Virginia DSS · Assisted Living Facility

Silverado Alexandria

📍 2807 King Street, Alexandria, VA, 22302

ID 49264Two Year licenseActive
8
Inspections
On record
5
With violations
Visits that cited something
3
Clean visits
Nothing cited
9
Violations cited
Individual findings
9
Standards cited
Distinct rules
1
Complaint visits
Prompted by a complaint

Silverado Alexandria was inspected 8 times between March 28, 2023 and April 23, 2026 by the Virginia Department of Social Services. 5 of those visits ended with violations cited and 3 with none. Across that history VDSS cited 9 violations under 9 distinct standards. 1 inspection was prompted by a complaint.

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

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

Provider Information

Facility type
Assisted Living Facility
License type
Two Year
License expires
09/30/2027
Administrator
Megan Fritz
Licensing inspector
Nina Wilson
Inspector phone
(703) 635-6074
Approved for
Assisted Living · Non-Ambulatory · Special Care Unit

Inspection History

8

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

April 23, 2026Complaint survey4 violations
Inspection dates
04/23/2026
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Technical assistance
Licensing inspector (LI) reviewed the following standards with the facility: 22VAC40-73-490.
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: 04/23/2026 Time in: 11:05 AM Time out: 4:43 PM 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 02/19/2026 regarding allegations in the area(s) of: Personnel, Resident Care and Related Services and Complaint Investigation Number of residents present at the facility at the beginning of the inspection: 69 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: 7 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 7 Observations by licensing inspector: Licensing inspector observed a medication pass, residents participating in scheduled activities, and residents dining for lunch. Additional Comments/Discussion: 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 Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov
Violations
22VAC40-73-640-A
Based on resident record review and staff interview, the facility failed to have, keep current, and implement a written plan for medication management to include methods for verifying that medication orders have been accurately transcribed to medication administration records (MARs) within 24 hours of receipt of a new order or change in an order.
Evidence
  1. Resident 6’s Physician Order Review indicated that resident 6 was prescribed Memantine HCI 10 MG (give 1 tab by mouth twice daily, 9:00 am and 5:00 pm) on 04/16/2026; however, resident 6’s April 2026 MAR indicated that Memantine HCI 10 MG was not administered until the evening (5:00 pm) of 04/21/2026.
  2. Resident 8’s Physician Order Review indicated that resident 8 was prescribed Acetaminophen 500 MG (2 tabs twice a day scheduled, 9:00 am and 5:00 pm) on 04/02/2026; however, resident 8’s April 2026 MAR indicated that Acetaminophen 500 MG was not administered until the evening (5:00 pm) of 04/04/2026.
  3. During the onsite inspection, staff 1 acknowledged that resident 6’s medication, Memantine HCI 10 MG and resident 8’s medication, Acetaminophen 500 MG were not transcribed onto the MAR within 24 hours of receipt of new orders.
Plan of correction
Resident 6’s order for Memantine HCI 10 MG and Resident 8’s order for Acetaminophen 500 MG were reviewed immediately upon identification of the deficiency. Both medications were verified with the physician orders and transcribed accurately onto the Medication Administration Record (MAR). The residents are currently receiving medications as ordered by the physician. An audit of all current resident physician orders and corresponding MARs was conducted by the Director of Health Services/designee to ensure all medication orders and recent changes had been accurately transcribed and implemented within the required timeframe. Any discrepancies identified during the audit were corrected immediately. The community updated and reinforced the medication management process to ensure all new medication orders and order changes are transcribed to the MAR within 24 hours of receipt. A standardized medication order verification process has been implemented requiring: Verification of all new orders and changes by the receiving nurse/medication technician. A secondary review by the Director of Health Services/designee within 24 hours to confirm accurate transcription and implementation. All licensed nurses and medication management staff received re-education on the community’s medication management policies and procedures, specifically focusing on: Timely transcription of physician orders to the MAR. Verification procedures for new medication orders and order changes. The Director of Health Services/designee will conduct weekly audits of physician orders and MAR transcription accuracy for four weeks, followed by monthly audits for an additional two months to ensure ongoing compliance. Audit findings will be reviewed with the clinical leadership team and corrective action will be taken immediately if concerns are identified. All corrective actions outlined above were completed or will be completed by: June 30th, 2026 Responsible Person: Director of Health Services, Administrator, and/or Designee
22VAC40-73-680-D
Based on resident record review and staff interview, the facility failed to ensure that medications should be administered in accordance with the physician’s or other prescriber’s instructions.
Evidence
  1. Resident 6 was prescribed Memantine HCI 10 MG (give 1 tab by mouth twice daily) on 04/16/2026; however, resident 6’s April 2026 medication administration record (MAR) indicated that the medication was not administered until 04/21/2026.
  2. Resident 8 was prescribed Acetaminophen 500 MG (2 tabs twice a day scheduled) on 04/02/2026; however, resident 8’s April 2026 MAR indicated that the medication was not administered until 04/04/2026.
  3. During the onsite inspection, 04/23/2026, staff 1 acknowledged that resident 6’s Memantine CI 10 MG and resident 8’s Acetaminophen 500 MG were not administered in accordance with the physician or other prescriber’s instructions.
Plan of correction
Resident 6’s order for Memantine HCI 10 MG and Resident 8’s order for Acetaminophen 500 MG were immediately reviewed upon identification of the deficiency. Both medications were verified against the physician orders, transcribed accurately to the Medication Administration Record (MAR), and administered in accordance with the prescribed orders. The attending physicians were notified of the delayed initiation of the medications, and residents were monitored for any adverse outcomes. The Director of Health Services/designee conducted an audit of all current physician orders and corresponding MARs to ensure medications were being administered as prescribed. Any discrepancies identified during the audit were corrected immediately, and prescribing providers were notified as appropriate. The community reinforced medication management and medication administration procedures to ensure timely transcription, implementation, and administration of all physician orders. The following measures were implemented: All new medication orders and order changes will be reviewed and transcribed to the MAR within 24 hours of receipt. A secondary verification process was implemented to confirm medications are available, transcribed, and initiated as ordered. Daily clinical review of new orders and missed medication reports by the Director of Health Services/designee. All licensed nurses and medication management staff received re-education on: Timely initiation and administration of medications as prescribed. Accurate MAR transcription and documentation procedures. Communication and escalation procedures when medication orders are received or medications are unavailable. The Director of Health Services/designee will conduct weekly audits of physician orders, MARs, and medication administration records for four weeks to ensure medications are administered in accordance with prescriber instructions. Audits will continue monthly for an additional two months. Any identified concerns will result in immediate corrective action and re-education. All corrective actions outlined above were completed or will be completed by: June 12th, 2026 Responsible Person: Director of Health Services / Administrator / Designee
22VAC40-73-660-A-3
Based on observation and staff interview, the facility failed to ensure the individual responsible for medication administration should keep the keys to the storage area on his person.
Evidence
  1. During the onsite inspection, 04/23/2026, licensing inspector (LI) observed that the third-floor nurse’s station doors were open, the medication cart was inside, with the keys hanging from the lock, and staff 3 was on a telephone call sitting out of arms reach of the cart. The keys remained hanging from the medication cart while staff 3 pushed the cart to the activity room where residents were seated for a scheduled activity. Staff 3 stated, “I am going to wash my hands,” the keys continued to hang from the medication cart while staff 3 walked towards the dining area to wash their hands.
  2. During the onsite inspection, 04/23/2026, staff 1 confirmed witnessing that the keys were hanging from the medication cart inside of the nurse’s station.
Plan of correction
Immediately upon identification of the deficiency, staff 3 was counseled regarding proper medication cart security procedures and the requirement to maintain medication cart keys on their person at all times during medication administration. The medication cart keys were immediately secured appropriately. An immediate review of medication security practices was conducted by the Director of Health Services/designee to ensure medication carts, medication rooms, and medication storage areas were properly secured throughout the community. No additional unsecured medication carts or medication storage concerns were identified during the review. All licensed nurses and medication management staff received re-education on: Medication security requirements under 22VAC40-73-660-A.3. Proper handling and control of medication cart and medication room keys. Resident safety and prevention of unauthorized access to medications. Expectations for maintaining visual supervision and security of medication storage areas during medication administration. The Director of Health Services/designee will conduct random medication pass observations and medication cart security audits weekly for four weeks, followed by monthly audits for an additional two months to ensure ongoing compliance. Any identified concerns will result in immediate corrective action and re-education as indicated. All corrective actions outlined above were completed or will be completed by: June 12, 2026 Responsible Person: Director of Health Services / Administrator / Designee
22VAC40-73-650-A
Based on observation and staff interview, the facility failed to ensure that no medication, dietary supplement, diet, medical procedure, or treatment should be started, changed, or discontinued by the facility without a valid order from a physician or other prescriber.
Evidence
  1. During the onsite inspection, 04/23/2026, licensing inspector (LI) observed staff 3 complete a medication pass. LI observed staff 3 administer resident 1’s medication, Quetiapine Fumarate 50 MG (1 tablet by mouth three times per day; every day 9:00 AM, 2:00 PM, 9:00 PM); however, prior to administration, staff 3 crushed the Quetiapine Fumarate 50 MG tablet and mixed the medication in chocolate pudding. Prior to LI asking additional questions, staff 3 stated, “Resident 1 cannot tolerate it, so I crush it, but the order does not say to crush it. I crush and put it in pudding and sometimes use the house shake.”
  2. Staff 3 acknowledged that an order to crush resident 1’s Quetiapine Fumarate 50 mg was needed and would later communicate the need to their supervisor
Plan of correction
Immediately upon identification of the deficiency, Resident 1’s physician was notified regarding the resident’s difficulty tolerating whole medications. A physician order was obtained clarifying administration instructions for Quetiapine Fumarate 50 MG, including authorization for crushing the medication as clinically appropriate. The Medication Administration Record (MAR) and resident care plan were updated accordingly. The Director of Health Services/designee conducted an audit of all residents receiving crushed medications to ensure there was a valid physician order authorizing altered medication administration. Any missing or incomplete orders identified during the audit were immediately addressed with the prescribing provider and updated in the resident record and MAR. All medication management staff received re-education on: Proper medication administration procedures. Verification of physician authorization prior to altering medication administration. The requirement for physician orders prior to crushing, splitting, discontinuing, or otherwise altering medication administration. Documentation and communication expectations related to resident medication tolerance concerns. The Director of Health Services/designee will conduct weekly medication administration audits for four weeks to verify physician orders are present for all altered medication administration practices. Audits will then continue monthly. Findings will be reviewed with the clinical leadership team and corrective action will be implemented immediately if concerns are identified. All corrective actions outlined above were completed or will be completed by: June 12, 2026 Responsible Person: Director of Health Services / Administrator / Designee
February 3, 2026Inspection1 violation
Inspection dates
02/03/2026
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 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: 02/03/2026 Time in: 1:09 PM Time out: 1:49 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 12/15/2025 regarding allegations in the area(s) of: Administration and Administrative Services, Admission, Retention and Discharge of Residents, and Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 63 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Licensing inspector observed residents interacting with peers, staff, and visitors and engaged in scheduled activities. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. However, violation(s) not related to the self-report 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 Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov
Violations
22VAC40-73-70-A
Based on record review and staff interview, the facility failed to report to the regional licensing office within 24 hours any major incident that had negatively affected or that threatened the life, health, safety, or welfare of any resident.
Evidence
  1. The licensing department received an incident report on 12/15/2025 stating alleged misconduct between resident 1 and resident 2 that occurred on 12/06/2025.
  2. During the onsite inspection, 02/03/2026, staff 1 confirmed that the licensing department was not notified within 24 hours of the alleged incident that occurred on 12/06/2026.
Plan of correction
The incident dated 12/06/2025 was reported to the regional licensing office upon identification of reporting delay. Administrator reviewed reporting requirements with the leadership team immediately following the survey. Clarification provided that reportability is based on allegation or potential threat, not investigation outcome. All Leadership staff re-educated on regulatory reporting requirements. Decision-making authority for reportability centralized to the Administrator or designee.
February 3, 2026Inspection1 violation
Inspection dates
02/03/2026
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: 02/03/2026 Time in: 1:50 PM Time out: 2:23 PM 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 02/03/2026 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: 63 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Licensing inspector (LI) observed residents visiting with peers, staff, and visitors and participating in scheduled activities. Additional Comments/Discussion: LI and administrator discussed that a first-floor unit’s occupancy. 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. 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 Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov
Violations
22VAC40-73-460-D
Based on resident record review and staff interview, the facility should provide supervision of resident schedules, care, and activities, including attention to specialized needs, such as prevention of falls and wandering from the premises.
Evidence
  1. The licensing department received a self-report on 02/03/2026 stating that resident 1 eloped from the front door of the safe, secure facility due to the doors still being disengaged from a visitor entering around 4:04 pm.
  2. Staff 3, who was no longer working on shift, witnessed resident 1 walking outside of the facility and contacted staff 4 at approximately 4:05 pm. Staff 4 contacted leadership, who responded via car, and two other care managers who responded on foot.
  3. Resident 1 walked 0.3 miles following a winter storm, in areas off facility premises where the sidewalks were not properly shoveled, with temperatures in the low 30’s.
  4. Resident 1 returned to the safe, secure facility at approximately 5:16 pm.
  5. During the onsite inspection, 02/03/2026, staff 1 confirmed that resident 1 eloped from the front door of the safe, secure facility. Staff 1 also acknowledged that resident 1’s well-being was affected due to the low temperature and the recent winter storm and that the facility was unaware of resident 1’s elopement until an off-shift staff member contacted the receptionist desk.
Plan of correction
Specific Resident/Situation Cited: Resident #1 was immediately assessed upon return. Vital signs were obtained and no injury noted. The physician and responsible party were notified directly following Resident #1 return to community. A comprehensive reassessment was completed within 24 hours; resident remained with no negative outcomes from incident. The Individualized Service Plan was updated within 72 hours to reflect high elopement risk and enhanced supervision requirements. Medication regimen was reviewed with the Medical Director. Director of Health Services to reassess 100% of residents for elopement risk within 7 days. 100% service plans audited for documentation of wandering risk and supervision level. All secured exit alarms and door delay systems tested and confirmed operational. Effective immediately, staff must visually clear the area in front of doors prior to door disengagement. Staff must remain within visual proximity of the entrance until the door fully re-engages. Staff Re-Education completed. Elopement drills increased to monthly for the next 3 months. Response times recorded and reviewed. The facility recognizes that supervision must remain continuous during door access in a secured setting and has revised procedures to ensure consistent monitoring during door disengagement. The Administrator or designee is responsible for implementation and ongoing compliance with all components of this Plan of Correction and address/resolve any variance that may occur
August 19, 2025Inspection0 violations
Inspection dates
08/19/2025
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 IMPAIRMENTS22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report
Technical assistance
Licensing Inspector reviewed the following standard with the facility: 22VAC40-73-260 and 22VAC40-73-490.
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: 08/19/2025 Time in: 11:04 AM Time out: 3:20 PM Time in: 4:42 PM Time out: 5:15 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: 66 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: Licensing inspector observed residents participating in scheduled activities, engaging with peers, staff, and loved ones, dining for lunch, and entering and exiting the community for outings. 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 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 Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
August 19, 2025Inspection0 violations
Inspection dates
08/19/2025
Areas reviewed
22VAC40-80 THE LICENSE
Comments
Type of inspection: Other Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 08/19/2025 Time in: 3:20 PM Time out: 4:41 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: 66 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: 0 Observations by licensing inspector: Licensing inspector observed residents resting in their apartments and participating in scheduled activities. Additional Comments/Discussion: A modification request was submitted in August, for an increase in capacity from 66 to 90 residents. During the onsite inspection, the identified rooms for modification were measured to ensure compliance with applicable standard(s) or law. The evidence gathered during the investigation did not support the (allegation(s)/self-report) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
April 30, 2025Inspection1 violation
Inspection dates
04/30/2025
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
Technical assistance
Licensing inspector reviewed the following with the facility: 22VAC40-73-45, 22VAC40-73-50, 22VAC40-73-1110B
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: 06/03/2025 Time in: 11:03 AM Time out: 4:15 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: 66 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. 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: 3 Observations by licensing inspector: Licensing inspector observed the physical plant of the facility. LI observed residents interacting with visitors, staff, and peers. LI observed residents engaging in scheduled activities and dining for lunch. Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. 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 Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov.
Violations
22VAC40-73-450-A
Based on resident record review and staff interview, the facility failed to ensure that the preliminary plan was signed and dated by the person who developed the plan and the resident or their legal representative.
Evidence
  1. Resident 2 and Resident 3’s preliminary plans were not signed and dated by the resident or their legal representatives.
  2. On 04/30/2025, LI interviewed staff 5 who confirmed that the preliminary plans of Resident 2 and Resident 3 were not signed by the resident or their legal representatives.
Plan of correction
Effective immediately on 4/30/25, the Administrator implemented a process to ensure that the initial care plan is presented to, reviewed with, and signed by resident and/or responsible party, as appropriate, on or within seven days prior to the day of admission. Administrator or designee will review service plans for all move-ins for 60 days to ensure compliance. The Administrator or designee is responsible for implementation and ongoing compliance with all components of this Plan of Correction and address/resolve any variance that may occur.
August 31, 2023Inspection2 violations
Inspection dates
08/31/2023
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS
Technical assistance
Documentation was discussed with the provider.
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 8/31/23 (8:50 AM - 4:45 PM) Number of residents present at the facility at the beginning of the inspection: 66 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. An exit meeting was held. Number of resident records reviewed: 10 Number of interviews conducted with staff: 2 Observations by licensing inspector: Meals, medication administration, activities 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (703) 431-4247 or by email at m.massenberg@dss.virginia.gov.
Violations
22VAC40-73-660-B
Based on documentation and observation, the facility failed to limit medication storage to an out-of-sight place in the rooms of residents whose UAIs indicate that they are capable of self-administering medication.
Evidence
  1. Neosporin + Pain Relief was observed in the bathroom shelf of Resident #4. Resident #4's record contained an order, dated 2/9/22, for Diclofenac gel (DX: Pain). Resident #4's UAI, updated 7/21/23, states that she needs her medication to be administered by professional nursing staff.
Plan of correction
Specific resident/situation cited: Resident experienced no negative outcome due to Neosporin with Pain Relief being present in bathroom. Measures to address the concern and how it will be monitored: The Director of Health Services (DHS) or designee will conduct weekly resident room audits for 100% of community for one month to ensure all medications are stored properly. During and at the conclusion of the three months, the DHS and Administrator or their designees, will re-evaluate and initiate necessary action or extend the review period. The Administrator or designee is responsible for implementation and ongoing compliance with all components of this Plan of Correction and address/resolve any variance that may occur.
22VAC40-73-680-M
Based on observation and interview, the facility failed to ensure that PRN medications are available and properly stored at the facility.
Evidence
  1. Resident #6's PRN Loperamide (ordered 3/18/22) and PRN Acetaminophen (ordered 12/2/21) were not present during the medication cart inspection. Facility staff confirmed that the PRN medications were not present, at the time of the medication cart inspection.
Plan of correction
Specific resident/situation cited: Resident experienced no negative outcomes from the lack of PRN medication present in medication cart as resident did not require them. Medication orders were discontinued at time of inspection due to not being administered in over 30 days. Measures to address the concern and how it will be monitored: Director of Health Services (DHS) or designee will re-educate LPNs to monitor the availability of PRN medications for the residents per physician orders. DHS or designee will educate LPNs to work with physicians to discontinue any unnecessary medication orders (PRN medications that residents are not requiring for 30 days or more). The DHS or designee will conduct monthly audits of 100% of the medication carts and PRN orders to verify frequency of use of PRN medication and availability. During and at the conclusion of the three months, the DHS and Administrator, or their designees, will re-evaluate and initiate necessary action or extend the review period. The Administrator or designee is responsible for implementation and ongoing compliance with all components of this Plan of Correction and address/resolve any variance that may occur.
March 28, 2023Inspection0 violations
Inspection dates
03/28/2023
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity32.1 Reported by persons other than physicians63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Comments
Licensing Inspector (LI) conducted an announced initial inspection on 3/28/2023 due to a change in ownership. LI walked the physical plant, verified window and room measurements, reviewed policies and procedures and tested the call bell system. The Building, Fire and Health Inspections have been submitted and reviewed. No violations cited today and exit interview held. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Lynette Storr, Licensing Inspector at (703) 479-4708 or by email at lynette.storr@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.