Brightview Fair Oaks — Virginia Inspection Report

Inspections

On record

With violations

Visits that cited something

Clean visits

Nothing cited

Violations cited

Individual findings

Standards cited

Distinct rules

Complaint visits

Prompted by a complaint

Brightview Fair Oaks was inspected 5 times between July 25, 2024 and January 22, 2026 by the Virginia Department of Social Services. 4 of those visits ended with violations cited and 1 with none. Across that history VDSS cited 14 violations under 10 distinct standards.

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

02/19/2027

Administrator

Franc Cooper

Licensing inspector

Marshall Massenberg

Inspector phone

(804) 543-5188

Approved for

Non-Ambulatory · Special Care Unit · Assisted Living

Inspection History

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

January 22, 2026Inspection5 violations

Inspection dates

01/22/2026

Areas reviewed

22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE

Technical assistance

Documentation was discussed with the provider.

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: 1/22/26 (8:00 AM - 5:00 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: 70 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: Six Number of interviews conducted with residents: Two Number of interviews conducted with staff: Three Observations by licensing inspector: Meals, Medication Administration, Activity 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 Marshall Massenberg, Licensing Inspector at (804) 543-5188 or by email at Marshall.x.massenberg@dss.virginia.gov

Violations

22VAC40-73-250-B

Based on interview, the facility did not ensure that staff records are retained at the facility, treated confidentially, and kept in a locked area.

Evidence

Staff data, for 16 staff members, was unable to be verified during the inspection. Facility staff reported that the staff records are maintained in a computer database. Nobody in the building, during the inspection, was able to access all of the staff information that was requested during the inspection.

Plan of correction

The facility stores staff records in an electronic database which did contain all the requested documents at the time of inspection. However, an unforeseeable gap in delegating access occurred. Access to the electronic record system has been provided to additional staff members in the facility to insure contingency at all times.

22VAC40-73-325-B

Based on record review, the facility did not ensure that fall risk ratings were reviewed and updated after each fall by a resident.

Evidence

Resident #1's progress notes indicated that she fell on 7/9/25. Resident #1's record did not include information about her fall risk assessment being reviewed/updated after her fall on 7/9/25. Resident #2's progress notes indicated that she fell on 12/18/25. Resident #2's record did not include information about her fall risk assessment being reviewed/updated after her fall on 12/18/25. Resident #4's progress notes indicated that he fell on 12/13/25. Resident #4's record did not include information about his fall risk assessment being reviewed/updated after his fall on 12/13/25.

Plan of correction

There were no adverse outcomes noted for the residents as a result of these occurrences. An audit of all fall incident reports for all listed residents was conducted and there was no other findings of the violation. The fall risk ratings have been updated for the incidents noted on 12/13/25 and 12/18/25. The record for the incident dated 7/9/25 cannot be corrected retrospectively. The Health Services Director will review each fall report to ensure the fall risk rating is updated prior to signing and saving the document. Compliance will be monitored through monthly QA reviews.

22VAC40-73-320-B

Based on record review and interview, the facility did not ensure that a tuberculosis risk assessment is completed annually on each resident as

Evidence

d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: Tuberculosis risk assessments for Resident #1 (11/28/25), Resident #3 (9/15/24), and Resident #5 (1/7/26) were reviewed during the inspection. The tuberculosis risk assessments, included in the records for these residents (#1, #3 and #5), were not consistent with the current screening form published by the Virginia Department of Health. The risk assessments did not include any risk assessment conclusions/findings that stated that no further testing was indicated, or that the individual is believed to be free of tuberculosis in a communicable form based upon the tuberculosis risk assessment.

Plan of correction

There was no adverse outcome for any resident in the facility as a result of the violation. The tuberculosis risk assessment form has been updated to affirm that no further testing is indicated, or that the individual is believed to be free of tuberculosis.

22VAC40-73-680-M

Based on observation and interview, the facility did not ensure that PRN medication is available and properly stored at the facility.

Evidence

Resident #3's PRN Antacid/Antigas suspension, and Guaifenesin-Pseudoephedrine tablets were not available for administration; at the time of the medication cart inspection. Resident #7's PRN Acetaminophen, Loperamide, and Ondansetron were not available for administration, at the time of the medication cart inspection. Facility staff confirmed that the listed PRNs were not present, at the time of the medication cart inspection.

Plan of correction

The residents were assessed by the medical provider and no adverse outcome was observed. Upon review, the medications remained active in the electronic health record but were no longer being requested by the residents, and the staff relying on the resident's requests for PRN medications did not refill the medications. The medical provider discontinued the PRN medications and the electronic health record was updated to reflect the change. All nursing staff will receive in-service training on PRN medication management to include PRN medications that are infrequently requested. Compliance will be monitored through monthly QA reviews.

22VAC40-73-640-A

Based on documentation and interview, the facility failed to implement the medication management plan to ensure that each resident’s medications ordered for the resident are filled and refilled in a timely manner to avoid missed dosages.

Evidence

Resident #7's January medication administration record (MAR) was reviewed during the inspection. Resident #7's MAR states that his Simvastatin (ordered 3/13/25) was not administered on 1/6, 1/7, or 1/8. The MAR notes stated that the medication was awaiting a refill.

Plan of correction

Upon review, The facility nurse appropriately requested the refill but the pharmacy designated the medication as "too soon to refill," which resulted in a temporary unavailability of the medication. The resident was assessed by the medical provider and no adverse outcome was observed. All nursing staff received reeducation on timely follow-up on refill requests with the pharmacy. Nursing staff will be required to escalate refill issues to the Health Services Director if a medication is designated as “"too soon to refill" and doses are at risk of being missed. The Health Services Director will monitor missed medication doses related to pharmacy refill issues weekly for 30 days, then monthly thereafter. Compliance will be monitored through monthly QA reviews.

September 11, 2025Inspection1 violation

Inspection dates

09/11/2025

Areas reviewed

22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUNDS

Technical assistance

Documentation was discussed with the provider.

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: 9/11/25 (12:20 PM - 1:40 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 8/12/25 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: 84 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: One Number of interviews conducted with residents: None Number of interviews conducted with staff: Five Observations by licensing inspector: Facility Documentation, Building and Grounds 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 (complaint(s)/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 Marshall Massenberg, Licensing Inspector at (804) 543-5188 or by email at Marshall.x.Massenberg@dss.virginia.gov.

Violations

22VAC40-73-460-D

Based on documentation and interview, the facility did not provide supervision of resident schedules, care, and activities, including attention to specialized needs, such as prevention of falls and wandering from the premises.

Evidence

Facility documentation indicates that Resident #1 was observed outside of the facility on 8/10/25 at approximately 2:30 PM. Facility staff were reported to have intervened and escorted the resident back to the facility, before he reached Lee Highway. Prior to him exiting the building, facility staff observed Resident #1 in the facility's safe, secure unit at approximately 2 PM on 8/10/25. Facility documentation indicates that Resident #1 is believed to have exited the unit through a window that had been opened in another resident's room. The window’s security mechanism, used to keep the window from opening fully, had been broken and removed. The window screening had also been removed. Resident #1 was admitted to the facility’s safe, secure unit on 8/4/25. Resident #1's record was observed during the inspection. Resident #1's record included an Assessment of Serious Cognitive Impairment form, dated 7/14/25, that states that the resident has a serious cognitive impairment and an inability to recognize danger or protect his own safety and welfare. Resident #1's physical examination form, dated 7/14/25, states that he is "very mobile/ambulatory." Resident #1's individualized service plan (ISP) indicates that he has frequent awareness/poor judgment issues and that he makes unsafe or inappropriate decisions. The ISP also states that he "may wander outside; health or safety may be jeopardized, but participant is not combative about returning and does not require professional consultation or intervention."

Plan of correction

The resident exited the unit after dismantling the standard restrictive-window mechanism which was atypical and unanticipated. The resident's pre-admission assessment and interviews with family members did not indicate any wandering or elopement tendencies. The resident was quickly located after exiting the unit and returned safely to the facility within approximately 3 minutes. A full head-to-toe assessment was completed by nursing staff and no injury was noted. The resident and all other residents were reassessed for elopement risk. The resident received additional support including increased engagement in programming/activities and a 1:1 caregiver for increased supervision while adjusting to a new environment. All memory care staff was re-educated on elopement prevention, environmental safety checks, and timely identification and reporting of behavioral changes that may indicate potential risks. The Maintenance team will perform a weekly safety check of all windows and restrictive-window mechanisms and the Safety Committee will include an elopement risk review monthly.

January 17, 2025Inspection6 violations

Inspection dates

01/17/2025

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 GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 - SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE

Technical assistance

Documentation was discussed with the provider.

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: 1/17/25 (8:45 AM - 5:45 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: 84 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: Six Number of interviews conducted with residents: Two Number of interviews conducted with staff: Three Observations by licensing inspector: Meals, Medication Administration, Activity 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 Marshall Massenberg, Licensing Inspector at (804) 543-5188 or by email at Marshall.x.massenberg@dss.virginia.gov.

Violations

22VAC40-73-680-D

Based on record review, the facility did not ensure that medications are administered in accordance with the physician's instructions.

Evidence

Resident #1's record contained an order for sliding scale insulin with the following instructions: For BS < 70: Call MD; For BS 150-200: Give 2 Units SQ; For BS 201-250: Give 4 Units SQ; For BS 251-300: Give 6 Units SQ; For BS 301-350: Give 8 Units SQ; For BS 350+: Call MD;
Resident #1's January 2025 MAR contained documentation that the resident’s sliding scale insulin was administered when the resident's blood sugar was below 150 on the following dates/times: 1/1/25 (BS 134 - breakfast administration); 1/1/25 (BS 103 - bedtime administration); 1/2/25 (BS 128 - bedtime administration); 1/10/25 (BS 112 - breakfast administration); 1/11/25 (BS 105 - breakfast administration); 1/15/25 (BS 123 - breakfast administration).
No information was included in the January MAR to document the amount of insulin that was administered on the listed dates.

Plan of correction

There was no adverse outcome noted for this resident as a result of this occurrence. An audit of all residents' insulin records was conducted and there was no other finding of this deficient practice. By 4/14/2025, all nurses and Medication Technicians will be re-educated on the facility's Medication Management policy which is consistent with the standards set forth by the licensing agency, to ensure all medications are administered according to the physician's instructions. Nurses and Medication Technicians will also be re-educated on appropriate documentation procedures and requirements when using the eMAR system. The Health Services Director will audit all resident care orders and administration records monthly to ensure compliance with prescriber’s orders for medication administration.

22VAC40-73-660-B

Based on observation and record review, the facility did not ensure that medication storage in resident rooms is limited to out-of-sight places in the rooms of residents whose UAIs (uniform assessment instruments) indicate that each resident is capable of self-administering their medication.

Evidence

Total Restore supplements and Robitussin syrup were observed on a shelf in the room of Resident #4. Resident #4's uniform assessment instrument (UAI), dated 9/24/24, states that he needs staff assistance in order to administer his medications.

Plan of correction

All observed medications stored in the resident's room were removed. The resident received information regarding requirement for clinical staff to manage all physicians' orders, store, and administer all medications, unless otherwise specified subsequent to an assessment. The Assisted Living Director and Health Services Director will ensure compliance on a monthly basis. Other staff, when appropriate, will report any observation of medications being stored in a resident's room.

22VAC40-73-680-M

Based on observation and interview, the facility did not ensure that PRN medication is available and properly stored at the facility.

Evidence

Resident #4's PRN Acetaminophen 325mg, Hall’s cough drops, and Polyethylene Glycol were not available for administration; at the time of the medication cart inspection. Resident #5's PRN Trazadone, Acetaminophen 650mg, and Bisacodyl suppositories were not available for administration; at the time of the medication cart inspection. Resident #7's PRN Acetaminophen 500mg and Docusate 100mg were not available for administration, at the time of the medication cart inspection. Facility staff confirmed that the listed PRNs were not present, at the time of the medication cart inspection.

Plan of correction

There were no adverse outcomes noted for these residents as a result of this occurrence. All residents' PRN medications were reviewed and ordered, and are available in the medication carts. Additionally, Medication Technicians will conduct audits and medication cart inspections to include each resident, at least, monthly. All findings will be documented and communicated to the Wellness Nurse. The Health Services Director will audit all resident care orders monthly to ensure compliance with prescriber’s orders for PRN medication administration.

22VAC40-73-320-B

Based on record review and interview, the facility did not ensure that each resident received an annual tuberculosis risk assessment.

Evidence

Tuberculosis risk assessments for Resident #1 (10/1/23) and Resident #6 (4/20/23) were more than a year old, at the time of the inspection. Facility staff confirmed that the risk assessments were more than a year old, at the time of the inspection.

Plan of correction

An audit of all residents' records was conducted to ensure compliance. The indicated annual tuberculosis risk assessments were conducted, completed and placed in the residents' records. Residents' records will be reviewed monthly by the Health Services Director to ensure compliance with this standard.

22VAC40-73-1110-B

Based on record review and interview, the facility did not ensure that an annual review of continued appropriateness for residence in the special care unit was completed.

Evidence

The most recent reviews of appropriateness for Resident #1 (10/23/23) and Resident #6 (7/5/23) were more than a year old, at the time of the inspection. Facility staff confirmed that the most recent reviews were more than a year old, at the time of the inspection.

Plan of correction

An audit of all residents' records was conducted to ensure compliance. The indicated annual reviews of continued appropriateness forms for residence in the special care unit were completed and placed in the residents' records. Residents' records will be reviewed monthly by the Administrator and Health Services Director to ensure compliance with this standard.

22VAC40-73-450-G

Based on record review and interview, the facility did not ensure that the master service plan is filed in the resident's record.

Evidence

Resident #2's individualized service plan (ISP) was not located in the resident’s record, at the time of the record review. Resident #3's ISP was not located in the resident’s record, at the time of the record review. Facility staff confirmed that the ISPs were not present in the record, at the time of the record reviews.

Plan of correction

An audit of all ISP’s in residents' records was conducted and there was no other finding of this practice. The indicated ISP which had been signed prior to the inspection was located and placed in the resident's record. The Administrator and Health Services Director will ensure ISP's are appropriately signed and promptly placed in the resident's records as required. Resident ISP's will be reviewed monthly to monitor compliance.

October 17, 2024Inspection2 violations

Inspection dates

10/17/2024

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDING AND GROUNDS

Technical assistance

Documentation was discussed with the provider.

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: 10/17/24 (8:30 AM - 12:30 PM). The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: Two Number of interviews conducted with residents: One Number of interviews conducted with staff: Two Observations by licensing inspector: Medication administration, Building and Grounds 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 Marshall Massenberg, Licensing Inspector at (804) 543-5188 or by email at Marshall.x.Massenberg@dss.virginia.gov

Violations

22VAC40-73-680-M

Based on observation and interview, the facility did not ensure that PRN medications are available and properly stored at the facility.

Evidence

PRN Loperamide and Ondansetron, ordered for Resident #2, were not present at the time of the medication cart inspection.
Facility staff confirmed that the medications were not present, at the time of the medication cart inspection.

Plan of correction

Not published by VDSS.

22VAC40-73-680-D

Based on observation and documentation, the facility did not ensure that medications are administered in accordance with the physician's instructions.

Evidence

The medication pass for Resident #1 was observed during the inspection.
Resident #1's Levothyroxine was administered along with her other 8:00 AM medications. Resident #1's October medication administration record (MAR) lists her Levothyroxine’s administration time as 8:00 AM, since 10/10/24. Prior to 10/10/24, Resident #1's Levothyroxine was scheduled for 7:00 AM.
Resident #1's record contained an order for Levothyroxine, signed 9/5/24, that calls for the medication to be administered 1 hour "prior to AM meds."

Plan of correction

Not published by VDSS.

July 25, 2024Inspection0 violations

Inspection dates

07/25/2024

Areas reviewed

22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESSARTICLE 1 – SUBJECTIVITY63.2- (1) GENERAL PROVISIONS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION

Comments

Type of inspection: Initial Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/26/2024 10:30 AM to 2:50PM 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: 0 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: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Additional Comments/Discussion: Change of Ownership- Room measurements taken. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website should the facility be issued a license to operate. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of a licensed facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.