7
Inspections
On record
3
With violations
Visits that cited something
4
Clean visits
Nothing cited
12
Violations cited
Individual findings
10
Standards cited
Distinct rules
1
Complaint visits
Prompted by a complaint

Cogir of Alexandria Fillmore was inspected 7 times between July 7, 2023 and April 22, 2026 by the Virginia Department of Social Services. 3 of those visits ended with violations cited and 4 with none. Across that history VDSS cited 12 violations under 10 distinct standards. 1 inspection was 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
03/31/2027
Administrator
Christina Bernstein
Licensing inspector
Nina Wilson
Inspector phone
(703) 635-6074
Approved for
Assisted Living · Non-Ambulatory

Inspection History

7

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

April 22, 2026Inspection0 violations
Inspection dates
04/22/2026
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND
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: 04/22/2026 Time in: 11:51 AM Time out: 12:30 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 04/06/2026 regarding allegations in the area(s) of: Resident Care and Related Services and Building and Ground Number of residents present at the facility at the beginning of the inspection: 86 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: Licensing inspector observed residents entering and exiting the facility for community outings and dinging for lunch. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
March 13, 2026Inspection6 violations
Inspection dates
03/13/2026, 03/17/2026
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS
Technical assistance
Licensing inspector (LI) reviewed the following standards with the facility: 22VAC40-73-320, 22VAC40-73-325, 22VAC40-73-550, 22VAC40-73-950, and 22VAC40-73-970.
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: 03/13/2026 Time in: 9:48 AM Time out: 6:47 PM 03/17/2026 Time in: 2:14 PM Time out: 3:50 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: 85 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 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 (LI) observed residents dining for lunch and dinner, residents entering and exiting the facility for community outings, and residents engaged in scheduled activities. 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. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of these inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov
Violations
22VAC40-73-640-A
Based on licensing observation and staff interview, the facility failed 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 a plan for proper disposal of medication.
Evidence
  1. During the onsite inspection, 03/17/2026 licensing inspector (LI) requested to review resident 13’s medication cart. During the review, LI noted that an over-the-counter (OTC) medication, Dulcolax was in the medication cart. Staff 11 stated that the medication was removed from resident 13’s unit on a separate day and stored in the medication cart. Staff 7 confirmed that resident 13 does not have a physician’s order for Dulcolax.
  2. The medication management plan stated, “discontinued, expired, or unused medications shall be removed from active medication supply and stored securely until disposal.” Staff 7 and staff 11 acknowledged that the OTC medication was not disposed of properly.
Plan of correction
1. Steps to correct the noncompliance with the standard: • The OTC medication (Dulcolax) was removed from the medication card on 3/17/2026, in the presence of the LI. The Director of Health and Wellness and the LPN in Charge disposed of the medication on 3/17/2026. 2. Measures to prevent the noncompliance form occurring again: • The Director of Health & Wellness will re-educate the Registered Medication Aides (RMAs) and the LPNs on procedures for any medication, for which resident does not have a current order, and review the medication management plan. • The LPNs and RMAs will conduct weekly medication carts to MAR audits to ensure compliance with the standard. 3. Person(s) responsible for implementing each step and/or monitoring any preventive measure(s): • The Director of Health & Wellness will be responsible for implementation and monitoring, to ensure compliance with the standard.
22VAC40-73-870-A
Based on observations and staff interview, the facility failed to ensure that the interior and exterior of all buildings should be maintained in good repair and kept clean and free of rubbish.
Evidence
  1. During the onsite inspection, 03/13/2026, licensing inspector (LI) toured the second floor, wellness office and noted ceiling tile missing in the ceiling; and on the tour of the fourth floor. LI observed cabinets missing, leaving an opening in the floor, a spout exposed, chipped painting, and discolored walls.
  2. During the onsite inspection, 03/13/2026, staff 6 and staff 7 confirmed that the wellness office was missing a ceiling tile and the fourth floor was missing cabinets, which indicated that those areas of the building was not maintained in good repair.
Plan of correction
Systemic Changes / Preventative Measures • Implemented a weekly environmental audit conducted by maintenance and department leadership to identify repair needs. • Utilize the work order tracking system with priority levels to ensure timely completion of all maintenance items. • Conducted staff re-education on promptly reporting environmental concerns to maintenance and placing a work order. • Added monthly leadership walkthroughs to ensure ongoing compliance with building condition standards. Monitoring Plan • Executive Director and Maintenance Director will review weekly work order logs for compliance. • Any identified deficiencies will be corrected within 24–72 hours, depending on severity. • Ongoing compliance will be reviewed during monthly quality assurance meetings.
22VAC40-73-620-B
Based on staff record review and staff interview, the facility failed to ensure that the oversight specified in subsection A of this section should be on site and include the following: action taken in response to the recommendations noted in subdivision 3 of this subsection should be documented in the resident’s record.
Evidence
  1. The oversight of special diet (11/17/2025) provided a recommendation for resident 4, “speech therapy consult for dysphagia and least restrictive diet textures.”
  2. Upon request, 03/13/2026, the facility did not provide documentation of action taken in response to the recommendations noted in the oversight of special diet.
  3. During the onsite inspection, 03/13/2026, staff 7 acknowledged that documentation of action taken in response to the recommendations noted in the oversight of special diet was not provided to licensing inspector upon request.
Plan of correction
1. Steps to correct the noncompliance with the standard: • Resident 4 had a Home Health Speech evaluation on 03/16/2026. 2. Measures to prevent the noncompliance from happening again: • Oversight of Special Diet Report will be reviewed upon receipt. All recommendations will be followed up on with physicians/NPs as indicated. The Director of Health and Wellness will review to ensure that action has been taken on the recommendations no later than 14 business days after receipt of report. 3. Person(s) responsible for implementing each step and/or monitoring any preventive measure(s) The Director of Health and Wellness will be responsible for ensuring that all recommendations are acted upon and implemented as required
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, 03/17/2026, the facility did not provide documentation of the resident emergency reviews completed at least every six months.
  2. During the onsite inspection, 03/17/2026, staff 7 acknowledged that documentation of resident emergency reviews were not provided to licensing upon request.
Plan of correction
Corrective Actions Taken • A comprehensive resident emergency procedures review has been completed with all current staff. • All staff participating in the training have signed and dated attendance documentation, which is now maintained in a centralized compliance file. Systemic Changes / Preventative Measures • Implemented a biannual training schedule to ensure emergency procedures are reviewed with all staff every six months. • Established a standardized sign-in sheet and documentation process to capture employee signatures and dates for each training. • Assigned responsibility to the Executive Director and/or designee to oversee compliance and ensure trainings are completed timely. • Incorporated emergency procedure reviews into new hire onboarding to ensure immediate compliance upon hire. Monitoring Plan • A tracking log will be maintained to monitor completion of all required staff trainings. • Compliance will be reviewed during monthly QA/management meetings. • Any staff who miss scheduled training will be required to complete a make-up session within 7 days.
22VAC40-73-460-B
Based on record review and staff interview, the facility failed to ensure care provision and service delivery should be resident-centered to the maximum extent possible and include prompt response by staff to resident needs as reasonable to the circumstances.
Evidence
  1. February 2026 call pendant report indicated that resident 7 requested support on 02/26/2026 at 8:11 am and received a response in 42 minutes; requested support 02/27/2026 at 4:06 am and received a response in 3 hours and 16 minutes.
  2. February 2026 call pendant report indicated that resident 8 requested support on 02/26/2026 at 8:12 am and received a response in 33 minutes.
  3. February 2026 call pendant report indicated that resident 6 requested support on 02/26/2026 at 7:26 pm and received a response in 33 minutes.
  4. February 2026 call pendant report indicated that resident 5 requested support on 02/27/2026 at 4:16 am and received a response in 1 hour and 16 minutes.
  5. February 2026 call pendant report indicated that resident 9 requested support on 02/27/2026 at 9:44 am and received a response in 45 minutes; and 02/27/2026 at 12:13 pm and received a response in 34 minutes.
  6. February 2026 call pendant report indicated that resident 10 requested support on 02/27/2026 at 5:19 am and received a support in 1 hour and 21 minutes.
  7. During the onsite inspection, 03/13/2026, licensing inspector (LI) asked staff 7 the expectation for staff to respond to the call pendant request. Staff 7 stated, 20 minutes or earlier. Staff 7 acknowledged that not all resident call pendant requests received a prompt response by staff and that the facility does not have a policy regarding call pendants.
Plan of correction
• With respect to the specific resident/situation cited: Residents #7, 6, 5, 9, 10 did not experience any negative outcomes. • With respect to how the facility will identify residents/situations for the identified concerns: Health and Wellness Director (HWD) followed up on all the residents impacted. Reviewed identified that the residents were serviced timely, it was the pendant reset option that caused the appearance of extended times. The pendent reset option was reviewed with the front line team and the communities service provider to ensure proper resetting occurs after a call bell alert. HWD conducted Call Bell audits in February and March to ensure resetting the alerts were working properly. • With respect to what systemic measures have been put into place to address the stated concern HWD is reviewing response times in the community with response times. The community does have a Call Alert Policy (GP18-Resident Alert Call Sysytem) and it has also been reviewed with team member #7. • With respect to how the plan of correction will be monitored The Executive Director or designee is responsible for implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur.
22VAC40-73-450-F
Based on resident record review and staff interview, the facility failed to ensure that individualized service plans should be reviewed and updated at least once every 12 months and as needed for a significant change of a resident’s condition.
Evidence
  1. Resident 1’s ISP (01/16/2026) stated, “independent, resident does not require assistance with toileting” and “independent, resident does not require assistance with transferring;” however, the Uniform Assessment Instrument (UAI, 01/20/2026) indicated that mechanical help is needed with tolieting and tranfers.
  2. Resident 3’s ISP (03/13/2026) stated, “independent, resident does not require assistance with bathing,” “independent, resident does not require assistance with dressing,” and “independent, resident does not require assistance with toileting;” however, the UAI (11/26/2025) indicated that mechanical help is needed wiht bathing, dressing, and toileting.
  3. Resident 4’s ISP (03/03/2026) did not include toileting support; however, the UAI (01/20/2026) indicated mechanical help with toileting.
  4. Resident 5’s ISP (02/03/2026) did not include bowel and bladder support; however, the UAI (12/30/2025) indicated “incontinent, weekly or more.”
  5. During the onsite inspection, 03/13/2026, staff 7 acknowledged that resident 1, resident 3, resident 4, and resident 5’s ISPs were not updated to include information obtained from their UAIs.
Plan of correction
1. Steps to correct the compliance with the standard: Resident #1: New UAI, assessment and ISP meeting scheduled with resident for 04/07/2026. Resident #3: New UAI, assessment and ISP meeting scheduled with resident for 04/06/2026. Resident #4: New UAI, assessment and ISP meeting scheduled for 04/05/2026. Resident #5: New UAI, assessment and ISP meeting scheduled for 04/08/2026. 2. Measures to prevent non-compliance from occurring again: The Director of Health & Wellness provided education to the nurses regarding the requirement for UAI and ISP documentation. The Director of Health & Wellness will review all UAI and ISP documentation prior to signing the documents as completed. 3. Person(s) responsible for implementing each step and/or monitoring any preventive measure: The Director of Health & Wellness will be responsible for implementing and monitoring each step and preventive measures; to include identifying and correcting any discrepancies, to ensure compliance with the standard.
March 26, 2025Inspection4 violations
Inspection dates
03/26/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS
Technical assistance
Licensing inspector (LI) reviewed the following standards with the facility: 22VAC40-73-70, 22VAC40-73-490. and 22VAC40-73-680.
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: 03/26/2025 Time in: 10:43 AM Time out: 5:08 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: 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: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: LI observed the physical plant of the facility. LI observed the residents dining for lunch, participating in scheduled activities, interacting with visitors, and entering and exiting the facility from the community. 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. 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
22VAC40-73-870-I
Based on observation and staff interview, the facility failed to ensure that elevators were in good running condition and inspected annually.
Evidence
  1. The elevator inspection expired on 03/31/2022. The elevator continued to fail inspections due to the phone line not working.
  2. On 03/26/2025, LI interviewed staff 6 who confirmed that the elevator had not passed inspection since 03/31/2022.
Plan of correction
1. Elevators had phone lines installed and passed inspection on 4/30/2025. 2. Elevators will be scheduled annually for inspection. 3. Maintenance Director educated on timely annual inspections and compliance 4. Maintenance Director/designee review permits intermittently to ensure compliance with annual inspections. 5. Date of Compliance 6/20/2025
22VAC40-73-450-F
Based on resident review and staff interview, the facility failed to review and update the individualized service plan (ISP) at least once every 12 months and as needed for a significant change of a resident’s condition.
Evidence
  1. Resident 4’s fall risk rating (completed, 01/20/2025) indicated to implement high risk fall prevention interventions; however, the ISP (completed on 11/14/1024) indicated a moderate risk for falls.
Plan of correction
1. Resident #4 ISP was updated for change in condition. 2. Residents service plans reviewed and updated. 3. Health and Wellness team educated on updating ISP after changes in condition. 4. Health and Wellness Director/designee will review charting after falls for compliance. 5. Date of Compliance 6/20/25.
22VAC40-73-680-D
Based on resident record and staff interview, the facility failed to ensure that medications were administered in accordance with the physician’s or other prescriber’s instructions and consistent with the standards of practice outlined in the current medication aid curriculum approved by the Virginia Board of Nursing.
Evidence
  1. Resident 3 had an order for Levothyroxin tab 88 MCG, Mirtazapine tab 30 MG ODT, Vitamin C 1000 MG, and Vitamin E Cap 180 MG; however, these medications were not present in medication cart at the time of inspection.
  2. Resident 4 had an order for Aspirin Low CHW 81 MG, Hydralazine tab 10 MG, Vitamin B12 Ortal Tablet Extended, and Release 1000 MCG; however, these medications were not present in the medication cart at the time of inspection.
  3. On 03/26/2025, LI completed the medication review with staff 5, who confirmed that resident 3 and resident 4’s medications were not present in the medication cart.
Plan of correction
1. Resident #3 and Resident #4 medication was available on 3/26/25 and administered in accordance with Virginia standards of practice. 2. Medication carts were reviewed to ensure all residents medications were available. 3. Health and Wellness team were educated on processes for ordering and medication delivery. 4. Health and Wellness Director/designee will review medication carts intermittently to ensure medications are available. 5. Date of Compliance 6/20/25
22VAC40-73-260-A
Based on staff review and staff interview, the facility failed to ensure that each direct care staff member maintained current certification in first aid from American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department.
Evidence
  1. Staff 1 and staff 2’s record contained a CPR certification from NationalCPRFoundation.
  2. On 03/26/2025, LI interviewed staff 5 confirmed that staff 1 and staff 2’s CPR certifications were not from the required organizations.
Plan of correction
1. Staff #1 and Staff #2 obtained current certification in CPR from an acceptable institution. 2. All staff charts were reviewed for certification and all in compliance as of 4/4/2025. 3. Employees were educated on keeping certifications current. 4. BOM/Designee will monitor employee charts for current certifications. 5. Date of Compliance 6/20/2025
February 6, 2025Complaint survey0 violations
Inspection dates
02/06/2025
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-80 COMPLAINT INVESTIGATION
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: 02/06/2025 Time in: 12:30 p.m. Time out: 3:425 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 11/25/2024 regarding allegations in the area(s) of: Administration and Administrative Services and Admission, Retention and Discharge of Residents Number of residents present at the facility at the beginning of the inspection: The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 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 (LI) toured the physical plant of the facility. LI observed residents participating in scheduled activities, dining in the dining room for lunch, and exiting the facility for community outings. Additional Comments/Discussion: none An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov. Should you have any questions, please contact Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov.
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
March 29, 2024Inspection2 violations
Inspection dates
03/29/2024
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND
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: 03.29.2024; Start Time: 10:39 am End Time: 3:31 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: 73 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: 6 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: LI toured the physical plant of the facility, and observed residents involved in independent pursuits. LI also observed a medication pass. 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 703.635.6074or by email at nina.wilson@dss.virginia.gov
Violations
22VAC40-73-660-A-1
Based on medication pass observation the facility failed to ensure that the medication cabinet was locked prior to walking away to administer medication.
Evidence
  1. 03/29/24 LI observed staff to prepare medications, turned to administer the medication but failed to lock the prior to walking away to administer the medication to the resident. LI prompted staff to secure medication cart.
Plan of correction
In respect to the specific resident/situation cited: The RMA was provided in-service education on 03/29/2024: Securing the Medication Cart During a Medication Pass. In respect to how the facility will identify residents/situations with the potential for the identified concerns: Medication Pass observations will be completed by the Director of Clinical Services or designee weekly for the next 4 weeks then quarterly, thereafter. With respect to what systemic measures have been put into place to address the stated concern: Random medication cart checks will be completed by the Director of Clinical Services or designee weekly for 4 weeks, then randomly thereafter to verify that medication carts are secured appropriately during medication pass.
22VAC40-73-870-I
Based on Elance at Alexandria’s records, it was found that the facility failed to provide a certificate of inspection.
Evidence
  1. The elevator certificate was dated 03/31/2022.
Plan of correction
In respect to the specific resident/situation cited: Elevator repairs for the 4 elevators have been ongoing. Initial repairs began 05/09/2024, additional parts have been ordered with an estimated completion date of 05/30/2024. The City of Alexandria re-inspection is scheduled for June 2024. In respect to how the facility will identify resident/situations with the potential for the identified concerns: The community work order/task list system will be monitored weekly, by the Director of Environmental Services. With respect to what systemic measures have been put in place to address the stated concern: Weekly monitoring of the community work order /task list system, by the Director of Environmental Services to ensure that all inspections are scheduled timely so that any follow up/repairs can be completed, with a re-inspection prior to expiration date of certificates/licenses.
January 3, 2024Inspection0 violations
Inspection dates
01/03/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS
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: 1/3/2024 (1:00 PM - 5:00 PM) Number of residents present at the facility at the beginning of the inspection: 79 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of interviews conducted with staff: 2 Observations by licensing inspector: Meal, medication administration An exit meeting was held. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (703) 431-4247 or by email at m.massenberg@dss.virginia.gov.
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
July 7, 2023Inspection0 violations
Inspection dates
07/07/2023
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS
Technical assistance
Documentation was discussed with the provider.
Comments
An unannounced initial inspection was conducted on 7/7/23. At the time of entrance, 95 residents were in care. An activity was observed. Building and grounds were inspected. Facility documentation was observed and records were reviewed. The sample size consisted of three resident records and three staff records. No violations were cited. An exit meeting was held.
Violations
No violations cited
The inspector documented no violation of standards at this inspection.