Virginia DSS · Assisted Living Facility

Sunrise of Vienna

📍 374 Maple Avenue West, Vienna, VA, 22180

ID 49697One Year licenseActive
9
Inspections
On record
7
With violations
Visits that cited something
2
Clean visits
Nothing cited
47
Violations cited
Individual findings
41
Standards cited
Distinct rules
3
Complaint visits
Prompted by a complaint

Sunrise of Vienna was inspected 9 times between July 31, 2023 and December 18, 2025 by the Virginia Department of Social Services. 7 of those visits ended with violations cited and 2 with none. Across that history VDSS cited 47 violations under 41 distinct standards. 3 inspections were prompted by a complaint.

A violation is a licensing standard - a rule in the Virginia Administrative Code - that the inspector found the facility was not meeting. Each is shown with the evidence the inspector recorded and, where VDSS publishes it, the facility's own plan of correction.

Every inspection listed here is currently published on the VDSS site.

Provider Information

Facility type
Assisted Living Facility
License type
One Year
License expires
02/02/2027
Administrator
Auria Kharazmi
Licensing inspector
Nina Wilson
Inspector phone
(703) 635-6074
Approved for
Assisted Living · Non-Ambulatory · Special Care Unit

Inspection History

9

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

December 18, 2025Inspection22 violations
Inspection dates
12/18/2025, 12/19/2025
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 IMPAIRMENTS
Technical assistance
Licensing inspector (LI) reviewed the following standards with the facility: 22VAC40-73-440, 22VAC40-73-200
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: 12/18/2025 10:24 AM Time out: 6:40 AM 12/19/2025 Time in: 12:25 PM Time out: 3:02 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: 69 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Number of staff records reviewed: 5 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: Licensing inspector observed residents entering and exiting the facility for community outings, residents participating in scheduled activities, residents dining for lunch and dinner, and residents interacting with peers and staff. 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 Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov.
Violations
22VAC40-73-680-K
Based on resident record review and staff interview, the facility failed to ensure that the use of PRN medications was prohibited, unless one or more of the following conditions exist: medication aides administer the PRN medication when the facility has obtained from the resident’s physician or other prescriber a detailed medication order. The order should include symptoms that indicate the use of the medication, exact dosage, the exact time frames the medication is to be given in a 24-hour period, and directions as to what to do if symptoms persist.
Evidence
  1. Resident 1’s December Physician Order Sheet indicated that they were prescribed Levalbuterol Tartrate Inhalation 45 MCG (2 puff inhale orally every 4 hours as needed for wheezing/sob) and Midodrine HCI 5 MG (1 tablet by mouth every 8 hours as needed for hypotension SBP less than 100). Resident 1’s PRN medication orders, Levalbuterol Tartrate Inhalation 45 MCG and Midodrine HCI 5 MG did not include directions as to what to do if symptoms persist.
  2. During the onsite inspection, 12/19/2025, staff 6 confirmed that resident 1’s PRN medications, Levalbuterol Tartrate Inhalation 45 MCG and Midodrine HCI 5 MG did not include directions as to what to do if symptoms persist.
  3. Resident 5’s December Physician Order Sheet indicated that they were prescribed GlycoLax Oral Powder 17 GM (give 1 scoop by mouth every 24 hours as needed), Ondansetron 4 MG (give 1 tablet orally every 12 hours as needed for nausea and vomiting), Trazadone HCI 50 MG (give 25 mg by mouth every 24 hours as needed for insomnia), and Tylenol 325 MG (give 2 tablet by mouth every 6 hours as needed for mild pain/headache). Resident 5’s PRN medication orders, GlycoLax Oral Powder 17 GM, Ondansetron 4 MG, Trazadone HCI 50 MG, and Tylenol 325 MG, did not include directions as to what to do if symptoms persist.
  4. During the onsite inspection, 12/19/2025, staff 6 confirmed that resident 5’s PRN medication orders, GlycoLax Oral Powder 17 GM, Ondansetron 4 MG, Trazadone HCI 50 MG, and Tylenol 325 MG, did not include directions as to what to do if symptoms persist.
  5. Resident 6’s December Physician Order Sheet indicated that that they were prescribed Loperamide HCI 2 MG (give 1 tablet by mouth every 6 hours as needed for diarrhea) and Zofran 4 MG (give 1 tablet by mouth every 6 hours as needed for nausea/vomiting).
  6. During the onsite inspection, 12/19/2025, staff 6 confirmed that resident 6’s PRN medication orders, Loperamide HCI 2 MG and Zofran 4 MG, did not include directions as to what to do if symptoms persist.
  7. Resident 7’s December Physician Order Sheet indicated that they were prescribed Acetaminophen 325 MG (give 2 tablet by mouth every 6 hours as needed), Ativan 0.5 MG (give 0.5 mg by mouth every 4 hours as needed for agitation), Imodium 2 MG (give 1 tablet by mouth every 6 hours as needed for diarrhea), Oxycodone HCI 5 MG (give 5 mg by mouth every 4 hours as needed for pain/SOA), Senna S 8.6-50 MG (give 1 tablet by mouth every 24 hours as needed for constipation), and Zofran 4 MG (give 1 tablet by mouth every 8 hours as needed for nausea/vomiting). Resident 7’s PRN medication orders, Acetaminophen 325 MG, Ativan 0.5 MG, Imodium 2 MG, Oxycodone HCI 5 MG, Senna S 8.6-50 MG, and Zofran 4 MG, did not include directions as to what to do if symptoms persist.
  8. During the onsite inspection, 12/19/2025, staff 6 confirmed that Acetaminophen 325 MG, Ativan 0.5 MG, Imodium 2 MG, Oxycodone HCI 5 MG, Senna S 8.6-50 MG, and Zofran 4 MG, did not include directions as to what to do if symptoms persist.
Plan of correction
1. Acting resident care director or designee will ensure that PRN orders include symptoms that indicate the use of medication, exact dosage, the exact time frames the medication is to be given in a 24-hour period and directions as to what to do in symptoms persist. 2. Staff accepting new or changed PRN medication orders will be educated as to the above criteria and to document them on the Documentation of Physician’s or Other Prescriber’s Oral Order for PRN (As Needed) Medication (032-05-0530-02-eng (02/18) form. 3. Residents receiving PRN medications will be audited to ensure their orders include all
22VAC40-73-310-B
Based on resident record review and staff interview, the facility failed to ensure that assisted living facilities should not admit an individual before a determination has been made that the facility can meet the needs of the individual. The facility should make the determination based upon the following information at a minimum: a documented interview between the administrator or a designee responsible for admission and retention decisions, the individual, and his legal representative, if any. In some cases, conditions could create special circumstances that make it necessary to hold the interview on the date of admission.
Evidence
  1. Upon request, the facility did not provide a documented interview for resident 2 (admit date, 11/20/2025) and resident 3 (admit date, 06/16/2025).
  2. During the onsite inspection, 12/19/2025, staff 6 confirmed that resident 2 and resident 3’s documented interview between the administrator or a designee and the individual and his legal representative was not provided to licensing upon request.
Plan of correction
1. The Executive Director or Designee will provide proof of documented interview to new residents or their responsible parties and resident #2 and #3.
22VAC40-73-260-A
Based on staff record review and staff interview, the facility failed to ensure that each direct care staff member should maintain current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. The certification must either be in adult first aid or include adult first aid. To be considered current, first aid certification from community colleges, hospitals, volunteer rescue squads, or fire departments should have been issued within the past three years.
Evidence
  1. Staff 1 (hire date, 10/24/2023) records indicated that the first aid certification from American Red Cross expired on 11/07/2023.
  2. During the onsite inspection, 12/18/2025, staff 6 confirmed that staff 1’s first aid certification from American Red Cross was expired.
  3. Staff 2 (hire date, 09/21/2023) records indicated that the first aid certification was from National CPR Foundation. The first aid certification was valid for 2 years (issue date, 09/26/2023).
  4. During the onsite inspection, 12/18/2025, staff 6 confirmed that staff 2’s first aid certification expired 09/2025 and was not from one of the required organizations: American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department.
  5. Staff 4 (hire date, 03/28/2025) records indicated that the first aid certification was from National CPR Foundation. The first aid certification was valid for 2 years (issue date, 03/29/2025).
  6. During the onsite inspection, 12/18/2025, staff 6 confirmed that the first aid certification was not from one of the required organizations.
Plan of correction
1. The Resident Care Coordinator or Designee will ensure that direct care staff, including staff #1 staff #2, and staff #4, maintain current certification in First Aid from the American Red Cross, American Heart Association, National Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. 2. The certification will be in either adult first aid or include adult first aid. 3. The Resident Care Coordinator or Designee will ensure the documentation of completion and retain in employees’ personnel files.
22VAC40-73-250-D
Based on staff record review and staff interview, the facility failed to ensure that each staff person on or within seven days prior to the first day of work at the facility and each household member prior to coming in contact with residents should submit the results of a risk assessment, documenting the absence of tuberculosis in a communicable form as
Evidence
  1. d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence:
  2. Upon request, the facility did not provide a risk assessment, documenting the absence of tuberculosis in a communicable form for staff 3 (hire date, 08/15/2024) and staff 4 (hire date, 03/28/2025).
  3. During the onsite inspection, 12/18/2025, staff 6 confirmed that the risk assessment, documenting the absence of tuberculosis in a communicable form, for staff 3 and staff 4 was not provided to licensing upon request.
Plan of correction
1. Human Resources Manager or Designee will ensure that each staff person, on or within seven days prior to the first day work, at the facility, prior to coming into contact with residents, should submit the results of a risk assessment documenting the absence of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health. 2. Staff #3 and #4 will complete this form.
22VAC40-73-45-A
Based on record review and staff interview, the facility failed to ensure that each facility should prepare and provide, upon request of the prospective resident or resident and resident’s legal representative, if any, a statement that the facility maintains liability insurance in force to compensate residents or other individuals for injuries and losses from the negligent acts of the facility. The statement should be made on the liability insurance statement form provided by the department.
Evidence
  1. Upon request during the onsite inspection on 12/18/2025, the facility did not provide a liability statement form provided by the department.
  2. During the onsite inspection, 12/18/2025, staff 6 provided proof of liability insurance and confirmed that the liability statement form was not provided to licensing upon request.
Plan of correction
1.The Executive Director ensured active liability insurance coverage was in place and completed the required liability insurance statement form. 2. All facility records were reviewed to confirm liability insurance coverage applied to all residents and individuals. 3: The Executive Director will maintain the liability insurance statement in the administrative compliance file and verify coverage annually and upon policy renewal. 4. The Executive Director will audit the liability insurance documentation annually and document verification in the facility compliance log.
22VAC40-73-640-A
Based on observation, record review and staff interview, the facility failed to ensure to have, keep current, and implement a written plan for medication management. The facility’s medication plan should address procedures for administering medication and should include: methods to ensure that each resident’s prescription medications and any over-the-counter drugs and supplementals ordered for the resident were filled and refilled in a timely manner to avoid missed dosages; and methods for verifying that medication orders have been accurately transcribed to medication administration records (MARs) within 24 hours of receipt of a new order or change in an order.
Evidence
  1. Resident 5 received a discontinue order for Folic Acid 1 MG (start date, 06/16/2025; give 1 tablet by mouth one time a day), Multivitamin (start date, 06/16/2025; give 1 tablet by mouth one time a day), and Vitamin B12 1000 MCG (start date, 06/16/2025; give 1 tablet by mouth one time a day) on 10/29/2025; however, resident 5’s October 2025 MAR indicated that Folic Acid, Multivitamin, and Vitamin B12 were administered on 10/29/2025 through 10/31/2025.
  2. Resident 5 received a discontinue order for Sennosides-Docusate Sodium 8.6-50 MG (start date, 06/17/2025; give 1 tablet by mouth one time a day) and Terazosin HCI 1 MG (start date, 06/16/2025; give 1 capsule by mouth one time a day) on 12/10/2025; however, resident 5’s December 2025 MAR indicated that Sennosides-Docusate Sodium and Terazosin HCI was administered 12/10/2025 through 12/13/2025.
  3. During the onsite inspection, 12/19/2025, staff 6 confirmed that resident 5’s medications, Sennosides-Docusate Sodium and Terazosin HCI, were not accurately transcribed to MAR within 24 hours of receipt of a change in an order.
Plan of correction
1. Executive Director or Designee will keep current and implement a written plan for medication management. 2. The plan will address procedures for administering medication and will include: methods to ensure that each resident’s prescription medications and any over-the-counter drugs and supplements ordered for the resident were filled and refilled in a timely manner to avoid missed dosages; and methods for verifying that medication orders have been accurately transcribed to medication administration records within 24 hours of receipt of a new order or change in an order. 3. Evidence outlined in number 1 has been corrected for resident #5. Evidence 2 has been corrected for resident #5.
22VAC40-73-350-B
Based on resident record review and staff interview, the facility failed to ensure that the assisted living facility should ascertain, prior to admission, whether a potential resident is a registered sex offender if the facility anticipates the potential resident would have a length of stay greater than three days or in fact stays longer than three days and should document in the resident’s record that this was ascertained and the date the information was obtained.
Evidence
  1. Upon request, the facility did not provide documentation that prior to admission resident 1 (admit date, 11/20/2025) and resident 5 (admit date, 06/16/2025) were not included on the sex offender registration list.
  2. During the onsite inspection, 12/19/2025, staff 6 confirmed that resident 1 and resident 5’s sex offender check was not provided to licensing upon request.
Plan of correction
1. Executive Director or Designee will ascertain, prior to admission, whether a resident is a registered sex offender. 2. Executive Director or Designee will document in the resident’s record that this information was ascertained and the date the information was obtained. 3. Executive Director or designee will complete steps 1 and 2 above for residents #1 and #5.
22VAC40-73-220-A
Based on private duty record review and staff interview, the facility failed to ensure that when private duty personnel from licensed home care organizations provide direct care or companion services to residents in an assisted living facility, the following applies: before direct care or companion services are initiated, the facility should obtain, in writing, information on the type and frequency of the services to be delivered to the resident by private duty personnel, review the information to determine if it is acceptable, and provide notification to the home care organization regarding any needed changes.
Evidence
  1. Upon request, the facility did not provide private duty personnel records for resident 7 and resident 8.
  2. During the onsite inspection, 12/18/2025, staff 7 provided a list of residents who receive private duty aide services; however, staff 7 acknowledged that records for private duty personnel were not on site. Staff 7 also confirmed that resident 7 and resident 8’s private duty personnel records were not provided to licensing upon request.
Plan of correction
1. The Resident Care Coordinator or Designee will obtain information in writing of the type and frequency of the services to be delivered to the resident by private duty personnel. 2. The Resident Care Coordinator or Designee will review the information to determine if it is acceptable. 3. The Resident Care Coordinator or Designee will provide notification to the homecare organization regarding any needed changes. 4. Items 1,2 and 3 will be completed for resident #7 and resident #8
22VAC40-73-1110-A
Based on resident record review and staff interview, the facility failed to ensure that prior to admitting a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia to a safe, secure environment, the licensee, administrator, or designee should determine whether placement in the special care unit was appropriate. The determination and justification for the decision should be writing and should be retained in the resident’s file.
Evidence
  1. Upon request, the facility did not provide a determination and justification prior to admitting resident 5 (admit date, 06/16/2025) and to the safe, secure environment. 2.During the onsite inspection, 12/19/2025, staff 6 confirmed that documentation of determination and justification prior to admitting resident 5 to the safe, secure environment was not provided to licensing upon request.
Plan of correction
1. The acting Resident Care Director or Designee will ensure that prior to admitting a resident with serious cognitive impairment due to a primary psychiatric diagnosis of dementia to a safe, secure environment, the licensee, administrator, or designee should determine whether placement in the special care unit was appropriate. 2. The determination and justification for the decision will be writing on the Assessment of Serious Cognitive Impairment form (032-05-0078-05-eng(02/18) and Approval for Placement in Special Care Unit form (See 22 VAC 40-73-1100) and will be retained in the resident’s file.
22VAC40-73-830-E
Based on record review and staff interview, the facility failed to ensure to provide a written response to the council prior to the next meeting regarding any recommendations made by the council for resolution of problems or concerns.
Evidence
  1. According to resident council meeting documentation, a meeting occurred on 02/20/2025, 03/27/2025, 04/23/2025, 05/22/2025, 07/31/2025, 08/28/2025, 09/18/2025, 10/16/2025, and 11/19/2025.
  2. Upon request, the facility did not provide a written response to the resident council for the following dates: 02/20/2025, 03/27/2025, 04/23/2025, 05/22/2025, 07/31/2025, 08/28/2025, 09/18/2025, 10/16/2025, and 11/19/2025.
  3. During the onsite inspection, 12/18/2025, staff 6 confirmed that a written response was not provided to the council prior to the next meeting regarding any recommendations made by the council for resolution of problems or concerns.
Plan of correction
1. The Activities and Volunteer Coordinator or Designee will ensure to provide a written response to the Resident Council, prior to the next meeting, regarding any recommendations made by the council for resolution of problems or concerns. 2. The Activities and Volunteer Coordinator or Designee will submit these written responses to the Executive Director for review.
22VAC40-73-490-A-3
Based on record review and staff interview, the facility failed to ensure that each assisted living facility should retain a licensed health care professional who has at least two years of experience as a health care professional in an adult residential facility, adult day center, acute care facility, nursing home, or licensed home care or hospice organization, either by direct employment or on a contractual basis, to provide on-site health care oversight. All residents should be included at least annually in health care oversight.
Evidence
  1. The health care oversight was completed 04/28/2025 through 05/21/2025 and 10/31/2025 through 11/10/2025. The health care oversights did not include documentation of the residents that were reviewed for each of the oversight periods.
  2. During the onsite inspection, 12/18/2025, staff 6 confirmed that documentation of the residents that were reviewed on the healthcare oversights, 04/28/2025 through 05/21/2025 and 10/31/2025 through 11/10/2025, was not provided to licensing upon request.
Plan of correction
1. Executive Director or Designee will ensure that healthcare oversight includes documentation of the residents who were reviewed for each oversight period.
22VAC40-73-680-E
Based on resident record review, the facility failed to ensure that medical procedures or treatments ordered by a physician or other prescriber should be provided according to his instructions and documented. The documentation should be maintained in the resident’s record.
Evidence
  1. Resident 7 (admit date, 11/02/2023) was prescribed Calmoseptine External Ointment 0.44-20.6% (start date, 04/05/2024; apply to sacrum topically every shift for prevent skin breakdown).
  2. During the onsite inspection, 12/19/2025, licensing inspector requested to review resident 7’s medication cart with staff 7. During the review of the medication cart, resident 7’s Calmoseptine External Ointment was not available for administration.
Plan of correction
1. Acting Resident Care Director or Designee will ensure that medical procedures or treatments ordered by a physician or other prescriber should be provided according to his or her instructions and be documented and maintained in the residents’ record. 2. Staff who administer medication will be reeducated as indicated above. 3. Evidence 2 was corrected for resident #7.
22VAC40-73-970-E
Based on record review and staff interview, the facility failed to ensure that a record of the required fire and emergency evacuation drills should be kept in the facility for two years.
Evidence
  1. Upon request the facility did not provide documentation that a fire drill was conducted for the following months in 2025: February, May, July, and September.
  2. During the onsite inspection, 12/18/2025, staff 6 confirmed that a record of the required fire and emergency evacuation drills for February, May, July, and September 2025 were not provided to licensing upon request.
Plan of correction
1. The Maintenance Coordinator or Designee will complete required fire and evacuation drills. 2. The Maintenance Coordinator or Designee will maintain documentation at the facility for two years.
22VAC40-73-680-M
Based on resident record review, the facility failed to ensure that medication ordered for PRN administration should be available, properly labeled by the specific resident, and properly stored at the facility.
Evidence
  1. During the onsite inspection, 12/19/2025, licensing inspector (LI) requested to review resident 1’s medication cart with staff 7. During the review, LI observed that resident 6’s medication cart did not include Ondansetron 4 MG (start date, 03/05/2025; give 1 tablet orally every 12 hours as needed for nausea and vomiting).
  2. During the onsite inspection 12/19/2025, LI requested to review resident 7’s medication cart with staff 7. Staff 7 provided a current physician order sheet with all PRN medications. During the review, LI observed that resident 7’s medication cart did not include Ativan 0.5 MG (give 0.5 mg by mouth every 4 hours as needed for agitation), Oxycodone HCI 5 MG (give 5 mg by mouth every 4 hours as needed for pain/SOA), and Senna S 8.6-50 MG (give 1 tablet by mouth every 24 hours as needed for constipation).
Plan of correction
1. Acting Resident care Director or designee will ensure that medication ordered for PRN administration should be available, properly labeled by the specific resident and properly stored at the facility. 2. Staff members who administer medication will be reeducated as to the standard outlined above. 3. Evidence 1 has been corrected for resident #1. Evidence 2 has been corrected for resident #7.
22VAC40-73-930-D
Based on resident record review and staff interview, the facility failed to ensure that for each resident with an inability to use the signaling device, in addition to any other services, the following should be met: unless subsection C of this section was applicable, once the resident had gone to bed each evening until the resident have arisen each morning, at a minimum, direct care staff should make rounds no less often than every two hours, except that rounds should be made on a different frequency if requested by the resident and agreed by the facility. Any agreement for a different frequency must be writing, specify the frequency, be signed and dated by the resident and the facility, and be retained in the resident’s record. If there is a change in the resident’s condition or care needs, the agreement should be reviewed and if necessary, the frequency of rounds should be adjusted. If an adjustment was made, the former agreement should be replaced with a new agreement or with compliance with the frequency specified in this subdivision.
Evidence
  1. November and December 2025’s Resident Check-in documentation stated that staff completed nightly rounds once during the third shift (11 pm – 7 am) for resident 1 on 11/20/2025, 11/23/2025 through 12/02/2025, 12/06/2025, 12/12/2025 - 12/15/2025, and 12/17/2025; and twice during the third shift on 11/19/2025, 11/21/2025, 12/03/2025 through 12/05/2025, 12/08/2025 through 12/10/2025, and 12/16/2025.
  2. November and December 2025’s Resident Check-in documentation stated that staff completed nightly rounds twice during the third shift for resident 4 on 11/20/2025, 11/26/2025 through 11/27/2025, and 12/2025; three times during the third shit on 11/21/2025 through 11/25/2025, 11/28/2025 through 12/18/2025.
  3. November and December 2025’s Resident Check-in documentation was not completed on the third shift for resident 5 on 11/25/2025, 11/27/2025, and 12/10/2025.
  4. November and December 2025’s Resident Check-in documentation stated that staff completed nightly rounds once during the third shift for resident 5 on 11/20/2025 through 11/23/2025, 11/28/2025 through 12/08/2025, 12/11/2025 through 12/19/2025; and twice during the third shift on 11/24/2025, 11/26/2025, and 12/09/2025.
  5. November and December 2025’s Resident Check-in documentation was not completed on the third shift for resident 6 on 11/27/2025 and 12/10/2025.
  6. November and December 2025’s Resident Check-in documentation stated that staff completed nightly rounds once during the third shift for resident 6 on 11/20/2025 through 11/25/2025, 11/28/2025 through 12/08/2025, and 12/11/2025 through 12/19/2025; and twice on 11/26/2025 and 12/09/2025.
  7. Resident 1, resident 4, and resident 5’s Individualized Service Plan (ISP) stated an “inability to use signaling device with need for night safety checks.”
  8. During the onsite inspection, 12/19/2025, staff 6 confirmed that once resident 1, resident 4, resident 5, and resident 6 had gone to bed each evening until they had arisen each morning, at a minimum, direct care staff did not make rounds no less often than every two hours.
Plan of correction
1.Resident Care Coordinator or Designee will ensure that for each resident with an inability to use the signaling device, in addition to any other services, the following should be met: Once the resident had gone to bed each evening until the resident has arisen each morning, at a minimum, direct care staff should make rounds no less often than every two hours. 2.Resident Care Coordinator or Designee will review and update tasks for residents with an inability to use a signal device to ensure direct care staff will be prompted to conduct rounds no less than every two hours from when the resident goes to sleep at night and rises in the morning.
22VAC40-73-1110-B
Based on resident record review and staff interview, the facility failed to ensure that six months after placement of the resident in the safe, secure environment and annually thereafter, the licensee, administrator, or designee should perform a review of the appropriateness of each resident’s continued residence in the special care unit.
Evidence
  1. Upon request, the facility did not provide documentation of a six-month review of the appropriateness of resident 6’s (admit date, 01/08/2025) placement in the safe, secure environment.
  2. During the onsite inspection, 12/19/2025, staff 6 confirmed that resident 6’s six-month review of the appropriateness of placement in the safe, secure environment was not provided to licensing upon request.
Plan of correction
1. The acting Resident Care Director or Designee will ensure that six months after placement of the resident in the safe, secure environment and annually thereafter, the licensee, administrator, or designee will perform a review of the appropriateness of each resident’s continued residence in the special care unit. 2. The acting Resident Care Director or Designee will document this review on the Review of Appropriateness of Continued Residence in Special Care Unit (032-05-0081-02-eng (02/18) form.
22VAC40-73-120-C
Based on staff record review and staff interview, the facility failed to ensure that all staff should be trained in the relevant laws, regulations, and the facility’s policies and procedure sufficiently to implement emergency and disaster plans for the facility, procedures for handling of resident emergencies, use of the first aid kit and knowledge of its location, handwashing techniques, standard precautions, infection risk-reduction behavior, and other infection control measures; confidential treatment of personal information; requirements regarding the rights and responsibilities of residents; methods of alleviating common adjustment problems that could occur when a resident moves from one residential environment to another; and for direct care staff, the needs, preferences, and routines of the residents for whom they would provide care.
Evidence
  1. Staff 3 (hire date, 08/15/2024), staff 4 (hire date, 03/28/2025), and staff 5’s (hire date,11/05/2025) initial trainings included Abuse and Neglect Prevention; Community Introduction; Compliance and Code of Conduct; How to Prevent and Respond to Workplace Violence; Life at Sunrise; Resident and Dementia Care; Reporting Events, Compliance 101 Training, Foundations; and Healthcare Insurance Portability and Accountability Act (HIPAA) Training.
  2. During the onsite inspection, 12/18/2025, licensing inspector (LI) requested for staff 6 to provide an overview of each training listed on staff 3, staff 4, and staff 5’s initial trainings. Staff 6 did not provide an overview and confirmed that the listed trainings were not specific to relevant laws, regulations, and the facility’s policies and procedures.
Plan of correction
1. The facility confirmed that all required staff training related to emergency and disaster procedures, resident emergencies, first aid, infection control, confidentiality, resident rights, and adjustment support had been completed. The missing training documentation form was completed and placed in the appropriate staff records 2. A review of all staff training files was conducted to identify any additional missing or incomplete documentation forms. Any identified documentation gaps were corrected to ensure records accurately reflected completed training 3. The facility implemented a standardized process to ensure all required training documentation forms are completed, verified, and filed promptly upon training completion. Leadership reinforced accountability for maintaining accurate and complete training records.. 4. The facility implemented a standardized process to ensure all required training documentation forms are completed, verified, and filed promptly upon training completion. Leadership reinforced accountability for maintaining accurate and complete training records.
22VAC40-73-990-A
Based on record review and staff interview, the facility failed to ensure that assisted living facility should have a written plan for resident emergencies.
Evidence
  1. Upon request, the facility failed to provide a written plan for resident emergencies.
  2. During the onsite inspection, 12/18/2025, staff 6 confirmed that a written plan for resident emergencies was not provided to licensing upon request.
Plan of correction
1. The Executive Director or Designee will create and maintain a written plan for resident emergencies.
22VAC40-73-240-F
Based on volunteer record review and staff interview, the facility failed to ensure that prior to beginning volunteer service, all volunteers should attend an orientation including information on their duties and responsibilities, resident rights, confidentiality, emergency procedures, infection control, the name of their supervisor, and reporting requirements. Volunteers should sign and date a statement that they have received and understand this information.
Evidence
  1. Upon request, the facility did not provide volunteer records for volunteer 8 and volunteer 9.
  2. During the onsite inspection, 12/18/2025, staff 6 confirmed that volunteer 8 and volunteer 8’s records were not provided to licensing upon request.
Plan of correction
1. The Activities and Volunteer Coordinator or Designee will ensure prior to beginning volunteer services volunteers, including volunteers #8 and #9, will attend an orientation including information on their duties and responsibilities, resident rights, confidentiality, emergency procedure, infection control, the name of their supervisor, and reporting requirements. 2. The Activities and Volunteer Coordinator or Designee will ensure volunteers sign and date a statement they have received and understand this information. 3. Volunteers #8 and #9 will sign and date such a statement.
22VAC40-73-680-D
Based on resident record review and staff interview, the facility failed to ensure that medications should be administered in accordance with the physician’s or other prescriber’s instructions and consistent with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing.
Evidence
  1. Resident 5 was prescribed Folic Acid 1 MG (give 1 tablet by mouth one time a day), Multivitamin (give 1 tablet by mouth one time a day), and Vitamin B12 1000 MCG (give 1 tablet by mouth one time a day). Resident 5’s medications, Folic Acid, Multivitamin, and Vitamin B12 were discontinued on 10/29/2025; however, resident 5’s October 2025 MAR indicated that these medications were administered, 10/29/2025 through 10/31/2025.
  2. During the onsite inspection, 12/19/2025, staff 6 confirmed that resident 5’s Folic Acid, Multivitamin, and Vitamin B12 were not administered according to the physician’s or other prescriber’s instructions and consistent with the standards of practice outlined in the current medication aide curriculum approved by the Virginia Board of Nursing.
  3. Resident 5 was prescribed Sennosides-Docusate Sodium 8.6-50 MG (give 1 tablet by mouth one time a day) and Terazosin HCI 1 MG (give 1 capsule by mouth one time a day). Resident 5’s medications, Sennosides-Docusate Sodium and Terazosin HCI, were discontinued on 12/10/2025; however, resident 5’s December 2025 MAR indicated that these medications were administered, 12/10/2025 through 12/13/2025.
  4. During the onsite inspection, 12/19/2025, staff 6 confirmed that resident 5’s Sennosides-Docusate Sodium and Terazosin HCI, were administered according to the physician’s or other prescriber’s instructions and consistent with the standards of practice outlined in the current medication aide curriculum approved by the Virginia Board of Nursing.
Plan of correction
1. Executive Director or Designee will ensure that medications will be administered in accordance with the physician’s or other prescriber’s instructions and consistent with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing. 2. Staff who administer medication will be reeducated as indicated above. 3. Evidence 1 was corrected for resident #5. Evidence 3 was corrected for resident #5
22VAC40-73-990-B
Based on record review and staff interview, the facility failed to ensure that procedures in the plan for resident emergencies required in subsection A of this section should be reviewed by the facility at least every six months with all staff. Documentation of the review should be signed and dated by each staff person.
Evidence
  1. Upon request, the facility failed to provide documentation that resident emergencies were reviewed at least every six months with all staff.
  2. During the onsite inspection, 12/18/2025, staff 6 confirmed that documentation of review of resident emergencies was signed and dated at least every six months was not provided to licensing upon request.
Plan of correction
1.The Executive Director or designee will ensure that procedures in the plan for resident emergencies will be reviewed by the facility at least every six months with all staff. 2.Documentation of the review should be signed and dated by each staff person.
22VAC40-73-970-D
Based on record review and staff interview, the facility failed to ensure that immediately following each required fire and emergency evacuation drill, there should be an evaluation of the drill by the staff in order to determine the effectiveness of the drill. The licensee or administrator should immediately correct any problems identified in the evaluation and document the corrective action taken.
Evidence
  1. On 03/12/2025, a fire drill was completed on the second shift (3 pm – 11 pm). The fire drill documentation stated, “verbal training was implemented for vach checks and door safety,” “team members manually closed resident doors and employ evacu-check device with instruction/verbal training,” and “need more training” for team members knowing how to use extinguishers.
  2. On 04/30/2025, a fire drill was completed on the second shift. The fire drill documentation stated that team members “failed” to rescue endangered residents and team members “failed” to bring fire extinguishers.”
  3. On 08/30/2025 a fire drill was completed on the first shift. The fire drill documentation stated that team members “failed” to rescue endangered residents, team members “failed” to check doors for heat, team members “failed” to bring fire extinguishers, and team members “failed” to know how to use extinguishers.
  4. On 10/24/2025 a fire drill was completed on third shift (11 pm – 7 am). The fire drill documentation stated that team members “failed” to manually close resident doors and team members “failed” to bring fire extinguishers.
  5. During the onsite inspection, 12/18/2025, staff 6 confirmed that the licensee or administrator did not immediately correct and problems identified in the evaluation and document the corrective action taken for the following fire drills: 03/12/2025, 04/30/2025, 08/30/2025, and 10/24/2025.
Plan of correction
1. The Maintenance Coordinator or Designee will ensure that immediately following each required fire and emergency evacuation drill, there should be an evaluation of the drill by the staff in order to determine the effectiveness of the drill. 2. The Maintenance Coordinator or Designee will immediately address concerns noted in the evaluation and document the corrective action taken.
November 6, 2025Complaint survey9 violations
Inspection dates
11/06/2025
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 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: 11/06/2025 from 10:17 a.m. to 4:02 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 10/13/2025 regarding allegations in the area(s) of: Staffing and Supervision and Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 70 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation(s) of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint 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 Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov.
Violations
22VAC40-73-70-A
Based on record review and interview, the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident.
Evidence
  1. During the onsite inspection on 11/06/2025, Resident 1’s record included a progress note that indicated the resident returned to the facility from the hospital with bruises and scratches on 10/10/2025.
  2. During an interview on 11/06/2025, Staff 1 confirmed an incident report was not completed for Resident 1 and the noted bruising/scratches on 10/10/2025.
Plan of correction
1. Deficiency Statement The facility failed to notify the licensing office of a bruise observed after hospital admission. 2. Immediate Corrective Actions - Reviewed incident with nursing staff and reinforced notification requirements. 3. Systemic Changes - Update procedure to define reportable changes (e.g., bruises, injuries, skin tears). - Implement a Notification Checklist for post-hospital admission assessments. -Add audit step in admission/re-admission workflow. 4. StaffTraining -Conduct in-service on: 12/10/25 • Resident rights under 22VAC40-73-70(A). • Notification protocols for changes in condition. - Maintain signed training logs. 5. Monitoring -Audit of hospital return admissions for 30 days. - Monthly audits for 3 months. - Report compliance to QAPI committee. 6. Responsible Parties RCD or designee 7. Timeline -Training: By December 31st 2025 - First audit report: January 15th 2026 8. Evidence of Compliance - Updated Checklist. - Staff training logs and audit reports.
22VAC40-73-640-A
Based on observation, the facility failed to implement their written plan for medication management which includes methods for verifying that medication orders have been accurately transcribed to medication administration record (MARs) within 24 hours of receipt of a new order or change in an order.
Evidence
  1. During the onsite inspection on 11/06/2025, Resident 1’s record indicated their Dexamethasone order was changed on 09/17/2025 from 4mg by mouth twice a day to 4mg by mouth every morning and 2mg by mouth at 2:00p.m.
  2. Upon review of Resident 1’s September 2025 MAR, the resident’s changed Dexamethasone order dated 09/17/2025 was not transcribed accurately to the MAR until 09/19/2025.
  3. Resident 1’s record included an order dated 10/08/2025 to administer Dexamethasone 4mg twice daily in the morning and from 12:00p.m.- 2:00p.m.; however, the afternoon dosage of the medication was scheduled to be administered at 2:00p.m. on Resident 1’s October 2025 MAR.
  4. Resident 1’s record included an order to discontinue Seroquel two 25mg tablets by mouth as needed every 2 hours on 10/08/2025 with no other orders for Seroquel in Resident 1’s record.
  5. Resident 1’s October 2025 MAR documents the following Seroquel orders and their administration on the following days: a. 50 mg by mouth in the morning on 10/8/2025, 10/09/2025, and 10/10/2025 (start date 04/10/2025; d/c date 10/10/2025). b. 75 mg by mouth at bedtime on 10/07/2025 (start date 10/07/2025; d/c date 10/07/2025). c. 75 mg by mouth at bedtime on 10/07/2025 and 10/09/2025 (start date 04/09/2025; d/c date 10/10/2025). There was no indication on Resident 1’s MAR of a PRN Seroquel order.
  6. During the onsite inspection on 11/06/2025, Staff 1 indicated there is not one individual solely responsible for transcribing medications into the MAR to ensure accuracy.
Plan of correction
Not published by VDSS.
22VAC40-73-280-B
Based on record review and interview, the facility failed to maintain a written plan that specifies the number and type of direct care staff required to meet the day-to-day, routine direct care needs and any identified special needs for the residents in care.
Evidence
  1. During the onsite inspection on 11/06/2025, the facility did not provide written plan that specifies the number and type of direct care staff required to meet the day-to-day, routine direct care needs and any identified special needs for the residents in care upon request.
  2. During an interview with Staff 2 on 11/06/2025, the staff plan of the facility was described as the following: a. First shift (7 a.m.-3 p.m.) requires two med techs total for the assisted living (AL) and Reminiscence units with three care managers for the assisted living (AL) and six care managers total for the Reminiscence units. b. Second shift (3p.m.-11p.m.) requires two med techs total for the assisted living (AL) and Reminiscence units with three care managers for the assisted living (AL) and six care managers total for the Reminiscence units. c. Third shift (11p.m.-7a.m.) requires one med tech total for the assisted living (AL) and Reminiscence units with two care managers for the assisted living (AL) and four care managers total for the Reminiscence units.
  3. The following was noted from the staff schedule of the first and second shift from September, October, and November 2025: a. There was one med tech during the first shift on 10/9/25, 10/12/25, 10/14/25, 10/16/25, 10/23/25, 10/27/25, 10/28/25, 10/29/25, and 10/30/25. b. On 9/12/25, there were two care managers on first shift. c. There was one med tech during the second shift on 9/11/25,10/3/25, 10/4/25, 10/6/25, 10/9/25, 10/12/25, 10/14/25, 10/16/25, 10/27/25, 10/28/25, 10/29/25, 10/30/25, and 11/6/25. d. On 9/5/25, there were two care managers on second shift. e. On 10/31/25, there was one care manager in the Reminiscence unit on second shift.
  4. Staff 1 and Staff 2 were unable to provide the staff schedule for the third shift upon request and 2. During an interview with Staff 2 on 11/06/2025, the staff plan of the facility was described as the following: a. First shift (7 a.m.-3 p.m.) requires two med techs total for the assisted living (AL) and Reminiscence units with three care managers for the assisted living (AL) and six care managers total for the Reminiscence units. b. Second shift (3p.m.-11p.m.) requires two med techs total for the assisted living (AL) and Reminiscence units with three care managers for the assisted living (AL) and six care managers total for the Reminiscence units. c. Third shift (11p.m.-7a.m.) requires one med tech total for the assisted living (AL) and Reminiscence units with two care managers for the assisted living (AL) and four care managers total for the Reminiscence units.
  5. The following was noted from the staff schedule of the first and second shift from September, October, and November 2025: a. There was one med tech during the first shift on 10/9/25, 10/12/25, 10/14/25, 10/16/25, 10/23/25, 10/27/25, 10/28/25, 10/29/25, and 10/30/25. b. On 9/12/25, there were two care managers on first shift. c. There was one med tech during the second shift on 9/11/25,10/3/25, 10/4/25, 10/6/25, 10/9/25, 10/12/25, 10/14/25, 10/16/25, 10/27/25, 10/28/25, 10/29/25, 10/30/25, and 11/6/25. d. On 9/5/25, there were two care managers on second shift. e. On 10/31/25, there was one care manager in the Reminiscence unit on second shift. (continued on separate attachment)
Plan of correction
Not published by VDSS.
22VAC40-73-680-D
Based on record review, the facility failed to ensure medications be administered in accordance with the physician's or other prescriber’s instructions.
Evidence
  1. During the onsite inspection on 11/06/2025, Resident 1’s August 2025 MAR indicated the resident did not receive their evening (7:00p.m.- 9:00p.m.) medications (9 medication total) ordered for administration on 08/16/2025. 2. Resident 1’s record included an order dated 08/15/2025 to start Dexamethasone 4mg by mouth for 7 days; however, Resident 1’s August 2025 MAR indicates the resident only received the medication for 6 days from 08/16/2025 to 08/21/2025. Resident 1’s record did not include an order to discontinue the medication a day early.
  2. Resident 1’s record included orders dated 09/17/2025 to discontinue Dexamethasone 4mg twice a day and start Dexamethasone 4mg by mouth every morning and Dexamethasone 2mg by mouth every afternoon at 2:00p.m.; however, Resident 1’s September 2025 MAR indicates this change in administration of the medication did not occur until 09/19/2025.
  3. Resident 1’s record included an order to discontinue Seroquel two 25mg tablets by mouth as needed every 2 hours on 10/08/2025; however, Resident 1’s October 2025 MAR did not have a PRN dose for this medication. 5.There were no other orders for Seroquel in Resident 1’s record; however, Resident 1’s August, September, and October 2025 MAR documents the following Seroquel orders were administered on the following days: a. 25 mg – give 50 mg by mouth in the morning (start date of 04/10/2025; d/c date of 10/10/2025) from 08/01/2025-09/30/2025, 10/8/2025, 10/09/2025, and 10/10/2025. b. 25 mg – give 75 mg by mouth at bedtime (start date of 04/09/2025 and d/c date of 10/10/2025) from 08/01/2025-08/15/2025, 08/17/2025- 09/29/2025, 10/07/2025 and 10/09/2025. c. 75 mg by mouth at bedtime (start date 10/07/2025; d/c date 10/07/2025) on 10/07/2025.
Plan of correction
1. Deficiency Statement The facility failed to administer medications in accordance with prescriber instructions and the Registered Medication Aide curriculum, as required by 22VAC40-73-680(D). 2. Systemic Procedure Updates - Updated Medication Administration Procedure to require: • Verification of order, MAR, and dosage by RMA or licensed nurse before administration. • Define allowable ±1-hour window for scheduled dosing. • Real-time supervision expectations for competency maintenance. • Consequences for non-compliance. 4. Training & Competency - Conduct mandatory RMA/CNA medication administration training aligned with Board-approved curriculum. - Include hands-on return demonstration and direct observation by a supervisor. - Document all completed trainings and retain competency checklists. 5. Double-Check & Supervision Process - Implement mandatory independent double-check for all routine and high-risk medications: • Two qualified staff verify medication, dose, route, and timing before administration. - Supervisors perform periodic spot audits during medication rounds. 6. Monitoring & Quality Assurance - Daily MAR reviews for 30 days to confirm compliance. - Monthly audits for 3 months evaluating correct time frame, route, and dose. - QAPI committee reviews audit data quarterly. 1-:Roles &Responsibilities Resident Care Director )/designee :Ensure staff training, oversee double-checks and monitor auaits 8. Timeline Summary - Procedure update: Completed by 12/20/25. - Staff training & competency checks: 12/20/25. -Audit implementation begins: January 1st 2025 9. Evidence of Compliance - Training curricula and signed competency checklists - MAR error review documentation and QAPI minutes
22VAC40-73-650-A
Based on record review and interview, the facility failed to ensure no medication be started, changed, or discontinued by the facility without a valid order from a physician or other prescriber.
Evidence
  1. During the onsite inspection on 11/06/2025, Resident 1’s July and August 2025 MAR indicated the resident was administered Dexamethasone 1mg daily from 07/25/2025 to 08/20/2025; however, Resident 1’s record did not include a valid order for this medication to be administered from 07/25/2025 to 08/20/2025.
  2. Resident 1’s August 2025 MAR also indicated the resident began receiving Dexamethasone 4 mg by mouth two times a day on 08/22/2025; however, Resident 1’s record did not include a valid order for this medication.
  3. Resident 1’s record included an order to discontinue Seroquel two 25mg tablets by mouth as needed every 2 hours on 10/08/2025 with no other orders for Seroquel in Resident 1’s record; however, Resident 1’s August and September 2025 MAR indicates the resident was administered and scheduled to receive the following Seroquel: a. 25 mg – give 50 mg by mouth in the morning with start date of 04/10/2025 and d/c date of 10/10/2025. b. 25 mg – give 75 mg by mouth at bedtime with start date of 04/09/2025 and d/c date of 10/10/2025. The October 2025 MAR for Resident 1 also includes the following Seroquel orders: a. 25 mg – give 3 tablet by mouth at bedtime with start date of 10/07/2025 and d/c date of 10/07/2025.
  4. During the onsite inspection on 11/06/2025, the facility was unable to provide valid Dexamethasone orders for 07/25/2025 to 08/20/2025 and 08/22/2025 and scheduled Seroquel orders for Resident 1.
Plan of correction
Not published by VDSS.
22VAC40-73-310-M
Based on record review and interview, the facility failed to ensure if hospice care is provided, there is a written agreement between the assisted living facility and any hospice program that provides care in the facility.
Evidence
  1. During the onsite inspection on 11/06/2025, Resident 1’s record documents the resident admitted to hospice with Collateral Contact 1 on 10/7/2025.
  2. During a review of Resident 1’s record, an unsigned hospice agreement was observed in the resident’s chart.
  3. Resident 1’s individual service plan (ISP) (dated 4/29/2025) did not include or acknowledge the use of hospice services.
  4. During the onsite inspection on 11/06/2025, Staff 1 was unable to provide a signed written agreement between the facility and Collateral Contact 1.
Plan of correction
1. Deficiency Statement The facility admitted/retained a resident receiving hospice services without obtaining required documentation and assurances as outlined in 22VAC40-73-31 0(M). 2. Immediate Corrective Action -Updated current resident's receiving hospice services record to include: •Hospice plan of care. • Facility responsibilities for ADLs, medication administration, and coordination. - Notified hospice provider and scheduled care coordination meeting: by 30 days. 3. Systemic Changes to Prevent Recurrence - Revised admission procedure to require: • Hospice provider's written assurance prior to admission or retention. - Added hospice verification checklist to pre-admission screening process. - Incorporated hospice admission requirements into staff orientation and annual training. 4. Responsible Parties I Resident Care Director /designee :Verify hospice documentation and care coordination. IWellness Nurse/designee: Ensure checklist completion before admission. 5. Timeline Immediate correction: Completed on 11/7/25. Procedure revision: By 11/7/25 6. Monitoring I Quality Assurance - Conduct monthly audits of all hospice admissions for 3 months. --Report findings to GAPl-committee - Ongoing compliance checks during quarterly chart reviews. 7. Evidence of Compliance - Copies of hospice agreements and care plans. - Updated admission procedure and checklist. -Audit reports after admission to hospice services. - Staff training logs and audit reports
22VAC40-73-720-A
Based on record review, the facility failed to ensure a valid written Do Not Resuscitate (DNR) order is included in the individualized service plan (ISP).
Evidence
  1. During the onsite inspection on 11/06/2025, Resident 1’s record included a valid written DNR order; however, the written order is not documented in Resident 1’s ISP (dated 4/29/2025).
Plan of correction
Not published by VDSS.
22VAC40-73-290-A
Based on interview, the facility failed to maintain a written work schedule that includes the names and job classifications of all staff working each shift, with an indication of whomever is in charge at any given time.
Evidence
  1. During an onsite inspection on 11/06/2025, Staff 1 and Staff 2 were unable to provide a written work schedule for the third shift (11p.m.- 7a.m.) for September, October, and November 2025.
Plan of correction
Not published by VDSS.
22VAC40-73-450-F
Based on record review and interview, the facility failed to ensure the individualized service plans(ISP) are reviewed and updated at least once every 12 months and as needed for a significant change of a resident’s condition.
Evidence
  1. During the onsite inspection on 11/06/2025, Resident 1’s record indicates the resident admitted to hospice services on 10/07/2025; however, the ISP for Resident 1 (dated 4/29/2025) was not updated to reflect this significant change.
  2. During the onsite inspection on 11/06/2025, Staff 1 was unable to provide an updated ISP for Resident 1 completed upon this significant change.
Plan of correction
1. Deficiency Statement The facility failed to review and update residents' Individualized Service Plans (ISPs) at least annually and following changes in condition; as required by 22VAC40-73-450(F). 2. Immediate Corrective Actions - Reviewed all current resident ISPs and updated any overdue plans. - Documented changes in condition and revised ISPs accordingly. - Notified responsible parties of updates. 3. Systemic Policy & Procedure Updates - Updated ISP policy to require: • Annual review and update of all lSPs. •Immediate update upon any change in resident condition. - Added ISP compliance checklist to admission and quarterly review processes. 4. StaffTraining - Conduct mandatory in-service on ISP requirements under 22VAC40-73-450(F). - Train staff on identifying triggers for ISP updates (hospitalization-;-functional changes;n ew diagnoses). Maintain signed training logs. 5. Monitoring & Quality Assurance - Monthly audits of ISP timeliness and accuracy for 3 months. - Quarterly QAPI review of ISP compliance metrics. - Implement corrective action for any missed updates. 6. Roles & Responsibilities Resident Care Director/designee: Ensure timely ISP updates and supervise audits Resident Coordinator /designee : Complete ISP reviews and updates; maintain documentation 7. Timeline Summary - Immediate corrections: 12/1/2025 - Procedure update: Completed by: 1/1/2026 - Staff training: Completed by: 12/20/2025 - First audit report: Within 60 days 8. Evidence of Compliance - Updated ISP checklist - Training materials and signed logs - Audit reports and QAPI me¿ting minutes
August 13, 2025Inspection4 violations
Inspection dates
08/13/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 08/13/2025 Time in: 12:25 PM Time out: 3:01 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-report incident was received by VDSS Division of Licensing on 08/06/2025 regarding allegations in the area(s) of: Resident Care and Related Services, Buildings and Grounds, and Additional Requirements for Facilities That Care for Adults with Serious Cognitive Impairments Number of residents present at the facility at the beginning of the inspection: 66 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: 2 Observations by licensing inspector: Licensing inspector observed residents entering and exiting the facility for community outings, dining for lunch, and participating in scheduled activities. 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 Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov.
Violations
22VAC40-73-930-D
Based on resident record review and staff interview, the facility to ensure that for each resident with an inability to use the signaling device, in addition to any other services, once the resident has gone to bed each evening until the resident has arisen each morning, at a minimum, direct care staff make rounds no less often than every two hours, except that rounds may be made on a different frequency if requested by the resident and agreed to by the facility.
Evidence
  1. Resident 1 individualized service plan (ISP, effective date, 11/08/2024) and resident 2’s ISP (effective date, 07/02/2025) stated, “I require night safety check due to inability to use signaling device.”
  2. Resident 1’s task report (dated, 08/06/2025) indicated that staff 4 documented rounds at 1:10 AM, 3:31 AM, 5:01 AM, 6:48 AM, and 7:01 AM.
  3. Resident 2’s task report (dated, 08/06/2025) indicated that staff 4 documented rounds at 5:01 AM and 6:49 AM.
  4. During the onsite inspection, staff 1 confirmed that resident 1 and resident 2’s rounds were not completed no less than every two hours on 08/06/2025.
Plan of correction
Not published by VDSS.
22VAC40-73-460-A
Based on resident record reviews and staff interview, the facility failed to ensure to assume general responsibility for the health, safety, and well-being of the residents.
Evidence
  1. On 08/06/2025, the facility reported an allegation of sexual abuse between Resident 1 and Resident 2 that morning. The report indicated Staff 4 witnessed Resident 2 unclothed and being inappropriate with Resident 1 who is unable to provide consent for such contact.
  2. During the onsite inspection, staff 1 provided screenshots of video evidence of the incident between resident 1 and resident 2 from within resident 1's apartment on 08/06/2025 at 7:01 AM to 7:11 AM provided by resident 1's family member. Staff 1 acknowledged that resident 2 was in resident 1’s room for more than twenty minutes and less than fifty minutes, affecting the safety and wellbeing of resident 1 and resident 2.
Plan of correction
Not published by VDSS.
22VAC40-73-130-A
Based on record review and staff interview, the facility failed to ensure that all staff who were mandated reports under 63.2-1606 of the Code of Virginia report suspected abuse, neglect, or exploitation of residents in accordance with that section.
Evidence
  1. As incident report completed by the facility was received by licensing on 08/06/2025 regarding an allegation of sexual abuse between two residents on a safe, secure unit.
  2. During an onsite inspection on 08/22/2025, staff 1 confirmed that Adult Protective Services (APS) was not notified of the allegation of sexual assault that occurred on 08/06/2025.
Plan of correction
Not published by VDSS.
22VAC40-73-1130-C
Based on resident record review and staff interview, the facility failed to ensure that during night hours, when 22 or fewer residents were present, at least two direct care staff members where awake and on duty at all times in each special care unit and were responsible for the care and supervision of the residents.
Evidence
  1. The August 2025 staff schedules indicated that there were 2 direct support professionals and 1 lead medication technician scheduled on 08/06/2025.
  2. During the onsite inspection on 08/13/2025, staff 1 and staff 2 confirmed that there were 20 residents on the second floor, safe secure unit with two staff scheduled on the evening of 08/06/2025. Additionally, staff 1 and staff 2 confirmed that there were 18 residents on the third floor, safe secure unit, with one staff scheduled on the evening of 08/06/2025.
  3. Staff 1 and staff 2 acknowledged the census of each special care unit would require at least 2 direct care staff members and the third floor only had one staff member on the evening of 08/06/2025.
Plan of correction
Not published by VDSS.
August 13, 2025Complaint survey1 violation
Inspection dates
08/13/2025
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 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: 08/13/2025 Time in: 9:35 AM Time out: 12:24 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 07/29/2025 regarding allegations in the area(s) of: Administration and Administrative Services and Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 66 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: 3 Observations by licensing inspector: Licensing inspector observed residents dining for breakfast and lunch, interacting with staff and peers, participating in scheduled activities, and engaging with physical therapist. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegations 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 Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov.
Violations
22VAC40-73-460-B
Based on record review and staff interview, the facility failed to ensure care provision and service delivery was resident-centered to the maximum extent possible and included resident participation in decisions regarding the care and services provided to them and prompt response by staff to resident needs as reasonable to the circumstances.
Evidence
  1. Resident 1’s progress note (dated, 06/28/2025) stated, “discoloration on their left middle finger.” Resident 1 was “unable to explain event causing trauma.”
  2. Resident 1’s progress note (dated, 07/07/2025) stated that POA would contact the primary care physician to schedule an appointment to assess the discoloration.
  3. Resident 1’s progress note (dated 07/09/2025) stated, “taken to appointment on yesterday 07/08/25 by POA for concern for right hand bruising/swelling.”
  4. During the onsite inspection, staff 2 confirmed that nursing staff are capable of scheduling medical appointments when needed. Staff 2 was unable to determine the reason that resident 1 was not provided prompt medical response to an unknown injury. Staff 2 acknowledged that resident 1’s injury was noted on 06/28/2025 and did not receive medical care until 07/07/2025.
Plan of correction
Not published by VDSS.
June 27, 2025Complaint survey3 violations
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: 10/21/2024 Time In: 11:01 AM Time Out: 2:00 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 10/06/2024 regarding allegations in the areas of: Staffing and Supervision; Admission, Retention, and Discharge of Residents; Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 51 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Licensing inspector (LI) toured the physical plant of the facility. LI observed residents interacting with peers and staff, entering and exiting the facility for community outings, visiting with friends and family, and engaging in scheduled activities. Additional Comments/Discussion: N/A 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)/self-report); area(s) of non-compliance with standard(s) or law were: A violation notice was issued; any violation(s) not related to the (complaint(s)/self-report) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility
Violations
22VAC40-73-440-A
Based on resident record review, the facility failed to ensure that all residents of and applicants to assisted living facilities were assessed face to face using the uniform assessment instrument (UAI). The UAI was completed whenever there is a significant change in the resident’s condition.
Evidence
  1. Resident 1’s UAI was completed on 06/06/2024 and reassessed on 06/07/2024 and was not updated to include a change in condition.
Plan of correction
Not published by VDSS.
22VAC40-73-320-A
Based on resident records review, the facility failed to ensure that prior to admitting a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia to a safe, secure environment, the licensee determined whether placement in the special care unit was appropriate. The determination and justification for the decision was in writing and retained in the resident’s file.
Evidence
  1. Upon request the facility did not provide resident 2 and resident 3’s written determination and justification for placement in a safe, secure environment.
  2. On 10/21/2024, licensing inspector (LI) interviewed Staff 1 who confirmed that resident 2 and resident 3’s records did not include written determination and justification for placement in a safe, secure environment.
Plan of correction
Not published by VDSS.
22VAC40-73-1100-A
Based on resident record review and staff interview, the facility failed to ensure that prior to placing a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia in a safe, secure environment, the facility obtained the written approval.
Evidence
  1. Upon request the facility did not provide resident 3’s written approval to place them in a safe, secure environment.
  2. On 10/21/2024, licensing inspector (LI) interviewed Staff 1 who confirmed that resident 3’s record did not include written approval to place them in safe, secure environment.
Plan of correction
Not published by VDSS.
June 20, 2025Inspection7 violations
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS
Technical assistance
Licensing inspector reviewed 22VAC40-73-50, 22VAC40-73-210, and 22VAC40-73-610, 22VAC40-73-950.
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: Date: 01/29/2025 Time in: 10:15 a.m. Time out: 3:52 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: 49 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 3 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: LI observed residents entering and exiting the facility for outings, residents participating in scheduled activities, eating breakfast and lunch in the dining room, and medication passes. Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure The departments 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 Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov.
Violations
22VAC40-73-120-A
Based on staff record review, the facility failed to ensure that the orientation and training occurred within the first seven working days of employment. Until this orientation and training is completed, the staff person assumed job responsibilities under the sight supervision of a trained direct care staff person or administrator.
Evidence
  1. Staff 3’s (hire date, 12/11/2024) record indicated that the initial training (completed, 12/11/2024) was incomplete. The initial training did not include compliance with regulations for assisted living facilities, procedures to implement emergency and disaster plans, procedures for handling resident emergencies, knowledge and use of the first aid kit, infection risk-reduction behavior, confidential treatment of personal information, detecting and reporting suspected abuse, and reporting and documenting incidents.
Plan of correction
Administrator or designee will conduct a review of all staff folders to ensure onboarding and required training have been completed per company policy.
22VAC40-73-460-B
Based on resident review, the facility failed to ensure that care provision and service delivery was resident-centered to the maximum extent possible and include personalization of care and services tailored to the resident’s circumstances and preferences.
Evidence
  1. Resident 1’s individualized service plan (ISP, completed on 07/16/2024) stated, “I require night rounds every 2 hours by direct care staff during my hours of sleep.”
  2. For the month of December 2024, rounds were not completed every 2 hours for 8 days.
  3. For the month of January 2025, rounds were not completed every 2 hours for 8 days.
Plan of correction
A full audit of all resident ISPs to be conducted to by community along with a all staff in service training to review and ensure individualized service plans are tailored to each residents circumstance and preferences.
22VAC40-73-990-B
Based on record review and staff interview, the facility failed to ensure that the procedures for resident emergencies were reviewed at least every six months with all staff.
Evidence
  1. The emergency preparedness and response plan was reviewed on 11/21/2024. The emergency preparedness and response plan was not reviewed with all staff prior to 11/21/2024.
  2. On 01/29/2025, LI interviewed staff 6 who confirmed that the emergency preparedness and response plan was not reviewed with all staff prior to 11/21/2024.
Plan of correction
All current Team members will have reviewed resident emergency response plans by July 15th 2025.
22VAC40-73-990-C
Based on record review and staff interview, the facility failed to ensure that all staff on duty participated in an exercise in which the procedures for resident emergencies were practiced every six months.
Evidence
  1. An elopement drill was practiced on 04/24/2024. There was no documentation of another drill six months after 04/24/2024.
  2. On 01/29/2025, LI interviewed staff 6 who confirmed that an emergency drill was not completed every six months.
Plan of correction
Elopement drills have been conducted per regulations as of June 27th 2025. Drills listed below were conducted and provided to state license inspector.
22VAC40-73-490-A
Based on record review and staff interview, the facility failed to ensure that a health care oversight was completed at least every six months.
Evidence
  1. A healthcare oversight was documented as completed on 10/31/2024. There was no other documentation of a healthcare oversight being completed.
  2. On 01/29/2025, licensing inspector (LI) interviewed staff 5 (hire date, 10/21/2024) who stated not being able to locate the document.
Plan of correction
Healthcare oversight has been doucmneted and completed by the community RCD and a copy of documentation is avalible in the community.
22VAC40-73-1110-A
Based on 1 out of 7 resident record review, the facility failed to ensure that prior to admitting a resident with a serious cognitive impairment to a safe, secure environment to determine whether placement in the special care unit is appropriate.
Evidence
  1. Resident 4’s (admitted, 03/31/2024) record did not include an appropriateness of placement assessment prior to admittance to the safe, secure environment.
  2. Upon request the facility was unable to provide an appropriateness of placement dated prior to 03/21/2024.
Plan of correction
Full audit and review of residents residing in a secure neighborhood will be c completed by July 15th 2025
22VAC40-73-970-A
Based on record review and staff interview, the facility failed to ensure that the fire and emergency evacuation drill frequency and participation were accordance with the current edition of the Virginia Statewide Fire Prevention Code.
Evidence
  1. The fire drills were not documented as completed the months of January through August 2024.
  2. Upon request documentation of a fire drill, each shift per quarter was not provided.
  3. On 01/29/2025, LI interviewed staff 6 who confirmed that fire drills were not completed the months of January through August 2024.
Plan of correction
Emergency Evacuation drills have been conducted per state regulations as if June 27th 2025. Drills listed below were conducted and to be provided to state license inspector.
January 25, 2024Inspection1 violation
Inspection dates
01/25/2024
Areas reviewed
Administration and Administrative ServicesPersonnelStaffing and SupervisionAdmission, Retention and Discharge of ResidentsResident Care and Related ServicesBuildings and GroundsEmergency PreparednessMixed PopulationSafe, Secure Environment
Comments
Date of Inspection: January 25, 2024 Type of Inspection: Renewal Inspection If you have any questions or email changes, please do not hesitate to contact me at laura.lunceford@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov. Census 31 Number of records reviewed and interviews conducted- 8 records (staff and residents), 9 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. The Licensing Inspector observed the residents during activities, snacks and meal times. The Licensing Inspector reviewed the following at the time of inspection: fire drills, emergency drills, pharmacy review, activity calendars and menus. The Licensing Inspector and the Administrator discussed the risk assessment ratings for the violations for this inspection. Please complete the “plan of correction” and “date to be corrected” for each violation cited on the violation notice and returned it to the office. You will need to specify how the deficient practice will be or has been corrected. 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).
Violations
22VAC40-73-250-C
Based on staff record review and staff interview, it was determined that the staff records were not complete as required.
Evidence
  1. Four of four staff records were missing personal and social data as required.
Plan of correction
It was identified that 4 team member files were missing required paperwork: demographic and social. The Business Office Coordinator completed and audit for the 4 team member charts previously reviewed and identified the missing required information. Team member files will be completed as per regulatory requirements. The Business Office Coordinator will complete an audit of all team member files and all corrections will be made. Additional training will be provided to the communities Business Office Coordinator on the required forms and the importance of the team member file being complete before the start of employment. The Executive Director/Business Office Coordinator will randomly audit new team member files to assure that the required paperwork had been completed. The results of the audit and plan of correction will be discussed during the Quality Assurance Performance Improvement meetings, with the Executive Director and the Management Team and changes will be made to the monitoring plan based on the results as needed.
November 27, 2023Inspection0 violations
Inspection dates
11/27/2023
Areas reviewed
Administration and Administrative ServicesPersonnelAdmission, Retention and Discharge of ResidentsResident Care and Related Services
Comments
Date of Inspection: November 27, 2023 Type of Inspection: Monitoring Inspection If you have any questions or email changes, please do not hesitate to contact me at laura.lunceford@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov. Census 28 Number of records reviewed and interviews conducted- 10 records, 8 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. The Licensing Inspector observed the residents during activities, snack time and meals. The Licensing Inspector reviewed resident charts and interviewed staff and residents during the inspection.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
July 31, 2023Inspection0 violations
Inspection dates
07/31/2023
Areas reviewed
Administration and Administrative ServicesPersonnelStaffing and SupervisionAdmission, Retention and Discharge of ResidentsResident Care and Related ServicesResident Accommodations and Related ProvisionsBuildings and GroundsEmergency PreparednessMixed PopulationSafe, Secured Environment
Comments
Date of Inspection: July 31, 2023 Type of Inspection: Initial inspection If you have any questions or email changes, please do not hesitate to contact me at laura.lunceford@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov. There were no residents in care at the time of inspection. The Licensing Inspector conducted an announced initial inspection. The Licensing Inspector toured the physical plant, verified window and room measurements, policies and procedures, staff and resident records files. The Building, Fire and Health Inspections have been submitted and reviewed. No violations were found at the time of inspection.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.