Virginia DSS · Assisted Living Facility

Poet's Walk Leesburg

📍 102 Desmond Plaza SE, Leesburg, VA, 20175

ID 52344One Year licenseActive
4
Inspections
On record
3
With violations
Visits that cited something
1
Clean visits
Nothing cited
31
Violations cited
Individual findings
29
Standards cited
Distinct rules
1
Complaint visits
Prompted by a complaint

Poet's Walk Leesburg was inspected 4 times between August 7, 2025 and January 6, 2026 by the Virginia Department of Social Services. 3 of those visits ended with violations cited and 1 with none. Across that history VDSS cited 31 violations under 29 distinct standards. 1 inspection was prompted by a complaint.

A violation is a licensing standard - a rule in the Virginia Administrative Code - that the inspector found the facility was not meeting. Each is shown with the evidence the inspector recorded and, where VDSS publishes it, the facility's own plan of correction.

Every inspection listed here is currently published on the VDSS site.

Provider Information

Facility type
Assisted Living Facility
License type
One Year
License expires
02/12/2027
Administrator
Hanny Kuma
Licensing inspector
Amanda Velasco
Inspector phone
(703) 397-4587
Approved for
Non-Ambulatory · Assisted Living · Special Care Unit

Inspection History

4

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

January 6, 2026Inspection25 violations
Inspection dates
01/06/2026, 01/09/2026
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY63.2- (1) GENERAL PROVISIONS22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Technical assistance
Reviewed requirements regarding files after a Change of Ownership, Reviewed accessing renewal application through public website. 490-D
Comments
Type of inspection: Renewal Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 01/06/2025 9:00 AM to 3:40 PM 01/09/2025 8:55 AM to 12:40 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: 48 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: 3 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 6 Observations by licensing inspector: Activities, Meals, and Medication pass. Additional Comments/Discussion: The Acknowledgement of Inspection form for both dates of the inspection were reviewed on 01/09/2025 via teams with staff members due to the buildings and ground incident that occurred on 01/06/2026. The facility was encouraged to submit the renewal applications as soon as possible in anticipation of their upcoming expiration. 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 Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Violations
22VAC40-73-1140-B
Based on staff record review and staff interview, the facility failed to ensure direct care staff attended at least 10 hours training in cognitive impairment within four months of the starting date of employment in the safe, secure unit.
Evidence
  1. Staff 5, hired on 02/03/2025, was a direct care staff member that works in the safe, secure unit. Staff 5’s record contained .75 hours of cognitive impairment training completed since 02/03/2025.
  2. In an interview with the LI on 01/09/2026, Staff 8 confirmed that Staff 5 did not attend at least 10 hours of training in cognitive impairment within 4 months of their starting date of employment, 06/03/2025, in the safe, secure unit.
Plan of correction
Required training hours were added to Staff #5’s training profile. Staff #5 is required to complete all outstanding training by 2/28/2026. The Administrator will audit all staff training records to ensure compliance.
22VAC40-73-440-A
Based on resident record review and staff interview, the facility failed to ensure that all residents and applicants were assessed face to face using the UAI instrument at admission, annually, and whenever there is a significant change in the resident's condition.
Evidence
  1. Resident 4’s (admitted 11/11/2021) record contained a UAI dated 12/19/2024.
  2. In an interview with the LI on 01/06/2026, Staff 8 confirmed that it had not been updated annually.
  3. Resident 5’s (admitted 07/28/2024) record contained a signed ISP dated 07/29/2024. Staff 8 showed the LI an unsigned copy on the computer dated 07/29/2025.
  4. In an interview with the LI on 01/06/2026, Staff 8 confirmed that the UAI was not signed.
Plan of correction
A UAI was completed for the resident. The Director of Nursing (DON) is responsible for completing, signing, and updating UAIs upon admission, annually, and following any significant change in condition. Documentation has been placed in the resident’s chart. This was completed on [date].
22VAC40-73-670-1
Based on staff record review, resident record review, and staff interview, the facility failed to ensure staff responsible for medication administration were licensed by the Commonwealth of Virginia to administer medications or registered with the VA Board of Nursing as a medication aide.
Evidence
  1. During a tour of the facility on 01/06/2026, the LI observed that Staff 9 was working the cart.
  2. In an interview with the LI on 01/06/2026, Staff 8 stated that Staff 9 would be passing medications during the medication pass observation.
  3. After a review of the license lookup tool provided by DH online, Staff 9’s license as a Registered Medication Aide expired on 11/30/2025. Staff 8 stated that Staff 9 had been passing medications all morning to all residents with scheduled medication and pulled Staff 9 off the cart.
  4. On 01/06/2026, Staff 8 provided a Medication Admin Audit Report for Staff 9 to show all passes completed by Staff 9 between 12/01/2025 and 01/06/2026. The document contains 454 pages of medication administration records for multiple residents. The report indicates that medication was passed for 33 residents on 01/06/2026, and approximately 4,700 doses were passed to 45 residents total from 12/01/2025 to 01/06/2025.
  5. On 01/06/2026, Staff 2 provided a schedule containing the dates worked by Staff 9 between 11/30/2025 and 01/06/2026. Staff 9 was scheduled on the following dates on various shifts: November 30th, 2025 through December 04th, 2025, December 06th through December 07th, 2025, December 09th, 2025 through December 12th, 2025, December 15th, 2025 through December 18th, 2025, December 20th, 2025 through December 21st, 2025, December 23rd, 2025 through December 25th, 2025, December 29th, 2025, January 03rd, 2025 through January 24th, 2025 and January 06th, 2025.
  6. In an interview with the LI on 01/09/2026, Staff 8 confirmed that Staff 9’s license to practice as a registered medication aide was expired from 11/30/2025.
Plan of correction
Staff #9 renewed their Medication Aide license on 1/7/2026. A copy of the current license is attached. The Administrator and Administrative Assistant will conduct monthly audits of all licensed staff credentials. Outlook reminders will be established to ensure ongoing compliance.
22VAC40-73-640-A
Based on facility document review, resident record review, direct observation, and staff interview, the facility failed to ensure a written plan for medication management was kept current, implemented, and addressed procedures for administering medication including required components.
Evidence
  1. On page seven (7) of the facility’s medication management plan, it states “Staff must begin by washing their hands and assembling the equipment necessary for administration.”
  2. On 01/09/2026, the LI observed Staff 10 pass medications with the same gloves on, not washing their hands, for three residents.
  3. On 01/09/2026, the LI observed Staff 10 drop a pill on the floor while preparing medication to be passed. The pill was then thrown into the open trash can on the side of the cart.
  4. The facility’s medication management plan does not cover disposal of non-narcotic medication.
  5. On page 1 of the Resident Medication Administration policy, it sates “Medications are to be prepared, administered, and documented by qualified staff members per your state guidelines.”
  6. On 01/09/2026, the LI observed Staff 10 document the medication pass for 13 residents that were not observed by the LI. Staff 10 stated that the medication had been passed earlier but there was not enough time to document.
  7. In an interview with the LI on 01/09/2026, Staff 8 confirmed that the medication management plan had not been implemented.
Plan of correction
Staff 10 was reeducated on proper medication administration procedures on 1/15/2026. Director of Nursing will conduct random medication administration audits to ensure compliance.
22VAC40-90-30-B
Based on staff record review and staff interview, the facility failed to ensure the sworn statement or affirmation was completed by all applicants for employment.
Evidence
  1. The LI requested a list of employees with hire dates. The employee list contained approximately 32 individuals with hire dates prior to the change of ownership that occurred on 08/13/2025.
  2. In an interview with the LI on 01/06/2026 and 01/09/2026, Staff 1 and 5 confirmed that the staff hired before 08/13/2025 had not completed sworn statements or affirmations as required due to the Change in Ownership.
Plan of correction
Background checks and sworn statements will be completed for all staff hired prior to 8/13/2025. This process will be completed by 4/1/2026. The Administrator is responsible for oversight.
22VAC40-90-40-B
Based on staff record review and staff interview, the facility failed to ensure criminal history record reports were obtained on or prior to the 30th day of employment for each employee.
Evidence
  1. The LI requested a list of employees with hire dates. The employee list contained approximately 32 individuals with hire dates prior to the change of ownership that occurred on 08/13/2025.
  2. In an interview with the LI on 01/06/2026 and 01/09/2026, Staff 1 and 5 confirmed that the staff hired before 08/13/2025 had not completed criminal history record reports as required due to the Change in Ownership.
Plan of correction
Background checks and sworn statements will be completed for all staff hired prior to 8/13/2025. This process will be completed by 4/1/2026. The Administrator is responsible for oversight.
22VAC40-73-290-B
Based on direct observation and staff interview, the facility failed to ensure a procedure for pasting the name of the current on-site person in charge in the facility that is conspicuous to the residents and the public was developed and implemented.
Evidence
  1. Upon arrival on 01/09/2026, the LI observed the posted Manager on Duty as Staff 8; however, Staff 10 stated that they were current person in charge.
  2. In an interview with the LI on 01/09/2026, Staff 2, Staff 10, and Staff 8 confirmed that Staff 8 was not in the building and/or the current on site person in charge.
Plan of correction
The Manager on Duty schedule is posted on a whiteboard in the lobby. All managers are listed, and the current Manager on Duty is color-coded with a key provided. This deficiency was corrected on 1/17/2026. The Administrator is responsible for maintenance.
22VAC40-73-200-C
Based on staff record review and staff interviews, the facility failed to ensure direct care staff met one of the requirements upon hire or within two months of employment.
Evidence
  1. Staff 5’s (hired as direct care staff on 02/03/2025) and Staff 6’s (hired as direct care staff on 10/17/2025) records did not include documentation of having met one of the requirements of direct care staff upon hire or within two months of employment.
  2. In an interview with the LI on 01/09/2026, Staff 8 confirmed that Staff 5 and Staff 6’s qualifications did not meet the requirements.
Plan of correction
Personnel files for Staff #5 and Staff #6 were reviewed, and all required documentation was requested. The Administrator and Administrative Assistant will conduct monthly audits of staff files to ensure all direct care staff meet employment and annual requirements. Full compliance will be achieved by 4/1/2026.
22VAC40-73-45-A
Based on facility document review and staff interview, the facility failed to ensure liability insurance coverage was maintained according to the capacity tiers.
Evidence
  1. On 01/06/2026, Staff 1 provided a copy of the liability insurance dated to expire on 04/15/2026. The insurance provided did not list the current licensee as insured.
  2. In an interview with the LI on 01/06/2025, Staff 1 stated that it might not be the correct copy and they would attempt to locate the current liability insurance.
  3. On 01/09/2026, LI provided an opportunity to upload the document via a shared folder during the on-site inspection. The document was not uploaded for review at the time of inspection.
Plan of correction
Liability insurance was updated in the licensee’s name. A copy was obtained on 1/28/2026 and is attached for review. The Administrator is responsible for maintaining a copy of the insurance policy on-site and providing it upon request.
22VAC40-73-280-B
Based on facility document review and staff interview, the facility failed to ensure a written staffing plan was maintained that specifies the number and type of direct care staff required to meet the day-to-day, routine direct care needs and any identified special needs.
Evidence
  1. The LI requested a copy of the written staffing plan in writing to Staff 2 and Staff 8 on 01/09/2026.
  2. The written staffing plan was not provided for review on 01/09/2026 during the inspection.
Plan of correction
A daily staffing schedule template was created in Schedule Pop. Staff will follow the required 1:10 staff-to-resident ratio. The Administrative Assistant is responsible.
22VAC40-73-520-I
Based on direct observation and staff interview, the facility failed to ensure the written schedule of activities was developed monthly, included required information and substitutions, and was posted in a conspicuous place or otherwise available to residents and their families.
Evidence
  1. On 01/06/2026 and 01/09/2026, the LI did not observe a posted activity calendar.
  2. In an interview with the LI on 01/06/2026, Staff 8 stated that the January calendar was not complete due to the change in activity director. Staff 8 stated they were still using the December calendar which was posted on the back of resident doors and provided to resident families digitally. Staff 8 confirmed that resident families receive it digitally, but most residents do not.
  3. In an interview with the LI on 01/09/2026, Staff 8 confirmed that the activity calendar was not provided to residents or posted.
Plan of correction
The activities calendar was uploaded to the daily digital platform and is displayed on televisions throughout the facility. In addition, a large monthly activities calendar is posted in the main hallway. The Activities Director is responsible for posting and maintaining the calendar.
22VAC40-73-560-E
Based on direct observation, resident record review and staff interview, the facility failed to ensure resident records were kept current, retained at the facility, and kept in a locked area.
Evidence
  1. Upon the LI’s arrival at the facility on 01/09/2026, Staff 10 stepped away from the medication carts to allow the LI access to the safe, secure unit. When arriving back to the medication carts, the LI observed the computer open to Resident 6’s electronic medication administration record.
  2. In an interview with the LI on 01/09/2026, Staff 8 confirmed that the resident records were not kept current, and Resident 6’s record was left open to access.
Plan of correction
Background checks and sworn statements will be completed for all staff hired prior to 8/13/2025. This process will be completed by 4/1/2026. The Administrator is responsible for oversight.
22VAC40-73-240-F
Based on facility document review and staff interview, the facility failed to ensure volunteers attended an orientation prior to beginning volunteer service and signed and dated a statement that they received and understood orientation information.
Evidence
  1. The LI requested the volunteer records for any active volunteers on 01/06/2026. Staff 8 provided one active volunteer, Collateral Contact 1.
  2. Collateral Contact 1’s record did not contain a statement that they received and understood orientation information.
Plan of correction
Orientation documents were provided to Collateral Contact #1. All volunteers will receive orientation documentation. The Administrator is responsible for compliance.
22VAC40-73-1180-B
Based on direct observation and staff interview, the facility failed to ensure that ordinary materials or objects were inaccessible to residents when there were indications that they may be harmful to a resident.
Evidence
  1. Upon the LI’s arrival at the facility on 01/09/2026, Staff 10 stepped away from the medication carts to allow the LI access to the safe, secure unit.
  2. When walking back to the medication carts, the LI observed that both carts were parked to the left of the entrance to the dining area where residents were having breakfast. The LI observed both carts containing a basket with various supplies, including hand sanitizer, on the top of the cart. The cart to the right, identified as the cart for the 300-400 hallway, also contained wipes.
  3. During the observed medication pass, Staff 10 was gathering medication out of the cart to the left, identified as the cart for the 100-200 hallway. At the same time, Resident 20 went to the cart and began to grab the wipes. Resident 20 picked up the wipes, opened the container, and began to pull the wipes out of the container. Neither the staff in the adjacent dining area nor Staff 10 responded until the LI got the attention of Staff 10 to remove the cleaning wipes.
Plan of correction
Staff #10 was re-educated on required procedures. On 1/15/2026.The DON completed the training and will continue monitoring compliance.
22VAC40-73-40-B-9
Based on resident record review, staff record review and staff interview, the facility failed to ensure that records, reports, plans, schedules and other information was kept and maintained as required by this chapter.
Evidence
  1. The LI requested a list of employees with hire dates. The employee list contained approximately 32 individuals with hire dates prior to the change of ownership that occurred on 08/13/2025.
  2. During a review of Staff 5’s files on 01/06/2025, the LI observed that Staff 5, hired on 02/03/2025, the LI observed that Staff 5’s record was not brought current to reflect the Change of Ownership that occurred in August of 2025. Staff 5’s record contained an orientation, sworn statement or affirmation, criminal record report, and job description completed in or around February of 2025 at the time of hire.
  3. The LI requested a list of residents with admission dates. The resident list contained approximately 35 residents with admission dates prior to the change of ownership that occurred on 08/13/2025.
  4. During a review of Resident 2, Resident 3, Resident 4, and Resident 5’s files on 01/06/2025, the LI observed Resident 2 (Admitted 12/15/2023), Resident 3 (Admitted 02/25/2025), Resident 4 (Admitted 11/11/2021), and Resident 5 (Admitted 04/01/2025), were not brought current to reflect the Change of Ownership that occurred in August of 2025. Records for Resident 2, Resident 3, Resident 4, and Resident 5 contained agreements, disclosure forms, written assurance, and interviews dated at time of noted admissions.
  5. In an interview with the LI on 01/06/2026 and 01/09/2026, Staff 1 and 5 confirmed that the staff and resident records for those hired or admitted prior to 08/13/2025 had not been maintained as required with the Change of Ownership.
Plan of correction
Staff 10 was reeducated on resident rights and resident records keeping on 1/15/2026. All direct care staff will complete training 4/1/2026.
22VAC40-73-280-A
Based on direct observation and staff interview, the facility failed to ensure there was staff adequate in knowledge, skills, and abilities and sufficient in numbers to provide services to attain and maintain the physical, mental, and psychosocial well-being of each resident.
Evidence
  1. On 01/09/2026, the LI arrived at the facility and observed three (3) direct care staff alongside one (1) registered medication aide serving breakfast, getting residents out of bed, and administering medication (RMA only).
  2. In an interview with the LI, Staff 10 stated that they had a call out and had to work two carts to cover for the other individual.
  3. The LI requested a copy of the schedule, including the actual worked shifts, for 01/09/2026. The facility provided a schedule for 01/09/2026, that included one certified medication tech from 7:00 AM to 3:00 PM and four caregivers from 7:00 AM to 3:00 PM.
  4. In an interview with the LI on 01/09/2026, Staff 8 confirmed that there were not enough staff to adequately meet resident needs on 01/09/2026.
Plan of correction
A daily staffing schedule template was created in Schedule Pop. Staff will follow the required 1:10 staff-to-resident ratio. The Administrative Assistant is responsible for maintaining schedules.
22VAC40-73-680-D
Based on direct observation, resident record review, and staff interview, the facility failed to ensure medication was administered in accordance with the physician or other prescribers’ instructions and consistent with the standards of practice approved by the Virginia Board of Nursing.
Evidence
  1. Resident 4’s Medication Review Report, signed 12/15/2025, contains the following orders: a. Aspirin Low CHW 81 MG: Chew and Swallow 1 tablet by mouth every morning b. Acetamin Tab 500 MG: Take 2 tablets by mouth twice daily c. Buspirone Tab 7.5 MG: Take 1 tablet by mouth three times daily d. Famotidine Tab 20 MG: Take 1 tablet by mouth twice daily e. Memantine Tab HCL 5MG: Take 1 tablet by mouth twice daily f. Calcium+D3 Tab 315-250: Take 1 tablet by mouth twice daily
  2. On 01/09/2026, the LI observed Staff 10 crush the following medications prior to administering: Aspirin, Acetamin, Buspirone, Famotidine, Memantine, and Calcium.
  3. Resident 4’s record does not contain an order to crush medication.
  4. In an interview with the LI on 01/09/2026, Staff 10 stated that they did not know where to review if Resident 4 had a crush order. Staff 8 confirmed medication was not administered per physician orders.
Plan of correction
Staff #10 was re-educated on the Six Rights of Medication Administration on 1/15/2026. The DON will continue quarterly medication administration training.
22VAC40-73-610-B
Based on direct observation and staff interview, the facility failed to ensure menus, including substitutions or additions, were dated and posted for the current week in an area conspicuous to residents.
Evidence
  1. On 01/06/2026 and 01/09/2026, the LI did not observe a posted menu including substitutions.
  2. On 01/06/2026, Staff 8 provided a copy of the menu. The menu stated the breakfast was pancakes. The LI observed breakfast as waffles. There were no substitutions listed on the menu.
  3. In an interview with the LI on 01/09/2026, Staff 8 confirmed that the menu was not posted.
Plan of correction
Menus, substitutions, and additions were uploaded to the daily digital platform and are displayed on televisions throughout the facility. The Dining Director is responsible for updating menus daily.
22VAC40-73-680-H
Based on direct observation, resident record review, and staff interview, the facility failed to ensure all medications administrations to residents were documented on the medication administration record (MAR) at the time of administration.
Evidence
  1. On 01/09/2026, the LI observed Staff 10 document the medication pass for 13 residents that were not observed by the LI. Staff 10 stated that the medication had been passed earlier but there was not enough time to document.
  2. Medication Lists and Medication Administration Audit reports were collected and reviewed for the following 13 residents: a. Resident 5, 13 medications and/or treatments marked as administered at 9:37 AM b. Resident 7, eight (8) medications and/or treatments were marked as administered at 9:25 AM, two (2) medications and/or treatments were marked as administered at 9:27 AM c. Resident 8, five (5) medications were marked as administered at 9:28 AM d. Resident 9, 10 medications were marked as administered at 9:28 AM e. Resident 10, one (1) medication was marked as administered at 9:30 AM f. Resident 11, two (2) medications were marked as administered at 9:34 AM g. Resident 12, six (6) medications were marked as administered at 9:35 AM h. Resident 13, five (5) medications were marked as administered at 9:35 AM i. Resident 14, three (3) medications were marked as administered at 9:35 AM j. Resident 15, seven (7) medications marked as administered at 9:38 AM k. Resident 16, eight (8) medications marked as administered at 9:36 AM l. Resident 17, five (5) medications and/or treatments marked as administered at 9:37 AM m. Resident 18, eight (8) medications were marked as administered at 9:29 AM and 10 medications were marked as administered at 9:30 AM
  3. In an interview with the LI on 01/09/2026, Staff 10 stated that they were not documenting medication as it was administered to ensure that all residents received medication due to the shortage of staff support. Staff 8 confirmed that the medication was not documented at the time of administration.
Plan of correction
Staff #10 was re-educated on the Six Rights of Medication Administration on 1/15/2026. The DON will provide medication administration training during orientation and quarterly.
22VAC40-73-530-C
Based on direct observation and staff interview, the facility failed to ensure freedom of movement was provided for the residents to common areas and to their personal spaces. The facility may not lock residents out of or inside their rooms.
Evidence
  1. While walking back to the medication cart after a medication pass observation on 01/09/2026, the LI overheard Resident 6 state “I’m locked out.”
  2. In an interview with the LI on 01/09/2026, Resident 6 stated that the door was locked, and they couldn’t get in. The LI attempted to open the locked door with Resident 6 present. The LI got the attention of Staff 11 to open the door for Resident 6.
  3. During the inspection on 01/09/2026, the LI observed 27 resident rooms locked while residents were out of the building.
  4. In an interview with the LI, Staff 10 stated that the doors remain locked to ensure residents don’t enter other resident rooms.
Plan of correction
Resident room doors are unlocked. Communication to families will be sent on or before 2/28/2026. The Executive Director and Director of Nursing are responsible for ensuring doors remain unlocked. Staff will be re-educated by 2/28/2026.
22VAC40-73-450-E
Based on resident record review and staff interview, the facility failed to ensure the individualized service plan (ISP) was signed and dated by the licensee, administrator, or his designee and by the resident or his legal representative.
Evidence
  1. On 01/06/2026, Staff 8 showed the LI an unsigned copy of Resident 5’s (admitted 07/28/2024) ISP on the computer dated 11/22/2025.
  2. On 01/06/2026, Staff 8 showed the LI an unsigned copy of Resident 4’s (admitted 11/11/2021) ISP on the computer dated 12/29/2025.
  3. In an interview with the LI on 01/09/2025, Staff 8 confirmed that Resident 4 and Resident 5’s ISP was not signed by facility staff or the resident and/or the resident’s legal representative.
Plan of correction
The Individualized Service Plans (ISPs) for Residents #4 and #5 were signed by the residents and/or their legal representatives.
22VAC40-80-120-E-1
Based on direct observation and staff interview, the facility failed to ensure the following items were posted on the premises: the most recently issued license, the most recent inspection findings, and any other documents required by the commissioner.
Evidence
  1. On 01/06/2026 and 01/09/2026, the LI did not observe the license posted in an area conspicuous to the public.
  2. In an interview with the LI on 01/06/2026 and 01/09/2026, Staff 8 confirmed that the license was not posted.
Plan of correction
The current license was framed and posted in the lobby on 1/10/2026. The Administrator is responsible for ensuring the license remains always posted.
22VAC40-73-680-C
Based on direct observation, resident record review, and staff interview, the facility failed to ensure medication was administered no earlier than one hour before and not later than one hour after the facility's standard dosing schedule.
Evidence
  1. Resident 19’s Medication Review Report, signed 12/23/2025, contains the following orders: a. CoQ10 Cap 200 MG: Take one capsule by mouth once daily b. Enalapril Tab 10 MG: Take 2 tablets by mouth every morning c. Fluoxetine Cap 10 MG: Take 1 capsule by mouth every morning d. Magnesium Tab 250MG: Take 1 tablet daily by mouth e. Selenium Cap 200 MCG: Take 1 capsule by mouth once daily f. Vitamin B-12 Tab 1000MCG: Take 1 tablet by mouth once daily
  2. During a medication pass for Resident 19, the LI observed Staff 10 administer the following medications approximately 2 hours after they were due at 8:00 AM: Coq10, Enalapril, Fluoxetine, Magnesium, Selenium, Vitamin B012.
  3. Resident 19’s Medication Admin report shows that the medications listed above were administered at 10:20 AM.
  4. In an interview with the LI on 01/09/2026, Staff 8 confirmed that medication was administered more than one hour after the schedule administration time.
Plan of correction
Staff #10 was re-educated on the Six Rights of Medication Administration on 1/15/2026. The DON will continue quarterly medication administration training.
22VAC40-73-950-E
Based on facility document review and staff interview, the facility failed to ensure an orientation and semiannual review of the emergency preparedness and response plan was developed, implemented, and documented by signing and dating for all staff, residents and volunteers.
Evidence
  1. The LI requested a copy of the emergency preparedness orientation or semi-annual review with staff and residents on 01/06/2026 and 01/09/2026.
  2. The facility was provided with an opportunity to submit the plan for review via shared folder online on 01/09/2026. In an interview with the LI on 01/09/2026, Staff 2 stated they would locate the information and submit it.
  3. The emergency preparedness plan orientation or semi-annual review was not submitted for review during the course of the inspection on 01/06/2026 and 01/09/2026.
Plan of correction
The Emergency Preparedness Plan will be reviewed with staff, residents, and volunteers by 4/1/2026. The Administrator is responsible for ensuring review occurs at orientation and semiannually.
22VAC40-73-100-A
Based on facility document review, direct observation, and staff interview, the facility failed to ensure an infection control program was developed, in writing, implemented, and addressed surveillance, prevention, and control of disease and prevention consistent with the CDC and OSHA regulations.
Evidence
  1. Upon arrival to the facility on 01/09/2026, the LI was let into the safe, secure unit by Staff 10. Staff 10 walked the LI from the front of the building to the medication carts. Staff 10 did not wash their hands or apply hand sanitizer and put on gloves to begin passing medication. The same gloves remained on Staff 10’s hands from the first medication pass to the third medication pass, including time for documentation and walking to resident rooms to ascertain the location of residents not in the dining area.
  2. The facility’s Infection Control Program states the following on page 08 under Hand Hygiene: “All individuals must adhere to strict hand hygiene practices, including washing hands frequently with soap and water for at least 20 seconds or using alcohol-based hand sanitizers when soap and water are not available.”
  3. In an interview with the LI on 01/09/2026, Staff 8 confirmed the infection control program was not implemented relating hand hygiene.
Plan of correction
Staff #10 was re-educated on proper hand hygiene practices on 1/15/2026. The DON completed the training and will continue monitoring compliance.
October 7, 2025Inspection4 violations
Inspection dates
10/07/2025
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS for FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report
Technical assistance
610. Weekly menu needs to be posted in conspicuous place. Disclosure statement current version is 11/24, update contact information.
Comments
Type of inspection: ¿Monitoring¿ Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/07/2025, 10:30 a.m. to 2:40 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 43 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 and 1 partial for medication audit. Number of staff records reviewed: 3 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Lunch and movies 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 Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017 or by email at Jacquelyn.Kabiri@dss.virginia.gov
Violations
22VAC40-73-680-B
Based upon observation, the facility failed to ensure that medications shall remain in the pharmacy-issued container, with the prescription label or direction label attached, until administered to the resident.
Evidence
  1. On 10/07/2025, at approximately 12:38 p.m., the Licensing Inspector (Ll) audited the medication cart and observed that the prescription medication BREO Ellipta inhalation powder inhaler was not contained in a box with identifiable resident information.
  2. Staff 4 conformed the inhaler was not in a prescription box and belonged to resident 6.
  3. Photo evidence taken.
Plan of correction
Director of nursing removed all meds do not have identifiable resident information and obtain new medication orders if applicable. Medication cart audits will be conducted weekly by the med tech and followed up by DON to ensure compliance with pharmacy issued containers and label. Pharmacy medication audits will also be done monthly. DON will ensure compliance by 11/01/2025.
22VAC40-73-350-B
Based on review of resident records, the facility failed to ascertain, prior to admission, whether a potential resident is a registered sex offender.
Evidence
  1. Resident 1 had an admission date of 07/14/2025 and the resident's record did not contain a Sex Offender Screening.
  2. Resident 2 had an admission date of 09/15/2025 and the resident's record did not contain a Sex Offender Screening.
  3. Resident 4 had an admission date of 08/31/2024 and the resident's record did not contain a Sex Offender Screening
  4. During an interview with Staff 1 and Staff 2, they were unable to locate the sex off ender screenings at the time of the inspection.
Plan of correction
A new sex offender check was conducted for resident 1, 2, and 4 which was updated immediately to be included in their administrative chart. An audit was completed for all residents to ensure registered sex offender search was completed and on their file by 10/10/2025. Administrative Assistant will ensure sex offender registry will be checked for all incoming residents.
22VAC40-73-870-A
Based on observations made during a tour of the building, the facility failed to ensure the interior of the building shall be maintained in good repair and kept clean and free of rubbish.
Evidence
  1. The Licensing Inspector (LI) observed the following during the facility tour: a. A set of blinds in resident 5 's room were torn and broken, held together at one end with a rubber band.
  2. In the Blue Ridge Cafe: a. A brown wall divider had three veneer squares intact, while the fourth square was missing. Glue residue was visible where the missing square had once been. b. A set of wooden blinds had a broken area. c. The paint on the walls was scratched and marked in the dining area.
  3. The main kitchen door was stained and marked with scrapes and yellow discoloration.
  4. The door to Room 215 had large black scratches across the middle.
  5. The carpet in front of room 208 had a long white stain.
  6. The main door near the salon had black scrapes and areas where paint had been scraped off the middle section.
  7. Photo evidence taken.
Plan of correction
The community is undergoing renovations. New paint work was started on 10/13/2025 to refresh the community. Window blinds that were missing torn in resident 5’s room and dining room were replaced immediately. Regular spot cleaning for carpets and monthly carpets shampooing as applicable will be conducted by the Maintenance Director.
22VAC40-73-860-I
Based on direct observation, the facility failed to ensure cleaning supplies and other hazardous materials are in a locked area.
Evidence
  1. On 10/07/2025, at approximately 10:08 a.m., the Licensing Inspector (LI) observed that resident 4's bathroom in the memory care facility contained one bottle of Listerine mouthwash, one spray bottle of Downy Wrinkle Releaser, two cans of Lysol disinfecting spray, and two bottles of body lotion, all stored in an unlocked area. Resident 4 also had a desk in the bedroom with a cup containing two pairs of scissors, which was also in an unlocked area.
  2. At approximately 12:29 p.m., the Licensing Inspector (LI) observed one white glass bottle of Old Spice aftershave, one bottle of Adidas aftershave, and one green disposable razor stored in an unlocked cabinet in resident 5's bathroom within the memory care facility.
  3. Photo evidence taken.
Plan of correction
All hazardous materials were locked away immediately in resident 4 and 5’s room. Families were notified immediately to ensure hazardous materials are locked away in the cabinet under the sink when visiting their loved ones. In addition, weekly rounds will be completed by the DON, ED, and Maintenance director to ensure compliance with hazardous materials being locked away. All cleaning supplies and other hazardous materials will be locked away by 11/07/25.
October 7, 2025Complaint survey2 violations
Inspection dates
10/07/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/07/2025, 9:30 A.M. To 10:30 A.M. 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 10/03/2025 regarding allegations in the area(s) of: Resident Care and Related Services, Complaint Investigation. Number of residents present at the facility at the beginning of the inspection: 43 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 2 Number of interviews conducted with residents:0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Lunch and activities. Additional Comments/Discussion: none. The evidence gathered during the investigation supported the allegation(s) of non-compliance with standard(s) or law, and violation(s) were 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 Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017 or by email at Jacquelyn.Kabiri@dss.virginia.gov
Violations
22VAC40-73-640-A
Based on documentation and interview, the facility failed to implement their written plan for medication management.
Evidence
  1. On 10/03/2025, the Licensing Inspector (LI) received an APS report stating that resident 1 arrived at INOVA Hospital on 10/02/2025 with two Exelon (Rivastigmine 9.5 mg) patches on their arm, neither of which had a written indication of the date or time.
  2. Resident 1’s October Electronic Administration Record (eMAR) was reviewed during the inspection. Resident 1’s e-MAR states that a Rivastigmine 9.5 mg patch was to be applied to the skin once daily every morning.
  3. Staff 2 provided the medication management plan to include the general and specific procedures on the administration of medication. 4 In an interview with the LI, Staff 2 confirmed that the resident arrived at the hospital wearing two Rivastigmine 9.5 mg patches. They also stated that the procedure is to remove the old patch before applying a new one. Furthermore, Staff 2 clarified that the integrity of the patch material prohibits using a marker to indicate the date and time of placement.
Plan of correction
Training was provided to all Medtechs immediately after the incident was reported to us by the family on 10/3 regarding following written plan for medication management. Director of Nursing will conduct random medication administration audits to ensure compliance.
22VAC40-73-680-D
Based on record review and staff interview, the facility failed to administer medication in accordance with the physician's or other prescriber’s instructions.
Evidence
  1. Upon record review during the onsite inspection on 10/07/2025, Resident 1 has a physician order dated 02/26/2025, Rivastigmine Dis 9.5 mg, apply a new patch to the skin once daily every morning.
  2. In an interview with the LI, staff 2 confirmed that resident 1 arrived at the hospital on 10/02/2025 wearing two Rivastigmine 9.5 mg patches.
Plan of correction
Initial training was provided to all Medtechs immediately after the incident. Additional training was also provided during all hands Medtech training regarding following medication administration in accordance with the physician’s order on 10/23.
August 7, 2025Inspection0 violations
Inspection dates
08/07/2025
Areas reviewed
22VAC40-73 BUILDINGS AND GROUND
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: 08/07/2025, 10:00 a.m. to 11:00 a.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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: 08/07/2025, 10:00 a.m. to 11:00 a.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 43 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 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: None Additional Comments/Discussion: Initial measurements of sq ft for all room models. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website should the facility be issued a license to operate. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of a licensed facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017 or by email at Jacquelyn.Kabiri@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.