Inspection dates
04/01/2025
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 PREPAREDNESS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS
Technical assistance
Comments
Violations
22VAC40-73-120-A
Based on record review, the facility did not ensure the orientation and training required in subsections B and C of this section shall occur within the first seven working days of employment.
Evidence
- The record for Staff #4 did not contain the orientation and training during inspection on 4/1/25.
- Staff #1 confirms the orientation and training were not present in the Resident’s record during inspection on 4/1/25.
Plan of correction
1. Staff 4 have received all required education and validation of this in their personnel records was validated April 1, 2025.
2. A review of staff records of those hired since February 2025 confirmed that the correct form is being used by the Human Resource department.
3. It has been confirmed by AL Administrator that the correct form that has all the initial training required is being completed and documented currently.
4. The AL Administrator and/or HR representative will conduct a bi-weekly review x 6 weeks of staff records to ensure compliance with this part of the standards. Any variances observed will be immediately corrected and staff re-educated.
5 The audit of staff records was completed April 3, 2025.
22VAC40-73-320-A
Based on the record review, the facility did not ensure that within the 30 days preceding admission, a person shall have a physical examination by an independent physician. The report of such examination shall be on file at the assisted living facility and shall contain the following: A statement that the individual does not have any of the conditions or care needs prohibited by 22VAC40-73-310 H;
Evidence
- The physical examination for Resident #1 (completed 02/03/2025) did not include if the resident has any of the conditions or care needs prohibited by 22VAC40-73-310 H.
- Staff #1 confirms page 2 of the ISP was not completed in the record during inspection on 4/1/25.
Plan of correction
22VAC40-73-320-A (Physical examination and report)
1. Resident 1’s H&P was reviewed on 04/02/2025. A supplemental assessment addressing 22VAC40-73-310 H was completed by the physician on-site on 04/02/2025. Documentation updated in the residents’ record by HWD
2. A review of H&P for all residents admitted from 2/18/2025 to 04/01/2025 was com audited by 04/05/2025. Nine (9) residents were identified with incomplete documentation regarding prohibited conditions under 22VAC40-73-310 H. Updated physicals or physician addendums were obtained for eight (8) residents as of 04/12/2025. The remaining update is pending and expected by 4/18/2025.
3. A Move in Documentation Checklist for Resident Clinical Chart was implemented on 04/06/2025. Move-In Coordinator, and nursing staff were retrained on 22VAC40-73-310 H and new procedures on 04/12/2025 by HWD
4. HWD and MCD will audit all new H&P forms monthly using the checklist.
Results will be reviewed in monthly QAPI meetings by the Administrator and QAPI Committee. Issues will prompt immediate staff retraining and process review.
Ongoing from: 04/08/2025
5. All corrective actions, including audits, staff training, checklist implementation, and policy updates, were completed by 04/12/2025. One outstanding physician addendum is pending and will be obtained no later than 04/18/2025. Monitoring and compliance tracking are ongoing through the facility’s QAPI process, with regular review of new admission physicals and documentation compliance.
22VAC40-73-550-G
Based on the record review, the facility did not ensure the rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each resident or his legal representative or responsible individual as stipulated in subsection H of this section and each staff person.
Evidence
- of this review shall be the resident's, his legal representative's or responsible individual's, or staff person's written acknowledgment of having been so informed, which shall include the date of the review and shall be filed in the resident's or staff person's record.
Evidence:
- The record for Staff #4 did not contain the rights and responsibilities of residents in assisted living facilities.
- Staff #1 confirms the rights and responsibilities of residents in assisted living facilities were not present in the staff’s record during inspection on 4/1/25.
Plan of correction
22VAC40-73-550-G (Resident Rights)
1. Staff 4 have received all required education to include resident rights and validation of this in their personnel records was validated April 1, 2025.
2. A review of staff records of those hired since February 2025 confirmed that the correct form is being used by the Human Resource department.
3. It has been confirmed by AL Administrator that the correct form that has all the initial training required is being completed and documented currently.
4. The AL Administrator and/or HR representative will conduct a bi-weekly review x 6 weeks of staff records to ensure compliance with this part of the standards. Any variances observed will be immediately corrected and staff re-educated.
5 The audit of staff records was completed April 3, 2025.
22VAC40-73-250-A
Based on the record review, the facility did not ensure the personal and social data be maintained on staff and included in the staff record are as follows: An original criminal record report and a sworn disclosure statement.
Evidence
- The record for Staff #3 did not contain the criminal record check during inspection on 4/1/25.
- The record for Staff #4 did not contain the sworn disclosure during inspection on 4/1/25.
- Staff #1 confirms the criminal record report and a sworn disclosure statement were not present in the Staff’s record during inspection on 4/1/25.
Plan of correction
22VAC40-73-250-A (Staff Health Records and requirements)
1. Staff 3 did not have the required VA State Police criminal record check due to misinterpretation of license date. Staff #3 did have a criminal record check from the company’s background screening company. A VA State Police criminal record will be submitted in the next two weeks. Staff #4 have filled out required sworn statements and in their personal records.
2. A review of staff records of those hired since the opening of the Assisted Living Facility confirmed that the processing of team members not having correct VA State Police criminal record and sworn statement were processed.
3. It has been confirmed by AL Administrator that the correct criminal background check form is used and the correct Sworn Statement that has all the initial training required is being completed and documented currently.
4. The AL Administrator and/or HR representative will conduct a bi-weekly review x 6 weeks of staff records to ensure compliance with this part of the standards. Any variances observed will be immediately corrected and staff re-educated.
5 The audit of staff records was completed April 3, 2025.