17
Inspections
On record
10
With violations
Visits that cited something
7
Clean visits
Nothing cited
41
Violations cited
Individual findings
26
Standards cited
Distinct rules
11
Complaint visits
Prompted by a complaint
Premier Residential and Assisted Living was inspected 17 times between May 1, 2023 and April 3, 2026 by the Virginia Department of Social Services. 10 of those visits ended with violations cited and 7 with none. Across that history VDSS cited 41 violations under 26 distinct standards. 11 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
Georgiana Johnson
Licensing inspector
Donesia Peoples
Inspector phone
757 353-0430
Approved for
Residential Only · Ambulatory Only
Inspection History
17Select an inspection to read the areas reviewed, the inspector's comments and any violations cited.
April 3, 2026Complaint survey
Inspection dates
04/03/2026
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 PREPAREDNESS22VAC40-80 COMPLAINT INVESTIGATION
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 04/03/2026 at 8:06 am to 11:00am.
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 03/30/2026 regarding allegations in the area of: Resident Care and Related Services
Number of residents present at the facility at the beginning of the inspection: 28
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:
Number of interviews conducted with residents: 4
Number of interviews conducted with staff: 2
Observations by licensing inspector: Breakfast was observed and residents were observed in the common areas of the facility.
Additional Comments/Discussion: None
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
22VAC40-73-930-B
Based on observation, and staff interviews the facility failed to ensure in buildings licensed to care for 20 or more residents under one roof, there shall be a signaling device that terminates at a central location that is continuously staffed and permits staff to determine the origin of the signal or is audible and visible in a manner that permits staff to determine the origin of the signal.
Evidence
- During a tour of the facility on 04/03/2026 the Licensing Inspector (LI) did not observe a signaling device that terminates to a central location that is continuously staffed and permits staff to determine the origin of the signal. The facility has a census of 28 residents.
- During an interview on 04/03/26 with staff #2, staff #2 confirmed the signaling device used to alert staff was disconnected and not in use as of 03/28/2026.
Plan of correction
Not published by VDSS.
22VAC40-73-680-B
Based on resident and staff interviews the facility failed to ensure medications shall be removed from the pharmacy container, or the container shall be opened, by a staff person licensed, registered, or acting as a medication aide on a provisional basis as specified in 22VAC40-73-670 and administered to the resident by the same staff person.
Evidence
- During an interview on 04/03/26 with resident #1, resident #1 stated on the morning of 04/03/26 staff #1 administered medications to resident #1.
- Resident #1’s April 2026 Medication Administration Records (MARs) documents the resident was administered the following scheduled 8 am medications on 04/03/26. • Bupropion for depression • Donepezil for depression • Dulera inhaler for COPD • Lisinopril for hypertension • Vitamin B-12 for Vitamin deficiency • Vitamin D2 for Vitamin deficiency
- During an interview on 04/03/26 with resident #2, resident #2 stated on the morning of 04/03/26 staff #1 administered medications to resident #2.
- Resident # 2’s April 2026 Medication Administration Records (MARs) documents the resident was administered the following scheduled 8 am medications on 04/03/26: • Geri-Lanta for indigestion • Hydroxyzine for itching • Omeprazole • Triamcinolone for inflammation
- During an interview on 04/03/26 with resident #3, resident #3 stated on the morning of 04/03/26 staff #1 administered medications to resident #3
- Resident #3’s April 2026 Medication Administration Records (MARs) documents the resident was administered the following scheduled 8 am medications on 04/03/26: • Acyclovir for infection • Bupropion for depression • Hydroxyzine for itching/anxiety • Loratadine for allergies • Methylphenidate for ADHD
- During an interview on 04/03/26 with staff #1, staff #1 stated at 7:30 am on 04/03/26, staff #1 administered the scheduled 8am medications to residents #1, #2, #3, and #4. Staff #1 stated staff #2 removed the medications from the pharmacy container and staff #2 placed the medications in a cup. Staff #2 then gave the medications in a cup to staff #1 and staff #1 gave the medications in a cup to the residents. Staff #1 confirmed staff #1 is not licensed, registered, or acting as a medication aide on a provisional basis to administer medications.
- During an interview on 04/03/26 with staff #2, staff #2 stated at 7:30 am on 04/03/26, staff #2 removed the medications from the pharmacy container and staff #2 placed the medications in a cup. Staff #2 then gave the medications in a cup to staff #1 and staff #1 gave the medications in a cup to the residents. Staff #2 confirmed staff #1 is not licensed, registered, or acting as a medication aide on a provisional basis to administer medications.
Plan of correction
Not published by VDSS.
April 3, 2026Complaint survey
Inspection dates
04/03/2026
Areas reviewed
22VAC40-73 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 GROUND22VAC40-80 COMPLAINT INVESTIGATION
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 04/03/2026 at 11:00 am to 11:40 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 02/26/2026 regarding allegations in the area of: Resident Care and Related Services
Number of residents present at the facility at the beginning of the inspection: 28
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:
Number of interviews conducted with residents: 4
Number of interviews conducted with staff: 2
Observations by licensing inspector: Linens and furnishings for resident rooms were observed.
Additional Comments/Discussion: None
An exit meeting will be conducted to review the inspection findings.
The evidence gathered during the investigation did not support the (compliant) 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
November 5, 2025Complaint survey
Inspection dates
11/05/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-80 COMPLAINT INVESTIGATION
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 11/05/2025 from 8:42 am to 3:52 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 10/27/2025 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: 29
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: 2
Observations by licensing inspector: Breakfast and lunch were observed.
Additional Comments/Discussion: None
An exit meeting will be conducted to review the inspection findings.
The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: Resident 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
22VAC40-73-440-A
Based on the record review and staff interview the facility failed to ensure the Uniform Assessment Instrument (UAI) shall be completed at least annually.
Evidence
- The record for resident #2, admission date 9/10/24, contains a UAI completed 09/01/24. The resident’s record does not contain a UAI completed annually after 09/01/24.
- During an interview on 11/05/25 with staff #2, staff #2 confirmed an annual UAI has not been completed after 09/01/24 for resident #2.
Plan of correction
Not published by VDSS.
22VAC40-73-450-F
Based on the record review and staff interview the facility failed to ensure individualized service plans (ISP) shall be reviewed and updated at least once every 12 months and as needed for a significant change in a resident’s condition.
Evidence
- The record for resident #2 contains an ISP dated 09/03/24. The resident’s record does not contain an annual ISP completed after 09/03/24.
- During an interview on 11/05/25 with staff #2, staff #2 confirmed an annual ISP has not been completed after 09/03/24 for resident #2.
Plan of correction
Not published by VDSS.
22VAC40-73-440-D
Based the record review and staff interview the facility failed to ensure for private pay individuals, the assisted living facility shall ensure that the uniform assessment instrument is completed as required by 22VAC30- 110.
Evidence
- The record for resident #2 contains a UAI dated 09/01/2024 that does not document if help is needed or not needed in the following areas: bathing, dressing, toileting, and mobility.
- During an interview with staff #2, staff #2 confirmed resident #2’s UAI does not document if help is needed or not needed in the areas of bathing, dressing, toileting, and mobility.
Plan of correction
Not published by VDSS.
November 5, 2025Complaint survey
Inspection dates
11/05/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-80 COMPLAINT INVESTIGATION
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 11/05/2025 from 8:42 am to 3:52 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 10/27/2025 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: 29
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: 2
Observations by licensing inspector: An observation of breakfast and lunch was completed.
Additional Comments/Discussion: None
An exit meeting will be conducted to review the inspection findings.
The evidence gathered during the investigation did not support the (compliant) 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 (Donesia Peoples), Licensing Inspector at (757) 353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
November 5, 2025Complaint survey
Inspection dates
11/05/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-80 COMPLAINT INVESTIGATION
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 11/05/2025 from 8:42 am to 3:52 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 10/27/2025 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: 29
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: 2
Observations by licensing inspector: An observation of breakfast and lunch was completed.
Additional Comments/Discussion: None
An exit meeting will be conducted to review the inspection findings.
The evidence gathered during the investigation did not support the (compliant) 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 (Donesia Peoples), Licensing Inspector at (757) 353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
November 5, 2025Complaint survey
Inspection dates
11/05/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-80 COMPLAINT INVESTIGATION
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 11/05/2025 from 8:42 am to 3:52 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 09/25/2025 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: 29
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: 2
Observations by licensing inspector: An observation of breakfast and lunch was completed.
Additional Comments/Discussion: None
An exit meeting will be conducted to review the inspection findings.
The evidence gathered during the investigation did not support the (compliant) 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 (Donesia Peoples), Licensing Inspector at (757) 353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
November 5, 2025Inspection
Inspection dates
11/05/2025. 11/07/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE
Comments
Type of inspection: Renewal
Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced renewal inspection took place on 11/05/2025 from 8:42 am to 3:52 pm and 11/07/2025 from 10:05 am to 10:20 am.
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
Number of residents present at the facility at the beginning of the inspection: 29
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: 3
Number of interviews conducted with staff: 2
Observations by licensing inspector: Breakfast and lunch were observed. A medication pass observation was completed for three residents. The following were reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, medication carts, fire inspection report, health inspection report, and a staffing schedule.
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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-930-B
Based on observation, and staff interviews the facility failed to ensure in buildings licensed to care for 20 or more residents under one roof, there shall be a signaling device that terminates at a central location that is continuously staffed and permits staff to determine the origin of the signal or is audible and visible in a manner that permits staff to determine the origin of the signal.
Evidence
- During a tour of the facility on 11/05/2025 the Licensing Inspector (LI) did not observe a signaling device that terminates to a central location that is continuously staffed and permits staff to determine the origin of the signal. The facility has a census of 29 residents.
- During an interview on 11/05/25 with staff #4, staff #4 confirmed the signaling device used to alert staff was disconnected and not in use as of 11/03/25.
Plan of correction
Not published by VDSS.
22VAC40-73-660-A
Based on observation and staff interview the facility failed to ensure medications shall be stored in a manner consistent with current standards of practice.
The storage area shall be locked.
Evidence
- During a tour of the facility on 11/05/2025 at 8:44am, the Licensing Inspector (LI) observed the medication cart to be unlocked and unstaffed.
- During an interview on 11/05/2025 with staff #1, staff #1 confirmed staff #1 left the medication cart unlocked and unstaffed at the time of 8:44am.
Plan of correction
Not published by VDSS.
22VAC40-73-260-A
Based on the record review and staff interview the facility failed to ensure each direct care staff member who does not have current certification in first aid as specified in subdivision 1 of this subsection shall receive certification in first aid within 60 days of employment.
Evidence
- The record for staff # 1 contains a first aid certification dated 03/02/2023 and valid for 2 years.
- Upon request, and during an interview on 11/05/2025 staff #4 was not able to provide evidence staff #1 has a current certification in first aid.
Plan of correction
Not published by VDSS.
22VAC40-73-450-C
Based on the record review and staff interview the facility failed to ensure the comprehensive individualized service plan (ISP) shall be completed within 30 days after admission and shall include the following:
Evidence
- The record for resident #1, admission date 09/09/25, contains a preliminary ISP completed 09/02/2025. The resident’s record does not contain an ISP completed within 30 days after the resident’s admission date.
- The record for resident #4 admission date of 09/10/24, contains a preliminary ISP completed 09/03/24. The resident’s record does not contain an ISP completed within 30 days after the resident’s admission date.
- During an interview on 11/05/25 with staff #4, staff #4 confirmed an ISP was not completed within 30 days after the admission for residents #1 and #4.
- The record for resident #2 contains the following: • a UAI dated 10/04/24 documents a need for medication management for high cholesterol, schizophrenia, and diabetes. • a physical exam and physician orders dated 12/02/24 that identify medication management needs for a diagnosis of diabetes, hypertension, high blood pressure, and schizophrenia. • A physical exam dated 12/16/24 that documents an allergy to the medication Lisinopril and needs for a diabetic diet. Resident’s #2 ISP dated 12/02/24 and 08/13/25 does not include a description of services to be provided for the resident’s medical diagnosis, allergy, and diabetic diet as documented on the UAI, physician orders, and physician exams.
- Resident #2’s ISP dated 12/02/24 and 08/13/25 does not include a date identified for the needs documented on the ISP.
Plan of correction
Not published by VDSS.
22VAC40-73-320-A
Based on the record review and staff interview the facility failed to ensure within the 30 days preceding admission, a person shall have a physical examination by an independent physician. The report of such examination shall be on file at the assisted living facility,
Evidence
- The record for resident #3, admission date 07/07/25, does not contain a physical examination completed within 30 days prior to the resident’s admission to the facility. Resident #3’s physical examination is dated as completed 8/05/25.
- Upon request, and during an interview on 11/05/25 with staff #4, staff #4 confirmed the physical exam in the record is dated as completed on 08/05/25 and staff #4 was not able to provide a physical examination completed with 30 days of admission for resident #3.
Plan of correction
Not published by VDSS.
August 12, 2025Complaint survey
Inspection dates
08/12/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-80 COMPLAINT INVESTIGATION
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 08/12/2025 at 10:25 am to 11:00 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 08/01/2025 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: 28
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: 3
Number of interviews conducted with staff: 1
Observations by licensing inspector: An observation of the facility’s food and snack supply was completed. Records for maintenance of buildings and groups were completed.
Additional Comments/Discussion: None
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, violations 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.
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
No violations cited
The inspector documented no violation of standards at this inspection.
March 21, 2025Inspection
Inspection dates
03/21/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS
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: An unannounced monitoring inspection took place on 03/21/2025 from 11:09 am to 12:50 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 03/12/2025 regarding allegations in the area of: Resident Care and Related Services
The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility.
Number of residents present at the facility at the beginning of the inspection: 26
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: 3
Observations by licensing inspector: Residents were observed in the common areas.
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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-460-A
Based on the record review and staff interview the facility failed to assume the general responsibility for the health, safety, and well-being of the residents.
Evidence
- Staff #1 submitted the following incident report via email to the Licensing Inspector on 03/12/25: “resident #1 attempted to place a pillow over resident’s #1 roommate head and used a cigarette lighter to burn the night lamp cord. Resident #1 punched staff #2 in the face, resulting in visible swelling.”
- Resident’s #2 progress note dated 03/12/25 documents the following: “resident #2 complained about resident #1 behavior of talking abusively, threatening to fight resident #2” Resident #1 took the lamp and told resident #2, resident #1 will burn down the place. Resident #1 attempted to place a pillow over the head of resident #2.
- During an interview on 03/21/25, with staff #2, staff #2 acknowledged on the day of 03/12/25, resident #2 reported to staff #2 that resident #1 attempted to place a pillow over the head of resident #2 and staff #2 observed a burned lamp cord located in residents #1 and #2 room. Staff #2 contacted the police and the police officer removed resident # 1 from the facility.
Plan of correction
At Premier Residential and Assisted Living, we remain fully committed to the safety, dignity, and well-being of our residents and staff. In response to the incident involving Resident #1 on March 12, 2025, the facility acted promptly and appropriately. Staff immediately contacted law enforcement when Resident #1 exhibited dangerous behavior toward a roommate and assaulted a staff member. Resident #1 was removed from the facility and taken to the hospital for psychiatric evaluation. Unfortunately, the hospital determined the resident to be "psychiatrically stable" and discharged him back into our care due to insurance limitations. When we contacted the resident’s guardian, they confirmed that no alternate placement was available. The state ombudsman also informed us that we were required to reaccept the resident since a safe discharge plan could not be arranged.
It is important to note that the facility made every effort to engage Resident #1 in ongoing care and treatment. The resident refused to be seen by both the facility’s physician and a visiting mental health provider on two separate occasions—December 24, 2024, and March 5, 2025. These refusals were documented in the resident’s medical record, and the guardian was notified both times. Despite these setbacks, the facility continued to monitor Resident #1 closely, document all medication refusals, and maintain consistent communication with external providers and responsible parties. Staff remained vigilant, increasing observation and taking proactive steps to ensure the safety of other residents in the shared room.
In light of this situation, the facility has implemented several corrective actions. We’ve enhanced our behavior monitoring protocols, provided staff with additional training on de-escalation techniques and managing high-risk behaviors, and strengthened coordination with local behavioral health partners. We are actively exploring long-term solutions for managing residents with complex psychiatric needs, including potential referral relationships with higher-level care facilities. While this incident reflects broader systemic gaps in mental health placement and support, Premier Residential and Assisted Living has remained compliant, compassionate, and committed to responsible care.
October 15, 2024Inspection
Inspection dates
10/15/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE
Technical assistance
Disclosure Statement
Written Assurance (level of care)
Resident Rights (LA Info)
Resident Agreement
Comments
Type of inspection: Renewal
Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced renewal inspection took place on 10/15/2024 from 8:00 am to 2:37 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: 27
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: 3
Number of interviews conducted with residents: 2
Number of interviews conducted with staff: 2
Observations by licensing inspector: Breakfast and lunch were observed. A medication pass observation was completed for two residents. The following was reviewed: resident and staff records, medication carts, fire inspection report, health inspection report, and a staffing schedule. The call bell system was monitored.
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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-450-C
Based on the record review the facility failed to ensure the comprehensive individualized plan (ISP) shall be completed with 30 days after admission and shall include the following:
Description of needs and date identified based upon the sources as listed in this subsection.
Evidence
- Resident’s #1 ISP dated 7/01/24 does not include a date identified for the description of needs.
Plan of correction
To correct the issue with Resident #1's Individualized Service Plan
(ISP), the facility will ensure that every ISP includes a "date identified" for each described need, as required by 22VAC40- 73-450-C. Starting now, the care coordinator will review each new resident’s ISP within 30 days of admission to confirm all needs have an assigned date. Staff involved in ISP documentation will receive additional training to make sure this requirement is consistently met.
To maintain compliance, the facility will conduct monthly checks of ISPs to confirm that each one is complete, with a specific focus on the "date identified" field. Any issues found will be corrected immediately, and staff retraining will be provided if
needed. This plan will be reviewed every three months to ensure it remains effective.
22VAC40-73-950-F
Based on review the facility failed to ensure the facility shall review the emergency preparedness plan annually.
Evidence
- Staff #4 was unable to provide documentation of an annual review of the facility’s emergency preparedness plan.
Plan of correction
To address the identified deficiency regarding the annual review of the facility's emergency preparedness plan, the facility has implemented a structured policy to ensure compliance with 22VAC40- 73-950-F. The facility administrator will conduct a thorough review of the emergency preparedness plan on an annual basis and document the review process. This review will include a comprehensive evaluation of emergency procedures, resource availability, staff roles, and any updates required by regulatory changes or emerging best practices. All findings and updates will be documented in an annual report, signed and dated by the administrator, and stored in a designated emergency preparedness binder accessible to all staff.
Additionally, the facility will establish an annual review reminder system to prevent future oversights. The facility's management software will include a recurring calendar alert, and
staff will be reminded of the review requirement in monthly team meetings leading up to the scheduled review. To ensure staff readiness, staff #4 and all relevant personnel will undergo refresher training on emergency preparedness documentation and review processes. Compliance will be verified by quarterly internal audits, with results presented to the administrator to ensure sustained adherence to the annual review mandate.
22VAC40-73-970-A
Based on review the facility failed to ensure fire and emergency drill frequency and participation shall be in accordance with the current edition of the Virginia Statewide Fire Prevention Code (13VAC5-51). The drills requested for each shift in a quarter shall not be conducted in the same month.
Evidence
- Staff #4 was unable to provide evidence of fire and emergency evacuation drills completed in each shift for every quarter for the year of 2024.
- Staff #4 provided documentation of a fire drill completed on 8/14/23, 10/01/24, and 10/02/24.
Plan of correction
To address the deficiency identified regarding the annual review of the facility's emergency preparedness plan, the facility administrator conducted a thorough review of the plan, documenting the process to ensure compliance with 22VAC40- 73-950-F. This review included a comprehensive evaluation of emergency procedures, resource availability, staff roles, and any necessary updates due to regulatory changes or emerging best practices. Findings and updates were documented in an annual report, signed and dated by the administrator, and stored in a designated emergency preparedness binder accessible to all staff.
In addition, the facility established a reminder system to prevent
future oversights. Management software was updated to include a recurring calendar alert, and staff were reminded of the review requirement in monthly team
meetings leading up to the scheduled review. Staff #4, along with relevant personnel, completed refresher training on emergency preparedness documentation and review processes. Quarterly internal audits were implemented to verify compliance, with results presented to the administrator to ensure sustained adherence to the annual review mandate.
22VAC40-73-990-C
Based on the onsite review and staff interview the facility failed to ensure at least every six months, all staff currently on duty on each shift shall participate in an exercise in which the procedures for resident emergencies are practiced. Documentation of each exercise shall be maintained in the facility for at least two years.
Evidence
- Staff #4 was unable to provide documentation of staff participation in an exercise in which the procedures for resident emergencies were practiced every 6 months.
Plan of correction
The facility reviewed and acknowledged the deficiency in the documentation of emergency procedures exercises as required by 22VAC40-73-990-C. It was
determined that staff participation in mandatory emergency exercises every six months was not consistently documented, which was identified during the onsite review. The facility administration and staff fully understood the importance of these emergency preparedness exercises for resident safety and compliance.
To address this issue, the facility immediately implemented corrective actions to ensure adherence to the regulation. The facility’s management held a staff meeting to emphasize the requirement of biannual emergency preparedness exercises for all staff members across all shifts. A tracking log was created to document these exercises, capturing each staff member's attendance, role, and participation details. Additionally, the facility designated a staff member to be responsible for overseeing the scheduling, execution, and documentation of these emergency exercises, ensuring continuity and compliance.
Moving forward, the facility will maintain documentation of each exercise for a minimum of two years, as required. All staff members received training on the revised protocol to reinforce the importance of emergency preparedness and documentation requirements. The facility's leadership will conduct periodic audits to confirm that exercises are being conducted and properly documented in alignment with state regulations, ensuring that resident safety remains a top priority and that the facility consistently meets compliance standards.
22VAC40-73-640-A
Based on the onsite record review, it was determined that the facility failed to implement a written plan for medication management to include:
methods to prevent the use of outdated, damaged, or contaminated medications
Evidence
- During the medication cart observation with staff #2, the following medication for resident #5 was located on the medication cart: Sodium Chloride, expired 7/16/24.
Plan of correction
Upon discovering that an expired medication was present on the medication cart, immediate steps were taken to address the issue and prevent recurrence. Staff #2 was instructed to immediately remove the expired Sodium Chloride from the cart, ensuring that resident #5 would not receive any outdated medication.
Additionally, a full inspection of the medication cart was conducted to identify any other potentially expired or compromised medications. All expired or damaged medications were removed, and the cart was restocked with current, unexpired medications to comply with 22VAC40-73-640-A regulations and ensure resident safety.
To prevent future occurrences, the facility has implemented a stricter protocol for medication management. We revised our Medication Management Policy to include mandatory weekly checks of all medication carts for expired, damaged, or contaminated medications. A new checklist was introduced for staff to document each weekly inspection, with signatures from the staff member conducting the review and their supervising nurse. Training was provided to all relevant staff members on the updated protocol, emphasizing the importance of regularly monitoring medication dates and maintaining safe storage practices.
Lastly, we have instituted a quarterly audit process for medication management to ensure ongoing compliance with state regulations. Our quality assurance team will oversee these audits, which will include surprise checks of all medication carts and storage areas. Results from these audits will be reviewed by management to identify any trends or areas needing improvement. We believe this corrective action plan, combined with consistent training and oversight, will help prevent the use of outdated medications and enhance our facility’s commitment to safe, high-quality care.
22VAC40-73-260-A
Based on the record review the facility failed to ensure each direct care staff member who does not have current certification in first aid as specified in subdivision 1 of this subsection shall receive certification in first aid within 60 days of employment.
Evidence
- The record for staff #1 (personal care aide), hire date of 6/30/24, did not contain documentation of a certification in first aid.
- The record for staff #3 (personal care aide), hire date of 5/02/24, did not contain documentation of a certification in first aid.
- Staff #4 reviewed the records for staff #1 and staff #3 and was not able to provide documentation of certification in first aid for staff #1 and staff #3.
Plan of correction
To comply with 22VAC40-73-260- A and ensure all direct care staff members obtain first aid
certification within the required
60-day period, the facility will take immediate corrective action for
staff members identified as non- compliant. Staff #1 and Staff #3, both of whom are without documented first aid certification, will be enrolled in an accredited first aid training program within the next 30 days. Upon completion, their certifications will be promptly added to their personnel records, and a designated staff member will
verify the documentation to ensure compliance. This immediate action will address the current deficiency and bring the facility into compliance with Virginia Department of Social Services (VDSS) regulations.
To prevent future lapses in first aid certification documentation, the facility will implement updates to its onboarding and record- keeping policies. The onboarding process will now include a mandatory first aid certification check for all new hires in direct care roles. Those without certification upon hiring will be required to complete the training within 30 days, which will provide ample time before the 60-day deadline. Additionally, the facility will perform a monthly audit of
employee files to confirm that all certifications, including first aid, are current and accurately documented. These audits will be conducted by the compliance
officer or a designated supervisor, ensuring ongoing adherence to VDSS requirements.
Furthermore, staff will receive additional training and reminders about certification requirements, reinforcing the importance of maintaining valid credentials. The facility will communicate these expectations clearly to all new hires and emphasize the regulatory requirements during orientation. Supervisors will also be briefed on the new compliance procedures to ensure awareness and accountability across the team. This enhanced process will help maintain regulatory compliance and improve the overall quality and safety of care provided to residents by ensuring all direct care staff are properly certified and prepared for emergency situations.
22VAC40-73-450-F
Based on the record review the facility failed to ensure individualized service plans (ISP) shall be reviewed and updated at least once every 12 months and as needed for a significant change in the resident’s condition.
Evidence
- The record for resident #3, admission date of 8/01/23 and discharge date of 10/11/24, contains an ISP completed 8/11/23. The resident’s ISP was not reviewed and updated at least once every 12 months after 8/11/23.
- Staff #4 reviewed the record for resident #3 and was not able to provide an ISP completed 12 months after the date of 8/11/23.
Plan of correction
Our facility has implemented a corrective action plan to ensure full compliance with regulation 22VAC40-73-450-F regarding timely updates of Individualized Service Plans (ISPs). An automated reminder system is now active within our record- keeping software, alerting staff 30 days before each resident’s ISP requires review. Monthly internal audits are conducted to confirm that all ISPs are current and have been reviewed within the required 12-month timeframe. Staff training sessions have been scheduled on a quarterly basis to reinforce the importance of maintaining updated ISPs.
Additionally, we have assigned a dedicated staff member to oversee ISP compliance, ensuring no plan exceeds the mandated review period. This action plan has strengthened our adherence to regulatory standards and enhances the quality of personalized care for our residents.
22VAC40-73-970-E
22VAC40-73-970-E Based on the record review the facility failed to ensure a record of the require fire and emergency evacuation drills shall include the items as listed in this subsection:
Evidence
- The facility’s record of fire drill dated 10/01/24 did not include the following: time of the drill, number of staff and residents participating, and weather conditions.
- The facility’s record of fire drill dated 10/02/24 did not include the following: time of the drills and weather conditions.
Plan of correction
Following a thorough review of the fire drill records, the facility identified that the fire drills conducted on 10/01/24 and 10/02/24 did not fully meet the documentation requirements outlined in 22VAC40-73-970-E. Specifically, records were missing critical details, including the time
of each drill, the number of participating staff and residents, and weather conditions at the time of the drills. This oversight was audits of fire drill records, verifying that each entry includes all required information. These audits will allow us to identify and correct any documentation gaps promptly. We are confident that these measures will help maintain our commitment to safety, ensuring that each drill record accurately reflects the full scope of our emergency preparedness activities.
promptly addressed to ensure compliance with all regulatory requirements and improve the accuracy and thoroughness of our emergency preparedness records.
To rectify these deficiencies, the facility immediately implemented a standardized documentation template for fire and emergency drills. The template includes required fields for time, participant numbers, and weather conditions, among other pertinent information.
Training was conducted with all staff members responsible for emergency drill documentation to reinforce the importance of recording all required details accurately and consistently.
Additionally, the facility's leadership reviewed the drill procedures and documentation requirements with all team members to ensure a comprehensive understanding and strict adherence going forward.
To prevent future discrepancies, the facility will conduct monthly
22VAC40-73-320-A
Based on the onsite record review, it was determined that the facility failed to ensure within the 30 days preceding admission, a person shall have a physical examination by an independent physician and shall contain all included in this section (22VAC40-73-320-A).
Evidence
- The record for resident #1, admission date of 7/01/24, contains a physical exam dated 5/31/24, and it did not include the following: A statement that the individual does not have any of the conditions or care needs prohibited by 22VAC40-73-310-H (airborne infectious diseases, psychotropic medications, and continuous licensed nursing care).
- The record for resident #2, admission date of 3/19/24, contains a physical exam dated 03/01/24 and it did not include the following: The resident’s address; a statement that the individual does not have any of the conditions or care needs prohibited by 22VAC40-73-310-H; a statement that specifies whether the individual is considered to be ambulatory or nonambulatory; a statement that specifies whether the individual is or is not capable of self-administering medication.
Plan of correction
To address the deficiencies noted in the record review, the facility will implement corrective actions to ensure compliance with 22VAC40-73-320-A. First, a
standardized checklist will be created for all pre-admission physical examinations, capturing each required component, including statements on prohibited conditions, ambulation status, and medication self- administration capabilities. This checklist will be provided to independent physicians conducting physical examinations prior to resident admission to ensure they are aware of, and comply with, state regulations.
Administrative staff will also review all physical exams for completeness before finalizing admission paperwork to prevent similar oversights.
Additionally, the facility will initiate a training session for administrative staff focused on admission documentation compliance. This training will cover the regulatory requirements, including 22VAC40- 73-320-A and 22VAC4073-310-H,
to reinforce understanding of the necessary documentation elements. Staff will be instructed on the importance of verifying that each physical exam includes
statements addressing the resident’s ability to self-administer medication, ambulation status, and the absence of prohibited care needs. Training completion will be documented and included in personnel records.
Lastly, the facility will conduct regular audits of resident records
to verify compliance with admission documentation requirements. These audits will occur monthly, focusing on recent admissions to identify and rectify documentation gaps promptly.
Results will be discussed in quality assurance meetings to assess whether the corrective actions are effective. This proactive approach will support ongoing compliance with state regulations, ensuring the safety and well-being of residents and maintaining the facility's commitment to high standards of care.
22VAC40-73-250-D
Based on the record review the facility failed to ensure each staff person on or within 7 days prior to the first day of work at the facility prior to coming in contact with residents shall submit the results of a risk assessment documenting the absence of tuberculosis (TB) 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. The risk assessment shall be no older than 30 days. Evidence:
- The record for staff #3, hire date of 5/02/24, did not contain a risk assessment for TB completed on or within 30 days prior to the first day of work.
- The record for staff #3 contains a risk assessment for TB dated 7/18/24.
- Staff #4 reviewed the record for staff #3 and was not able to provide documentation of a risk assessment for TB completed on or 30 days prior to staff #3’s first day of work.
Plan of correction
To ensure compliance with staff training requirements, all personnel will be screened for TB, and all records will be updated to reflect current in- service training and CPR/First Aid certification status for Basic Life Support (BLS) providers. This includes regular monthly checks to verify the accuracy and completeness of all records. Additionally, CPR/First Aid training sessions will be held on- site for all new hires within their first two weeks of employment to ensure prompt certification and readiness for emergency situations. To maintain ongoing compliance, the administrator will conduct quarterly audits of training records, addressing any discrepancies through immediate corrective actions.
Training completion will be documented and added to each employee’s personnel file.
These measures will ensure that all staff members maintain essential certifications as required by VDSS.