Virginia DSS · Assisted Living Facility

Brightview Dulles Corner

📍 13700 Magna Way, Herndon, VA, 20171

ID 49310One Year licenseActive
8
Inspections
On record
4
With violations
Visits that cited something
4
Clean visits
Nothing cited
11
Violations cited
Individual findings
11
Standards cited
Distinct rules
0
Complaint visits
Prompted by a complaint

Brightview Dulles Corner was inspected 8 times between March 15, 2023 and December 10, 2025 by the Virginia Department of Social Services. 4 of those visits ended with violations cited and 4 with none. Across that history VDSS cited 11 violations under 11 distinct standards.

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
09/30/2026
Administrator
Rehana Majeed
Licensing inspector
Jacquelyn Kabiri
Inspector phone
(703) 397-3017
Approved for
Assisted Living · Special Care Unit · Non-Ambulatory

Inspection History

8

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

December 10, 2025Inspection2 violations
Inspection dates
12/10/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: ¿Monitoring¿ Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/10/2025, 10:45 a.m. to 1:00 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 11/25/2025 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: 85 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 2 Number of interviews conducted with residents:0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Activities Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the (complaint(s)/self-report) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017 or by email at Jacquelyn.Kabiri@dss.virginia.gov
Violations
22VAC40-73-640-A
Based on record review and staff interview, the facility failed to implement a written plan for medication management to include the use methods for verifying that medication orders were accurately transcribed to the electronic medication administration record eMAR within 24 hours of receipt of a new order or a change in an order.
Evidence
  1. During the onsite inspection on 12/10/2025, review of the physician’s order dated 09/17/2025 confirmed Lexapro 20 mg was prescribed to be administered to resident 1 daily.
  2. The Licensing Inspector (LI) reviewed resident 1’s eMAR for the following dates: a. 09/18/2025–09/20/2025: Lexapro 20 mg daily was not listed on the eMAR for resident 1. b. 10/01/2025–10/31/2025: Lexapro 20 mg daily was not listed on the eMAR for resident 1. c. 11/01/2025–11/30/2025: Lexapro 20 mg was listed as administered beginning on 11/25/2025 through 11/30/2025 and ongoing as prescribed.
  3. Review of the facility’s medication management plan stated: “A licensed nurse will review all orders for appropriateness and complete a triple check for each medication/treatment order. The nurse on duty verifies the order accuracy in the eMAR and indicates such on the pharmacy stamp. A third check is to be completed by the Health Services Director or designated nurse within 24 hours or the next business day.”
  4. During an interview, staff 1and staff 2 confirmed that nursing staff failed to follow up with the pharmacy, which resulted in resident 1 not receiving Lexapro 20 mg daily for a period of 66 days.
  5. Staff 1 and staff 2 further acknowledged that the facility’s medication management policies and procedures were not followed.
Plan of correction
Steps Correct non-compliance: All Wellness Nurses have been re-trained on Medication Management to include the use of methods for verifying that medication orders were accurately transcribed to the electronic medication administration record eMAR within 24 hours of receipt of a new order or a change in an order. Measures to prevent non-compliance: Audit of all charts regarding medication accuracy and administration was conducted and completed on 12/22/25. Person responsible for implementation and/0r ongoing monitoring: HSD or designee will review all orders for appropriateness and complete a triple check for each medication order. POC to be reviewed at monthly QAPI meeting
22VAC40-73-680-D
Based on the record review and staff interview, the assisted living facility failed to ensure that medications were administered in accordance with the physician’s instructions and consistent with the standards of practice by the Virginia Board of Nursing.
Evidence
  1. A self-reported incident was received by the Licensing Inspector (LI) regarding a medication error involving resident 1 and their physician’s order for Lexapro 20 mg daily upon admission on 09/18/2025.
  2. The LI reviewed all physician orders for resident 1 and confirmed that an order dated 09/17/2025 for Lexapro 20 mg daily was present; however, the medication was not administered until 11/25/2025.
  3. During the onsite inspection conducted on 12/10/2025, staff 1 confirmed that an error occurred in obtaining the prescription from the facility’s pharmacy. As a result, the medication was not entered into the Electronic Medication Administration Record (EMAR).
  4. Staff 1 further stated that when a medication is not entered into the EMAR, it does not appear in the system for the medication technicians; therefore, it would not be administered to resident 1.
Plan of correction
Steps Correct non-compliance: Medication, Lexapro 20 mg daily was started the next day of finding the error on 11/25/25. Measures to prevent non-compliance: All Wellness Nurses have been re-trained on Medication Management to include the use of methods for verifying that medication orders were accurately transcribed to the electronic medication administration record eMAR within 24 hours of receipt of a new order or a change in an order. Person responsible for implementation and/0r ongoing monitoring: HSD or designee will review all orders for appropriateness and complete a triple check for each medication order. HSD or designee will review all physician orders upon move in and ensure medications are available. POC to be reviewed at monthly QAPI meeting.
December 10, 2025Inspection0 violations
Inspection dates
12/10/2025
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Technical assistance
TA: Conversation w/ family, residents that freely leave the locked facility to be aware of other residents attempting to leave behind them.
Comments
Type of inspection: ¿Monitoring¿ Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/10/2025, 9:45 a.m. to 10:45 a.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the nspection. A self-reported incident was received by VDSS Division of Licensing on 11/23/2025 regarding allegations in the area(s) of: Resident Care and Related Services, Staffing and Supervision. Number of residents present at the facility at the beginning of the inspection: The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents:0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Activities Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017 or by email at Jacquelyn.Kabiri@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
August 20, 2025Inspection1 violation
Inspection dates
08/20/2025
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 08/20/2025, 10:00 a.m. to 3:40 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: 79 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 and 1 interview only. Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: Activities Additional Comments/Discussion: None 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 Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017 or by email at Jacquelyn.Kbairi@dss.virginia.gov
Violations
22VAC40-73-680-B
Based on observation and interview with staff, the facility failed to ensure medications remained in the pharmacy issued container, with the prescription label or direction label attached, until administered to the resident.
Evidence
  1. On August 20, 2025, at approximately 12:27 p.m., the Licensing Inspector (LI) observed Staff 2 administering medications and conducted an audit of their assigned medication cart. During the audit, a clear plastic cup containing nine (9) 25 mg tablets of QUEtiapine was observed. The tablets were not stored in a prescription bottle or labeled with identifiable information.
  2. Staff 1 and Staff 2 confirmed the LI’s findings during the inspection and stated that they were unable to determine to whom each tablet of medication belonged.
  3. Photo evidence taken.
Plan of correction
Clear plastic cup containing nine, 25mg tablets of Quetipine were removed from med cart on the day of survey 8/20/25 Measures to Prevent the Non-Compliance: All med carts were audited by LPN for any medications were not stored in a prescription bottle or labeled with identifiable information on 8/20/25. All health and wellness associates administering medications ( Med techs/LPN) re-trained on 8/20/25 regarding appropriate labeling and storing in a prescription bottle with identifiable information. Person responsible for implementation and/or ongoing monitoring: HSD or designee will audit med carts or appropriate storage and labeling once per week for 4 weeks to measure continued compliance. POC to be reviewed at monthly QAPI/Safety meeting for compliance.
May 30, 2025Inspection2 violations
Inspection dates
05/30/2025
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES63.2 Protection of adults and reporting
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: 05/30/2025, 9:00 a.m. to 12:00 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 03/25/2025 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: 81 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: None. Additional Comments/Discussion: None. 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 Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017 or by email at Jacquelyn.Kabiri@dss.virginia.gov
Violations
63.2-1808-A-11
Based on record review and staff interview, the facility failed to ensure that staff were considerate and respectful of the rights, dignity, and sensitivities of persons who are aged, infirm, or disabled.
Evidence
  1. A self-report was submitted via email to the licensing inspector on 03/28/2025, regarding an incident that occurred on 03/25/2025. The report alleged that staff 3 provided direct care to resident 1 in a manner that was disrespectful and failed to demonstrate appropriate concern for the resident's dignity and sensitivities.
  2. On 05/30/2025, the LI and staff 1 reviewed video footage of the incident that occurred on 03/25/2025. The video showed staff 3 performing direct care duties for resident 1 in a disrespectful and inappropriate manner.
  3. Staff 1 acknowledged the findings.
Plan of correction
Steps to correct the non-compliance: Staff 3 was immediately suspended from work until a thorough investigation was completed. Staff 3 was terminated after investigation revealed disrespectful and failure to demonstrate appropriate concern for resident 1.Measures to to prevent non-compliance: All direct care associates completed in-service on Resident Rights and facility policy on reporting abuse, neglect, or financial exploitation. Plan of correction and all incident reports will be reviewed by Executive Director or designee with facility Director team at monthly QAPI/Safety Committee meetings for compliance/next steps. WSV director will conduct ongoing trainings include real-time observation of resident interaction and reinforcement of respectful practices.
22VAC40-73-70-C
Based on record review and interview, the facility failed to submit a written report of each incident specified in subsection A of this section to the regional licensing office within seven days from the date of the incident.
Evidence
  1. On 03/25/2025, an incident occurred involving resident 1 and staff 3. The facility reported the incident via e-mail on 03/28/2025. Significant information and actions were taken, but the facility failed to make the required final report.
  2. Staff 1 confirmed the final report of the incident between resident 1 and staff 3 on 03/25/2025 was not submitted within 7 days from the date of the incident.
Plan of correction
Steps to correct the non-compliance: Executive Director reviewed VA Regulation specific to incident Reporting to clearly outline responsibilities and timeliness for the required final report. Measures to prevent non-compliance: Executive Director reviewed facility policy related to resident incidents, With all members of the Director team for timely notification. Executive Director or designee will perform weekly audits for any incidents x2 months to ensure incident reporting timeliness is met per VA regulations/ Plan of Correction and weekly audits to be reviewed at mothly QAPI/Safety Committee meetings for compliance next steps.
November 26, 2024Inspection0 violations
Inspection dates
11/26/2024
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES
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: 11/26/2024, 11:30 AM-1:15 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 11/26/2024 regarding allegations in the area(s) of: Discharged resident. Number of residents present at the facility at the beginning of the inspection: 61 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Lunch Additional Comments/Discussion: Interviewed POA. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017, or by email at Jacquelyn.Kabiri@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
August 12, 2024Inspection6 violations
Inspection dates
08/12/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS63.2- (1) GENERAL PROVISIONS63.2- (18) FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORTNone
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: 08/12/2024, 9:00 am-2:40pm and 08/13/2024, 9:30 am-3:00 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: 60 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 16 Number of staff records reviewed: 5 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 2 Observations by licensing inspector: Activities, Breakfast and Lunch. 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 Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017 or by email at Jacquelyn.Kabiri@DSS.virginia.gov.
Violations
22VAC40-73-700-1
Based on the review of Resident records and Physicians' orders, the facility failed to ensure when oxygen therapy is provided the physician's order includes the oxygen source.
Evidence
  1. Resident 3’s physician’s order, dated 03/21/2024, for oxygen does not state the source of oxygen being compressed gas or a concentrator.
Plan of correction
Steps to correct the non-compliance: Resident 3's physician order for oxygenupdated to include the source of oxygen on 8/15/2024. Measures to prevent the non-complinace: Currecnt residents with physician orders for oxygen were audited and corrected if no source of oxygen is specified in the physician order on 8/15/2024. Health and wellness nurses in-serviced on required source for any resident physician Oxygen orders on 8/30/2024. HSD or designee will audit resident physician Oxygen orders for source once per week for 4 weeks to measure the continued compliance. Person responsible for Implementing and Monitoring: POC to. be reviewed at monthly QAPI/Safety committee meeting by the HSD or designee for compliance.
22VAC40-73-660-A-7
Based on observation, the facility failed to ensure that single-use and dedicated medical supplies are appropriately labeled and stored.
Evidence
  1. During the inspection and medication cart audit on 08/12/2024, at 12:17 pm, the LI (Licensing Inspector) observed 1 box of BD Nano 2nd gen pen needles without a prescription label or other identifiable information. 2.Photos taken as evidence.
Plan of correction
Steps to Correct Non-Compliance: 1 box of BD Nano 2nd gen pen needles were removed from med cart and labeled with the appropriate label on the day of survey 8/12/2024. Measures to Prevent the non-compliance All med carts were audited for appropriatelabeling and storage of single use and dedicated medical supplies on 8/12/2024. All health and wellness associates administering medications ( med techs/LPN)re-trained regarding appropriate labeling and storage of single-use and dedicated medical supplies on 8/30/2024. Person Responsible for Implementation and/or Monitoring: HSD or designee will audit med carts for appropriate labeling and storage of single use and dedicated medical supplies once per week for 4 weeks to measure continued compliance. POC to be reviewed at monthly QAPI/Safety meetings for compliance.
22VAC40-73-460-A
Based on record review and interview, the facility failed to assume general responsibility for the health, safety, and well-being of the residents.
Evidence
  1. LI observed Resident 12 during the inspection on 08/13/2024, during a medication pass in their wheelchair.
  2. Resident 12’s wheelchair arm on the right side, had exposed foam over the metal. The black leather covering is torn and worn exposing the foam underneath.
  3. Resident 12 stated in an interview that the armrest with the exposed foam and metal, gets caught at the dining table and bothers his arm.
  4. Photos taken as evidence.
Plan of correction
Steps to Correct the non-Compliance: The resident/family is responsible to purchase and maintain residents's DME. The community is responsible for notifying the resident/ need for the maintenance and repair. The resident/family is responsible for the approval and payment for repair and replacement of parts or device. Community discussed needs for repair/replacement and approval for payment with esident 12/family on 8/15/2024. Resident 12's wheel chair was replaced on 8/26/2024. Measures to prevent the non-compliance: All Health and Wellness associates inserviced to notify community Directors if any resident's DME needs maintenance or repair. Community HSD inservicd on notification of resident/family and to get for DME epair and replacement on 8/12/2024 POC to be reviewed Person responsible for Implementation or Monitoring: POC to. be reviewed at monthly QAPI/Safety committee meeting by the HSD or designee for compliance.
22VAC40-73-220-B
Based on the Resident record review and a staff interview, the facility failed to ensure that direct care or companion services are reflected on the Resident’s ISP. (Individualized Service Plan.
Evidence
  1. Resident 7’s ISP does not indicate the specific duties and frequency of those duties companion personnel will provide.
Plan of correction
Steps to correct the non-compliance: Resident 7's ISP updated to indicate the specific duties and frequency of the duties, companion personnel will provide for resident 7 on 8/12/2024. Measures to prevent the non-compliance: Currect Residents with direct care or companion services ISPs are being audited, if necessary to indicate the specific duties and frequency of the duties companion personnel will provide by 8/12/2024. Health and Wellness nurses in-services on the requirements of the ISp to include the specific duties and frequency of the duties companion personnel will provide for resident on 8/30/2024. HSD or designee will audit residents with direct careor companion care services ISPS once per 4 weeks to measure the continued compliance. Person responsible for Implementing and Monitoring: POC to be reviewed at monthly QAPI/Safety meetings by HSD or dsignee
22VAC40-73-410-A
Based on record review, the facility failed to obtain the resident’s signature on the acknowledgment of Orientation form upon admission to the facility for new residents including emergency response procedures, mealtimes, and use of the call system.
Evidence
  1. Resident 2 (admitted on 05/25/2024) did not have an orientation form signed by the resident. 2.Resident 5 (admitted on 12/20/2023) did not have an orientation form signed by the residents.
Plan of correction
Steps to correct Non-Compliance: Resident 2 and 5 orientation acknowledgement form for receiving orientation including emergency response procedures, mealtimes, and use of call bell system were signed on 8/15/2024. Measures to prevent the non-compliance: Current resident's orientation (handbook acknowledgement form) will be reviewed and signed by residents and as appropriate, thier legal representatives will be reviewed, signed, dated by the residents and their RP with a completion date of 10/30/2024. All sales associates and BOD in-serviced on apprpriate signatures of the resident and as appropriate as their RP for the resident orientation (handbook) acknowledgement form on 8/15/2024. Person responsible for implementing/Monitoring: BOD or designee will audit resident's business files for approperiate signature on the oreintation (handbook) acknowledgement for for 4 weeks to measure continued compliance. Any forms not meeting compliance will be flagged and corrected immediately by BOD or designee.POC to be reviewed at monthly QAPI/Safety meetings for continued compliance.
22VAC40-73-40-A
Based on staff interviews and a review of records, the facility failed to be in compliance with all regulations for licensed assisted living facilities and terms of the license issued by the department; with relevant federal, state, and local laws, with other relevant regulations; and with the facility’s own policies and procedures.
Evidence
  1. In an interview with the LI (Licensing Inspector) Resident 11 stated that the call bells are answered too slowly.
  2. In an interview with the LI, Resident 12 stated that the staff takes a long time to answer the call bells.
  3. Staff 1 stated during the interview on 08/13/2024, with the LI (Licensing Inspector) that the facility’s policy for call bell answer time is between 7-10 minutes. 4.The facility’s call bell logs confirm the following times: A. On 8/2/2024, 10:47 am, Resident 13’s call bell was responded to in 1 hr and 45 minutes. B. On 8/2/2024, 7:57 pm, Resident 14’s call bell was responded to in 45 minutes. C. On 8/4/2024, 6:48 pm, Resident 16’s call bell was responded to in 48 minutes. D. On 8/5/2024, 1:50 pm, Resident 12’s call bell was responded to 39 minutes. E. On 8/11/2024, 7:48 pm, Resident 15’s call bell was responded to in 59 minutes.
Plan of correction
Steps to correct the non-compliance: The community cannot retroactively correct the call bell response times noted on 8/2,8/4,8/5,and 8/11/2024. Measures to prevent the non-complinace: A printout of the response times will be run daily by HSD or designee andreviewed daily at morning stand up meeting with all directors. All calls answered in greater than 10 minutes will be investigated and reson for delay documente. Health and Wellness associates in-serviced on the call bell response procedure and expectations to answer calls in a timley manner on 8/12/2024. POC to be reviewed at monthly QAPI/Safety Committee meetings by HSD or designee for compliance. Person responsible for Implementing and monitoring,
September 18, 2023Inspection0 violations
Inspection dates
09/18/2023
Areas reviewed
Administration and Administrative ServicesPersonnelStaffing and SupervisionAdmission, Retention and Discharge of ResidentsResident Care and Related ServicesBuildings and GroundsEmergency PreparednessMixed PopulationSafe, Secure Environment
Comments
Date of Inspection: September 18, 2023 Type of Inspection: Renewal Inspection If you have any questions or email changes, please do not hesitate to contact me at laura.lunceford@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov. Census 28 Number of records reviewed and interviews conducted- 6 records (staff and residents), 8 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. The Licensing Inspector observed the residents in activities and throughout the facility. The Licensing Inspector reviewed the following at the time of inspection: dietician report, pharmacy review, resident council minutes, fire drills, menus and activity calendars.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
March 15, 2023Inspection0 violations
Inspection dates
03/15/2023
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity32.1 Reported by persons other than physicians63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Technical assistance
Discussed Standards 110.A, 950.A, 950.F, 350.A, B, C Please update the posted resident rights to reflect the current Licensing Administrator – Sharae Henderson, 804-629-3479
Comments
Licensing Inspector (LI) conducted an announced initial inspection on 3/5/2020. LI walked the physical plant, verified window and room measurements, reviewed policies and procedures and staff records and tested the call bell system. The Building, Fire, Elevator and Health Inspections have been submitted and reviewed. No violations cited today and exit interview held. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Lynette Storr, Licensing Inspector at (703) 479-4708 or by email at lynette.storr@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.