection History

8

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

June 4, 2025Inspection1 violation
Inspection dates
06/04/2025
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 IMPAIRMENTS63.2 GENERAL PROVISIONS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An on-site renewal inspection was conducted on June 04, 2025, between approximately 1:00 PM and 2:45 PM. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 17 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 2 Number of interviews conducted with staff: 1 Observations by licensing inspector: Residents were observed interacting with each other and staff. Interactions were appropriate. Residents were appropriately dressed and groomed for the time of day, weather conditions, and activities they were engaged in. The residents were observed conducting a resident council meeting with staff observing but not interfering or attempting to take over the meeting. Additional Comments/Discussion: The facility has recently completed major renovations to the apartments and general areas of the facility. 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 Coy Stevenson, Licensing Inspector at (804) 972-4700 or by email at coy.stevenson@dss.virginia.gov.
Violations
22VAC40-73-450-E
The facility did not ensure that individual service plan for each resident was signed and dated by the licensee, administrator, or his designee, (i.e., the person who has developed the plan), and by the resident or their legal representative, as applicable.
Evidence
  1. A review of the individualized service plan for Resident #2 was not signed by either the licensee, administrator, or their designee, or by the resident or their legal representative.
  2. Staff #2 confirmed the required signatures were missing from the resident’s service plan.
Plan of correction
The ISP that was found to not have signatures has been corrected as signatures were obtained by both the resident and administrator on 6-4-25. An audit of all resident files will be conducted to ensure that no others are missing signatures and will be conducted monthly going forward.
August 15, 2024Complaint survey0 violations
Inspection dates
08/15/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 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: 08/15/2024 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A (complaint/self-reported incident) was received by VDSS Division of Licensing on 08/05/2024 regarding allegations in the area(s) of: Resident care; physical conditions of the facility The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. The alleged violations were not occurring in the assisted living portion of the facility. The complainant was provided with the contact information for the responsible oversight agency. 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 Coy Stevenson, Licensing Inspector at 804-972-4700 or by email at coy.stevenson@dss.virginia.gov. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
July 10, 2024Inspection0 violations
Inspection dates
07/10/2024
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-90 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
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: 1 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 3 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 4 Observations by licensing inspector: An inspection of the resident’s apartment and common areas of the facility were inspected. The licensing inspector observed the registered medication aide assist the resident with the self-administration of her medications. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Coy Stevenson, Licensing Inspector at (804) 972-4700 or by email at 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: 07/10/24 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: 1 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 3 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 4 Observations by licensing inspector: An inspection of the resident’s apartment and common areas of the facility were inspected. The licensing inspector observed the registered medication aide assist the resident with the self-administration of her medications. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Coy Stevenson, Licensing Inspector at (804) 972-4700 or by email at coy.stevenson@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
March 4, 2024Complaint survey0 violations
Inspection dates
03/04/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-80 COMPLAINT INVESTIGATION
Technical assistance
Discussed with the provider the need to ensure that over-the-counter medications for clients are appropriately labeled with the name of the resident(s) the medication is to be given to as directed.
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: An onsite inspection occurred on March 04, 2024. 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 November 08, 2023 regarding allegations in the area(s) of: Medication/Medical Issues Housekeeping/Sanitation Number of residents present at the facility at the beginning of the inspection: Nine The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: Zero Number of staff records reviewed: Zero Number of interviews conducted with residents: Zero Number of interviews conducted with staff: Two Observations by licensing inspector: Medication pass; storage of medications; resident rooms; dining areas; common areas of the facility Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Coy Stevenson, Licensing Inspector at (804) or by email at coy.stevenson@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
July 27, 2023Inspection3 violations
Inspection dates
07/27/2023
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS
Technical assistance
Under new ownership, ensuring staff training, care planning, and physical examinations are correct and up-to-date.
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7-27-2023, 9:00 – 11:15 a.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 10 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility, medication pass observation, interview with staff, record review, and emergency supplies. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the 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 Alexandra Poulter, Licensing Inspector at (804)662-9771 or by email at alex.poulter@dss.virginia.gov
Violations
22VAC40-73-980-A
Based on observation and interview with staff, the facility failed to ensure a complete first aid kit was on hand at the facility.
Evidence
  1. The first aid kit onsite did not have a blanket, cold pack, or first aid instruction manual located in it.
  2. Staff #1 was present and observed these items were not in the first aid kit during inspection.
Plan of correction
On 9/8/2023 all items have been updated into the first aid kit. Blanket, cold pack and first aid instruction manual.
22VAC40-73-870-A
Based on record review and interview with staff, the facility failed to ensure the interior of the building was maintained in good repair and kept clean.
Evidence
  1. The following are descriptions of the interior of the building (all on the first floor of the facility): A. Water stains on the ceiling with varying darkness of stains; B. Water stains around a circular speaker on the ceiling; C. Dark gray/black circular stain on the carpeting; D. Additional water stains on the ceiling accompanied by black spots on the ceiling; E. Black paint or other similar substance streaked on the carpeting; and F. Rust-colored spots on the ceiling in the hallway.
  2. Staff #1 was present throughout the tour and observed and confirmed the aforementioned areas were not maintained in good repair and kept clean. Photographic evidence was obtained.
Plan of correction
On 9/13/2023 all carpets have been cleaned by professionals. And all ceilings have been painted.
22VAC40-73-40-D-2
Based on record review, the facility failed to ensure that if a resident chooses to stay when a facility is sold, there must be a new resident agreement between the resident and the new licensee that meets the specifications of 22VAC40-73-390.
Evidence
  1. The following six out of six residents reviewed had resident agreements dated as their previous admission date (under the previous licensee) and did not have a new resident agreement with the new licensee that met the specific requirements of 22VAC40-73-390:
  2. Resident #1 admitted 4-05-2018;
  3. Resident #2 admitted 11-25-2020;
  4. Resident #3 admitted 10-23-2021;
  5. Resident #4 admitted 9-01-2022;
  6. Resident #5 admitted 1-17-2017; and
  7. Resident #6 admitted 4-01-2021.
Plan of correction
All new contracts will be completed in 30 days.
May 12, 2023Inspection3 violations
Inspection dates
05/12/2023
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-80 THE LICENSE
Technical assistance
Resident Agreement with ALF requirements
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: May 12, 2023, 10:49 -11:45 am The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 12 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alex Poulter, Licensing Inspector at (804)662-9771 or by email at alex.poulter@dss.virginia.gov
Violations
22VAC40-80-120-A-1
Based on observation, the facility failed to operate within the terms of the license including using the operating name of the facility.
Evidence
  1. The facility’s outdoor signage on 5-12-2023 contained the formerly operating name of the facility instead of the current facility’s name from the months of February 2023 to the inspection in May. Photographic evidence was obtained.
Plan of correction
Not published by VDSS.
22VAC40-73-320-A
Based on record review and interview with staff, the facility failed to ensure the physical examination contained a description of the person’s reactions to any known allergies.
Evidence
  1. Resident #1 admitted 3-15-2023. Resident #1’s Report of Resident Physical Examination dated 3-14-2023 documented allergy reactions to Azithromycin, Gabapentin, and Tramadol; however, no description of reactions to the allergies were documented.
Plan of correction
Not published by VDSS.
22VAC40-73-970-A
Based on interview with staff, the facility failed to ensure fire and emergency evacuation drill frequency and participation was in accordance with the current edition of the Virginia Statewide Fire Prevention Code (13VAC5-51).
Evidence
  1. There were no documented fire and emergency evacuation drills, as confirmed by Staff #1on 5-12-2023.
Plan of correction
Not published by VDSS.
May 12, 2023Inspection4 violations
Inspection dates
05/12/2023
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 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: 5-12-2023, 9:53 – 10:48 am 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 3-07-2023 regarding allegations in the areas of Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 12 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alexandra Poulter, Licensing Inspector at (804)662-9771 or by email at alex.poulter@dss.virginia.gov
Violations
22VAC40-73-860-I
Based on observation, record review and interview with staff, the facility failed to store cleaning supplies and other hazardous materials in a locked area.
Evidence
  1. Resident #1 admitted 7-28-2021. A “Psychiatric Periodic Evaluation” dated 3-02-2023 documented the resident’s diagnoses as “Depression, anxiety, and a history of psychosis.” A facsimile note to Resident #1’s physician documented on 3-01-2023, “Resident [#1] attempted suicide yesterday by drinking chemicals.” “Interdisciplinary Progress Notes” by Staff #1 following the 2-28-2023 incident involving Resident #1 documented, “Called placed to hospital to check on status of resident. Told resident has been transferred to [hospital] …Resident [#1] now has a PEG tube… willing to voluntarily accept psych care.” A facility tour on 5-12-2023 by the licensing inspector showed an unlocked door with accessible chemicals located in a housekeeping closet, as well as accessible chemicals in the laundry room unlocked and accessible to residents, both on the second floor of the facility. Photographic evidence was obtained.
Plan of correction
Resident #1 no longer resides at the AL. All other residents are at risk of potential exposure or ingestion of hazardous materials that are unlocked/unsecured. Maintenance has conducted a full audit of all utility doors on both ALF/SNF to ensure they are operate as designed, they are all operational. The utility doors have been secured. Staff have been educated throughout ALF as well as all housekeepers regarding ensuring all utility doors to include the housekeeping closet is never left unattended and always secured. The same education was provided regarding the laundry area. Rounds are being completed daily (M-F) and on weekends by medication technician to ensure staff compliance with education and security of cleaning supplies and hazardous materials.
22VAC40-73-430-H-1
Based on record review and interview, the facility failed to ensure a dated discharge statement signed by the licensee or administrator contained the date on which the resident, his legal representative, or designated contact person was notified of the planned discharge and the name of the legal representative or designated contact person who was notified; and the date of the actual discharge from the facility.
Evidence
  1. Resident #1’s “Discharge Notification and Statement” did not contain: The date or signature of the licensee or administrator; The date on which the resident, his legal representative, or designated contact person was notified of the planned discharge and the name of the legal representative or designated contact person who was notified; nor the date of the actual discharge from the facility.
Plan of correction
This resident is no longer in the facility. It is our standard process to have administrator date and sign discharge notification and statement. An audit is being completed to ensure that this is being done moving forward. It is our standard process to include date on which resident or legal rep/designated contact is notified as well as to include discharge date from facility. This is to be included in our audit.
22VAC40-73-580-B
Based on record review, the facility failed to ensure if a resident's individualized service plan [ISP], physical examination report, mental health status report, or any other document indicates that the resident has a psychiatric condition that contributes to self-isolation, a qualified mental health professional shall make a determination in writing whether the resident should have the option of having meals in his room. If the determination is made that the resident should not have this option, then the resident shall have his meals in the dining area.
Evidence
  1. Resident #1’s “Psychiatric Periodic Evaluation” dated 11-09-2022 documented the resident’s diagnoses as Depression, GAD (generalized anxiety disorder), and psychosis.
  2. “Interdisciplinary Progress Notes” dated 5-17-2022 documented “Resident [#1] remains in [resident’s] room most of the time. Does not eat in the dining room. Resident appears depressed. Angry at times.”; however, there was no documentation in Resident #1’s record by a qualified mental health professional determining that the resident should have the option of having meals in the resident’s room.
Plan of correction
Resident #1 no longer resides at the AL. Other residents with psychiatric conditions that contributes to self-isolation are potentially at risk. A qualified mental health professional will evaluate this group of residents and determine in writing whether the resident should have the option should have the option of having meals in his room or should not have this option and should have meals in the dining area. The individualized service plan will be updated to reflect psychiatric condition that may lead to self-isolation. Staff will be educated on signs and symptoms of depression, psychosis an anxiety and educated to report these symptoms or changes in behavior to nursing. The mental health professional will also be educated on need to document meal area for those residents with psychiatric conditions that contribute to isolation. Residents will be reviewed minimally weekly and PRN for changes in behavior, socialization, etc. that could contribute to self-isolation and notify psychiatry for further evaluation.
22VAC40-73-860-J
Based on record review and interview with staff, the facility failed to ensure a resident may be permitted to keep his own cleaning supplies or other hazardous materials in an out-of-sight place in his room if the resident does not have a serious cognitive impairment. The cleaning supplies or other hazardous materials shall be stored so that they are not accessible to other residents.
Evidence
  1. “Interdisciplinary Progress Notes” for Resident #1 dated 2-28-2023 documented, “Received call from receptionist. Asked if we had @ [sic]resident by the name [Resident #1]. [Resident #1] has called 911… Resident [#1] found sitting in chair vomiting. Juice bottle found sitting by her chair [with a] strong odor. Smell of some type of chemical… Resident [#1] [was] asked if [resident] drank any from juice bottle, resident stated, “I’m ready to be [with] the Lord”… Room checked [after] resident left. Multiple bottles of cleaning fluids found locked in wood box multiple suitcases. Most bottles wrapped as much as 2 inches thick [with] duct tape. 1 bottle of pine sol found open. Resident [#1] would not allow staff to go in [resident’s] room. Only came out for meds + immediately returned to room.” A previous note dated 2-06-2023 to the resident’s physician by Staff #1 documented, “Off all psych meds. Very paranoid…” Staff #1 acknowledged staff had not been going in Resident #1’s room “for months” and were not aware of chemicals present in the resident’s room. Photographic evidence obtained of accessible chemicals to resident as seen on 5-12-2023 during inspection, including bleach, detergent, stain lifter detergent, disinfectant cleaner, glass cleaner, and non-acid bathroom cleaner.
Plan of correction
Resident #1 no longer resides at the AL. All other residents are potentially at risk of cleaning supplies or hazardous materials that are not secured to prevent accessibility to other residents. A letter will be sent to families of ALF residents regarding not bringing personal cleaning products considered hazardous or poisonous into the residents as they are not authorized. Staff educated that if these chemicals are seen in the resident rooms, that they are to be removed immediately for resident safety. Education was provided to staff regarding approved list of chemicals for facility cleaning purposes. This education included proper storage, knowledge of Safety Data Sheet (SDS) for each chemical, locking closets when not being actively used by approved staff. Rounds are being completed daily (M-F) and on weekends by medication technician to ensure staff compliance with education and security of cleaning supplies and hazardous materials. Date of correction: 6/29/23-staff education Date of correction: 7/14/2023-for family letter
January 27, 2023Inspection0 violations
Inspection dates
01/27/2023
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONSXX 22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Technical assistance
Will show repair invoices from recent repairs related to water leaking.
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: 1-27-2023, 10:45 a.m. – 11:30 a.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: N/A The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: Buildings and Grounds inspection for the initial inspection. Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website should the facility be issued a license to operate. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of a licensed facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alexandra Poulter, Licensing Inspector at (804)662-9771 or by email at alex.poulter@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.