18
Inspections
On record
14
With violations
Visits that cited something
4
Clean visits
Nothing cited
35
Violations cited
Individual findings
29
Standards cited
Distinct rules
11
Complaint visits
Prompted by a complaint
English Meadows Manassas Campus was inspected 18 times between December 11, 2023 and April 14, 2026 by the Virginia Department of Social Services. 14 of those visits ended with violations cited and 4 with none. Across that history VDSS cited 35 violations under 29 distinct standards. 11 inspections were prompted by a complaint.
A violation is a licensing standard - a rule in the Virginia Administrative Code - that the inspector found the facility was not meeting. Each is shown with the evidence the inspector recorded and, where VDSS publishes it, the facility's own plan of correction.
VDSS publishes inspections on a rolling window. 17 of these 18 are still on the state's site; the other 1 has since dropped off it and is reproduced from Assisted Living Magazine's archive of the original VDSS reports.
Provider Information
Facility type
Assisted Living Facility
License type
One Year
License expires
06/10/2026
Administrator
Julie Jenkins
Licensing inspector
Sarah Pearson
Inspector phone
(540) 680-9469
Approved for
Assisted Living · Special Care Unit
Inspection History
18Select an inspection to read the areas reviewed, the inspector's comments and any violations cited.
April 14, 2026Inspection
Inspection dates
04/14/2026
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
Type of inspection: Monitoring
Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: Date: 4/14/2026 Time in: 10:30 am Time Out: 11:30 am
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 2/26/2026 regarding allegations in the area(s) of:
Resident Care and Related Services.
Number of residents present at the facility at the beginning of the inspection: 67
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: 1 Observations by licensing inspector:
Additional Comments/Discussion:
An exit meeting will be conducted to review the inspection findings.
The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law.
If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. 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 Ishmel Paige, Licensing Inspector at (804)-963-0360 or by email at ishmel.l.paige@dss.virginia.gov
Violations
22VAC40-73-460-D
Based on record review and staff interview, the facility failed to ensure supervision of resident schedules, care, and activities, including attention to specialized needs, such wandering from the premises.
Evidence
- The department received a Self-Incident Report on 2/26/2026 regarding a Resident 1 eloping from memory care unit. The report indicated Resident 1 exited through a window in Resident 2’s room and wandered from the premises. The report stated Resident 1 was last seen on the secure unit around 5:00 p.m. and was found by police around 5:43 p.m. in a local subdivision approximately 200 yards for the window they exited from.
- According to the National Weather Service, the temperature in Manassas, Virginia around 5:00 p.m. was approximately 40-45 degrees.
- During onsite inspection on 4/14/2026, Staff 1 acknowledged that Resident 1 wandered from the premises on 2/26/2026. Staff 1 also confirmed that staff followed their policy regarding missing resident from memory care to include immediately contacting law enforcement and look for resident.
Plan of correction
The facility window was not malfunctioning or unsecured. Photo evidence was provided to VDSS at the time of the self-reported incident. The window was compromised by physical force, which rendered it unsecured and allowed the resident to exit. Documented safety checks met company and VDSS standards. The resident was not harmed during the incident. The community will continue conducting emergency drill training with staff.
22VAC40-73-1150-B
Based on record review and staff interview, the facility failed to ensure that there shall be protective devices on the bedroom and bathroom windows of residents and on windows in common areas accessible to residents to prevent the windows from being opened wide enough for a resident to crawl through.
Evidence
- On 2/26/2026, the facility reported Resident 1 eloped from the memory care unit through Resident 2’s window.
- During the onsite inspection on 4/14/2026, Staff 1 acknowledged Resident 1 exited the memory care unit from Resident 2’s bedroom window on 2/26/2026.
- Following the onsite inspection, on 4/27/2026, Staff 1 provided the following observations of Resident 2’s window, identified immediately following Resident 1’s elopement on 2/26/2026: a. Lower window sash removed with screen pushed out. b. The physical windowpanes were not broken. c. Left latch of window was broken. d. Window was opened wide enough for the resident to crawl through.
Plan of correction
The facility window was not malfunctioning or left unsecure. Photo evidence was provided to VDSS at the time of the self-reported incident. The window was compromised by human physical force and was no longer secure, allowing the resident free passage. The resident sustained no harm during this incident.
April 14, 2026Inspection
Inspection dates
04/14/2026; 04/15/2026
Areas reviewed
22VAC40-73-(1} GENERAL PROVISIONS22VAC40-73-(2} ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73-(3} 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-(9} EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUSCOGNITIVE IMPAIRMENTS
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: 4/14/2026 9:30am - 4:30pm and 4/15/2026 10am - 2:30pm 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: 67 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: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: Li's observed
residents partaking in activities, walking around the facility and going on outings with their visitors.
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 01) 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 VOSS Licensing Programs, please visit:
www.dss.virginia.gov
Violations
22VAC40-90-40-B
Based on staff record review and staff interview, the facility failed to ensure that the criminal
history record report shall be obtained within 30 days of employment for each employee.
Evidence
- During onsite inspection on 4/14/2026, Staff 5’s record indicated a hire date of 03/05/2025; however, Staff 5’s criminal history record report was obtained on 4/14/2026. 2. Staff 1 acknowledged Staff 5's criminal history record report was not obtained within 30 days of employment.
Plan of correction
The discrepancy was corrected on the day of inspection. The Executive Director obtained Staff 5’s criminal
history report. The Business Office will run background checks for all new hires, and the Executive
Director or designee will verify that each check is completed within 30 days of employment.
22VAC40-73-1180-B
Based on observation and staff interview, the facility failed to ensure that when there are
indications that ordinary materials or objects may be harmful to a resident, these materials or objects
shall be inaccessible to the resident except under staff supervision.
Evidence
- During the onsite inspection on 4/14/2026, the unattended memory care nursing station in memory care was observed to have exposed medications, deodorant, dove soap, shaving cream, hair conditioner, barrier ointment, odor eliminator, batteries, wound cleanser, hand sanitizer, perfume, staples, hair clippers/razors, and germicidal cleanser. 2. The hallway in memory care was observed to have body wash and non-alcoholic wipes that were accessible to residents and not under supervision. 3. Staff 1 acknowledged that ordinary materials and objects that may be harmful to residents should be inaccessible to residents except under staff supervision.
Plan of correction
At the time of inspection, all identified items were removed and secured in the Executive Director’s office.
No residents sustained harm or injury. The community has secure storage for personal hygiene items and
other supplies that may be harmful. The Memory Care Director and/or designee will retrain caregivers on
properly securing all potentially harmful supplies. The locked storage area has been identified and is
accessible to caregivers and registered medication aides. The Memory Care Director and/or designee will
conduct weekly sweeps of resident rooms to ensure potentially harmful items are stored properly.
22VAC40-73-290-A
Based on policy review, schedule review and staff interview, the facility failed to maintain a
written work schedule that includes the names and job classifications of all staff working each shift, with
an indication of whomever is in charge at any given time.
Evidence
- During onsite inspection on 4/14/2026, when reviewing the work schedule 11/15/2025 - 11/28/2026, the rubric attached noted that the person in charge would have an asterisk (*) by their name; however, the work schedule provided did not have a visible asterisk by any staff’s name to indicate the staff member in charge. 2. Staff 1 acknowledged that the work schedules reviewed did not indicate who was in charge at any given time.
Plan of correction
The scheduling software has been updated to reflect who’s in charge on any given shift. This has been
built into the software and cannot be manipulated. When the schedule is printed, we will easily be able to
identify who’s in charge. Manager on Duty signage is also available at the front desk.
22VAC40-73-860-D
Based on observation and staff interview, the facility failed to ensure all doors shall open
and close readily and effectively.
Evidence
- During the onsite inspection on 4/14/2026, the courtyard exit doors in the Assisted Living unit were unable to open and close readily and effectively due to the door unalignment. Licensing staff were unable to exit into the courtyard without additional assistance from maintenance. 2. Staff 1 acknowledged that the doors should open and close readily and effectively.
Plan of correction
The door was adjusted and is now properly aligned. It opens and closes without difficulty. The
Maintenance Director and/or designee will conduct building walkthroughs to ensure electronic doors
continue to operate properly.
22VAC40-73-660-A
Based on LI observation and staff interview, the facility failed to ensure a medicine cabinet,
container, or compartment shall be used for storage of medications and dietary supplements prescribed
for residents when such medications and dietary supplements are administered by the facility.
Medications shall be stored in a manner consistent with current standards of practice and locked.
Evidence
- During the onsite inspection on 4/14/2026, an unattended nursing station with unlocked cabinets was observed in the safe, secure environment. 2. In the unlocked cabinets, prescribed medication, TRUPLUS LANC MIS 33G for Resident 9 and ONETOUCH DELICA PLUS LANCET 30 GAUGE for Resident 10, was observed. 3. Staff 1 acknowledged that medication should be locked in a storage area.
Plan of correction
At the time of inspection, the lancet boxes were placed in a locked storage area. No resident sustained
harm or injury. The community has backup storage for excess diabetic supplies. The Memory Care
Director and/or designee will retrain Registered Medication Aides to ensure all diabetic supplies are
securely stored in a locked area. The locked storage area has been identified and is accessible to
Registered Medication Aides. The Memory Care Director and/or designee will conduct weekly sweeps of
the nurses’ station to verify proper storage.
April 14, 2026Complaint survey
Inspection dates
04/14/2026; 04/15/2026
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73-{5) ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-80 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: 4/14/2026 9:30am -4pm & 4/15/2026 10am -2:30pm
A complaint was received by VDSS Division of Licensing on 02/26/2026 regarding allegations in the area(s) of: Resident Care, Admission, Retention and Discharge of Resident
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: 67
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: 2 Number of interviews conducted with staff: 2
Observations by licensing inspector: Observed the residents partaking in activities, eating in the dining room and going on walks with their pets.
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:
22VAC40-73-(3) PERSONNEL
22VAC40-73-(5) ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS
22VAC40-73-(6) RESIDENT CARE AND RELATED SERVICES
22VAC40-73-(7) RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS
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 VOSS Licensing Programs, please visit: www.dss.virginia.gov
Violations
22VAC40-73-700-1
Based on record review and interview, the facility failed to ensure that when oxygen therapy is provided a valid physician's or other prescriber's order that includes the oxygen source, such as compressed gas or concentrators or delivery device, such as nasal cannula, reservoir nasal cannulas, or masks.
Evidence
- During the onsite inspection on 4/14/2026 and 04/15/2026, Resident 1’s record contained prescriber’s order written on 08/27/2025 as “O2 – 3L NC PRN w exertion.” The order did not include the oxygen source or the delivery device.
- Staff 1 and 2 acknowledged that it was the only oxygen order for Resident 1 and did not contain oxygen source and device during the onsite inspection.
Plan of correction
Resident 1 no longer resides in the community. The Director of Nursing or designee will audit current residents with oxygen orders to ensure each order includes the oxygen source and delivery device. If needed, a new order will be obtained.
22VAC40-73-680-D
Based on record review and interview, the facility failed to ensure that medications shall be administered in accordance with the physician's or other prescriber’s instructions.
Evidence
- Resident 1’s record contained progress note written by Staff 3 that “Resident is doing well, denied pain and is on 1L nasal cannula……”
- Resident 1’s record contained order written on 08/27/2025 for “O2 – 3L NC PRN”.
- Staff 2 confirmed that Resident 1’s order was for 3L of oxygen and there was no indication why Resident 1 was on 1L of oxygen.
- Resident 1 was prescribed Levothyroxine 75mcg three (3) times a day on 4/18/2025. Resident 1’s October 2025 MAR indicated that from 10/02/2025 to 10/06/2025 the medication was not administered with a note “waiting on pharmacy”.
- Resident 1’s June 2025 MAR indicated the on 6/01/2025 Resident 1’s Hydralazine Tab 25mg three (3) times daily prescribed on 4/18/2025 indicated that Staff 3 did not administer the medication with a note “previous shift”.
- Resident 1’s June 2025 MAR indicated on 6/01/2025, 6/08/2025 and 6/13/2025 that Resident 1’s Bumetanide Tab 0.5mg and Bumetanide Tab 1mg both once daily and both prescribed on 4/18/2025 were not administered with a note “not sure if previous shift administered”
Plan of correction
The Director of Nursing or Designee will utilize the missed medication report every weekday to review recent medication passes to identify discrepancies. Any discrepancies will be corrected by the Director of Nursing or Designee. The Director of Nursing or Designee with retrain Registered Medication aides on what steps to take when discrepancies are noted in real time. Our pharmacy has developed a quality call with the Director of Nursing every weekday to review any discrepancies.
22VAC40-73-640-A
Based on record review and interview, the facility failed to implement their written plan for medication management to include methods to ensure that each resident's prescription medications and any over- the- counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages and methods for verifying that medication orders have been accurately transcribed to medication administration records (MARs) within 24 hours of receipt of a new order or change in an order;
Evidence
- Resident 1’s record contained an order written on 08/27/2025 for “O2 – 3L NC PRN”. Resident 1’s ISP (completed 2/26/2026) and progress notes indicated their use of oxygen. Staff 2 confirmed that oxygen was in use by Resident 1 throughout their admission at the facility as well.
- Resident 1’s October 2025 and November 2025 MAR did not include Resident 1’s oxygen.
- Facility medication management plan and reference material states that the “Director of Nursing/RCC and/or Designee will review physician’s orders and compare those to the Electronic Medication Administration Record to ensure accuracy.” The plan further states that the pharmacy is responsible for input within 24 hours but the “DON/RCC/Nurse/MT is responsible for verifying accurate input of the new order or change in the order.”
- The following medications for Resident 1 were noted to be unavailable for administration in October 2025: -Levothyroxine 75mcg three (3) times a day from 10/02/2025 to 10/06/2025. -Loperamide 2mg Tab (HSTK) every six (6) hours from 10/14/2025 to 10/24/2025.
- Facility medication management plan and reference material states that the “all orders for medication, over the counter and supplements are promptly sent to the pharmacy.” It continues to state, “…existing medications are present as soon as possible to prevent missed doses.”
- Staff 1 and Staff 2 acknowledged the missed medication administration due to not being properly refilled and the MARs.
Plan of correction
The Director of Nursing or Designee will utilize the missed medication report every weekday to review recent medication passes to identify discrepancies. The Director of Nursing or Designee with retrain Registered Medication aides on what steps to take when a discrepancy is noted while on duty, this includes, what to do if a resident desire’s a medication change. Training will include how to best document special circumstances surrounding a medication pass.
April 14, 2026Complaint survey
Inspection dates
04/14/2026
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-80 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: 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 2/17/2026 regarding allegations in the area(s) of: Resident Care.
Number of residents present at the facility at the beginning of the inspection: 67
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: 1 Number of interviews conducted with staff: 1
Observations by licensing inspector: LI observed residents watching television in a common area, resident records, building and grounds, and resident rooms.
Additional Comments/Discussion: N/A
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. 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
Violations
22VAC40-73-720-A
Based on resident record review and staff interview, the facility failed to ensure that written Do Not Resuscitate (DNR) Orders are included in the resident’s individualized service plan.
Evidence
- A DNR order was observed in Resident 1’s record dated 7/23/2025.
- On Resident 1’s ISP dated 2/16/2026, page one notes that the Residents code status is DNR; however, on page two of the ISP it notes that the Residents code status is Full Code.
- Staff acknowledged that Resident 1’s ISP does not accurately reflect the written DNR order as there is a discrepancy between page one and page two as to the resident’s code status.
- Photo evidence was obtained.
Plan of correction
The care team’s electronic software correctly displayed the resident’s code status on the day of the violation. The second page of the ISP in the resident’s medical chart was corrected that same day. The company has since upgraded the care software system, and the new system accurately carries the code status into the generated ISP document. The Memory Care Director and Director of Nursing will audit the current resident population, identify any DNR discrepancies, and correct them in real time.
April 14, 2026Complaint survey
Inspection dates
04/14/2026
Areas reviewed
22VAC40-73-(4} STAFFING AND SUPERVISION22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
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: 04/14/2026 9:30am - 10:30am
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
A complaint was received b VOSS Division of Licensing on 10/07/2025 regarding allegations in the areas of: Resident Care and Additional requirements for facilities that care for adults with serious cognitive impairments.
Number of residents present at the facility at the beginning of the inspection: 67
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: 2
Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2
Observations by licensing inspector: LI observed residents walking around and partaking in activities.
Additional Comments/Discussion: N/A
An exit meeting will be conducted to review the inspection findings.
The evidence gathered during the investigation supported the allegation(s) of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint(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 VOSS Licensing Programs, please visit: www.dss.virqinia.gov
Should you have any questions, please contact Alexandra Roberts, Licensing Inspector at (804) 845-6956 or by email at Alexandra.n.roberts@dss.virqinia.gov
Violations
22VAC40-73-460-B
Based on facility record review and interview, the facility failed to ensure prompt response by staff to resident needs.
Evidence
- Facility Signal Response Time Policy states that "call lights should be answered within 10 minutes... " and "call lights are not to exceed 20 minutes....".
- LI reviewed all available facility call bell response time logs from 03/12/2026 to 04/12/2026 for all residents in the facility. Logs indicated 20+ calls that exceeded 20 minutes without response for 10+ residents. Call logs indicated the longest response times: a. Resident 1's longest response time was 1:45:16 on 03/16/2026 followed by 1:37:27 on 03/12/2026. There were 9 instances of response times exceeding 10 minutes from 03/12/2026 to 04/12/2026. b. Resident 2's longest response time was 03/24/2026, taking 03:16:30 followed by 1:25:48. There were 10 instances of response times exceeding 10 minutes from 03/12/2026 to 04/12/2026.
- Call bell response time logs indicated more than five (5) other residents that received call bell responses that exceeded both 10 minutes and 20 minutes during 03/12/2026 to 04/12/2026.
- Staff 1 acknowledged the identified alerts on the days reviewed that exceeded 5 minutes which does not align with the facility's policy for response time to provide prompt response to resident needs
Plan of correction
The community added two additional iPads to support call bell monitoring. Call bell activity will be reviewed each weekday for follow-up by the department director or designee. Concierge team will continue to be part of the escalation process for monitoring.
January 6, 2026Inspection
Inspection dates
01/06/2026
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS for FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Technical assistance
22VAC40-73-120
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: Date: 1/6/2026 Time In: 12:30pm Time Out: 2:00pm
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 12/21/2025 regarding allegations in the area(s) of: Personnel and Resident Care and Related Services.
Number of residents present at the facility at the beginning of the inspection: 64
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: 2
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 1
Observations by licensing inspector: reviewed staff and resident records.
Additional Comments/Discussion: N/A
An exit meeting will be conducted to review the inspection findings.
The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. However, violation(s) not related to the self-report but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law.
If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview.
Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected.
Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area.
Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice.
The department's inspection findings are subject to public disclosure.
Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility.
For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov
Should you have any questions, please contact Ishmel Paige, Licensing Inspector at (804)-963-0360 or by email at ishmel.l.paige@dss.virginia.gov
Violations
22VAC40-73-450-E
Based on resident record review and staff interview, the facility failed to ensure that the individualized service plan shall be signed and dated by the licensee, administrator, or his designee, (i.e., the person who has developed the plan), and by the resident or his legal representative.
Evidence
- During inspection on 1/6/2026, Resident 1’s record included their most current Individualized Service Plan (ISP) dated 12/23/2024 without any signatures from resident or their legal representative, licensee, administrator, or designee.
- Staff 1 acknowledged that there were no signatures on Resident 1’s ISP date 12/23/2024.
Plan of correction
Director of Nursing or Designee will perform quarterly audits to review ISPs to ensure accuracy and completeness. They will pull 15%-20% of the files to audit. Attempts to get the resident or legal representative to sign ISP will be captured on the document for DSS review. Starting February 1, 2026 and ongoing.
22VAC40-73-260-A
Based on staff record review and interview, the facility failed to ensure that each direct care staff member shall maintain current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department.
Evidence
- During inspection on 1/6/2026, Staff 1 acknowledged that Staff 2 (Hire Date: 10/15/25) was the assigned caregiver and Staff 3 (Hire Date: 1/22/25) was the Medication Aid for Resident 1 as it relates to the self-reported incident on 12/21/2025.
- During staff record review, Staff 2 and Staff 3 did not have documentation or a certificate of First Aid.
- Staff 1 acknowledged that Staff 2 and Staff 3 records did not include First Aid certification.
Plan of correction
Business Office Manager or Designee will perform an audit every 60 days to review first aide documentation records on existing employees and new employees. Starting February 1, 2026 and ongoing.
22VAC40-73-440-A
Based on resident record review and staff interview, the facility failed to ensure that the Uniform Assessment Instrument (UAI) was completed at least annually.
Evidence
- During inspection on 1/6/2026, Resident 1’s record (admitted 9/23/2024) included one UAI dated 9/16/2024.
- Staff 1 acknowledged that UAI was not completed annually for Resident 1.
Plan of correction
Director of Nursing or Designee will perform quarterly audits to review UAIs to ensure accuracy and completeness. They will pull 15%-20% of the files to audit. Starting February 1, 2026 and ongoing.
22VAC40-73-550-G
Based on resident record review, staff record review and staff interview, the facility failed to ensure that the rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each resident or legal representative or responsible individual and each staff person.
Evidence
- During inspection on 1/6/2026, Resident 1’s record included a review of Resident Rights and Responsibilities dated 9/20/2024.
- Staff 2’s record (Hire Date: 10/15/25) included an unsigned copy of Resident Rights and Responsibilities.
- Staff 1 acknowledged that the Resident Rights and Responsibilities were not reviewed annually for Resident 1 and acknowledged the unsigned copy in Staff 2’s record.
Plan of correction
February has been identified as “Resident Rights Month.” Resident rights for all staff and residents will be reviewed annually and a copy placed in the administrative files for all parties. The Business Office Manager or designee will perform quarterly audits to ensure accuracy and completeness. They will pull 15%-20% of the files to audit. Starting February 1, 2026 and ongoing.
January 6, 2026Complaint survey
Inspection dates
01/06/2026
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS
Comments
Type of inspection: Complaint
Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: Date: 1/6/2026 Time In: 9:10am Time Out: 1:00pm
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 6/11/2025 regarding allegations in the area(s) of: Staffing and Supervision and Resident Care and Related Services.
Number of residents present at the facility at the beginning of the inspection: 64
The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility.
Number of resident records reviewed: 5
Number of staff records reviewed: 4
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 1
Observations by licensing inspector: Facility policies and staff and resident records were reviewed. Call bells were tested. Lunch was observed.
Additional Comments/Discussion:
An exit meeting will be conducted to review the inspection findings.
The evidence gathered during the investigation supported the allegations of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law.
If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview.
Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected.
Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area.
Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice.
The department's inspection findings are subject to public disclosure.
Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility.
For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov
Should you have any questions, please contact Ishmel Paige, Licensing Inspector at (804)-963-0360 or by email at ishmel.l.paige@dss.virginia.gov
Violations
22VAC40-73-280-A
Based on record review and staff interview, the facility failed to ensure that adequate staffing in knowledge, skills, and abilities and sufficient in numbers to provide services to attain and maintain the physical, mental, and psychosocial well-being of each resident as determined by resident assessments and individualized service plans, and to ensure compliance with this chapter.
Evidence
- During inspection on 1/6/2026, LI reviewed the facility’s “Written Staff Plan” and Staff Schedule for 6/1/25-6/14/25.
- According to the “Written Staff Policy” and their average daily census, the staff coverage should be: 7am-3pm: 3 RMA and 4 CNA/PCA 3pm-11pm: 3 RMA and 4 CNA/PCA 11pm-7am: 1 RMA and 5 CNA/PCA
- The facility schedule for 6/1/25-6/14/25 was reviewed and showed the following: 7am-3pm: 3 RMA and 4 CNA/PCA were not scheduled or maintained for 9 out of the 14-day period. 3pm-11pm: 3 RMA and 4 CNA/PCA were not scheduled or maintained for 10 out of the 14-day period. 11:00-7:00am: 1 RMA and 5 CNA/PCA were not scheduled or maintained from 6/1/25-6/14/25.
- Staff 1 acknowledged that the facilities policy regarding staff coverage was not followed.
- Photo evidenced obtained.
Plan of correction
The Director of Nursing or designee will review staffing schedule prior to publication to ensure we align with the staffing plan. The Director of Nursing will notify the Executive Director of any challenges with staffing prior to publication.
22VAC40-73-460-B
Based on record review and interview, the facility failed to ensure that prompt response by staff to resident needs as reasonable to the circumstances.
Evidence
- During onsite inspection on 1/6/2026, call bells were reviewed and tested along with resident interviews regarding call bell response times.
- LI reviewed policy regarding “Single Response Time.” The policy states that call lights should be answered within 6 minutes. If staff are unable to meet in that 6-minute window, they will page on a RMA or LPN to help. Lastly, the policy states that if a call light exceeds 20 minutes disciplinary action will occur.
- Staff 1 provided the Call Bell Log for all residents on 1/5/2026-1/6/2026 which documented 94 total alerts were made with 31 alerts exceeding 6 minutes.
- The Call Bell Log for Resident 1 from 12/7/2025-1/6/2026 indicated 98 total alerts were made with 43 alerts exceeding 6 minutes.
- The Call Bell Log for Resident 2 from 12/11/2025-1/5/2026 indicated 29 total alerts were made with 16 alerts exceeding 6 minutes.
- Staff 1 acknowledged that their policy regarding response time was not being followed.
- Photo evidence was obtained.
Plan of correction
Our concierge team from the hours of 8:30a-7:30p, seven days per week will be added to the escalation of our call bell system to assist with additional oversight and announcement of calls for assistance. The Executive Director or designee will review the average call response times weekly.
January 6, 2026Inspection
Inspection dates
01/06/2026
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS for FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Technical assistance
22VAC40-73-100
Comments
Type of inspection: Monitoring
Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: Date: 1/6/2026 Time In: 2:00pm Time Out: 2:35pm
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 12/21/2025 regarding allegations in the area(s) of: Personnel and Resident Care and Related Services.
Number of residents present at the facility at the beginning of the inspection: 64
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: 1
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 1
Observations by licensing inspector: Resident Records, Staff Training Records, Video of Incident
Additional Comments/Discussion: N/A
An exit meeting will be conducted to review the inspection findings.
The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law.
If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview.
Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected.
Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area.
Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice.
The department's inspection findings are subject to public disclosure.
Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility.
For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov
Should you have any questions, please contact (Ishmel Paige), Licensing Inspector at (804)-963-0360 or by email at ishmel.l.paige@dss.virginia.gov
Violations
22VAC40-73-550-G
Based on staff record review and staff interview, the assisted living facility failed to ensure the rights and responsibilities of residents in assisted living facilities were reviewed annually with each resident or his legal representative or responsible individual.
Evidence
- During inspection on 1/6/2026, Staff 2 (Hire Date: 1/9/2024) did not have documentation of Resident Rights and Responsibilities being reviewed for the year 2025.
- Staff 1 acknowledged that Staff 2’s record did not include the review of Resident Rights and Responsibilities in 2025.
Plan of correction
February has been identified as “Resident Rights Month.” Resident rights for all staff and residents will be reviewed annually and a copy placed in the administrative files for all parties. The Business Office Manager or designee will perform quarterly audits to ensure accuracy and completeness. They will pull 15%-20% of the files to audit. Starting February 1, 2026 and ongoing.
22VAC40-73-210-F
Based on staff review and interview, the facility failed to ensure that at least two of the required hours of training shall focus on infection control and prevention.
Evidence
- During inspection on 1/6/2026, Staff 2’s annual training records (Hire Date: 01/09/2024) indicated Staff 2 completed 15 hours of training in the year of 2025; however, the training hours did not include infection control and prevention training.
- Staff 1 acknowledged that Staff 2’s 2025 training records did not include at least two hours focused on infection control and prevention.
Plan of correction
Infection control is currently a part of our onboarding curriculum. The Business Office Manager or designee with perform quarterly audits to ensure compliance and completion for all new associates. Starting February 1, 2026 and ongoing.
22VAC40-73-110-1
Based on record review and staff interview, the facility failed to ensure that staff were considerate and respectful of the rights, dignity, and sensitivities of persons who are aged or infirm or who have disabilities.
Evidence
- On 12/22/2025, the facility self-reported an allegation of abuse of Resident 1 by Staff 2 to licensing.
- During inspection on 1/6/2026, Staff 1 showed a video of the reported incident from 12/18/2025 of Resident 1 and Staff 2 at approximately 6:51 a.m. The video showed Staff 2 assisting Resident 1 with changing/dressing while in the bed. Staff 2 can be seen repeatedly shoving the resident towards the wall and speaking loudly at the resident who can be heard verbally expressing discomfort.
- Staff 1 acknowledged Staff 2’s actions were inappropriate and not respectful of Resident 1.
Plan of correction
Currently, all care associates have been assigned new training on compassionate care when supporting ADLs. This will also be assigned to our annual training curriculum too. Training was assigned on 12/29/25 in response to the self-reported incident.
January 6, 2026Complaint survey
Inspection dates
01/06/2026
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-80 Complaint Investigation
Technical assistance
22VAC40-73-880
Comments
Type of inspection: Complaint
Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: Date: 1/6/2026 Time In: 9:10am Time Out: 12:24pm
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 6/26/2025 regarding allegations in the area(s) of: Resident Care and Related Services and Buildings and Grounds.
Number of residents present at the facility at the beginning of the inspection: 64
The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility.
Number of resident records reviewed: 0
Number of staff records reviewed: 0
Number of interviews conducted with residents: 3
Number of interviews conducted with staff: 4
Observations by licensing inspector: Temperatures were taken and reviewed throughout the facility. Kitchen observation due to reported fire with no concerns noted.
Additional Comments/Discussion: N/A
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 Ishmel Paige, Licensing Inspector at (804)-963-0360 or by email at ishmel.l.paige@dss.virginia.gov
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
April 28, 2025Complaint survey
Inspection dates
04/28/2025
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint
Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 4/28/2025 from1:30 p.m. to 5:00 p.m.
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
A complaint was received by VDSS Division of Licensing on 4/17/2025 regarding allegations in the area(s) of: resident care and medication administration
Number of residents present at the facility at the beginning of the inspection: 52
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: Building and grounds
Additional Comments/Discussion: n/a
An exit meeting will be conducted to review the inspection findings.
The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: resident care and medication management
A violation notice was issued; any violation(s) not related to the complaints 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 Jeff Marnien, Licensing Inspector at (540) 571-0189 or by email at Jeffrey.marnien@dss.virginia.gov
Violations
22VAC40-73-650-A
Based on record review and staff interview, the facility failed to ensure medications were not started, changed, or discontinued by the facility without a valid order from a physician or other prescriber.
Evidence
- Resident 1, admitted 8/2/2024, had an order for Pradaxa 150mg capsule, ordered 9/4/2024. The medication administration record (MAR) identified a total of 17 (morning) 8:00 a.m. doses not administered and 16 (evening)8:00 p.m. doses not administered. Non-administered doses labeled as “Medication on Hold” were dated 9/7/2024, 9/8/2024, 9/11/2024, 9/12/2024, 9/16/2024, 9/17/2024, 9/18/2024, 9/24/2024, 9/25/2024, 9/26/2024, 9/27/2024.
- The LI requested staff 1 and staff 2, hired 11/14/2024, to provide the physician order to hold the medication.
- Staff 1 and staff 2 confirmed there was no order to hold the medication, and an explanation could be provided why the “hold” designation was used.
Plan of correction
The Administrator and Director of Nursing (DON) will ensure that all medication orders are properly addressed, and that staff receive appropriate training following the identification of any discrepancies, in accordance with the facility’s order management policy. The facility’s medication management and order review plans were reviewed with all staff on March 27, 2025. The Administrator will ensure these policies are reviewed with all new hires during orientation and are revisited annually with existing staff.
22VAC40-73-450-C
Based on record review and staff interview, the facility failed to ensure a comprehensive individualized service plan was completed within 30 days after admission.
Evidence
- The Licensing Inspector (LI) requested resident 1’s record, admitted 8/2/2024. The LI observed the initial individualized service plan (ISP), dated 8/5/2025.
- The LI asked staff 1, hired 10/31/2024, for the comprehensive service plan. Staff 1 stated a comprehensive service plan was not in the record and could not be provided.
Plan of correction
The DON or designee will ensure the initial ISP is created on the day of assessment and will review as needed based on the residents change in condition. DON will review ISP monthly and as needed. Educated DON after the inspection on 4/30/2025.
22VAC40-73-680-D
Based on record review and staff interviews, the facility failed to ensure medications shall be administered in accordance with the physician's or other prescriber’s instructions.
Evidence
- Resident 1 order for had an order for Dabigatran Etexilate (Pradaxa) 75mg cap also known as Pradaxa; take 1 capsule by mouth twice daily for blood clots, do not crush.
- Staff 1 and staff 2 on 4/28/2025 during interview with LI, discussed the 33 instances Pradaxa 75mg capsule was not administered in the month of September 2024. Staff 1 and staff 2 stated the instances Pradaxa 75mg capsule was not administered was not according to the physician order, an explanation why codes: “Medication on Hold” and “Patient unable to take medication”, was unavailable and follow up between the facility and the physician was not documented.
Plan of correction
The Administrator and Director of Nursing (DON) will ensure that all Medication orders receive appropriate training on following the identification of orders discrepancies and the order management policy. The facility medication management plan as well as order review plan has already been reviewed with all staff in March 27th 2025. The administrator will ensure that this is reviewed with new hires and completed annually with current staff.
22VAC40-73-460-A
Based on record review and staff interviews, the facility failed to assume general responsibility of a resident.
Evidence
- Resident 1 was ordered an anti-coagulant Pradaxa 75mg, one capsule by mouth twice daily for blood clots.
- In September 2024, 33 doses of Pradaxa 75mg capsules were not administered to resident 1 without documented follow-up with the physician and were not in accordance with the physician's order. Of the 33 missed doses, 11 were labeled as “Medication on hold,” despite no hold order being recorded from the physician.
- On 10/1/2024, resident 1 was experiencing a mental status change, confusion, left facial drop, and aphasia and was sent to the emergency room for further evaluation. An MRI was completed revealing a parietal lobe lacunar infarct (small stroke in the parietal lobe). Hospital discharge notes indicated resident 1 was to resume Pradaxa 75mg capsule and received a new order Pradaxa 150mg capsule by mouth every 12 hours, do not crush.
- Staff 1 and staff 2 confirmed resident 1 medication was not administered as ordered in September 2024 and resident 1 was sent to the hospital on 10/1/2024 and returned 10/2/2024 with a new diagnosis and new medication orders.
Plan of correction
The Administrator and Director of Nursing (DON) will ensure that staff receive adequate instruction on processing medication orders, particularly following the identification of any discrepancies, in accordance with the facility’s order management guidelines. The medication management strategy and order verification procedures were reviewed with all staff on March 27, 2025. The Administrator will be responsible for making sure this information is covered during onboarding for new employees and revisited annually with existing personnel.