Virginia DSS · Assisted Living Facility

Cogir of West End, Alexandria

📍 5550 Cardinal Place, Alexandria, VA, 22304

ID 49925One Year licenseActive
11
Inspections
On record
7
With violations
Visits that cited something
4
Clean visits
Nothing cited
36
Violations cited
Individual findings
29
Standards cited
Distinct rules
6
Complaint visits
Prompted by a complaint

Cogir of West End, Alexandria was inspected 11 times between September 5, 2023 and March 11, 2026 by the Virginia Department of Social Services. 7 of those visits ended with violations cited and 4 with none. Across that history VDSS cited 36 violations under 29 distinct standards. 6 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
03/14/2027
Administrator
Nathan Salisbury
Licensing inspector
Nina Wilson
Inspector phone
(703) 635-6074
Approved for
Non-Ambulatory · Special Care Unit · Assisted Living

Inspection History

11

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

March 11, 2026Complaint survey4 violations
Inspection dates
03/11/2026
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 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: 03/11/2026 Time in: 1:20 PM Time out: 3:15 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 02/18/2026 regarding allegations in the area(s) of: Personnel, Staffing and Supervision, Resident Care and Related Services and Complaint Investigation. Number of residents present at the facility at the beginning of the inspection: 72 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: 3 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Licensing inspector (LI) observed residents 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 allegations of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint(s) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of these inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov
Violations
63.2-1808-A-11
Based on video recording, the facility failed to ensure that residents were treated with courtesy, respect, and consideration as a person of worth, sensitivity, and dignity.
Evidence
  1. Collateral contact 1 provided a video recording on 02/15/2026 of resident 3 receiving ADL and transfer support by staff 5 on 02/03/2026. During the video, staff 5 can be seen assisting resident 3 to bed around 6:26 pm. As staff 5 assists the resident 3 with standing, resident 3 falls face first onto the bed. Staff 5 is then seen placing forearm on the back of resident 3, advised resident 3 not to move, and called for assistance of Staff 4. Approximately 6:29 pm, Staff 4 enters resident 3’s room to assist with transferring to the bed. Once resident 3 is in bed, staff 5 can be seen pulling resident 3’s arm to assist with getting to the side of the bed, then staff 4 is seen pulling resident 3’s leg while staff 5 pulls the resident’s clothing to successfully transfer the resident to the side of their bed.
  2. The video recording reflected that resident 3 was not treated with courtesy, respect, and consideration as a person of worth, sensitivity, and dignity during their transfer to bed on 02/03/2026 by staff 4 and staff 5.
Plan of correction
Not published by VDSS.
22VAC40-73-450-F
Based on resident record review and staff interview, the facility failed to ensure that individualized service plans (ISP) 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 3’s Uniformed Assessment Instrument (UAI, 01/22/2026) indicated support with transferring, “physical assistance 2,” (mechanical and human help).
  2. Resident 3’s ISP (dated, 07/23/2025) stated, “transferring: extensive. Resident requires frequent hands on assistance with transfers and/or change in person.” The ISP does not indicate a one or two person assist with transfers.
  3. During the onsite inspection, 03/11/2026, staff 1 stated that resident 3’s ISP should indicate the level of assistance required and confirmed that resident 3’s ISP does not indicate a one or two person assist with transfers.
Plan of correction
BOD, ED or designee will audit all staff records for compliance. BOD, ED or designee will conduct an all staff meeting to review resident rights and obtain appropriate acknowledgment. BOD will maintain a tracker to remain in compliance annually. ED will conduct an audit every month to ensure compliance.
22VAC40-73-450-F
Based on resident record review and staff interview, the facility failed to ensure that individualized service plans (ISP) 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 3’s Uniformed Assessment Instrument (UAI, 01/22/2026) indicated support with transferring, “physical assistance 2,” (mechanical and human help).
  2. Resident 3’s ISP (dated, 07/23/2025) stated, “transferring: extensive. Resident requires frequent hands on assistance with transfers and/or change in person.” The ISP does not indicate a one or two person assist with transfers.
  3. During the onsite inspection, 03/11/2026, staff 1 stated that resident 3’s ISP should indicate the level of assistance required and confirmed that resident 3’s ISP does not indicate a one or two person assist with transfers.
Plan of correction
HWD, ED, or designee will audit all ISP's for residents that receive care services and ensure compliance on completing ISP annually and/or change in condition. HWD will monitor assessment due dates to ensure timely completion. HWD will complete assessment upon notification of resident change in condition and conduct a care plan meeting. ED and/or HWD will audit assessment due dates monthly to ensure compliance. ED will attend care plan meetings post assessment to ensure completion and discuss with the family.
22VAC40-73-550-G
Based on staff record review and staff interview, the facility failed to ensure that the rights and responsibilities of residents in assisted living facilities should be reviewed annually with each staff person.
Evidence
  1. of this review should be the staff person’s written acknowledgment of having been informed, which should include the date of the review and should be filed in the staff person’s record. Evidence:
  2. Staff 5 (hire date, 10/24/2024) records indicated that resident rights training was completed on 02/22/2025.
  3. During the onsite inspection, 03/11/2026, staff 1 and staff 2 acknowledged that staff 5 did not complete resident rights training annually.
Plan of correction
Not published by VDSS.
March 11, 2026Complaint survey4 violations
Inspection dates
03/11/2026
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-80 COMPLAINT INVESTIGATION
Technical assistance
The licensing inspector (LI) reviewed the following standards with the facility: 22VAC40-73-640. LI recommends that the facility submits the medication management plan for VDSS clinical team to review.
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: 03/11/2026 Time in: 3:15 PM Time out: 7:14 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 11/17/2025 regarding allegations in the area(s) of: Staffing and Supervision, Resident Care and Related Services and Complaint Investigation. Number of residents present at the facility at the beginning of the inspection: 72 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Licensing inspector (LI) observed residents entering and exiting the facility for community outings and residents interacting with peers and staff in the lobby area. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s); area(s) of non-compliance with standard(s) or law were: Resident Care and Related Services and Complaint Investigation A violation notice was issued; any violation(s) not related to the complaint(s) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of these inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov
Violations
22VAC40-73-280-B
Based on record review and staff interview, the facility failed to maintain a written plan that specified 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. Upon request, 03/11/2026 the facility did not provide the written staffing plan to the licensing representative.
  2. During the onsite inspection, 03/11/2026, staff 1 confirmed that the written staffing plan was not provided to the licensing representative upon request.
Plan of correction
HWD, ED, or designee will audit all staffing plans for residents that receive care services and ensure the appropriate staff needed is implemented. HWD will ensure staffing plan reflects the number of staff needed to perform care services during completion of care plan. ED will review the staffing plan and ensure it reflects the number of staff needed for care services post care plan meeting.
22VAC40-73-680-D
Based on resident record review 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 outlines in the current medication aide curriculum approved by the Virginia Board of Nursing.
Evidence
  1. Resident 1 was prescribed Antacid 500 MG (take 1 tablet by mouth three times daily for indigestion for 7 days; start date, 05/20/2025); however, June 2025 medication administration record (MAR) indicated that resident 1 was administered this medication until 06/19/2025.
  2. Resident 1 was prescribed Estradiol Cre 0.01% (insert 1 GM at bedtime for 14 days; start date, 05/21/2025); however, June and July’s 2025 MAR indicated that resident 1 was administered this medication until 07/08/2025.
  3. Resident 1 was prescribed Fosfomycin Tromethamine 3 GM (3 GM by mouth Q72) every 3 days at 8:00 AM; start date, 08/28/2025); however, August 2025 MAR indicated that resident 1 was not administered this medication until 08/31/2025.
  4. Resident 1 was prescribed Triad Wound Dressing (1 gram one time per day every day at 8:30 AM; start date, 09/12/2025); however, September 2025 MAR indicated that resident 1 was not administered this medication until 09/14/2025.
  5. Resident 1 was prescribed Lactulose 10 GM/15 ML (15 milliliter by mouth one time per day every day at 8:00 AM; start date, 11/04/2025); however, November 2025 MAR indicated that resident 1 was not documented as administered after 11/06/2025.
  6. During the onsite inspection, 03/11/2026, licensing inspector (LI) reviewed June through November 2025 MARs and noted that resident 1’s (prescribed Freestyle KIT LITE, use as directed to check blood sugar before meals and at bedtime) blood sugar was inconsistently documented as completed (June, 9 days; July, 20 days; August,20 days; September, 26 days; October, 20 days; and November, 7 days.
  7. During the onsite inspection, 03/11/2026LI reviewed June through November 2025 MARs and noted that resident 1’s (prescribed Losartan 50 MG, take 1 tablet by mouth once daily for blood pressure, hold for SBP less than 110) blood pressure was inconsistently documented as completed (June, 9 days; July, 8 days; August, 28 days; September, 20 days; October, 16 days; and November, 4 days.
  8. Resident 1 was prescribed Glargin YFGN 100U/ML (inject 40 units subcutaneously twice daily for diabetes mellitus; start date, 05/20/2025); however, this medication was not documented as administered on 06/18/2025.
  9. Resident 1 was prescribed Sucralfate 1 GM (take 1 tablet by mouth three times daily for supplement; start date, 06/19/2025); however, this medication was not documented as administered at 8:00 AM on 07/04/2025.
  10. Resident 1 was prescribed Acetaminophen 325 MG (take 2 tablets by mouth three times daily for pain; start date, 05/20/2025); however, this medication was not documented as administered at 2:00 PM on 08/15/2025.
  11. Resident 1 was prescribed Lactulose 10 MG (give 30 ML by mouth once daily for bowel regimen. Hold for loose stools or diarrhea; start date, 05/21/2025); however, this medication was not documented as administered or held on 08/21/2025.
  12. Resident 1 was prescribed PEG 3350 POW (mix 17 GM in 8 ounces of liquid and give orally once daily for bowel movement); however, this medication was not documented as administered on at 8:00 AM on 08/21/2025.
  13. During the onsite inspection, 03/11/2026, staff 1 confirmed that resident 1 was prescribed Antacid 500 MG, Estradiol Cre 0.01%, Fosfomycin Tromethamine 3 GM, Triad Wound Dressing, and Lactulose 10 GM/15 ML. Staff 1 also acknowledged that June – September and November 2025’s MARs indicated that resident 1 was not administered their medication in accordance with the physician’s instructions as entered by the pharmacy.
Plan of correction
HWD, ED or designee will audit all physician orders and complete med cart audits to ensure staff is following updated orders. HWD, ED will re-educate staff on physician order review and admission expectations regarding physician orders. HWD, RCC, ED or designee will complete an ongoing weekly quality assurance meeting to perform continual physician order audits. HWD, Wellness Nurse, or designee will conduct a weekly MAR review for accuracy.
22VAC40-73-390-A
Based on resident record and staff interview, the facility failed to ensure that financial arrangement for accommodations, services, and care that specified listing of specific charges for accommodations, services, and care to be made to the individual resident signing the agreement, the frequency of payment, and any rules relating to nonpayment.
Evidence
  1. Resident 1 admitted to the facility on 06/01/2025.
  2. Resident 1’s agreement (signed, 04/30/2025) indicated that the “Assisted Living – Care Level monthly charge was $3,220.00;” however, the Schedule of Resident Rates and Fees and Description of Service Levels (Exhibit 2) do not match the $3,220.00, Care Level monthly charge(s).
  3. During the onsite inspection, 03/11/2026, staff 3 acknowledged that Exhibit 2 does not match the care level charge of $3,220.00. Staff 3 stated that there was a change of fees that occurred around April 2025 and the most recent and accurate Exhibit 2 may not have been added to resident 1’s agreement. Staff 3 was unable to provide the accurate resident rates and fees for the month of April 2025 to compare to resident 1’s monthly Assisted Living – Care Level charge.
Plan of correction
BOD, ED, or designee will audit all financial records for current residents to ensure appropriate pricing is reflected on both agreement and schedule of fees. CRD will ensure the resident's agreement and schedule of fees are accurate while signing agreement and issue the resident a copy. ED will ensure the resident's agreement and schedule of fees are accurate upon move in. BOD will ensure the resident's agreement and schedule of fees are accurate prior to moving the resident into the system.
22VAC40-73-650-A
Based on resident record review and staff interview, the facility failed to ensure that no medication, dietary supplement, diet, medical procedure, or treatment should be started, changed, or discontinued by the facility without a valid order from a physician or other prescriber. Medications include prescription, over-the-counter, and sample medications.
Evidence
  1. Upon request, 03/11/2025, the facility did not provide resident 1’s written or discontinued orders from 06/01/2025 through 11/2025.
  2. During the onsite inspection, 03/11/2026, staff 1 confirmed that written and discontinued orders were not provided to licensing upon request. Staff 1 also acknowledged that the physician order sheet that was provided to licensing did not include any medications that were discontinued or discontinue order dates.
Plan of correction
HWD, ED or designee will audit all physician orders and complete med cart audits to ensure staff is following updated orders. HWD, ED will re-educate staff on physician order review and admission expectations regarding physician orders HWD, RCC, ED or designee will complete an ongoing weekly quality assurance meeting to perform continual physician order audits.
January 29, 2026Inspection13 violations
Inspection dates
01/29/2026
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Technical assistance
Licensing inspector (LI) reviewed the following standards with the facility: 22VAC40-73-220, 22VAC40-73-260, 22VAC40-73-320, 22VAC40-73-325, 22VAC40-73-490, and 22VAC40-73—450.
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: 01/29/2026 Time in: 10:32 AM Time out: 5:30 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: 77 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: 6 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 4 Observations by licensing inspector: Licensing inspector (LI) observed residents participating in physical therapy, entering and exiting the facility for community outings, interacting with staff, peers, and visitors, and engaging 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
22VAC40-73-100-A
Based on record review and staff interview, the facility failed to ensure that the administrator should ensure at least an annual review of infection prevention and policies and procedures for any necessary updates. A licensed health care professional, practicing within the scope of his profession and with training in infection prevention, should be included in the review to ensure compliance with applicable guidelines and regulations. Documentation of the review should be maintained at the facility.
Evidence
  1. Upon request, 01/29/2026, the facility did not provide documentation of the annual review of the infection control program.
  2. During the onsite inspection, 01/29/2026, staff 7 stated that a review was completed with staff, but confirmed documentation of the review was not maintained at the facility.
Plan of correction
ED, HWD, or designee will assign a licensed healthcare professional to facilitate annual in-service on infection control program. ED, HWD, or designee will in-service new associates at onboarding and annually thereafter. ED, HWD, or designee will conduct an all staff training annually to ensure compliance with all staff. An audit will be conducted to ensure complaince with current staff.
22VAC40-73-950-E
Based on record review and staff interview, the facility should develop an orientation and semi-annual review on the emergency preparedness and response plan for all staff, residents, and volunteers, with emphasis placed on an individual’s respective responsibilities. The review should be documented by signing and dating.
Evidence
  1. Upon request, 01/29/2026, the facility did not provide a semi-annual review on the emergency preparedness and response plan for all staff and residents.
  2. During the onsite inspection, 01/29/2026, staff 7 confirmed that the facility did not provide documentation of a semi-annual review with signatures and dates on the emergency preparedness and response plan for all staff and residents to licensing upon request.
Plan of correction
BOD, ED, or designee will review the emergency preparedness with all new hires at onboarding prior to working within the community. BOD, ED, or designee will schedule an all staff meeting to review the emergency preparedness every 6 months, twice per year to meet the regulatory statndard.
22VAC40-73-290-A
Based on record review and staff interview, the facility failed to maintain a written work schedule that included the name and job classifications of all staff working each shift, with an indication of whomever was in charge at any given time. The facility should maintain a copy of the schedule for two years.
Evidence
  1. Upon request, 01/29/2026, the facility did not provide April 2025 and June 2025’s written work schedule to licensing upon request.
  2. During the onsite inspection, 01/29/2026, staff 7 confirmed that April 2025 and June 2025’s written work schedules to include the name and job classifications of all staff working each shift, with an indication of whomever was in charge at any given time was not provided to licensing upon request. Staff 7 confirmed that a copy of April 2025 and June 2025’s written work schedule was not maintained at the facility.
Plan of correction
HWD, ED, or designee will audit the printed schedules to ensure regulatory complaince. HWD, ED, or designee will obtain past schedules to meet regulation and maintain on hand as required for 2 years. HWD, ED, or designee will check printed schedules monthly for record compliance to include schedule changes, attendance, and supervisory indication.
22VAC40-73-990-B
Based on record review and staff interview, the facility failed to ensure that the 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, 01/29/2026, the facility did not provide documentation of a review of procedures for resident emergencies.
  2. During the onsite inspection, 01/29/2026, staff 7 provided a review of mental health emergencies. Staff 7 confirmed that the review did not cover all of the procedures in the plan for resident emergencies required in subsection A.
Plan of correction
MD, ED, or designee will review resident emergency protocols with all new associates at orientation upon hire. MD, ED, or designee will schedule an all staff meeting to review resident emergency protocols every 6 months, twice per year to meet the regulatory standard.
22VAC40-73-150-B-2
Based on licensing inspector’s observation and staff interview, the facility failed to notify the department’s regional licensing office in writing within 14 days of a change in a facility’s administrator, including the resignation of an administrator, appointment of an acting administrator, and appointment of a new administrator, except that the time period for notification may differ as specified in subdivision 2 of this subsection.
Evidence
  1. During the onsite inspection, 01/29/2026, staff 7 confirmed that staff 11’s last day of employment was 11/12/2025.
  2. Staff 8 confirmed that collateral contact 2 was notified via email on 11/25/2025; however, the regional licensing office was not included on the email notification.
Plan of correction
ED, BOD, or designee will ensure to notify the regional office in addition to the Long Term Care Board upon administrator changes.
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. Such record should include the date and time of the drill, the number of residents participating, and weather conditions.
Evidence
  1. July 2025 through December 2025’s fire drill records did not include the date and time of the drill, the number of residents participating, and weather conditions.
  2. During the onsite inspection, 01/29/2026, staff 7 confirmed that fire drills records did not include the date and time of the drill, the number of residents participating, and weather conditions.
Plan of correction
Maintenance Director (MD) or designee will conduct an unnannounced evacuation drill monthly, rotating the shift in which the drill is conducted. There will be a meeting held immediately following the drill to review effectiveness and establish corrections needed. ED will ensure monthly evacuation drills are conducted and will partipate in the drills to provide additional expectations and standards. MD will maintain the attendance signature ledger to identify partipants and file in the ED's office.
22VAC40-73-560-I
Based on resident record review and staff interview, the facility failed to ensure that a current picture of each resident should be readily available for identification purposes or, if the resident refuses to consent to a picture, there should be a narrative physical description, which is annually updated, maintained in his file.
Evidence
  1. Resident 4’s (admit date, 12/22/2025) chart did not include a current picture readily available for identification purposes.
  2. During the onsite inspection, 01/29/2026, staff 7 confirmed that resident 4’s chart did not include a current picture or a narrative physical description.
Plan of correction
HWD, ED, or desigee will complete audit of all resident records to ensure compliance. HWD, ED or designee will audit new admission records monthly to ensure compliance. HWD, ED, or designee will capture resident photo or description upon admission. HWD, ED or designee will audit all admissions monthly for prior year's current month to update resident photo annually.
22VAC40-73-950-F
Based on record review and staff interview, the facility failed to ensure to review the emergency preparedness plan annually or more often as needed, document the review by signing and dating the plan, and make necessary plan revisions.
Evidence
  1. Upon request, 01/29/2026, the facility did not provide documentation of the emergency preparedness plan annual review.
  2. During the onsite inspection, 01/29/2026, staff 7 confirmed that documentation of the emergency preparedness plan annual review was not provided to licensing upon request.
Plan of correction
BOD, ED, or designee will review the emergency preparedness with all new hires at onboarding prior to working within the community. BOD, ED, or designee will schedule an all staff meeting to review the emergency preparedness every 6 months, twice per year to meet the regulatory standard.
22VAC40-73-970-A
Based on record review and staff interview, the facility failed to ensure that fire and emergency evacuation drill frequency and participation should be in accordance with the current edition of the Virginia Statewide Fire Prevention Code. The drills required for each shift in a quarter should not be conducted in the same month.
Evidence
  1. Upon request, 01/29/2026, the facility did not provide fire drill documentation for the months of March through June 2025.
  2. During the onsite inspection, 01/29/2026, staff 7 and staff 10 confirmed that fire drill documentation was not provided for the months of March through June 2025.
Plan of correction
Maintenance Director (MD) or designee will conduct an unnannounced fire drill monthly, rotating the shift in which the drill is conducted. There will be a meeting held immediately following the drill to review effectiveness and establish corrections needed. ED will ensure monthly fire drills are conducted and will partipate in the drills to provide additional expectations and standards. MD will maintain the attendance signature ledger to identify partipants and file in the ED's office.
22VAC40-73-45-B
Based on record review and staff interview, the facility failed to ensure that the statement was made on the liability insurance statement form provided by the department.
Evidence
  1. Upon request, 01/29/2026, the facility did not provide a liability insurance statement.
  2. During the onsite inspection, 01/29/2026, staff 7 confirmed that the liability insurance statement form was not provided to licensing upon request
Plan of correction
22VAC40-73-45. Liability Insurance ED, BOD or designee, will ensure completion of the liability insurance statement using the form provided by the Virginia Dept of Social Services. The form will be available to present upon request. ED, BOD, or designee will monitor the expiration date of the liability insurance to maintain compliance BOD has placed current liability completed statement form in business office.
22VAC40-73-980-H
Based on licensing observation and staff interview, the facility failed to ensure the availability of a 96-hour supply of emergency food. At least 48 hours of the supply must be on site at any given time, of which the facility’s rotating stock may be used.
Evidence
  1. During the onsite inspection, 01/29/2026, licensing inspector (LI) requested to view the storage area that held emergency food and water. LI observed the storage area with staff 9, who stated that the facility was cycling out emergency food, so it did not spoil. Staff 9 stated that the facility did not have 48 hours supply of emergency food on site.
  2. Picture taken.
Plan of correction
Culinary Director and ED will complete an audit of emergency food supply and replinish what is necessary to meet the state requirement. ED will complete a quarterly audit to ensure emergency supply food is within date and is fully stocked to meet requirement.
22VAC40-73-50-A
Based on record review and staff interview, the facility failed to ensure to prepare and provide a statement to the prospective resident and the prospective resident’s legal representative, if any, that discloses information about the facility. The statement should be on a form developed by the department.
Evidence
  1. Upon request, 01/29/2026, the facility did not provide a disclosure statement.
  2. During the onsite inspection, 01/29/2026, staff 7 confirmed that the disclosure statement was not provided to licensing upon request.
Plan of correction
ED, BOD will complete an audit of all resident charts for compliance and correction. CRD, BOD will ensure all new admissions are provided the disclosure statement at agreement signing and prior to admission. The ED will complete an additional check prior to admission to ensure compliance.
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. April 2025 through December 2025 resident council documentation did not include a written response to the council prior to the next meeting.
  2. During the onsite inspection, 01/29/2026, staff 7 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 for the months of April 2025 through December 2025.
Plan of correction
Activities Director (RLD) or designee will inform all directors of resident concerns expressed during resident council. RLD or designee will ensure the plan and outcome of those concerns are clearly defined and provided to the residents prior to the upcoming resident council. RLD or designee will make copies of that literature and ensure it is available to all residents for review. ED will review the response to those concerns to verify that all concerns have been addressed prior to it being shared to the residents.
January 29, 2026Complaint survey0 violations
Inspection dates
01/29/2026
Areas reviewed
22VAC40-73 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: 01/29/2026 Time in: 5:31 PM Time out: 6:09 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 12/22/2025 regarding allegations in the area(s) of: Resident Care and Related Services and Complaint Investigation Number of residents present at the facility at the beginning of the inspection:77 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed:1 Number of staff records reviewed: 0 Number of interviews conducted with residents:0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Licensing inspector observed residents engaging with peers and staff 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 did not support the allegation(s) 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 14, 2025Inspection5 violations
Inspection dates
03/14/2025
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: 22VAC40-73-240, 22VAC40-73-325, 22VAC40-73-620, 22VAC40-73-720, 22VAC40-73-930, and 22VAC40-73-970-E.
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: 03/14/2025 Time in: 9:55 AM Time out: 5:59 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: 58 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: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: Licensing inspector (LI) observed the physical plant of the facility. LI observed a medication pass, residents dining for lunch, and participating in scheduled activities. 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
22VAC40-73-650-A
Based on resident record review and staff interview, the facility failed to ensure that no medication was started without a valid order from a physician or other prescriber.
Evidence
  1. Resident 1’s (admit date, 02/27/2025) physical examination, recommendations for care included medications, which were used as physician orders.
  2. On 03/14/2025, LI interviewed staff 4 who confirmed that physical examinations were used as physician orders. Staff 4 stated that it made the admission process more seamless.
Plan of correction
1) The Facility’s Senior Health and Wellness Director ensured that signed physician’s order was placed in the record of Resident 1. 2) The Facility has included an additional form (Admission Orders) for physicians to complete prior to a resident’s move in to ensure compliance with the standard. 3) The Facility’s Senior Health and Wellness Director and Executive Director will review all admission documents in scheduled move in debrief meetings to ensure compliance.
22VAC40-73-950-F
Based on record review and staff interview, the facility failed to review the emergency preparedness plan annually and document with signature and date.
Evidence
  1. Upon request the facility did not provide the annual review of the emergency preparedness and response plan.
  2. On 03/14/2025, LI interviewed staff 1 who confirmed that an annual review of the emergency preparedness and response plan was not provided.
Plan of correction
4) The Facility’s Executive Director has signed the emergency preparedness plan. 5) The Facility’s Senior Health and Wellness Director and Executive Director will review the emergency preparedness plan to ensure that it is signed in Quality Assurance Meetings in July and December 2025. 6) The Facility’s Executive Director and Maintenance Director will review and ensure that the emergency preparedness plan is signed annually.
22VAC40-73-1140-A
Based on staff record review and staff interview, the facility failed to ensure that the administrator attended at least 12 hours of training in cognitive impairment within three months of the starting date of employment.
Evidence
  1. Staff 1’s (hire date, 09/24/2024) record did not include cognitive impairment training.
  2. On 03/14/2025, LI interviewed staff 1 who confirmed that cognitive impairment training was not included in staff records.
Plan of correction
1) The Executive Director will re-complete training in cognitive impairment since records relating to initial completion were not available at the time of the inspection. 2) The Executive Director will ensure that the proof of completion of this training is placed in the Facility staff records. 3) The Facility’s Business Office Director will review training records to ensure compliance.
22VAC40-73-490-A
Based on record review and staff interview, the facility failed to provide health care oversight at least every six months. All residents were included at least annually.
Evidence
  1. The healthcare oversight was completed 04/28/2025 through 04/28/2025 and reviewed 9 residents.
  2. On 03/14/2025, LI interviewed staff 4 who confirmed that the healthcare oversight was completed annually and reviewed 9 residents.
Plan of correction
Facility Senior Health and Wellness Director and Executive Director reviewed the requirements of this standard with the Licensing Inspector. As the new manager of the Facility, information for the first half of the year was not available at the time of the inspection. Facility Senior Health and Wellness Director will complete the oversight monthly. Facility’s Senior Health and Wellness Director and Executive Director will review the healthcare oversight to ensure compliance in Quality Assurance Meetings in July and December 2025.
22VAC40-73-950-E
Based on record review and staff interview, the facility failed to develop and implement a semiannual review on the emergency preparedness and response plan for all staff and residents.
Evidence
  1. Upon request the facility did not provide a semi-annual review of the emergency preparedness and response plan.
  2. On 03/14/2025, LI interviewed staff 1 who confirmed that a semi-annual review of the emergency preparedness and response plan was not provided.
Plan of correction
7) The Facility’s Executive Director and Resident Lifestyle Director will conduct a semiannual review of the emergency preparedness plan with residents and staff. 8) The Facility’s Executive Director and Resident Lifestyle Director will document in the facility records their semiannual review of the emergency preparedness plan with residents and staff. 9) The Facility’s Senior Health and Wellness Director and Executive Director will review records of the semiannual review of the emergency preparedness plan with residents and staff in Quality Assurance Meetings in July and December 2025.
October 3, 2024Complaint survey4 violations
Inspection dates
10/03/2024
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 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: 10/03/2024 Time In: 12:43 PM Time Out: 4:03 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 09/18/2024 regarding allegations in the area(s) of: Personnel: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 63 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 6 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: LI observed residents interacting with staff, entering and exiting the campus for community activities, and residents at the nursing station. 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. 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. 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
22VAC40-73-650-A
Based on resident record review and staff interview, the facility failed to ensure that no medication, dietary supplement, diet, medical procedure, or treatment should be started, changed, or discontinued by the facility without a valid order from a physician or other prescriber. Medications include prescription, over-the-counter, and sample medications.
Evidence
  1. The medication cart contained a bubble pack of Vitamin D2 5000U (take 1 capsule by mouth every week –supplement) for Resident 1 (admit date, 03/01/2023). Resident 1 did not have an order for Vitamin D2 5000U.
Plan of correction
1) Bubble pack of Vitamin D2 50000U was removed from the medication cart. 2.) Facility reviewed the chart of Resident 1 and confirmed an order dated 9/5/2019, to administer Vitamin D2 50000U (1 capsule by mouth every week) and a discontinuation order or that medication dated 7/16/2024. 3) Facility’s Senior Heath and Wellness Director will conduct inservicing of medication technicians and nurses regarding the process and protocols to follow when facility receives a discontinuation order for prescription medications and any over-the-counter drugs and supplements ordered for residents, including the removal of those medications from the medication carts.
22VAC40-73-680-I
Based on resident record review and staff interview, the facility failed to ensure that the Medication Administration Record (MAR) included the name, signature, and initials of all staff administering medications. A master list may be used in lieu of this documentation on individual MARs.
Evidence
  1. Resident 1’s September 2024 MAR had 8 unidentified initials of staff members who administered scheduled medications. The name and signature lines of the September MAR were blank.
  2. During the onsite inspection on 10/03/2024, staff 1 was unable to provide an updated and current master list of staff names, signatures, and initials for staff administering medications for the MAR.
Plan of correction
1) Facility has on ¿le a master list of the names and initials of all sta¿ who administer medications. 2) Facility has on ¿le a master list of the names and initials of all sta¿ who administer medications to Resident 1.
22VAC40-73-680-D
Based on resident record review, the facility failed to ensure that medications were administered in accordance with the physician’s or other prescriber’s instructions.
Evidence
  1. Resident 1 had an order for Rytary 48.75-195 capsule ER to be administered 1 capsule by mouth three times a day for Parksinsons.
  2. Resident 1 September 2024 MAR indicated Rytary was not available for administration on 09/05/2024 at 1:00 pm and 6:00 pm or 09/06/2024 at 8:00 am and 1:00 pm.
  3. On 10/03/2024, staff 2 verified resident 1 was not administered Rytary on at least two occasions on 09/05/2024 and 09/06/2025 (4 doses total) as the medication was not available.
Plan of correction
1) Facility con¿rmed that Rytary and all other prescription medications and any over-the-counter drugs and supplements were ¿lled and available for administration to Resident 1. 2) Facility’s Senior Health and Wellness Director conducted inservicing of all nurses and medication technicians on the processes and protocols to follow to ensure that prescription medications and any over-the-counter drugs and supplements ordered for residents are ¿lled and re¿lled in a timely manner. 3) Facility’s Senior Health and Wellness Director and designated nurses will conduct routine audits of medications and orders to ensure that all prescription medications and any over-the- counter drugs and supplements ordered for residents are ¿lled and available for administration. 4) Results of routine audits will be reviewed with the Executive Director of the Facility. 5) Facility interviewed all sta¿ members who administered medications to Resident 1. 6) Facility took corrective action as to the sta¿ member who documented administering Rytary to Resident 1 when it was not available for administration.
22VAC40-73-640-A
Based on resident record review and staff interviews, the facility failed to ensure to implement their written medication management plan to 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.
Evidence
  1. Resident 1 has an order for Rytary 48.75-195 Capsule ER, give 1 capsule by mouth three times a day for Parkinson, that was not available for administration on 09/05/2024 at 1:00 pm and 6:00 pm or 09/06/2024 at 8:00 am and 1:00 pm, per September 2024 medication administration record (MAR).
  2. A Progress Note indicated that Rytary medication was delivered on 09/06/2024.
  3. On 10/03/2024, staff 1 was interviewed and acknowledged the last dose of Rytary for Resident 1 was administered on 09/05/2024.
  4. On 10/03/2024, staff 2 was interviewed and acknowledged per protocol the in-house physician should be contacted to refill a day’s worth of medication to avoid missed dosages of medications.
  5. The facility’s medication management plan stated, “The community staff should review all on-demand medications daily and re-order when a 5-day supply of the medication is remaining. Emergency refills must be called to the pharmacy. The community should indicate the date and time the medication is needed.”
Plan of correction
Facility confirmed that Rytary and all other prescription medications and any over-the-counter drugs and supplements were filled and available for administra¿on to Resident 1. 2) Facility’s Senior Heath and Wellness Director conducted inservicing of all nurses and medication technicians on the processes and protocols to follow to ensure that prescription medications and any over-the-counter drugs and supplements ordered for residents are filled and refilled in a timely manner. 3) Facility’s Senior Health and Wellness Director and designated nurses will conduct routine audits of medications and orders to ensure that all prescrip¿on medications and any over-the counter drugs and supplements ordered for residents are filled and available for administration 4) Results of routine audits will be reviewed with the Executive Director of the Facility.
February 29, 2024Complaint survey1 violation
Inspection dates
02/29/2024
Areas reviewed
Staffing and SupervisionResident Care and Related Services
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 02/29/2024 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 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: 18 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to Resident Care and Related Services and Staffing and Supervision, but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov
Violations
22VAC40-73-460-B
Based on resident record review and resident interview, the facility staff failed to promptly respond to resident’s needs.
Evidence
  1. · According to the Detailed Event Report for the nurse call light response times there were 39 instances between 11/7/2023 and 11/8/2023 in which the nurse call response time was greater than 30 minutes. The following residents rang for assistance using their nurse call pendant, all listed below were answered after 30 minutes: · Res A on 11/7/2023 at 1:18am, 4:43am, 7:36am, 12:48am, 2:40pm, 4:25pm, 6:13pm, 7:05pm, 9:51pm and on 11/8/2023 at 4:13pm and 9:26pm · Res B 0n 11/7/20283 at 7:36am · Res C on 11/7/2023 at 12:44pm · Res D on 11/7/2023 at 12:53pm and on 11/8/2023 at 1:13am and 8:26am · Res E on 11/7/2023 at 3:44pm and on 11/8/2023 at 1:46pm · Res F on 11/7/2023 at 4:16pm, 6:22pm and on 11/8/2023 at 2:44pm · Res G on 11/7/2023 at 5:38pm and on 11/8/2023 at 9:16am · Res H on 11/7/2023 at 6:00pm · Res I on 11/7/2023 at 7:20pm · Res J on 11/7/2023 at 8:08pm · Res K on 11/8/2023 at 5:11am and 9:51am · Res L on 11/8/2023 at 9:14am · Res M on 11/8/2023 at 9:38am · Res N on 11/8/2023 at 10:11am · Res O on 11/8/2023 at 12:40pm · Res P on 11/8/2023 at 12:45pm · Res Q on 11/8/2023 at 7:27pm and 9:26pm · Res R on 11/8/2023 at 7:45pm · Res S on 11/7/2023 at 8:05pm
Plan of correction
Immediate Actions Taken: ED met with each resident and/or their responsible party to address the extensive pendant response time. Additionally, community wide improvement plan for pendant response time was addressed to all residents who attended Resident Council on 4/25/2024 and Coffee and Chat with the ED on 4/10/2024. Plan for Continued Compliance: Pendant Response Time Report is generated daily and sent to ED and DCS for review and follow up over the next 30 days and will then be routinely reviewed during daily Manager’s Meeting thereafter.
February 29, 2024Inspection5 violations
Inspection dates
02/29/2024
Areas reviewed
Administration and Administrative ServicesPersonnelStaffing and SupervisionAdmission, Retention and Discharge of ResidentsResident Care and Related ServicesResident Accommodations and Related ProvisionsBuilding and GroundsEmergency PreparednessAdditional Requirements for Facilities that Care for Adults with Cognitive ImpairmentsBackground Checks for Assisted Living FacilitiesSworn Statement
Comments
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: 7 Number of staff records reviewed: 4 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 4 Observations by licensing inspector: LI team toured the physical plant of the facility, and observed residents involved in independent pursuits. This LI team 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) 635-6074 or by email at nina.wilson@dss.virginia.gov
Violations
22VAC40-73-620-B
Based on resident records review and staff interview, the facility staff failed to follow-up on the Dietician’s recommendations to the resident’s physician.
Evidence
  1. Dietary Report completed on February 12, 2024, by, Margaret Radzikowski, contained documentation for: · Resident C recommending change diet to Regular, regular textures, think liquids. · Resident G recommending discontinue NAS diet. Start No Concentrated Sweets diet. Staff D stated there was no documentation of the communication from the facility to the physician regarding dietary recommendations from the dietician for Resident C or G. Review of resident records and physician orders for Resident C and G did not show evidence of implementation of dietary recommendations from February 12, 2024 Dietician report.
Plan of correction
A.) With respect to the specific resident/situation cited: Physicians for residents C and H have been notified of dietitian recommendations. B.) With respect to how the facility will identify residents/situations with the potential for the identified concerns: The Director of Clinical Services and/or designee will complete full review of dietitian recommendations from February visit within the next 4 weeks then quarterly thereafter to verify appropriate follow ups are completed. C.) With respect to what systemic measures have been put into place to address the stated concern: The Director of Clinical Services and/or designee have reached out to consulting dietitian to open line of communication for subsequent visits and best process to communicate recommendations to ensure timely follow up.
22VAC40-73-680-D
Based on resident records review and staff interview, the facility staff failed to ensure that medications were administered in accordance with the physician’s or other prescriber’s orders.
Evidence
  1. Resident A had a prescription dated 11/16/2000 for Atorvastatin 10 mg Tablet, take 1 tablet by mouth at bedtime. The January 2024 and February 2024 Medication Administration Record (MAR) contained documentation that the medication was not administered on January 10, January 11 January 19, January 29, January 31, or February 2.
Plan of correction
A.) With respect to the specific resident/situation cited: New Director of Clinical Services and/or designee will hold refresher in-service with the Nursing team on medication management expectations which includes managing supplies, availability and appropriate notifications when supplies are low. B.) With respect to how the facility will identify residents/situations with the potential for the identified concerns: Director of Clinical services and/or designee will perform weekly medication administration audit weekly for 4 weeks then randomly thereafter to verify all medications are administered ordered. C.) With respect to what systemic measures have been put into place to address the stated concern: Director of Clinical Services and/or designee will follow up with assigned staff weekly for any discrepancies noted during the review and issue appropriate corrective actions.
22VAC40-73-40-A
Based on resident records review and staff interview, the facility staff failed to follow the facility’s Weight Tracking and Monitoring policy. The policy states that “All assisted living residents will be weighed upon move-in and quarterly unless a significant weight change is noted.”
Evidence
  1. Resident D’s last weight was obtained on 11/15/2023, Res E’s last recorded weight was on 9/19/2019, Res F’s last recorded weight was on 6/29/2021, and Res H had no recorded weights from January 1- December 31, 2023. Staff interviewed stated there were no other weights documented in Resident D, E, F or H’s medical record.
Plan of correction
A.) With respect to the specific resident/situation cited: Resident E and H weights have been obtained since survey visit. Resident D and F remain pending per residents’ request. B.) With respect to how the facility will identify residents/situations with the potential for the identified concerns: Director of Clinical Services and/or designee will review all resident records within the next 4 weeks for recent weights to identify follow up and updates as needed which may include Responsible Party and Physician notification if unable to obtain weight. A weight verification within 24 hours will be obtained for significant variances. Routine weight obtainment and review will be completed quarterly thereafter. C.) With respect to what systemic measures have been put into place to address the stated concern: Director of Clinical Services and/or designee will establish routine schedule for resident weight to be completed on a quarterly basis. Director of Clinical Services and/or designee will hold staff meeting to establish and review weight monitoring expectation moving forward.
22VAC40-73-710-E
Based on resident records review and staff interview, the facility staff failed to address the use of bedrails on the resident’s Individualized Service Plan (ISP).
Evidence
  1. Resident D, E and F’s ISP did not address the use of bedrails
Plan of correction
A.) With respect to the specific resident/situation cited: ISPs for residents D, E and F have been updated to reflect plan of care for bedrails usage. B.) With respect to how the facility will identify residents/situations with the potential for the identified concerns: The Director of Clinical Services and/or designee will collaborate with the nursing team to complete full audit and 05/31/2024 inspection within the next 4 weeks then monthly thereafter of residents who may have bedrails and review ISPs as applicable. C.) With respect to what systemic measures have been put into place to address the stated concern: The Director of Clinical Services and/or designee will hold staff meeting to review with nursing staff the importance of identifying residents who are using bedrails and communicating with their supervisor to verify all process are in place in accordance with the policies and regulations. The Director of Clinical Services and/or designee will complete audit of resident with siderails monthly during QA meeting and review continued need and appropriateness of usage during comprehensive annual reassessments.
22VAC40-73-710-B
Based on resident records review and staff interview, the facility staff failed to obtain a physician’s order for a restraint (bedrail) before the restraint was used.
Evidence
  1. Resident D, E and F did not have an order from a physician to use a restraint (bedrail) on file.
Plan of correction
A.) With respect to the specific resident/situation cited: Orders for bedrail have been obtained for residents D, E and F. B.) With respect to how the facility will identify residents/situations with the potential for the identified concerns: The Director of Clinical Services and/or designee will collaborate with the nursing team to complete full audit and inspection within the next 4 weeks then monthly thereafter of residents who may have bedrails and review for physician orders as applicable. C.) With respect to what systemic measures have been put into place to address the stated concern: The Director of 05/31/2024 Clinical Services and/or designee will hold staff meeting to review with nursing staff the importance of identifying residents who are using bedrails and communicating with their supervisor to verify all process are in place in accordance with the policies and regulations. The Director of Clinical Services and/or designee will complete audit of resident with siderails monthly during QA meeting and review continued need and appropriateness of usage during comprehensive annual reassessments.
January 29, 2024Complaint survey0 violations
Inspection dates
01/29/2024
Areas reviewed
Administration and Administrative ServicesStaffing and SupervisionBuilding and Grounds
Comments
Date of Inspection: January 29, 2024 Type of Inspection: Complaint inspection Standards Investigated: As stated above Complaint was determined not valid. If you have any questions, please do not hesitate to contact me at (703) 635-6074 or nina.wilson@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection, you can find the information on the internet: www.dss.virginia.gov The Administrator and the Licensing Inspector discussed the risk assessment ratings for the violations for this inspection.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
November 29, 2023Inspection0 violations
Inspection dates
11/29/2023
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: LI entered the facility at 8:52 am on 11/29/2023 and exited at 3:15 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: 83 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: 5 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 0 Observations by licensing inspector: LI observed medication administration. 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jamie Eddy, Licensing Inspector at (703) 479-5247 or by email at jamie.eddy1@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
September 5, 2023Inspection0 violations
Inspection dates
09/05/2023
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS
Comments
Type of inspection: Initial Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: LI entered the facility at 9:05 am on 9/5/2023 and exited at 3:50 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of staff records reviewed: 89 Observations by licensing inspector: LI walked the physical plant. LI observed emergency preparedness supplies. 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 should the facility be issued a license to operate. 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 a licensed facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jamie Eddy, Licensing Inspector at (703) 479-5247 or by email at jamie.eddy@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.