Virginia DSS · Assisted Living Facility

Sunrise of McLean Village

📍 1515 Chain Bridge Road, Mc Lean, VA, 22101

ID 49266One Year licenseActive
11
Inspections
On record
6
With violations
Visits that cited something
5
Clean visits
Nothing cited
14
Violations cited
Individual findings
14
Standards cited
Distinct rules
3
Complaint visits
Prompted by a complaint

Sunrise of McLean Village was inspected 11 times between April 19, 2023 and May 7, 2026 by the Virginia Department of Social Services. 6 of those visits ended with violations cited and 5 with none. Across that history VDSS cited 14 violations under 14 distinct standards. 3 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
11/01/2026
Administrator
Maureen Davis
Licensing inspector
Ishmel Paige
Inspector phone
(804) 963-0360
Approved for
Non-Ambulatory · Special Care Unit · Assisted Living

Inspection History

11

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

May 7, 2026Inspection0 violations
Inspection dates
05/07/2026
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND63.2- (16) PROTECTION OF ADULTS AND REPORTING22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OF AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Technical assistance
22VAC40-73-450 Individualized Service Plans 22VAC40-90-30 Sworn Statement or Affirmation
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: Date: 5/7/2026 Time In: 10:05am Time Out: 1:20pm 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 2/18/2026 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: 94 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: 2 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: Memory Care Group Activity, Resident Rooms, Building and Grounds 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 Ishmel Paige, Licensing Inspector at (804)-963-0360or by email at ishmel.l.paige@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
October 7, 2025Inspection1 violation
Inspection dates
10/07/2025
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 – SUBJECTIVITY22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Technical assistance
Resident emergency drills, healthcare oversight, record storage/ organization. Ensure renewal application is received completed prior to expiration date.
Comments
Type of inspection: Renewal Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/07/2025 8:55 AM to 3:22 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: 94 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 4 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: Breakfast meals, activities, medication pass, and lunch meals on both AL and safe, secure units. 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 Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Violations
22VAC40-73-680-M
Based on direct observation, resident record review, and staff interview, the facility failed to ensure that medications ordered for PRN [as needed] administration were available and properly stored at the facility.
Evidence
  1. Resident 8’s signed Order Summary Report contained a PRN order for the following medications: a. Acetaminophen Oral Tablet 325 MG: Give 2 tablet by mouth every 6 hours as needed for Pain – Ordered 02/03/2025. b. Loperamide HCI Oral Tablet 25 MG: Give 1 tablet by mouth every 6 hours as needed for diarrhea – Ordered 02/09/2025.
  2. During a medication pass observation for Resident 8, the LI requested to see the PRN medications – Loperamide and Acetaminophen. Staff 7 stated they were not available.
  3. In an interview with the LI on 10/10/2025, Staff 7 and Staff 8 confirmed that Resident 8’s medication was not available and stored at the facility.
Plan of correction
1. Resident Number 8’s ordered as needed (PRN) medications will be available and properly stored at the community. 2. Other residents’ ordered as needed (PRN) medications will be available and properly stored at the community. 3. The Resident Care Director or designee will educate staff who administer medications that medications ordered for as needed (PRN) administration must be available and properly stored at the community. 4. The Resident Care Director or designee will audit residents’ records weekly for twelve (12) weeks to ensure medications ordered for as needed (PRN) administration remain available and properly stored at the community.
June 10, 2025Inspection3 violations
Inspection dates
06/10/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION
Technical assistance
470-C: Ensure services are provided to prevent clinically avoidable complications including dehydration. 220-A/B: Ensure private duty records contain all required components.
Comments
Type of inspection: Monitoring A self-reported incident was received by VDSS Division of Licensing on 05/27/2025 regarding allegations in the areas of: 1. Resident Care and Related Services 2. Staffing and Supervision Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/10/2025 9:45 AM to 1:57 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: 95 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: 2 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 5 Observations by licensing inspector: Memory Care - Activities Additional Comments/Discussion: N/A 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-reported incident 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 Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Violations
22VAC40-73-40-A
Based on resident record review and staff interview, the facility failed to ensure compliance with the facility’s own policies and procedures.
Evidence
  1. On 05/27/2025, Staff 1 reported an incident report to the licensing inspector via email including an allegation of abuse that occurred on 05/26/2025 at 1:10 AM between Staff 4 and Resident 1.
  2. In an interview with the LI on 06/10/2025, Staff 2 stated that Staff 3 witnessed the incident between Staff 4 and Resident 1.
  3. In an interview with the LI on 06/10/2025, Staff 3 confirmed that they reported their concerns to facility leadership at the end of their shift.
  4. Staff 1 provided the LI a copy of the “Abuse, Neglect, & Exploitation – Preventing, Reporting and Investigation” policy. Page three (3) of the policy states the following under six (6.), “Every Team Member and Volunteer is a Mandated Reporter and has a duty to report known or suspected abuse, neglect, and/or exploitation to local and state/provincial authorities in accordance with applicable state laws and regulations…b. The report of abuse, neglect, or abuse must be made within the timeframes and through the format required by applicable laws and regulations…” Page four (4) under seven (7.) states “If there is reasonable suspicion of criminal activity against a resident, the individual Mandated Reporter will report the suspicion immediately to a. Local police/ Law Enforcement. b. State/Provincial licensing agency and to all other agencies, as required by applicable laws and regulations.”
  5. In an interview with the LI on 06/10/2025, Staff 1 confirmed that the facilities own policies regarding Abuse, Neglect & Exploitation – Preventing, Reporting and Investigation” were not followed.
Plan of correction
1. Staff member number 3 reeducated regarding community abuse and neglect reporting expectations. 2. Community staff reeducated regarding community abuse and neglect reporting expectations. 3. The Resident Care Coordinator or designee will randomly interview staff and ask them to articulate abuse and neglect reporting expectations for twelve weeks. 4. The Resident Care Coordinator or designee will reeducate staff regarding abuse and neglect reporting expectations, as indicated during these random interviews.
22VAC40-73-110-1
Based on resident record review and staff interview, the facility failed to ensure that all staff were considerate and respectful of the rights, dignity, and sensitivities of persons who are aged, infirm, or disabled.
Evidence
  1. On 05/27/2025, Staff 1 reported an incident report to the licensing inspector via email including an allegation of abuse that occurred on 05/26/2025 at 1:10 AM between Staff 4 and Resident 1.
  2. In a phone interview with the LI on 06/10/2025, Staff 3 confirmed the reported allegation that Staff 4 was found sleeping on the floor of Resident 1's room, while Resident 1 was lying in bed undressed.
  3. In an interview with the LI on 06/10/2025, Staff 1 acknowledged that Staff 4’s actions were not considerate and respectful of the rights, dignity, and sensitivities of person who are aged, infirm, or disabled.
Plan of correction
1. Terminated staff member number 4’s employment. 2. Staff reeducated regarding expectations to be considerate and respectful of the rights, dignity, and sensitivities of persons who are aged, infirm, or disabled. Staff reeducated that they may not sleep while on duty at work. 3. The Resident Care Coordinator or designee will randomly visit the community at night, in July, August, and September, to ensure staff remain awake while on duty. 4. The Executive Director or designee will ask residents, during Residents’ Association meetings in July, August, and September, if staff treat them considerately and respect their rights, dignity, and sensitivities. Executive Director or designee will address concerns voiced.
22VAC40-73-1130-C
Based on facility document review and staff interview, the facility failed to ensure that the following number of direct care staff members were always awake and on duty in each special care unit during night hours: when 23 to 32 residents are present, at least three direct care staff members.
Evidence
  1. In an incident report submitted to the LI on 05/30/2025, it is reported that Staff 4 stated they took a power nap in Resident 1’s room on the night of 05/26/2025 into 05/27/2025.
  2. In an interview with LI on 06/10/2025, Staff 1 confirmed that there were 27 residents in the Safe, Secure Unit on the night of 05/26/2025 into 05/27/2025. Staff 1 stated that there were two (2) direct care staff (Staff 3 and Staff 4) assigned to the Safe, Secure Unit, and one (1) medication tech assigned to float between the Safe, Secure Unit and the Assisted Living Unit. The LI reviewed the time cards of Staff assigned to the unit on 05/26/2025 into 05/27/2025.
  3. In an interview with the LI on 06/10/2025, Staff 1 confirmed that there were not three (3) direct care staff members who were awake and on duty in the Safe, Secure unit when 23-32 residents were present on the night of 05/26/2025 into 05/27/2025.
Plan of correction
1. Three awake and on duty direct care staff will be assigned to the special care neighborhood during night hours when 23 to 32 residents are present. 2. Resident Care Coordinator educated of expectation that three awake and on duty direct care staff need to be assigned to the special care neighborhood during night hours when 23 to 32 residents are present. 3. Resident Care Coordinator will review staffing schedules weekly for twelve weeks to ensure that three awake and on duty direct care staff are assigned to the special care neighborhood during night hours when 23 to 32 residents are present. 4. Executive Director or Designee will review staffing schedules weekly for twelve weeks to ensure that three awake and on duty direct care staff were assigned to the special care neighborhood during night hours when 23 to 32 residents are present.
June 10, 2025Inspection0 violations
Inspection dates
06/10/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION
Technical assistance
720-A: Ensure DNR is listed on ISP Acting Admin Qualifications
Comments
Type of inspection: Monitoring A self-reported incident was received by VDSS Division of Licensing on 06/06/2025 regarding allegations in the area(s) of: 1. Resident Care and Related Services 2. Staffing and Supervision Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/10/2025 2:00 PM to 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: 95 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: Memory Care – Activities 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 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 Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 15, 2025Complaint survey2 violations
Inspection dates
05/15/2025
Areas reviewed
22VAC40-80 COMPLAINT INVESTIGATION22VAC40-73 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 PREPAREDNESS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION
Comments
Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 04/04/2025 regarding allegations in the area(s) of: 1. Staffing and Supervision 2. Resident Care and Related Services 3. Resident Accommodations and Related Provisions Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/16/2025 8:40 AM to 3:08 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: 90 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 5 Number of staff records reviewed: 0 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. However, violation(s) not related to the complaint 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. 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 Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Violations
22VAC40-73-280-B
Based on facility document review and staff interview, the facility failed to ensure the written staffing plan was followed.
Evidence
  1. Staff 2 provided a copy of the Written Staffing plan, along with the Daily Labor Details and Daily Labor Reporting. The Daily Labor reporting indicates the target hours for a wellness nurse is eight (8) hours a day, seven (7) days a week.
  2. Staff 2 provided the schedule for April 2025. There was no nurse on site the following: 04/06/2025, 04/12/2025, 04/13/2025, 04/19/2025, and 04/25/2025.
  3. In an interview with the LI on 05/15/2025, Staff 1 stated a nurse is only on-site Monday through Friday. Staff 1 acknowledged the plan was not followed as written.
Plan of correction
1. Written Staffing Plan revised to reflect current nurse staffing. Budget allowances may indicate nurse target hours above actual staffing. Community Disclosure Statement clarifies nurse staffing. 2. The Resident Care Director or designee will staff nurses according to the Written Staffing Plan. 3. The Resident Care Director or designee will report deviations from the Written Staffing plan, specifically regarding nurse staffing, to the Executive Director weekly for twelve weeks. 4. The Executive Director will compare actual nurse staffing against the Written Staffing Plan weekly for twelve weeks.
22VAC40-73-50-A
Based on resident record review and staff interview, the facility failed to ensure the disclosure form was on the form developed by the department.
Evidence
  1. Resident 1’s, admitted 04/13/2025, record contains a disclosure form signed by the legal representative. The disclosure form template is dated 10/19.
  2. In an interview with the LI on 05/15/2025, Staff 1 acknowledged that it was not on the department form.
Plan of correction
1. Adopted Community Disclosure Statement form developed by the Department. 2. Residents entering the community on or after the date of compliance will be provided this form. 3. The Executive Director will educate team members involved in the move-in process to ensure they provide this version of the form to new residents. 4. The Executive Director or designee will randomly audit new residents’ records to ensure the revised form was provided. These audits will be completed weekly for four weeks and monthly for three months.
October 21, 2024Inspection2 violations
Inspection dates
10/21/2024, 10/22/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY63.2- (1) GENERAL PROVISIONS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION
Comments
Type of inspection: Renewal Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/21/2024 9:45 AM to Approximately 3:00PM 10/22/2024 10:00 AM to 4:30 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: 82 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 4 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: meals, activities, medication pass, and medication cart audit (on both assisted living and special care unit) 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 Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Violations
22VAC40-73-560-E
Based on direct observation and staff interview, the facility failed to ensure that all resident records are kept in a locked area.
Evidence
  1. During a tour of the building with Staff 2 on 10/21/2024, the LI observed an unlocked nurse’s station that contained cabinets that stored the residents’ charts.
  2. In an interview with the LI, Staff 2 confirmed that the resident charts were all stored in this area.
  3. Photo evidence obtained.
Plan of correction
1. Door to Wellness Office locked when not occupied by a staff person. 2. Residents’ records will be stored in secure areas. This may include a locked cabinet, office, or storage area. 3. The Executive Director will educate Wellness Department staff of the expectation to secure residents’ records as outlined in above item 2. 4. The Executive Director or designee will conduct rounds to ensure records securely stored. These audits will be completed weekly for one month and monthly for three months.
22VAC40-80-120-E-2
Based on direct observation and staff interview, the facility failed to ensure the most recent inspection summary and findings was posted in a place conspicuous to the public.
Evidence
  1. Upon entering the building on 10/21/2024, the LI observed an inspection summary posted from 10/16/2023. The most recent inspection was completed was 09/20/2024.
  2. During the preliminary exit meeting with the LI on 10/21/2024, Staff 1 confirmed that the most recent inspection had not yet been posted.
  3. Photo evidence obtained.
Plan of correction
1. Most recent inspection summary and findings posted in a place conspicuous to the public. Not realizing the encounter on 09/20/2024 was an inspection, the Executive Director did not post the document signed on 09/20/2024. The inspector arrived at this community, then realized the issue requiring inspection did not pertain to this community. The inspector left the premises without inspecting any resident records or conducting any staff interviews. 2. The Executive Director or designee will ensure posting of most recent inspection summary and findings in a place conspicuous to the public. 3. The inspector reeducated the Executive Director by instructing her to post any signed inspection-related documents indicating an encounter between the Department of Social Services and the community. The Executive Director voiced understanding. 4. The Resident Care Coordinator or designee will verify most recent inspection summary and findings posted in a place conspicuous to the public weekly for one month and monthly for three months.
September 20, 2024Inspection0 violations
Inspection dates
09/20/2024
Areas reviewed
22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Other Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/20/2024 11:37 AM to 12:07 AM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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: 1 Observations by licensing inspector: N/A Additional Comments/Discussion: The investigation into the complaint was suspended because the complainant submitted the wrong facility at the time of filing. The resident involved in the complaint has never resided at that facility. The complaint has been referred to the appropriate licensing inspector for further review. 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 Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
August 12, 2024Complaint survey4 violations
Inspection dates
08/12/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESSARTICLE 1 – SUBJECTIVITY32.1- (37) REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2- (1) GENERAL PROVISIONS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 08/07/2024 regarding allegations in the area(s) of staffing and supervision, resident care and related services, and resident accommodations and related provisions. Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 08/12/2024 9:10 AM to 4:05 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: 73 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Number of staff records reviewed: 4 Number of interviews conducted with residents: 6 Number of interviews conducted with staff: 4 Observations by licensing inspector: meals (dining area and room delivery) and activities. Additional Comments/Discussion: Two residents had private duty personnel that were present and participated in interviews. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were resident accommodations and related provisions and staffing and supervision. 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 Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Violations
22VAC40-73-450-H
Based on resident record review and staff interview, the facility failed to ensure that the care and services specified in the individualized service plan are provided to each resident,
Evidence
  1. On the facility’s “POC [Plan of Care] Response History”, Assistance to Bathroom is described as “Support provided- How resident uses the bathroom, (commode, bedpan, urinal, and/or changing while in bed) transfers on/off toilet, cleanses self after elimination; changes pad; manages ostomy or catheter; and adjusts clothing.”
  2. Resident 5’s Uniform Assessment Instrument (UAI), dated 05/02/2024, states that Resident 5 needs physical assistance with toileting. The UAI also notes that Resident 5 is incontinent of both bowel and bladder weekly or more.
  3. Resident 5’s individualized service plan (ISP), reviewed 05/16/2024 by the facility, states “I need 2-person physical assistance to the bathroom.”
  4. The “POC [Plan of Care] Response History” shows that 1-person assist was provided by staff under “Assistance to bathroom” a total of 19 times between 07/30/2024 and 08/12/2024.
  5. Resident 5’s “Task List Report” states that “Assistance to Bathroom” was scheduled to occur seven (7) times a day at the following times: 00:00, 04:00, 06:00, 08:00, 13:00, 17:00, 21:00. The “Task List Report” states that this was initiated on 05/08/2024.
  6. The “POC [Plan of Care] Response History” shows that support was provided by staff for Resident 5 under “Assistance to bathroom” a total of two (2) times out of the scheduled seven (7) times on four (4) days between 07/30/2024 and 08/12/2024.
  7. The “POC [Plan of Care] Response History” shows that support was provided by staff for Resident 5 under “Assistance to bathroom” a total of three (3) times out of the scheduled seven (7) times on nine (9) days between 07/30/2024 and 08/12/2024.
  8. Resident 4 is the spouse of Resident 5. Resident 4 stated that the facility does not provide adequate care for Resident 5, stating the resident needs more changes. Resident 4 stated that the facility agreed to come in every 3-4 hours but that never happens. Resident 4 attributed Resident 5’s repeated UTI’s to the lack of changing when referencing Resident 5’s incontinent care. Resident 4 stated that the staff agreed to change Resident 5 a minimum of six (6) times.
  9. Resident 7’s UAI, dated 03/21/2024, states that physical assistance is needed for bathing, dressing, and toileting. The UAI also notes that Resident 7 is incontinent of bowel less than weekly and incontinent of bladder weekly or more.
  10. Resident 7’s “Task List Report” states that “Assistance to Bathroom” was scheduled to occur seven (7) times a day at the following times: 01:00, 06:00, 07:00, 12:00, 14:30, 17:00, and 22:30. The “Task List Report” states that this was initiated on 03/22/2024.
  11. The “POC [Plan of Care] Response History” shows that support was provided by staff for Resident 7 under “Assistance to bathroom” a total of one (1) time out of the scheduled seven (7) times on one (1) day between 07/30/2024 and 08/12/2024.
  12. The “POC [Plan of Care] Response History” shows that support was provided by staff for Resident 7 under “Assistance to bathroom” a total of two (2) times out of the scheduled seven (7) times on three (3) days between 07/30/2024 and 08/12/2024.
  13. The “POC [Plan of Care] Response History” shows that support was provided by staff for Resident 7 under “Assistance to bathroom” a total of three (3) times out of the scheduled seven (7) times on two (2) days between 07/30/2024 and 08/12/2024.
  14. In an interview with the LI on 08/12/2024, Staff 3 acknowledged that the task lists were not being completed according to the scheduled interventions; however, stated that, for Resident 7, it was due to a revision completed recently on the task of “Assistance to bathroom.”
Plan of correction
1. Resident Number 5 no longer resides at this community. Physician’s Move-In Orders indicating a primary diagnosis of recurrent urinary tract infections prior to move-in. Additionally, progress note from INOVA Hospital indicating that while in another country Resident Number 5 experienced recurrent urinary tract infections and in February of this year Resident Number 5 developed a drug-resistant urinary tract infection. Resident Number 5 came to the United States from another Country to be treated for infection at an American Hospital. Resident Number 5 was discharged to Skilled Nursing Facility in March of this year where she developed another infection. Resident Number 5 moved into this community on May 8, 2024, and subsequently tested negative for a urinary tract infection on May 17, 2024. Additionally, community staff recommended pure wick external catheter to Resident Number 5’s spouse, which he declined. Unfortunately, Resident Number 5 had a history of urinary tract infections prior to moving to this community and spouse declined recommended interventions to reduce future infections. Violation Notice states that Resident Number 5 needs two-person physical assistance to the bathroom per her Interdisciplinary Service Plan. However, Resident Number 5’s Interdisciplinary Service Plan actually states she needs one-person physical assistance to the bathroom due to being changed in bed. Resident Number 7’s Task Lists and Point of Care response history documentation reflect corresponding scheduled interventions. Violation Notice states that the Resident Number 7’s Task List report indicates scheduled assistance to bathroom started on March 22, 2024. However, the Task List was updated on August 7, 2024, when scheduled tasks began. The Task List shows documentation corresponding to appropriate changing frequency. 2. Assisted Living Coordinator and Reminiscence Coordinator or designee will audit Task Lists and Point of Care response history documentation for residents’ who receive assistance to the bathroom to ensure provision of scheduled interventions. Assisted Living Coordinator and Reminiscence Coordinator or designee will audit documentation for residents who require transfer assistance to ensure residents’ Uniform Assessment Instruments, Interdisciplinary Service Plans, Tasks Lists, and Point of Care response history reflect the need for the appropriate number of staff to assist them. 3. Assisted Living Coordinator and Reminiscence Coordinator or designee will educate care staff regarding the importance of providing and documenting services in residents’ Point of Care response history as outlined on their Task Lists. 4. Assisted Living Coordinator and Reminiscence Coordinator or designee will audit Task Lists and Point of Care response history documentation for residents’ who receive assistance to the bathroom to ensure provision of scheduled interventions weekly for one month and monthly for three months. Assisted Living Coordinator and Reminiscence Coordinator or designee will audit documentation for residents who require transfer assistance to ensure residents’ Uniform Assessment Instruments, Interdisciplinary Service Plans, Tasks Lists, and Point of Care response history reflect the need for the appropriate number of staff to assist them weekly for one month and monthly for three months.
22VAC40-73-930-D
Based on resident record review and staff interview, the facility failed to ensure that the Individualized Service Plan (ISP) specified a minimum frequency of daily rounds to be made by direct care staff to monitor for emergencies or other unanticipated resident needs, and documentation that rounds were made for each resident with the inability to use the signaling device.
Evidence
  1. Resident 3 was admitted on 05/09/2023 and resides in the special care unit.
  2. Resident 3’s “Service Plan”, reviewed by the Licensing Inspector on 05/17/2024, states “Inability to use signaling device with need for nightly safety checks” in the “Focus” column. Under the Goal column, the Service Plan notes, “My safety needs will be anticipated and met daily due to my inability to use my signaling device through the next review date. The Interventions noted, “I require night safety check due to inability to use signaling device”.
  3. The “Freq/Resolve” column was blank.
  4. The plan does not specify the minimum frequency of daily rounds.
  5. Upon request, the facility did not provide documentation that rounds were made.
  6. In an interview with the LI on 08/12/2024, Staff 1 stated that the rounding policy for the facility is every 3-4 hours; however, they do not have a written policy.
  7. In an interview with the LI on 08/12/2024, Staff 1 confirmed the minimum frequency of rounds was not included on Resident 3’s ISP.
Plan of correction
1. Resident Number 3’s Frequency and Resolve column completed within his Interdisciplinary Service Plan. The Interdisciplinary Service Plan specifies the minimum number of frequencies of daily rounds. Documentation of rounds completed. 2. The Reminiscence Coordinator and Assisted Living Coordinator or Designee will identify other residents who may be unable to use a signaling device. These team members will update those residents’ Interdisciplinary Service Plans to reflect the inability to use a signaling device. Frequency and Resolve column will be completed for these residents. The Interdisciplinary Service Plans will also specify the minimum number of frequencies of daily rounds for these residents. Documentation of rounds will be completed for these residents. 3. The Assisted Living Coordinator or Reminiscence Coordinator or designee will educate team members that some residents cannot use a signaling device and that staff should refer to residents’ Interdisciplinary Service Plans for information on the minimum number of frequencies of daily rounds for these residents. Staff will be educated to document rounds completed for these residents. 4. The Reminiscence Coordinator and Assisted Living Coordinator or Designee will audit Interdisciplinary Service Plans for those residents who may be unable to use a signaling device These staff will ensure those residents’ Interdisciplinary Service Plans: Reflect the inability to use a signaling device; Include completion of the Frequency and Resolve column; Specify the minimum number of frequencies of daily rounds. These staff will also audit documentation of rounds for these residents. These audits will be completed weekly for one month and monthly for three months.
22VAC40-73-460-B
Based on resident record review and staff interview, the facility failed to ensure that care provision and service delivery was resident centered to the maximum extent possible and included resident participation in decisions regarding the care and services provided to him and personalization of care and services tailored to the resident's circumstances and preferences.
Evidence
  1. Resident 2 was admitted on 06/17/2023.
  2. Resident 2’s Physician Move in Orders, dated 06/14/2023, state that the resident should be on a regular, consistent carb diet. Resident 2 has a primary diagnosis of [Diagnosis].
  3. Resident 2’s Nutrition review, conducted on 07/26/2024, states “Resident wants to check BS daily. Resident only has oral DM medication. Unnecessary BS check daily. Current diet provides adequate nutrition and diet order remains appropriate. No other nutritional intervention needs currently. Continue with CCHO (Controlled Carbohydrate) diet.”
  4. Resident 2 stated “they don’t really care about diabetes people.” Resident 2 states there are not a lot of options available, food is not what is advertised, and it took them three months to get sugar free options. Resident 2 is looking to have more sugar free options to help control their sugar due to their diabetes.
  5. Staff 3 confirmed that they were aware Resident 2 wants to eat a sugar free diet to manage diabetes and asked how to continue to accommodate if the diet order is controlled carbs.
  6. Resident 1 showed the LI the breakfast that was served to the room. Resident 1 stated that they requested no butter because of their diet. Resident 1 touched the bread and stated, “This is all grease.” Resident 1 stated that there is no point in asking for anything because nobody listens. Resident 1 stated, “This is not the way to live.”
  7. Resident 1’s progress notes mention the residents’ concerns over meals on 07/29/2024 by care team staff and 07/26/2024 by the dietician. The Nutrition Review Note on 07/26/2024 states “Resident dislikes a lot of dining food. Resident comes out for meals. [Resident 1’s] appetite did not change.”
  8. Resident 1’s progress notes, written by Staff 3, state “Monthly Wellness Visit completed with daughter and resident. Concerns over dining and no other concerns.”
Plan of correction
1. Assisted Living Coordinator or designee will meet with Resident Number 2 to review sugar-free and reduced sugar options available to him. Executive Director or designee will meet with Resident Number 1 to better understand her dining preferences and work to accommodate. Incidentally, Resident Number 1 states there is no point in asking for anything because nobody listens. Community Staff provided evidence of ten Door Dash receipts, signed by resident. These indicate receipt of meals ordered and purchased by the community. These meals were personally delivered to the resident when she vocalized that she did not prefer meals offered in the dining room. Additionally, Resident Number 1’s Monthly Communication Note indicates that resident was happier with the food as of June 28, 2024. 2. Executive Director or designee will schedule and facilitate a resident meeting to discuss dining options and offer residents the opportunity to provide feedback. 3. Executive Director or designee will educate staff who serve meals to offer residents options consistent with both their dietary needs and their personal preferences. 4. Executive Director or designee will schedule and facilitate a resident meeting to discuss dining options and offer residents the opportunity to provide feedback monthly for three months; in addition to the initial meeting referenced in item number two of this section.
22VAC40-73-280-A
Based on resident interview, resident record review, and staff interview, the facility failed to ensure that they had staff adequate in knowledge, skills, and abilities, and sufficient in numbers to attain and maintain physical, mental, and psychosocial well-being of each resident.
Evidence
  1. Resident 1 stated that there were not enough staff. Resident 1 stated that nobody comes in to check on them, open the blinds, or say good morning. Resident 1 stated they had a fall and pressed the button, but nobody came, and they had to continue to wait. Nobody came so they crawled to open the door and yelled help.
  2. Resident 2 stated that the staff are quick to answer the button; however, that “some staff are friendly, and some are not.”
  3. Resident 4 is the spouse of Resident 5. Resident 4 stated that there are not enough staff, and that the staff are not trained. Resident 4 stated that they had to train staff to take care of Resident 5 and there is “no compassion.” Resident 4 stated that the staff are “arrogant” and give dirty looks when asking for assistance.
  4. In an interview with Resident 3 and Collateral Contact 1, Collateral Contact 1 stated that staff provide prompt care for Resident 3; however, sometimes the meals aren’t delivered correctly and that there are not a lot of facility options for Resident 3. Collateral Contact 1 must request the correct meal and do activities with Resident 3.
  5. Staff 2 stated that Resident 3 was a two person assist and provided a list of two person assists that contains Resident 3’s name. Resident 3’s ISP states “I need 1person physical assistance with Mechanical Help to the bathroom.”
  6. Resident 3’s “POC Response History” is marked that Resident 3 was changed with a 1 person assist on 07/30/2024, 07/31/2024, 08/02/2024, 08/05/2024, 08/06/2024, 08/07/2024, 08/08/2024, and 08/10/2024, and 08/11/2024.
  7. Resident 7 stated that the staff is a little slow. Resident 7 stated “I think they could use a little more staff.” Resident 7 also stated “I think they are a little more aggressive than they need” and gave the example of the dining staff throwing napkins down on the table.
Plan of correction
1.Resident Number 1’s Interdisciplinary Service Plan dated May 30, 2024 indicates that resident chooses to be independent with personal care. Resident Number 1 was given option, during this care plan review, to increase care level to receive personal support including assistance with TED hose and daily blind opening and closing. These services would come with an additional cost, which Resident Number 1 declined. Essentially, Resident Number 1 would like increased services; however, she does not want to pay for them. Resident Number 1 fell on June 20, 2024. Call system records indicate Resident Number 1 pressed her personal help button at 6:39 AM. Staff responded at 6:44 AM; five minutes and 28 seconds from initial alert. Staff documented that Resident Number 1 was found on the floor in sitting position. No evidence of Resident Number 1 having crawled to her door. Executive Director or designee will meet with Resident Number 3’s Responsible Party to better understand comments regarding meal accuracy and choices. Violation Notice sates that resident Number 3’s Interdisciplinary Service Plan indicates one person assist. Resident Number 3’s Interdisciplinary Service Plan actually states that he needs assistance of two people. Staff member referenced by Resident Number 7 no longer works at this community. 2. Assisted Living Coordinator and Reminiscence Coordinator or designee will audit documentation for residents who require assistance to ensure residents’ Interdisciplinary Service Plans and Point of Care response history reflect the need for the appropriate number of staff to assist them. 3. Executive Director or designee will provide reeducation to certain staff regarding customer service expectations. 4. Assisted Living Coordinator and Reminiscence Coordinator or designee will audit documentation for residents who require assistance to ensure residents’ Interdisciplinary Service Plans and Point of Care response history reflect the need for the appropriate number of staff to assist them weekly for one month and monthly for three months. Executive Director or designee will elicit feedback from residents during the next three monthly Residence Association Meetings to gauge their satisfaction with how staff members care for them.
October 6, 2023Complaint survey0 violations
Inspection dates
10/06/2023
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: 10/06/2023 (9:00 AM - 5:30 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 10/6/23 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: 49 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 Observations by licensing inspector: Facility documentation An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (703) 431-4247 or by email at m.massenberg@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
October 6, 2023Inspection2 violations
Inspection dates
10/06/2023
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 GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE 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: 10/6/23 (9:00 AM - 5:30 PM) Number of residents present at the facility at the beginning of the inspection: 49 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: 8 Number of interviews conducted with residents: 4 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
22VAC40-73-680-D
Based on observation and documentation, the facility failed to ensure that medications are administered in accordance with the physician's or other prescriber’s instructions and consistent with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing.
Evidence
  1. Resident #1’s morning medication administration was observed, during the inspection. Resident #1’s record contains insulin orders, dated 7/21/23 and 9/20/23, that call for the resident to receive insulin before meals. During the inspection, Resident #1’s insulin was administered after she ate breakfast.
Plan of correction
1. Staff will administer Resident #1's insulin as ordered. 2. The Resident Care Director or Designee will identify other residents scheduled to receive insulin prior to meals and audit their Medication Administration Records to ensure insulin has been administered per order. 3. The Resident Care Director or Designee will educate team members who administer medications on the importance of following insulin orders, specifically related to mealtime parameters. The Resident Care Director or Designee will also educate team members who administer medications on where to find these types of instructions in order to follow them. 4. The Resident Care Director or Designee will evaluate the order in which team members administer medications to residents in the community to ensure mealtime insulin orders can be reasonably followed. 5. The Resident Care Director or Designee will monitor insulin administration three times per week for one month and then weekly for one month.
22VAC40-73-660-B
Based on observation and documentation, the facility failed to limit medication storage to an out-of-sight place in the rooms of residents whose UAIs have indicated that the residents are capable of self-administering their medication.
Evidence
  1. Medication administration for Resident #1 was observed during the inspection. Salonpas pain relieving patches and Refresh eye drops were observed in Resident #1’s room. Resident #1’s Uniform Assessment Instrument (UAI), dated 4/25/23, states that the resident needs her medication administered by professional nursing staff. Resident #1’s record also contains an Assessment of Serious Cognitive Impairment form, dated 5/1/23, that states that she has a serious cognitive impairment with an inability to recognize danger or protect her own safety and welfare.
Plan of correction
1. The Reminiscence Coordinator removed the Salonpas pain relieving patches and Refresh eye drops from Resident #1’s room. 2.The Reminiscence Coordinator or Designee will visit other residents’ rooms to look for medications. The Reminiscence Coordinator will remove medications he finds. 3. The Reminiscence Coordinator will educate Resident #1’s spouse on the importance of not bringing medications to the community or leaving them in Resident #1's room. The Reminiscence Coordinator will educate other family members as indicated. 4. The Reminiscence Coordinator will educate his staff to look for medications in residents' rooms and report sightings to him. 5. The Reminiscence Coordinator or Designee will look in residents' rooms for medications three times per week for one month and then weekly for one month.
April 19, 2023Inspection0 violations
Inspection dates
04/19/2023
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 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
Technical assistance
Please update the posted resident rights to reflect the current Licensing Administrator – Sharae Henderson, 804-629-3479
Comments
Licensing Inspector (LI) conducted an announced initial inspection on 4/19/2023. LI walked the physical plant, verified window and room measurements, reviewed policies and procedures and staff background checks 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. 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.