Virginia DSS · Assisted Living Facility

Cambridge Landing Memory Care

📍 304 Bowman Mill Road, Strasburg, VA, 22657

ID 52841Conditional licenseActive
10
Inspections
On record
4
With violations
Visits that cited something
6
Clean visits
Nothing cited
17
Violations cited
Individual findings
15
Standards cited
Distinct rules
4
Complaint visits
Prompted by a complaint

Cambridge Landing Memory Care was inspected 10 times between June 29, 2023 and April 2, 2026 by the Virginia Department of Social Services. 4 of those visits ended with violations cited and 6 with none. Across that history VDSS cited 17 violations under 15 distinct standards. 4 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. 1 of these 10 is still on the state's site; the other 9 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
Conditional
License expires
10/23/2026
Administrator
Meta Patton
Licensing inspector
Angela Via
Inspector phone
(540) 682-1739
Approved for
Assisted Living · Non-Ambulatory · Special Care Unit

Inspection History

10

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

April 2, 2026Inspection1 violation
Inspection dates
04/02/2026
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND63.2- (1) General Provisions63.2- (17) Licensure and Registration Procedures63.2- (18) Facilities and Programs22VAC40-80 The Licensing Process
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: April 2, 2026, from 10:00 a.m. until 11:15 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: 26 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: The Licensing Inspector toured the community inside and outside. The Licensing Inspector reviewed the following at the time of inspection: required postings, measurements of resident rooms and windows, current health inspections, current fire inspections, water temperatures, signaling devices, emergency food and water supplies, and emergency power source. 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 Angie Via, Licensing Inspector at (540) 682-1739 or by email at Angela.via@dss.virginia.gov
Violations
22VAC40-73-860-I
Based on observation and staff interview, the facility failed to store ordinary materials that may be harmful to a resident in an inaccessible area.
Evidence
  1. During a tour of the facility on 04/02/2026, LI observed an unattended cleaning cart in the hallway with cleaning liquids sitting on top, including Windex, Zep cleaning solution, and toilet bowl cleaner.
  2. During a tour and interview with the LI on 04/02/2026, staff 1 confirmed the cleaning cart was unattended with chemicals on top and not secured.
  3. Photo evidence taken.
Plan of correction
We are looking into purchasing a new housekeeping cart with a hood. Until then, housekeeping staff is keeping all chemicals locked in the cabinet on the cart, and our maintenance director and I are monitoring to ensure this is being done consistently.
December 11, 2024Inspection11 violations
Inspection dates
Dec. 11, 2024 and Dec. 12, 2024
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/11/24 9:15 a.m.to 3:30 and 12/12/24 9:00 to 4:30 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The evidence gathered during the initial inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The applicant has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to maintain future compliance with applicable standard(s) or law. If the applicant wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website should the facility be issued a license to operate. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of a licensed facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jill James, Licensing Inspector at (540) 418-2631 or by email at jill.james@dss.virginia.gov
Violations
22VAC40-73-190-C
Based on record reviews and staff interview, the facility failed to ensure that staff had training on duties and responsibilities prior to being placed in charge when manager was not on the premises.
Evidence
  1. Review of records for staff 1 (hired 9/29/2023) and staff 2 (hired 10/28/2023) did not include documentation of training on staff in charge duties and responsibilities.
  2. On 12/12/2024, staff 9 confirmed staff 1 and 2 had been assigned as staff in charge, there was no training, no documentation of training or job description that described their duties and responsibilities.
Plan of correction
All employee files audited. Job descriptions, duties and responsibilities reviewed and signed. Staff #2 is not a medication aid and is not a designated person in charge.
22VAC40-73-240-F
Based on record reviews and staff interview, the facility failed to ensure all volunteers attended an orientation prior to beginning volunteer service.
Evidence
  1. Records did not contain documentation of orientation for volunteers 1 (application 4/19/2023), 2 (11/16/2022), and 3 (application not dated).
  2. On 12/12/2024, staff 11 confirmed that volunteers 1, 2 and 3 were currently providing volunteer services and they had not completed orientation to her knowledge. Staff 11 also confirmed records did not include documentation of completion of orientation.
Plan of correction
All volunteers will be oriented to the facility prior to offering volunteer services.
22VAC40-73-260-A
Based on record review and staff interview, the facility failed to ensure that each direct care staff member who did not have certification in first aid received certification within 60 days of employment.
Evidence
  1. Records for staff 1 (hired 11/28/2023) included a first aid certificate dated as completed on 4/23/2024.
  2. On 12/22/2024, staff 8 confirmed that staff 1 had not completed first aid by the 60th day of employment and the only other first aid certificate on file had a completion date of 4/23/2024.
Plan of correction
Audit of all staff records. All new hires will have first aid and CPR within 30 days of employment.
22VAC40-73-350-A
Evidence
  1. On 12/12/2024, the licensing inspector requested documentation of VDSP notifications.
  2. On 12/12/2024, staff 9 confirmed VDSP notifications had not been received for some time and determined that the facility had not been registered with VDSP since the ownership and email address changed in July 2023.
Plan of correction
Facility is registered with the Virginia State Police sex offender notification system.
22VAC40-73-610-B
Based on observation and staff interview, the facility failed to ensure the menu for meals and snacks for the current week was posted in an area conspicuous to residents.
Evidence
  1. On 12/11/2024, during a tour of the facility, the licensing inspector observed the menu for the day posted in the dining room.
  2. On 12/11/2024, staff 8 confirmed that the weekly menu was not posted in an area conspicuous to residents and that the facility practice was to post the weekly menu in the kitchen and only the menu for the day was posted in the dining room.
Plan of correction
Menus are posted on menu board in hallway.
22VAC40-73-610-E
Based on observation and staff interview, the facility failed to ensure that a copy of a diet manual containing acceptable practices and standards for nutrition was available.
Evidence
  1. On 12/22/2024, the licensing inspector toured the kitchen and did not observe a diet manual.
  2. On 12/22/2024, staff 8 and staff 9 confirmed the facility did not have a diet manual.
Plan of correction
Diet Manual purchased and in the dietary department.
22VAC40-73-620-B
Based on document reviews, the facility failed to ensure that the oversight of special diets included a certification statement from the dietician that all requirements of the review were met.
Evidence
  1. The oversight review of special diets completed on 10/22/2024 did not contain a certification statement from the dietician that the review included an evaluation of the adequacy and included an evaluation of the adequacy and acceptance of the residents? diets.
Plan of correction
Contracted dietician notified of specific requests of licensing inspector. Future oversights will include this information.
22VAC40-73-950-A
Based on document reviews and staff interview, the facility failed to develop a written emergency preparedness and response plan.
Evidence
  1. On 12/12/2024, the licensing inspector requested the emergency preparedness plan. The emergency binder provided contained a blank template titled Extended Care Facility Emergency Response Guidelines as well as a generalized handout for disaster planning for food service establishments.
  2. On 12/12/2024, staff 9 confirmed there was no written emergency preparedness and response plan for the facility.
Plan of correction
Written Disaster plan developed and in final stages of completion.
22VAC40-73-950-E
Based on document reviews and staff interview, the facility failed to implement a semi-annual review on the emergency preparedness and response plan for all residents, staff, and volunteers.
Evidence
  1. On 12/12/2024, the licensing inspector requested supporting documentation to show that a review of the emergency preparedness and response plan was conducted with residents, staff, and volunteers over the past year.
  2. On 12/12/2024, staff 9 provided a training log with staff signatures dated 3/28/2024 titled Evacuation, which did not include what was covered in the training.
  3. On 12/12/2024, staff 9 confirmed there was no additional documentation to show a semi-annual review had been completed on the emergency preparedness and response plan.
  4. On 12/12/2024, staff 9 confirmed there was no written emergency preparedness and response plan for the facility.
Plan of correction
Review of Emergency Preparedness Plan will be completed semi-annually and as needed.
22VAC40-73-970-A
Based on document reviews and staff interview, the facility failed to ensure monthly fire drills were completed.
Evidence
  1. The record for fire and emergency evacuation drills documented that a fire drill was last completed on 8/30/2024.
  2. On 12/12/2024, staff 9 confirmed the fire drills were not conducted for September 2024, October 2024 and November 2024.
Plan of correction
Monthly Fire drills will be conducted.
22VAC40-73-990-A
Based on documentation and staff interview, the facility failed to ensure staff participated in an exercise in which procedures for handling resident mental health emergencies were reviewed.
Evidence
  1. On 12/12/2024, the licensing inspector requested documentation of all resident emergency exercises conducted since the last inspection on 11/06/2023. There was no documentation provided that resident mental health emergencies were practiced.
  2. On 12/12/2024, staff 9 confirmed that staff had not participated in exercises on handling mental health emergencies.
Plan of correction
Mental Health Emergency drills will be completed upon hire and semi-annually.
March 27, 2024Complaint survey0 violations
Areas reviewed
Resident Care and Related Services
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: 03/27/2024 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: 23 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: 3 Number of interviews conducted with staff: 1 Observations by licensing inspector: Additional Comments/Discussion: Licensing Inspectors observed residents participating in activity programs. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the (allegation(s)/self-report) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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. Use the following last two statements on every Inspection Summary: For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
January 31, 2024Complaint survey0 violations
Inspection dates
Jan. 31, 2024
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES
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: LI entered the facility at 2:30 pm on 1/31/2024 and exited at 2:47 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 1/5/2024 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: 22 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: 2 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 0 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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 Jamie Eddy, Licensing Inspector at (703) 479-5247 or by email at jamie.eddy1@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
November 6, 2023Inspection2 violations
Inspection dates
Nov. 6, 2023
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 ? SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE
Technical assistance
Please submit your renewal application 30 days prior to the expiration of your current license. A new license cannot be issued without the submission of a renewal application.
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: LI entered the facility at 8:30 am on 11/6/2023 and exited at 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: 24 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: 0 Number of interviews conducted with staff: 0 Observations by licensing inspector: LI observed medication administration. LI observed residents eating breakfast and lunch. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview (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 Jamie Eddy, Licensing Inspector at (703) 479-5247 or by email at jamie.eddy1@dss.virginia.gov
Violations
22VAC40-73-680-D
Based on a review of records during the renewal inspection on 11/6/2023, the facility failed to ensure that medications were administered in accordance with the physician’s or other prescriber’s instructions for one of six residents.
Evidence
  1. The November 2023 Medication Administration Record (MAR) for Resident 5 (R5) documented that at approximately 8:00 am on 11/6/2023 the systolic blood pressure for R5 was 109.
  2. The signed physician’s orders of 4/10/2023 documented that R5 is not to receive Metoprolol 25 mg if systolic blood pressure is less than 110.
  3. According to the November 2023 MARS, Staff #1 administered Metoprolol at approximately 8 am on 11/6/2023 to R5.
Plan of correction
The provider’s responses for the “plan of correction” were not received as of 12/5/2023 and will not appear on the violation notice.
22VAC40-73-680-I
Based upon a review of records, the facility failed to ensure that Medication Administration Records (MARS) included date and time given and initials of direct care staff administering the medication for one of six residents.
Evidence
  1. According to the Controlled Drug Record for Resident 1 (R1), staff administered an as needed (prn) dose of Lorazepam on 11/2/2023 at approximately 6:15 pm.
  2. There are neither initials of staff administering the prn Lorazepam, nor the time given documented on the MARS for R1 on 11/2/2023.
Plan of correction
The provider’s responses for the “plan of correction” were not received as of 12/5/2023 and will not appear on the violation notice.
November 6, 2023Inspection0 violations
Inspection dates
Nov. 6, 2023
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
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: LI entered the facility at 8:30 am on 11/6/2023 and exited at 1:40 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 10/1/2023regarding allegations in the area(s) of resident care and related services. Number of residents present at the facility at the beginning of the inspection: 24 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: 2 Observations by licensing inspector: Additional Comments/Discussion: The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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 Jamie Eddy, Licensing Inspector at (703) 479-5247 or by email at jamie.eddy1@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
September 21, 2023Inspection3 violations
Inspection dates
Sept. 21, 2023
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 ? SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS
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: LI entered the facility at 8:43 am on 9/21/2023 and exited at 3:05 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: 23 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 3 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: LI observed medication administration. LI observed residents eating breakfast and engaging in activities. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jamie Eddy, Licensing Inspector at (703) 479-5247 or by email at jamie.eddy1@dss.virginia.gov
Violations
22VAC40-73-260-A
Based upon a review of records during a mandated inspection conducted on 9/21/2023, the facility failed to ensure that each direct care staff member had a current certification in first aid within 60 days of employment.
Evidence
  1. The staff record for Staff #3, who was hired on 7/15/2023, did not contain a current certification in first aid.
Plan of correction
Staff #3 has completed First Aid training on 9/21/2023. All staff files have been audited to ensure compliance. Training log sheets will be kept updated and current to track training needs.
22VAC40-73-640-A
Based upon a review of records, the facility failed to ensure that medication orders were transcribed to Medication Administration Record (MAR) within 24 hours of receipt of a new order or change in an order.
Evidence
  1. The record for Resident #1 contained a physician's order to discontinue Furosemide 20mg on 8/16/2023.
  2. The discontinued order for Furosemide 20mg was listed on the September 2023 MAR for Resident #1.
Plan of correction
Nurse will audit all orders received in the EMAR system for accuracy. The audits will take place daily as orders are received by the physician.
22VAC40-73-680-I
Based upon a review of records and observations, the facility failed to ensure that Medication Administration Records (MARs) include the date prescribed and initials of direct care staff administering the medication.
Evidence
  1. The September 2023 MAR for Resident #2 (R2) did not include the date the following medications were prescribed: Risperidone, Probiotic, and Cipro.
  2. The September 2023 MAR for Resident #1(R1) did not include the date Furosemide 40mg was prescribed.
  3. Licensing Inspector (LI) observed Staff #1 administer medications to R1 at approximately 9:25 am on 9/21/2023 and to R2 on 9/21/2023 at approximately 9:45 am.
  4. LI reviewed September 2023 MARS for R1 and R2 and observed that Staff #1 did not initial the MARs for 9/21/2023 for the medication administered to R1 at approximately 9:25 am and to R2 at approximately 9:45 am.
  5. The September 2023 MAR for Resident #5 did not have initials of direct care staff who administered medications at approximately 8:00 am on 9/2/2023.
Plan of correction
Facility will be live with new electronic medication administration system (EMAR) and all medication aids will be trained on using the new system by 10/10/2023. Nurse will check medication orders for accuracy prior to initial use of EMAR system. All staff will receive an in-service on proper documentation. To include the 5 rights of medication administration and signing off administered medication. Nurse audited all paper MARS for accuracy. Nurse will audit all medication orders to ensure accuracy on all orders in the electronic system.
September 21, 2023Complaint survey0 violations
Inspection dates
Sept. 21, 2023
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
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: LI entered the facility at 8:43 am on 9/21/2023 and exited at 2:45 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 8/21/2023) regarding allegations in the area(s) of resident care and related services and additional requirements for facilities that care for adults with serious cognitive impairments. 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: 0 Observations by licensing inspector: LI observed staff interacting with residents. LI observed the resident’s rooms. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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 Jamie Eddy, Licensing Inspector at (703) 479-5247 or by email at jamie.eddy@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
July 19, 2023Complaint survey0 violations
Inspection dates
July 19, 2023 and Aug. 2, 2023
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
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: LI entered the facility at 1:35 pm on 7/19/2023 and exited at 3:15 pm. LI entered the facility at 9:35 am on 8/2/2023 and exited at 10:35 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 7/14/2023 regarding allegations in the area(s) of: resident care and related services, resident accommodations and related provision, and additional requirements for facilities that care for adults with serious cognitive impairments. 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: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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 Jamie Eddy, Licensing Inspector at (703) 479-5247 or by email at jamie.eddy@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
June 29, 2023Inspection0 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 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSING PROCESS
Technical assistance
New resident agreement and facility disclosure statement t to be provided to all residents and/or legal representative; sworn affirmation and criminal history report via Virginia State Police to be obtained on all employees;job descriptions to be provided to all employees.
Comments
Type of inspection: Initial Date(s) of inspection and time the licensing inspectors were on-site at the facility for each day of the inspection: 06/29/2023 from approximately 9:30am until 1:30pm. 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: 27 The licensing inspectors 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: 15 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspectors: activities calendar, menu, dietary oversight, pharmacy review and postings 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 Rhonda Whitmer, Licensing Inspector at (540) 292-5932 or by email at rhonda.whitmer@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.