Virginia DSS · Assisted Living Facility

The Barclay at Tuckahoe

📍 567 N. Parham Road, Henrico, VA, 23229

ID 50392One Year licenseActive
15
Inspections
On record
7
With violations
Visits that cited something
8
Clean visits
Nothing cited
19
Violations cited
Individual findings
18
Standards cited
Distinct rules
7
Complaint visits
Prompted by a complaint

The Barclay at Tuckahoe was inspected 15 times between April 25, 2024 and May 14, 2026 by the Virginia Department of Social Services. 7 of those visits ended with violations cited and 8 with none. Across that history VDSS cited 19 violations under 18 distinct standards. 7 inspections were prompted by a complaint.

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

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

Provider Information

Facility type
Assisted Living Facility
License type
One Year
License expires
11/30/2026
Administrator
Sabrina Richmond
Licensing inspector
Tyia Venable
Inspector phone
(804) 393-2157
Approved for
Special Care Unit · Assisted Living

Inspection History

15

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

May 14, 2026Inspection0 violations
Inspection dates
05/14/2026
Areas reviewed
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: 5/14/2026, 12:20pm-12:50pm 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 4/23/2026 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: 135 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: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: Licensing inspector observed all required postings Additional Comments/Discussion: Licensing inspector spoke with the administrator and resident regarding the incident. 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 Tyia Venable, Licensing Inspector at 804-393-2157 or by email at tyia.venable2@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
November 26, 2025Inspection1 violation
Inspection dates
11/26/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Other Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/26/2025, 8:45am-10am 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 11/21/2025 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: 109 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: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: Licensing inspector observed all required facility postings and reviewed facility documentation. Additional Comments/Discussion: An exit meeting was 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 Tyia Venable, Licensing Inspector at 804-393-2157 or by email at tyia.venable2@dss.virginia.gov
Violations
22VAC40-73-460-A
Based on a review of facility documentation, resident records, and staff records, the facility did not ensure the health, safety, and well being of a resident.
Evidence
  1. Licensing inspector reviewed the internal facility incident report which documented that Staff 1 hit the hand and was physically rough with Resident 1.
  2. Licensing inspector reviewed the witness statements regarding the incident which stated Staff 1 hit the hand of Resident 1 and was rough with him when putting him in bed.
  3. When asked Staff 2 stated, based on the evidence Staff 1 was rough with Resident 1 and Staff 1 also hit the hand of Resident 1.
Plan of correction
The staff member involved in the incident has been removed from employment duties. This individual will not return to resident care. Training completed on 11/20/2025 for abuse/neglect prevention but the facility will conduct random competency checks on 15 employees related to abuse neglect prevention over the next 30 days.
October 28, 2025Inspection9 violations
Inspection dates
10/28/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Technical assistance
Technical assistance provided regarding updating forms to reflect the change in ownership.
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: 10/28/2025, 10:25am-4pm 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: 102 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 4 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: Licensing inspector observed the medication pass, resident lunch, and required facility postings. Additional Comments/Discussion: An exit meeting was 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 Tyia Venable, Licensing Inspector at (804)393-2157 or by email at tyia.venable2@dss.virginia.gov
Violations
22VAC40-73-260-A
Based on a review of staff records, the facility did not ensure that each direct care staff who did not have a current certification in first aid received within 60 days of employment.
Evidence
  1. Staff 6’s (hire date 8/14/25) did not contain a current first aid certification.
  2. Staff 7’s (hire date 8/12/25) did not contain a current certification in first aid within 60 days of employment.
  3. Staff 1 and Staff 2 were unable to provide documentation of first aid certification for Staff 6 and Staff 7.
Plan of correction
The facility is auditing all direct care staff employee records to ensure they have a current first aid certificate. The facility will ensure that all first aid certificate are obtained by 12/15/2025 The Director of Business Office (and/or appropriate designee) will track all first aid certificates to ensure compliance. The Director of Business Office (and/or appropriate designee) will obtain a first aid certificate from all new hires and track expiration dates. The Executive Director (or appropriate designee) will ensure that all first aid certificates are completed on time. The Regional Operations Team will spot-check five direct staff records each visit for compliance
22VAC40-73-50-A
Based on a review of resident records, the facility did not ensure a statement was prepared and provided to the prospective resident and the prospective resident’s legal representative, if any, that disclosed information about the facility.
Evidence
  1. Resident 1’s record did not contain a disclosure statement from the facility.
  2. Resident 2’s record did not contain a disclosure statement.
  3. When asked, Staff 1 and Staff 2 were unable to provide disclosure statements for Resident 1 and Resident 2.
Plan of correction
The facility will ensure that all residents receive a disclosure statement The Executive Director (and/or appropriate designee) will ensure that all residents have received the disclosure statement by 02/15/2026. The Executive Director (or appropriate designee) will ensure that all new residents receive a notice of disclosure as part of their admission package
22VAC40-73-550-G
Based on a review of resident records, the facility did not ensure
Evidence
  1. of an annual review of resident rights and responsibilities with each resident or their legal representative, was filed in the resident’s record. Evidence:
  2. Resident 1’s (admit date 5/14/24) record did not contain an annual review of resident rights and responsibilities.
  3. Resident 2’s (admit date 10/24/22) record did not contain an annual review of the rights and responsibilities of residents.
  4. Resident 5’s (admit date 1/5/24) record did not contain an annual review of the rights and responsibilities of residents.
  5. When asked, Staff 1 and Staff 2 were unable to provide documentation of an annual review of resident rights and responsibilities with Resident 1, Resident 2, and Resident 5.
Plan of correction
The facility is completing a residents’ rights review. The facility will ensure that residents’ rights are reviewed yearly and by November 1st of each year. The Executive Director (and/or appropriate designee) will ensure that this requirement is met
22VAC40-73-310-D
Based on a review of resident records, the facility did not ensure the assisted living administrator provided written assurance to the resident that the facility has the appropriate license to meet their care needs at the time of admission.
Evidence
  1. Resident 1’s record did not contain a written assurance document signed by the facility administrator.
  2. Resident 2’s record did not contain a written assurance document signed by the facility administrator.
  3. When asked, Staff 1 and Staff 2 were unable to provide a written assurance document for Resident 1 and Resident 2.
Plan of correction
The facility will ensure that all residents receive written assurance that the facility has the appropriate license to meet their needs at the time of admission. This task will be completed by 02/15/2026. The Executive Director will ensure that all residents have received an assurance notice by 02/15/2026. The Executive Director (and/or appropriate designee) will ensure that all new residents receive the assurance notice as part of their admission package.
22VAC40-73-320-B
Based on a review of resident records, the facility did not ensure risk assessments for tuberculosis were completed annually on each resident.
Evidence
  1. Resident 5’s last documented tuberculosis assessment was dated 4/16/24.
  2. Resident 3’s last documented tuberculosis assessment was dated 4/16/24.
  3. Resident 1’s last documented tuberculosis assessment was dated 5/23/24.
  4. Resident 4’s last documented tuberculosis assessment was dated 4/16/24.
  5. Staff 1 and Staff 2 were unable to provide documentation of risk assessments for tuberculosis for Resident 5, Resident 3, Resident 1, and Resident 4.
Plan of correction
The residents TB screening identified during the survey were corrected. Furthermore, the facility is auditing all resident records to ensure all TB risk assessments are completed. The Wellness Director (or appropriate designee) will ensure that all TB risk assessments are completed by July yearly The Executive Director (and/or appropriate designee) will ensure that all residents’ TB risk assessments are completed, and this requirement is met. The Regional Wellness Team will spot-check five resident records to ensure compliance with this requirement.
22VAC40-73-950-E
Based a review of facility documentation, the facility did not ensure a semi annual review on the emergency preparedness and response plan for all staff, residents, and volunteers was documented.
Evidence
  1. Licensing inspector reviewed facility documentation and there was no documented evidence of a semi annual review of the emergency preparedness and response plan for all staff, residents, and volunteers.
  2. When asked, Staff 1 and Staff 2 were unable to provide documentation of a semi annual review of the emergency preparedness and response plan.
Plan of correction
The facility will complete the semi-annual review of the emergency preparedness and response plan The Executive Director (and/or appropriate designee) will ensure that the emergency preparedness and response plan is reviewed in January and July of each year The Regional Operations Team will review the completion of the review twice a year
22VAC40-73-720-A
Based on a review of resident 3’s record, the facility did not ensure the do not resuscitate (DNR) orders were included in the individualized service plan.
Evidence
  1. Resident 3 has an order for DNR.
  2. Resident 3’s individualized service plan dated 9/26/2025, states they are full code.
  3. Staff 2 stated the DNR orders could be found in the facility’s electronic system, however it was not noted on the current individualized service plan.
Plan of correction
The ISP in question was corrected. Furthermore, the facility is auditing all resident ISPs and updating the advance directives. The Wellness Director and Assistant Wellness Director will be re-educated on this requirement; re-education will be completed by 11/18/2025. The Executive Director (and/or appropriate designee) will spot-check five ISPs per month and for three additional months thereafter. The Regional Wellness Team will spot-check five records every month and for three consecutive months thereafter.
22VAC40-73-1110-B
Based on a review of resident 5’s record, the facility did not ensure six months after placement of the resident in the safe, secure environment, the licensee, administrator, or designee performed a review of the appropriateness of the resident’s continued residence in the special care unit.
Evidence
  1. Licensing inspector reviewed resident 5’s record and there was no documentation of a six month review of appropriateness of placement in the special care unit.
  2. Resident 5 was admitted to the special care unit on 10/15/24.
  3. When asked, Staff 1 and Staff 2 were not able to provide documentation of a six month review of appropriateness of placement in the special care unit.
Plan of correction
The six months after placement review were completed for the residents identified. Furthermore, the facility is completing an audit to ensure all six-month post-placement reviews are completed. This audit will be completed by 12/15/2025. The Wellness Director and Assistant Wellness Director will be reeducated on this requirement; re-education will be completed by 11/18/2025 The Executive Director (and/or or appropriate designee) will spot-check five appropriate placement forms monthly and for three consecutive months thereafter The Regional Wellness Team will spot-check five records each visit to the community to ensure compliance.
22VAC40-73-410-A
Based on a review of resident records, the facility did not ensure an orientation was provided and acknowledged as being received by the resident and/or their legal representative.
Evidence
  1. Resident 1’s record did not contain documentation of an orientation to the facility.
  2. Resident 2’s record did not contain acknowledgement of having received an orientation to the facility.
  3. Resident 4’s record did not contain acknowledgement of having received an orientation to the facility.
  4. Resident 5’s record did not contain documentation of an orientation to the facility.
  5. When asked, Staff 1 and Staff 2 were unable to provide documentation of an orientation to the facility for Resident 1, Resident 2, Resident 4, and Resident 5.
Plan of correction
The facility will audit and ensure all residents receive and acknowledge orientation. The Executive Director (and/or appropriate designee) will ensure that all new admission receive the orientation upon admission The regional operation team will spot check new admissions every month for compliance and for three consecutive months thereafter.
September 15, 2025Complaint survey0 violations
Inspection dates
09/15/2025
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS
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: 9/15/2025, 1:20pm-1:40pm 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 8/15/2025 regarding allegations in the area(s) of: admission, retention, and discharge of residents. Number of residents present at the facility at the beginning of the inspection: 143 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 reviewed facility documentation. Additional Comments/Discussion: The potential resident was not admitted to the facility, therefore there was no resident record. An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation 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 Tyia Venable, Licensing Inspector at (804)393-2157 or by email at tyia.venable2@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
January 15, 2025Complaint survey0 violations
Inspection dates
01/15/2025
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 01/15/2025 approximate time 10:02a.m-2: 35p.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 01/14/2025 regarding allegations in the area of buildings and grounds. Number of residents present at the facility at the beginning of the inspection: 132 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: N/A Number of staff records reviewed: N/A Number of interviews conducted with residents: N/A Number of interviews conducted with staff: 2 Observations by licensing inspector: operation of front door working with no concerns Additional Comments/Discussion: 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 Angela Rodgers-Reaves, Licensing Inspector at (804) 840-0253 or by email at Angela.r.reaves@dss.virginia.gov. Violation Notice Issued: No
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
January 15, 2025Complaint survey0 violations
Inspection dates
01/15/2025
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: On 01/15/2025 approximate time 10:02a.m-2:35p.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 12/09/2024 regarding allegations in the area of resident care and related services. Number of residents present at the facility at the beginning of the inspection: 132 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: N/A Number of interviews conducted with residents: N/A 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 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 Angela Rodgers-Reaves, Licensing Inspector at (804) 840-0253 or by email at Angela.r.reaves@dss.virginia.gov Violation Notice Issued: No
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
January 15, 2025Complaint survey0 violations
Inspection dates
01/15/2025
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 01/15/2025 approximate time 10:02a.m-2:26p.m The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 11/22/2024 regarding allegations in the staffing and supervision 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: 132 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: N/A Number of staff records reviewed: N/A Number of interviews conducted with residents: N/A Number of interviews conducted with staff: 5 Observations by licensing inspector: Observation of staff assigned to the memory care unit Additional Comments/Discussion: 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 Angela Rodgers-Reaves, Licensing Inspector at (804) 840-0253 or by email at Angela.r.reaves@dss.virginia.gov Violation Notice Issued: No
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
January 15, 2025Complaint survey0 violations
Inspection dates
01/15/2025
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: On 01/15/2025 approximate time 10:05-2:26p.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 12/09/2024 regarding allegations in the area of building and grounds. Number of residents present at the facility at the beginning of the inspection: 132 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: N/A Number of staff records reviewed: N/A Number of interviews conducted with residents: N/A Number of interviews conducted with staff: 3 Observations by licensing inspector: Facility documentation and dining area of memory care unit Additional Comments/Discussion: 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 Angela Rodgers-Reaves Licensing Inspector at (804) 840-0253 or by email at Angela.r.reaves@dss.virginia.gov Violation Notice Issued: No
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
October 31, 2024Inspection4 violations
Inspection dates
10/31/2024
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: On 10/31/2024 approximate time 9:50a.m-4:26p.m. On 11/12/2024 approximate time 10:02a.m-4:30p.m. On 11/18/2024 approximate time 10:55a.m-4:05p.m. On 11/20/2024 approximate time 12:14p.m-4:17p.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: 132 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: 4 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 5 Observations by licensing inspector: Observation of noon time medication administration pass conducted Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov. Should you have any questions, please contact Angela Rodgers-Reaves, Licensing Inspector at (804) 840-0253 or by email at Angela.r.reaves@dss.virginia.gov Violation Notice Issued: Yes
Violations
22VAC40-73-250-D
Based on the review of facility records and staff interviews the facility failed to ensure that an initial tuberculosis examination and report was obtained as required.
Evidence
  1. Staff #2 Documented date of hire: 12/13/2023 Upon request and review of facility records with staff #3 the facility did not submit for the inspector’s review documented evidence that they had obtained verification that staff #2 is free of tuberculosis in a communicable form. The Virginia Tuberculosis(TB) Assessment form in the employee’s record that was submitted for the inspector’s review is not dated to verify that the screening assessment was conducted on owithin seven days prior to the first day of work at the facility.
Plan of correction
THE FACILITY'S RESPONSE: "The Facility rectified the employee record on 12/04/2024. The Facility is conducting an audit for all employees’ personnel records and rectifying any identified discrepancies. The Facility will ensure that the Virginia Tuberculosis (TB) assessment form is completed and signed for each employee. The Director of Business office (and/or appropriate designee) will ensure that all TB assessment forms and completed, signed and filed in the employee personnel record"
22VAC40-73-1150-B
Based on observation and staff interviews, the facility failed to ensure that protective devices on the bedroom windows of residents and on windows in common areas accessible to residents prevents the windows from being opened wide enough for a resident to crawl through. The protective devices on the windows shall be in conformance with the Virginia Uniform Statewide Building Code (13VAC5-63).
Evidence
  1. Accompanied by facility staff #s 3 and 8 on11/20/2024 and as evidenced by the photographs taken on the safe and secure environment of the facility the windows in room #s 145, 140, 116 and a window in the common area near room # 145 did not have protective devices that would prevent the windows from being opened wide enough for a resident to crawl through.
Plan of correction
THE FACILITY'S RESPONSE: "The facility requested a visit from the Fire Marshal for window inspection and recommendations to ensure residents’ safety. The facility communicated with the building inspector and was notified that an egress point to the windows is not required. The facility will provide a plan once the Fire Marshal completes its inspection/visit. The Executive Director (and/or appropriate designee) will provide a follow up in the next two weeks."
22VAC40-73-90
Based on the review of facility records and staff interviews the facility failed to ensure that a criminal history record report was obtained on or prior to the 30th day of employment for each employee.
Evidence
  1. Staff #1 Documented date of hire: 12/13/2023 Staff #1: verification that the facility had obtained a copy of the staff’s criminal record report. Staff #3 stated that the document was not in the employee’s facility records or archived record.
Plan of correction
The Facility rectified the employee record on 12/04/2024. The Facility is conducting an audit for all employee personnel records and rectifying any identified discrepancies. The Facility will ensure that all employees have a background check in their personnel records. The Director of Business Office (and/or appropriate designee) will ensure that all current employees and new hire background checks are completed. The Executive Director (and/or appropriate designee) will ensure compliance by sampling 5 employees records monthly for at least the next three consecutive months.
22VAC40-73-250-B
Based on interviews conducted with facility staff and the review of staff records on 11/12/2024 the facility failed to ensure that all staff records are retained at the facility. During the review of staff records and staff interviews on 11/12, 20/2024 and upon request the facility did not maintain on site at the facility documented
Evidence
  1. of: Facility annual training for two of the staff records reviewed. -Resident Hospice contract - Home health agreement/assessment/notes for resident
Plan of correction
THE FACILITY'S RESPONSE: "The Facility will ensure that a third party agreement is completed for all outside providers. The Facility will ensure that outside providers’ notes are provided to the community and made available for review. The Director of Wellness (and/or appropriate designee) will communicate expectations with all outside providers to include and not limited to Home Health and Hospice. The Director of Wellness (and/or appropriate designee) will audit providers binders at least bi-weekly to ensure notes are available in the binders. The Executive Director (and/or appropriate designee) will ensure this requirement is met and in compliance."
October 31, 2024Complaint survey1 violation
Inspection dates
10/31/2024
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: On 10/31/2024 approximate time 9:50a.m-4:26p.m On 11/12/2024 approximate time 10:02a.m-4:30p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A was received by VDSS Division of Licensing on 10/02/2024 regarding allegations in the area of resident care and related services. Number of residents present at the facility at the beginning of the inspection: 132 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: N/A Number of interviews conducted with residents: N/A Number of interviews conducted with staff: 2 Observations by licensing inspector: Reviewed facility documentation 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 Angela Rodgers-Reaves, Licensing Inspector at (804) 840-0253 or by email at Angela.r.reaves@dss.virginia.gov Violation Notice Issued: Yes
Violations
22VAC40-73-680-D
Based on the review of facility records and staff interviews the facility failed to ensure that medications were administered in accordance with the physician's or other prescriber’s instructions and consistent with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing.
Evidence
  1. Resident #1 The facility submitted for the inspector’s review a 07/27/2024 physician’s order for 1-500mg tablet of the medication Levothyroxine to be administered to the resident daily. The resident’s medication administration record (MAR) charting for July 2024 that was submitted for the inspector’s review is not documented to note that the medication Levothyroxine was administered to the resident as prescribed.
Plan of correction
FACILITY'S RESPONSE: "The Facility will re-educate all nurses and medication technicians on medication administration and physicians’ orders. The Director of Wellness (and/or an appropriate designee) will re-educate nurses and medication technicians monthly for three consecutive months. The Director of Wellness (and/or an appropriate designee) will review daily medication administration to ensure all medications are administered and documented. The Executive Director (and/or an appropriate designee) will follow up to ensure compliance."
October 31, 2024Inspection1 violation
Inspection dates
10/31/2024
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: On 10/31/2024 approximate time 9:50a.m-4:26p.m On 11/12/2024 approximate time 10:02a.m-4:30p.m 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 09/24/2024 regarding allegations in the area of resident care and related services 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: 132 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: N/A Number of interviews conducted with residents: N/A Number of interviews conducted with staff: 3 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the allegation 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 Angela Rodgers-Reaves, Licensing Inspector at (804) 840-0253 or by email at Angela.r.reaves@dss.virginia.gov Violation Notice Issued: Yes 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: On 10/31/2024 approximate time 9:50a.m-4:26p.m On 11/12/2024 approximate time 10:02a.m-4:30p.m The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-report incident was received by VDSS Division of Licensing on 09/24/2024 regarding allegations in the area of resident care and related resident care and related services 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: 132 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: N/A Number of interviews conducted with residents: N/A Number of interviews conducted with staff: 3 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the allegation 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 Angela Rodgers-Reaves, Licensing Inspector at (804) 840-0253 or by email at Angela.r.reaves@dss.virginia.gov Violation Notice Issued: Yes
Violations
22VAC40-73-680-D
Based on facility documentation and staff interviews the facility failed to ensure that medications were administered in accordance with the physician's or other prescriber’s instructions and consistent with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing.
Evidence
  1. Resident #1 The facility reported on 09/24/2024 that staff #1 administered four different medications to resident #1 that were not prescribed by the resident’s physician. Staff #1 stated during a telephone interview that she did in fact make the error and reported it immediately.
Plan of correction
THE FACILITY'S RESPONSE: "The Facility will re-educate all nurses and medication technicians on medication administration and physicians’ orders. The Director of Wellness (and/or an appropriate designee) will re educate nurses and medication technicians monthly for three consecutive months. The Executive Director (and/or an appropriate designee) will follow up to ensure compliance."
October 31, 2024Inspection0 violations
Inspection dates
10/31/2024
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: On 10/31/2024 approximate time 9:50a.m-4:26p.m. On 11/12/2024 approximate time 10:02a.m-4:30p.m 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 08/15,18/2024 regarding allegations in the areas of resident care and related services and additional requirements for facilities that care for adults with cognitive impairments. Number of residents present at the facility at the beginning of the inspection: 132 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: N/A Number of interviews conducted with residents: N/A Number of interviews conducted with staff: 4 Observations by licensing inspector: Additional Comments/Discussion: 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 Angela Rodgers-Reaves Licensing Inspector at (804) 840-0253 or by email at Angela.r.reaves@dss.virginia.gov Violation Notice Issued: No
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
October 31, 2024Complaint survey0 violations
Inspection dates
10/31/2024
Comments
A complaint was received by VDSS Division of Licensing on 09/13/2024 regarding allegations in the area of staffing. Number of residents present at the facility at the beginning of the inspection: 132 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: N/A Number of staff records reviewed: N/A Number of interviews conducted with residents: N/A Number of interviews conducted with staff: 4 Observations by licensing inspector: Additional Comments/Discussion: Clarification was offered to staff regarding no ratio required for the assisted living program. Facility staff provided confirmation that the direct care staff assist each other when needed and that there a quite a few call outs. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation 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 Angela Rodgers-Reaves, Licensing Inspector at (804) 840-0253 or by email at Angela.r.reaves@dss.virginia.gov Violation Notice Issued: No
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
July 15, 2024Inspection1 violation
Inspection dates
07/15,23,24/2024
Comments
Number of residents present at the facility at the beginning of the inspection: 145 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 9 Number of staff records reviewed:5 Number of interviews conducted with residents:5 Number of interviews conducted with staff: 7 Observations by licensing inspector: Medication administration pass observed Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Angela Rodgers-Reaves, Licensing Inspector at (804) 840-0253 or by email at Angela.r.reaves@dss.virginia.gov
Violations
22VAC40-73-660-B
Based on observation the facility failed to ensure that medications and any dietary supplements were stored so that they are not accessible to other residents.
Evidence
  1. On 07/15/2024 during a walk-through of the facility accompanied by facility staff the inspector observed the following: Resident #1 As evidenced by the photographs taken, prescribed and over the counter medications were observed in the resident’s unlocked kitchen cabinet. Also observed was a pill bottle noting the medication Tramadol being stored on the kitchen counter near the toaster that had four individual pills next to the pill bottle. Resident #10 As evidenced by the photographs taken, prescribed and over the counter medications were observed being stored in an unlocked manner in the resident’s unlocked cabinet near a handheld blow dryer. Resident #11-room 216 As evidenced by the photographs taken, prescribed and over the counter medications were observed being stored in a unlocked manner in the resident’s room on the kitchen counter and table.
Plan of correction
FACILITY'S RESPONSE: "1) Residential residents' who are not on a level of care and self-manage medications will receive ongoing education on the proper storage of medications in their apartment. 2) General Medication Storage Guideline and audit form will be used to conduct frequent audits of residential apartments to ensure appropriate medication storage practices are being followed. Identification of individual(s) and/or staff position(s) responsible for implementing the preventative measures: Executive Director, Director of Clinical Services, Assistant Director of Clinical Services and/or designee"
April 25, 2024Inspection2 violations
Inspection dates
04/25/2024
Comments
Type of inspection: Initial Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: On 04/25/2024 Approximate time 9:00a.m-12:03p.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: The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: N/A Number of staff records reviewed:1 Number of interviews conducted with residents: N/A Number of interviews conducted with staff: 2 Observations by licensing inspector: As random bedrooms measurements were conducted in the independent living program of the facility observations were made of the individuals living spaces. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Angela Rodgers-Reaves, Licensing Inspector at (804) 840-0253 or by email at Angela.r.reaves@dss.virginia.gov. Violation Notice Issued: Yes
Violations
22VAC40-73-870-E
Based on observation and interviews with staff the facility failed to ensure that all equipment was in good repair and condition.
Evidence
  1. Accompanied by the facility administrator and the maintenance director and as evidenced by the pictures taken during a tour of the facility on 04/25/2024, temporary/ portable/mobile air conditioner units were observed in place at the end of the hallways on the 2nd and 3rd floors. The maintenance director stated that the hallway air conditioner units were being used to supplement the air due to one of the four air conditioner motors being inoperable and a replacement motor was on order.
Plan of correction
FACILITY'S RESPONSE: "Measures to Prevent Non-Compliance from Occurring Again: On 4/11/24, it was identified that the main air handler for the HVAC VAC System had a motor that needed to be replaced. The community immediately obtained a quote from the HVAC vendor on 4/11/24 and the quote was approved the same day with a delivery date of 4/26/24 and an installation date of 5/1/24. (8) 1-Ton portable AC units were rented and installed on 4/12/24 to condition the corridors. (6) Additional 1-Ton portable AC units were rented and installed on 4/26/24 due to warmer climates after initial installation to further assist with conditioning corridors and ensure compliance with the standard. Persons Responsible: Executive Director, Environmental Services Director and Home Office Support Team"
22VAC40-73-880-C
Based on observation and interviews with staff the facility failed to ensure that the temperatures in the common areas used by the residents did not exceed 80°F.
Evidence
  1. The temperature readings recorded by the facility’s maintenance director on 04/25/2024 revealed the following: Second floor on the even side of the hallway 82 degrees. Second floor on the odd side of the hallway 81.3 degrees. Third floor on the odd side of the hallway 81 degrees.
Plan of correction
FACILITY'S RESPONSE: "Measures to Prevent Non-Compliance from Occurring Again: On 4/11/24, it was identified that the main air handler for the HVAC VAC System had a motor that needed to be replaced. The community immediately obtained a quote from the HVAC vendor on 4/11/24 and the quote was approved the same day with a delivery date of 4/26/24 and an installation date of 5/1/24. (8) 1-Ton portable AC units were rented and installed on 4/12/24 to condition the corridors. (6) Additional 1-Ton portable AC units were rented and installed on 4/26/24 due to warmer climates after initial installation to further assist with conditioning corridors and ensure compliance with the standard. Persons Responsible: Executive Director, Environmental Services Director and Home Office Support Team"