Virginia DSS · Assisted Living Facility

The Warren

📍 935 Ox Road, Woodstock, VA, 22664

ID 49412Provisional licenseActive
23
Inspections
On record
14
With violations
Visits that cited something
9
Clean visits
Nothing cited
71
Violations cited
Individual findings
50
Standards cited
Distinct rules
17
Complaint visits
Prompted by a complaint

The Warren was inspected 23 times between April 13, 2023 and April 2, 2026 by the Virginia Department of Social Services. 14 of those visits ended with violations cited and 9 with none. Across that history VDSS cited 71 violations under 50 distinct standards. 17 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
Provisional
License expires
11/08/2026
Administrator
Lori Myrtle
Licensing inspector
Angela Via
Inspector phone
(540) 682-1739
Approved for
Assisted Living · Non-Ambulatory

Inspection History

23

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

April 2, 2026Complaint survey4 violations
Inspection dates
04/02/2026
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND32.1- (37) Reported by persons other than physicians63.2- (1) General Provisions63.2- (16) Protection of adults and reporting22VAC40-80 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: April 2, 2026, from 12:45 p.m. until 2:00 p.m. 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 03/27/2026 regarding allegations in the area(s) of: Resident Care and Related Services Buildings and Grounds Number of residents present at the facility at the beginning of the inspection: 36 The licensing inspectors completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 5 Observations by licensing inspector: The Licensing Inspector toured the community inside and outside, checked kitchen for supplies, inventoried supply closet, and interviewed residents and staff. The Licensing Inspector reviewed the following at the time of inspection: resident records and supplies available in the community. 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 complaint; 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. 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 Angie Via, Licensing Inspector at (540) 682-1739 or by email at Angela.Via@dss.virginia.gov
Violations
22VAC40-73-440-B
Based on resident record review and staff interviews, the facility failed to ensure the Uniform Assessment Instrument (UAI) was completed and signed by a qualified assessor and administrator or designee.
Evidence
  1. Record for resident 1, admitted 04/24/2025, contained a UAI dated 3/8/2025 unsigned by the administrator or the administrator’s designee.
  2. Resident 2, admitted 11/04/2024, contained a UAI dated 11/01/2024 that was not signed by the assessor, the administrator, or the administrator's designee.
  3. Staff 1 acknowledged the UAIs for residents 1 and 2 were not signed as required by the standard.
Plan of correction
Not published by VDSS.
22VAC40-73-450-A
Based on resident record review and staff interview, the facility failed to ensure that the preliminary plan of care was developed on or within seven days prior to admission to address the basic needs of the resident to adequately protect the health, safety, and welfare of the resident.
Evidence
  1. Record for resident 1, admitted 04/24/2025, contained a preliminary plan of care dated and signed 04/25/2025, which is not on or within seven days prior to admission.
  2. During an interview with the LI on 04/02/2026, staff 1 acknowledged the facility failed to ensure the preliminary plan of care was developed to address the basic needs of resident 1 at or before time of admission.
Plan of correction
Not published by VDSS.
22VAC40-73-100-C-3
Based on direct observation and staff interviews, the facility failed to ensure a readily accessible necessary personal protective equipment for staff and volunteers, including soap and gloves.
Evidence
  1. A complaint was received on 03/27/2026 to the licensing office that facility did not have adequate supplies, including gloves and soap.
  2. During a tour with staff 2 on 04/02/2026, licensing inspectors (LIs) observed three bottles of soap for wall dispensers and two boxes of large gloves in the supply closet. Staff 2 confirmed the supply closet was the only location where extra supplies were stored.
  3. During an interview with staff 4 on 04/02/2026, staff 4 confirmed there have been times when there were no gloves or soap, including dish soap in the kitchen.
  4. During an interview with staff 5 on 04/02/2026, staff 5 confirmed there were times when there was no dish soap in the kitchen. Staff 5 stated that he went and bought dish soap for the kitchen. Staff 5 showed a large bottle of Dawn Ultra on the three-compartment sink that was being used, which he stated he purchased.
  5. During an interview with staff 1 on 04/02/2026, staff 1 confirmed that there were only two boxes of large gloves in supply closet. Staff 1 stated that an order came on 04/01/2026 but not all of the items ordered were available for delivery.
  6. Photo evidence taken.
Plan of correction
Not published by VDSS.
22VAC40-73-320-A
Based on resident record reviews and staff interviews, the facility failed to obtain a physical examination by an independent physician within 30 days preceding admission.
Evidence
  1. The admission date for resident 1 was 04/24/2025. The date of the face-to-face physical examination for resident 1 was 03/19/2025, which is not within 30 days preceding admission as required.
  2. Staff 1 and 3 acknowledged that the physical examination report for resident 1 was not completed according to the standard.
Plan of correction
Not published by VDSS.
November 12, 2025Complaint survey3 violations
Inspection dates
11/12/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 ADDITIONAL REQUIREMENTS for FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS63.2- (16) Protection of adults and reporting22VAC40-80 Complaint Investigation
Comments
Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 11/3/2025 regarding allegations in the area(s) of: Resident Care and Related Services Buildings and Ground Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/12/2025 from 10:00 a.m. until 12:17 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: 39 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 7 Observations by licensing inspector: Licensing inspector toured the community and resident room, interviewed resident and staff, spoke with pest control, and reviewed relevant policies and procedures. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the complaint of non-compliance with standard(s) or law, and violation(s) were 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 Angela Via, Licensing Inspector at (540) 682-1739 or by email at Angela.Via@dss.virginia.gov
Violations
22VAC40-73-70-A
Based on resident record review and staff interviews, the facility failed to report to the regional licensing office within 24 hours any major incident that had negatively affected or that threatened the life, health, safety, or welfare of any resident.
Evidence
  1. During an interview with LI on 11/12/2025, staff 2 stated that a bed bug was first found in resident 1’s room on 9/24/2025 at 2:46 p.m. Staff 2 provided LI with a picture of the bed bug found by Ecolab pest control.
  2. During an interview with LI on 11/12/2025 when asked if the facility reported the presence of the bed bug to regional licensing office, staff 2 stated, “I did not report to DSS (Department of Social Services), because it was not an outbreak. When LI asked if bed bug was reported to the health department, staff 2 stated, “I didn’t know I needed to.”
Plan of correction
The Executive Director will report to the DSS regional licensing office within 24 hours of any major incidents that has negatively affected or that threatens the life, health, safety, or welfare of any resident.
22VAC40-73-40-A
Based on resident record review and staff interviews, the licensee failed to ensure compliance with the facility's own policies and procedures.
Evidence
  1. A complaint received by the regional licensing office on 11/3/2025 which alleged that “a resident on the dementia unit has brought in bed bugs and management is doing nothing about it.”
  2. Staff 1, 2, 4, 5, and 7 confirmed the previous presence of bed bugs in resident 1’s room.
  3. Licensing inspector (LI) was given a copy of the Procedure: Receiving Furniture- Bed Bug Prevention Protocol, which specifies “upon arrival, furniture must be visually inspected outside of the main building before being brought in”. Procedure also stated that “furniture may not be immediately placed in rooms” and will be held in a “designated furniture quarantine area (garage, maintenance shed, or isolated room) for at least 24 hours”. Documentation should include a furniture receiving log, which includes date of arrival, source, inspector’s name, notes on condition, and clearance date and placement location.
  4. During an interview with LI on 11/12/2025, staff 3 confirmed that furniture should be inspected prior to move in and a checklist completed.
  5. During an interview with LI on 11/12/2025, staff 7 was asked if furniture was moved directly into resident rooms when it arrived. Staff 7 responded, “Yes, it does.” When LI asked staff 7 if move in checklist was completed, staff 7 responded, “I did not complete move in checklist”.
  6. During an interview with LI on 11/12/2025, staff 2 was asked where the designated furniture quarantine area, such as a garage, maintenance shed, or isolation room was for furniture to stay at least 24 hours per the Procedure: Receiving Furniture- Bed Bug Prevention Protocol. Staff 2 stated that there was not a designated furniture quarantine area on the campus, nor was there room for one. LI referred to procedure and staff 2 acknowledged procedure was not being followed.
Plan of correction
All new resident admissions will undergo a comprehensive inspection by the Maintenance Director, including all furniture, personal items, and clothing, in accordance with Inspirit Senior Living admissions policy. The Executive Direction will ensure compliance by requiring the Maintenance Director to sign off on the Inspirit Senior Living Bed Policy during admission. Any future pest control findings will be reported by the Executive Director immediately to the regional management team to ensure adherence to Inspirit Senior Living Policies.
22VAC40-73-460-A
Based on resident record review and staff interviews, the facility failed to assume general responsibility for the health, safety, and well-being of the residents.
Evidence
  1. A complaint received by the regional licensing office on 11/3/2025 alleged that “a resident on the dementia unit has brought in bed bugs and management is doing nothing about it.”
  2. Resident 1 moved into the community on 8/27/2025.
  3. During a phone interview with LI on 11/12/2025, Ron Davis with Ecolab confirmed the presence of bed bugs in resident 1’s room on September 24, 2025, and October 21, 2025. LI asked Ron Davis with Ecolab if there was any way to prevent bed bugs from entering the building during the move in process, and he stated that leaving furniture isolated for a week will prevent bed bugs from entering the facility because bed bugs need people to survive and do so by coming out at night to bite and feed. If the bed bugs are unable to bite people and get nourishment, the bed bugs will die.
  4. During interview with LI on 11/12/2025, staff 2, 3, and 7 acknowledged that the facility failed to follow the Procedure: Receiving Furniture- Bed Bug Prevention Protocol. By doing so, the facility failed to assume general responsibility for the health, safety, and well-being of the residents.
Plan of correction
The Executive Director will report to the DSS Licensing Inspector and to the Virginia Health Department as required to assume general responsibility for the health, safety, and well-being of the residents.
November 12, 2025Complaint survey0 violations
Inspection dates
11/12/2025
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICESARTICLE 1 – SUBJECTIVITY63.2- (1) General Provisions
Comments
Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 11/12/2025 regarding allegations in the area(s) of: Resident care and related services Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/12/2025 from 12:20 p.m. until 1:32 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: 39 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: Licensing inspector reviewed resident record, including Hospice notes, physician’s orders, and medication administration record (MAR). 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. 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 Angela Via, Licensing Inspector at (540) 682-1739 or by email at Angela.Via@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
September 15, 2025Inspection14 violations
Inspection dates
09/15/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY63.2- (1) GENERAL PROVISIONS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION
Comments
Type of inspection: Renewal Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 9/15/2025 from 9:30 a.m. until 4:48 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: 36 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: 9 Number of interviews conducted with staff: 7 Observations by licensing inspector: The Licensing Inspector toured the community and observed the residents during activities and meals. The Licensing Inspector reviewed the following at the time of inspection: sample of resident and employee records, medication administration, fire drills, emergency drills, pharmacy review, menus, activity calendars, verified appropriate amount of liability insurance, and dietician report. 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 Angela Via, Licensing Inspector at (540) 682-1739 or by email at Angela.Via@dss.virginia.gov
Violations
22VAC40-73-410-A
Based on resident record review and staff interview, the facility failed to provide an orientation, upon admission, for new residents and their legal representatives, which included emergency response procedures, mealtimes, and use of the call system. Acknowledgment of having received the orientation must be and dated by the resident and, as appropriate, his legal representative, with documentation kept in the resident's record.
Evidence
  1. Record for resident 1, admit date 5/2/2025, did not contain a documented orientation that was signed by the resident or legal representative.
  2. Record for resident 2, admit date 4/2/2025, did not contain a documented orientation that was signed by the resident or legal representative.
  3. Record for resident 4, admit date 2/22/2025, did not contain a documented orientation that was signed by the resident or legal representative.
  4. Staff 5 presented an acknowledgement of the resident handbook as what was used to comply with this standard, but this document does not contain the required information.
  5. During an interview with the LI on 9/15/2025, staff 5 confirmed there was no documented orientation for residents 1, 2, and 4 and their respective legal representatives, which included emergency response procedures, mealtimes, and use of the call system.
Plan of correction
Resident Wellness Director along with the Resident Care Director will meet with all new residens and their families at time of move and document orienting resident to meal times, emergency response procedures as well as the use of the call bell system. Executive Director will provide oversite to maintain compliance to standards.
22VAC40-73-860-I
Based on observation and staff interview, the facility failed to store cleaning supplies and other hazardous materials in a locked area.
Evidence
  1. During a tour of the facility on 9/15/2025, two licensing inspectors observed maintenance and cleaning supplies, including Pro-treat for condensate drain pans, Crystal stain block, WD-40, and Magnum blue pre-spotter degreaser, in an unlocked housekeeping closet marked biohazard.
  2. During an interview with the LI on 9/15/2025, staff 5 confirmed the facility failed to store cleaning supplies and other hazardous materials in a locked area.
  3. Photo evidence taken.
Plan of correction
Maintenance Director will ensure that all chemicals remain locked and out of reach of residents. Executive Director will provide oversight to ensure compliance.
22VAC40-73-260-A
Based on staff record reviews and staff interview, the facility failed to ensure direct care staff members maintained current certification in first aid.
Evidence
  1. Record for staff 7, hired 1/20/2025, did not contain current first aid certification.
  2. Record for staff 9, hired 5/27/2025, did not current first aid certification.
  3. During an interview with LI on 9/15/2025, staff 5 was unable to provide verification that staff 7 and 9 maintained current certification in first aid.
Plan of correction
Resident Wellness Director along with the Resident Care Director will ensure that all First Aid certification is up to date and posted within 60 days of hire. Executive Director will provide oversite to maintain compliance.
22VAC40-73-720-A
Based on record review and staff interview, the facility failed to ensure Do Not Resuscitate (DNR) Orders for withholding cardiopulmonary resuscitation from a resident in the event of cardiac or respiratory arrest were only carried out in a licensed assisted living facility when both a valid written order had been issued by the resident's attending physician and the written order was included on the individualized service plan.
Evidence
  1. Resident 4, admitted 2/22/2025, had a signed physician’s Do Not Resuscitate (DNR) order dated 2/26/2025.
  2. Individualized service plan (ISP) for resident 4 was not updated with DNR code status until 9/15/2025 (date of inspection).
  3. During an interview with the LI on 9/15/2025, staff 6 confirmed that resident 4’s ISP did not contain the physician ordered code status as required.
Plan of correction
Resident Wellness Director along with Resident Care Director will ensure that Service Plans are updated as soon code status is changed with service plan stating resident wishes. Executive Director will provide oversight to maintain compliance.
63.2-1720-A
Based on staff record reviews and staff interview, the facility failed to obtain an original criminal history record report for each employee within 30 days of employment.
Evidence
  1. The Licensing Inspector (LI) requested all criminal history record reports (CHRR) for all new staff hired since the last mandated inspection on 10/9/2024.
  2. Staff 10, hired 11/30/2024, contained a CHRR dated 9/15/2025 (date of the inspection).
  3. Staff 11, hired 5/13/2025, contained a CHRR dated 9/15/2025 (date of the inspection).
  4. Staff 12, hired 5/6/2025, contained a CHRR dated 9/15/2025 (date of the inspection).
  5. During an interview with the LI on 9/15/2025, staff 5 acknowledged the facility ran the CHRRs for staff 10, 11, and 12 on the day of the inspection and thus failed to obtain the required reports within 30 days of employment as required by the standard.
Plan of correction
Executive Director along with the Resident Care Director will ensure that all background checks are completed within 30 days of hire. Compliance will be monitored by the Executive Director.
22VAC40-73-310-D
Based on resident record review and staff interview, the facility failed to provide written assurance to the resident that the facility had the appropriate license to meet his care needs at the time of admission with a signed copy of the written assurance retained in the resident’s record.
Evidence
  1. Record for resident 1, admit date 5/2/2025, did not contain a written assurance that was signed by the resident or legal representative.
  2. Record for resident 2, admit date 4/2/2025, did not contain a written assurance that was signed by the resident or legal representative.
  3. Record for resident 4, admit date 2/22/2025, did not contain a written assurance that was signed by the resident or legal representative.
  4. Staff 5 presented the resident admission agreement page for residents 1, 2, and 4 as what is used to fulfill this standard, but it did not contain the required information.
  5. During interview with LI on 9/15/2025, staff 5 confirmed they did not provide written assurances to residents 1, 2, and 4.
Plan of correction
Resident Wellness Director will meet with the family and resident along with review any medical documentation along with a history and physical to determine needs and will provide a letter of written assurance to the family and require family and or resident signature and will be kept in the resident business file. Executive Director will provide oversite to maintain compliance.
22VAC40-73-930-D
Based on record review and staff interview, the facility failed to document rounds that were made for residents with an inability to use the signaling device.
Evidence
  1. During an interview on 9/15/2025, the Licensing Inspector (LI) asked staff 6 if residents 2 and 4 were able to use a signaling device. Staff 6 responded, “no”.
  2. LI requested documentation of rounds completed on resident 2 and 4.
  3. During a follow-up interview with the LI, staff 6 confirmed the documentation of rounding for residents with an inability to use the signaling device was not being completed.
Plan of correction
Resident Wellness Director along with the Resident Care Director will ensure that service plans are updated with the residents inability to use a signaling device and documentation of safety checks. Executive Director will provide oversight to ensure compliance.
22VAC40-73-280-A
Based on record review and staff interview, the facility failed to have staff sufficient in numbers to provide services to attain and maintain the physical, mental, and psychosocial well-being of each resident as determined by resident assessments and individualized service plans.''
Evidence
  1. ''
  2. On the day of inspection, 9/15/2025, two licensing inspectors were present on the Sage unit from 9:45 a.m. until 9:58 a.m. This unit utilizes a WanderGuard pendant system. The registered medication aid (RMA) arrived on the unit at 9:52 a.m. The direct care aid (DCA) arrived on the unit at 9:58 a.m. For eight minutes, there were no staff members present.
  3. During the eight minutes when no staff members were present, resident 2 was observed going into other resident’s rooms, disrobing down to their incontinence brief, which appeared soiled, continuing to wander in the hallway and into another resident’s room.
  4. During an interview on 9/17/2025 with staff 13, when asked if there was a DCA assigned on the Sage unit, staff 13 stated “nobody was on the unit this morning”, due to providing care to a resident on assisted living. When asked about the needs of residents on the Sage unit, staff 13 stated that out of the 18 residents, six are a two- person assist and two have wandering/aggressive behaviors. Staff 13 stated, “It’s hard to take care of this building with three staff, and we only have three staff all the time; only two DCAs and one med tech (RMA).” '
  5. During an interview with staff 3 when asked how many staff were scheduled, staff 3 stated they began working at The Warren in February and since then there had consistently only been two DCAs. Occasionally there had been a third DCA scheduled, but that was rare. Staff 3 stated all residents were heavy care and the “staff ratio was not enough to care for people”.
  6. During an interview with staff 4, when asked about staffing, staff 4 stated they had worked at the facility for seven months, and there were consistently two DCAs and a med tech (RMA). Staff 4 stated they rarely had a third DCA scheduled from 5 to 9 p.m. Staff 4 stated that out of “36 residents more than 10 need two people and almost all on Sage needed two- people”. LI asked staff 4 what happened if someone on assisted living required two people, and staff 4 stated, “Sage are left unattended”.
  7. While staff 13 was passing medications on assisting living and staff 3 and 4 were caring for a two person assist on assisted living, there was no staff on duty on the Sage unit to provide care or oversight/redirection to the residents in care. During this time the facility failed to ensure staff sufficient in numbers to provide services to attain and maintain the physical, mental, and psychosocial well-being of the residents.
Plan of correction
Resident Wellness Director along with the Resident Care Director will ensure that there are an adequate number of staff to meet the needs of the number of staff that are residing in the community. Resident Wellness Director as well as the Resident Care Director will meet with staff to ensure that there is one team member at all times on the Wanderguard neighborhood. Executive Director will provide oversite to maintain compliance with the standards.
22VAC40-73-450-A
Based on record review and staff interview the facility failed to ensure that the preliminary plan of care was developed to address the basic needs of the resident to adequately protect the health, safety, and welfare of the resident.
Evidence
  1. Record for resident 1, admitted 5/2/2025, did not contain a preliminary plan of care.
  2. During an interview with the LI on 9/15/2025, staff 5 acknowledged the facility failed to ensure the preliminary plan of care was developed to address the basic needs of resident 1.
Plan of correction
Resident Wellness Director along with the Resident Care Director will ensure that a Plan of Care is created on the day of or within 7 days prior to the admission of resident stating that the facility can address the basic needs of this resident. Executive Director to provide oversight to maintain compliance.
22VAC40-73-260-B
Based on staff record reviews and staff interview, the facility failed to ensure there was at least one staff person in the building at all times who had current certification in Cardiopulmonary Resuscitation (CPR). 1. Record for staff 7, hired 1/20/2025, did not contain a current CPR certification certificate. 2. Record for staff 9, hired 5/27/2025, did not contain a current CPR certification certificate. 3. On the 6 a.m. to 2 p.m. shift on 8/31/2025, 9/13/2025, and 9/14/2025, staff 7 and 9 were the only staff listed on the schedule. 4. During an interview with the LI on 9/15/2025, staff 5 was unable to provide verification that staff 7 and 9 maintained current certification in CPR as required.
Plan of correction
Resident Wellness Director along with the Resident Care Director will ensure that all team members have first aid and that it posted within 60 days of hire. Resident Wellness Director along with the Resident Care Director will ensure that at least one person on each shift will have an up to date and current CPR certification. Resident Care Director will maintain all schedules as required by state standards Executive Director will provide oversite to maintain compliance.
22VAC40-73-250-C
Based on staff record reviews and staff interview, the facility failed to ensure personal and social data was maintained on staff and included in the staff record.
Evidence
  1. Record for staff 7, hired 1/20/2025, did not contain the required personal and social data.
  2. Record for staff 8, hired 7/29/2025, did not contain the required personal and social data.
  3. Record for staff 9, hired 5/27/2025, did not contain the required personal and social data or verification that the employee received a copy of the current job description.
  4. During an interview with LI on 9/15/2025, staff 5 confirmed the only personal and social information/data collected upon hire was on the employee application which did not include all of the required information such as employee’s date of birth or name and phone number of the emergency contact. Staff 5 also confirmed the facility did not have verification that staff 9 had received a copy of the required job description.
Plan of correction
Executive Director along with the Resident Care Director will ensure that all new team members have a completed a social data form to include an emergency contact along with all required information according to state standards while completing the new hire paperwork.
22VAC40-73-980-A
Based on resident record review and staff interview, the facility failed to ensure a complete first aid kit was on hand at the facility and contained all the required items as listed in the subsection.
Evidence
  1. The facility first aid kit was inventoried and missing adhesive tape and band-aids in assorted sizes.
  2. During an interview with the LI on 9/15/2025, staff 5 confirmed that the facility first aid kit did not contain all of the required elements.
Plan of correction
Resident Wellness Director along with Activities Director will ensure that first aid kits are reviewed monthly and replenished out of date items. Executive Director to provide oversight to maintain compliance.
22VAC40-73-1030-B
Based on staff record review and staff interview, the facility failed to ensure direct care staff, within four months of the starting date of employment, attended six hours of training in working with individuals who have cognitive impairments.
Evidence
  1. Staff 7, hired 1/20/2025, had only one hour of documented training for individuals with cognitive impairments.
  2. Staff 9, hired 5/27/2025, had only one hour of documented training for individuals with cognitive impairments.
  3. During an interview with the LI on 9/15/2025, staff 5 confirmed the facility did not ensure that staff 7 and 9 attended six hours of documented training for individuals with cognitive impairments.
Plan of correction
Resident Wellness Director along with the Resident Care Director will ensure that training is completed according to state regulation during the allotted time frame for individuals with cognitive impairments. Executive Director to provide oversight to ensure compliance.
22VAC40-73-350-B
Based on record reviews and staff interview the facility failed to ascertain, prior to admission, whether a potential resident was a registered sex offender and document in the resident's record this was ascertained and the date the information was obtained.
Evidence
  1. Record for resident 1, admitted 5/2/2025, did not contain evidence of a registered sex offender search.
  2. During an interview with the LI on 9/15/2025, staff 5 confirmed the facility failed to ascertain, prior to admission, whether a resident 1 was a registered sex offender and document in resident 1’s record this was ascertained and the date the information obtained.
Plan of correction
Resident Wellness Director along with the Resident Care Director will ensure that a sex offender search is completed prior to resident moving into the community. Executive Director will provide oversite to ensure compliance with Standard.
July 11, 2025Inspection1 violation
Inspection dates
07/11/2025
Areas reviewed
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: 7/11/2025 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 4/23/2025 regarding allegations in the area of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 39 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: NA Number of interviews conducted with residents: NA Number of interviews conducted with staff: 1 Observations by licensing inspector: NA Additional Comments/Discussion: 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 Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov
Violations
22VAC40-73-680-D
Based on self-reported incident and resident record review, the facility failed to administer medications in accordance with the physician’s or other prescriber’s instructions.
Evidence
  1. Self-reported incident from the facility stated resident 1 missed doses of hydrocodone 5/325mg from 4/10/2025-4/17/2025.
  2. The Medication Administration Record (MAR) for April 2025 for resident 1 indicated Hydrocodone-Aceta 5-325 MG tab, take 1 tablet by mouth 3 times a day for pain (ordered 12/21/2024) was not administered at 6:00am from 4/10/2025-4/15/2025, at 12:00pm from 4/10/2025-4/15/2025 and at 6:00pm from 4/9/2025-4/15/2025. 19 doses were not administered to resident 1.
Plan of correction
Resident Wellness Director and Resident Care Director will have weekly medication technician meetings to review compliance with the medication administration in accordance with Inspirit Senior Living Medication Management Policy. Executive Director will oversee to maintain compliance. Resident Wellness Director and Resident Care Director will perform a weekly narcotic count audit. The Executive Director will oversee to maintain compliance.
July 2, 2025Complaint survey13 violations
Inspection dates
07/02/2025
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 ADDITIONAL REQUIREMENTS for FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-80 Complaint Investigation
Comments
Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 2/7/2025 regarding allegations in the area(s) of: Resident Care and Related Services Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7/2/2025 from 9:43 a.m. until 4:13 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: 39 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Licensing inspector requested closed resident record. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the complaint of non-compliance with standard(s) or law, and violation(s) were 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 Angela Via, Licensing Inspector at (540) 682-1739 or by email at Angela.Via@dss.virginia.gov
Violations
63.2-1606-A
Based on resident record review and staff interview, the facility failed to immediately report suspicions of abuse, neglect or exploitation of an aged or incapacitated adult.
Evidence
  1. Incident dated 7/30/2024 at 2:30 p.m. indicated that resident 1 attempted to put his hands down resident 2’s shirt. Documentation provided indicated there was previous history of these types of incidents specifically resident 1 was previously caught kissing resident 2.
  2. During an interview with the LI, staff 1 confirmed resident 2 was unable to tell what happened during the incident on 7/30/2024 due to a diagnosis of dementia and also stated resident 2 was in a wheelchair and unable to move the wheelchair independently. During the same interview staff 2 added that resident 2 was verbal but “doesn’t make sense”.
  3. Internal facility documentation dated 7/30/2024 indicated the POA for resident 1 was notified. During an interview with the LI staff 1 stated the POA for resident 2 was also notified by phone but there was no documentation that such notification had been made. The same report also listed preventative steps to include one on one, documentation in the resident service notes, educate resident, setting boundaries, medication review, and frequent safety checks to ensure both residents are safe.
  4. During an interview with the LI, staff 1 confirmed the facility failed to immediately report the incident of possible abuse to Adult Protective Services as required by Code.
Plan of correction
Resident Wellness Director along with the Resident Care Director will ensure that any suspicion of abuse, neglect or exploitation of an aged or incapacitated adult is immediately reported to the proper authorities. They will also ensure that any communications with family regarding the situations will be documented in both resident charts. Executive Director to provide oversight to ensure compliance with standards.
22VAC40-73-560-H
Based on resident record review and staff interview, the facility failed to retain a complete resident record for at least two years following discharge.
Evidence
  1. Resident 1, admitted 7/12/2024, was discharged from the facility on 1/7/2025.
  2. During the inspection on 7/2/2025, LI requested resident 1’s complete resident record. Staff 1 provided a photocopied stack of documents which contained no original documents with no original signatures and confirmed to the LI what was provided was resident 1’s complete medical record.
  3. After reviewing the provided documentation, licensing staff requested the following items: a. Original documents for the photocopies that were provided b. Physical examination preceding admission c. Mental Health Screening d. Sex Offender Information e. All signed physician orders from 7/12/2024 through 1/7/2025 f. All facility progress notes from 7/12/2024 through 1/7/2025 g. All physician progress notes from 7/12/2024 through 1/7/2025 h. Any additional required assessments completed which were not provided originally
  4. Staff 1 was able to provide a physical exam dated 10/28/2024 (resident 1’s admit date was 7/12/2024), one photocopied signed physician’s order dated 7/31/2024, and one facility progress note dated 8/3/2024.
  5. During an interview with the LI and LA on 7/2/2025, staff 1 confirmed they failed to retain a completed resident record and were unable to provide any additional signed physician's orders, physician’s progress notes or any additional facility progress notes and were not able to provide any original documents as requested for resident 1.
Plan of correction
Resident Wellness Director along with the Resident Care Director will ensure proper storage of charts once resident is no longer in the community. Original documents will be maintained according to DSS standards and complete original records will be available for review. Executive Director to provide oversite to ensure compliance to standard.
22VAC40-73-330-B
Based on resident record review and staff interview, the facility failed to conduct a mental health screening when a resident displayed behaviors or patterns of behavior indicative of behavioral disorders that caused concern for the health, safety, or welfare of either that resident or others who could be placed at risk of harm by the resident.
Evidence
  1. Progress note for resident 1 dated 8/3/2024 stated, “Resident was attempted [sic] to be redirected due to him getting aggressive” but no mental health screening was conducted.
  2. On 11/18/2024, facility notified the LI that resident 1 became aggressive with a staff member. Resident record did not contain information about a mental health screening at that time.
  3. During an interview with LI on 7/2/2025, staff 1 confirmed that the mental health screening was not completed as required.
Plan of correction
Resident Wellness Director along with the Resident Care Director will ensure any resident that displays behaviors of concern for the health, safety or welfare of themselves or other residents, a mental health screening will be obtained and reviewed to ensure that the community can continue to meet the residents needs while keeping everyone safe. Executive Director to provide oversight to ensure compliance and the ability to meet resident's needs.
22VAC40-73-460-E
Based on resident record review and staff interviews, the facility failed to document any notable changes in condition, functioning, or altered behavior and the corresponding actions taken along with the appropriate assistance provided when the resident has observable unmet needs.
Evidence
  1. 24-hour report dated 7/23/2024 indicated that resident 1 was walking into other resident rooms. There was no documentation of corresponding action taken or assistance provided to the resident.
  2. 24-hour report dated 7/30/2024 indicated that resident 1 got aggressive while pushing another resident. There was no documentation of corresponding action taken or assistance provided to the resident.
  3. 24-hour report dated 9/2/2024 indicated that resident 1 kept stating he was leaving due to being tired of being at facility. There was no documentation of corresponding action taken or assistance provided to the resident.
  4. 24-hour report dated 9/25/2024 indicated that resident 1 had a pocketknife. There was no documentation of corresponding action taken or assistance provided to the resident.
  5. During an interview with LI on 7/2/2025, staff 1 and 2 confirmed that there was no documentation of the corresponding actions taken or assistance provided to the resident for each of the incidents listed on the 24-hour report.
Plan of correction
Resident Wellness Director will in-service staff on documentation of behaviors and ensure that any documentation of illness or behavior are followed up on within 24 hours and documented. Care staff will be instructed to document redirection provided to residents when and where needed. Resident Wellness Director along with Resident Care Director will ensure that care plans are updated according to assessments of increased needs. Executive Director to provide oversight to ensure compliance of standard.
22VAC40-73-300-B
Based on resident record review and staff interview, the facility failed to maintain a method of written communication between direct care staff on all shifts of significant happenings, problems, complaints, injuries, and incidents experienced by residents with the written communication retained for at least two years and the information included in the record of the involved resident.
Evidence
  1. During review of resident 1’s medication administration record (MAR), a Wanderguard was added in September 2024 and subsequently was noted as missing, broken, or removed a total of 26 times in September 2024, 86 times in October 2024, and 34 times in November 2024. There were no entries on the September 2024 communication log or the partial month of October 2024 communication log to notify staff of the issues with resident 1’s wanderguard.
  2. Licensing staff requested the remainder of the communication logs for October 2024 through January 2025 to review documentation of incidents or significant happenings relayed to direct care staff related to resident 1.
  3. During an interview with the LI on 7/2/2025, staff 1 confirmed they were unable to provide any communication logs for mid-October 2024 through January 2025.
Plan of correction
Resident Care Director along with the Resident Wellness Director will ensure that the 24-hour log is being completed daily and will review each day to ensure that all significant findings, any problems, complaints or injuries that occur is followed up on in a timely fashion and documented. Executive Director to provide oversight to ensure compliance.
22VAC40-73-680-D
Based on resident record review and staff interview, the facility failed to administer medications in accordance with the physician’s or other prescriber’s instructions.
Evidence
  1. The record for resident 1 contained one signed physician's order dated 7/31/2024 for naltrexone 50 mg tablet 1 tablet by mouth daily to start on 7/31/2024.
  2. Naltrexone 50 mg tablet did not appear on any of the medication administration records (MARs) for resident 1 from July 2024 through January 2025.
  3. During an interview with LI on 7/2/2025, staff 2 confirmed the facility failed to follow the signed physician’s order and also confirmed that naltrexone 50 mg tablet was never on the MARs for resident 1 and could offer no explanation as to why the medication was not administered as ordered.
Plan of correction
Resident wellness Director will ensure that medications ordered are in the community within timely manner and that all signed orders from the physician are followed up on. Executive Director to provide oversight to ensure compliance.
22VAC40-73-310-D
Based on resident record review and staff interview, the facility failed to provide a written assurance to the resident that the facility had the appropriate license to meet the care needs of the resident at the time of admission.
Evidence
  1. The record for resident 1 did not contain a written assurance.
  2. During an interview with the LI on 7/2/2025, staff 1 was unable to confirm that a written assurance was provided to resident 1 to ensure the facility had the appropriate license to meet his care needs at the time of admission.
Plan of correction
Resident Wellness Director along with the Resident Care Director will meet with the Executive Director to discuss the ability to meet the needs of any resident coming into the community. Once reviewed, the Executive Director will ensure a Written Assurance is provided to family and a copy maintained in resident file.
22VAC40-73-330-A
Based on resident record review and staff interview, the facility failed to conduct a mental health screening prior to admission if behaviors or patterns of behavior caused or continued to cause concern for the health, safety, or welfare of that individual or others who could be placed at risk of harm by that individual.
Evidence
  1. Resident 1’s record did not contain a mental health screening.
  2. During an interview with the LI on 7/2/2025, staff 1 confirmed there was no mental health screening and one had not been completed prior to admission.
Plan of correction
Resident Wellness Director along with the Resident Care Director will review records of residents prior to being admitted to the community and ensure any mental health concerns in the previous 6 months will have a mental health screening prior to admission to ensure community ability to care for and meet resident's needs. Executive Director to provide oversight to ensure compliance with standard.
22VAC40-73-340-A
Based on resident record review and staff interviews, the facility failed to determine the appropriateness of the admission, for an individual with behavioral disorders, by obtaining information about the individual's psychosocial and behavioral functioning from primary sources, such as family members, friends, or physician and documenting the source and content of the information obtained.
Evidence
  1. Resident 1’s record did not contain documentation that information regarding psychosocial and behavioral functioning was gathered from primary sources to determine the appropriateness of the admission.
  2. During an interview with the LI on 7/2/2025, staff 1 and 2 confirmed there was no documentation regarding psychosocial and behavioral functioning gathered from primary sources which was to be used to determine the appropriateness of the admission.
Plan of correction
Resident Wellness Director along with the Resident Care Director will ensure that a face-to-face assessment is completed on all potential residents to the community and review medical documents along with interviews with family to ensure that needs can be met and ensure the facilities ability to keep resident safe within 30 days prior to move in. Executive Director will provide oversight to ensure compliance.
22VAC40-73-320-A
Based on resident record review and staff interviews, the facility failed to obtain a physical examination by an independent physician within 30 days preceding admission.
Evidence
  1. The admission date for resident 1 was 7/12/2024. The physical examination report for resident 1 was dated 10/28/2024.
  2. During an interview on 7/2/2025, staff 1 and staff 2 confirmed that the facility failed to obtain a physical examination for resident 1 prior to admission.
Plan of correction
Resident Wellness Director along with Resident Care Director will ensure that there is a signed History and Physical from a licensed physician dated no earlier than 30 days prior to move in and assess the community's ability to meet care needs of resident. Executive Director to provide oversight to ensure compliance with standard.
22VAC40-73-70-C
Based on resident record review, the facility failed to submit a written report of each incident specified in 22VAC40-73-70-A to the regional licensing office within seven days from the date of the incident.
Evidence
  1. Regional licensing office received incident reports for resident 1 on 11/18/2024 and 1/7/2025.
  2. LI received an email from staff 1 on 11/18/2024 reporting an initial incident with resident 1. The final written report for the incident was sent to the LI on 11/29/2024, which is beyond the seven-day reporting requirement.
  3. LI received an email from staff 1 on 1/7/2025 reporting an initial incident with resident 1. The final written report on the incident was sent to LI on 1/18/2025, which is beyond the seven-day reporting requirement.
Plan of correction
Resident Wellness Director along with Executive Director will ensure that all major incidents that threaten the life, safety and or welfare of a resident will be reported initially within 24 hours of incident and will have final written report submitted within 7 days to DSS. Executive Director will review incidents daily along with Resident Wellness Director to maintain compliance with reporting.
22VAC40-73-310-B
Based on resident record review and staff interviews, the facility failed to ensure the individual's needs could be met prior to admission by reviewing, at a minimum, a completed Uniform Assessment Instrument, a physical examination report, and completing a documented interview between administrator, the individual, and his legal representative.
Evidence
  1. The Uniform Assessment Instrument (UAI) for resident 1 was dated 7/12/2024, the day of resident 1’s admission.
  2. The physical examination report for resident 1 was dated 10/28/2024, which was after resident 1’s admission date of 7/12/2024.
  3. During an interview with the LI on 7/2/2025, staff 1 and 2 confirmed that the facility failed to obtain a physical examination for resident 1 prior to admission and also confirmed the UAI was not completed prior to admission preventing the facility from reviewing the information from either of these required documents to help make the determination that the facility could meet resident 1’s needs.
  4. During an interview on with the LI on 7/2/2025, staff 1 also confirmed the documented interview was not conducted prior to admission or on the day of admission as required.
Plan of correction
Resident Wellness Director along with the Resident Care Director will ensure that a face-to-face assessment is completed on all potential residents to the community and review medical documents along with interviews with family to ensure that needs can be met and ensure the facilities ability to keep resident safe within 30 days prior to move in. Resident Wellness Director along with Resident Care Director will ensure that there is a signed History and Physical from a licensed physician dated no earlier than 30 days prior to move in and assess the community's ability to meet care needs of resident. Executive Director to provide oversight to ensure compliance with standard.
63.2-1808-A-15
Based on resident record review and staff interview, the facility failed to ensure the resident was free of physical or mechanical restraints except in the following situations and with appropriate safeguards: a. as necessary for the facility to respond to unmanageable behavior in an emergency situation, which threatens the immediate safety of the resident or others; b. as medically necessary, as authorized in writing by a physician, to provide physical support to a weakened resident.
Evidence
  1. The MAR for resident 1 indicated that a WanderGuard was applied on 9/9/2024. Resident 1’s record did not contain a signed physician’s order for the WanderGuard device to be applied.
  2. Power of Attorney (POA) for resident 1 signed a refusal to participate in elopement interventions on 7/12/2024 on page 13 of the admission documents.
  3. Resident 1’s ISP dated 7/12/2024 did not include that he was wearing or required a WanderGuard device however the 24-Hour Report dated 7/12/2024, day of admission, stated WanderGuard was present on resident 1 on day of admission.
  4. Staff 1 confirmed the facility did not have a signed physician’s order for a Wanderguard device for resident 1 and confirmed it was the facility’s policy to obtain a physician’s order prior to placing a Wanderguard device on a resident.
  5. During an interview with the LI on 7/2/2025, staff 1 stated resident 1 had a Wanderguard in place on the day of admission but could not provide an explanation why there was no physician’s order present for the Wanderguard or why the medication administration record showed the application of the wanderguard beginning September 9, 2024. The application of the Wanderguard placed a restraint on resident 1, which was not authorized by a physician.
  6. During a facility tour with licensing staff on 7/2/2025, staff 1 confirmed the doors to the Sage unit (also known as their Wanderguard unit) would not open when a resident wearing a Wanderguard was close to the door and also confirmed that during those instances no other residents or visitors could enter or exit the unit thus restricting freedom of movement of other residents residing on the unit who do not wear or require a Wanderguard. Staff 1 confirmed not all of the residents who resided on the Sage unit wore or required a Wanderguard.
Plan of correction
Resident Wellness Director along with the Resident Care Director will ensure that there is a signed order for any intervention regarding to safety along with consent form the resident POA. Behaviors will be documented that indicates the need for such devices (wanderguard) along with interventions put into place and documented on the Service Plan. Door to wanderguard area is an egress and opens after 15 seconds as to not restrict movement of residents. Executive Director to provide oversight to ensure compliance with standard.
March 19, 2025Complaint survey4 violations
Inspection dates
03/19/2025
Areas reviewed
Administration and Administrative ServicesStaffing and SupervisionResident Care and Related Services
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 3/19/2025 & 3/20/2025 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: 35 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 17 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 8 Observations by licensing inspector: The LI observed residents participating in activity programs and eating lunch. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: Administration and Administrative Services, Staffing and Supervision and 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 Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov
Violations
22VAC40-73-680-C
22VAC40-73-680C Based on resident record review, the facility failed to administer medications not earlier than one hour before and not later than one hour after the facility’s standard dosing schedule.
Evidence
  1. Resident 8’s March 2025 Medication Administration Record indicated Preservision ARed Tablets , take 1 tab by mouth two times a day for supplement, prescribed on 1/23/2025 scheduled for 6:00am and 6:00pm were documented as administered at the following times: 3/8/2025 (7:51am), 3/9/2025 (9:12pm), 3/11/2024 (7:13am and 7:54pm), 3/12/2025 (7:07am), 3/13/2025 (10:23am and 7:09pm), 3/14/2024 (7:07pm), 3/15/2025 (8:08pm), 3/16/2025 (8:02pm), and 3/17/2025 (7:09am and 8:02pm).
  2. Resident 8’s March 2025 Medication Administration Record indicated Alprazolam 0.25 mg tablet , take 1 tablet by mouth twice a day at 7:00am and 7:00pm, prescribed 2/7/2025 were documented as administered at the following times: 3/15/2025 (8:08pm), and on 3/17/2025 (8:02pm).
Plan of correction
Resident Wellness Director and Resident Care Director will have weekly medication aide meetings to review compliance with the medication administration in accordance with facility Medication Management Policy. Executive Director will oversee to maintain compliance. All medication Aides will attend a 4 hour refresher course offered by facility pharmacy.
22VAC40-73-460-B
22VAC40-73-460B Based on facility record review, the facility failed to respond promptly to resident needs.
Evidence
  1. The Building Detailed Escalation Event Report (call bell history report) for Resident 9 indicates 5 instances in which it took staff more than 15 minutes to respond to the resident’s call bell at on 3/14/2025 at 12:12am (19 mins), 8:50am (29 mins), 7:17pm (29 mins) and on 3/15/2025 at 1:59am (18 mins) and at 11:48pm (60 mins).
  2. The Building Detailed Escalation Event Report (call bell history report) for Resident 10 indicates 2 instances in which it took staff over 15 minutes to respond to the resident’s call bell on 3/14/2025 at 2:56am (26 mins) and at 8:34pm (33 mins).
  3. The Building Detailed Escalation Event Report (call bell history report) for Resident 12 indicates 1 instance in which it took staff over 15 minutes to respond to the resident’s call bell on 3/15/2025 at 4:31am (69 mins).
  4. The Building Detailed Escalation Event Report (call bell history report) for Resident 11 indicates 1 instance in which it took staff over 15 minutes to respond to the resident’s call bell on 3/14/2025 at 11:04am (30 mins).
  5. The Building Detailed Escalation Event Report (call bell history report) for Resident 2 indicates 1 instance in which it took staff over 15 minutes to respond to the resident’s call bell on 3/14/2025 at 12:10pm (41 mins).
  6. The Building Detailed Escalation Event Report (call bell history report) for Resident 13 indicates 1 instance in which it took staff over 15 minutes to respond to the resident’s call bell on 3/14/2025 at 12:16pm (42 mins).
  7. The Building Detailed Escalation Event Report (call bell history report) for Resident 6 indicates 1 instance in which it took staff over 15 minutes to respond to the resident’s call bell on 3/14/2025 at 1:20pm (19 mins).
  8. The Building Detailed Escalation Event Report (call bell history report) for Resident 14 indicates 2 instances in which it took staff over 15 minutes to respond to the resident’s call bell on 3/14/2025 at 8:43pm (19 mins) and on 3/15/2025 at 9:34am (15 mins).
  9. The Building Detailed Escalation Event Report (call bell history report) for Resident 15 indicates 1 instance in which it took staff over 15 minutes to respond to the resident’s call bell on 3/15/2025 at 1:03am (24 mins).
  10. The Building Detailed Escalation Event Report (call bell history report) for Resident 17 indicates 1 instance in which it took staff over 15 minutes to respond to the resident’s call bell on 3/15/2025 at 11:17pm (102 mins).
  11. The Building Detailed Escalation Event Report (call bell history report) for Resident 4 indicates 1 instance in which it took staff over 15 minutes to respond to the resident’s call bell on 3/15/2025 at 11:47pm (42 mins).
Plan of correction
Resident Wellness Director along with the Resident Care Director will monitor response times daily of the call pendant system. Staff will be in-serviced on response times of call bells to ensure that residents needs are being met. To be overseen by the Executive Director to maintain compliance.
22VAC40-73-450-C
Based on resident record review, the facility failed to develop an Individualized Service Plan that included a written description of what services will be provided to address identified needs, and if applicable, other services, and who will provide them.
Evidence
  1. Resident 4 had a physician’s order to insert foley catheter written on 3/5/2025.
  2. Resident 4’s Individualized Service Plan developed on 12/1/2024 was not updated to include a description of needs related to the foley catheter.
Plan of correction
Resident Wellness Director along with the Resident Care Director will review care plans to ensure that all catheter care orders are included and care plans match the UAI to ensure proper care of residents. Executive Director will oversee to maintain compliance.
22VAC40-73-280-A
Based on facility records, resident records and staff interviews, the facility failed to have staff adequate in knowledge, skill and abilities and sufficient in number to provide services to attain and maintain the physical, mental and psychological well-being of each resident.
Evidence
  1. LI asked Staff 5 if there was a sufficient number of direct care staff to care for the residents, staff 5 stated: if everything flows, it is not an issue, but if a resident falls, or if a resident returns from the hospital, or if there are treatments or a family member has a question or concern we do not have a sufficient amount of direct care staff. LI asked how often the forementioned occurrences happen in a week and staff 5 stated 2-3 times a week.
  2. Staff 5 stated: there’s no way for one person to pass medications within the two-hour window, it is impossible.
  3. LI asked Staff 6 if there was enough direct care staff to care for the residents, staff 6 stated: there is no way we can get to call lights when we are helping residents that need two people to assist them. Census needs to increase before another staff member can be hired.
  4. LI asked Staff 7 if there was a sufficient number of direct care staff to care for the residents, staff 7 stated: it is debatable, some days are good and some days aren’t, there are call bell delays, we have to speed up, we can’t spend time with residents, we need to get to the next resident. Care is given, just delayed because we are caring for others (residents).
  5. LI asked Staff 8 if there was a sufficient number of direct care staff to care for the residents, staff 8 stated: No, the girls are running around, medications are not passed timely, too many residents to pass medications to.
  6. Between 3/8/2025-3/19/2025, Resident 8’s March Medication Administration Record indicated she received 15 prescribed medications after facility’s dosing schedule.
  7. There were 20 instances, according to the Building Escalation Detailed Event Report (call bell history report) for 3/14/2025-3/15/2025, in which it took staff more than 15 minutes to respond to the resident’s call bell
Plan of correction
Resident Care Director and Resident Wellness Director will review schedules to maintain staff that are adequate in knowledge and with skills to provide and maintain the physical, mental and psychosocial well being of each resident and to maintain compliance. Executive Director to oversee to ensure compliance being maintained.
November 19, 2024Complaint survey0 violations
Inspection dates
11/19/2024
Areas reviewed
Resident Care and Related Services
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/19/2024 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: 34 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: LI observed residents eating lunch and participating in activity programs. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the (allegation(s)/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 Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
October 23, 2024Complaint survey0 violations
Inspection dates
10/23/2024
Areas reviewed
Resident Care and Related Services
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/23/2024 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: 34 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: 4 Number of interviews conducted with staff: 2 Observations by licensing inspector: LI observed residents eating lunch and participating in activity programs. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation 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 Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
October 23, 2024Complaint survey0 violations
Inspection dates
10/23/2024
Areas reviewed
Resident Care and Related ServicesPersonnel
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/23/2024 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: 34 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 20 Number of staff records reviewed: 0 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 3 Observations by licensing inspector: LI observed residents eating lunch and participating in activity programs. Additional Comments/Discussion: 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. 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 Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
October 23, 2024Complaint survey0 violations
Inspection dates
10/23/2024
Areas reviewed
Resident Care and Related Services
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/23/2024 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: 34 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: LI observed residents eating lunch and participating in activity programs. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. 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 Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
October 9, 2024Inspection8 violations
Inspection dates
10/09/2024
Areas reviewed
Administration and Administrative ServicesPersonnelStaffing and SupervisionAdmission, Retention and Discharge of ResidentsResident Care and Related ServicesResident Accommodations and Related ProvisionsBuilding and GroundsEmergency PreparednessBackground Checks for Assisted Living FacilitiesSworn Statement
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: October 9th & 10th, 2024 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: 35 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: 1 Number of interviews conducted with staff: 5 Observations by licensing inspector: LI observed residents eating meals and participating in activity programs. 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 Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov
Violations
22VAC40-90-40-B
Based on staff records review, the facility failed to obtain a criminal history record report on or prior to the 30th day of employment for each employee.
Evidence
  1. Staff 1, hired 2/1/2024, had a criminal background check on file dated 3/8/2024.
  2. Staff, 2, hired 12/18/2023, had a criminal background check on filed dated 3/7/2024.
  3. Staff 3, hired 5/27/2024, had a criminal background check on filed dated 10/9/20204.
Plan of correction
Resident Care Director with oversight of the Executive Director will ensure that Criminal Background checks are obtained within 30 days of hire. This will happen immediately and moving forward. Executive Director will provide oversight to maintain compliance.
22VAC40-73-260-C
Based on observation and staff interview, the facility failed to post in the facility a listing of all staff who have current certification in first aid or CPR.
Evidence
  1. During facility tour on the day of inspection did not see a listing of staff who had first aid or CPR certification.
  2. Staff 4 said there was not a listing of staff with first aid or CPR certification posted in the facility.
Plan of correction
Current up to date CPR/First Aid certification to be posted monthly with accurate information at the facility. Resident Care Director and or Resident Wellness director will update certification to maintain postings that are current and up to date with the Executive Director providing oversight for compliance.
22VAC40-73-560-F
Based on observation, the facility failed to ensure that all records are treated with confidentiality and that information shall be made available only when needed for care of the resident.
Evidence
  1. During tour of the facility on the day of inspection the LI observed binders on two medication carts that were not supervised that contained resident information.
  2. Picture evidence.
Plan of correction
Resident Wellness Director will in-service staff on confidentiality and med tech best practices and confidentiality and the proper handling of confidential information. Executive Director to provide oversight to maintain compliance.
22VAC40-73-550-G
Based on resident record review, the facility failed annually review the rights and responsibilities with each resident or his legal representative.
Evidence
  1. Resident 3 and 4 did not have an annual review documented in their resident record.
Plan of correction
All residents will have annual review of Resident Rights with proper documentation to remain in residents charts. Resident Care Director will ensure that this is completed and documented in residents chart with oversight by Executive Director.
22VAC40-73-50-A
Based on resident record review, the facility failed to disclose whether or not the facility has an on-site emergency electrical power source for the provision of electricity during an interruption of the normal electric power supply.
Evidence
  1. Resident 1, admitted 2/28/2024, and Resident 4 admitted,10/1/2024, had a Disclosure Statement on file that did not include information regarding the facility’s on-site emergency electrical power source.
Plan of correction
Executive Director will review the Disclosure Statement for facility and will ensure that the most current form is being used and it is notated on the Disclosure Statement signed by residents whether or not the facility has an onsite emergency electrical power source for compliance.
22VAC40-73-620-A
Based on facility record review, the facility failed to have oversight at least every six months of special diets by a dietician or nutritionist for each resident who has such a diet.
Evidence
  1. The last Oversite of Special Diets on file was conducted on 11/7/2023.
Plan of correction
Dining Services Director will maintain records of Dietary oversight of special diets and ensure that they are completed every 6 months with the oversight of the Executive Director to maintain compliance.
22VAC40-73-680-C
Based on resident record review, the facility failed to administer medications not earlier than one hour before and not later than one hour after the facility’s standard dosing schedule, except those drugs that are ordered for specific times, such as before, after, or with meals.
Evidence
  1. Resident 1 who was prescribed Acetaminophen 500 mg caplet on 2/8/2024 to be administered at 8am was administered the medication at 9:21am on 8/28/2024.
  2. Resident 1 who was prescribed Lisinopril 20 mg tab on 2/28/2024 to be administered at 8am was administered the medication at 9:12am on 9/28/2024 and at 9:08am on 9/20/2024.
  3. Resident 2 who was prescribed Acidophilus Probiotic tablet on 9/19/2024 for 7am was administered the medication at 9:23am on 9/21/2024, at 11:44am on 8/21/2024, at 11:43am on 8/11/2024 and at 8:24am on 8/7/2024.
  4. Resident 2 who was prescribed Melatonin 10 mg tablet on 5/30/2024 for 6pm was administered the medication at 7:04pm on 10/8/2024, at 7:35pm on 10/6/2024, at 8:06pm on 10/5/2024, at 7:22pm on 9/21/2024 and at 7:20pm on 9/2/2024.
  5. Picture evidence.
Plan of correction
Resident Wellness Director will review passing times of all residents to ensure there is enough allotted time for medications to be passed on time and adjust accordingly with Pharmacy. Executive Director will provide oversight to ensure compliance with the VA Board of Nursing Medication Administration guidelines and will review facility medication administration policy and review with all medication aides.
22VAC40-73-450-C
Based on observation, staff interview and resident record review, the facility failed to identify on the Individualized Service Plan (ISP) the resident’s needs.
Evidence
  1. LI observed adaptive cups with handles on the dining room table prior to lunch being served. LI asked which residents were using the adaptive cups and identified Resident 1.
  2. The ISP on file for Resident 1, dated 8/4/2024, did not identify the use or need for an adaptive cup.
Plan of correction
Resident Wellness Director along with the Resident Care Director will obtain orders for all residents that need adaptive devices and will ensure proper documentation on Care Plan and review with families. Executive Director will offer oversight to maintain compliance.
September 18, 2024Complaint survey6 violations
Inspection dates
09/18/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESSARTICLE 1 – SUBJECTIVITY63.2- (1) GENERAL PROVISIONS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION
Comments
Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 06/26/2024 regarding allegations in the area(s) of medication/medical issues and records. Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/18/2024, 10:00 AM to 7:00 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: 32 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 2 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 6 Number of interviews conducted with collateral contacts: 2 Observations by licensing inspector: Medication Cart, Activities, Building Tour, Wanderguard Unit. Additional Comments/Discussion: A review of all prescribed narcotics was completed during inspection. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard (s) or law. However, violation(s) not related to the complaint but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Violations
22VAC40-73-450-F
Based on resident record review and staff interview, the facility failed to ensure Individualized Service Plans were reviewed and updated as needed for a significant change of a resident’s condition performed by a staff person in conjunction with the resident.
Evidence
  1. Resident 6’s record contained a DNR order signed on 04/29/2024 by Resident 6 and the resident’s physician.
  2. Resident 6’s record contains an ISP signed on 02/12/2024 with Staff 6 under the development of the plan.
  3. Resident 6 signed the ISP additionally for under the service plan review or update with no listed date or facility staff signature.
  4. Resident 6’s ISP did not contain the DNR order.
  5. Staff 1 and 2 confirmed the DNR order was not on the ISP.
Plan of correction
Resident Wellness Director along with the Resident Care Director will ensure that Care Plans are updated and presented to family for signature with any significant resident care changes and or code status updates. Executive Director to provide oversight to ensure compliance.
22VAC40-73-1040-A
Based on resident record review, direct observation, and staff interview, the facility failed to ensure before the resident movement is restricted, behavioral observations or other
Evidence
  1. showing that the resident cannot recognize danger or protect their safety is reflected in the residents record. Evidence:
  2. The facility serves a mixed population, and does not have a safe, secure unit.
  3. During the onsite tour of the facility on 09/18/2024 with Staff 1, the LI observed a closed hallway door leading to resident rooms. Staff 1 stated this hallway is considered the “Wanderguard Unit.” Staff 1 stated that while the Wanderguard Unit remains unlocked, Resident 2 and Resident 4 wear pendants that lock both the unit and front door when Residents 2 or 4 come near so that they cannot leave the unit or premises. Staff 1 stated that Resident 3 was admitted with an ankle monitor that tracks movement limiting the ability to leave the facility.
  4. During an interview with Staff 3 on 09/18/2024 around 10:45 AM, Staff 3 stated that residents residing on the Wanderguard Unit were unable to leave without family.
  5. Resident 2’s Individualized Service Plan (ISP), dated 07/05/2024, stated the following under the psycho-social focus— “Resident will remain on the Memory Care Unit with staff monitoring or on assisted living within line of sight of staff or family/responsible party.”
  6. Resident 4’s ISP, dated 07/12/2024, stated the following under the psychosocial focus— “Resident resides in the Memory Care Unit. Resident will remain on the Memory Care Unit or in the line of sight of staff or family/responsible party at all times when off the unit.”
  7. During the preliminary exit on 09/18/2024, Staff 1 confirmed that there was no documentation regarding behavioral reasons to as why movement was limited on the Wanderguard Unit.
  8. Staff 1 stated that staff can take residents on a walk or sit with them outside, but they cannot leave without staff. Staff 1 confirmed if a staff member is not available, they cannot leave.
  9. Staff 1 confirmed that they were not sure why Staff 3 thought they were not allowed to take residents out of the unit.
  10. Photo evidence obtained.
Plan of correction
Doors in the Wander Guard Unit leading to the outside are equipped with a security monitoring of residents with serious cognitive impairment that consists of door alarms, security bracelets that are part of an alarm system, and a delayed egress mechanism. Resident Wellness Director along with Resident Care Director will ensure that before a residents movement is restricted, behavioral observations or other evidence showing that the resident cannot recognize danger or protect their safety is reflected in the residents record. This will also be documented on the residents Individual Service Plan. The community does have a secured outdoor area for the residents use and/or will provide direct care staff supervision while residents with serious cognitive impairments are outside. Weather permitting, residents with serious cognitive impairments shall be reminded of the opportunity to be outdoors on a daily basis. Resident Wellness Director along with Resident Care Director will In-Service all staff members in the following areas: • Doors in the Wander Guard Unit leading to the outside. • The community does have a secured outdoor area for the residents use and/or will provide direct care staff supervision while residents with serious cognitive impairments are outside. • Weather permitting, residents with serious cognitive impairments shall be reminded of the opportunity to be outdoors on a daily basis. Executive Director will provide oversight to ensure compliance.
22VAC40-73-860-I
Based on direct observation and staff interview, the facility failed to ensure that cleaning supplies and other hazardous materials were stored in a locked area.
Evidence
  1. During the onsite tour of the facility on 09/18/2024 with Staff 1, Staff 1 stated that they have one hallway that is considered the “Wanderguard Unit” for residents diagnosed with dementia.
  2. In the kitchen area of the Wanderguard Unit, an open pumpkin carving kit with serrated knives were observed in unlocked cabinets.
  3. In the activity office adjacent to the dining area of the Wanderguard Unit, three (3) bottled of Greasecutter Plus, two (2) bottles of Lime-A-Way, and two (2) bottles of Febreeze room spray were observed on the cabinet while the door was open.
  4. Licensing Inspector observed a purse placed on the floor inside the doorless closet in the hallway near the main dining room that contained prescription medication and cigarettes.
  5. Staff 2 confirmed that the bag belonged to a staff member.
  6. Photo evidence obtained.
Plan of correction
The Maintenance Director will maintain all chemicals in a locked area at all times to ensure safety of residents. Executive Director to provide oversight to ensure compliance. The Resident Care Director along with Resident Wellness Director will ensure that all Team members personal belongings are kept in an area secured that residents do not have access to. Executive Director to provide oversight to ensure compliance. Life Enrichment Director will maintain and keep all supplies that could potentially be dangerous or cause harm to residents with cognitive impairment in an area that is not accessible to residents. Executive Director to provide oversight to ensure compliance.
22VAC40-73-290-B
Based on direct observation and staff interview, the facility failed to ensure the name of the current person in charge was posted in a place that was conspicuous to residents and the public.
Evidence
  1. During the tour of the facility including the hallways, kitchen, lobby, and activity areas, the name of the person in charge was not posted in a place that was conspicuous to residents and the public.
  2. Staff 1 confirmed that the information had been taken down due to staffing changes and needing to be re-typed.
Plan of correction
The Resident Care Director along with the Resident Wellness Director will ensure that Staff in Charge is posted daily to reflect the correct information. In the event changes occur it will be updated and replaced as soon as completed. Executive Director will provide oversight to ensure compliance.
22VAC40-73-560-F
Based on direct observation, staff interviews and resident record review, the facility failed to ensure that all records were treated confidentially.
Evidence
  1. The LI observed a posting of residents with an active Do Not Resuscitate (DNR) order featuring the first and last name of 20 residents in a doorless closet in the hallway near the main dining area.
  2. The LI observed a posting of residents needing two-person assist featuring the first and last name of eight (8) residents in a doorless closet in the hallway that leads from the resident rooms and lobby to the main dining area.
  3. Staff 1 and 2 confirmed this was the staff wellness room.
  4. Photo evidence obtained.
Plan of correction
The Resident Care Director along with Resident Wellness Director will ensure that all postings to include DNR’s will be posted in an area that is compliant to HIPAA and confidentiality is maintained. Executive Director to provide oversight to ensure compliance.
22VAC40-73-1070-B
Based on observation, the facility failed to ensure that when there are indications that ordinary objects may be harmful to a resident with a serious cognitive impairment, objects shall be inaccessible to the resident except under staff supervision. 1. During the onsite tour of the facility on 09/18/2024 with Staff 1, Staff 1 stated that they have one hallway that is considered the “Wanderguard Unit” for residents diagnosed with dementia. 2. In the kitchen area of the Wanderguard Unit, an open pumpkin carving kit with serrated knives were observed in unlocked cabinets. 3. Photo
Evidence
  1. taken.
Plan of correction
Resident Wellness Director along with Resident Care Director and Life Enrichment Director will ensure that any object that could potentially cause harm to residents with serious cognitive impairment be kept in a locked cabinet or in an area without access to residents. Executive Director to provide oversight to ensure compliance.
February 1, 2024Complaint survey4 violations
Inspection dates
02/01/2024
Areas reviewed
Resident Care and Related Services
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 2/1/2024 & 02/08/2024 9:30am-1:30pm The acknowledgement of inspection for was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 1/10/2024 regarding allegations in the area of personnel. Number of residents present at the facility at the beginning of the inspection: 33 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegations of non-compliance with standards or law, and violations were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be founds 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 the applicable standards 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 VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov
Violations
22VAC40-73-640-A
Based on resident record review and staff interview, it was determined that the facility staff failed to adhere to the medication management plan.
Evidence
  1. Two nursing staff failed to document the narcotic counts for residents in care of the change of shift as required.
  2. The December 2023 Controlled Drug Count Sheet was missing two person signatures for 15 out of 31 days on day shift; 8 out of 31 days on the evening shift; and 18 out of31 days for night shift.
  3. The January 2024 Controlled Drug Count Sheet was missing two person signatures for 5 out of 31 days for day shift; 5 out of 31 days for evening shift, and 14 out of 31 days for night shift.
  4. The December 2023 and January 2024 Controlled Drug Count Sheet were missing two person signatures for all three shifts for 12 out of 31 days for January 2024.
Plan of correction
Resident Wellness Director will review The Warren medication administration plan with all med techs to ensure proper documentation of all Controlled Drug Counts sheets requiring two medication aide/nurse signatures at each shift/staff change. Resident Wellness Director will monitor for accuracy and consistency of Narcotic Count Sheets to maintain compliance. Executive Director will provide oversight to ensure compliance.
22VAC40-73-680-C
Based on direct observation of Licensing Inspector 2, the facility failed to administer physician ordered medications within the timeframe as required.
Evidence
  1. Resident A received 12 pills from the medication aide at 10:03am on 2/1/2024 though the medication was ordered for 8am.
  2. Resident B received 12 pills from the medication aide at 9:55am on 2/1/2024 though the medication was ordered for 8am.
Plan of correction
Wellness Director will review late medications with all medications aides and ensure that proper documentation and notification to physicians that is consistent with the Standards of Practice outlined in the curriculum approved by the Virginia Board of Nursing for Medication Aides. Executive Director will provide oversight to ensure compliance
22VAC40-73-680-D
Based upon a review of records, the facility failed to ensure that medications were administered in accordance with the physician's or other prescriber's instructions.
Evidence
  1. Resident A is scheduled to receive one tablet of Hydrocodone/APAP at approximately 6am, 10am, 2pm and 6pm daily.
  2. According to the Controlled Drug Administration Sheet on 1/8/2024, Resident A received Hydrocodone/APAP, one tablet at approximately the following times: 5:06am, 9:00am, 10:43am, 1:37pm and 6pm.
  3. According to the Controlled Drug Administration Sheet on 1/9/2024, Resident A received Hydrocodone/APAP one tablet at approximately the following times: 6am, 10:26am, 1:12pm, 5:27pm and 7:37pm.
Plan of correction
Resident Wellness Director or designee will ensure that medications are administered in accordance with the physician’s instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. • New medication orders and/or refills will be provided within 24 hours. • Medication will be available at time of administration. • Resident Wellness Director or designee will monitor medication pass quarterly on medication aides. • Licensed nursing staff will review the electronic medication administration records (EMAR’s) routinely for accuracy, correctness and proper documentation to include holes or omissions in EMAR’s. Executive Director will provide oversight to ensure compliance.
22VAC40-73-450-D
Based upon a record review and staff interview conducted during a complaint inspection that took place of 02/01/2024 and 02/08/2024, the facility failed to have a documentation to show the coordinated plan of care on the Individualized Service Plan (ISP) between the facility and the Hospice agency for one of two records.
Evidence
  1. Resident A's ISP, dated 10/20/2023, had no documentation of a coordinated plan of care and services required between the facility and the Hospice agency.
Plan of correction
Resident Wellness Director with the assistance of the Resident Care Director or designee will review all current Hospice Resident ISP’s for accuracy and will ensure that all ISP’s include the services form the plan of care that will be provided by the Hospice company for those residents and update upon changes and yearly. Executive Director will provide oversight to ensure compliance.
February 1, 2024Complaint survey4 violations
Inspection dates
02/01/2024
Areas reviewed
Staffing and SupervisionResident Care and Related Services
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 2/1/2024, 9:30am-1:30pm The acknowledgement of inspection for was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 1/11/2024 regarding allegations in the area of staffing and supervision and resident care and related services. Number of residents present at the facility at the beginning of the inspection: 33 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 17 Number of staff records reviewed: 0 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegations of non-compliance with standards or law, and violations were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be founds 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 the applicable standards 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 VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov
Violations
22VAC40-73-440-A
Based upon a review of records, the facility failed to ensure that all residents of assisted living facilities were assessed using the Uniform Assessment Instrument (UAI) at least annually for eight out of seventeen residents.
Evidence
  1. Resident 2 last UAI was completed 12/22/2022
  2. Resident 3 last UAI was competed 12/15/2022
  3. Resident 5 last UAI was completed 12/7/2022
  4. Resident 6 last UAI was completed 1/10/2023
  5. Resident 7 last UAI was completed 1/19/2023
  6. Resident 8 last UAI was completed 1/27/2023
  7. Resident 14 last UAI was completed 12/15/2022
  8. Resident 15 last UAI was completed 12/25/2022
Plan of correction
Resident Wellness Director with the support of the Resident Care Director will ensure that all residents have current UAI (Uniform Assessment Instrument) upon admission and is updated yearly or upon changes. An audit of all current residents will be completed to ensure compliance and accuracy. Executive Director will provide oversight to ensure compliance.
22VAC40-73-280-A
Based upon review of records and interviews, the facility has failed to ensure staff sufficient in numbers to provide services to attain and maintain the physical, mental and psychosocial well-being of each resident as determined by resident assessments and individualized service plans for the evening shift (2pm to 10pm) and the overnight shift (10pm to 6am).
Evidence
  1. Interview with Collateral Contact 1 conducted on 2/1/2024 at approximately 10:00am revealed that the facility staff two direct care staff and one medication aide for every shift.
  2. The staff scheduled for January 2024 documented that there are consistently tow direct care staff and one medication aide on the evening and overnight shifts.
  3. According to ISPs, Residents 4, 5, 10 and 13 require mechanical help, physical assistance - human help with transferring. Resident 5 is transferred with a Hoyer lift that requires two people to perform the task. Resident 12 requires mechanical help, physical assistance-supervision with transferring.
  4. Collateral Contact 2 interviewed on 2/1/2024 at approximately 1:00pm revealed that Resident 14 often receives assistance from family members with changing incontinence products. Collateral Contact 2 commented that "not enough staff" is the biggest area of concern. Collateral Contact 2 revealed that Resident 14 has been found sitting in wet incontinence products for what appears to have been a long period of time. According to Collateral Contact 2, staff have asked family members to help with changing Resident 14's incontinence products.
Plan of correction
Resident Wellness Director with support of Resident Care Director will ensure that there is sufficient staffing for the needs of the facility to maintain the physical, mental and psychosocial well-being of each resident. This will be done by reassessment of all current residents to capture those care levels accurately. Care Plans will be updated to reflect. Staffing will be adjusted with resident need. (Staffing was adjusted on the day of inspection) Executive Director will provide oversight to ensure compliance.
22VAC40-73-450-A
Based upon a review of records, the facility failed to ensure that the comprehensive individualized service plans were completed within 30 days after admission for two of seventeen residents.
Evidence
  1. Resident 16 was admitted on 11/16/2023. No ISP was found in her record.
  2. Resident 17 was admitted on 11/28/2023. No ISP was found in her record.
Plan of correction
Resident Wellness Director with the support of the Resident Care Director will ensure that all residents will have an Individualized Service Plan completed upon admission and a comprehensive Plan will be developed within 30 days of move in. A review of all charts will be conducted to ensure that all residents have a current up to date Individualized Service Plan reflecting current needs Executive Director will provide oversight to ensure compliance
22VAC40-73-450-F
Based upon a review of records, the facility failed to ensure that the individualized service plans (ISPs) were updated once every 12 months for nine out of seventeen residents.
Evidence
  1. Resident 2 last ISP was updated 3/22/2022
  2. Resident 3 last ISP was updated 3/15/2022
  3. Resident 5 last ISP was updated 3/7/2022
  4. Resident 6 last ISP was updated 4/11/2022
  5. Resident 7 last ISP was updated 4/16/2022
  6. Resident 8 last ISP was updated 4/30/2022
  7. Resident 9 last ISP was updated 4/30/2022
  8. Resident 14 last ISP was updated 12/15/2022
  9. Resident 15 last ISP was updated 1/4/2023
Plan of correction
Resident Wellness Director with assistance of the Resident Care Director or designee will review all current ISP’s for accuracy and will ensure that all ISP’s are updated yearly and upon changes. Executive Director will provide oversight to ensure compliance.
February 1, 2024Complaint survey2 violations
Inspection dates
02/01/2024
Areas reviewed
Personnel
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: 2/1/2024, 9:30am-1:30pm The acknowledgement of inspection for was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 1/16/2024 regarding allegations in the area of personnel. Number of residents present at the facility at the beginning of the inspection: 33 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of staff records reviewed: 2 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegations of non-compliance with standards or law, and violations were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be founds 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 the applicable standards 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 VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov
Violations
22VAC40-73-260-A
Based on a review of records, the facility failed to ensure that each direct care staff member without current certification in first aid received certification in first aid within 60 days of employment for one of two staff records.
Evidence
  1. Staff 1 was hired as direct care aide on 11/20/23. The staff record for Staff 1 did not contain first aid certification.
Plan of correction
Resident Wellness Director with the support of the Resident Care Director will ensure that all team members are enrolled and receive First Aide Certification within their first 60 days of employment. Executive Director will provide oversight to ensure compliance.
22VAC40-73-250-C
Based on a review of records conducted during complaint inspection on 2/1/2024, the facility failed to maintain in the staff record a sworn disclosure statement for one of two staff records.
Evidence
  1. No sworn disclosure statement was found in the record for Staff 1 who was hired on 11/20/2023.
Plan of correction
Resident Care Director with the support of the Executive Director will conduct an audit of all current staff charts for disclosure statement completion and ensure that all new staff hired, moving forward will complete the sworn disclosure statement as part of the new hire paperwork. Executive Director will provide ongoing oversight to ensure compliance.
February 1, 2024Complaint survey0 violations
Inspection dates
02/01/2024
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: LI Eddy and LI Lunceford entered the facility at 9:20 am on 2/1/2024 and exited at 1:30 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 1/11/2024 regarding allegations in the area(s) of personnel and resident care and related services. Number of residents present at the facility at the beginning of the inspection: 33 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Additional Comments/Discussion: 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. 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 Jamie Eddy, Licensing Inspector at (703) 479-5247 or by email at jamie.eddy1@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
December 20, 2023Complaint survey0 violations
Inspection dates
12/20/2023
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL
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: LI entered the facility at 10:20 am on 12/20/2023 and exited at 12:00 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 11/24/2023 regarding allegations in the area(s) of general provisions, administration and administrative services, and personnel. Number of resident records reviewed: 7 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 0 Observations by licensing inspector: Additional Comments/Discussion: 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. 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 Jamie Eddy, Licensing Inspector at (703) 479-5247 or by email at jamie.eddy1@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
November 8, 2023Complaint survey3 violations
Inspection dates
11/08/2023
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: LI entered the facility at 8:45 am on 11/8/2023 and exited at 12:55 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 (10/26/2023 regarding allegations in the area(s) of general provisions, administration and administrative services, and resident care and related services. Number of residents present at the facility at the beginning of the inspection: 39 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s); 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 Jamie Eddy, Licensing Inspector at (703) 479-5247 or by email at jamie.eddy1@dss.virginia.gov
Violations
22VAC40-73-680-D
Based on a review of records during a complaint inspection on 11/8/2023, the facility failed to ensure that medications were administered in accordance with the physician’s or other prescriber’s instructions.
Evidence
  1. Resident 1 (R1) has a signed physician’s order to receive Clonazepam 1mg three times a day.
  2. The Controlled Drug Administration Sheet for September 2023 for R1 documents that Clonazepam was not administered to R1 on: 9/2/2023 at approximately 2 pm, on 9/4/2023 at approximately 10:00 pm; 9/9/2023 at approximately 2 pm; and 9/20/2023 at approximately 10 pm.
  3. According to documentation on the September 2023 MAR for Resident 2, on 10/18/2023 the 2 pm scheduled dose of Hydrocod/APAP “medication was not given, and dose was missed.”
Plan of correction
Resident Care Director and or designee will ensure the medication refresher that is scheduled by 11/30/2023 that is consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing on documentation and medication passing be completed. Executive Director will provide oversight to ensure compliance.
22VAC40-73-640-A
Based upon a review of records, the facility failed to follow their medication management policy to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes.
Evidence
  1. According to the facility’s medication management plan under the narcotic section on page 5, “Two community certified staff members who are authorized to administer medications will complete a controlled drug count at the beginning and ending of each shift.”
  2. The controlled drug count sheets reviewed for November 2023 did not document that two people completed the controlled drug count at the beginning and ending of each shift.
Plan of correction
Resident Wellness Director with support of Resident Care Director and/or designee will ensure each Medication Aide is in-serviced on Inspirit Senior Living Medication Management Policy for counting off medication carts at the beginning and ending of each shift, documenting in the shift sign off sheet and ensuring that two registered medication aides complete the count. Executive Director will provide oversight to ensure compliance.
22VAC40-73-680-I
Based on interview with the administrator, the facility failed to ensure the Medication Administration Record (MAR) included initials of direct care staff administering the medication.
Evidence
  1. During an interview at approximately 12:40 pm on 11/8/2023, the administrator reported: • On the MAR for 9/20/2023, no initials of direct care staff administering medications were entered onto the MAR for the 10pm dosage of Clonazepam for R1 on 9/20/2023. • The September 2023 MAR was altered on 10/23/2023, by a staff person, who is not direct care staff at The Warren, to reflect that Clonazepam had been given at approximately 10 pm on 9/20/2023 to R1 and the initials entered on the MAR were for a direct care staff member who was not working that day and time. • The administrator confirmed that when it was discovered that it was a different staff person who was working on 9/20/2023 at approximately 10 pm, the initials on the MAR were changed again to those of the direct care staff person who was listed on the work schedule for that day and time.
Plan of correction
Resident Care Director and or designee will ensure understanding for documenting in the MAR when medications are administered or reporting if meds not given as outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. Resident Care Director and or designee will ensure that any outside person coming into provide an oversite will meet to discuss concerns of findings from the audit before amending any records. Executive Director will provide oversight to ensure compliance.
October 23, 2023Inspection2 violations
Inspection dates
10/23/2023
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: LI entered the facility at 1:10 pm on 10/23/2023 and exited at 2:45 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 (10/19/2023) 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: 38 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 0 Observations by licensing inspector: Additional Comments/Discussion: 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 Jamie Eddy, Licensing Inspector at (703) 479-5247 or by email at jamie.eddy1@dss.virginia.gov
Violations
22VAC40-73-680-D
Based upon a review of records, the facility failed to ensure that medications shall be administered in accordance with the physician’s or other prescriber’s instructions.
Evidence
  1. The October Medication Administration Records for Residents #1, #2, and #3 indicated that on 10/18/2023, the residents did not receive medications ordered by physicians to be administered at approximately 2:00pm.
Plan of correction
Resident Wellness Director will begin employment on 11/6/2023 and will provide a four-hour medication refresher that is consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing on documentation and medication passing. Executive Director will provide oversight to ensure compliance.
22VAC40-73-560-F
Based upon observations made during a focused monitoring inspection conducted on 10/23/2023, the facility failed to ensure that all records were treated confidentially.
Evidence
  1. At approximately 1:20 pm and 2:35 pm, Licensing Inspector (LI) observed the Narcotic Logbook for the 200 Hall lying on top of the medication cart that was in the 200 hallway.
Plan of correction
Resident Wellness Director with support of Resident Care Director and/or designee will ensure each Medication Aide is in-serviced on confidentiality to maintain compliance and protect resident information. Executive Director will provide oversight to ensure compliance.
October 3, 2023Inspection3 violations
Inspection dates
10/03/2023
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESSARTICLE 1 – SUBJECTIVITY32.1 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 LICENSE
Technical assistance
Please submit your renewal application 30 days prior to the expiration of the current license. A new license cannot be issued without a renewal application.
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: LI entered the facility at 8:30 am on 10/3/2023 and exited at 12:45 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: 37 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 4 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: LI observed medication administration. LI walked the physical plant. LI observed residents eating 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 Jamie Eddy, Licensing Inspector at (703) 479-5247 or by email at jamie.eddy1@dss.virginia.gov
Violations
22VAC40-73-260-A
Based upon record review, the facility failed to ensure that each direct care staff maintained current certification in first aid for two of the four staff whose records were reviewed.
Evidence
  1. The record for Staff #1 contained a first aid certification that expired 4/2023.
  2. The record for Staff #2 did not contain certification of first aid.
Plan of correction
Resident Wellness Director or designee with support of Resident Care Director and/or designee will ensure each direct care staff member maintain current certification in first aid and obtain within first 60 days of employment. An audit of all personnel files will be completed. Facility staff that are found out of compliance will be scheduled for the next available class. Executive Director will provide oversight to ensure compliance.
22VAC40-73-700-2
Based upon observation, the facility failed to ensure the posting of a “No Smoking-Oxygen in Use” sign in a room where oxygen tanks were present.
Evidence
  1. On 10/3/2023 LI observed oxygen tanks and an oxygen concentrator in room 206.
  2. LI did not observe a “No Smoking-Oxygen in Use” posted on the door of room 206.
Plan of correction
Executive Director or Resident Care Director will ensure that all residents that require Oxygen Therapy have posted No Smoking signage outside of rooms in accordance with State Regulations. Executive Director will review charts to ensure proper postings. Maintenance Director and Resident Wellness Director will be made aware of need for signs at resident move in. Executive Director will provide oversight to ensure proper postings and state compliance.
22VAC40-73-450-E
Based upon record review, the facility failed to ensure that Individualized Service Plans (ISPs) were signed and dated by the resident or his legal representative for three out of six residents.
Evidence
  1. On 10/3/2023 Licensing Inspector (LI) reviewed the records of Resident #1, #4, and #6 and observed that the ISPs were not signed by either the resident or his or her designee.
Plan of correction
Resident Wellness Director or designee will review all current ISPs and schedule meeting to have signed by family and residents. Resident Wellness Director or designee will ensure that all ISPs are signed by family and residents upon completion. Executive Director will provide oversight to ensure compliance.
August 28, 2023Complaint survey0 violations
Inspection dates
08/28/2023
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: LI entered the facility at 11:30 am on 8/28/2023 and exited at 1:35 pm on 8/28/2023. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 8/24/2023 regarding allegations in the area(s) of resident care and related services. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: Additional Comments/Discussion: 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. 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 Jamie Eddy, Licensing Inspector at (703) 479-5247 or by email at jamie.eddy@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
April 13, 2023Inspection0 violations
Inspection dates
04/13/2023
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS32.1 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 PROCESS
Technical assistance
Discussion that files previously closed remain as the property of Greenfield who will need to find storage for off the premises once the sale is complete.
Comments
An initial inspection was conducted on 4/13/2023 due to a change in ownership of the facility. The facility had previously had a full renewal inspection on 3/13/23 at which time they earned a three year license. Current census at the facility is 32. There was documentation that families, guardians or other representatives had been notified as per the standards of the forthcoming change in ownership. As per the application administrative and facility staff will not change. With a change of ownership a conditional license, which is a license for 6 months, is issued. This inspector reviewed with staff the basic changes that would need to occur during the next six months: new signed agreements and disclosures, new background checks and sworn disclosures, all contracts need to be updated and in general everything needs to be changed to the new name and owners. As required with a conditional license the facility will have site visits every sixty days until the renewal is due. The agreements, disclosures and background checks should be completed in the first 60 days. All current residents and staff will now have a new admission and hire date respectively. No change in the certificate of occupancy is required as there is no capacity change. The fire inspection was completed 8/23/22 and the health inspection 12/30/22. Following completion of the transfer of ownership the facility will seek inspection in the new name of the facility. No outstanding physical plant issues identified. Thank you to staff and residents for your cooperation during this initial inspection process. Should you have any concerns or questions contact Sharon DeBoever, licensing inspector at (540) 292-5930 or email at sharon.deboever@dss.virginia.gov. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.