Virginia DSS · Assisted Living Facility

Benchmark at Alexandria

📍 3440 Berkeley Street, Alexandria, VA, 22302

ID 50446One Year licenseActive
10
Inspections
On record
9
With violations
Visits that cited something
1
Clean visits
Nothing cited
25
Violations cited
Individual findings
19
Standards cited
Distinct rules
3
Complaint visits
Prompted by a complaint

Benchmark at Alexandria was inspected 10 times between January 17, 2024 and February 3, 2026 by the Virginia Department of Social Services. 9 of those visits ended with violations cited and 1 with none. Across that history VDSS cited 25 violations under 19 distinct standards. 3 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
09/30/2026
Administrator
Carol Tarlowoh
Licensing inspector
Nina Wilson
Inspector phone
(703) 635-6074
Approved for
Non-Ambulatory · Special Care Unit · Assisted Living

Inspection History

10

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

February 3, 2026Complaint survey3 violations
Inspection dates
02/03/2026
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: 02/03/2026 Time in: 3:01 PM Time out: 4:42 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 01/15/2026 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: 90 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: Licensing inspector (LI) observed residents participating in scheduled activities. Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: Resident Care and Related Services and Complaint Investigation. A violation notice was issued; any violation(s) not related to the complaint 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
22VAC40-73-460-B
Based on resident record review and staff interview, the facility failed to ensure that care provision and service delivery should be resident-centered to the maximum extent possible and include prompt response by staff to resident needs as reasonable to the circumstances.
Evidence
  1. During the onsite inspection on 02/03/2026, the automated e-call system (pull cord and pendant) indicated that staff responded to resident 1’s call pendant: a. On 01/17/2026 through 01/18/2026, 01/20-2026, and 02/03/2026, staff responded to the call bell between 31 to 37 minutes on 5 separate occasions. b. On 01/10/2026 through 01/16/2026, staff responded to the call bell between 41 to 49 minutes on 7 separate occasions. c. On 02/02/2026, staff responded to the call bell within 50 minutes on 1 occasion. d. On 02/03/2026, staff responded to the call bell within 62 minutes on 1 occasion.
  2. The Emergency Response System policy stated, “during monthly Safety Committee meetings, pendant and pull cord reports should be reviewed to discuss response times, highlight trends, and identify interventions as needed.”
  3. During the onsite inspection, 02/03/2026, staff 1 stated that the expectation is for call pendants to receive a response in “less than twenty minutes.” Staff 1 acknowledged that there were several instances within January and February 2026 where resident 1’s call pendant was not responded to in less than twenty minutes.
Plan of correction
1. Corrective Action for the Affected Resident The resident referenced in the complaint survey had their care needs reviewed with staff to reinforce expectations for timely response to call systems and resident requests. 2. Measures Implemented to Prevent Recurrence To improve response times and ensure prompt response to resident needs: • Staffing coverage was evaluated and additional staffing adjustments were implemented to improve response capacity during peak care times. • Direct care staff were re-educated regarding expectations for timely response to resident call systems. • Leadership reinforced the expectation that pendant alerts should receive prompt response whenever possible. • The community strengthened its process for reviewing e-call system response reports. Since implementing these measures, the facility’s average response time is currently 14 minutes or less. 3. Monitoring Plan To ensure ongoing compliance: • The Executive Director, Traditional Care Director and/or designee will review daily e-call response response reports from the emergency response system. • Call response trends will be reviewed during monthly safety committee meetings to identify trends and implement corrective actions as needed. 4. Responsible Party Executive Director and Traditional Care Director. 5. Date of Compliance: March 17, 2026
22VAC40-73-450-F
Based on resident record and staff interview, the facility failed to ensure that individualized service plans (ISPs) should be reviewed and updated at least once every 12 months and as needed for a significant change of a resident’s condition. The review and update should be performed by a staff person with the qualifications specified in subsection B of this section and in conjunction with the resident and, as appropriate, with the resident’s family, legal representative, direct care staff, case manager, health care providers, qualified mental health professionals, or other persons.
Evidence
  1. Resident 1’s (admit date, 12/31/2025) progress note (dated, 01/12/2026) indicated care concerns related to their Continuous Positive Airway Pressure (CPAP) mask; however, resident 1’s ISP did not include the CPAP machine as an assistive device.
  2. During the onsite inspection, 02/03/2026, staff 1 confirmed that resident 1’s ISP was not reviewed and updated to include the use of a CPAP machine.
  3. During the onsite inspection, 02/03/2026, staff 2 provided documentation that resident 1 received occupational therapy (OT) from collateral contact 1. Staff 1 confirmed that resident 1’s ISP was not reviewed and updated to include the services received from collateral contact 1.
Plan of correction
1. Corrective Action for the Affected Resident The individualized service plan (ISP) for the resident referenced in the survey was reviewed and updated to include the resident’s CPAP machine as an assistive device and to reflect the resident’s occupational therapy services. The updated ISP was reviewed with appropriate staff to ensure awareness of the residents’ care needs. 2. Measures Implemented to Prevent Recurrence To prevent future occurrences: • The clinical leadership team reviewed procedures for timely ISP updates when new equipment, treatments, or services are introduced. • A new Resident Care Director has been hired and will receive education regarding requirements for updating ISPs when there is a change in condition, assistive device usage, or therapy services. • A process has been implemented requiring review of therapy orders, physician documentation, and new assistive devices during weekly resident review meetings to ensure appropriate ISP updates. 3. Monitoring Plan To ensure compliance: • The Resident Care Director or designee will conduct monthly audits for a period of 3 months of new admissions and clinical updates to confirm ISPs reflect current services and assistive devices. • A Bi-monthly ISP audit of 10% of resident records will be conducted to verify that changes in resident condition or services are documented appropriately. 4. Responsible Party: Resident Care Director and Executive Director.
22VAC40-73-450-H
Based on resident record review and staff interview, the facility failed to ensure that the care and services specified in the individualized service plan (ISP) were provided to each resident.
Evidence
  1. Resident 1’s ISP (dated, 12/31/2025) stated, “resident requires 1 person assist (bed mobility);” “turn and reposition frequently overnight and check brief for an incontinence to prevent skin breakdown.”
  2. Resident 1’s Activities of Daily Living (ADL) Verification Worksheet indicated that on the 11:00 pm to 6:59 am shift, 01/14/2026, 01/16/2026 through 01/23/2026, and 01/24/2026 through 02/02/2026 “ADL Mobility” either was not documented as completed or marked as “did not occur.”
  3. During the onsite inspection, 02/03/2026, staff 1 acknowledged that care and services specified in resident 1’s ISP were not being provided to the resident.
Plan of correction
1. Corrective Action for the Affected Resident The resident’s care plan was reviewed with direct care staff to ensure that bed mobility assistance and repositioning overnight, as outlined in the ISP, are consistently provided and documented. Staff assigned to the resident were re-educated regarding the residents’ specific care requirements. 2. Measures Implemented to Prevent Recurrence The following corrective actions have been implemented: • Direct care staff received re-education regarding documentation expectations and completion of ADL verification worksheets. • Nursing leadership reviewed procedures for ensuring that required care tasks outlined in the ISP are completed and documented each shift. • Shift supervisors have been instructed to verify completion of required documentation prior to shift change. • 3. Monitoring Plan To ensure ongoing compliance: • The Traditional Care Director or designee will conduct weekly audits of ADL documentation and service delivery records for a period of 3 months. Bi-monthly audits of 10% of resident records will be completed to ensure continued compliance. • Findings will be reviewed with staff and additional training will be provided if documentation or service delivery concerns are identified. 4. Responsible Party: Traditional Care Director 5. Date of Compliance: March 17, 2026.
February 3, 2026Inspection2 violations
Inspection dates
02/03/2026
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 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: 02/03/2026 Time in: 4:42 PM Time out: 5:53 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 02/02/2026 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: 90 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: 3 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, staff, and visitors in the common areas and exercising in the gym. 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
22VAC40-73-460-A
Based on resident record review and staff interview, the facility failed to assume general responsibility for the health, safety, and well-being of the residents.
Evidence
  1. The licensing department received an initial incident report on 02/02/2026 regarding the elopement(s) of resident 1.
  2. The final report, received on 02/08/2026, stated that on 02/01/2026, resident 1 eloped from the safe, secure unit through the side stairwell door and left the community around 3:21 pm. Resident 1 then walked through the main entrance door of the facility outside the safe, secure environment, at approximately 3:25 pm. Resident 1 was returned to the safe, secure unit by staff 5.
  3. The final report, received on 02/08/2026, also indicated that resident 1 eloped from the safe, secure unit for a second time on 02/01/2026. Resident 1 eloped from a different stairwell door and left the facility around 4:06 pm. Resident re-entered the facility at 4:07 pm, 02/01/2026 through the main entrance of the facility outside of the safe, secure environment. Resident 1 was returned to the safe, secure unit by staff 5. Staff 2 and staff 3 walked resident 1 to their room to rest.
  4. During the onsite inspection, 02/03/2026, as it relates to the first elopement of resident 1 on 02/02/2026, staff 1 stated that after reviewing video footage, resident 1 exited the stairwell at 3:21 pm and entered the facility through the main entrance outside of the safe, secure environment. Staff 5 returned resident 1 to the safe, secure unit and completed a full body assessment. Following the assessment, staff 5, working as the person in charge, left resident 1 on the safe, secure unit with staff 3 and staff 4, and returned to assisted living floor(s).
  5. During the onsite inspection, 02/03/2026, as it relates to the second elopement of resident 1 on 02/02/2026, staff 1 stated that after reviewing video footage, it was noted that staff 2 left resident 1 in their room to provide care to another resident. Staff 3 left resident 1 in their room to conduct a head count and check all doors on the unit to ensure they were secured. Staff 1 stated that while staff 2 and staff 3 were completing these tasks, resident 1 eloped from the safe, secure unit and exited the stairwell at 4:06 pm and entered the facility through the main entrance outside of the safe, secure environment at 4:07 pm. Staff 5 returned resident 1 to the safe, secure environment and completed a full body assessment. Staff 5 remained on the safe, secure environment unit to provide additional support.
  6. Staff 1 acknowledged that resident 1’s well-being was affected by an ability to elope from the safe, secure environment without staff’s knowledge, navigate two separate stairwells, and returned on their own without staff intervention or assistance.
Plan of correction
Not published by VDSS.
22VAC40-73-40-A
Based on record review and staff interview, the facility failed to ensure compliance with all regulations for licensed assisted living facilities and terms of the license issued by the department; with relevant federal state, and local laws; with other relevant regulations; and with the facility’s own policies and procedures.
Evidence
  1. The licensing department received an incident report on 02/02/2026 stating that resident 1 eloped from the safe, secure unit through the egress doors at 3:25 pm and again at 4:07 pm. Resident 1 entered the facility through the main entrance on both instances, alerting staff of their elopement.
  2. Missing Resident Response Plan and Drills Policy stated, Activation of a door alarm/alert: “if safe, secure unit egress door alarms, associates immediately search area adjacent to alarmed door (inside and out).”
  3. During the onsite inspection, 02/03/2026, staff 1 acknowledged that the facility did not follow own policies when staff 2 and staff 3 did not immediately search area adjacent to the alarmed door (inside and out).
Plan of correction
Not published by VDSS.
August 20, 2025Inspection7 violations
Inspection dates
08/20/2025
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 IMPAIRMENTS
Technical assistance
Licensing Inspector (LI) reviewed the following standards with the facility: 22VAC40-73-310, 22VAC40-73-325, 22VAC40-73-970, and 22VAC40-73-1110.
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: 08/20/2025 Time in: 10:55 AM Time out: 6:44 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 64 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Number of staff records reviewed: 6 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: Licensing inspector observed residents participating in scheduled activities, entering and exiting the community for outings, dining for breakfast, and interacting with staff and peers. Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov. Should you have any questions, please contact Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov.
Violations
22VAC40-73-990-B
Based on record review and staff interview, the facility failed to ensure that procedures in the plan for resident emergencies were reviewed by the facility at least every six months with all staff. Documentation of the review should be signed and dated by each staff person.
Evidence
  1. Upon request, the facility did not provide documentation of resident emergency review with all staff.
  2. During the onsite inspection, 08/20/2025, staff 7 confirmed that resident emergency reviews with all staff were not documented as completed every six months.
Plan of correction
1. Corrective Action for Affected Staff/Residents: All staff will participate in emergency procedure reviews at the October staff meeting, and documentation will be signed and dated. 2. Identification of Other Potentially Affected Individuals: All staff are potentially affected. Each staff member will be scheduled for review. 3. Systemic Changes Made to Prevent Recurrence: Semi-annual reviews will be incorporated into the community’s training calendar. 4. Monitoring to Ensure Ongoing Compliance: The Executive Director will review sign-in sheets after each review to ensure 100% compliance. 5. Completion Date: 10/01/2025
22VAC40-73-1130-C
Based on record review and staff interview, the facility failed to ensure that during the night hours, when 22 or fewer residents were present, at least two direct care staff members were awake and on duty at all times in each special care unit and was responsible for the care and supervision of the residents.
Evidence
  1. April 2025’s staff schedule for the safe, secure environment was assigned one staff for the care and supervision of ten residents.
  2. During the onsite inspection, 08/20/2025, staff 7 acknowledged that April 2025’s staff schedule for the safe, secure environment assigned one staff for the care and supervision of ten residents.
Plan of correction
1. Corrective Action for Affected Staff/Residents: All residents in the safe, secure unit were reviewed following the inspection. There were no identified negative outcomes or care concerns resulting from the lack of a second staff member on the dates cited. 2. Identification of Other Potentially Affected Individuals A full audit of the staff scheduling from May 1, 2025 – June 30, 2025 was conducted. No other deficiencies were identified. 3. Systemic Changes Made to Prevent Recurrence: The scheduler and the Executive Director were educated on regulatory requirements for special care staffing. Effective 6/10/25, the staffing schedule reflects the appropriate staffing levels. 4. Monitoring to Ensure Ongoing Compliance: Beginning June 10, 2025, the Executive Director or designee began auditing staffing schedules weekly for 90 days, then monthly for three additional months to ensure two staff are scheduled and present each shift in the special care unit to ensure ongoing compliance. 5. Completion Date: 09/01/2025
22VAC40-73-640-A
Based on observation and staff interview, the facility failed to ensure to implement a written plan for medication that included a plan for proper disposal of medication.
Evidence
  1. During the onsite inspection, 08/20/2025, LI observed resident 8’s medication (Morphine Sulfate Oral Solution 100 MG per 5 mL) in plain view, stored in a box under the wellness director’s desk. Staff 7 was present at the time of LI’s observation and acknowledged that the medication was discontinued.
  2. The facility’s medication management plan directs staff to “destroy” expired or discontinued medication “per BSL Controlled Substance Policy.”
  3. Picture taken.
Plan of correction
1. Corrective Action for Affected Staff/Residents: The discontinued medication was destroyed immediately following inspection. Staff were re-trained on disposal procedures. 2. Identification of Other Potentially Affected Individuals All residents with discontinued or expired medications are potentially affected. Medication carts and storage were reviewed to ensure compliance. 3. Systemic Changes Made to Prevent Recurrence A retraining of the Controlled Substance Management policy conducted to ensure the plan for proper disposal of medications met state requirements. Medications will be destroyed promptly after discontinuation or returned to the resident/resident responsible party; hospice provider in accordance with the policy. 4. Monitoring to Ensure Ongoing Compliance Weekly spot audits of medication storage and logs will be performed by the Resident Care Director. 5. Completion Date: 09/30/2025
22VAC40-73-220-A
Based on private duty record review and staff interview, the facility failed to ensure private duty personnel from a licensed home care organization met the requirements of 22VAC40-73-250-D 1 through D 4 regarding tuberculosis and were provided orientation and training regarding the facility’s policies and procedures related to the duties of private duty personnel.
Evidence
  1. Upon request, the facility did not provide private duty 5’s tuberculosis risk assessment.
  2. Upon request, the facility did not provide documentation of orientation and training for private duty 4, private duty 5, and private duty 6.
  3. During the onsite inspection, 08/20/2025, staff 7 confirmed that a risk assessment documenting the absence of tuberculosis in a communicable form was not completed for private duty 5. Additionally, staff 7 confirmed that orientation and training regarding the facility’s policies and procedures was not included in private duty 4, private duty 5, and private duty 6’s records.
Plan of correction
1. Corrective Action for Affected Staff/Residents TB risk assessments were immediately requested and obtained for private duty personnel. Orientation and training will be completed and documented by 9/30/2025 2. Identification of Other Potentially Affected Individuals All current and future private duty aides are potentially affected. Records of each were reviewed. 3. Systemic Changes Made to Prevent Recurrence A Private Duty Checklist is now required prior to assignment, verifying TB clearance and completion of orientation. 4. Monitoring to Ensure Ongoing Compliance The Director of Business Administration, or designee will review private duty records monthly to confirm compliance. 5. Completion Date: 09/30/2025
22VAC40-73-490-A-3
Based on record review and staff interview, the facility failed to ensure that all residents were included at least annually in healthcare oversight.
Evidence
  1. The healthcare oversight completed on 10/23/2024 did not indicate which residents were reviewed during the review period.
  2. The healthcare oversight completed on 03/18/2025 and 03/19/2025 indicated that six residents were evaluated for their ability to self-administer medications. The healthcare oversight did not include any other resident reviews.
  3. During the onsite inspection, 08/20/2025, staff 7 confirmed that all residents were not included at least annually on the healthcare oversight.
Plan of correction
1. Corrective Action for Affected Staff/Residents: The full census will be printed and used during the healthcare oversight process. The census will then be attached to the VDSS Record of Healthcare Oversight model form to ensure all residents are included in the annual review. 2. Identification of Other Potentially Affected Individuals: All residents are potentially affected. Records were reviewed to verify required oversight will be captured for each. 3. Systemic Changes Made to Prevent Recurrence: Oversight reports will now identify each resident by name and date reviewed, and will be stored in a centralized binder. 4. Monitoring to Ensure Ongoing Compliance: The Resident Care Director will cross-check the roster quarterly; ED/Designee will audit semi-annually. 5. Completion Date: 09/30/2025
22VAC40-73-950-E
Based on record review and staff interview, the facility failed to develop and implement a semiannual review on the emergency preparedness and response plan for all staff, residents, and volunteers, with emphasis placed on an individual’s respective responsibilities. The review should be documented by signing and dating.
Evidence
  1. Upon request, the facility did not provide documentation of a semi-annual review on the emergency preparedness and response plan for all staff, residents, and volunteers.
  2. During the onsite inspection, 08/20/2025, staff 7 confirmed that the semi-annual review on the emergency preparedness and response plan for all staff, residents, and volunteers were not documented as completed by signing and dating.
Plan of correction
1. Corrective Action for Affected Staff/Residents A facility-wide emergency preparedness review and training will be conducted October 15, 2025. 2. Identification of Other Potentially Affected Individuals All staff, residents, and volunteers are potentially affected. Attendance will be documented. 3. Systemic Changes Made to Prevent Recurrence Emergency preparedness reviews will be scheduled every six months and tracked on the Safety Committee calendar. 4. Monitoring to Ensure Ongoing Compliance The Safety Committee Chair or designee will maintain training logs and submit them to the Executive Director for verification. 5. Completion Date: 10/15/2025
22VAC40-73-490-A-2
Based on record review and staff interview, the facility failed to ensure for residents who meet the criteria for assisted living care a licensed health care professional, practicing within the scope of the health care profession, provided health care oversight at least every three months, or more often if indicated, based on the health care professional’s professional judgement of the seriousness of a resident’s needs or stability of a resident’s condition.
Evidence
  1. The healthcare oversight was completed 04/1/2024 through 10/23/2024 and 03/18/2025 through 03/19/2025.
  2. During the onsite inspection, 08/20/2025, staff 7 confirmed the facility does not employ a licensed health care professional who was on site on a fulltime basis with their healthcare oversight for residents who met the criteria for assisted living care being completed by a regional licensed healthcare professional every six month. Staff 7 confirmed over the past year the healthcare oversight was completed on 10/23/2024, 03/18/2025, and 03/19/2025.
Plan of correction
1. Corrective Action for Affected Staff/Residents Benchmark at Alexandria is in the process of hiring a licensed health care professional who will be onsite and be responsible for conducting required oversight visits at least every 180 days, or more if clinically indicated, in accordance with the regulation. In the interim, oversight is being covered by a regional nurse specialist to ensure no gaps in compliance. 2. Identification of Other Potentially Affected Individuals All residents receiving assisted living level of care are potentially affected. Each resident’s record will be reviewed to ensure appropriate oversight is scheduled until the onsite licensed health care professional is in place. In addition, Benchmark’s policy and community practice is a weekly tracking meeting. Here, all residents are reviewed over the course of each month. 3. Systemic Changes Made to Prevent Recurrence The onsite licensed health care professional will be responsible for timely completion and documentation of all required oversight. The VDSS Record of Healthcare Oversight model form will be maintained by the onsite licensed health care professional. 4. Monitoring to Ensure Ongoing Compliance Executive Director (ED) or designee will audit oversight documentation quarterly to verify compliance. 5. Completion Date: 10/31/2025 (target date for onsite licensed health care professional hire and oversight schedule).
January 17, 2025Inspection1 violation
Inspection dates
01/17/2025, 01/23/2025
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS ARTICLE 1 – SUBJECTIVITY
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 1/17/2025 Time in: 9:39 a.m. Time out: 11:00 a.m. 1/23/2025 Time in: 11:46 a.m. Time out: 1:50 p.m. 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 11/29/2024 regarding allegations in the area(s) of: Personnel, Additional Requirements for Facilities that Care for Adults with Serious Cognitive Impairments, and Article 3: Safe, Secure Environment Number of residents present at the facility at the beginning of the inspection: 43 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 4 Observations by licensing inspector: Licensing inspector (LI) toured the safe, secure environment unit. LI observed residents engaging in physical therapy, interacting with staff and peers in the common area, and walking to and from their bedrooms. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov. Should you have any questions, please contact Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov.
Violations
22VAC40-73-1140-B
Based on record reviews and staff interviews, the facility failed to ensure that direct care staff attended at least 10 hours of training in cognitive impairment within four months of the starting date of employment in the safe, secure environment.
Evidence
  1. During the review of serious cognitive impairment training for the safe, secure environment unit, licensing inspector (LI) observed that 33 direct care staff and nurse’s records did not include serious cognitive impairment training. 22 out of 33 direct care staff and nurses hire dates were between one year and four months.
  2. The serious cognitive impairment training titled “Dementia: Connect First – Live Event” was a half an hour. The 22 direct staff and nurse’s records did not include this training.
  3. On 1/23/2025, LI interviewed staff 5 who confirmed that “Dementia: Connect First – Live Event” was the serious cognitive impairment training.
Plan of correction
Not published by VDSS.
January 17, 2025Inspection2 violations
Inspection dates
01/17/2025, 01/23/2025
Areas reviewed
22VAC40-73 PERSONNEL
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 1/17/2025 Time in: 9:39 a.m. Time out: 11:00 a.m. 1/23/2025 Time in: 10:14 a.m. Time out: 11:45 a.m. 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 10/18/2024 regarding allegations in the area(s) of: Personnel Number of residents present at the facility at the beginning of the inspection: 43 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 5 Observations by licensing inspector: Licensing inspector (LI) toured the safe, secure environment unit. LI observed residents interacting with peers and staff, participating in physical therapy, and dining for breakfast. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov. Should you have any questions, please contact Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov.
Violations
22VAC40-73-220-B
Based on private duty personnel review and staff interview, the facility failed to ensure that information on the type and frequency of the services delivered to the resident and a review of an original criminal history record report were obtained.
Evidence
  1. Private duty personnel 6’s record did not include a criminal history report or information on the type and frequency of services delivered to resident 2.
  2. On 1/17/2025, LI interviewed staff 2 who confirmed that private duty personnel 6’s record did not include a criminal history report of information on the type and frequency of services delivered to resident 2.
Plan of correction
Not published by VDSS.
22VAC40-73-1130-A
Based on record reviews and staff interview, the facility failed to ensure that at least two direct care staff members were awake and on duty at all times in each special care unit, who were responsible for the care and supervision of the residents
Evidence
  1. The October 2024 staff schedule indicated that there was one staff scheduled one each shift (10/18/2024), 7:00 a.m. through 3 p.m., 3:00 p.m. through 11:00 p.m., and 11:00 p.m. through 7:00 a.m.
  2. The October 2024 employee timecard indicated that one direct care staff clock into work 7:00 a.m. through 3 p.m., 3:00 p.m. through 11:00 p.m., and 11:00 p.m. through 7:00 a.m. on 11/29/2024.
  3. On 1/17/2025, LI interviewed staff 3 who confirmed there was only one direct care staff scheduled to work on the safe, secure environment unit on 10/18/2024.
Plan of correction
Not published by VDSS.
January 17, 2025Inspection3 violations
Inspection dates
01/17/2025, 01/23/2025
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISIONARTICLE 1 – SUBJECTIVITY
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: 01/17/2025 Time In: 9:39 AM Time Out: 11:00 AM 01/23/2025 Time In: 1:50 PM Time Out: 2:22 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 11/12/2024 regarding allegations in the area(s) of: Staffing and Supervision, Article I – Subjectivity Number of residents present at the facility at the beginning of the inspection: 42 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: 7 Observations by licensing inspector: Licensing inspector (LI) toured the physical plant of the facility. LI observed residents engaging in scheduled activities, dining for breakfast and lunch in the dining area, entering and exiting the facility for community outings, exercising in the gym, and residents participating in physical therapy. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov. Should you have any questions, please contact Nina Wilson, Licensing Inspector at (703) 635 – 6074 or by email at nina.wilson@dss.virginia.gov.
Violations
22VAC40-73-430-H-1
Based on record reviews and staff interview, the facility failed to ensure at the time of discharge a dated statement was provided to the resident, legal representative, and designated contact person.
Evidence
  1. Resident 1’s progress notes (12/2/2024) indicated that their legal representative was not provided a written discharge statement.
  2. On 1/17/2025, LI interviewed staff 5 who confirmed that the legal representative was not provided a written discharge statement.
Plan of correction
Not published by VDSS.
22VAC40-73-1130-A
Based on facility record review, the facility failed to ensure at least two direct care staff members were awake and on duty at all times in each special care unit who were responsible for the care and supervision of the residents.
Evidence
  1. On 11/12/2024, resident 1, resident 2, resident 3, resident 4, resident 5, and resident 6 resided on the safe, secure unit.
  2. On 1/17/2025, LI interviewed staff 2 who confirmed that there were residents 1, 2, 3, 4, 5, and 6 resided on the safe, secure unit on 11/12/2024.
  3. November 2024 staff schedule indicated that staff 6 and staff 7 were assigned to the special care unit on 11/12/2024; however, staff 6 and staff 7 did not clock in or clock out on 11/12/2024.
Plan of correction
Not published by VDSS.
22VAC40-73-1150-A
Based on facility record review and staff interview, the facility failed to ensure that doors that lead to unprotected areas were monitored or secured through devices that conform to applicable building and fire codes, including door alarms and delayed egress mechanisms. Residents who reside in safe, secure environments were prohibited from exiting the facility or the special care unit if applicable building and fire cords were met.
Evidence
  1. On 11/12/2024, resident 1 eloped from the facility through an unsecured fire door on the special care unit.
  2. On 1/17/2025, during a tour of the facility with staff 1 and staff 2, to ensure that the fire doors were secured, but the fire doors delayed egress mechanism were malfunctioning. The doors did not open or alarm when the pressure plate was pushed for 15 – 30 seconds.
  3. On 1/23/2025, LI interviewed staff 4 who stated that the fire doors on the special care unit were not equipped with an egress mechanism functionality for the safety of the residents.
Plan of correction
Not published by VDSS.
October 17, 2024Complaint survey2 violations
Inspection dates
10/17/2024
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/17/2024 Time In: 9:15 AM Time Out: 12:53 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 10/16/2024 regarding allegations in the areas of: Personnel and Complaint Investigation Number of residents present at the facility at the beginning of the inspection: 29 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: 5 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Licensing inspector (LI) observed breakfast being served, residents interacting with peers and staff, and residents exiting the community for activities. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov. Should you have any questions, please contact Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov.
Violations
22VAC40-73-1130-A
Based on record reviews and staff interview, the facility failed to ensure that at least two direct care staff members were awake and on duty at all times in the special care unit who were responsible for the care and supervision of the residents.
Evidence
  1. During a review of the special care unit census, July 2024 through January 2025, LI observed that there were six residents present on the unit October through November 2024.
  2. The October and November 2024 staff schedule indicated that one staff was scheduled 10/18/2024 and 11/28/2024 on each shift, 7:00 a.m. through 3 p.m., 3:00 p.m. through 11:00 p.m., and 11:00 p.m. through 7:00 a.m.
  3. There was one staff scheduled, 3:00 p.m. through 11:00 p.m., and two staff scheduled, 7:00 p.m. through 11:00 p.m. There was one staff scheduled, 11:00 p.m. through 7:00 a.m.
  4. On 1/17/2025, LI interviewed staff 5 who confirmed that there was only one staff scheduled on each shift on the safe, secure environment unit in October and November 2024.
Plan of correction
Not published by VDSS.
22VAC40-73-430-H-1
Based on record reviews and staff interview, the facility failed to ensure at the time of discharge a dated statement was provided to the resident, legal representative, and designated contact person.
Evidence
  1. Resident 1’s progress notes (12/2/2024) indicated that their legal representative was not provided a written discharge statement.
  2. On 1/17/2025, LI interviewed staff 5 who confirmed that the legal representative was not provided a written discharge statement.
Plan of correction
Not published by VDSS.
September 16, 2024Inspection3 violations
Inspection dates
09/16/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS
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: 09/16/2024 Time In: 11:41 AM Time Out: 5:54 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 26 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: 3 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: LI toured the physical plant of the facility, observed the administration of medication and observed residents involved in independent pursuits: lunch and dinner dining, residents resting in their room, lounging in the common areas, and walking around the facility. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov. Should you have any questions, please contact Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov
Violations
22VAC40-73-250-D
Based on facility record review, the facility failed to ensure that the health information required by these standards shall be maintained at the facility and be included in the staff record for each staff person, and also shall be maintained at the facility for each household member who comes in contact with residents. Initial tuberculosis examination and report: each staff person on or within seven days prior to the first day of work at the facility and each household member prior to coming in contact with residents shall submit the results of a risk assessment, documenting the absence of tuberculosis in a communicable form as
Evidence
  1. d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. The risk assessment shall be no older than 30 days.
  2. Staff 1’s (hire date, 03/04/2024) tuberculosis examination was completed on 02/14/2024. Upon request Staff 1’s risk assessment was not provided.
  3. On 09/17/2024, LI received an email from Staff 4 with Staff 1’s risk assessment, 02/14/2024.
Plan of correction
1) Staff 1’s risk assessment was emailed to the inspector on September 17th, 2024. 2) The Director of Business Administration was In-serviced on the Tuberculin Skin Testing for Associates policy (HR-100-7) on November 6th, 2024. 3) The Director of Business Administration will audit random associate files monthly to verify that a completed TB Screening Risk Assessment is present for six months to ensure ongoing compliance.
22VAC40-73-970-E
Based on facility record review, the facility failed to ensure that the required fire and emergency evacuation drills contained number of staff and residents participating, and the time it took to complete the drill.
Evidence
  1. May 2024 fire drill documentation was missing the number of staff participating.
  2. June 2024 fire drill documentation was missing the time it took to complete the drill.
  3. July 2024 fire drill documentation was missing the time it took to complete the drill and the number of staff participating.
  4. August 2024’s fire drill documentation was missing the number of residents participating, the number of staff participating, and has two different start times, 6:45 AM and 6:52 AM.
Plan of correction
1) A Fire Drill will be conducted by November 30th, 2024, to include the number of staff and residents participating, and the time it took to complete the drill. 2) The Plant Operations Director was in-serviced on the Fire Safety policy (C-100-09) on November 5th, 2024. 3) The Executive Director or Designee will audit fire drills monthly to ensure the number of staff and residents participating, and the time it took to complete the drill are included on the Fire Frill/Evacuation Exercise form. Audits should occur for six months to ensure ongoing compliance.
22VAC40-73-640-A
Based on resident record review and staff interview, the facility failed to ensure a written plan for medication management was implemented. The facility’s medication plan shall address procedures for administering medication and shall include methods to ensure that each resident’s prescription medications and any over-the-counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages.
Evidence
  1. Resident 2 (admit date, 08/28/2024), who self-administered medications had an order for Symbicort 160 mcg-4/5 mcg/actuation HFA aerosol inhaler (inhale 2 puffs twice daily) that was not available for self-administration.
  2. On 09/16/2024, LI interviewed Staff 4 who confirmed that the medication was not present on-site.
  3. Resident 2 has an order for Dicyclomine 20 mg tablet (instructions unavailable on medication list) that was not available for self-administration.
  4. On 09/16/2024, LI interviewed Resident 2 who stated it was realized that the Dicyclomine 20 mg medication was unavailable for self-administration when preparing weekly pill organizer. Resident 2 stated that the nursing team was notified.
  5. On 09/16/2024, LI interviewed Staff 4 who stated that Resident 2 informed the nursing team that Dicyclomine 20 mg had run out. Staff 4 stated that Resident 2 missed one dose, but the medication would be available the next day. Staff 4 stated that Resident 2 would only miss the one dose of medication. Staff 4 stated that the nursing team does not track the medication for those who self-administer. Staff 4 stated that there is not a timeline or a certain number of instances where the self-administer missed medication doses before re-assessing consent for self-administration.
  6. Resident 2 (admit date, 03/04/2024), who self-administered had an order for Symbicort 160 mcg-4.5 mcg/actuation HFA aerosol inhaler that was not available on-site.
Plan of correction
1) An up-to-date list of medications was obtained for resident number 2 on November 1st, 2024. The Dicyclomine was delivered to the community on September 16th, 2024. 2) Nurses and Medication Aides will be in-serviced on the Medication Management policy by November 30th, 2024. 3) The Resident Care Director or Designee will audit residents who self-administer medication quarterly, to ensure they have a current list of medications and that medications are available to the residents. Audits will occur for six months to ensure ongoing compliance.
March 25, 2024Inspection0 violations
Inspection dates
03/25/2024
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: March 25, 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 0 The Licensing Inspector conducted an announced initial inspection on March 25, 2024. The Licensing Inspector walked the physical plant, verified window and room measurements, reviewed policies and procedures and records. The Building, Fire and Health Inspections have been submitted and reviewed.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
January 17, 2024Complaint survey2 violations
Inspection dates
01/17/2024, 01/23/2025
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 RELATED22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY
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: 1/17/2025 Time In: 11:00 a.m. Time Out: 12:23 p.m. 01/23/2025 Time In: 9:14 am Time Out: 2:34 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 12/2/2024 regarding allegations in the area(s) of: Personnel, Staffing and Supervision, Admission, Retention and Discharge of Residents, Resident Care and Related Services, Additional Requirements for Facilities that Care for Adults with Serious Cognitive Impairments, Article 3: Safe, Secure, Environment, and Complaint Investigation Number of residents present at the facility at the beginning of the inspection: 42 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 7 Observations by licensing inspector: Licensing inspector (LI) toured the safe, secure environment. LI observed residents within the safe, secure environment interacting with staff, participating in physical therapy, walking to and from their rooms, and sitting in the common area. Additional Comments/Discussion: None 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 complaints but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov. Should you have any questions, please contact Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov.
Violations
22VAC40-73-1130-A
Based on record reviews and staff interview, the facility failed to ensure that at least two direct care staff members were awake and on duty at all times in the special care unit who were responsible for the care and supervision of the residents.
Evidence
  1. During a review of the special care unit census, July 2024 through January 2025, LI observed that there were six residents present on the unit October through November 2024.
  2. The October and November 2024 staff schedule indicated that one staff was scheduled 10/18/2024 and 11/28/2024 on each shift, 7:00 a.m. through 3 p.m., 3:00 p.m. through 11:00 p.m., and 11:00 p.m. through 7:00 a.m.
  3. There was one staff scheduled, 3:00 p.m. through 11:00 p.m., and two staff scheduled, 7:00 p.m. through 11:00 p.m. There was one staff scheduled, 11:00 p.m. through 7:00 a.m.
  4. On 1/17/2025, LI interviewed staff 5 who confirmed that there was only one staff scheduled on each shift on the safe, secure environment unit in October and November 2024.
Plan of correction
1. All residents who resided in the special care unit during the period of October – November 2024 were reviewed to ensure that their care needs had been met. 2. The scheduler and the Executive Director were educated on regulatory requirements for special care staffing. Effective 6/10/25, the staffing schedule will reflect the appropriate staffing levels. 3. Beginning June 10, 2025, the Executive Director or designee will audit staffing schedules weekly for 90 days, then monthly for three additional months to ensure two staff are scheduled and present each shift in the special care unit to ensure ongoing compliance.
22VAC40-73-430-H-1
Based on record reviews and staff interview, the facility failed to ensure at the time of discharge a dated statement was provided to the resident, legal representative, and designated contact person.
Evidence
  1. Resident 1’s progress notes (12/2/2024) indicated that their legal representative was not provided a written discharge statement.
  2. On 1/17/2025, LI interviewed staff 5 who confirmed that the legal representative was not provided a written discharge statement.
Plan of correction
1. A complete audit of discharges occurring between October 1, 2024 and March 31, 2025 was conducted. No additional instances of missing discharge statements were identified. 2. Staff involved in discharges will be re-trained by June 30, 2025 on requirements for Virginia discharge documentation standards. 3. Beginning June 2025, the Director of Business Administration or designee will review all discharges bi-weekly for 60 days, then monthly for four months to verify compliance with written discharge documentation and ensure ongoing compliance.