Inspection dates
03/10/2026
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 PREPAREDNESS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Technical assistance
Comments
Violations
22VAC40-90-40-B
Based on the employee record review and staff interviewed, the facility failed to ensure the criminal history record report was obtained on or prior to the 30th day of employment for each employee.
1. Staff #4’s record did not have documentation of a criminal background record check criminal history record report. The staff’s date of hire was documented as 09/11/2025.
2. Staff #1 acknowledged the aforementioned staff’s record did not have documentation of a criminal background record check.
Plan of correction
1.On 3/10/2026, the facility could not provide documentation that a criminal history record report was
obtained on or prior to 30th day of employment,
2. A Virginia State Police background check was completed for Staff #4 on 3/12/2026.
3. Human Resources was educated on obtaining a Virginia State Police background check on all new
employees at time of hire within 30 days of employment.
4. The Administrator/designee will preform audits on employee files of new hires for 10 weeks to ensure
Virginia State Police criminal background record reports are completed.
22VAC40-73-450-D
Based on record reviewed and staff interviewed, the facility failed to ensure when hospice care is provided to a resident, the assisted living facility and the licensed hospice organization shall communicate and establish an agreed upon coordinated plan of care for the resident. The services provided by each shall be included on the individualized service plan (ISP).
Evidence
- 1 Resident #3’s record included a hospice plan of care for services.
- Staff #2 acknowledged resident #3’s ISP did not document hospice services provided to resident #3.
Plan of correction
1. On 3/10/2026, a resident’s ISP failed to include information regarding hospice plan of care for services.
2. The ISP for Resident #3 was updated on 3/10/2026 to reflect the coordinated plan of care for the resident between the facility and hospice organization.
3. Resident Care Coordinator was educated on including hospice plan of care for ervices on ISP when applicable.
4. The Director of Nursing/designee will perform audits for 3 months to ensure ISPs reflect all of the residents needs including hospice plan of care.
22VAC40-73-980-A
Based on observation and staff interviewed, the facility failed to ensure the first aid kit included all required items.
Evidence
- The first aid kit did not include a flashlight and extra batteries.
- Staff #2 acknowledged the first aid kit did not include all required items.
Plan of correction
1. On 3/10/2026, the facility failed to ensure all required items were in the first aid kit including a flashlight and extra batteries.
2. A flashlight and extra batteries were placed back into the first aid kit on 3/10/2026.
3. All staff were educated on ensuring items removed from the first aid kit are replaced or returned to the first aid kit after use.
4. The Director of Nursing/designee will perform weekly audits to ensure all items are in the first aid kit for 3 months and then on a monthly basis to ensure compliance.
22VAC40-73-650-A
Based on record reviewed and staff interviewed, the facility failed to ensure no medication, dietary supplement, diet, medical procedure, or treatment shall be started, changed, or discontinued by the facility without a valid order from a physician or other prescriber. Medications include prescription, over-the counter, and sample medications.
Evidence
- Resident #1’s record did not include a physician or prescriber’s order to start resident #1’s Citrucel POW. Resident #1’s March 2026 medication administration record documented the resident was prescribed, Citrucel POW 15 grams by mouth one time a day for constipation.
- Staff #5 acknowledged the aforementioned record did not have signed and dated order tostart the Citrucel POW medication.
Plan of correction
1. On 3/10/2026, the facility did not include a physician or prescriber’s order to start a medication.
2. The facility has since discontinued Resident #1’s Citrucel POW medication.
3. Staff education was completed on having signed orders in place from an outside provider prior to
entering medication orders for residents.
4. The Director of Nursing/designee will perform audits for 10 weeks to ensure all medications have signed physician or prescriber orders in place.