Virginia DSS · Assisted Living Facility

Harpers Station Yorktown

📍 4501 Victory Boulevard, Yorktown, VA, 23693

ID 51145One Year licenseActive
5
Inspections
On record
5
With violations
Visits that cited something
0
Clean visits
Nothing cited
19
Violations cited
Individual findings
18
Standards cited
Distinct rules
0
Complaint visits
Prompted by a complaint

Harpers Station Yorktown was inspected 5 times between August 22, 2024 and February 12, 2026 by the Virginia Department of Social Services. 5 of those visits ended with violations cited and 0 with none. Across that history VDSS cited 19 violations under 18 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
02/21/2027
Administrator
Seth Kenny
Licensing inspector
Alyshia Walker
Inspector phone
(757) 670-0504
Approved for
Special Care Unit · Assisted Living · Non-Ambulatory

Inspection History

5

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

February 12, 2026Inspection3 violations
Inspection dates
02/12/2026, 02/23/2026
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 GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 2/12/2026 8:30 am- 3:55 pm; 2/23/2026 10:00 am- 3:30 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: 77 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 6 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 4 Observations by licensing inspector: n/a 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. 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 Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Violations
22VAC40-73-640-A
Based on record review, the facility failed to implement its written plan for medication management, specifically regarding its methods to ensure accurate counts of all controlled substances whenever assigned medication staff changes.
Evidence
  1. The facility’s MAR/MOR- Change of Shift Accuracy Check policy states, “The MAR/MOR Sign off Sheet will be initialed by outgoing and incoming Nurse/Medication Assistant Tech at the change of every shift after MAR/MOR has been perused for accuracy.”
  2. A review of the Change of Shift-Controlled Medication Count Sheet for the month of February 2026 documented staff failed to ensure counts of all controlled substances occurred 4 times between outgoing and incoming Nurse/Medication Assistant Tech for controlled medications.
  3. Staff #4 acknowledged the Change of Shift-Controlled Medication Count Sheet was not completed for each change of shift.
Plan of correction
(1) The actions taken to correct each cited deficiency: a. Audit was conducted to identify deficiency. b. Any missing signatures on the February 2026 Change of Shift-Controlled Medication Count Sheets were reviewed with the staff involved. Date to be completed by: 2/12/2026 (2) The actions taken to prevent similar recurrences: a. All medication Staff (nurses and Medication Aides will complete mandatory re-training on controlled substance shift change count procedures and MAR/MOR change of shift accuracy check policy Date to be completed by 4/17/26 b. Weekly Audits to be conducted by DORS, RCC or designee weekly for the next 8 weeks Date to be completed by 5/28/2026 c. Continuing with facility’s monthly Quality Assurance (QA) program. Date to be completed by: Ongoing
22VAC40-73-680-C
Based on observation, the facility failed to ensure medications to be administered no earlier than one hour before and no later than one hour after the facility’s standard dosing schedule, except for those drugs that are ordered for specific times.
Evidence
  1. During the on-site inspection on 2/12/2026, the Licensing Inspector observed the following 8:00 am medications being administered more than an hour outside the standard dosing schedule. The following 9:00 am medications were administered by Staff #6: Resident #5 at 10:57 am: amlodipine 5 mg, Lisinopril 20 mg, Meloxicam 15mg, memantine Hcl 5mg Resident #6 at 11:09 am: amiodarone 200mg, aspirin 81mg, atorvastatin 20 mg, duloxetine 30 mg Resident #7 11:17 am: amlodipine 10 mg, prednisolone acetate 1%, Triamcinolon cre 0.1%
  2. Staff # 6 acknowledged the medication was being administered outside of the standard dosing schedule.
Plan of correction
(1) The actions taken to correct each cited deficiency: a. Staff #6 received immediate re-education on medication timing requirements and proper administration windows completed on (2) The actions taken to prevent similar recurrences: a. All medication staff (Nurses and Medication Aides/Techs) will be re-trained on the one-hour before/after medication administration window by 4/17/2026. b. Director of Resident Services (DORS), Resident Care Coordinator (RCC) or Designee will continually review medication assignments and resident groupings adjusting as needed to ensure completion within the required timeframe.
22VAC40-73-580-A
Based on a review of facility documentation and interview, the facility failed to ensure that it obtained an annual inspection report from the Virginia Department of Health.
Evidence
  1. During the on-site inspection of the facility on 2/12/2026, the most current health inspection provided by the facility was dated 7/8/2024.
  2. Staff #1 acknowledged the 7/8/2024 inspection was the facility’s most recent inspection by the health department.
Plan of correction
(1) The actions taken to correct each cited deficiency: a. On 2/12/2026 Staff # 1 called the Local Health Department (VDH) inspector to inquire about status of Food Health Inspection Report as facility was already granted a Food Establishment Permit valid through 7/31/2026 b. On 2/20/26 the Virginia Department of Health performed the Food Health Inspection with passing results and the extension of Food Establishment Permit to 02/20/2027 Date to be completed by: 2/20/26 (2) The actions taken to prevent recurrences: a. Staff #1 spoke with VDH to get a better understanding of how VDH schedules inspections. VDH stated that they should routinely schedule their unannounced inspections. b. Executive Director or Designee will call VDH to inquire and document inquiry concerning due Food Establishment Inspections prior to expiration of current permit. Date to be completed by: 2/20/26
February 3, 2025Inspection3 violations
Inspection dates
02/03/2025
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Technical assistance
200-D (facility should obtain a copy of the certificate for all direct care staff; not all DCS’s certificate can be verified as facility do hire caregivers that are not licensed). 450-D: hospice individual services should be noted on the ISP, if the facility is going to note hospice services and attach hospice plan with services, the ISP would need to indicate such, and the plan should be attached. 660-B: storage of medications, individuals not permitted to keep their own medication in room should be periodically checked to ensure all medications are properly stored on the medication cart.
Comments
Type of inspection: Renewal An on-site mandated renewal inspection was conducted on 2-3-25 (Ar 07:47 a.m./Dep 16:00 p.m.) The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 45 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Yes Number of resident records reviewed: 4 Number of staff records reviewed: 3 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 5 Observations by licensing inspector: medication pass (AL and SCU), first aid kit, water temperature, 96 hour emergency supplies, lunch meal 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 (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov
Violations
22VAC40-73-610-B
Based on observation and staff interviewed, the facility failed to ensure the menu for the snacks for the current week was dated and posted in an area conspicuous to residents.
Evidence
  1. On 2-3-25, the menu on the safe, secure unit posted near the nurse’s station and activity room did not include snacks.
  2. The menu on the assisted living unit near the elevator across from the dining room did not include snacks.
  3. Staff #1 acknowledged the snacks for the current week was not dated and posted for the residents.
Plan of correction
(2) The actions taken to correct each cited deficiency: Available snacks to be posted in main communal area of Assisted Living and Near Serving area in Memory Care Date to be completed by: 02/21/2025 (2) The actions taken to prevent similar recurrences: Snack Options will be approved and audited by Executive Director prior to being posted to ensure all meals, and snacks are included and dated.
22VAC40-73-720-A
Based on record reviewed and staff interviewed, the facility failed to ensure when a valid written order for Do Not Resuscitate (DNR) is in the record it should be included in the individualized service plan (ISP).
Evidence
  1. On 2-3-25, resident #1’s record included a valid written order for DNR dated 12-4-24. The resident’s personal and social data form also noted the resident’s DNR. The resident’s individualized service plan (ISP) dated 12-3-24 noted the resident was a “Full Code…staff would perform CPR in the event of cardiac or respiratory arrest”.
  2. Staff #2 acknowledged the resident’s record did include a valid written order for DNR and the ISP noted resident to receive CPR in the event of cardiac or respiratory arrest.
Plan of correction
(3) The actions taken to correct each cited deficiency: Residents ISP and social data form will be corrected to appropriate wishes for DNR. Date to be completed by: 02/11/2025 (2) The actions taken to prevent similar recurrences: DNR is uploaded into electronic file by Director of Sales, in coordination with Director of Resident Services. All coordinating documents will match according to residents wishes for life saving measures. Resident charts will be audited in accordance with our monthly Quality Assurance Audits.
22VAC40-73-580-B
Based on observation and staff interviewed, the facility failed to ensure resident’s record included an agreement as an option to have all meals in room.
Evidence
  1. On 2-3-25, resident #4 acknowledged having all meals in room and not eating in the facility’s dining room. The resident’s record did not have documentation of this written agreement to this effect, signed and dated by both the resident and the licensee or administrator and filed in the resident’s record.
  2. Staff #2 and #5 both when asked, acknowledged the resident eats all meals in room and does not dine in the facility’s dining room.
  3. Staff #2 acknowledged the facility did not have a specific written agreement to eat meals in the room that was signed and dated by the licensee or administrator.
Plan of correction
(1) The actions taken to correct each cited deficiency: Residents can practice the right to dine in their apartments. Meals are documented when eaten in residents’ rooms, as there is a fee for room delivery. Date to be completed by: 02/21/2025 (2) The actions taken to prevent similar recurrences: Resident’s meal agreement will be implemented at time of admission and completed for current residents. states choice to eat meals in apartment and/or dining room. We will keep meal tickets for delivery for documentation of location of meals. This will be signed by executive director for acknowledgement. Date to be completed by: 3/21/2025
January 16, 2025Inspection1 violation
Inspection dates
01/16/2025
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Monitoring An on-site unannounced inspection conducted on 1-16-25. (Ar 1:23 p.m./Dep 3:15 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 12-26-24 regarding allegations in the area of resident care and related services. Number of residents present at the facility at the beginning of the inspection: 47 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: Number of interviews conducted with residents: Number of interviews conducted with staff: 4 Observations by licensing inspector: window resident exited on scu/ facility video 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. 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 (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov
Violations
22VAC40-73-460-D
Based on self-report of a resident elopement received from the facility’s safe, secure unit, the facility failed to ensure that it shall provide supervision of resident schedules, care, and activities, including attention to specialized needs, such as prevention of falls and wandering from the premises.
Evidence
  1. On 12-25-24, per the facility’s revised self-report, interviews with the facility administrator, and facility video recording at 7:37 p.m., resident #1, who reside in the facility safe, secure unit, was observed to be agitated, trying to exit the facility door near resident’s room on two occasions. Resident observed on video trying to use the facility keypad to exit the facility and pushing on the door.
  2. Per the facility’s video, resident then enters another room (1009) on the safe, secure unit. The facility video at 8:01 p.m. shows resident #1 walking on the sidewalk/parking lot side of the Assisted Living (ALF) section of the facility. Resident enters the front entrance of the ALF through the automatic sliding door and goes toward the safe, secure unit area of the building. Resident exits the building again with staff following resident out the front entrance to the ALF building.
  3. The facility contacts the local police for assistance. Resident runs into wooded area between the facility and a church. Staff continues to follow resident. Police report noted resident back in facility (20:24:39). Upon return to room, the resident was evaluated by staff #2, observed an abrasion on bridge of nose and skin tear on left hand above thumb, first aid provided.
Plan of correction
1. Director of Maintenance to install two mechanical devices that disable the ability for the secondary window in rooms with exterior windows that are not surrounded encompassed by exterior fencing. Completion Date: 12/30/24 2. Facility to continue monthly elopement drills to review elopement policy and procedures. Completion Date: Ongoing
September 21, 2024Inspection8 violations
Inspection dates
09/21/2024
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Monitoring An on-site monitoring inspection conducted on 10-21-24. Ar 07:30 a.m./ Dep 16:25 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 12 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Yes Number of resident records reviewed: 3 Number of staff records reviewed: 3 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 5 Observations by licensing inspector: Breakfast meal, emergency preparedness supply, first aid kit, water temperature 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 (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov
Violations
22VAC40-73-410-A
Based on record reviewed and staff interviewed, the facility failed to have documentation acknowledging having received orientation to the facility for two of three records reviewed.
Evidence
  1. On 10-21-24, resident #2’s record did not have documentation of having received orientation to the facility. The resident’s date of admit noted as 10-1-24.
  2. Resident #3’s record did not have documentation of having received orientation to the facility. The resident’s date of admit noted as 9-28-24.
  3. Staff #1 and #2 acknowledged residents #2 and #3’s record did not have documentation of acknowledgement of receiving orientation to the facility.
Plan of correction
The facility will ensure to obtain documentation acknowledging having received orientation to the facility. Records will be reviewed and documentation will be obtained regarding acknowledgement of orientation to facility. Resident orientation checklist completed and attached. Date to be completed by: 11/8/24
22VAC40-73-450-A
Based on records reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) included the assessed needs for three of three records reviewed.
Evidence
  1. On 10-21-24, resident record review with staff #2, resident #1’s uniform assessment instrument (UAI) dated 10-3-24 noted transferring need assessed as mechanical help/physical assistance. The individualized service plan (ISP) dated 10-15-24 noted mechanical help/supervision. “resident will need assistance of grab bars and wheelchair…staff will provide supervision with bathing. Staff will report any changes in their physical needs to the person in charge”. Resident’s eating need assessed as independent. The ISP noted, “staff will provide reminders of all meals and supervision during mealtimes”. Wheeling need assessed as mechanical help. The ISP noted wheeling as mechanical and supervision. “resident needs supervision with transferring into wheelchair. Staff will monitor to ensure resident is propelling wheelchair safely, locked brakes and getting assistance with transferring”.
  2. Resident #2’s UAI dated 9-6-24 noted stairclimbing need assessed as mechanical help/supervision. The ISP dated 10-1-24 (10-6-24) noted stairclimbing as mechanical help/physical assistance. “Resident will need handrails and physical assistance to perform stairclimbing safely”. Staff #2 made written change to ISP prior to the inspector taking a photograph of the ISP document.
  3. Resident #3’s UAI dated 9-10-24 noted bathing need assessed as mechanical help/physical assistance. The ISP dated 10-10-24 noted “bathing needs help, yes Mechanical & Human Help Supervision. Resident requires the use of shower chair and grab bars for bathing. Care staff will set up showers, and provide supervision for bathing while encouraging to participate to the highest level of independence”.
  4. Staff #2 acknowledged the residents’ assessed needs and care plan were not in agreement.
Plan of correction
Facility will ensure individualized service plans include the assessed needs. Records will be reviewed including UAI. Level of assistance will be audited and checked for accuracy and corrected if need be. Residents needs and care plan will be in agreement. Corrected ISP attached. ISPs are audited and documented for accuracy on a monthly basis during facilities internal quality assurance check. Date to be completed by: 11/15/24 and Ongoing
22VAC40-73-40-B-10
Based on document reviewed and staff interviewed, the facility failed to ensure that any document required by the standard to be posted was in at least 12-point type or equivalent size, unless otherwise specified.
Evidence
  1. On 10-21-24, the facility assisted living activities calendar posted on the bulletin board located near the mailboxes was observed to be in less than 12-point type.
  2. Staff #1 acknowledged the posted schedule’s font was not at least 12-point type.
Plan of correction
Administrator and Activites Director will ensure that the activites calendar posted on the bulletin board located near mailboxes and all other areas of the facility will be at- least 12-point type. New Calendars will be printed in 12-point type to replace the calendar posted with less than 12-point type. This will be reviewed with Administrator prior to putting calendars out to residents monthly. Calendar with corrected size to be attached. Date to be completed by: 11/1/2024
22VAC40-73-610-E
Based on staff interviewed, the facility failed to ensure a copy of a diet manual containing acceptable practices and standards for nutrition was kept current and readily available to personnel responsible for food preparation.
Evidence
  1. On 10-21-24, during a tour of the kitchen with staff #1, staff #6 was not able to provide the inspector a copy of the diet manual.
  2. Staff #1 and #6 acknowledged the facility did not have a copy of the diet manual as required.
Plan of correction
A list of acceptable diets are located in the director of resident services manual. The facility will ensure that a copy of this and standards for nutrition is kept and readily available to personnel responsible for food preparation. Will ensure acknowledgement and understanding of acceptable practices and standards are understood. Dietary Manual attached, acceptable diets attached. Date to be completed by: 11/8/24
22VAC40-73-100-C-2
Based on observation and staff interviewed, the facility failed to ensure blood glucose monitoring practices that are consistent with CDC recommendations were followed.
Evidence
  1. On 10-21-24 during the medication pass observation with staff #3, resident #2’s blood glucose instrument (glucometer) was not labeled as required.
  2. Staff #1 and #3 acknowledged the resident’s blood glucose instrument (glucometer) was not labeled.
Plan of correction
To ensure consistency with CDC recommendations. All glucose instruments will be labeled as required. Clinical staff meeting to be conducted regarding proper labeling of instruments. This will be audited monthly during clinical internal quality assurance check. Date to be completed by: 10/21/2024
22VAC40-73-680-M
Based on record reviewed, staff interviewed and observation, the facility failed to ensure that medications ordered for PRN administration was available, properly labeled for the specific resident, and properly stored at the facility.
Evidence
  1. On 10-21-24 during the medication pass observation with staff #3, resident #1’s October medication administration record (MAR) noted resident prescribed Miconazole Nitrate as needed, PRN. A check of the medication cart was conducted, and this specific PRN medication was not available in the facility.
  2. Staff #2 and #3 acknowledged the resident’s PRN Miconazole Nitrate was not available in the facility.
Plan of correction
The facility will ensure that medications ordered for PR and administration are available at all times 2 residents. Medications will be properly labeled for specific resident. And properly stored at the facility. Community will ensure that medications are available at all times by communicating with families and residents prior to medication running out. Community will financially take responsibility of medications if there is a delay in regard to family or resident obtaining the medication from pharmacy. Cart audits are conducted on regular basis, and PRNS evaluated monthly on facilities quality assurance evaluation. Medications to be sent for refill several 5-7 days prior to running out to obtain medication prior to running out. Date to be completed by: 11/8/24 and On-Going
22VAC40-73-290-A
Based on documents reviewed and staff interviewed, the facility failed to ensure that facility written work schedule included the names, and job classification of all staff working each shift, with an indication of whomever is in charge at any given time.
Evidence
  1. On 10-21-24, the management, maintenance, dietary, activity schedule neither the clinical schedule indicated whoever is in charge at any given time. The management, maintenance, dietary, and activity schedules did not include the names of the staff person. The activity calendar provided did not include the job classification of the staff noted.
  2. Staff #1 and #2 acknowledged the written schedules provided did not include all of the required information.
Plan of correction
The facility will ensure that facility written work schedules include the names, and job classifications of all staff working each shift and indication of whoever is in charge at any given time. The person in charge will be notated on the maintenance, Management, dietary, and activities schedule. The names of the staff will be notated on the management, maintenance, dietary, and the activities schedule. The activities calendar will provide the job classification of the staff member noted. Each corrected staff scheduled attached. Date to be completed by: 11/5/24
22VAC40-73-610-B
Based on observation and staff interviewed, the facility failed to ensure the menu for meals and snacks for the current week was dated and posted in an area conspicuous to residents.
Evidence
  1. On 10-21-24, the facility’s menu for meals and snacks for the current week was not posted in the facility.
  2. Staff #1 acknowledged the posted menu and snack for the current week was not posted in the facility on the morning of 10-21-24.
Plan of correction
Facility will ensure that the menu for meals and snacks for current week was dated and posted in a conspicuous area. Residents will be able to view daily. A menu for meals and snacks will be posted. Date to be completed by: 10/21/24
August 22, 2024Inspection4 violations
Inspection dates
08/22/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSING PROCESS
Comments
Type of inspection: Initial An announced on-site mandated visit was conducted on 8-22-24 by two inspectors from the Peninsula Licensing Office (PLO). (Ar 09:22 a.m./ Dep 13:35 p.m.) The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: N/A The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Yes Number of resident records reviewed: N/A Number of staff records reviewed: N/A Number of interviews conducted with residents: N/A Number of interviews conducted with staff: 2 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the initial inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The applicant has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to maintain future compliance with applicable standard(s) or law. If the applicant 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 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 (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov
Violations
22VAC40-73-960-B
Based on observation and staff interviewed, the facility failed to ensure the fire and emergency evacuation drawing included all required information.
Evidence
  1. On 8-22-24 during a tour of the facility with staff #1 and #2, the fire and emergency evacuation postings show the primary and secondary escape routes, telephones, fire alarm boxes, and fire extinguishers.
  2. Staff #1 acknowledged the fire and emergency evacuation postings in the facility did not include all requirements.
Plan of correction
1. Facility’s Executive Director and Maintenance Director shall amend current fire and emergency evacuation drawings to included secondary escape routes, telephones, fire alarm boxes and fire extinguishers.
22VAC40-73-870-A
Based on observation and staff interviewed, the facility failed to ensure the interior and exterior of all buildings, was maintained in good repair and kept clean and free of rubbish.
Evidence
  1. On 8-22-23 during a tour of the facility with staff #1 and #2, the wall to the right of the entrance was observed to have a hole. The wall in the bathroom of room # 1016 was observed to have a hole above the bathroom lights.
  2. The fenced grass area outside of the safe, secure unit was observed to have a low drain resembling a hole in the ground. Also observed was a board that stood approximately 2 feet tall with nails in it ground near the drain.
  3. Staff #1 acknowledged the buildings and grounds items were in need of repair.
Plan of correction
1. Facility’s Director of Maintenance to install face plate covers over conduit boxes that are missing faceplates. 2. (a) Facility’s Director of Maintenance to install raised garden bed over low drainage area in the safe, secure unit grass area to permanently make this area inaccessible for foot traffic. (b) Facility’s Director of Maintenance to remove approximately 2-foot-tall board from ground from safe, secure unit grass area. Correction date: 1.8/22/23 2.(a) 9/2/2024 (b) 8/22/2024
22VAC40-73-925-A
Based on observation and staff interviewed, the facility failed to ensure it had toilet tissue accessible to each commode and soap accessible to each face/hand washing sink and each bathtub or shower.
Evidence
  1. On 8-22-24, during a tour of the facility with staff #1 and #2, the sampled rooms observed did not have toilet tissue and soap accessible in the bathrooms.
  2. Staff #1 stated facility did not supply these items.
Plan of correction
1. Facility’s Director of Maintenance shall order ample supply of Toilet Tissue and Soap to meet the needs of facility’s capacity and continue ordering to maintain a surplus.
22VAC40-73-860-G
Based on observation and staff interviewed, the facility failed to ensure the hot water at taps available to residents shall be maintained within a range of 105 degrees Fahrenheit (F) to 120 degrees F.
Evidence
  1. On 8-22-24 during a tour of the facility with staff #2, the water temperature in the memory care rooms were 122.4 degrees in room #1010 and 124.9 degrees in room #1009.
  2. Staff #2 acknowledged the water temperature in the rooms were not within the required range 105 to 120 degrees F.
Plan of correction
1. Facility has contacted licensed plumber on 8/23/24 to ensure that the automatic mixer valve is calibrated properly and set within the temperature range of 105°F to 120°F. 2. Facility’s Maintenance Department shall measure and record water temperatures once daily after the licensed plumber’s inspection on 8/26/2024 for one week post visit. If all temperatures fall within the required range the facility with then continue with regular monthly water temperature checks.