Virginia DSS · Assisted Living Facility

Morningside House of Fredericksburg

📍 3020 Gordon W. Shelton Boulevard, Fredericksburg, VA, 22401

ID 50381Two Year licenseActive
9
Inspections
On record
5
With violations
Visits that cited something
4
Clean visits
Nothing cited
23
Violations cited
Individual findings
21
Standards cited
Distinct rules
4
Complaint visits
Prompted by a complaint

Morningside House of Fredericksburg was inspected 9 times between January 29, 2024 and March 23, 2026 by the Virginia Department of Social Services. 5 of those visits ended with violations cited and 4 with none. Across that history VDSS cited 23 violations under 21 distinct standards. 4 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
Two Year
License expires
07/31/2027
Administrator
Kimberly Brathwaite
Licensing inspector
Patricia Koval
Inspector phone
(804) 621-6046
Approved for
Non-Ambulatory · Assisted Living · Special Care Unit

Inspection History

9

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

March 23, 2026Complaint survey1 violation
Inspection dates
03/23/2026
Areas reviewed
¿ 22VAC40-73 RESIDENT CARE AND RELATED SERVICES¿ 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS¿ 22VAC40-80 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: 03/23/2026 Time in: 11:04 AM Time out: 12:00 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 07/12/2025 regarding allegations in the area(s) of: Resident Care and Related Services, Additional Requirements for Facilities That Care for Adults with Serious Cognitive Impairments, and Complaint Investigation Number of residents present at the facility at the beginning of the inspection: 45 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: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Licensing inspector observed residents interacting with peers and staff, dining for lunch, participating in scheduled activities, and walking the hallways. Additional Comments/Discussion: The Emergency Preparedness and Response Plan should be updated to Morningside House of Fredericksburg. 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 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
22VAC40-73-530-C
Based on licensing observation and staff interview, the facility failed to provide freedom of movement for the residents to common areas and to their personal spaces. The facility should not lock residents out of or inside their rooms.
Evidence
  1. During the onsite inspection, 03/23/2026, LI toured the safe, secure facility with staff 1. During the tour, LI and staff 3 noted that resident 1, resident 2, resident 3, resident 4, resident 5, resident 6, resident 7, resident 8, resident 9, resident 10, resident 11, resident 12, and resident 13’s bedroom doors were locked.
Plan of correction
The facility reviewed its door-locking practices within the secure unit and implemented changes to ensure resident freedom of movement while maintaining safety. The resident bedroom doors will remain unlocked to allow access to personal spaces and common areas. Some resident's doors may only be locked if the resident is assessed as capable of independently maintaining and using a key, and this practice aligns with the resident’s rights and individualized service plan. The facility implemented internal review measures to ensure doors are appropriately managed throughout the day. The DHW and/or their liaison will conduct scheduled environmental checks during each shift to confirm resident doors are unlocked unless permissibly locked under approved criteria daily for 2 weeks, weekly for 4 weeks, then at random for reviews thereafter every 30 days. Any inconsistencies will be addressed and corrected immediately.
March 23, 2026Inspection3 violations
Inspection dates
03/23/2026
Areas reviewed
¿ 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES¿ 22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03/23/2026 Time in: 2:10 PM Time out: 2:49 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-report was received by VDSS Division of Licensing on 11/03/2025 regarding allegations in the area(s) of: Administration and Administrative Services and Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 45 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: 2 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Licensing inspector observed residents interacting with peers and staff, dining for lunch, participating in scheduled activities, and walking the hallways. 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 Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov
Violations
22VAC40-73-640-A
Based on resident record review and staff interview, the facility failed to ensure to implement their written plan for medication management to include methods to ensure that staff who were responsible for administering medications were adequately supervised, including periodic direct observation of medication administration.
Evidence
  1. During the onsite inspection, 03/23/2026, the facility’s medication management plan was reviewed and stated the following as it relates to staff that administer medications: “orientation included review of this plan, medication policies, use of the eMAR, error reporting, and the Five Rights of Medication Administration; and new staff receive supervised medication passes by Director of Health and Wellness (DHW)/Licensed Practical Nurse (LPN).”
  2. The licensing department received an incident report, 11/03/2025, that stated, “during the morning medication pass, a registered medication aide in training, staff 1 administered medications intended for resident 2 to resident 1. The training aide, staff 2, pointed to indicate the intended resident, but the trainee misidentified the individual and proceeded to administer the medications to the wrong resident.”
  3. During the onsite inspection, 03/23/2026, staff 4 confirmed that resident 1 and resident 2’s medication error occurred when staff 2 did not adequately supervise staff 1, who was in training during the medication pass on 11/03/2025.
Plan of correction
The community self-reported the incident to licensing in a timely manner at the time of occurrence in accordance with regulatory requirements. At the time of the incident, the community provided education to both team members involved. The facility reviewed its medication management plan to evaluate current practices and identify opportunities for strengthening oversight. The medication management plan was updated to include enhanced measures specific to the training and authorization of trainers responsible for medication administration training. The updated process requires medication pass observations to be completed and evaluated prior to clearing trainers to independently supervise others. This ensures trainers demonstrate competency and adherence to medication administration standards before assuming training responsibilities. The facility monitors compliance through DHW and ADHW review of medication pass observations, trainer clearances, and ongoing oversight of medication management practices to ensure continued compliance and prevent recurrence.
22VAC40-73-70-A
Based on record review and staff interview, the facility failed to report to the regional licensing office within 24 hours any major incident that negatively affected or that threatened the life, health, safety, or welfare of any resident.
Evidence
  1. During the onsite inspection, 03/23/2026, LI reviewed staff 2’s records and noted a documentation dated 03/10/2026 stated, “on 03/03/2026 staff 2 stopped AM medication pass while clocked in, left the building to pick up Tropical Smoothie for coworkers and self. Medication cart was left in the middle of main and unattended. Medication pass ended late;” however, the incident was not reported to the regional licensing office.
  2. During the onsite inspection, 03/23/2026, staff 3 confirmed that the incident involving late medication administration on 03/03/2026 was not reported to the regional licensing office within 24 hours of the event.
Plan of correction
The facility reviewed its incident reporting procedures to ensure all required incidents are reported to the appropriate parties within 24 hours as required by regulation, and the Administrator is made aware timely. The facility implemented a standardized internal reporting process and education that educates team members on reporting all incidents meeting reportable criteria to be communicated to the administrator immediately upon its occurrence. Leadership reviews each incident to determine reportability and ensure timely submission within the required 24-hour timeframe
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.
Evidence
  1. On 11/03/2026, staff 1 (hire date, 10/30/2025) administered resident 2’s morning medication (Amlodipine Besylate 5 MG, Carvedilol 25 MG, Quetiapine Fumarate 50 MG, and DOK 100 MG Softgel) to resident 1.
  2. During the onsite inspection, 03/23/2026, staff 4 acknowledged resident 1’s orders (Amlodipine Besylate 5 MG, Carvedilol 25 MG, Quetiapine Fumarate 50 MG, and DOK 100 MG Softgel) were not followed as they received resident 2’s medication on 11/03/2025.
Plan of correction
This citation was related to a self-reported incident. The facility reviewed medication administration practices to ensure medications are administered strictly in accordance with prescribers’ orders. The facility implemented additional oversight procedures for medication administration and training practices to reinforce adherence to medication orders and proper resident identification using the five rights of medication administration. Compliance is monitored through DHW and/or its designee to complete and review medication pass observations to prevent reoccurrence. Medication pass observations will occur for all medication staff immediately. Then a recurring schedule for all designated medication staff until all are completed every 6 months. All medication staff will have med pass observations twice a year.
March 23, 2026Inspection0 violations
Inspection dates
03/23/2026
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03/23/2026 Time in: 12:41 PM Time out: 2:10 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 12/26/2025 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: 45 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: Licensing inspector observed residents interacting with peers and staff, dining for lunch, participating in scheduled activities, and walking the hallways. Additional Comments/Discussion: 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. 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 23, 2026Complaint survey0 violations
Inspection dates
03/23/2026
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: 03/23/2026 Time in: 12:01 PM Time out: 12:40 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 08/30/2025 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: 45 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Licensing inspector observed residents interacting with peers and staff, dining for lunch, participating in scheduled activities, and walking the hallways. Additional Comments/Discussion: 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. 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.
July 8, 2025Complaint survey0 violations
Inspection dates
07/08/2025
Areas reviewed
22VAC40-80 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: 7/8/2025 2:45 P.M. – 4:00 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 4/30/2025 regarding allegations in the area(s) of: resident care Number of residents present at the facility at the beginning of the inspection: 49 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 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 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 Jeff Marnien, Licensing Inspector at (540) 571-0189 or by email at Jeffrey.marnien@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
September 16, 2024Complaint survey7 violations
Inspection dates
09/16/2024, 10/21/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-80 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: 9/16/2024 9:00 a.m. – 4:20 p.m.; 10/21/2024 10:10 a.m. – 2:00 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 9/6/2024 regarding allegations in the area(s) of: Resident Care Number of residents present at the facility at the beginning of the inspection: 50 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: 4 Observations by licensing inspector: Activity being provided to the residents, meal being served. Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s); area(s) of non-compliance with standard(s) or law were: incident reports, physician orders, individualized service plan, facility policies and procedures, resident care. A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jeff Marnien, Licensing Inspector at (540) 571-0189 or by email at Jeffrey.marnien@dss.virginia.gov
Violations
22VAC40-73-470-C
Based on record review and staff interview, the facility failed to provide services to prevent clinically avoidable complications.
Evidence
  1. Resident 1’s weight prior to admission (admitted 6/7/2024) was documented on the physical examination (5/29/2024) to be 140 lbs.
  2. The resident’s weight was not checked and documented by the facility upon admission or through the month of June 2024. Staff 4 stated they made a mistake by not recording resident 1’s weight on admission.
  3. On 7/1/2024, resident 1’s weight was recorded at 104.4lbs. There were no interventions indicated in resident 1’s record until a six-month dietary review was conducted on 7/22/2024. On 7/28/2024 re-admission weight from the hospital was recorded at 104.4 lbs.
  4. Eight total entries in the communication log referenced resident 1’s meal intake. On the following eight entries, resident 1 was recorded to have eaten 25% or less: 6/10/2024, 6/26/2024, 7/5/2024, 7/14/2024, 7/29/2024, and 7/30/2024.
  5. Home health nursing documented providing skilled wound care on 7/10/2024, 7/16/2024, 7/19/2024, 7/22/2024, and 8/2/2024 to an open area on the sacrum. Home health physical therapy documented therapy visits on 7/17/2024 and 8/1/2024 with home health speech therapy completing an evaluation on 7/18/2024.
  6. Following the home health visits, the facility failed to document any follow-up after the physical therapy visit on 7/17/2024, speech therapy evaluation/visit on 7/18/2024, or the physical therapy visit on 8/1/2024.
Plan of correction
The ED or designee will retrain/reeducate all clinical licensed staff on admission weights and weight tracking. The ED, HWD, WC, RCC, or designee will audit 20% of the current resident population for accurate weight documentation by 6/2/24. To assist with ongoing compliance the ED or designee will conduct reviews of resident population weight recording on a monthly basis until 8/1/25.
22VAC40-73-580-F
Based on record review and staff interview, the facility failed to implement interventions as soon as a nutritional problem was suspected.
Evidence
  1. Resident 1’s (admitted 6/7/2024) weight on the pre-admission physical examination (dated 5/29/2024) was 140 lbs.
  2. Initial ISP (dated 6/7/2024) under Eating/Feeding included note that resident 1 required full assistance with eating and close monitoring for choking hazard.
  3. Resident 1’s weight was not recorded in June 2024. Facility recorded weight on 7/1/2024 was 104.4 lbs.
  4. The facility recorded resident 1’s percentage of meals consumed on 7/5/2024, 7/14/2024, 7/19/2024, 7/29/2024, 7/30/2024. Four entries referencing meal intake noted meal consumption to be 25% or less. Entries on 6/10/2024, 6/26/2024, 7/24/2024, 7/26/2024, recorded resident eating little to no food.
  5. A six-month dietary review of all residents on a special diet was completed on 7/22/2024. The dietitian notes for resident 1 recommended a concentrated calorie diet along with a good protein source and Juven two times daily to promote healing. There is no documentation demonstrating the facility provided specific actions to address resident 1’s weight loss. Evidence where the facility followed up on the dietitian’s recommendations could not be located in the resident’s record.
  6. LI reviewed physician’s progress notes for resident 1. No nutrition or weight loss concerns were noted nor was there any mention of the dietitian’s recommendations.
  7. Resident hospitalized on 7/22/2024. Upon return to the facility on 7/28/2024, resident 1’s facility recorded weight was documented as 104.4 lbs. Discharge recommendations from the hospital included changing resident 1’s diet to Dysphagia Diet. No evidence was located in resident 1’s chart that this diet change was made.
  8. On 10/21/2025, LI interviewed staff 4 who confirmed no additional meal consumption documentation was on file for resident 1.
Plan of correction
The ED or designee will retrain/reeducate the Health and Wellness Director, Wellness Coordinator, Resident Care Coordinator, or any staff responsible for preadmission skin assessments on company policy and procedure. The ED, Health and Wellness Director, Wellness Coordinator, Resident Care Coordinator, or designee will conduct an audit of 20% of current resident records by 8/2/2025 for completion of admission skin assessment. To assist with ongoing compliance the ED or designee will conduct reviews of all new resident records monthly until 8/1/25 to ensure skin assessment is completed on or before admission.
22VAC40-73-680-E
Based on record review and staff interview, the facility failed to ensure treatments ordered by a physician or other prescriber were documented and provided according to instructions.
Evidence
  1. A physician’s order was received on 6/27/2024 for home health to evaluate and treat the open area on resident 1’s coccyx.
  2. A skilled nursing (SN) home health evaluation completed on 7/10/2024 noted a sacral wound along with a newly identified wound on the left hip. Home health instructed facility to perform wound care in the absence of the skilled nurse and as needed (prn) if wound dressing was saturated. The SN documented facility staff were able to teach back dressing care at 100%. Facility failed to document follow up on the recommendations made by SN.
  3. The physician order sheet (POS) signed on 7/27/2024 did not include treatment of the open area on the sacrum that had previously been identified on both the physician referral dated 6/27/2024 and the home health order dated 7/10/2024.
  4. On 9/16/2024, LI reviewed documentation with staff 1 who acknowledged the order dated 6/27/2024 stated, “Home Health eval and treat for open area to coccyx” was not included on the POS.
  5. Physical Therapy (PT) Home Health visit, completed on 7/17/2024, provided instruction on the prevention of pressure ulcers through positioning and offloading techniques to reduce pressure on the wound. The physical therapist documented that the caregiver verbalized and demonstrated strategies to improve mobility related to transfers and ambulation. On 8/1/2024, PT educated caregivers on proper positioning when lying in bed along with frequent position changes to assist in healing of current pressure ulcers and to reduce the risk for developing new pressure ulcers. However, the facility failed to document any follow-up on the recommendations made after the visit.
  6. A speech therapy evaluation/visit was completed on 7/18/2024 and documented educating caregivers on therapeutic exercises during the visit to include safe swallow strategies, taking single bites, and upright positioning during meals. However, the facility failed to document any follow-up on the recommendations made after the ST visit.
  7. The treatment administration record (TAR) did not include a place for facility staff to document treatment of the open area on the sacrum. Progress notes did not include documentation of following up on PT or ST recommendations.
  8. Physician order dated 6/5/2024 indicated to check resident 1’s weight monthly. Facility failed to log resident weight on the TAR in June 2024. On 10/16/2024, Staff 4 confirmed that the facility did not weigh resident 1 upon admission; instead, they documented the weight from the admitting history and physical conducted by the physician on 5/29/2024.
Plan of correction
The ED or designee will retrain/reeducate the Health and Wellness Director, Wellness Coordinator, Resident Care Coordinator, or any staff responsible for treatment orders and follow up documentation. The Health and Wellness Director or designee will review and audit 100% of resident population to verify all treatment orders are correct and properly documented on the TAR. HWD, WC, RCC or designee will audit 10 resident records a month until 8/1/25 to ensure each has a correct treatment orders and those orders reflect correctly on the TAR.
22VAC40-73-440-F
Based on record review and staff interview, the facility failed to ensure the Uniform Assessment Instrument (UAI) was completed within 90 days of admission to the assisted living facility.
Evidence
  1. The LI requested resident 1’s UAI on 10/21/2024.
  2. On 9/16/2024, LI interviewed staff 4 who stated they were unable to locate and provide documentation of resident 1’s UAI.
Plan of correction
The ED or designee will retrain/reeducate the Health and Wellness Director, Wellness Coordinator, Resident Care Coordinator, Director of Sales & Marketing, and any UAI certified associates on UAI procedures. The ED, HWD, Wellness Coordinator, Resident Care Coordinator or designee will audit 100% of the current resident population for completed UAI by 6/2/24, To assist with ongoing compliance the ED or designee will conduct reviews of all new resident records monthly until 8/1/25.
22VAC40-73-450-F
Based on record review and staff interview, the facility failed to update the Individualized Service Plan (ISP) as needed for a significant change of a resident’s condition.
Evidence
  1. On 6/27/2024, the physician ordered home health to evaluate and treat an open area on resident 1’s coccyx.
  2. A skilled nursing home health evaluation for resident 1 was completed on 7/10/2024 with treatment initiated the same day. Home Health services were not included on the ISP.
  3. Dietitian consult completed on 7/22/2024 with recommendations made for concentrated calorie diet with Juven two times daily to promote wound healing. These recommendations were not updated on the ISP.
  4. Home health progress notes dated 6/19/2024, 7/16/2024, 7/17/2024, 7/19/2024, and 7/22/2024 all indicated the need for turning and repositioning to offload pressure to the sacral area. These recommendations were not documented on the ISP.
  5. Home health speech therapy evaluation and treatment completed on 7/18/2024 with focus on risk for aspiration and choking, along with decreased nutrition and hydration. These concerns were not documented on the ISP.
  6. On 9/16/2024, LI reviewed resident 1’s ISP with staff 1, who acknowledged the ISP had not been updated and did not include coordination of care with home health and dietitian’s recommendations.
Plan of correction
The ED or designee will retrain/reeducate the Health and Wellness Director, Wellness Coordinator, Resident Care Coordinator, and any ISP certified associates on Individualized Service Plans. The ED, Health and Wellness Director, Wellness Coordinator, Resident Care Coordinator, or designee will conduct an audit of 20% of current resident ISP records by 8/2/2025. To assist with ongoing compliance, the ED, HWD, WC, RCC, or designee will audit all current resident Individualized Service Plans until 8/1/25. ISP’s will be updated for residents during admission, annually, and for significant changed in condition.
22VAC40-73-40-A
Based on record review and staff interview, the facility failed to ensure compliance with the facility's own policies and procedures.
Evidence
  1. LI requested the facilities skin assessment policies and procedures.
  2. The Resident Care Skin Assessment Policy 244 provided by staff 1 stated the director of health and wellness (DHW) or designee will evaluate a resident on or before move-in to the community in an effort to decrease the incidence of skin breakdown with procedure six specifying the DHW or designee was responsible for documenting on the skin assessment form (Mem Form 244A) for any area of skin breakdown.
  3. LI requested documentation of the completed skin assessment.
  4. On 9/16/2024, staff 1 stated the skin assessment, which was to be completed on or before move-in, along with Form 244A (assessment after skin breakdown), were not completed.
Plan of correction
The ED or designee will retrain/reeducate the Health and Wellness Director, Wellness Coordinator, Resident Care Coordinator, or any staff responsible for preadmission skin assessments on company policy and procedure. The ED, Health and Wellness Director, Wellness Coordinator, Resident Care Coordinator, or designee will conduct an audit of 20% of current resident records by 8/2/2025 for completion of admission skin assessment. To assist with ongoing compliance the ED or designee will conduct reviews of all new resident records monthly until 8/1/25 to ensure skin assessment is completed on or before admission.
22VAC40-73-70-A
Based on record review and staff interview, the facility failed to report to the regional licensing office within 24 hours any major incident that negatively affected or threatened the life, health, safety, or welfare of any resident.
Evidence
  1. Licensing Inspector (LI) conducted a review of resident 1’s record (date of admission 6/7/2024) and noted a physician’s order dated 6/27/2024 for evaluation and treatment of open area on coccyx.
  2. On 9/16/2024, LI asked staff 1 for the self-report for resident 1’s wound.
  3. Communication log dated 7/1/2024 noted bruising to resident 1’s left rib cage area with x-ray ordered by the physician.
  4. On 9/16/2024, LI interviewed staff 1 who stated the self-report was not sent for either incident to the regional licensing office.
Plan of correction
The ED or designee will retrain/reeducate the entire staff on mandated reporting and regional licensing office reporting obligations. To assist with ongoing compliance, the ED or designee will review all clinical observations on a daily basis to ensure no incidents go unreported until 6/3/25
July 26, 2024Inspection5 violations
Inspection dates
07/26/2024
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 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: Renewal Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7/26/2024 8:30am – 5:00pm 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: 51 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: n/a Number of interviews conducted with staff: 3 Observations by licensing inspector: Observed activities, breakfast meal, medication pass, building and grounds, 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 (Jeff Marnien), Licensing Inspector at (540) 571-0189 or by email at Jeffrey.marnien@dss.virginia.gov Violation Notice Issued: Yes
Violations
22VAC40-73-980-A
Based on observation and staff interview, the facility failed to ensure the first aid kits were checked at least monthly to ensure that all items are present and items with expiration dates are not past their expiration date.
Evidence
  1. The LI observed the first aid kit, located in the Wellness Office, did not include a blanket, tweezers, hand sanitizer, scissors, and triangle bandage.
  2. Staff 4 acknowledged the first aid kit was missing items.
Plan of correction
All items within the First aid kit were replenished 8/1/24- First aid kit shall be checked at least monthly to ensure that all items are present and items with expiration dates are not past their expiration date. A complete first aid kit shall be on hand at the facility, located in a designated place that is easily accessible to staff but not to residents. All first aid kits will be signed off monthly by RMA on a ledger listing all items that should be included, date, and signature. ED on the last day of each month will finalize for completion.
22VAC40-73-610-B
Based on observations, the facility failed to ensure menu substitutions or additions was recorded on the posted menu.
Evidence
  1. During tour of the facility on 7/29/2024 the licensing staff observed the breakfast meal which included eggs, sausage, and toast with jelly.
  2. The posted menu included eggs, sausage, French toast, and grits.
  3. The posted menu was not updated with the toast with jelly substitution.
Plan of correction
Menu was corrected and updated 7/26/24, by Director of Dining Services. Any menu substitutions or additions shall be recorded on the posted menu by any Cook working or making the change immediately. All substitutions or additions shall be communicated to the Director after the substitution has been documented. The Director of Dining will be responsible for ensuring proper documentation is done prior to each meal.
22VAC40-73-1120-B
Based on record review and staff interview, the facility failed to ensure at least 21 hours of scheduled activities were available to the residents.
Evidence
  1. The July 2024 activity calendar did not document 21 hours of resident activities per week.
  2. Staff 2 confirmed the number of hours was not posted on the activity calendar demonstrating at least 21 hours of activities were scheduled per week.
  3. Photo evidence taken.
Plan of correction
Calendar demonstrated minimum of 21 hours requirement, but no ending time. Calendar was corrected for August 2024 calendar with the beginning and ending time for each activity daily. There shall be at least 21 hours of scheduled activities available to the residents each week for no less than two hours each day. Director of Activity was in serviced and understands the expectations going forward. ED will monitor monthly to ensure compliance.
22VAC40-73-680-M
Based on observation and staff interview, the facility failed to ensure that medications ordered for PRN administration was available, properly labeled for the specific resident, and properly stored at the facility.
Evidence
  1. LI observed a med pass, 7/26/2024, and reviewed the medication administration record (MAR). The LI observed prn medications listed on the MAR were missing from the medication cart.
  2. Resident 1 had a physician order for routine treatment of moisture wicking fabric (order date 6/11/2024) and prn cream in the medication cart (order date 7/13/2024) were not available.
  3. Resident 2 had a physician order for Aquaphor Ointment (order date 3/12/2024), and prn Loperamide 2mg capsule (order date 3/20/2024) were not available.
  4. Resident 3 had a physician order for prn Acetaminophen 325 mg tablet (order date 3/19/2024), prn Loperamide 2mg capsule (order date 3/12/2024), prn Nystatin (order date 3/19/2024), prn Miralax (order date 3/12/2024), and prn Ureacin –20 cream (order date 3/12/2024) were not available.
  5. Staff 3 acknowledged that the medications were not available.
Plan of correction
Full audit conducted from signed physician orders versus carts. All PRN medications were re-ordered and available for all residents in the community on 8/1/24. Medications ordered for PRN administration shall be available, properly labeled for the specific resident, and properly stored at the facility. Daily RMA will audit and reorder any medications that are 10 days or less from running out. This will be reported daily to Wellness Nurse. Wellness nurses will document and track all medications until they arrive in the community. ECP our electronic mar system has been equipped with medication re-order dial. In the event medication is destroyed or expired all medications can be easily ordered by the nurse or RMA with a push of a button. DON will be responsible for compliance and monthly auditing.
22VAC40-73-980-H
Based on observation and staff interview the facility failed to ensure the availability of a 96-hour supply of emergency food and drinking water and that at least 48 hours of the supply must be on site at any given time.
Evidence
  1. During tour of the facility on 7/26/2024 the LI observed 48 – 8oz. bottles.
  2. Staff 1 acknowledged that 48 hours of emergency water was not in stock.
Plan of correction
48-hour emergency water supply was replenished 8/1/24 by Director of Dinning Services. The community will ensure the availability of a 96-hour supply of emergency food and drinking water. 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. Stock will be rotated by Director of Dining at the end of each month and signed off and submitted to ED.
January 29, 2024Inspection0 violations
Inspection dates
01/29/2024
Areas reviewed
Administration and Administrative ServicesPersonnelStaffing and SupervisionAdmission, Retention and Discharge of ResidentsResident Care and Related ServicesBuildings and GroundsEmergency PreparednessMixed PopulationSafe, Secure Environment
Comments
Date of Inspection: January 29, 2024 Type of Inspection: Initial Inspection If you have any questions or email changes, please do not hesitate to contact me at laura.lunceford@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov. Census 55 The Licensing conducted an announced initial inspection. The Licensing Inspector walked the physical plant., verified window and room measurements, reviewed policies and procedures. The building, fire and health inspections have been submitted and reviewed. No violations were cited and an exit interview held.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
06/26/2028Inspection7 violations
Inspection dates
06/26/2028
Areas reviewed
22VAC40-73 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 IMPAIRMENTS63.2- (18) FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSING PROCESS
Comments
Type of inspection: Renewal Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 6/26/2025 9:30 A.M. – 6:50 P.M. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 49 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 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: Building and grounds, dining services, activities, and medication administration observation. 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 Jeff Marnien, Licensing Inspector at (540) 571-0189 or by email at Jeffrey.marnien@dss.virginia.gov
Violations
22VAC40-73-1110-A
Based on record review and staff interview, the facility failed to ensure prior to admitting a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia to a safe, secure environment, the licensee, administrator, or designee determined whether placement in the special care unit was appropriate. The determination must be in writing and retained in the resident’s chart.
Evidence
  1. The LI conducted a record review on 6/26/2025 of resident 2’s chart, admitted 6/18/2025. The LI observed the chart did not contain a written determination and justification.
  2. During an interview with staff 4 on 6/26/2025, staff 4 confirmed resident 2’s chart did not contain the required written determination and justification.
Plan of correction
The ED or designee will retrain/reeducate the Director of Sales and Marketing on written appropriate placement determination. To assist with ongoing compliance the ED or designee will conduct reviews of all new resident records weekly until 10/14/25 to ensure written appropriate placement determination has been retained the in resident’s chart.
22VAC40-73-680-K
Based on record review and staff interviews, the facility failed to ensure as needed (PRN) medications included directions as to what to do if symptoms persisted.
Evidence
  1. During a record review on 2/26/2025 the LI observed Albuterol 90 mcg, a PRN medication, for resident 5 (admitted 2/20/2025) did not include directions what to do if symptoms persisted.
  2. During interviews with staff 4 and staff 5 on 6/26/2025, they confirmed the Albuterol 90 mcg PRN does not include directions as to what to do if symptoms persisted.
Plan of correction
The ED or designee will retrain/reeducate the, community Physician, Health and Wellness Director, Wellness Coordinator, Resident Care Coordinator, and any clinical staff responsible to PRN medication orders on obtaining directions as to what to do if symptoms persist after PRN administration. The ED, Health and Wellness Director, Wellness Coordinator, Resident Care Coordinator, or designee will conduct an audit of 100% of current resident PRN orders by 8/14/2025. To assist with ongoing compliance, the ED, HWD, WC, RCC, or designee will audit all NEW PRN orders on a bi-weekly basis to ensure orders reflect what to do if symptoms persist after PRN administration until 10/14/25.
22VAC40-73-530-C
Based on observation and staff interview, the facility failed to ensure residents were not locked out of their rooms.
Evidence
  1. During the initial tour of the building on 6/26/2025 with staff 4, the LI observed all resident rooms were locked in the building.
  2. During the tour of the building, the LI interviewed Staff 4, who confirmed that the resident rooms were locked and that residents needed to request access to their room. Alternatively, staff would assist residents to their room if they observed the resident was tired and needed to lie down.
Plan of correction
The ED or designee will retrain/reeducate all community staff that resident rooms are to remain unlocked by 8/14/25. To assist with ongoing compliance, all resident rooms will remain unlocked.
22VAC40-73-970-E
Based on observation and staff interview, the facility failed to ensure a record of required fire and emergency evacuation drills recorded all nine elements of this subsection.
Evidence
  1. During a record review on 6/26/2025, the Licensing Inspector (LI) observed that the fire drill conducted on 3/16/2025 did not include two of the nine required data elements: the method used for notification of the drill and any problems encountered.
  2. During an interview with staff 4 on 6/26/2025, staff 4 confirmed the fire drill records did not include all the required elements of this subsection.
Plan of correction
The ED or designee will retrain/reeducate the Director of Plant Operations on the nine elements essential to a complete fire and emergency evacuation drill. To assist with ongoing compliance, the ED or designee will update the current fire and emergency evacuation drill form to reflect the nine elements of this subsection. Usage of the updated form will be implemented immediately upon its completion 7/25/25. To assist with ongoing compliance, the ED will audit all complete fire and emergency evacuation forms once drills have been completed on a monthly basis until 10/14/25.
22VAC40-73-1090-A
Based on record review and staff interview, the facility failed to ensure prior to admission to a safe, secure environment, the resident was assessed by an independent clinical psychologist licensed to practice in the Commonwealth, or by an independent physician, as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia, with an inability to recognize danger or protect his own safety and welfare.
Evidence
  1. The LI conducted a record review on 6/26/2025 of resident 2’s chart, admitted 6/18/2025. The LI observed the chart did not contain an assessment by a psychiatrist or physician that assessed the resident’s cognitive function, thought and perception, mood, behavior/psychomotor, speech, and appearance.
  2. During an interview with staff 4 on 6/26/2025, staff 4 confirmed resident 2’s chart did not contain the required assessment according to the standards.
Plan of correction
The ED or designee will retrain/reeducate the Director of Sales and Marketing, or any staff responsible for the admission paperwork process on form 032-05-0078-05. To assist with ongoing compliance, the DSM or designee will review all new admission’s to ensure form 032-05-0078-05 has been completed until 10/14/25.
22VAC40-73-1140-B
Based on record review and staff interview, the facility failed to ensure within four months of the starting date of employment in the safe, secure environment, direct care staff attended at least 10 hours of training in cognitive impairment.
Evidence
  1. During a record review on 6/26/2025, the LI observed staff 1, hired 2/27/2025, did not have 10 hours of cognitive impairment training within four months of their hire date.
  2. Staff 4 confirmed staff 1 did not have the required 10 hours of cognitive impairment training within four months of their hire date.
Plan of correction
The ED or designee will retrain/reeducate the BOM and HWD that direct care staff must have 10 hours of training cognitive impairment within four months of employment. To assist with ongoing compliance the community has the contracted education system Relias; implemented as of 6/1/25. The BOM will audit 100% of all new hire Relias transcripts to ensure 10 hours of education has been completed until 10/14/25.
22VAC40-73-260-A
Based on record review and staff interview, the facility failed to ensure direct care staff were first aid certified.
Evidence
  1. During record review on 6/26/2025, the LI observed that staff 1, a direct care aide (DCA), hired 2/27/2025, did not have a record of being first aid certified in their employee file.
  2. During an interview with staff 4 on 6/26/2025, staff 4 confirmed staff 1 did not have a current first aide certification.
Plan of correction
The ED or designee will retrain/reeducate all clinical staff on 260-A and the requirement to be first aid certified. The ED, BOM, or designee will do 100% audit of all direct care staff charts. To assist with ongoing compliance the ED or designee will conduct First Aide courses on a monthly basis until 10/14/25.Thereafter on a quarterly basis to ensure all new hires become certified.