The Gardens of Virginia Beach — 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

The Gardens of Virginia Beach was inspected 30 times between November 18, 2020 and May 7, 2026 by the Virginia Department of Social Services. 25 of those visits ended with violations cited and 5 with none. Across that history VDSS cited 90 violations under 51 distinct standards. 12 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.

VDSS publishes inspections on a rolling window. 3 of these 30 are still on the state's site; the other 27 have since dropped off it and are reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type

Assisted Living Facility

License type

One Year

License expires

05/19/2027

Administrator

Ira Pinkney

Licensing inspector

Donesia Peoples

Inspector phone

757 353-0430

Approved for

Special Care Unit · Assisted Living

Inspection History

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

May 7, 2026Inspection7 violations

Inspection dates

05/07/2026

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 IMPAIRMENTS22VAC40-90 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: An unannounced renewal inspection took place on 05/07/2026 at 8:53 am to 5:02 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: 88 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: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 6 Observations by licensing inspector: Breakfast, lunch, and an activity were observed. A medication pass observation was completed for three residents. The following were reviewed: resident and staff records, fire drills, fire inspection report, health inspection report, a staffing schedule. Water temperature was measured, and the call bell system was monitored. Additional Comments/Discussion: None 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov

Violations

22VAC40-73-390-B

Based on the record review and staff interview the facility failed to ensure copies of the signed agreement or acknowledgment and any updates as noted in subsection C of this section shall be provided to the resident and, as appropriate, the resident’s legal representative and shall be retained in the resident's record.

Evidence

The record for resident #2 does not contain a signed agreement.
Upon request, and during an interview on 05/07/26 with staff #5, staff #5 stated the written agreement was mailed to resident # 2’s legal representative on 03/19/26 however the facility has not received a copy signed by the resident or legal representative.

Plan of correction

1. The Administrator, Director of Nursing (DON), and BOD will conduct an audit of all resident files over the next 60 days to ensure all current residents have a signed Sinceri Senior Living Residency Agreement on file in their business file and electronic file. 2. A reminder will be sent out to any residents or legal representatives whose files are missing from the residency agreement. A deadline to have the document returned will be enforced to ensure all documents are received in a timely manner. 3. All new residents will sign the residency agreement on or before the day of financial move in, and a copy will be uploaded to their electronic file and a hardcopy placed in their financial file and kept in the business office. 4. A quarterly audit will be conducted on 10 % of resident files to ensure compliance.

22VAC40-73-50-B

Based on the record review and staff interview the facility failed to ensure written acknowledgment of the receipt of the disclosure by the resident or the resident’s legal representative shall be retained in the resident’s record.

Evidence

The record for resident #2 does not contain written acknowledgment of receipt of the facility’s disclosure statement.
Upon request, and during an interview on 05/07/26 with staff #5, staff #5 stated the disclosure statement was mailed to resident # 2’s legal representative on 03/19/26 however the facility did not have written acknowledgment of the resident’s legal representative receipt of the disclosure statement.

Plan of correction

1. Disclosure Statements were mailed out on 5/26/26 to the legal representative with a “return by” date of 6/3/26 to ensure the document is available and on file in the community IAW 22VAC40-73-50-50-B. 2. Community will conduct a quarterly audit of 15 % of resident files to ensure compliance. 3. All new residents/legal representatives will sign the written acknowledgement of the receipt of disclosure upon lease signing; a copy will be uploaded into the electronic health record; the original copy will be placed in the business file IAW state regulation.

22VAC40-73-640-A

Based on observation, medication record review, and staff interview the facility failed to ensure the facility shall implement a written plan for medication management to include methods to prevent the use of outdated, damaged, or contaminated medications. 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

During the observation of the medication cart located in the safe secure unit on 05/07/2026 at 9:43 am with staff # 1. The following expired medication was located on the medication cart. • Centrum Silver Vitamin expired 04/2026
Staff #1 confirmed on 05/07/2026 that the Centrum Silver Vitamin was labeled with an expiration date of 04/2026.
Resident #2’s May 2026 Medication Administration Records (MARs) documents the resident did not receive Mirtazapine 7.5mg at bedtime for insomnia on the following scheduled dates due to the medication not being available: 05/01/26, 05/04/26, 05/05/26, 05/06/26.
Resident #1’s May 2026 MARs documents the resident did not receive the following medications on 05/04/26 due to the medications not being available: • Folic Acid 1mg for supplementation • Multivitamin for vitamin supplement • Vitamin B-12 for Vitamin B12 deficiency

Plan of correction

1. Expired medication was removed from the medication cart on 5/7/26 immediately upon discovery. 2. DON or designee will conduct weekly medication cart audits to ensure all expired medications are removed and/or destroyed timely. In addition, verification that all medications listed on the eMAR are available to be administered as prescribed. 3. Any medications that are near expiring will be reordered and removed as needed or within 7 days of expiration. 4. Any medications that are not available will be updated in the eMAR appropriately with notes in the resident’s file indicating what steps that are being followed to ensure the medications are obtained from the pharmacy in a timely manner. All communication between the pharmacy, community and family will be properly documented immediately upon the knowledge of the medication being unavailable.

22VAC40-73-430-H-1

Based on the record review and staff interview the facility failed to ensure at the time of discharge, the assisted living facility shall provide to the resident and, as appropriate, his legal representative and designated contact person a dated statement signed by the licensee or administrator and a copy of the written statement shall be retained in the resident’s record.

Evidence

The record for resident #8, discharged on 04/27/26, does not contain a discharge statement.
Upon request, and during an interview on 05/07/26 with staff #4, staff #4 confirmed a discharge statement for resident #8 was not completed.

Plan of correction

1. Administrator updated the discharge statement and updated the resident’s file. 2. Community conducted an audit of all discharged resident files on 5/20/26 to ensure compliance according to Virginia Licensing Standard 22VAC40-73-430-H. All files were updated. 3. All current residents will have a discharge notice completed with one copy given to the resident or responsible party and one copy will be maintained in their business file IAW 22VAC40-73-430-H.

22VAC40-90-40-B

Based on the record review and staff interview the facility failed to ensure the criminal history record report was obtained on or prior to the 30th day of employment for each staff person.

Evidence

The record for staff #6, hire date 04/06/26, does not contain a criminal history report.
Upon request on 05/07/26, staff #5 was not able to provide a completed criminal history report for staff #6.

Plan of correction

1. Background check for staff #6 was run on 5/5/26 and currently maintained in employee’s personnel file. 2. All potential new hires will have a background check ran immediately upon receipt of signed employment offer. 3. Business Office Director (BOD) or designee will conduct a quarterly audit of 10 % of employee files to ensure all required new hire documents are available and on file.

22VAC40-73-1090-A

Based on the record review and staff interview the facility failed to ensure prior to his admission to a safe, secure environment, the resident shall have been assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare.

Evidence

The record for resident #1, admission to the safe secure environment on 04/04/26, contains an assessment of serious cognitive impairment dated 03/26/26 that documents the following: • A statement from the physician that states, the patient is able to identify danger and avoid it. • A response of no for the question, is the individual named above unable to recognize danger or protect his/her own safety and welfare.
During an interview on 05/07/26 with staff #4, staff #4 confirmed resident #1’s assessment of serious cognitive impairment states the following: • A statement from the physician that states, the patient is able to identify danger and avoid it. • A response of no for the question, is the individual named above unable to recognize danger or protect his/her own safety and welfare

Plan of correction

1. The responsible party of resident #1 has contacted and set up an appointment with an independent clinical psychologist licensed to practice in the Commonwealth. The clinic will call POA with date and time once available ETA June 2026. 2. . The DON and designee completed an audit of each memory care resident’s file on 5/17/26 to ensure proper documentation of the resident’s ability to recognize danger on the serious cognitive impairment form complies with 22VAC40-73-1090-A. 3. The Administrator, DON, or designee, will review the documentation on the serious cognitive impairment form prior to resident admission. Any discrepancies will be corrected by the attending physician to ensure appropriateness and compliance.

22VAC40-73-680-I

Based on the medication record review the facility failed to ensure the MAR shall include: Date and time given and initials of direct care staff administering the medication; Any medication errors or omissions.

Evidence

Resident #2’s May 2026 MARs does not include staff initials to indicate if the medication was administered or not administered on 05/06/2026 at the scheduled time at 6:30 pm for the following medication: • Tamsulosin 0.4mg for urinary retention.

Plan of correction

1. Resident #2’s MAR was immediately reviewed and corrected upon identification of the deficiency. The medication administration documentation for Tamsulosin 0.4mg scheduled for 05/06/2026 at 6:30 PM was reviewed with the staff member responsible for medication administration to verify whether the medication was administered or omitted. Appropriate clarification documentation was completed in the residents’ record. 2. Audits of all current resident MARs were conducted by the DON and designee on 5/8/26 and 5/11/26 to ensure medications were properly documented with staff initials, administration times, and any omissions were noted appropriately. All discrepancies identified during the audit were immediately addressed and corrected. 3. All medication aids will attend and successfully complete the Medication Aid refresher course through our contracted pharmacy provider (Guardian) within the next 90 days. Proof of completed coursework will be available and on file in the employee’s file.

February 3, 2026Inspection6 violations

Inspection dates

02/03/2026

Areas reviewed

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: An unannounced monitoring inspection took place on 02/03/26 at 9:25 am to 2:55 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: 103 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: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: Lunch and an activity were observed. Additional Comments/Discussion: None 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 (Donesia Peoples), Licensing Inspector at (757) 353-0430 or by email at donesia.peoples@dss.virginia.gov

Violations

22VAC40-73-320-A

Based on the record review and staff interview the facility failed to ensure the physical examination 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 record for resident #1, admission date of 1/29/26, contains a physical examination dated 1/12/26 that documents yes, the resident requires continuous licensed nursing care.
During an interview on 02/03/26 with staff #1, staff #1 confirmed the physical exam dated 01/12/26 for resident #1 documents yes, the resident requires continuous licensed nursing care.

Plan of correction

1.Upon discovery of the deficiency the Administrator immediately reviewed the physical examination for Resident #1. The physician’s statement indicating the resident requires continuous licensed nursing care was identified. 2.The facility contacted the resident’s physician to clarify the resident’s current medical status and obtain updated documentation. If the physician confirms the resident requires continuous licensed nursing care, the facility will coordinate with the resident and responsible party to arrange for transfer to an appropriate level of care. If the statement was documented in error, the physician will provide corrected documentation indicating the resident does not have prohibited conditions under 22VAC40-73-310 H. The administrator and/ or designee conducted an audit of all current resident records to ensure each physical examination includes a statement confirming the resident does not have prohibited conditions requiring continuous licensed nursing care. Any missing unclear documentation will be corrected by contacting the resident’s physician and have the documentation updated to current the resident’s current status. 3.The facility has implemented the following measures: a.A new admission checklist has been implemented to ensure all required elements of the physical examination are reviewed prior to admission. b.The Director of Nursing or designee will verify that the physical exam specifically documents the resident does not require continuous licensed nursing care before accepting admission. c.Any physical exam containing prohibited conditions will be reviewed immediately to determine if admission is appropriate. 4.The Administrator, DON, or designee will review all new admissions and physical examinations for compliance with 22VAC40-73-320-A prior to admission. A monthly audit of the resident records will be conducted for three months to ensure all physical examinations contain the required documentation. Any deficiencies will be corrected immediately.

22VAC40-73-450-C

Based on the record review and staff interview the facility failed to ensure the comprehensive ISP shall be completed within 30 days after admission.

Evidence

The record for resident #3, admission date of 12/05/25, contains an ISP dated 01/12/26. The resident’s record does not contain an ISP completed within 30 days after the resident’s admission.
The record for resident #4, admission date of 12/04/25, contains an ISP dated 01/10/26. The resident’s record does not contain an ISP completed within 30 days after the resident’s admission.
During an interview on 02/03/26 with staff #1, staff #1 confirmed the following: •resident #3’s ISP was completed on 01/12/26 and an ISP was not completed within 30 days after the resident’s admission. •resident #4’s ISP was completed on 01/10/26 and an ISP was not completed within 30 days after the resident’s admission.

Plan of correction

1.Resident #3 and #4 have had their comprehensive ISPs reviewed and updated to ensure they accurately reflect the residents’ current needs and services required. The ISPs are now complete and signed, and are maintained in the resident’s records. 2.The Administrator, DON, or designee conducted a 100% audit of all current resident records to verify that each resident has a comprehensive ISP completed within 30 days of admission as required. Any missing or incomplete documentation found during the audit was immediately corrected. Care Plan meetings are currently being conducted with each resident/POA. 3.To ensure ongoing compliance with ISP requirements: a.The facility will utilize the tracking system put in place by Sinceri Senior Living. This system helps the facility’s staff to monitor admission dates and required completion deadlines for comprehensive ISP. b.Upon admission the DON or designee will enter the resident’s preliminary ISP into the tracking system which will then generate the 30 days mark for the completion of the comprehensive ISP and send an alert when the deadline is nearing the 30-day time period.

22VAC40-73-440-A

Based on the record review and staff interview the facility failed to ensure all residents of and applicants to assisted living facilities shall be assessed face to face using the uniform assessment instrument in accordance with Assessment in Assisted Living Facilities (22VAC30-110). The UAI shall be completed prior to admission, at least annually, and whenever there is a significant change in the resident's condition.

Evidence

The record for resident #6 does not contain a current UAI. The UAI in the record is dated as completed on 02/22/2023.
During an interview on 02/03/26 with staff #1, staff #1 confirmed the record for resident #6 did not contain a current UAI and staff #1 was not able to provide a current UAI for resident #6.

Plan of correction

1.Resident #6’s record was reviewed immediately following survey. A current UAI was completed face-to-face with the resident on (date) by the DON, and/or designee. The updated UAI has been placed in the resident’s record to ensure compliance with regulatory requirements. 2.The DON/Designee conducted a 100% audit of all resident records to ensure that each resident has a current UAI completed prior to admission and annually thereafter in accordance with regulatory requirements. Any resident identified without a current UAI had the assessment completed immediately and placed in the resident’s records. 3.To prevent future occurrences, the facility has implemented the following plan: a. The DON/Designee will maintain a UAI tracking log to monitor admission dates and annual reassessment due dates for all residents. b.Resident records will be reviewed monthly to ensure assessments remain current. c.A reminder system/calendar has been implemented to notify the staff 30 days prior to the UAI expiration date. d.All assessments will be completed face-to-face by a qualified assessor as required by regulation. 4.All appropriate staff were trained on UAI requirements, documentation, and regulatory timelines in accordance with 22VAC30-110. Documentation of the training will be maintained in staff training records. 5.The Administrator or designee will conduct monthly records audits for three months, followed by quarterly audits, to ensure all UAIs remain current and compliant with state regulations.

22VAC40-73-970-A

Based on the facility record review and staff interview the facility failed to ensure fire and emergency evacuation drill frequency and participation shall be in accordance with the current edition of the Virginia Statewide Fire Prevention Code (13VAC5-51). The drills required for each shift in a quarter shall not be conducted in the same month.

Evidence

The facility record review for fire drills did not include documentation a fire drill was completed during the months of December 2025 and January 2026.
Upon request on 02/03/26, staff #5 was not able to provide a fire drill record for December 2025 and January 2026.

Plan of correction

1)A Fire drill was conducted on 02/18/2026 at 5:32 PM to ensure immediate compliance with fire safety requirements. Dates and shifts for our March and April drills are already in place by our maintenance director. All drills will be properly documented, including date, time, shift, staff participation, and any identified issues. 2)Any identified missing drills were discussed with the team and a plan put in place to ensure drills are conducted monthly making sure all shifts are completed quarterly. (a)A monthly fire drill schedule has been developed to ensure drills are conducted for each shift every quarter and are not conducted in the same month. (b)Our community TELS maintenance portal monitors completion by month, time and shift. (c)The Administrator, Maintenance Director/Designee will be responsible for ensuring drills are completed as scheduled. (d)Staff responsible for conducting fire drills (including Staff #5) have been updated on regulatory requirements, including frequency, shift participation, and documentation standards. (e)Fire drill documentation will be maintained in our TELS system that is readily accessible for review.

22VAC40-73-450-A

Based on the record review and staff interview the facility failed to ensure on or within seven days prior to the day of admission, a preliminary plan of care shall be developed to address the basic needs of the resident that adequately protects his health, safety, and welfare. EXCEPTION: A preliminary plan of care is not necessary if a comprehensive individualized service plan is developed, in conformance with this section, on the day of admission.

Evidence

The record for resident #2, admission date 01/19/26, does not contain a preliminary plan of care completed on or within seven days prior to admission, nor a comprehensive individualized service plan (ISP) completed on the day of admission.
The record for resident #3, admission date 12/05/25, does not contain a preliminary plan of care completed on or within seven days prior to admission, nor a comprehensive individualized service plan (ISP) completed on the day of admission.
The record for resident #4, admission date 12/04/25, does not contain a preliminary plan of care completed on or within seven days prior to admission, nor a comprehensive individualized service plan (ISP) completed on the day of admission.
During an interview on 02/03/26 with staff #1, staff #1 confirmed a preliminary plan of care was not completed on or within 7 days prior to admission nor an ISP completed on the day of admission for residents #2, #3, and #4.

Plan of correction

1.Resident #2, #3, and #4 records were reviewed immediately following the findings of the inspector. A preliminary plan of care and/or comprehensive individualized Service (ISP) was developed and placed in each resident’s record to ensure their needs are appropriately addressed and documented. 2.To prevent reoccurrence, the Administrator has reviewed the requirements of licensing standard 22VAC40-73-450-A with all staff responsible for admissions and resident documentation. Staff were retrained on the requirements that a preliminary plan of care must be completed within seven days prior to admission and a comprehensive care plan must be completed within 30 days following the admission. 3.The facility has implemented an Admission ISP tracker. This tracker includes verification that the preliminary plan of care has been completed within the required timeframe and that the comprehensive ISP is completed 30 days following admission. 4.The Administrator, DON, or designee will conduct a monthly chart audit using the tracker for the next three months to ensure that all new admissions have a preliminary plan of care completed within seven days of move-in and ISPs are completed within the required timeframe. Any findings that may require correcting during the auditing process will be addressed immediately with additional staff education as needed. 5.The Adminsitrator and DON are responsible for ensuring compliance with this regulation moving forward.

22VAC40-73-560-E

Based on observation the facility failed to ensure all resident records shall be kept in a locked area.

Evidence

During a tour of the facility on 02/03/26, the Licensing Inspector (LI) observed the facility’s resident records room to be unlocked with the door opened, and unstaffed.

Plan of correction

1.Immediately upon being notified of the violation on 02/03/26, the resident records room was secured. The door was closed and locked right away, and access was limited to authorized personnel only. Staff on duty at the time were counseled regarding the importance of maintaining the security and confidentiality of resident records. 2.Effective immediately a “lock immediately upon exit” practice has been implemented. 3.Only designated staff members are authorized to access the records room. 4.A visual reminder has been placed on the records room door to ensure it remains closed and locked when unattended. 5.Administrator or designee will conduct random daily checks going forward during their community rounds. Medication Assistants will be responsible for making rounds and ensuring the records room door is closed and locked after hours, weekends, and holidays when the Administrator or designee(s) are absent from the facility. Any non-compliance will be addressed immediately with additional training as appropriate.

October 9, 2025Complaint survey0 violations

Inspection dates

Oct. 9, 2025

Areas reviewed

Comments

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

October 9, 2025Complaint survey1 violation

Inspection dates

Oct. 9, 2025

Areas reviewed

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: An unannounced complaint inspection took place on 10/09/2025 from 09:10 am to 1:55 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 09/11/2025 regarding allegations in the area(s) of: Resident Care and Related Services and Personnel Number of residents present at the facility at the beginning of the inspection: 109 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 5 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 4 Observations by licensing inspector: Residents were observed in the common areas, and an observation of an activity was completed. The facility’s staffing schedule was reviewed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation’s area(s) of non-compliance with standard(s) or law were: Resident Care and Related Services 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. 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 (Donesia Peoples), Licensing Inspector at (757) 353-0430 or by email at donesia.peoples@dss.virginia.gov

Violations

22VAC40-73-110-1

Based on review of video footage, and staff interview the facility failed to be considerate and respectful of the rights, dignity, and sensitivities of persons who are aged or infirm or who have disabilities.

Evidence

Video footage dated 09/04/2025 at the time of 5:14 pm through 5:24 pm shows the following: Staff #2 was observed feeding resident #1 while resident #1 was sitting on the floor. Staff #2 did not ask resident #1 if his preference was to eat while sitting on the floor and did not offer assistance or care to remove the resident from the floor prior to feeding the resident.
During an interview on 10/09/2025 with staff #2, staff #2 confirmed to be the caregiver feeding the resident while the resident was on the floor as observed on the video dated 09/04/25.

Plan of correction

Employee(s) involved received corrective action. On 10-9-2025, The Director of Nursing and Executive Director met with the staff, to review expectations regarding resident dignity and proper assistance techniques. All caregivers on the unit were reminded verbally of residents? rights and the importance of preserving dignity during care interactions. Retraining: All direct-care staff (caregivers, RMAs, and Nurses) will complete mandatory in-service training on: Residents? Rights and Dignity in Care Proper Feeding Assistance and Positioning De-escalation and Communication Techniques with Cognitively Impaired Residents Supervisory Rounds: The Director of Nursing or designee will conduct unannounced rounds twice per shift for 30 days, to observe dining assistance and ensure respectful, safe interactions. Performance Accountability: Supervisors will document and address any observed deviations immediately, with progressive discipline as warranted. Ongoing Monitoring: Monthly quality assurance meetings will include dignity and resident-rights compliance review for at least three months. Safe and appropriate resident positioning during meals Verification of resident consent/preference Immediate reporting of dignity concerns to nursing management?( via call, email and/or EHR) All new hires will have 100% completion of new-hire orientation, including resident dignity and respect, completion of this orientation will be documented in employee file The Executive Director and Director of Nursing, or designee will jointly review dignity-related observations weekly for 60 days and report findings during monthly CQI or QA meeting. Follow-up documentation will be maintained in the facility’s quality assurance binder The effectiveness of corrective measures will be evaluated at the next Quality Improvement Committee meeting. All corrective actions and training will be completed by December 22, 2025.

September 4, 2025Inspection3 violations

Inspection dates

Sept. 4, 2025

Areas reviewed

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: An unannounced renewal inspection took place on 09/04/2025 from 8:10 am to 2:00 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:101 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: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: Breakfast, lunch, and an activity were observed. A medication pass observation was completed for three residents. The following were reviewed: resident and staff records, fire drills, fire inspection report, health inspection report, liability insurance, and a staffing schedule. Water temperature was measured, and the call bell system was monitored. Additional Comments/Discussion: None 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. 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 Donesia Peoples, Licensing Inspector at (757) 353-0430 or by email at donesia.peoples@dss.virginia.gov

Violations

22VAC40-73-440-A

Based on the record review and staff interview the facility failed to ensure the Uniform Assessment Instrument (UAI) shall be completed prior to admission, at least annually, and whenever there is a significant change in the resident’s condition.

Evidence

The record for resident #3 does not contain an annual UAI. The UAI in the record is dated as completed on 05/11/23.
Upon request on 09/04/25, staff #4 was not able to provide an annual UAI completed after 05/11/23 for resident #3.
The record for resident #4 does not contain an annual UAI. The UAI in the record is dated as completed on 03/05/24.
Upon request on 09/04/25, staff #4 was not able to provide an annual UAI completed after 03/05/24 for resident #4.

Plan of correction

1.Resident #3 and Resident #4’s records have been updated with new Uniform Assessment Instruments (UAI). The assessments were completed, ensuring they are current and reflective of residents? needs. Physicians and responsible parties were notified. 2.A facility-wide audit of all resident files was conducted to ensure: All residents have current annual UAIs on file. 3.UAI Compliance: A tracking log was created to monitor due dates for annual UAIs. The Assistant Director of Health and Wellness and/or designee is responsible for scheduling and completing UAIs at least 30 days prior to the due date. 4.The Executive Director and/or designee will review 5 random resident charts monthly for the next six months to ensure compliance with UAI, ISP, and oversight requirements. Results of chart audits will be reviewed in monthly Quality Assurance Committee meetings. 5.All corrective actions and retraining will be completed no later than November 1, 2025

22VAC40-73-450-A

Based on the record review and staff interview the facility failed to ensure on or within 7 days prior to the day of admission, a preliminary plan of care shall be developed to address the basic needs of the resident that adequately protects his health, safety, and welfare. Exception: A Preliminary plan of care is not necessary if a comprehensive individualized service plan (ISP) is developed, in conformance with this section, on the day of admission.

Evidence

The record for resident #4, admission date of 02/28/25 does not contain a preliminary plan of care completed on or within 7 days of admission or an ISP completed on the day of admission.
Upon request on 09/04/25, staff #4 was not able to provide a Preliminary ISP or an ISP completed on the day of admission for resident #1.

Plan of correction

1.Resident #4’s admission record has been corrected by developing a plan of care, followed by a comprehensive ISP. Responsible parties were informed, and the resident’s care plan was updated to ensure all basic needs are being met. 2.A facility-wide audit of all resident files was conducted to ensure: All newly admitted residents have a preliminary plan of care or a same-day ISP. 3.Preliminary Plans of Care: Admission packets were revised to include a mandatory preliminary plan of care template to be completed within 7 days prior to or on the day of admission. Clinical staff will receive training on requirements. 4.The Executive Director and/or designee will review 5 random resident charts monthly for the next six months to ensure compliance with UAI, ISP, and oversight requirements. Results of chart audits will be reviewed in monthly Quality Assurance Committee meetings. 5.All corrective actions and retraining will be completed no later than November 1, 2025

22VAC40-73-490-A

Based upon staff interview the facility failed to ensure if a facility employs a licensed health care professional, who is onsite on a full time basis, a licensed health care professional, practicing within the scope of the health care professional? s profession, shall provide health care oversight at least every six 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

Upon request on 09/04/2025, staff #4 was not able to provide a health care oversight completed during the current license period of 08/31/24 through 08/31/25 for residents who meet the criteria for assisted living care.

Plan of correction

1.The Director of Health and Wellness and/or designee shall be a Licensed Nurse and will provide health care oversight for all residents requiring assisted living care. Documentation of oversight is now in resident charts, covering the current license period. 2.A facility-wide audit of all resident files was conducted to ensure: All residents requiring assisted living services have health care oversight documented at least every six months. 3.Health Care Oversight: A six-month calendar reminder system was established to ensure timely oversight visits. 4.The Executive Director and/or designee will review 5 random resident charts monthly for the next six months to ensure compliance with UAI, ISP, and oversight requirements. Results of chart audits will be reviewed in monthly Quality Assurance Committee meetings. 5.All corrective actions and retraining will be completed no later than November 1, 2025

August 21, 2025Inspection0 violations

Inspection dates

08/21/2025

Areas reviewed

Comments

Type of inspection: Initial Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An announced initial inspection took place on 08/21/2025 at 10:00 am to 11:50 am. 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: 108 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: An observation of bedrooms, restrooms, dining area, common areas, medication carts, and the kitchen were observed. The facility’s first aid kit was reviewed and the water temperature was measured. Additional Comments/Discussion: Measurements were completed in bedrooms that will be used for residents. 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

July 17, 2025Complaint survey3 violations

Areas reviewed

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: An unannounced complaint inspection took place on 07/17/25 from 10:00 am to 3:08 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 07/07/2025 regarding allegations in the area(s) of: Staffing and Supervision, Resident Care and Related Services, and the Safe Secure Environment Number of residents present at the facility at the beginning of the inspection: 109 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 3 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 5 Observations by licensing inspector: Residents were observed in the common areas. The facility’s staffing schedule was reviewed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation’s area(s) of non-compliance with standard(s) or law were: Resident Care and Related Services 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. 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 (Donesia Peoples), Licensing Inspector at (757) 353-0430 or by email at donesia.peoples@dss.virginia.gov

Violations

22VAC40-73-680-I

Based on the record review and staff interview the facility failed to ensure the medication administration record (MAR) shall include date and time given, initials of direct care staff administering the medication and any medication errors or omissions.

Evidence

Resident’s #1 February 2025, March 2025, April 2025, and May 2025 MARs does not contain documentation the resident’s medications were omitted or administered on the following dates that did not include staff initials: ? 02/24/25, Trazadone scheduled 9pm ? 02/24/25, Acetaminophen and Buspirone, scheduled 8pm. ? 03/13/25, Trazadone, scheduled 9pm. ? 04/07/25, Diclofenac, scheduled 6pm. ? 04/17/25, 04/18/25, Triamcinolone 0.1% cream scheduled 8am. ? 04/20/25, 04/21/25 Buspirone and Acetaminophen scheduled 8pm. ? 05/04/25, Metoprol scheduled 8am ? 05/15/25 through 05/18/25, 05/21/25, 05/22/25, 05/24/25 through 05/29/25, and 05/31/25 Diclofenac scheduled 8am. ? 05/11/25, 05/19/25, 05/24/25, 05/25/25, 05/30/25 Diclofenac scheduled 8pm. ? 05/15/25, 05/22/25, 05/25/25, 05/29/25 Acetaminophen scheduled 8pm ? 05/27/25, 05/30/25, 05/31/25 Buspirone scheduled 8pm.
During an interview on 07/17/25 with staff #4, staff #4 reviewed the February 2025, March 2025, April 2025, and May 2025 MARs and confirmed the MARs did not document medications were omitted or administered on dates that did not include staff initials.

Plan of correction

1. A medication error review was conducted, Resident Physician notified of the findings. 2. A facility-wide audit of all residents? MARs will be conducted to identify and correct any missing documentation. 3.Medication Administration: Medication Documentation Policy implemented, requiring real-time documentation of medication administration. RMAs and nurses received retraining on MAR documentation standards. 4.Weekly MAR audits will be conducted by the Wellness Director and/or designee for three months, then monthly thereafter. 5.All corrective actions and staff retraining will be completed no later than November 1, 2025.

22VAC40-73-690-G

Based on the record review and staff interview the facility failed to ensure actions taken in response to the recommendations noted in the resident’s medication review.

Evidence

The record for resident #1 contains a medication review completed on 05/14/25. The medication review includes the following recommendation: “ ”resident with several medication orders that require clinical monitoring to follow therapy. Most recent lab work documented in chart is May 2024. Please consider checking the following labs to monitor therapy.? Resident’s #1 record did not contain documentation of actions taken in response to the recommendations noted on the medication review completed on 05/14/25.
The record for resident #1 does not contain documentation of lab work completed after the medication review dated 05/14/25.
Upon request, during an interview on 07/17/25 with staff #4, staff #4 confirmed the record for resident #4 did not contain documentation of the actions taken in response to the medication review completed on 05/14/25. Staff #4 was not able to provide documentation of lab work completed for resident #1 after the date of 05/23/24.

Plan of correction

Based on the record review and staff interview the facility failed to ensure actions taken in response to the recommendations noted in the resident’s medication review. Evidence: 1. The record for resident #1 contains a medication review completed on 05/14/25. The medication review includes the following recommendation: “ ”resident with several medication orders that require clinical monitoring to follow therapy. Most recent lab work documented in chart is May 2024. Please consider checking the following labs to monitor therapy.? Resident’s #1 record did not contain documentation of actions taken in response to the recommendations noted on the medication review completed on 05/14/25. 2. The record for resident #1 does not contain documentation of lab work completed after the medication review dated 05/14/25. 3. Upon request, during an interview on 07/17/25 with staff #4, staff #4 confirmed the record for resident #4 did not contain documentation of the actions taken in response to the medication review completed on 05/14/25. Staff #4 was not able to provide documentation of lab work completed for resident #1 after the date of 05/23/24.

22VAC40-73-930-D

Based on the record review, and staff interview the facility failed to ensure for each resident with an inability to use the signaling device, in addition to any other services, the following shall be met: The plan (Individualized Service Plan) ISP shall specify a minimal frequency of daily rounds to be made by direct care staff to monitor for emergencies or other unanticipated resident needs. The facility shall document the rounds that were made, which shall include the name of the resident, the date and time of the rounds, and the staff member who made the rounds.

Evidence

The record for resident #1 contains the following: ? A placement date of 12/05/22 into the facility’s safe secure unit. ? An assessment for serious cognitive impairment dated 12/08/22 that documents the resident has a primary psychiatric diagnosis of dementia and the resident is unable to recognize danger or protect his/her own safety and welfare. ? An ISP includes a date of 04/01/25 for supervision needs that documents the resident is unable to use the call light/pendant system to alert staff of the resident’s care needs.
Resident’s #1 ISP dated 04/01/25 does not include the minimum frequency of rounds to be made by direct care staff to monitor for emergencies or other unanticipated needs.
Upon request on 07/17/25, staff #4 was not able to provide documentation of rounds being made for resident #1 during the timeframe of 04/01/25 through 07/03/2025.
During an interview on 07/17/25 with staff #4, staff #4 confirmed the following: ? resident’s #1 ISP did not include the frequency of rounds to be made. ? The facility did not have documentation of the rounds that were made for resident #1 during the timeframe of 04/01/25 through 07/03/2025.

Plan of correction

1. Documentation of rounds has begun, including date, time, staff initials, and resident status. 2. ISPs for all residents in the safe secure unit were reviewed to confirm that residents unable to use call systems have a specified rounding frequency, and that rounds are documented. 3. A rounding log system was implemented in both paper and electronic form to ensure compliance. 4. Random chart audits will be completed monthly by the Assistant Director of Wellness and/or designee to ensure ISPs and rounding logs are complete. 5.Corrective action will be completed no later than November 1, 2025

July 17, 2025Complaint survey0 violations

Areas reviewed

Comments

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

June 16, 2025Inspection4 violations

Areas reviewed

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: An unannounced monitoring inspection took place on 06/16/2025 from 10:23 am to 1:37 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 06/04/2025 regarding allegations in the area(s) of: Personnel and Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 104 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: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: The facility’s staffing schedule was completed. 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 (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 (Donesia Peoples), Licensing Inspector at (757) 353-0430 or by email at donesia.peoples@dss.virginia.gov

Violations

22VAC40-73-120-A

Based on the record review and staff interview the facility failed to 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 #1, hire date 05/01/25, did not contain documentation of completion of an orientation and training.
Upon request during an interview with staff #4 on 06/16/25 the facility did not provide documentation of an orientation and training completed for staff #1.

Plan of correction

All agency vendors will receive onboarding and in-service documentation. Current agency employees will receive onboarding and in-service training. An agency vendor onboarding checklist will be created. Executive Director and/or designee will review agency employee files monthly. Date of completion 9-5-2025

22VAC40-73-460-A

Based on the record review and resident interview the facility failed to assume general responsibility for the health, safety, and well-being of the residents.

Evidence

Resident’s #1 physician note dated 06/05/25 documents the following: ?patient being seen today for bruising to bilateral arms. Left arm more bruised than right. Patient reports bruises due to the way staff is lifting her.?
During an interview on 06/16/25 with resident #1, resident #1 stated resident #1 received bruises on her lower arms as a result of staff grabbing the lower arms during transfers and lifting.
Resident’s #1 incident report dated 06/09/25 documents an incident occurring on 06/04/25 of concerns of bruises on resident’s #1 arm. The incident report documents ?resident surveillance viewed and assignment sheets review for responsible care staff. Agency aides termed from facility.?

Plan of correction

All employees will be educated about abuse and mandated reporting. All clinical staff will receive education on proper transfers. Clinical Manger and/or designee will review employee records to ensure training completion. Date of completion 9-5-2025

22VAC40-73-560-E

Based on the record review and resident interview the facility failed to assume general responsibility for the health, safety, and well-being of the residents.

Evidence

Resident’s #1 physician note dated 06/05/25 documents the following: ?patient being seen today for bruising to bilateral arms. Left arm more bruised than right. Patient reports bruises due to the way staff is lifting her.?
During an interview on 06/16/25 with resident #1, resident #1 stated resident #1 received bruises on her lower arms as a result of staff grabbing the lower arms during transfers and lifting.
Resident’s #1 incident report dated 06/09/25 documents an incident occurring on 06/04/25 of concerns of bruises on resident’s #1 arm. The incident report documents ?resident surveillance viewed and assignment sheets review for responsible care staff. Agency aides termed from facility.?

Plan of correction

Clinical Management and/or designee will conduct rounds during medication pass to ensure proper storage of medication book. In service and education regarding proper storage for medical/ health records will be conducted for all clinical staff Director of Health and Wellness of designee will conduct rounds at random to ensure proper storage of the medication book and all PHI. Date of Completion 9-5-2025

22VAC40-90-40-B

Based on the record review and staff interview the facility failed to ensure the criminal history report shall be obtained on or prior to the 30th day of employment for each employee.

Evidence

1 The record for staff #1 hire date 05/01/25 did not contain a criminal history report obtained on or prior to the 30th day
The record for staff #1, hire date 05/01/25, did not contain a criminal history report obtained on or prior to the 30th day of employment.
Upon request during an interview with staff #4 on 06/16/25 the facility did not provide documentation of a criminal history report completed on or prior to the 30th day of employment for staff #1.
On 06/23/25, staff #4 provided a criminal history report dated 06/18/25 for staff #1.

Plan of correction

All agency vendors will be educated about the Virginia criminal background checks regulation. Current agency employees will have back ground checks completed. An agency vendor checklist will be created, to include background checks are to be completed prior to the 30th day of employment. Executive Director and/or designee will review agency employee files will be reviewed monthly. Date of completion 9-5-2025

June 16, 2025Inspection0 violations

Areas reviewed

Comments

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

April 23, 2025Complaint survey1 violation

Areas reviewed

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: An unannounced complaint inspection took place on 04/23/2025 from 09:10 am to 11:02 am. 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 03/27/2025 regarding allegations in the area(s) of: Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 103 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: 4 Number of interviews conducted with staff: 4 Observations by licensing inspector: Residents were observed in the common areas, and an observation of an activity was completed. The facility’s pest control inspection report was reviewed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation’s area(s) of non-compliance with standard(s) or law were: Resident Care and Related Services 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. 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 (Donesia Peoples), Licensing Inspector at (757) 353-0430 or by email at donesia.peoples@dss.virginia.gov

Violations

22VAC40-73-560-E

Based on observation and staff interviews the facility failed to ensure all resident records shall be kept current, retained at the facility, and kept in a locked area, except that information shall be made available as noted in subsection F of this section.

Evidence

During a tour of the facility on 04/23/25, the Licensing Inspector (LI) observed a medication book and a narcotic binder located on top of the medication cart located on the 1st floor. The medication book and narcotic binder contained resident names, record of prescribed medications, and diagnosis information. The medication cart was unstaffed at the time of the observation.
During an interview on 04/23/25 with staff #1, staff #1 acknowledged to be the staff person assigned to the medication cart located on the 1st floor. Staff #1 acknowledged when staff # 1 was not present at the cart the medication book and narcotic binder remained on top of the cart. Staff #1 acknowledged the medication book and narcotic binder remains on top of the cart when the staff are not passing medication as there is not enough room in the medication cart to store the books.
During an interview on 04/23/25, with staff #2, staff #2 acknowledged the medication book and narcotic binder remain on top of the cart when the staff are not passing medication as there is not enough room in the medication cart to store the books.

Plan of correction

Director of Health and Wellness immediately removed book and placed inside the medication cart. Director of Health and Wellness conducted rounds during medication pass to ensure proper storage of medication book. In service regarding proper storage for medical/ health records will be conducted for all clinical staff by 5/23/2025 Director of Health and Wellness of designee will conduct rounds at random to ensure proper storage of the medication book and all PHI.

March 6, 2025Inspection2 violations

Areas reviewed

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: An announced monitoring inspection took place on 03/06/2025 from 1:30 pm to 2:45 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 03/03/2025 regarding allegations in the area(s) of: Resident Care and Related Services and the Safe Secure Environment. Number of residents present at the facility at the beginning of the inspection: 105 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: 2 Observations by licensing inspector: Monitoring of doors in the safe secure environment. Residents observed in the safe secure environment. Additional Comments/Discussion: None 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 (Donesia Peoples), Licensing Inspector at (757) 353-0430 or by email at donesia.peoples@dss.virginia.gov

Violations

22VAC40-73-1040-A

Based on the record review and staff interview the facility failed to ensure doors leading to the outside shall have a system of security monitoring of residents with serious cognitive impairments, such as door alarms, cameras, constant staff oversight, security bracelets that are part of an alarm system, or delayed egress mechanisms.

Evidence

Resident’s #1 incident report dated 03/03/25 documents the following: ?On 03/03/25 memory care resident, resident #1 was found in the back of the kitchen by the Culinary Director. It was discovered that the memory care door was not working properly at the time resident exited.?
During an interview with staff #2, staff #2 stated the following: the memory care unit staff was not aware resident #1 exited the memory care unit unsupervised. When resident #1 returned to the memory care unit, staff #2 checked the exit doors on the memory care unit and the door was unlocked. Staff #2 manually locked the exit doors with a key because the 15 second delay egress mechanism installed to lock the door was not working.

Plan of correction

The Memory Care Unit entrance doors were repaired on 3/4/25. They were check on 3/5/25, 3/6/25 and the problem was corrected. Facilities Director will perform on going random door checks to ensure the door alarm is functioning correctly. Random door checks will be completed monthly for 6 months and then quarterly for 6 months. ED/AM will be educated by the Regional Nurse on the Door and Window requirement for Memory Care by 4/7/25 and ongoing as needed.

22VAC40-73-440-B

Based on the record review the facility failed to ensure for private pay individuals, the UAI shall be completed by one of the following qualified assessors: an assisted living facility staff person who has successfully completed state- approved training on the uniform assessment instrument and level of care criteria for either public or private pay assessments, provided the administrator or the administrator's designated representative has successfully completed such training and approves and then signs the completed UAI, and the facility maintains documentation of completed training.

Evidence

Resident’s #1 UAI dated 01/24/25 was not signed by the assessor, facility’s administrator or the administrator’s designated representative.

Plan of correction

Resident #1 will have a UAI signed and completed by 3/27/25. An audit of all residents UAIs will be completed by 5/15/25. UAIs will be signed by the Executive Director or Designee Random audits will be completed monthly for 6 months and then quarterly for 6 months. Regional Nurse or designee will provide education on the UAI signature requirements by 4/7/25 and ongoing as needed.

January 24, 2025Complaint survey4 violations

Inspection dates

Jan. 24, 2025

Areas reviewed

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: An unannounced complaint inspection took place on 01/24/25 from 09:37 am to 11:57 am. 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 01/10/2025 regarding allegations in the area(s) of: Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 100 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: 0 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 5 Observations by licensing inspector: Residents were observed in the common areas, and an observation of an activity was completed. The facility’s staffing schedule was reviewed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation’s area(s) of non-compliance with standard(s) or law were: Resident Care and Related Services 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. 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 (Donesia Peoples), Licensing Inspector at (757) 353-0430 or by email at donesia.peoples@dss.virginia.gov

Violations

22VAC40-73-325-B

Based on the record review the facility failed to ensure the fall risk rating shall be reviewed and updated under each of the following circumstances: at least annually, when the condition of a resident changes, and after a fall.

Evidence

The record for resident #1 contains progress notes documenting the resident experienced a fall on 8/17/24, and 09/15/24. The resident’s record did not contain documentation of a fall risk rating completed after each fall.
Fall Risk ratings for resident #1 was requested and staff #1 was not able to provide fall risk ratings completed after the resident experienced a fall on 08/17/24, and 09/15/24.

Plan of correction

Resident #1 had a Fall Risk Assessment completed on 2/20/25. After a fall a post Fall Risk Assessments will be completed after every fall and will be reviewed at stand up the following day. An audit of all residents who have fallen in the last month will be completed by 3/31/25. Fall Risk assessments will be completed at least annually, at change of condition and following a fall. Random audits will be completed monthly for 6 months and then quarterly for 6 months.

22VAC40-73-440-A

Based on the record review the facility failed to ensure the Uniform Assessment Instrument (UAI) shall be completed at least annually.

Evidence

The record for resident #2, admission date 07/18/23, contains a UAI completed 8/18/23. The resident’s record did not contain a UAI completed annually after 8/18/23. The most recent UAI in the resident’s record is dated 01/24/25.

Plan of correction

Resident #1 will have a UAI completed by 3/7/25. An audit of all residents UAIs will be completed by 3/31/25. UAIs will be completed prior to admission, at least annually, and at significant change of condition. Random audits will be completed monthly for 6 months and then quarterly for 6 months.

22VAC40-73-450-E

Based on the record review the facility failed to ensure Individualized service plans (ISP) shall be signed and dated by the licensee, administrator, or his designee, and by the resident or his legal guardian.

Evidence

The record for resident #1, contains an ISP updated on 08/02/24. The ISP did not include the signature of the licensee, and the resident or the legal guardian.
The record for resident #2, contains an ISP updated on 10/02/24. The ISP did not include the signature of the licensee, and the resident or the legal guardian.

Plan of correction

Resident #1 and Resident #2 ISPs will be updated by 3/7/25. Family will be contacted for review and signature. An audit of all Resident ISPs will be completed by 3/31/25. Random audits will be completed monthly for 6 months and then quarterly for 6 months. Regular ISP review meeting will be held weekly on Wednesdays starting 4/2/25.

22VAC40-73-460-A

Based on the record review and staff interview the facility failed to ensure the facility shall assume general responsibility for the health, safety, and well-being of the residents.

Evidence

The record for resident #1 contains the following progress notes: 03/04/24, “resident #1 stated resident #2 scratch him.” 8/17/24, ?resident #2 came to care staff to inform us resident #1 was on the floor because resident #2 try to get resident #1 out of bed.? “Resident #1 was laying on the floor on his right side, resident #1 had no noted injuries at the time but groan in pain.” 11/26/24, ?Resident #1 found on floor, resident #2 reported that resident #2 was trying to get resident #1 out of the bed without assistance and resident #1 fell. Bruise noted on resident #1 left eye.? 12/03/24, staff #3 documented ?advised family that it is not safe for resident #1 to room with resident #2 as resident #2 has demonstrated poor safety awareness involving resident #1’s care. Hospice nurse is in agreement that they should not be rooming together as resident #2 tries to provide care that resident #2 should not do alone.?
During an interview on 01/24/25, with staff #1, staff #1 was not able to provide documentation to address the safety concerns as documented in the progress notes dated 03/04/24 8/17/24 11/26/24 and 12/03/24 concerns as documented in the progress notes dated 03/04/24, 8/17/24, 11/26/24, and 12/03/24.

Plan of correction

Care staff will encourage Resident #2 to participate in all daily activity programs in order to keep the resident #1 and #2 separate to avoid Resident #2 attempting to provide care for Resident #1 during the day time hours. During the evening/night, additional personnel oversight will be provided by Facility or Hospice services.

January 8, 2025Inspection8 violations

Inspection dates

Jan. 8, 2025

Areas reviewed

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: An announced monitoring inspection took place on 01/08/2024 from 9:50 am to 1:47 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 12/31/24, 01/01/25. and 01/02/25 regarding allegations in the area(s) of: Personnel and Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 105 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: 2 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: An activity was observed. Additional Comments/Discussion: None 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 (Donesia Peoples), Licensing Inspector at (757) 353-0430 or by email at donesia.peoples@dss.virginia.gov

Violations

22VAC40-73-1100-A

Based on the record review the facility failed to ensure prior to placing a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia in a safe, secure environment the facility shall obtain written approval, and the obtained written approval shall be in the resident’s file.

Evidence

The record for resident #2, admitted 10/31/22 into the facility’s safe secure environment does not contain written approval for placement into the safe, secure environment.
Resident’s #2 written approval for placement into the facility’s safe secure environment was requested, and staff #3 was not able to provide a written approval for placement into the safe, secure environment for resident #2.

Plan of correction

Secure Unit resident chart audit will be completed by March 25 and 6 month and annual review for appropriateness of placement will be completed and updated by March 25 by the ADRC.

22VAC40-73-1110-B

Based on the record review the facility failed to ensure six months after placement and annually thereafter, the licensee, administrator or designee shall perform a review of the appropriateness of each resident’s continues residence in the special care unit.

Evidence

The record for resident #2, admitted 10/31/22 into the safe, secure environment does not contain a six month and annually review of appropriateness of placement and continued residence in the special care unit.
A review of resident’s #2 appropriateness of placement and continued residence in the special care unit was requested and staff #2 was not able to provide a review appropriateness of placement and continued residence in the special care unit for resident #2.

Plan of correction

Secure Unit resident chart audit will be completed by March 25 and 6 month and annual review for appropriateness of placement will be completed and updated by March 25 by the ADRC.

22VAC40-73-110-1

Based on video footage and the record review the facility failed to ensure all staff shall be considerate and respectful of the rights, dignity, and sensitiveness of persons who are aged, infirm, or disabled.

Evidence

Video footage dated 12/31/24, shows staff #2 entering the room of resident #1 and communicating the following to resident #1: ?well you called your daughter so that made it fast. I got you ready for bed, you told me you didn’t want to go to bed so now you on my time.?
Resident’s #1 incident report dated 12/31/24 documents the following: ?staff #2 is suspected of verbally abusing resident #1. Staff #1 told patient because resident #1 called resident’s #1 daughter now you’re working on my time this incident was witnessed by video sent to ED by family member.?

Plan of correction

The employees that was involved with this situation have been terminated, all care staff will be In Serviced on Resident Rights and Abuse Prevention and Reporting by Feb 25,2025 by the ADRC.

22VAC40-73-325-B

Evidence

The record for resident #2 contains progress notes documenting the resident experienced a fall on 10/26/24, 10/29/24, 12/19/24, The resident’s record did not contain documentation of a fall risk rating completed after each fall.
Fall Risk ratings for resident #2 was requested and Staff #3 was not able to provide fall risk ratings completed after the resident experienced a fall on 10/26/24, 10/29/24, 12/19/24.

Plan of correction

ADRC and ED will review Incident Reports each scheduled work day and update fall risk ratings as appropriate to the incident by February 25, 2025

22VAC40-73-440-A

Based on the record review the facility failed to ensure the Uniform Assessment Instrument (UAI) shall be completed whenever there is a significant change in the resident’s condition.

Evidence

Evidence:
The record for resident #2, contains a hospice care plan with an effective date of 9/19/24. Resident’s #2 UAI is dated as completed on 8/24/24. The record for resident #2 does not contain a UAI completed when the resident had a significant change in condition to include start of hospice care services.

Plan of correction

All care plans and UAI’s will be updated by March 25, 2025 the ARDC will be responsible for the training being completed.

22VAC40-73-450-F

Based on the record review the facility failed to ensure Individualized service plans (ISP) shall be reviewed and updated at least once every 12 months and as needed for a significant change of a resident’s condition.

Evidence

The record for resident #2, contains a hospice care plan with an effective date of 9/19/24. Resident’s #2 ISP is dated as revised on 6/24/24. Resident’s #2 ISP was not reviewed and updated for the resident’s significant change in condition to include need for hospice care services.

Plan of correction

All individualized service plans will be reviewed and updated with all significant changes by March 1, 2025 the ARDC /ED will be responsible for the training getting completed.

22VAC40-73-450-H

Based on review of video footage and the record review the facility failed to ensure the facility shall ensure that the care and services specified in the individualized service plan are provided to each resident.

Evidence

Resident’s #1 UAI and ISP dated 6/05/24 documents the resident needs physical assistance with toileting. Video footage dated 01/01/25 shows staff #1 entering the room of resident #1. Resident #1 communicates to staff #1 that resident #1 needs to use the bathroom. Staff #1 does not assist resident #1 with using the restroom and exits the resident’s room.
Resident’s #1 Incident Report dated 01/03/25 documents the following: ?Staff #1 is suspected of neglect, this employee was asked by resident #1 to take resident #1 to the restroom and instead of taking resident #1 to the restroom staff #1 argues with the resident and then turns off the resident light and leaves and never takes the resident to the bathroom.?

Plan of correction

All individualized service plans will be reviewed and updated with all significant changes by March 1, 2025 the ARDC /ED will be responsible for the training getting completed.

22VAC40-73-460-B

Based on the record review the facility failed to ensure care provision and service delivery shall be resident centered to the maximum extent possible and include prompt response by staff to resident needs as reasonable to the circumstances.

Evidence

Resident’s #1 UAI and ISP dated 6/05/24 documents the resident needs physical assistance with bathing, toileting, transferring, walking, and mobility.
Resident’s #1 call bell logs for the month of December 2024 documents the facility did not promptly respond to the resident’s needs on the following dates and times: 12/11/24 @ 7:42am, wait time (59 mins.) 12/17/24 @ 7:33 am, wait time (82 mins.) 12/18/24 @ 4:25 pm, wait time (70 mins.) 12/21/24 @ 3:05 am, wait time (58 mins.) 12/21/24 @ 5:46 am, wait time (113 mins.) 12/22/24 @ 9:30 am, wait time (121 mins.) 12/26/24 @ 9:19 am, wait time (161 mins.) 12/29/24 @ 7:25 am, wait time (138 mins.) During an interview with resident #1, resident #1 stated she uses her call pendant when she needs physical assistance with bathing, transferring to her wheelchair, and with toileting.

Plan of correction

The executive director will receive a copy of the call bells daily and will address with the staff the call bells with an inadequate response time.

December 5, 2024Inspection1 violation

Inspection dates

Dec. 5, 2024

Areas reviewed

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: An unannounced monitoring inspection took place on 12/05/24 from 10:38 am to 12:15 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 12/02/24 and 12/03/24, and 12/05/24 regarding allegations in the area(s) of: The Safe Secure Environment and Buildings and Grounds Number of residents present at the facility at the beginning of the inspection: 102 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: Exit Doors and alarms were monitored in the safe secure environment. The facility’s most recent fire inspection report was reviewed. Additional Comments/Discussion: None 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 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. 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 (Donesia Peoples), Licensing Inspector at (757) 353-0430 or by email at donesia.peoples@dss.virginia.gov

Violations

22VAC40-73-1130-A

Based on the record review and staff interview the facility failed to ensure except during night hours, when 20 or fewer residents are present, at least two direct care staff members shall be awake on duty at all times in each special care unit who shall be responsible for the care and supervision of the residents.

Evidence

Resident’s #1 incident report includes the following: On 12/01/24 at 9:25 am, ?resident was found in the dining room of the assisted living portion of the community. This resident currently resides in the memory unit.?
During an interview with staff #1, staff #1 reported the following: staff #1 exited the special care unit approximately at 9:15 am and returned at 9:25 am. Staff #1 confirmed during the approximate time of 9:15am to 9:25 am, staff #2 was the only staff person present on duty in the special care unit. Upon return to the special care unit, Staff #1 heard the alarm on the special care unit doors and observed staff #5 returning resident #1 to the special care unit.
During an interview with staff #2, staff #2 reported the following: During the approximate time of 9:15 am to 9:25 am, staff #2 was in resident’s #2 room and was not aware resident #1 exited the special care unit unsupervised. 4.The facility’s census reports a total of 18 residents in the special care unit on the day of 12/01/24.

Plan of correction

Not published by VDSS.

October 31, 2024Complaint survey3 violations

Inspection dates

Oct. 31, 2024

Areas reviewed

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: An unannounced complaint inspection took place on 10/31/24 from 09:49 am to 01:03 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 10/22/2024 regarding allegations in the area(s) of: Staffing and Supervision, Resident Care and Related Services, and the Safe Secure Environment. Number of residents present at the facility at the beginning of the inspection: 105 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: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: Lunch and an activity was observed in the safe secure environment. Additional Comments/Discussion: None 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 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. 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 (Donesia Peoples), Licensing Inspector at (757) 353-0430 or by email at donesia.peoples@dss.virginia.gov

Violations

22VAC40-73-440-B

Evidence

Resident’s #2 UAI dated 08/16/24 was not signed by the assessor, facility’s administrator or the administrator’s designated representative.

Plan of correction

An audit of residents charts will be conducted to ensure all UAI's have the appropriate signatures in place. UAIs will have the appropriate signatures. DHW or designee will complete an audit monthly for 6 months.

22VAC40-73-450-E

Based on the record review the facility failed to ensure the individualized service plan (ISP) shall be signed and dated by the licensee, administrator, or his designee, (i.e., the person who has developed the plan), and by the resident or his legal representative.

Evidence

Resident’s #2 ISP revised on 9/13/24 was not signed and dated by the facility and by the resident or legal representative.

Plan of correction

DHW or designee will complete an audit of residents charts will be conducted to ensure all ISP's have the appropriate signatures in place. ISPs will have the appropriate signatures. In order to ensure better compliance Director of Health and Wellness will mail the ISP to the out of town families with a self-addressed stamped envelope if they not have the ability to sign via e-mail. DHW or designee will complete an audit monthly for 6 months.

22VAC40-73-930-D

Based on the record review the facility failed to ensure for each resident with an inability to use the signaling device the following shall be met: once the resident has gone to bed each evening until the resident has arisen each morning, at a minimum direct care staff shall make rounds no less than every two hours; the facility shall document the rounds that were made, which shall include the name of the resident, the date and time of the rounds, and the staff member who made the rounds. The documentation shall be retained at the facility for two years.

Evidence

Resident #1, resides in the facility’s safe secure environment and the resident’s ISP documents the following: “resident requires visual checks, hourly checks, night checks, additional safety monitoring, additional health monitoring.” The facility’s round logs did not include documentation rounds were made for resident #1 during the time of 11pm to 7am on the following dates: 10/01/24, 10/06/24, and 10/08/24.
Resident #2, resides in the facility’s safe secure environment and the resident’s ISP documents the following: “resident requires visual checks, hourly checks, night checks, additional safety monitoring, additional health monitoring.” The facility’s round logs did not include documentation rounds were made for resident #1 during the time of 11pm to 7am on the following dates: 10/01/24, 10/02/24, 10/04/24, 10/05/24, 10/06/24, 10/08/24, 10/12/24, 10/13/24, 10/16/24. 10/17/24, and 10/27/24.

Plan of correction

We have added additional documentation to reflect that 2-hour rounds are being completed between the hours of 11 PM and 7 AM. DHW or designee will complete an audit weekly for the first 3 months then monthly for 6 months to ensure round documentation is being completed.

July 10, 2024Inspection9 violations

Inspection dates

July 10, 2024 and July 11, 2024

Areas reviewed

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: An unannounced renewal inspection took place on 07/10/2024 from 8:00 am to 2:55 pm and 07/11/2024 from 9:19am to 1:40 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:101 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 5 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 3 Observations by licensing inspector: Breakfast, lunch, and an activity were observed. A medication pass observation was completed for three residents. The following were reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, fire inspection report, health inspection report, and a staffing schedule. Water temperature was measured, and the call bell system was monitored. Additional Comments/Discussion: None 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. 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 Donesia Peoples, Licensing Inspector at (757) 353-0430 or by email at donesia.peoples@dss.virginia.gov

Violations

22VAC40-73-260-A

Based on the record review and staff interview it was determined that the facility failed to ensure each direct care staff member shall maintain current certification in first aid.

Evidence

The record for staff # 5, hire date 05/05/05, does not contain a current certification in first aid. The record contains a certification in first aid that expired on 8/24/23.
Staff #7 acknowledged the record for staff #5 did not contain a current certification in first aid.

Plan of correction

An audit was completed on 7/23/24 of all direct care staff files to ensure that their CPR and First Aid cards are current. Those found not current have been scheduled to take the class to bring their cards current by August 31st, 2024 Staff #5 completed CPR/ First Aid training on 7/30/24 BOM will keep a tracking list of direct care staff CPR/First Aid expiration dates and arrange classes for care staff with upcoming expiration dates. ED will audit the list monthly for 6 months. Then Quarterly for 6 months.

22VAC40-73-440-B

Evidence

Resident’s #1 UAI dated 5/10/24 was not signed by the facility’s administrator or the administrator’s designated representative.
Resident’s #2 UAI dated 03/05/24 was not signed by the facility’s administrator or the administrator’s designated representative.
Resident’s #3 UAI dated 05/04/24 was not signed by the facility’s administrator or the administrator’s designated representative.
Resident’s #4 UAI dated 05/23/24 was not signed by the facility’s administrator or the administrator’s designated representative signature.

Plan of correction

UAI for Resident #1 was signed by the administrator. UAI for Resident #2 was signed by the administrator. UAI for Resident #3 was signed by the administrator. UAI for resident ##4 was signed by the administrator. The Director of Clinical or designee, will audit resident UAIs for missing signatures and will obtain the signature. The Director of Clinical or designee, will audit 25% of resident UAIs monthly for 6 months for signatures. Administrator and Director of Clinical will be re-educated on obtaining signatures on the UAIs. Responsible party: Director of Clinical

22VAC40-73-450-A

Based on the record review the facility failed to ensure on or within 7 days prior to the day of admission, a preliminary plan of care shall be developed to address the basic needs of the resident that adequately protects his health, safety, and welfare. Exception: A Preliminary plan of care is not necessary if a comprehensive individualized service plan (ISP) is developed, in conformance with this section, on the day of admission.

Evidence

The record for resident #4, admission date of 04/23/24 does not contain a preliminary plan of care completed on or within 7 days of admission or an ISP completed on the day of admission. The ISP in the record has an initiated date of 05/01/24.
The record for resident #5, admission date of 04/25/24, does not contain a preliminary plan of care completed on or within 7 days of admission or an ISP completed on the day of admission. The ISP in the record has an initiated date of 04/26/24. The ISP in the record has an initiated date of 04/26/24.
The record for resident #6, admission date of 03/19/24, does not contain a preliminary plan of care completed on or within 7 days of admission or an ISP completed on the day of admission. The ISP in the record has an initiated date of 04/14/24.
The record for resident #7, admission date 05/20/24 does not contain a preliminary plan of care completed on or within 7 days of admission or an ISP completed on the day of admission. The ISP in the record has an initiated date of 05/21/24.

Plan of correction

Resident #4 ISP was updated as preliminary ISP as of 4/23/24. Resident #5 ISP was updated as preliminary ISP as of 4/25/24. Resident #6 ISP was updated as preliminary ISP as of 3/19/24. Resident #4 ISP was updated as preliminary ISP as of 5/20/24. The Director of Clinical, or designee, will audit resident ISPs for preliminary plan of care upon admission/move in. ISPs will be updated as necessary. The Director of Clinical, or designee, will audit 25% of resident files monthly for 6 months for preliminary ISPs upon admission/move in. Clinical staff will be re- educated on creating a preliminary ISP for residents prior to or upon admission/move in. Responsible party: Director of Clinical

22VAC40-73-450-C

Based on the record review the facility failed to ensure the comprehensive individualized service plan (ISP) shall be completed within 30 days after admission and shall include a description of identified needs and date identified based upon the UAI (Uniform Assessment Instrument).

Evidence

Resident’s #1 UAI dated 03/05/24 documents mechanical help needs for bathing, transfers, and toileting. Resident’s #1 ISP dated 03/05/24 does not include the mechanical help needs for bathing transfers, and toileting.
Resident’s #2, UAI dated 05/04/24 documents a mechanical help needed for transfers. Resident’s #2 ISP dated 05/20/24 does not include the mechanical help needed for transfers.
Resident’s #5 UAI dated 05/25/24 documents mechanical help needs for bathing, toileting, and transfers. Resident’s #5 ISP dated 05/27/24 does not include the mechanical help needed for bathing, toileting, and transfers.

Plan of correction

Resident #1 ISP dated 3/5/24 was updated to include Mechanical assist for bathing, transfers, and toileting. Resident #2 ISP dated 5/4/24 was updated to include mechanical assist for transfers. Resident #5 ISP dated 5/25/24 was updated to include mechanical assist for bathing, toileting, and transfers. The Director of Clinical, or designee, will audit resident ISPs to include mechanical assist when indicated on the UAI. The Director of clinical, or designee, will audit 25% of resident ISPs for 6 months for the appropriate description of identified needs based upon the UAI. The Director of Clinical and Administrator will be re- educated on documenting the information listed on the UAI into the ISP. Responsible party: Director of Clinical

22VAC40-73-450-E

Evidence

Resident’s #1 ISP dated 07/25/23 and 04/28/24 was not signed and dated by the resident or legal representative.
Resident’s #2 ISP dated 03/05/24 was not signed and/or dated by the licensee, administrator, or designee by the resident or legal representative.
Resident’s #3 ISP dated 05/20/24 was not signed and/or dated by the licensee, administrator, or designee and by the resident or legal representative.
Resident’s #4 ISP dated 05/01/24 was not signed and/or dated by the licensee, administrator, or designee and by the resident or legal representative.
Resident’s #5 ISP dated 04/26/24 and 05/27/24 was not signed and/or dated by the licensee, administrator, or designee and by the resident or legal representative.
Resident’s #6 ISP dated 04/14/24 and 04/20/24 was not signed and dated by the resident or legal representative.
Resident’s #7 ISP dated 05/21/24 was not signed and/or dated by the licensee, administrator, or designee and by the resident or legal representative.
Resident’s #8 ISP dated 11/31/23 and 02/18/24 was not signed and dated by the resident or legal representative.

Plan of correction

Resident #1 ISP dated 7/25/23 and 4/28/24 was discussed with and signed by the POA. Resident #2 ISP dated 3/5/24 was discussed with and signed by the resident. Resident #3 has been discharged, unable to obtain a signature. Resident #4 ISP dated 5/1/24 was discussed with and signed by the POA. Resident #5 ISP dated 4/26/24 and 5/27/24 was discussed with and signed by the POA. Resident #6 ISP dated 4/14/24 and 4/20/24 was discussed with and signed by the resident. Resident #7 ISP dated 5/21/24 was discussed with and signed by the resident. Resident #8 ISP dated 11/31/23 and 2/18/24 was discussed with and signed by the resident. The Director of Clinical, or designee, will audit resident ISPs for resident/POA/licensee, administrator signatures and dates. ISPs will be discussed with resident/POA and signatures will be obtained if necessary. The Director of Clinical, or designee, will audit 25% of resident ISPs for 6 months for signatures and dates from licensee, administrator or person who developed the ISP and the resident / POA. Responsible party: Director of clinical

22VAC40-73-680-E

Based on the record review the facility failed to ensure medical procedures or treatments ordered by a physician or other prescriber shall be provided according to his instructions and documented. The documentation shall be maintained in the resident's record.

Evidence

The record for resident #1 contains physician orders dated 12/21/23 and 01/18/24 for an evaluation and treatment for physical therapy, speech therapy, and occupational therapy. The record for resident #1 did not contain documentation of an evaluation and treatment for physical therapy, and speech therapy.
Staff #6 was unable to provide documentation of completion of an evaluation and treatment of physical therapy and speech therapy for resident #1.

Plan of correction

Healthcare provider and POA for Resident #1was informed of the orders for PT, ST, OT on 12/21/23 and 1/18/24 and the orders might not have been followed through. No new orders were obtained. Director of Clinical or designee, will audit resident files for orders to provide therapy services. Therapy services will be initiated if necessary. The Director of Clinical, or designee, will audit 25% of resident recorders for 6 months for initiation of therapy orders. The clinical staff will be re-educated to ensure medical procedures or treatments ordered by a healthcare provider are provided according to the instructions and documented. Responsible party: Director of Clinical

22VAC40-73-680-I

Based on the record review the facility failed to ensure the Medication Administration Record (MAR) should include: Any medication errors or omissions, Exact dose given, and the name, signature, and initials of all staff administering medications. A master list may be used in lieu of this documentation on individual MARS.

Evidence

Resident’s #2 MAR did not contain staff initials and/or reason for omissions on the following dates for the following medications: (a) 06/05/24, 06/22/24, and 07/03/24 for Spironolactone 25mg tablet @ 3pm. (b) 06/15/24 and 06/21/24 for Eliquis 2.5mg tablet @ 8am. (c) 06/07/24 @ 7pm, 06/21/24 @ 8am and 7pm, and 06/22/24 @ 7pm for twice daily blood pressure check.
Resident’s #3 MAR did not contain staff initials and/or reason for omission, and the exact dose given on the following dates and times for the resident’s Novolog Flexpen 100/ml (Inject 6 units subcutaneously before meals and inject subcutaneously before meals per sliding scale.) (a) 06/04/24, 06/06/24, 06/09/24,06/12/24 and 06/24/24 @ 11am. (b) 06/03/24, 06/04/24, 06/05/24, 06/18/24, 06/21/24, 06/22/24, 06/23/24, 06/26/24, and 06/27/24 @ 4:00 p.m. (c) 07/03/24 07/04/24, 0706/24 and 0707/24 @ 8am and 11 am.
The facility’s master list used for the staff signature sheet did not include the initials and signature for staff #5.

Plan of correction

The healthcare provider and POA for resident #2 was informed of the missed medication administrations dated 6/5/24, 6/22/24, 7/3/24 for Spironolactone at 3 pm; for Eliquis 2.5 mg at 8am on 6/15/24, 6/21/24; and no BP readings on 6/7/24 at 7pm, 6/21/24 at 8am and 7pm, and 6/22/24 at 7pm. No new orders were given. The healthcare provider and POA for Resident #3 was informed of missed medication administration for Novolog Flexpen dose on 06/04/24, 06/06/24,06/09/24,06/1 2/24 and 06/24/24 @ 11am. 06/03/24, 06/04/24, 06/05/24, 06/18/24, 06/21/24, 06/22/24, 06/23/24, 06/26/24, and 06/27/24 @ 4:00 p.m. 07/03/24 07/04/24, 0706/24 and 0707/24 @ 8am and 11 am. The Master signature list was update with the signature of Staff #5. The Director of Clinical, or designee, will audit resident MARs for appropriate signatures and documentation. Missing signatures or documentation will result in re-education and personal documentation. The Director of Clinical, or designee, will audit 25% of resident MARs weekly for 6 months for appropriate signatures and documentation. Staff assigned to administer medications will be re-educated on proper medication administration documentation. Responsible party: Director of Clinical

22VAC40-73-990-C

Based on the onsite review and staff interview the facility failed to ensure at least every six months, all staff currently on duty on each shift shall participate in an exercise in which the procedures for resident emergencies are practiced. Documentation of each exercise shall be maintained in the facility for at least two years.

Evidence

Staff #6 was unable to provide documentation of staff participation in an exercise in which the procedures for resident emergencies were practiced every 6 months.

Plan of correction

Emergency Training was completed on July 18th, 19th, 24th and 26th. MD and DRC will ensure Emergency Drills will be performed every 6 months per the regulation. ED will Audit the Emergency Drills sheet binder bi-annually for 1 year to ensure compliance.

22VAC40-80-120-E-2

The facility failed to ensure certain documents related to the terms of the license are required to be posted on the premises of each facility. These are: the most recently issued license. The findings of the most recent inspection of the facility.

Evidence

During a tour of the facility on 07/10/24 and 07/11/24 the Licensing Inspector did not observe the Facility’s most recent issued license and the findings from the most recent inspection to be posted in the facility.
Staff # 6 acknowledged during the LI’s observation the facility’s license and most recent inspection was not posted in the facility.

Plan of correction

As of 7/23/24, The facility license is posted across from the business office and the most recent inspection results are located in a binder at the reception desk. ED will audit by making sure the license is in the binder and on the wall monthly for 6 months. Then Quarterly for 6 months.

July 10, 2024Inspection0 violations

Inspection dates

July 10, 2024 and July 11, 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 PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

May 14, 2024Complaint survey3 violations

Areas reviewed

22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 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: An unannounced complaint inspection took place on 05/14/24 from 09:12 am to 02:17 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 03/25/24, 03/27/24, 03/28/24, 04/12/24 and 04/25/24, regarding allegations in the area(s) of: Staffing and Supervision, Resident Care and Related Services, and the Safe, Secure Environment Number of residents present at the facility at the beginning of the inspection: 106 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: 1 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 0 Observations by licensing inspector: The call signaling system was monitored, and verification of the staffing schedule was completed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation’s area(s) of non-compliance with standard(s) or law were: Resident Care and Related Services 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. 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 (Donesia Peoples), Licensing Inspector at (757) 353-0430 or by email at donesia.peoples@dss.virginia.gov

Violations

22VAC40-73-460-B

Evidence

Resident’s #3 call bell logs for the month of April, and May 2024 documented the facility did not promptly respond to the resident’s pendant alert system on the following dates and times: 4/03 @ 7:07 am, wait time (69 mins.) 04/04 @ 6:09 pm, wait time (93 mins.) 04/12 @ 3:50 am, wait time (105 mins.) 04/22 @ 8:00am, wait time (172 mins.) 05/03 @ 10:11 pm, wait time (86 mins) Resident’s #3 UAI and ISP dated 09/02/23 documents the resident needs physical assistance and mechanical help with bathing, toileting, and wheeling.
During an interview with resident #3, resident #3 stated she uses her pendant alert system when needing assistance with getting out of the bed in the morning and using the bathroom. Resident #3 stated on several days the staff has taken longer than one hour to respond to the resident’s pendant alert system, which has resulted in involuntary urination. Resident’s #3 physician exam dated 08/14/23 documents the resident as non-ambulatory and the use of a wheelchair.

Plan of correction

Resident #3 is no longer a resident in the community. Immediately a print out of the Call Bell report from the previous day was begun to be delivered to the Executive Director or designee for review. In services will be held with all care staff reviewing the expectations of answering call bells. Environmental Services Director will do a complete community audit of all pull stations in resident apartments to assure all are functioning properly. Responsible party: Executive Director

22VAC40-73-680-D

Based on the record review the facility failed to ensure medications shall be administered in accordance with the physician’s or other prescriber’s instructions.

Evidence

The record for resident #1 contains a physician order dated 03/07/24 that includes the following: ?Fiasp Flextouch SUV, Latex free- 100 unit/1ML Insulin Pen, Inject 3 Units SQ TID Before Meals. Take an additional 1 unit for every 50 points over 200 for high sugars. Max daily dose 50 units.? The facility’s investigation report for resident #1 includes the following: “the resident did not receive her insulin dose on April 6, 2024 at the lunch meal or at the dinner meal;” ?On April 7, 2024, the resident was not given Insulin for her morning/noon meals and by dinner her BS was over 300. The (resident’s child) called 911 and had the resident taken to the ER.?

Plan of correction

Resident #1 is no longer at the community. The Physician and POA for Resident #1, were notified of the missed insulin doses. The Pharmacy was contacted on 4/5/24, no insulin was sent. The pharmacy was contacted again on 4/6/24 and arrived the same day that evening. An audit of MARs will be completed by the Director of Nursing, or designee, for documentation of medication administration. The clinical staff will be re-educated on documenting medication administration in the MARs. The Director of nursing, or designee, will audit MARs every month, for documentation of medication administration. Missed documentation will result in further re-education of the staff. Responsible party: Director of Nursing

22VAC40-73-680-I

Evidence

Resident’s #1 April 2024 MAR did not include the exact dose given for administering Insulin according to the physician order dated 03/07/24, ?Fiasp Flextouch SUV, Latex free- 100 unit/1ML Insulin Pen, Inject 3 Units SQ TID Before Meals. Take an additional 1 unit for every 50 points over 200 for high sugars. Max daily dose 50 units.?
Resident’s #1 April and May 2024 MAR, did not include reason for omission on the following dates and times for the resident’s prescribed order of ?Fiasp Flextouch SUV, Latex free- 100 unit/1ML Insulin Pen, Inject 3 Units SQ TID Before Meals. Take an additional 1 unit for every 50 points over 200 for high sugars. Max daily dose 50 units? for the following dates and times: 04/03/24 @ 7am 04/04/24 @ 7am and 11am 04/06/24 @ 4pm 04/07/24 @ 11 am and 4pm 04/11/24 @ 11am 04/13/24 @ 11am 04/14/24 @ 11am 04/16/ 24 @ 11am 04/18/24 @ 7am and 11am 05/04/24 @ 7am, 11am, and 4pm 05/05/24 @ 7am, 11am, and 4pm 05/06/24 @ 7am and 11am 05/08/24 @ 7am and 11am 05/09/24 @ 7am and 11am 05/10/24 @ 4pm 05/11/24 @ 4pm.
The April and May 2024 MARs for residents #1 and #2, did not include the name, signature, and initials of all staff administering medications, and/ or a master list.
Resident’s #2 April 2024, MAR did not include reason for omission on the following dates for the resident’s prescribed order dated 02/23/24, “Lantus Solostar Unit/1ML Insulin Pen, Inject 20 units Subcutaneously every evening.” 04/01/24 04/18/24 04/23/24 04/24/24 04/26/24.

Plan of correction

22VAC40-73-680-I Resident #1 is no longer a resident in the community. The Director of nursing, or designee, will audit the resident MARs for names, signatures and initials of staff administering medications. The staff administering medications will be re-educated on documenting their name, their signature, and their initials on the MARs. A Master list of names, signatures and initials will be created by the Director of Nursing, of staff administering medications. The Director of Nursing, or designee, will audit the Master list to ensure staff who are administering medications, have their name, signature, and initials on the Master list. Responsible party: Director of Nursing

February 29, 2024Complaint survey3 violations

Inspection dates

Feb. 29, 2024

Areas reviewed

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: An unannounced complaint inspection took place on 02/29/2024 from 10:20 am to 02:34 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 02/01/2024 and 02/29/2024 regarding allegations in the area(s) of: Staffing and Supervision, and Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 108 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 0 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 5 Observations by licensing inspector: Lunch was observed, and the call signaling system was monitored. Additional Comments/Discussion: None 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 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. 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 (Donesia Peoples), Licensing Inspector at (757) 353-0430 or by email at donesia.peoples@dss.virginia.gov

Violations

22VAC40-73-680-D

Based on the record review the facility failed to ensure medications shall be administered in accordance with the physician’s or other prescriber’s instructions.

Evidence

The record for resident #2 contains the following: a physician order dated 08/17/23, 10/02/23, and 11/30/23 for “Coumadin 5mg, take 1 tablet by mouth every day;” a physician order dated 10/03/23 for Coumadin 5 mg, “hold coumadin 10/2/23, 10/3/23, then start Coumadin 5mg.” Resident’s #2 medication administration record (MAR) does not include documentation the resident was administered Coumadin on the following dates: 09/07/23, 09/29/23, 10/04/23, 10/08/23, 10/18/23, 11/14/23, 12/01/23, 12/10/23, 12/11/23, 12/13/23, 12/14/23, 12/19/23.
The record for resident #3 contains a physician order dated 03/06/23 for ?atorvastatin calcium 80mg, take 1 tablet by mouth every day.? Resident’s #3 MAR does not include documentation the resident was administered atorvastatin calcium on the following dates: 09/07/23, 11/22/23, 11/24/23, 11/26/23, 11/27/23, 12/17/23, 19/19/23, 12/22/23.
The record for resident #3 contains a physician order dated 03/06/23 for ?carbidopa-levodopa 25-100mg, take 1 tablet by mouth three times daily.? Resident’s #3 MAR does not include documentation the resident was administered carbidopa-levodopa 3 times daily on the following dates: 09/07/23, 10/02/23, 10/09/23, 10/15/23, 10/20/23, 10/23/23, 10/25/23, 10/26/23, 10/28/23, 10/29/23, 11/22/23, 11/24/23, 11/25/23, 11/26/23, 11/27/23, 11/30/23 12/05/23, 12/06/23, 12/10/23, 12/22/23, 12/16/23, 12/19/23, 12/30/23.
2. The record for resident #3 contains a physician order dated 03/06/23 for ?amlodipine 5 mg, take 1 tablet by mouth every day.? Resident’s #3 MAR does not include documentation the resident was administered amlodipine on the following dates: 10/23/23, 10/25/23, 10/29/23, and 11/26/23.

Plan of correction

Resident #2 is no longer a resident in the community. The Physician and POA for Resident #3, were notified of the missed medications, Atorvastatin Calcium, Carbidopa-levodopa, and Amlodipine. No new orders were obtained from the physician. An audit of MARs will be completed by the Director of Nursing, or designee, for documentation of medication administration. The clinical staff will be re-educated on documenting medication administration in the MARs. The Director of nursing, or designee, will audit MARs every month, for documentation of medication administration. Missed documentation will result in further re-education of the staff. Responsible party: Director of Nursing

22VAC40-73-680-E

Based on the record review the facility failed to ensure medical procedures or treatments ordered by a physician or other prescriber shall be provided accorded to his instructions and documented. The documentation shall be maintained in the resident’s record. 1. The record for resident #2 contains a physician order dated 10/23/23 that includes the following instructions: Coumadin 5mg, recheck PT/INR 2 weeks. The resident’s record did not contain documentation the resident’s PT/INR was checked 2 weeks after the date of 10/23/23 or for the month of Nov. 2023. 2. Staff #5 acknowledged, the record for resident #2 did not contain documentation the resident’s PT/INR was checked 2 weeks after the date of 10/23/23 or during the month of Nov. 2023.

Plan of correction

Resident #2 is no longer a resident in the community. The physician and POA were notified of the missed medical procedure on 10/23/23, no new orders were given. An audit of resident healthcare practitioner orders for medical procedures will be completed by the Director of nursing, or designee, to ensure medical procedures or treatments have been followed as ordered. The clinical staff will be re- educated on following the healthcare practitioner’s orders for medical procedures or treatments when they are ordered. The Director of Nursing, or designee, will audit resident healthcare practitioner orders for medical procedures or treatments every month for documentation of completion of the orders. The Healthcare practitioner and the POA will be notified of missed orders for treatments or medical procedures and new orders will be obtained if applicable. ibl Responsible party: Director of Nursing

22VAC40-73-680-I

Based on the record review the facility failed to ensure the MAR should include the name, signature, and initials of all staff administering medications. A master list may be used in lieu of this documentation on individual MARS.

Evidence

The MARs for residents #2 and #3 did not include the name, signature, and initials of all staff administering medications, and/ or a master list.

Plan of correction

Resident #2 is no longer a resident in the community. The MAR for resident #3 was updated with the name, signature, and initials of the staff administering medications. The Director of nursing, or designee, will audit the resident MARs for names, signatures and initials of staff administering medications. The staff administering medications will be re-educated on documenting their name, their signature, and their initials on the MARs. A Master list of names, signatures and initials will be created by the Director of Nursing, of staff administering medications. The Director of Nursing, or designee, will audit the Master list to ensure staff who are administering medications, have their name, signature, and initials on the Master list. Responsible party: Director of Nursing

January 30, 2024Inspection2 violations

Inspection dates

Jan. 30, 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 PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

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: An announced monitoring inspection took place on 01/30/2024 from 9:40 am to 2:08 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 (01/19/2024) regarding allegations in the area(s) of: Personnel Number of residents present at the facility at the beginning of the inspection: 108 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: 1 Observations by licensing inspector: An observation of the assisted living and safe, secure environment was completed. Additional Comments/Discussion: None 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 (Donesia Peoples), Licensing Inspector at (757) 353-0430 or by email at donesia.peoples@dss.virginia.gov

Violations

22VAC40-73-110-1

Based on the onsite record review the facility failed to ensure all staff shall be considerate and respectful of the rights, dignity, and sensitiveness of persons who are aged, infirm, or disabled.

Evidence

Resident’s #1 incident report dated 01/19/24 includes documentation of resident #1 hearing staff #1 refer to resident #1 with the use of a curse word and the word “idiot.” The facility terminated staff #1 on 01/22/24.

Plan of correction

1.Staff members will receive re-training on Resident Rights. 2.Staff are assigned yearly re-training on Resident Rights. The Business Office Manager will audit staff education folders for appropriate 12 hrs of in-service documentation and if necessary, assign deficient staff work hours to complete their required training. 3.The Administrator, or designee, will audit 25% of staff education folders, quarterly, for attendance of at least 12 hrs of annual training. Staff will be given training time to complete their training per state regulation and 5 Star Policy.

22VAC40-73-210-B

Based on the record review the facility failed to ensure in a facility licensed for both residential and assisted living care, direct care staff who are certified nurse aides shall attend at least 12 hours of annual training.

Evidence

The record for staff #1, hired 04/05/19, did not include documentation of 12 hours of annual training.
Staff #1 training record documented 4.9 hours of annual training during the timeframe of 04/05/22-01/22/24.

Plan of correction

1.An audit of staff files will be completed and staff who have not completed their required training will be assigned work hours to completed the training. 2.The Business Office Manager will audit staff education folders for appropriate 12 hrs of in-service documentation and if necessary, assign deficient staff work hours to complete their required training. 3.The Administrator, or designee, will audit 25% of staff education folders, quarterly, for attendance of at least 12 hrs of annual training. Staff will be given training time to complete their training per state regulation and 5 Star Policy.

January 30, 2024Complaint survey2 violations

Inspection dates

Jan. 30, 2024

Areas reviewed

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: An unannounced complaint inspection took place on 01/30/24 from 09:40 am to 02:08 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 01/05/2024 regarding allegations in the area(s) of: Staffing and Supervision, Resident Care and Related Services, and the Safe, Secure Environment Number of residents present at the facility at the beginning of the inspection: 108 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 0 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: The call signaling system was monitored, and verification of the staffing schedule was completed. Additional Comments/Discussion: None 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 (Donesia Peoples), Licensing Inspector at (757) 353-0430 or by email at donesia.peoples@dss.virginia.gov

Violations

22VAC40-73-450-E

Based on the record review the facility failed to ensure the individualized service plan (ISP) shall be signed and dated by the licensee, administrator, or his designee, and by the resident or his legal guardian.

Evidence

Resident’s #2 ISP revised on 11/29/23 was not signed and dated by the facility and the resident or the legal guardian.
Resident’s #3 ISP revised on 08/21/23 was not signed and dated by the facility and the resident or the legal guardian.

Plan of correction

1.The ISP for Resident #2, revised 11/29/23, will be signed and dated by the Administrator and the POA. The ISP for Resident #3, revised on 8/21/23, will be signed and dated by the Administrator and the POA/legal guardian/resident. 2.An audit of ISPs will be completed by the Administrator, or designee, for signatures and dates per state regulation and 5 Star Policy. ISPs requiring signatures and dates will be presented to the POA/legal guardian/resident. 3.The Director of Resident Care, or designee, will audit 10% of resident ISPs every month, for signatures from the resident/legal guardian/POA and the administrator or his designee. The staff will be re-educated on obtaining signatures of POA/legal guardian/resident and administrator or his designee when updating/revising resident ISP.

22VAC40-73-930-D

Evidence

Residents #1, #2, and #3 ISP documents the following: “resident requires visual checks, hourly checks, night checks.” The record for residents #1, #2, did not include documentation rounds were made for the following dates and timeframes: 01/04/24, 01/07/24, 01/13/24, 01/20/24. 01/23/24, 01/25/24, and 01/28/24 during the 11pm-7am shift. Resident #1 and #2 reside in the facility’s safe secure environment. 2.The record for resident #3 did not include documentation rounds were made for the following dates and timeframes: 01/03/24, 01/08/24, and 01/12/24 during the timeframe of 11pm -7 am. Resident #3 reside in the facility’s safe secure environment.

Plan of correction

1.The staff assigned in Memory Care have been re-educated in making rounds and documenting the date and times of rounds for each resident with an inability to use the signaling device once the resident has gone to bed until the resident has arisen. 2.A Resident Rounds binder with a documentation chart for each resident in Memory Care will be created. The chart will include the resident name, the date and time of the rounds, and the staff member who is making the rounds. The Memory Care Director, or designee, will audit the binder daily and report deficient documentation to the Director of Resident Care. 3.The Director of Resident Care, or Designee, will audit the Resident Rounds binder weekly, for documentation per state regulations. The documentation will be maintained for 2 yrs with the Director of Resident Care.

August 22, 2023Inspection1 violation

Inspection dates

Aug. 22, 2023

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 RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

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: An announced monitoring inspection took place on 08/22/2023 from 11:29 am to 12:20 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 08/10/2023 regarding allegations in the area(s) of: Personnel Number of residents present at the facility at the beginning of the inspection: 111 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: 2 Observations by licensing inspector: An observation of residents in the safe, secure environment was completed. Additional Comments/Discussion: None 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 (Donesia Peoples), Licensing Inspector at (757) 353-0430 or by email at donesia.peoples@dss.virginia.gov

Violations

22VAC40-73-110-1

Based on the staff interview and record review the facility failed to ensure all staff shall be considerate and respectful of the rights, dignity, and sensitiveness of persons who are aged, infirm, or disabled.

Evidence

Resident’s #1 incident report dated 8/16/23 documents ?staff #2 saw staff #1 pulling on resident’s #1 arm, there was a bruise on resident’s #1 arm. Staff #1 was terminated.?
Licensing Inspector, interviewed staff #2. Staff #2 reported hearing resident #1 scream “stop”, staff #2 observed staff #1 “pulling on resident’s #1 left arm with full force in an attempt to get the resident to go to the resident’s room.” Staff #2 observed resident’s #1 left arm to “appear reddish”.

Plan of correction

Not published by VDSS.

July 25, 2023Inspection6 violations

Areas reviewed

22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 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: An unannounced renewal inspection took place on 07/25/2023 from 8:16 am to 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:111 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 5 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 3 Observations by licensing inspector: Breakfast, lunch, and an activity were observed. A medication pass observation was completed for four residents. Water temperatures were measured. The signaling system was monitored. Additional Comments/Discussion: None 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. 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 Donesia Peoples, Licensing Inspector at (757) 822-9957 or by email at donesia.peoples@dss.virginia.gov

Violations

22VAC40-73-1090-A

Based on the record review the facility failed to ensure prior to admission to a safe, secure environment, the resident shall have been assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare.

Evidence

The record for resident #8 contains an assessment of serious cognitive impairment dated 08/02/21 which includes a response of “No” for the question: is the individual unable to recognize danger or protect his/her own safety and welfare. The record documents a safe secure unit admission date of 08/06/21.
The record for resident #5 does not contain documentation of an assessment for serious cognitive impairment. The record documents an admission to the safe, secure unit on the date of 11/26/22, and an approval for placement in the safe, secure unit dated 11/11/22.

Plan of correction

Date of Correction- PCP for resident #8 will conduct reassessment on 8/21/23. PCP for resident #5 will conduct reassessment on 8/21/23. Plan of Correction- Going forward all Serious Assessments for Cognitive Impairment for all new admissions into our memory care community will be checked the Director of Resident Care or designee and then reviewed by the Executive Director for correctness prior to move in.

22VAC40-73-210-B

Based on record review the facility failed to ensure in a facility licensed for both residential and assisted living care, direct care staff who are certified nurse aides shall attend at least 12 hours of annual training.

Evidence

The record for staff #3, hired 04/05/19, did not include documentation of 12 hours of annual training.

Plan of correction

Date of Correction- Will have employee compliant with necessary remaining training by 9/15/23. Plan of Correction- Starting 8/21/23 random training audits will be conducted by the Business Office Manager or designee through 12/31/23. Each month 10 employee files will be audited for compliance with training.

22VAC40-73-210-D

Based on the staff record review the facility failed to ensure training for medication aides include continuing education required by the Virginia Board of Nursing,

Evidence

The Regulations Governing the Registration of Medication Aides by Virginia Board of Nursing, section 18VAC90-60-100- B, state that a medication aide shall have four hours each year of population-specific training in medication administration in the assisted living facility in which the aide is employed; or a refresher course in medication administration offered by an approved program
The record for staff #3, hired 04/05/19, a licensed medication aide (license effective date 10/07/16), did not contain documentation of completion of the continuing education required by the Virginia Board of Nursing.

Plan of correction

Date of Correction- Will have employee compliant with necessary continuing education training by 9/30/23. Plan of Correction- By 9/15/23 the Director of Resident Care will have audited all medication aides for compliance with continuing education training. The Business Office Manager will create a tickler by 9/30/23 that will keep record of each employees training anniversary review date.

22VAC40-73-450-C

Based on the record review the facility failed to ensure the ISP includes a description of identified needs based upon the UAI.

Evidence

Resident #2’s UAI dated 06/30/23 documents a mechanical help need for bathing. The ISP dated 06/30/23 does not include documentation of the mechanical help needed for bathing. 2 Resident #3’s UAI dated 02/08/23 documents mechanical help needed for stairclimbing and human help supervision 2.Resident #3’s UAI dated 02/08/23 documents mechanical help needed for stairclimbing and human help supervision needed for mobility. The ISP dated 02/08/23 does not include documentation of the mechanical help needed for stairclimbing and the human help needed for mobility.

Plan of correction

Date of Correction- Resident #2’s ISP was updated 8/17/23. Plan of Correction- Going forward Director of Resident Care and Assistant Director of Resident Care will review each other’s ISPs upon completion for correctness.

22VAC40-73-450-E

Based on the record review the facility failed to ensure the individualized service plan (ISP) shall be signed by the resident or his legal guardian.

Evidence

Resident #4’s ISP dated 05/05/23 was not signed by the resident or the legal guardian.
Resident #5’s ISP dated 07/17/23 was not signed by the resident or the legal guardian.
Resident #6’s ISP dated 05/05/23 was not signed by the resident or the legal guardian.
Resident # 7’s ISP dated 05/11/23 was not signed by the resident or the legal guardian.
Resident # 8’s ISP dated 07/06/23 was not signed by the resident or the legal guardian.
Resident # 9’s ISP dated 07/24/23 was not signed by the resident or the legal guardian.

Plan of correction

Date of Correction- Resident #5’s ISP was signed on 8/17/23, Resident #4’s ISP was signed on 8/10/23. Assistant Director of Resident Care has reached out to resident’s #6, #7,#8,#9 for signing. Awaiting response from families. Will have all ISPs signed by 9/30/23. Plan of Correction- Going forward Director of Resident Care or designee when unable to get in person signatures will document attempts made on ISP to families to sign and send ISPs through email with request for electronic signature.

22VAC40-90-40-C

Based on the onsite record review the facility failed to ensure any person required to obtain a criminal history report shall be ineligible for employment if the report contains convictions of barrier crimes.

Evidence

Staff #5, hired 06/06/23, criminal record report contains two convictions for barrier crimes (18.2-57).

Plan of correction

Date of Correction- Employee was terminated on 9/1/23. Plan of Correction: Regulation was reviewed by the Executive Director with the local licensing Inspector and the Licensing Administrator. Feedback was then provided to the on-site Human Resources Manager and 5 Star Senior Livings Regional Human Resources for future compliance.

March 9, 2023Inspection2 violations

Areas reviewed

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: An announced monitoring inspection took place on 03/09/2023 from 8:55 am to 10:30 am. 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 (02/03/2023) regarding allegations in the area(s) of: Personnel Number of residents present at the facility at the beginning of the inspection: 108 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: An observation of a resident’s room, and staff were observed interacting with residents. Additional Comments/Discussion: None 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 (Donesia Peoples), Licensing Inspector at (757) 353-0430 or by email at donesia.peoples@dss.virginia.gov

Violations

22VAC40-73-110-1

Evidence

Staff #3 acknowledged hearing staff #1 communicate profanity and inappropriate words towards resident #1.
Resident’s #1’s incident report dated 02/02/23 documents staff # 1 “made an unkind statement to the resident.” The incident report documented staff #1 “has been removed from the community and will be a Do Not Return.”
Staff # 2 and staff # 3 acknowledged resident #1 communicated to them his discomfort and feeling of disrespect with the profanity and inappropriate words communicated to him by staff #1.

Plan of correction

Person was an agency staff member from Gale Healthcare Solutions. The Agency staff member was sent out of the community on 2/2/23. Gale Healthcare Solutions was alerted of the Incident. APS and DSS were notified of the incident. Agency worker was marked as a Do Not Return and will not be allowed back into the community.

22VAC40-73-120-C

Based on the record review the facility failed to ensure all staff shall be trained in the relevant laws, regulations, and the facility’s policies and procedures sufficiently to implement requirements regarding the rights and responsibilities of residents.

Evidence

The record for staff #1 did not contain documentation of a training or review of the rights and responsibilities of residents.

Plan of correction

All agency staff that enter community starting 3/9/23 will sign a copy of the Resident’s Rights and will be kept on file in the Director of Resident Care’s office.

August 30, 2022Inspection7 violations

Inspection dates

Aug. 30, 2022 and Sept. 1, 2022

Areas reviewed

Technical assistance

Breakfast Menu & Weekly Breakfast Schedule

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: An unannounced renewal inspection was initiated on 08/30/2022 from 8:15am to 3:30pm and on 09/01/2022 from 8:39am to 2:34pm. 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: 94 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 5 Number of interviews conducted with residents: 5 Number of interviews conducted with staff: 4 Observations by licensing inspector: A tour of the facility was conducted to include inside and outside building grounds. Breakfast, lunch, and an activity were observed. A medication pass observation was completed for three residents. The following was reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, medication cart, emergency preparedness plan, fire inspection report, health inspection report, and a medication plan. Water temperatures were checked in two resident rooms. Call Bells for two residents were checked and staff responses were observed. Additional Comments/Discussion: None 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 may request a review and discussion of these findings with the inspectors 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 Donesia Peoples, Licensing Inspector at (757) 353-0430 or by email at donesia. peoples@dss.virginia.gov

Violations

22VAC40-73-210-B

Based on the onsite record review the facility failed to ensure in a facility licensed for both residential and assisted living care, all direct care staff shall attend at least 18 hours of training annually.

Evidence

The record for Staff #2 (Date of Hire (DOH)-04/05/19) did not include documentation of 18 hours of annual training.
The record for Staff #3 (DOH-02/01/16) did not include documentation of 18 hours of annual training.
Staff #7 acknowledged there is no evidence of documentation of 18 hours of annual training for Staff #2 and staff #3.

Plan of correction

Will have all employee training current by 1/1/23. An internal audit will be completed by the Executive Director or designee on all staff for training record compliance by 10/19/22. Going forward all training will be scheduled by the Business Office Manager or designee within 30 days of hire. Any employee who does not complete the required training will be removed from the schedule until completed. Community is currently assessing feasibility of an on-site staff training center for staff use.

22VAC40-73-260-A

Based on record review the facility failed to ensure each direct care staff member who does not have current certification in first aid as specified in subdivision 1 of this subsection 260-A, shall receive certification in first aid within 60 days of employment.

Evidence

The record for Staff #1 (DOH-06/21/22) did not include documentation of certification in first aid.
Staff #7 acknowledged there is no evidence of documentation of certification in first aid for staff #1.

Plan of correction

Will have all employees certified by 12/1/22. An internal audit will be completed by the Executive Director or designee on all staff records on First Aid/CPR compliance. The Business Office Manager or designee will create an employee tickler by 10/1/22 to verify continued compliance. The first CPR/First Aid class has been scheduled for 10/8/22 for staff who do not have up current certifications. These classes will continue until all staff are current.

22VAC40-73-260-C

Based on observation and staff interviewed, the facility failed to ensure the posted listing of staff certifications in first aid or cardiopulmonary resuscitation (CPR) or both was kept up to date.

Evidence

Licensing Inspector (LI) observed on 9/01/22 the First Aid and CPR list posted in the facility documented a date of 8/31/22 however the list was not current.
The First Aid and CPR list did not include the First Aid and CPR dates for staff #3, and staff #5. The record for staff # 3 documents a certification in first aid of 2/17/19 and a certification in CPR as of 2/16/21. The record for staff #5 documents a certification in First Aid as of 8/24/21 and a certification in CPR as of 8/24/21.
Staff #7 acknowledged the First Aid and CPR list posted in the facility was not current.

Plan of correction

Corrected on 8/30/22 The business office manager or designee will perform an employee audit by 10/1/22 to stay current on the employee’s certifications. The business office manager or designee will audit employee certifications to verify continued compliance.

22VAC40-73-290-B

Based on observation the facility failed to develop and implement a procedure for posting the name of the current on site person in charge.

Evidence

Upon arrival at the facility on 08/30/22 at 8:15 a.m. the LI observed a posting that documented the manager on duty as staff #6. Staff #6 was not on site at the facility upon the LI arrival at the facility.
Staff #6 acknowledged the posting of the name of the current on site person in change was not updated to document the person in charge when staff # 6 was not on site at the facility.

Plan of correction

Corrected on 8/30/22 Plan of Correction- The name of the current on-site person in charge is posted at the front of the community. To remain in continued compliance, it will be the front desk employee’s or designee’s responsibility to post the name daily.

22VAC40-73-490-A-2

Based on staff interview the facility failed to ensure a licensed health care professional, practicing within the scope of his profession, shall provide healthcare oversight at least every three months, or more often if indicated, based on his professional judgement of the seriousness of a resident’s needs or stability of a resident’s condition.

Evidence

Staff #6 acknowledged the facility did not have a current health care oversight.
LI requested a copy of the most recent health care oversight completed for the facility. Staff #6 informed the LI the most recent health care oversight was not able to be located. When requested by the LI, staff #6 was unable to provide a date of when the most recent health care oversight was completed.

Plan of correction

A quarterly healthcare oversight will be completed by 1/1/23. Community is currently reviewing contracts with outside vendors to provide quarterly healthcare oversight for the community.

22VAC40-73-620-A

Based on record review and staff interview the facility failed to ensure there shall be oversight at least every six months of special diets by a dietitian or nutritionist for each resident who has such a diet.

Evidence

LI observed in the facility kitchen a posting titled “special diets and residents with food allergies updated 8/19/22”, which documented the pictures, names of residents, and a list of allergies and diets for each resident pictured on the posting.
Per the posting located in the facility kitchen, resident #3 has a mechanical diet. Resident #11 has a pureed diet. Resident #14 has no tomato based food “upsets her stomach.”
Staff #6 acknowledged the facility does not have documentation of a dietary oversight.

Plan of correction

A quarterly dietician summary will be completed by 12/1/22. Executive Director and Director of Resident have meeting scheduled with the community’s contracted dietician on 10/5/22 to discuss the information and services needed for residents with specialized diets per the DSS standards. This information will be included in all future dietician visit summaries.

22VAC40-73-640-A

Based on the medication pass observation the facility failed to implement a written plan for medication management to include methods to prevent the use of outdated medications.

Evidence

LI observed the following expired medication on a medication cart at the facility: Hydralazine 25mg. tablets expired 2/7/2022 for resident # 1.

Plan of correction

The outdated medication was removed and disposed of on 8/30/22. Starting 9/29/22 Med cart audits will be conducted by the Director of resident care or designee weekly for four weeks, then every other week for four weeks, then monthly for four months to verify continued compliance.

February 25, 2022Inspection4 violations

Inspection dates

Feb. 25, 2022

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS

Comments

The Licensing Inspector completed an unannounced, non-mandated, monitoring investigation on 02/25/2022. The investigation was in reference to an initial facility self reported incident and completed on 03/14/2022. The Licensing Inspector interviewed staff, reviewed resident records and reviewed additional documentation to ensure compliance. During the inspection areas of non-compliance were observed and are contained within this violation notice. Please contact the facility Licensing Inspector, Kimberly Rodriguez at 757-586-4004 or email at kimberly.rodriguez@dss.virginia.gov for additional questions or concerns.

Violations

22VAC40-73-70-A

Based on resident record review the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affect the health, safety or welfare of any resident.

Evidence

#1: Licensing Inspector received report of staff to resident incident on 02/14/2022. Completion of investigation found that the allegation occurred on 02/10/2022. Evidence #2: While interviewing staff #1 and #2 with local public agency on 02/25/2022, staff #1 and #2 confirmed that facility staff reported the incident four days later to facility management.

Plan of correction

Not published by VDSS.

22VAC40-73-450-E

Based on resident record review the facility failed to ensure the individualized service plan shall be signed and dated by the resident or his legal representative.

Evidence

While reviewing the individualized service plan for resident #1, the Licensing Inspector observed resident #1's comprehensive service plan completed 9/5/2021 was not signed by the residents legal representative.

Plan of correction

Not published by VDSS.

22VAC40-73-450-G

Based on staff interview the facility failed to ensure the master service plan shall be maintained in a location accessible at all times to direct care staff.

Evidence

While interviewing staff # 3 and #4 with public agency, both staff informed the Licensing Inspector that both staff were not aware of the location of resident #1's individualized Service Plan nor had staff #3 or #4 reviewed resident #1's individualized service plan.

Plan of correction

Not published by VDSS.

22VAC40-73-680-K

Based on observation

Plan of correction

Not published by VDSS.

August 24, 2021Inspection1 violation

Inspection dates

Aug. 24, 2021 and Aug. 30, 2021

Areas reviewed

22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

Two Licensing Inspectors with the Division of Licensing conducted an hybrid inspection on 08/24/2021. The remaining documents were reviewed and the inspection was concluded on 08/30/2021. The Licensing Inspector reviewed the facility physical plant reviewed 4 resident and 4 staff records and reviewed additional facility documentation for compliance. During the inspection areas of non-compliance were identified and found within this violation notice. For additional questions or concerns please contact the facility Licensing Inspector, Kimberly Rodriguez at 757-586-4004 or by e-mail at Kimberly.rodriguez@dss.virginia.gov.

Violations

22VAC40-73-660-A-1

Based on observation of the facility physical plant the facility failed to ensure medications are locked.

Evidence

On 08/24/2021 two Licensing Inspectors observed resident #1's apartment containing Max Strength Aspercreme, Gaviscon Extra Strength Liquid Antacid and Mentholatum original ointment the following unlocked medications located on and below the residents nightstand and the residents bathroom. Evidence #2: Information provided by staff #2 verified that resident #1 medications should be locked and administered by facility staff.

Plan of correction

January 14, 2021Complaint survey4 violations

Inspection dates

Jan. 14, 2021 , Jan. 15, 2021 , Jan. 19, 2021 and Jan. 20, 2021

Areas reviewed

22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A complaint inspection was initiated on January 7, 2021 and concluded on January 20, 2021. A complaint was received by the department regarding allegations in the areas of Resident Care and Related Services as it related to staff performing resident transfers. The Executive Director was contacted by telephone to conduct the investigation. The licensing inspector emailed the Executive Director a list of documentation required to complete the investigation. The evidence gathered could not substantiate the allegation in the complaint; however, non-compliance with standards or law were cited, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice. Consultation was provided regarding: Assessment of Serious Cognitive Impairment documentation, Medication Administration Record documentation requirements, Completion of physician’s orders, Staff Training hours, and ISP/UAI updates.

Violations

22VAC40-73-310-H

Based on record review and discussion, the facility admitted and/or retained individuals with prohibited conditions.

Evidence

Resident #1 was administered Seroquel 25 mag daily without a completed treatment plan. ?Psychopharmacologic Medication Treatment Plan? dated 08-03-2020 did not include the plan of care, behavioral symptoms that indicate use of the psychoactive drug nor prognosis for the Seroquel.
Resident #2’s ISP dated 09-10-2020 documented, ?[Resident #2] will receive skilled nursing to treat stage 3 pressure sore...?.
Resident #2’s Physician’s Orders/Plan of Care dated 09-25-2020 documented, ?Pt [patient] has an unstageable PU [pressure ulcer] on left heel??
Staff #1 and Staff #2 acknowledged the aforementioned information and could not provide additional documentation for Resident #1 and Resident #2.

Plan of correction

Steps to correct the noncompliance with the standard Resident #1 no longer resides in the Community. Resident #2 no longer resides in the Community. Measures to prevent the noncompliance from occurring again The Director of Resident Care and/or designee will be educated by Executive Director and/or designee on the admission and retention of residents as it relates to pressure ulcers, specifically stage III and IV and the admission and retention of resident with orders for psychotropic medications. The Director of Resident Care and/or designee will be educated by Executive Director and/or designee on the components of the “Psychopharmacologic Medication Treatment Plan”. DRC/designee will meet with home health or hospice to review pressure ulcers weekly to determine stage, treatment and healing. The DRC and/or designee will communicate knowledge of pressure ulcers above a stage II to the Regional Director of Health Services and/or designee prior to admission/readmission for review monthly for three months. Current Residents receiving psychotropic medications will have their “Psychopharmacologic Medication Treatment Plan” reviewed to ensure the plan includes the plan of care, behavioral symptoms that indicate use of the psychoactive drug and the prognosis for the medication by the DRC and/or designee. New residents with orders for Psychotropic medications will have a “Psychopharmacologic Medication Treatment Plan” completed prior to moving in to the community. The DRC/designee will audit all new move ins weekly for 4 weeks then 2 time a month for 2 months to ensure all new resident with psychotropic medications have a completed “Psychopharmacologic Medication Treatment Plan”. Person(s) responsible for implementation of each step and/or monitoring preventative measures The Executive Director is responsible for implementation and monitoring.

22VAC40-73-325-B

Based on record review and discussion, the facility failed to ensure the fall risk ratings were reviewed and updated after each fall.

Evidence

“Nurse’s Notes” documented the following falls: a. Resident #2 - 11/06/2020 and 11/20/2020, and b. Resident #3 – 06/12/2020, 08/20/2020, 09/10/2020, 09/16/2020, and 09/29/2020. The residents? records did not contain fall risk ratings for the documented falls.
Staff #1 and Staff #2 acknowledged the records did not contain fall risk ratings for the aforementioned falls. Staff #1 and Staff #2 could not provide fall risk ratings for the aforementioned falls.

Plan of correction

Steps to correct the noncompliance with the standard Resident #2 no longer residents in the Community. Resident #3 no longer residents in the Community. The Director of Resident Care and/or designee will conduct a 30 day look back to ensure fall risk ratings were reviewed and updated following a fall. Measures to prevent the noncompliance from occurring again The DRC will be re-educated by Executive Director and/or designee on regulation 22VAC40-73-(5)-325-B including but not limited to completion of a fall risk review after each resident fall. The Director of Resident Care and/or designee will complete a fall risk review following each fall and ensure an update is documented. The DRC will bring documentation to the risk review meeting for verification, weekly for twelve weeks. Person(s) responsible for implementation of each step and/or monitoring preventative measures The Executive Director is responsible for implementation and monitoring.

22VAC40-73-650-E

Based on record review and discussion, the facility failed to ensure the resident’s record contained the physician’s or other prescriber’s signed written order or a dated notation of the physician’s or other prescriber’s order.

Evidence

Resident #1’s Individualized Service Plan (ISP) dated 09-10-2020 documented, ?[Resident #1] will use a hospital bed with half rails for turning and repositioning due to immobility/pain??
Resident #1’s record did not contain a physician’s written order for the half rails on the resident’s bed.
Staff #2 could not provide documentation of a physician’s written order for the half rails on Resident #1’s bed.

Plan of correction

Steps to correct the noncompliance with the standard Resident #1 no longer resides at the Community. Measures to prevent the noncompliance from occurring again Licensed Clinical staff will be re-educated by the Director of Resident Care and/or designee, on the need for written physician’s orders or dated and notated verbal orders for half rails on a resident’s bed. The DRC and/or designee will conduct random review of orders for half rails monthly for three months. Person(s) responsible for implementation of each step and/or monitoring preventative measures The Executive Director is responsible for implementation and monitoring.

22VAC40-73-660-B

Based on record review and discussion, the facility failed to ensure a resident may be permitted to keep his own medication in his room if the Uniform Assessment Instrument (UAI) has indicated that the resident is capable of self- administering medication.

Evidence

Resident #1’s UAI dated 09-10-2020 documented the resident is dependent in medication administration.
“Skilled Nursing Visit” notes dated 08-20-2020 documented, ?“ Moisture barrier cream left at bedside ”?
Staff #2 acknowledged Resident #1 was dependent in medication administration, and the barrier cream was left at bedside.

Plan of correction

Steps to correct the noncompliance with the standard Resident #1 no longer resides at the Community. Measures to prevent the noncompliance from occurring again DRC/Designee will re-educate current LPNs and CMAs regarding procedures for medications to be left at bedside. The Director of Resident Care and/or designee will educate Hospice teams on the requirements for medications, including creams and ointments to be left at the bedside. The DRC/designee will review current residents on hospice to ensure that any medications, creams or ointments at the bedside have appropriate documentation and storage. Person(s) responsible for implementation of each step and/or monitoring preventative measures The Executive Director is responsible for implementation and monitoring.

November 18, 2020Complaint survey3 violations

Inspection dates

Nov. 18, 2020 and Nov. 19, 2020

Areas reviewed

Comments

This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A complaint inspection was initiated on November 13, 2020 and concluded on November 19, 2020. A complaint was received by the department regarding allegations in the areas of resident care and related services. The Executive Director was contacted by telephone to conduct the investigation. The licensing inspector emailed the Executive Director a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the allegation of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice. The complaint is not valid. Consultation provided on documentation of actions taken when alleged incidents occur, incident reporting, and allergy reactions on physical examination forms was reviewed.

Violations

22VAC40-73-1110-A

Based on record review and discussion, the facility failed to ensure prior to admitting a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia to a safe, secure environment, the licensee, administrator, or designee determined whether placement in the special care unit is appropriate. The determination and justification for the decision shall be in writing and shall be retained in the resident's file.

Evidence

The following residents admitted to the Safe, Secure Environment (SSE) and had no determination and justification for placement by the licensee, administrator, or designee. A. Resident #1 admitted 12-11-19, B. Resident #2 admitted 09-09-19, and C. Resident #3 admitted 07-03-19.
Staff #1 confirmed during discussion the determination and justification for placement by the licensee, administrator, or designee had not been completed for the three residents mentioned.

Plan of correction

Steps to correct the noncompliance with the standard The Executive Director and/or designee will conduct a review to ensure residents admitted to the SSE within the last six months have the appropriate documentation in their record reflecting their determination and justification for placement into the SSE. Measures to prevent the noncompliance from occurring again The Executive Director and/or designee will review a new admission’s Approval for Placement in Special Care Unit DSS Form 032-05-0082-03-eng prior to admission to ensure determination and justification are present on the form. The Executive Director is responsible for the implementation of each step and/or monitoring preventative measures.

22VAC40-73-320-B

Based on record review and discussion, the facility failed to ensure a risk assessment for tuberculosis was completed annually on each resident as

Evidence

d by the completion of the current screening form. Evidence:
Resident #2 admitted 09-09-2019 to the facility. Resident did not have a completed annual tuberculosis screening on file at the time of inspection.
Staff #1 confirmed the annual tuberculosis form was not signed by the screener or dated to indicate what date the screening was completed.

Plan of correction

Steps to correct the noncompliance with the standard A tuberculosis annual risk assessment review will be completed for residents residing on the Special Care Unit (BTR). Measures to prevent the noncompliance from occurring again The DRC and Assistant DRC will be educated on the annual tuberculosis risk assessment protocol by the Executive Director/Designee. Person(s) responsible for implementation of each step and/or monitoring preventative measures The DRC (The Bridge to Rediscovery Program Manager) and/or designee will complete a monthly tuberculosis risk assessment review for three months. The Executive Director is responsible for the implementation of each step and/or monitoring preventative measures.

22VAC40-73-680-D

Based on record review and interview, the facility failed to ensure medications were administered in accordance with the physician's or other prescriber's instructions.

Evidence

The following residents? medications were not administered in accordance with the physician’s or other prescriber’s instructions according to their Medication Administration Records (MARs): A. Resident #1 ? Dronabinol 04-27-20 9:00 a.m. and 6:00 p.m., Glucerna 04-24-20 – 04-26-20 9:00 a.m., 1:00 p.m., and 6:00 p.m. and 04-27-20 9:00 a.m. and 1:00 p.m., Mirtazapine F/C and Quetiapine Fumarate F/C on 04-24-20 at 8:00 p.m.; B. Resident #2 ? Acetaminophen 04-24-20 and 04-25-20 8:00 a.m., Omeprazole 04-03-20 – 04-05-20 8:00 p.m. and 04-04- 20 – 04-06-20 8:00 a.m.; and C. Resident #3 ? Polyethylene Glycol 03-16-20 – 03-18-20 8:00 a.m., Magnesium and Buspar 03-29-20 at 8:00 p.m.
Staff #1 confirmed during discussion the aforementioned medications were not administered in accordance with the physician’s or other prescriber’s instructions.

Plan of correction

Steps to correct the noncompliance with the standard A Medication Administration Record (MAR) review will be completed for residents residing on the Special Care Unit (BTR). Measures to prevent the noncompliance from occurring again Licensed Clinical Staff and Medication Aides will be re-educated on medication refill management practices by the Director of Resident Care/Designee. Person(s) responsible for implementation of each step and/or monitoring preventative measures The Director of Resident Care(DRC) and/or designee will conduct a weekly MAR review for four weeks, then monthly for two months to validate that medications are given as prescribed and obtained timely from pharmacy or family when refills are needed. The Executive Director is responsible for the implementation of each step and/or monitoring preventative measures.