The Vero at Chesapeake — Virginia Inspection Report

Inspections

On record

With violations

Visits that cited something

Clean visits

Nothing cited

Violations cited

Individual findings

Standards cited

Distinct rules

Complaint visits

Prompted by a complaint

The Vero at Chesapeake was inspected 19 times between May 11, 2023 and June 18, 2026 by the Virginia Department of Social Services. 14 of those visits ended with violations cited and 5 with none. Across that history VDSS cited 44 violations under 33 distinct standards. 9 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

11/11/2026

Administrator

Michael Harden

Licensing inspector

Donesia Peoples

Inspector phone

757 353-0430

Approved for

Assisted Living · Non-Ambulatory

Inspection History

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

June 18, 2026Complaint survey0 violations

Inspection dates

06/18/2026

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 IMPAIRMENTS22VAC40-80 COMPLAINT INVESTIGATION

Comments

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

February 12, 2026Complaint survey1 violation

Inspection dates

02/12/2026

Areas reviewed

Comments

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 02/12/2026 at 10:00am to 1:53 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 01/16/2026 regarding allegations in the areas of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 117 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 0 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 4 Observations by licensing inspector: Residents were observed eating lunch and the call signaling system was monitored. Additional Comments/Discussion: The facility’s policy and procedures for infection control, admission and discharge of residents were reviewed. 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. 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov

Violations

22VAC40-73-140-E

Based on emails and staff interviews the facility failed to ensure for a facility licensed for both residential and assisted living care, the administrator shall be authorized to temporarily practice pursuant to § 54.1-2408.4 of the Code of Virginia.

Evidence

The Licensing Inspector (LI) received an email on 12/15/25 from staff #1 that included notification of a change in administrator stating staff #2 is the administrator at the facility as of 12/11/25. The administrator license provided by the facility for staff #2 is an out-of-state (South Carolina) license.
The Licensing Inspector (LI) sent an email to staff #1, and staff #2, on the dates of 12/15/25, 12/19/25, 01/14/26, requesting verification the facility and or staff #2 has notified the board of long-term care and received temporary authorization for staff #2 to practice as a licensed administrator. The facility did not provide a response nor verification.
The LI confirmed with collateral contact #1 via email on 01/28/26 and 03/06/26 that the facility or staff #2 had not submitted the required documentation to the board of long-term care to receive temporary authorization for staff #2 to practice as licensed administrator.
During an onsite interview on 02/12/26 with staff #3, staff #3 confirmed staff #2 is practicing as the administrator on record at the facility.
During a phone interview on 03/06/25 with staff #2, staff #2 confirmed staff #2 is practicing as the administrator on record at the facility and that staff #2 had not submitted the required documentation to the department of health professions to receive a temporary authorization to practice as an administrator.

Plan of correction

Pursuant to Virginia Code, facility administrator/designee and/or its corporate entities will submit the required Out-Of-State Practitioner Reporting Form to the Virginia Department of Health Professions, requesting temporary approval for the new Administrator to practice using their out-of-state license until a permanent license is obtained. This form will also be sent to this department as notification that said request has been submitted. Going forward, facility administrator/designee and/or its corporate entities will ensure that upon the changing of Facility Administrators, all required departments in the state of Virginia will be notified of said change and should the temporary/new administrator not be licensed in the State of Virginia, the required reporting form will be submitted. Date To Be Corrected March 9, 2026

October 22, 2025Inspection9 violations

Inspection dates

10/22/2025

Areas reviewed

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: An unannounced renewal inspection took place on 10/22/2025 at 8:10 am to 6:55 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 113 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 9 Number of staff records reviewed: 4 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 6 Observations by licensing inspector: Lunch, Dinner, and an activity were observed. A medication pass observation was completed for four residents. The following were reviewed: staffing schedule, emergency preparedness drills, medication carts, first aid kits, fire inspection report, certificate of liability insurance, and a health inspection report. Water temperature was measured, and the call bell system was monitored. Additional Comments/Discussion: 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov

Violations

22VAC40-73-640-A

Based on observation, record review, and staff interview the facility failed to develop and implement a written plan for medication management to include: Methods to prevent the use of outdated, damaged, or contaminated medications; 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 order.

Evidence

The facility’s medication management plan contains the following documentation: • Medications that have been expired will be removed from the medication cart to prepare for disposal. • MAR/Medication Audit tool to monitor the MAR reflects current correct medications, correct dose, correct times, and correct dates to be given.
During the medication cart observation on 10/22/25 with staff #4, the Licensing Inspector (LI) observed the following expired medication located on the medication cart: carvedilol tab 12.5 mg expired 09/30/25, prescribed to resident #10.
The record for resident #5 contains the following physician order dated 09/10/25: Polyethylene Glycol 17 Gram Powder Pack, give one packet by mouth once daily 17 grams in 8 ounces of liquid daily. Resident #5’s October 2025 MAR does not include instructions to mix the packet in 8 ounces of liquid. The MAR documents the following instructions with a start date of 09/10/25: “1 packet mixed in liquid by mouth every day.”
Resident #5’s October 2025 MAR includes the following instructions for Polyethylene Glycol 3350 Outer 17GM Powder: • Start date 09/16/25 “ mix 17-grams mixed with liquid of choice in 4 ounces of water, juice, coffee or tea on Monday, Wednesday, Friday.” Resident #5’s record does not contain a physician order for Polyethylene Glycol Powder “mix 17-grams mixed with liquid of choice in 4 ounces of water, juice, coffee or tea on Monday, Wednesday, Friday.”
During an interview on 10/22/25 with staff #7, staff #7 confirmed the following: • The facility was only administering one dose of Polyethylene Glycol Powder to resident #5 daily according to the physician order with a start date of 09/10/25. • resident #5’s October 2025 MAR was not accurate to document two instructions for Polyethylene Glycol Powder including the instructions with a start date of 09/16/25 as the facility did not have a physician order including the instructions as documented on the MAR for Polyethylene Glycol Powder “mix 17-grams mixed with liquid of choice in 4 ounces of water, juice, coffee or tea on Monday, Wednesday, Friday.”
Resident # 5’s October 2025 MAR documents the Polyethylene Glycol Powder was not administered according to the instructions to give on Mon. Wed, and Friday on the dates of (09/17/25, 09/22/25, 09/24/25, 09/26/25, 10/01/25, 10/03/25, 10/06/25, 10/08/25, and 10/10/25) and documents an exception reason as duplicate, medication already administered, or medication already given prescribed by different provider

Plan of correction

A 100% audit of the identified resident’s orders was conducted, and deficiencies were corrected at time of identification by the Health Services Director on 10/22/2025. All current resident orders will be reviewed by the Medical Director or their designee for accuracy and completeness. The Health Services Director or Assistant Health Services Director will audit all new orders weekly for 30-days, every other week for 30-days, then monthly thereafter to ensure clarity and accuracy of new orders and that they have been transcribed into the electronic medical record correctly. Results of audits will be discussed during monthly CQM/CQI meetings. Date of Correction: November 21, 2025

22VAC40-90-40-B

Based on the staff record review and staff interview the facility failed to ensure the criminal history record report shall be obtained within 30 days of employment for each employee.

Evidence

The record for staff #9, hire date 09/22/25, did not contain a criminal history record report.
The record for staff #10, hire date 07/21/25, did not contain a criminal history record report.
The record for staff #11, hire date 07/14/25, did not contain a criminal history record report.
Upon request and during an interview on 10/22/25 with staff #5, staff #5 confirmed the records for Staff #9, 10, and 11 did not contain a criminal history record report.

Plan of correction

New background checks were submitted for the staff members identified as being deficient. A 100% audit will be conducted of all current employee files by the Business Office Director and Executive Director. Monthly, beginning December 1, a 10% audit will be conducted on employee files to ensure background checks are present by the Executive Director or designee. The record of files audited will be maintained in a separate folder located with the employee files. Results of audits will be discussed during monthly CQM/CQI meetings. Date of Correction: November 21, 2025

22VAC40-73-670-1

Based on the staff record review, resident record review, observation, and staff interview the facility failed to ensure each staff person who administers medication shall be licensed by the Commonwealth of Virginia to administer medications or be registered with the Virginia Board of Nursing as a medication aide.

Evidence

Staff #3, hired 1/11/24, record contains a registered medication aide license expired 09/30/25. 2.During the medication pass observation completed on 10/22/25, Staff #3 was observed administering medications to resident’s # 4, and #6. 3.Resident #3’s October 2025 Medication Administration Record (MAR) documents staff #3 administered medications to resident #3 on the following dates: 10/01/25, 10/02/25, 10/03/25, 10/08/25, 10/09/25, 10/11/25, 10/12/25, 10/14/25, 10/15/25, 10/16/25, 10/17/25, 10/20/25, 10/21/25, and 10/22/25.
Resident #5’s October 2025 MAR documents staff #3 administered medications to resident #5 on the following dates: 10/06/25, and 10/12/25.
Upon request, and during an interview on 10/22/25 with staff #5, staff #5 was not able to provide an active registered medication aide license for staff #3. Staff #5 confirmed the registered medication aide license for staff #3 expired 09/30/25.

Plan of correction

Staff #3 was notified and renewed her license at the time the deficiency was identified on 10/22/2025. A 100% audit will be conducted by the Business Office Manager/Designee for all current employees to ensure licenses are current. During the monthly 10% audit of employee files, the Executive Director will ensure the staff members license is present and current. Results of audits will be discussed during monthly CQM/CQI meetings. Date of Correction: November 21, 2025

22VAC40-73-250-D

Based on the staff record review and staff interview health information required by these standards shall be maintained at the facility and be included in the staff record for each staff person, and also shall be maintained at the facility for each household member who comes in contact with residents. Initial tuberculosis examination and report. Subsequent tuberculosis evaluations and reports. Each staff person or household member required to be evaluated shall annually submit the results of a risk assessment, documenting that the individual is free of tuberculosis in a communicable form as

Evidence

d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence:
The record for staff #1, hire date 02/01/24, did not contain an initial and an annual risk assessment for TB.
The record for staff #2, hire date 05/24/24, did not contain an initial and an annual risk assessment for TB.
The record for staff #3, hire date 01/11/24, did not contain an initial and an annual risk assessment for TB.
The record for staff #4, hire date 02/01/24, did not contain an initial and an annual risk assessment for TB.
Upon request, and during an interview on 10/22/25 with staff #5, staff #5 confirmed the record for the following staff records did not contain an initial and an annual risk assessment for TB: • Staff #1 • Staff #2 • Staff #3 • Staff #4

Plan of correction

Tuberculosis testing will be conducted for 100% of the staff who have not had a tuberculosis test since October 1, 2025. Annually, tuberculosis testing will take place on October 1 or the first business day after, for all staff who have not received tuberculosis testing within 90-days of that date. New hires will be tested upon hire. The Health Services Director and Assistant Health Services Director will conduct testing and ensure results are filed in employee folders. The Business Office Manager/Designee will review test results and audit employee files to ensure results are placed in folder. During the monthly 10% audits the Executive Director will ensure tuberculosis test are present. Results of audits will be discussed during monthly CQM/CQI meetings. Date of Correction: November 21, 2025

22VAC40-73-680-B

Based on observation, and staff interview, the facility failed to ensure medications remain in the pharmacy issued container, with the prescription label or direction label attached, until administered to the resident.

Evidence

During the medication pass observation on 10/22/25 at 8:16 am with staff # 3 the Licensing Inspector (LI) observed medication pills in an unlabeled and opened cup inside the top drawer of the medication cart.
Staff #3 confirmed staff #3 removed medications prescribed to resident #3 from the pharmacy issued container on 10/22/25 around the time of 8:00am and placed the medications in the cup. The resident was not ready to take the medications and staff #3 kept the following medications in an opened and unlabeled cup inside the top drawer of the medication cart: • Carvedilol 25mg • Ferrous Sulfate 25mg • Furosemide 20mg • Losartan 25mg • Spironolactone 25mg

Plan of correction

Staff #3 was retrained at the time the deficiency was identified on 10/22/2025 by the Health Servies Director. Inservice training was conducted by the Health Services Director 10/29/2025 with all staff certified/licensed to administer medications specifying that medications will not be removed from their pharmacy issued container until such time that medication will be administered to the resident. Medication carts will be audited weekly for four weeks then monthly by the Health Services Director/Designee. Quarterly audits will be conducted by the Pharmacist or their designee to ensure staff adhere to medication administration code. Results of audits will be discussed during monthly CQM/CQI meetings. Date of Correction: November 21, 2025

22VAC40-73-410-A

Based on the record review and staff interview the facility failed to ensure upon admission the assisted living facility shall provide an orientation for new residents and their legal representatives, including mealtimes, and use of the call system. If needed, the orientation shall be modified as appropriate for residents with cognitive impairments. Acknowledgment of having received the orientation shall be signed and dated by the resident and, as appropriate, his legal representative, and such documentation shall be kept in the resident's record.

Evidence

The record for resident #2, admission date of 10/21/25 did not contain documentation of an orientation to mealtimes and use of the call system.
The record for resident #5, admission date of 09/11/25, did not contain documentation of an orientation to mealtimes and use of the call system.
The record for resident # 7, admission date of 02/26/25, did not contain documentation of an orientation to mealtimes and use of the call system.
Upon request on 10/22/25 and during an interview with staff #6, staff #6 was not able to provide documentation of an orientation to meals and use of the call system for the following residents: • Resident #2 • Resident #5 • Resident #7

Plan of correction

Upon admission, the Community Resources Director, will schedule new resident orientation the next business day after move-in. All department heads will participate in new resident orientation. The Community Resources Director will maintain the new resident orientation checklist in the resident admission packet. The Community Resources Director will audit all new admission packets for 30-days. Date of Correction: November 21, 2025

22VAC40-73-680-G

Based on observation and staff interview the facility failed to ensure over the counter medication shall be labeled with the resident’s name.

Evidence

During the medication cart observation on 10/22/25 with staff #3 the following over the counter medications located on the medication cart were not labeled with the resident’s name: • Vitamin B-12 • Melatonin • Calcium • Systane Lubricant Eye Drops • Miralax Powder
During an interview on 10/22/25 with staff #3, staff #3 confirmed the following over the counter medications were not located with the resident’s name: • Vitamin B-12 • Melatonin • Calcium • Systane Lubricant Eye Drops • Miralax Powder

Plan of correction

At the time deficiency was noted Health Services Director/Designee identified and labeled medications in medication cart. Health Services Director/Designee will educate all clinical staff on proper medication labeling of OTC per medication management guidelines by 11/21/25. Health Services Director/Designee will audit medication carts for proper labeling of meds weekly x4 weeks, then every other week x4weeks, then monthly. Results of audits will be reported at monthly CQM/CQI meeting.

22VAC40-73-310-D

Based on the record review and staff interview the facility failed to ensure upon review of the UAI prior to admission of a resident, the assisted living facility administrator shall provide written assurance to the resident that the facility has the appropriate license to meet his care needs at the time of admission. Copies of the written assurance shall be given to the legal representative and case manager, if any, and a copy signed by the resident or his legal representative shall be kept in the resident's record.

Evidence

The record for resident #2, admission date of 10/21/25 did not contain a signed copy of a written assurance. 2.The record for resident #4, admission date of 07/21/25 did not contain a signed copy of a written assurance.
The record for resident #5, admission date of 09/11/25, did not contain a signed copy of a written assurance.
The record for resident # 7, admission date of 02/26/25, did not contain a signed copy of a written assurance.
The record for resident #9, admission date of 05/15//25, did not contain a signed copy of a written assurance.
Upon request and during an interview on 10/22/25 with staff #6, staff #6 confirmed the records for the following residents did not contain a signed copy of a written assurance: • Resident #2 • Resident #4 • Resident #5 • Resident #7 • Resident #9

Plan of correction

A 100% audit of current resident agreements will be conducted to identify other residents at risk. The written assurance statement will be added to the residential admissions packet and all current residents will receive a new written assurance statement. The Community Resource Director will maintain an audit log of all current admissions and future admissions for 30-days. Date of Correction: November 21, 2025

22VAC40-73-940-A

Based on the fire inspection report review and the staff interview the facility failed to ensure an assisted living facility shall comply with the Virginia Statewide Fire Prevention Code (13VAC5-51) as determined by at least an annual inspection by the appropriate fire official. Reports of the inspections shall be retained at the facility for at least two years.

Evidence

The facility’s fire inspection report is dated as completed on 05/15/24.
Upon request, and during an interview with staff #8, staff #8 was not able to provide a fire inspection report completed annually after 5/15/24. Staff #8 confirmed the facility has not had an annual fire inspection completed by the appropriate fire official.

Plan of correction

The Fire Marshal’s office conducted the annual safety inspection on 11/13/2025. When the paperwork is received it will be forwarded to the licensing office. Date of Correction: 11/13/2025

October 3, 2025Complaint survey1 violation

Inspection dates

10/03/2025

Areas reviewed

22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-80 COMPLAINT INVESTIGATION

Comments

Type of inspection: Complaint Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 10/03/2025 at 12:46 pm to 1:35 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 10/02/2025 regarding allegations in the areas of: Buildings and Grounds Number of residents present at the facility at the beginning of the inspection: 113 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: The facility’s thermostat settings were monitored. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the (complaint(s)/self-report) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility The department's inspection findings are subject to public disclosure. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples. Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov

Violations

22VAC40-73-880-B

Based on observation and staff interview the facility failed to ensure a temperature of at least 72 degrees Fahrenheit shall be maintained in all areas used by residents during hours when residents are normally awake.

Evidence

During a tour of the facility on 10/03/25 (1:09 pm through 1:24 pm) with staff #2, the Licensing Inspector (LI) observed the thermostats to be read as set to cooling with the following temperatures: • thermostat located on the first-floor assisted living hallway, read a temperature of 68 degrees. • Thermostat located on the second-floor assisted living hallway, read a temperature of 70 degrees. • Thermostat located in the safe secure unit, read a temperature of 65 degrees.
During an interview with staff #2, staff #2 confirmed and observed the temperatures as set on cooling and the readings of 65, 68, and 70 degrees.

Plan of correction

Date of Correction: October 3, 2025; All thermostats set to 72°F The Maintenance Director conducted training with housekeeping and direct care staff on temperature setting on all facility thermostats. Follow-up training was conducted by the Executive Director during staff town hall meetings on October 28 and 29, 2025 on temperature requirements. Maintenance staff will conduct audits for 30-days to ensure thermostats remain set on 72°F.

October 3, 2025Complaint survey0 violations

Inspection dates

10/03/2025

Areas reviewed

Comments

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

October 3, 2025Inspection2 violations

Inspection dates

10/03/2025

Areas reviewed

Comments

Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced monitoring inspection took place on 10/03/2025 at 10:35 am to 12:45 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-report was received by VDSS Division of Licensing on 9/16/2025 regarding allegations in the areas of: Personnel and Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 113 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 4 Observations by licensing inspector: An activity was observed. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the self-report, area(s) of non-compliance with standard(s) or law were: Resident Care and Related Services 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 Donesia Peoples. Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov

Violations

22VAC40-73-300-B

Based on the record review, resident, and staff interviews the facility failed to ensure a method of written communication shall be utilized as a means of keeping direct care staff on all shifts informed of significant happenings or problems experienced by residents, including complaints and incidents or injuries related to physical or mental condition. The information shall be included in the records of the residents involved.

Evidence

Staff #3 emailed a self-reported incident to the Licensing Inspector (LI) on 09/16/25 reporting the following incident that occurred on 09/01/25: Resident #1 stated resident #1 requested the wheelchair from staff #1. Staff #1 pushed resident #1’s wheelchair towards resident #1 and the wheelchair hit resident #1’s leg causing a small skin tear that was dried up and scabbed over by the time the resident placed their pajamas on. Resident #1 showed staff #2 the skin tear and informed staff #2 what happened.”
During an interview on 10/03/25 with resident #1, resident #1 confirmed resident #1 informed staff #2 on 09/01/25 that staff #1 pushed a wheelchair towards resident #1 and the wheelchair hit the resident’s leg “causing a bleed to the resident’s lower calf area.”
The record for resident #1 did not contain documentation of resident #1 reporting a complaint and incident involving staff #1 on the day of 09/01/25.
During an interview on 10/03/25 with staff #2, staff #2 stated the following: • On 09/01/25, resident #1 informed staff #2 that staff #1 “became upset with resident #1 and pushed and shoved the wheelchair towards resident #1. The resident reported the wheelchair hit the bottom of resident #’s leg. • Staff #1 assessed resident #1 on 09/01/25 and observed a “red bump” on the bottom of the resident’s leg that was not a skin tear. Staff #1 stated staff #1 was not able to confirm how the red bump occurred on the resident’s leg. • Staff #1 confirmed staff #1 did not document the resident’s complaint about staff #1 in the resident’s record nor in a written notification to notify the facility staff of the resident’s complaint and red bump observed on the resident’s leg.

Plan of correction

Date of Correction: October 3, 2025; 24-hour log reviewed daily by direct care staff; walking rounds conducted; care tracker completed. The Health Services Director conducted training with direct care staff on completion of 24-hour log and care tracker. The Health Services Director and Assistant conducted training with direct care staff on walking rounds. The Health Services Director and Assistant Health Services Director will conduct audits for 30-days to ensure the 24-hour log, walking rounds, and care tracker are completed.

22VAC40-73-200-D

Based on the staff record review and staff interview the facility failed to ensure the facility shall obtain a copy of the certificate issued or other documentation indicating that the person has met one of the requirements of subsection C of this section, which shall be part of the staff member's record in accordance with 22VAC40-73-250.

Evidence

The record for staff #1 (personal care aide), hire date 07/29/25, did not contain documentation staff #1 has met one of the requirements for direct care staff.
Upon request, and during an interview on 10/03/25 with staff #4, staff #4 confirmed staff #1 was hired with the qualification as a personal care aide, and staff #4 confirmed a personal care aide certificate of completion was not located in staff #1’s record.

Plan of correction

Date of Correction: September 2, 2025; staff #1 was suspended September 2, 2025, and terminated September 15, 2025. Staff certifications and licenses will be checked prior to the first day of work inside the facility. The hiring manager will be responsible for obtaining and checking staff licenses and certifications with the Human Resources Director being the backup. All new hire files will be audited for 30-days to ensure license and certification have been verified.

August 26, 2025Complaint survey1 violation

Inspection dates

08/26/2025

Areas reviewed

Technical assistance

22VAC40-73-610. Menus for meals and snacks

Comments

Type of inspection: Complaint Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 08/26/2025 at 9:15 am to 12:45 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 8/11/2026 regarding allegations in the areas of: Resident Care and Related Services, and Buildings and Grounds Number of residents present at the facility at the beginning of the inspection: 113 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 0 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: The facility’s food supply, water supply, and snack availability was observed. Additional Comments/Discussion: 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: Buildings and Grounds 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 Donesia Peoples. Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov

Violations

22VAC40-73-870-E

Based on observation, the facility failed to ensure all furnishings, fixtures, and equipment, including furniture, window coverings, sinks, toilets, bathtubs, and showers, shall be kept clean and in good repair and condition.

Evidence

During a tour of the facility on 08/26/25 with staff #1, the Licensing Inspector (LI) observed an unclean substance to be located on the inside of two of the washing machines located on the 2nd Floor.

Plan of correction

1.Immediate Correction: a.Both washing machines on the 2nd floor were immediately cleaned and sanitized on 08/26/25. b.The Maintenance Director inspected all washers and dryers throughout the facility to ensure they were clean and in proper working condition. 2.Systemic Prevention: a.Housekeeping staff were re-educated on cleaning protocols for laundry equipment, including frequency, cleaning products, and documentation. b.A cleaning checklist for all laundry machines was implemented effective 08/27/25 to ensure regular cleaning and maintenance. c.The Maintenance Director will conduct bi-weekly inspections of all laundry areas to confirm compliance with cleanliness and repair standards. 3.Monitoring: a.The Maintenance Director or designee will review the housekeeping and maintenance logs weekly for the next 90 days to ensure ongoing compliance. b. Any deficiencies noted during monitoring will be corrected immediately, and staff will be re-educated as needed.

April 28, 2025Complaint survey0 violations

Inspection dates

04/28/2025

Areas reviewed

22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS

Comments

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 04/28/2025 from 10:05 am to 10:25 am. 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 04/12/2025 regarding allegations in the area(s) of: Admission, Retention, and Discharge of Residents. Number of residents present at the facility at the beginning of the inspection: 110 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: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

April 11, 2025Complaint survey0 violations

Inspection dates

04/11/2025

Areas reviewed

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

Technical assistance

22VAC40-73-520

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: 04/11/2025 from 1:25 pm to 2:30 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 04/07/2025 regarding allegations in the area(s) of: Resident Care and Related Services and Buildings and Grounds. Number of residents present at the facility at the beginning of the inspection: 108 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 5 Number of staff records reviewed: 0 Number of interviews conducted with residents: 5 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

March 18, 2025Complaint survey2 violations

Inspection dates

03/18/2025, 03/21/2025

Areas reviewed

22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03/18/2025 from 12:05 pm to 1:45 pm and 03/21/2025 from 11:25 am to 11:45 am. 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 03/12/2025 regarding allegations in the area(s) of: Personnel and Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 109 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: 5 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation(s) of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint(s) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations

22VAC40-73-460-A

Based on observation and interview, the facility failed to assume general responsibility for the health, safety, and well-being of the residents.

Evidence

Resident #2 was observed with a skin tear on their right arm.
Resident #2 indicated Staff #6’s nails scratched the resident during their shower the day prior (03/17/2025).
Resident #2 stated there have been at least two similar skin tears caused by Staff #6’s nails during bathing over the past two months.

Plan of correction

1. On the day of the incident, resident evaluated, area cleaned & a badge applied on the area. HSD was notified. 2. Resident individual care plan will be reviewed for further service needs by the HSD. 3. Direct staff members will be re-educated on the general responsibilities for the health and safety, and well-being of the residents by HSD/Designee. 4. Education/in-service needs will be submitted to the monthly CQI committee for analysis and further actions.

22VAC40-73-210-B

Based on record review and interview, the facility failed to ensure all direct care staff attend at least 18 hours of training annually. Direct care staff who are licensed health care professionals or certified nurse aides shall attend at least 12 hours of annual training.

Evidence

Staff #1 was unable to provide documentation of 2024 annual training for Staff #3 and Staff #5.

Plan of correction

1. Facility will ensure 18 hours annually training. Training will be provided in class and online. 2. BOD/department director/designee will ensure all direct care staff required training completed by April 30th, 2025. 3. BOD will audit all records for training and will complete monthly audits of 10% of employee records. 4. Findings will be submitted to the monthly CQI committee for analysis and further actions.

March 12, 2025Complaint survey7 violations

Inspection dates

03/12/2025

Areas reviewed

22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 EMERGENCY PREPAREDNESS

Technical assistance

22VAC40-73-460

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: 03/12/2025 from 9:50 am to 12:00 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 03/04/2025 regarding allegations in the area(s) of: Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 109 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: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation(s) of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint(s) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations

22VAC40-73-440-A

Based on record review, the facility failed to complete a resident’s UAI prior to admission, at least annually, and whenever there is a significant change in the resident's condition.

Evidence

Resident #1 and Resident #2 both admitted to the facility on 01/31/2025; however, Resident #1 and Resident #2’s record did not include a completed UAI.

Plan of correction

1- The UAIs completed for both resident# 1 on 1/9/25 and resident #2 on 2/27/25 after returning from the hospital by the HSD. 2- HSD/Designee will review 100% of new resident records to validate UAIs by 4/11/25. 3- HSD/AHSD will be educated on VA DSS requirements on UAIs by HSD/designee 4- Administrator/designee will randomly audit 5 residents UAI monthly. 5- Findings will be submitted to the monthly CQI committee for analysis and further actions.

22VAC40-73-450-A

Based on record review, the facility failed to ensure on or within seven days prior to the day of admission, a preliminary plan of care be developed to address the basic needs of the resident that adequately protects their health, safety, and welfare.

Evidence

Resident #1 and Resident #2 (both admitted 01/31/2025) did not have a preliminary plan of care in their record.

Plan of correction

1- The preliminary care plans were in progress pending for signature for residents 1 & 2. 2- HSD/Designee will review 100% of new resident records to validate preliminary care plans. 3- HSD/AHSD/designee will be educated on VA DSS requirements on preliminary care plans by the Administrator/designee. 4- Administrator/designee will randomly audit five residents care plans monthly. 5- Findings will be submitted to the monthly CQI committee for analysis and further actions.

22VAC40-73-470-F

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

Evidence

Per nursing notes, Resident #1 fell and hit their head on 02/11/2025 around 5:00 pm. The resident was noted to have “a scrape and a small knot on the right side of the head.” It also notes the resident “was shaking and vomiting” and was sent to the ER upon family request around 10:30 pm.
There was no indication the resident was recommended to go to the ER for treatment nor if the resident refused such recommendation initially after the fall.

Plan of correction

1- Facility will ensure community’s emergency hospitalization procedures and VA DSS standards followed. 2- An in-service on community’s emergency hospitalization policy and procedures, documentation, and VA DSS standards will be provided to clinical team by the HSD/designee. 3- New staff training on emergency hospitalization provided by HSD/AHSD. The training will be maintained by the BOD/designee. 4- BOD will audit all records for training and will complete monthly audits of 10% of employee records. 5- Education needs will be submitted to the monthly CQI committee for analysis and further actions.

22VAC40-73-640-A

Based on record review and interview, the facility failed to have a written plan for medication management to include methods to ensure that each resident's prescription medications and any over- the- counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages.

Evidence

Staff #1 was unable to provide the facility’s written plan for the facility’s procedures and/or methods to ensure that each resident's prescription medications and any over- the- counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages during the onsite inspection.

Plan of correction

1- Facility’s medication management will be updated on medication reorder procedure by RDHS/HSD/designee. 2- Clinical team will be educated on medication management policy and procedures by HSD/designee. 3- Residents and families will be educated on facility’s medication management by HSD/designee. 4- HSD/Designee will audit medication carts for low dose will be communicated with responsible parties and PCPs according to the facility’s policy and VA DSS standards. 5- Findings will be submitted to the monthly CQI committee for analysis and further actions.

22VAC40-73-680-D

Based on record review, the facility failed to ensure medications be administered in accordance with the physician's or other prescriber’s instructions.

Evidence

The February 2025 MAR indicates Resident #1 was not administered Trulicity on 02/19/2025 and 02/26/2025.

Plan of correction

1- Facility will ensure medications be administered in accordance with the physician's or other prescriber’s instructions. 2- Clinical team will be educated on medication management policy and procedures by HSD/designee. 3- HSD/Designee will audit MARs for missed does and will communicate with physicians and responsible parties monthly. 4- Findings will be submitted to the monthly CQI committee for analysis and further actions.

22VAC40-73-450-C

Based on record review, the facility failed to ensure the comprehensive ISP be completed within 30 days after admission and include the items identified in the standard.

Evidence

Resident #1 (admitted 01/31/2025) did not have a comprehensive ISP in their record.
Resident #2 admitted to the facility on 01/31/2025; however, the ISP in Resident #2’s record was dated 03/04/2025 and did not indicate the time frame for expected outcomes for the needs identified.

Plan of correction

1- Facility will ensure care plans will be completed within 30 days after admission and include the items identified in the standard by the HSD/designee. 2- HSD/Designee will review 100% of new resident records to validate care plans. 3- HSD/AHSD will be educated on VA DSS requirements on care plans by the Administrator/designee. 4- Administrator/designee will randomly audit five residents care plans monthly. 5- Findings will be submitted to the monthly CQI committee for analysis and further actions.

22VAC40-73-990-A

Based on interview, the facility failed to have a written plan for resident emergencies to include procedures for handling medical emergencies.

Evidence

Staff #1 was unable to provide the facility’s written plan for how the facility handles medical emergencies for residents during the onsite inspection.

Plan of correction

1- Facility’s medication management will be updated on resident emergencies to include procedures for handling medical emergencies by RDHS/HSD/designee. 2- Clinical team will be educated on medication management policy and procedures by HSD/designee. 3- Residents and families will be educated on facility’s medication management by HSD/designee. 4- Education needs will be submitted to the monthly CQI committee for analysis and further actions.

February 3, 2025Inspection1 violation

Inspection dates

02/03/2025

Areas reviewed

22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Comments

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 02/03/2025 from 10:00 am to 11:00 am. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 01/23/2025 regarding allegations in the area(s) of: Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 104 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: 1 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations

22VAC40-73-460-D

Based on interview and record review, the facility failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs.

Evidence

On 01/22/2025, Resident #1 was found in the main entry of the assisted living at approximately 10:40 pm.
Staff #1 indicated a door alarm in the safe, secure environment went off around 9:17 pm. Staff #2 disabled the alarm; however, a count was not conducted to ensure all residents were accounted for.

Plan of correction

1. Memory care doors and alarm system checked, and no issues found. 2. Nursing staff members will be trained on wandering and elopement, detecting behaviors, interventions, as well as on shift round, and head count expectations. 3. After hour activities for wandering residents updated. Resident Experience director/designee trained staff on individualized programming measures for residents with exit seeking behaviors. Programming boxes created to assist with activities for those residents. 4. Resident’s care plan and ISP updated. 5. Incident investigation outcome and intervention effectiveness will be reviewed during the next quality assurance meeting.

October 31, 2024Inspection3 violations

Inspection dates

10/31/2024

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Comments

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/31/2024 from 10:35 am to 12:45 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Three self-reported incidents were received by VDSS Division of Licensing on 10/10/2024, 10/18/2024, and 10/21/2024 regarding allegations in the area(s) of: Admission, Retention, and Discharge of Residents, Resident Care and Related Services, and Additional Requirements for Facilities that Care for Adults with Serious Cognitive Impairments. Number of residents present at the facility at the beginning of the inspection: 96 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 0 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 4 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the self-report; area(s) of non-compliance with standard(s) or law were: Resident Services and Additional Requirements for Facilities that Care for Adults with Serious Cognitive Impairments. A violation notice was issued; any violation(s) not related to the self-reports 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations

22VAC40-73-1150-A

Based on record review, the facility failed to ensure doors that lead to unprotected areas be monitored or secured through devices that conform to applicable building and fire codes, including door alarms, cameras, constant staff oversight, security bracelets that are part of an alarm system, pressure pads at doorways, delayed egress mechanisms, locking devices, or perimeter fence gates.

Evidence

On 10/09/2024, Resident #1 exited the safe, secure environment.
An observation noted in Resident #1’s record by Staff #3 indicates both Staff #3 and the receptionist “did not hear or see the alarm going off” and that the alarm did not “alert to the tablets.”

Plan of correction

Testing for each emergency exit will be completed by Maintenance Director and documented in TELS. Record logs will include a list of emergency door locations. Staff will be educated on elopement procedure. Monthly testing will be completed by the 15th of each month beginning November 15,2024. Compliance will be met by November 31st and continued monitoring by Administrator and/or Designee.

22VAC40-73-440-A

Based on discussion, the facility failed to ensure the UAI for residents be completed prior to admission, at least annually, and whenever there is a significant change in the resident's condition.

Evidence

Staff #2 was unable to provide a current UAI for Resident #1 and Resident #4.

Plan of correction

An audit of all resident charts will begin on 11/1/2024 for UAI compliance. Following audit of all charts, random selection of charts will be audited for UAI compliance weekly for 4 weeks and quarterly thereafter for the 1st and 2nd quarter of 2025. Compliance will be monitored by Health Services Director and/or Designee.

22VAC40-73-460-A

Based on record review and discussion, the facility failed to assume general responsibility for the health, safety, and well-being of the residents.

Evidence

On 10/18/2024, Resident #2 and Resident #3 were found on the floor after an apparent altercation.
Resident #2 sustained a major injury to their right shin.

Plan of correction

Rounding will be completed by staff at minimum of every two hours during sleeping hours. Unit will be appropriately staffed according to the census. Compliance is completed and will be monitored by Memory care manager and/ or Designee.

October 8, 2024Inspection6 violations

Inspection dates

10/08/2024

Areas reviewed

Technical assistance

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: 10/08/2024 from 8:35 am to 4:52 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: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 3 Observations by licensing inspector: Lunch and an activity were observed. A medication pass observation was completed for 4 residents. The following were reviewed: resident and staff records, medication carts, water temperatures, and the call bell system. 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations

22VAC40-73-450-A

Evidence

Resident #5 admitted to the facility on 01/02/2024; however, their ISP was completed on 01/04/2024.

Plan of correction

Not published by VDSS.

22VAC40-73-680-I

Based on record review, the facility failed to ensure the MAR accurately reflect the order within the record.

Evidence

Resident #5’s order for metoprolol changed on 08/09/2024 to include a parameter to hold for SBP<100 or HR<50; however, the MAR states the parameter is to hold for SBP less than 110 or pulse less than 50.

Plan of correction

Not published by VDSS.

22VAC40-73-450-F

Based on record review, the facility failed to review and update individualized service plans at least once every 12 months and as needed for a significant change of a resident’s condition.

Evidence

The last ISP for Resident #1 was completed on 08/07/2023. Additionally, Resident #1 had a significant change (moved to safe, secure environment) on 01/24/2024.
Resident #2 had a significant change (moved to safe, secure environment) on 05/08/2024; however, their ISP was last completed upon their admission to the facility on 04/01/2024.

Plan of correction

Not published by VDSS.

22VAC40-73-930-D

Based on record review, the facility failed to ensure that for each resident with an inability to use the signaling device, in addition to any other services, once the resident has gone to bed each evening until the resident has arisen each morning, at a minimum, direct care staff make rounds no less often than every two hours, except that rounds may be made on a different frequency if requested by the resident and agreed to by the facility.

Evidence

Staff were unable to provide documentation of rounds no less often than every two hours for each resident with an inability to use the signaling device for review during the onsite inspection.

Plan of correction

Not published by VDSS.

22VAC40-73-610-B

Based on observation, the facility failed to ensure menus for meals for the current week are dated and posted in an area conspicuous to residents.

Evidence

The posted menu for meals did not include the date.

Plan of correction

Not published by VDSS.

22VAC40-73-440-A

Based on record review, the facility failed to ensure the UAI for residents be completed at least annually and whenever there is a significant change in the resident's condition.

Evidence

The last UAI for Resident #1 was completed on 08/07/2023. Additionally, Resident #1 had a significant change on 01/24/2024.

Plan of correction

Not published by VDSS.

July 15, 2024Inspection1 violation

Inspection dates

07/15/2024

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Comments

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/15/2024 from 11:30 am to 12:00 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 07/08/2024 regarding allegations in the area(s) of: Personnel. Number of residents present at the facility at the beginning of the inspection: 89 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: 1 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations

22VAC40-73-110-1

Based on record review and interview, the facility failed to ensure staff are considerate and respectful of the rights, dignity, and sensitivities of persons who are aged, infirm, or disabled.

Evidence

On 07/02/2024, Staff #3 was verbally aggressive to Resident #1 while providing care.

Plan of correction

No harm was caused to this resident. Staff #3 was terminated from employment. All residents have the potential to be affected. Staff will be educated on mandated reporting and resident rights by LNHA or designee. HSD or Designee will randomly monitor 1x weekly to ensure resident rights and policy is followed, at which time, it will be reviewed at QAPI to determine further need for monitoring.

October 17, 2023Inspection6 violations

Inspection dates

10/17/2023

Areas reviewed

Technical assistance

22VAC40-73-210 22VAC40-73-450 22VAC40-73-1140

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: 10/17/2023. 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: 67 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 Observations by licensing inspector: Lunch and an activity were observed. A medication pass observation was completed for 4 residents. The following were reviewed: resident and staff records, medication carts, water temperatures, and the call bell system. 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations

22VAC40-90-40-B

Based on record review, the facility failed to obtain a criminal history record report on or prior to the 30th day of employment for each employee.

Evidence

The following staff did not have a criminal history record report completed on or prior to the 30th day of employment: Staff #6 (hired 8/28/2023) completed 10/4/2023, Staff #8 (hired 9/12/2023) not completed at the time of inspection on 10/17/2023, Staff #9 (hired 9/6/2023) not completed at the time of inspection on 10/17/2023, Staff #10 (hired 9/12/2023) not completed at the time of inspection on 10/17/2023, and Staff #11 (hired 9/5/2023) not completed at the time of inspection on 10/17/2023.

Plan of correction

Not published by VDSS.

22VAC40-73-310-H

Based on record review, the facility failed to ensure residents admitted or retained with psychotropic medications have treatment plans.

Evidence

Resident #1 has orders for Citalopram HBR F/C 10mg daily and Trazodone HCL 50mg PRN; however, there are not treatment plans for these psychotropic medications in Resident #1’s record.
Resident #2 has orders for Ramelteon 8mg daily and Trazodone HCL 50mg daily; however, there are not treatment plans for these psychotropic medications in Resident #2’s record.
Resident #3 has an order for Escitalopram Oxalate F/C 5mg daily; however, there is not a treatment plan for this psychotropic mediation in Resident #3’s record.
Resident #4 has an order for Trazodone HCL 50mg PRN; however, there is not a treatment plan for this psychotropic mediation in Resident #4’s record.
Resident #5 has orders for Venlafaxine HCL ER 150 mg daily and Trazodone HCL 50mg daily; however, there are not treatment plans for these psychotropic medications in Resident #5’s record.

Plan of correction

Not published by VDSS.

22VAC40-73-640-A

Based on observation, the facility failed to ensure their written plan for medication management includes methods to prevent the use of outdated medications.

Evidence

The following expired medications were observed in the medication carts at the facility: 2 bottles of Eye Health Lutein Ocutab 2mg tablets expired 7/2023 for Resident #9.

Plan of correction

Not published by VDSS.

22VAC40-73-260-A

Based on record review, the facility failed to ensure each direct care staff member maintain current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department.

Evidence

Staff #5 (hired 7/11/23) works as direct care staff and does not have a current certification in first aid.

Plan of correction

Not published by VDSS.

22VAC40-73-680-D

Based on record review, the facility failed to ensure medications be 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

An order dated 10/10/2023 for Resident #2 indicates to start Risperdal .25mg daily at 5pm; however, the MAR for Resident #2 does not include the new order. The medication was also not observed or available on the medication cart for administration.

Plan of correction

Not published by VDSS.

22VAC40-73-720-A

Based on record review, the facility failed to ensure a valid written Do Not Resuscitate (DNR) order has been issued by the resident's attending physician; and that the written order is included in the individualized service plan.

Evidence

Upon review of Resident #1’s record, their ISP (dated 5/26/23) indicates the resident as a DNR; however, the resident does not have a signed DNR order or Durable DNR in their record.

Plan of correction

Not published by VDSS.

July 24, 2023Inspection2 violations

Inspection dates

07/24/2023

Areas reviewed

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

Technical assistance

22VAC40-73-440

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: 07/24/2023. 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 07/15/2023 regarding allegations in the area(s) of: Part X Additional Requirements for Facilities that Care for Adults with Serious Cognitive Impairments. Number of residents present at the facility at the beginning of the inspection: 47 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 interviews conducted with staff: 2 Additional Comments/Discussion: All exits within safe, secure environment reviewed. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations

22VAC40-73-1150-A

Based on observation, record review and interview, the facility failed to ensure doors that lead to unprotected areas be monitored or secured through devices that conform to applicable building and fire codes, including door alarms, cameras, constant staff oversight, security bracelets that are part of an alarm system, pressure pads at doorways, delayed egress mechanisms, locking devices, or perimeter fence gates for residents residing in a safe, secure environment.

Evidence

On 07/15/2023 around 8:00 p.m., Resident #1 and Resident #2 who reside in a safe, secure environment were observed in unprotected areas outside of the facility. Resident #1 was noted across the street from the facility. Resident #1 and Resident #2 were last seen within the facility around 7:45 pm.
Staff #1 acknowledged the doors exiting the unit were unknowingly unsecured after a storm tripped the breaker to the memory care alarm system which permitted Resident #1 and Resident #2 to exit into unprotected areas.

Plan of correction

Not published by VDSS.

22VAC40-73-930-D

Based on record review and discussion, the facility failed to ensure for each resident with an inability to use the signaling device, once the resident has gone to bed each evening until the resident has arisen each morning, at a minimum, direct care staff make documented rounds no less often than every two hours, except that rounds may be made on a different frequency if requested by the resident and agreed to by the facility.

Evidence

Staff #2 provided and confirmed the evening rounds on residents within the safe, secure environment are scheduled and documented at 12am, 2am, 4am, and 6am; however, there are no documented evening rounds prior to 12am.

Plan of correction

Not published by VDSS.

June 29, 2023Inspection2 violations

Inspection dates

06/29/2023

Areas reviewed

Technical assistance

22VAC40-73-410 22VAC40-73-450 22VAC40-73-1090

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: 6/29/2023 from 9:00 am to 2:10 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: 42 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 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations

22VAC40-73-680-C

Based on observation and record review, the facility failed to ensure medications be administered not earlier than one hour before and not later than one hour after the facility's standard dosing schedule, except those drugs that are ordered for specific times, such as before, after, or with meals.

Evidence

A medication pass of Resident #5 was observed at 9:49 am with Staff #3.
Upon review of Resident #5’s physician orders and MAR, Resident #5 was admitted on 6/6/23 with an order for a Levothyroxine Sodium 125 mcg tablet every morning at 6 am; however, the medication is on the resident’s MAR and administered at 9 am.

Plan of correction

1. No residents were negatively affected by this deficient practice. 2. Resident #5’s MAR has been corrected to be equivalent with physician order. 3. All Residents receiving medication services will be reviewed to ensure medication orders coincide with the Medication Administration record. All Licensed staff will be educated on verifying and reconciling all new orders with the current MAR. 4. Health and Wellness Director/Designee will verify before any new order is transcribed to the current E-MAR. The Health and Wellness Director Designee will review the new order and verify with the current MAR on the next business day.

22VAC40-73-720-A

Evidence

Upon review of Resident #4’s record, their ISP (dated 5/30/23), June 2023 MAR, and face sheet indicates the resident as a DNR; however, the resident does not have a signed DNR order or Durable DNR in their record.
Upon review of Resident #5’s record, it is inconsistent to Resident #5’s code status as their face sheet indicates the resident is a DNR and their MAR indicates the resident is a full code. Resident #5’s record does not include a signed DNR order or Durable DNR nor does their ISP (dated 6/6/23) does not indicate the resident’s code status.

Plan of correction

1. No residents were negatively affected by this deficient practice. 2. Resident #4’s and #5’s record was corrected to be consistent of code status with the physician’s order, Individual Service Plan, Face Sheet, and Medication Administration Record 3. All residents MAR, ISP, Face Sheet, and physician order will be audited for consistency. All licensed staff will be educated on procedures to ensure physicians orders is included in ISP. 4. Health and Wellness Director/Designee will verify that residents code status is properly executed on Move in and as needed, and code status entered into ISP and EMAR.

May 11, 2023Inspection0 violations

Inspection dates

05/11/2023

Areas reviewed

22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 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 IMPAIRMENTS

Comments

Type of inspection: Initial Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/11/2023 from 9:00 am to 11:15 am. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Additional Comments/Discussion: The first aid kits, required postings, menu, and activity calendar were reviewed along with samples of the water temperature taken. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website should the facility be issued a license to operate. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of a licensed facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.