Virginia DSS · Assisted Living Facility

Viva Memory Care at Chesapeake

📍 130 Great Bridge Boulevard, Chesapeake, VA, 23320

ID 52886Conditional licenseActive
32
Inspections
On record
23
With violations
Visits that cited something
9
Clean visits
Nothing cited
59
Violations cited
Individual findings
39
Standards cited
Distinct rules
15
Complaint visits
Prompted by a complaint

Viva Memory Care at Chesapeake was inspected 32 times between September 17, 2020 and February 18, 2026 by the Virginia Department of Social Services. 23 of those visits ended with violations cited and 9 with none. Across that history VDSS cited 59 violations under 39 distinct standards. 15 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 32 is still on the state's site; the other 31 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
10/31/2026
Administrator
Kenya Bains
Licensing inspector
Donesia Peoples
Inspector phone
757 353-0430
Approved for
Assisted Living · Special Care Unit

Inspection History

32

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

February 18, 2026Inspection1 violation
Inspection dates
02/18/2026
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-80 THE LICENSE22VAC40-80 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: An announced initial inspection took place on 02/18/2026 at 1:05 pm to 1:53 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: 41 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: 3 Observations by licensing inspector: Measurement of resident rooms was completed. The water temperature was measured, and the call bell system was monitored. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. 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. 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 should the facility be issued a license to operate. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of a licensed facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov.
Violations
22VAC40-73-930-B
Based on observation, and staff interviews the facility failed to ensure in buildings licensed to care for 20 or more residents under one roof, there shall be a signaling device that terminates at a central location that is continuously staffed and permits staff to determine the origin of the signal or is audible and visible in a manner that permits staff to determine the origin of the signal.
Evidence
  1. During the Licensing Inspector (LI) observation of the facility’s call alert system on 02/18/2026 with staff #1, the pull cords located in the bathrooms and resident rooms that are to be used for residents to alert staff when assistance is needed were not working.
  2. During an interview on 02/18/26 with staff #1, staff #2, and staff #3, staff #1, staff #2, and staff #3 confirmed the facility did not have an operable and working signaling device that is accessible to the residents that alerts staff when the resident needs assistance.
Plan of correction
What has been done to correct? An inspection of the call bell system was conducted by the vendor and Maintenance Director How will occurrence be prevented? A quarterly testing of the call bell system will be conducted. Person Responsible? Maintenance Director and Executive Director
October 30, 2025Complaint survey0 violations
Inspection dates
Oct. 30, 2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 10/30/2025 at 11:15 am to 2:35 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 10/03/2025 regarding allegations in the area(s) of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 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: 3 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: An observation of the lunch was completed. Additional Comments/Discussion: None 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 (Donesia Peoples), Licensing Inspector at (757) 353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
October 30, 2025Complaint survey0 violations
Inspection dates
Oct. 30, 2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 10/30/2025 at 11:15 am to 2:35 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 10/02/2025 regarding allegations in the area(s) of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 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: 3 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: An observation of the lunch was completed. Additional Comments/Discussion: None 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 (Donesia Peoples), Licensing Inspector at (757) 353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
October 30, 2025Inspection0 violations
Inspection dates
Oct. 30, 2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced monitoring inspection took place on 10/30/2025 at 10:41 am to 11:15 am. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-report was received by VDSS Division of Licensing on 9/27/2025 regarding allegations in the area(s) of: The Safe Secure Unit 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: 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: An observation of the facility’s exit doors was completed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. 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 (Donesia Peoples), Licensing Inspector at (757) 353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
September 11, 2025Complaint survey2 violations
Inspection dates
Sept. 11, 2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 09/11/2025 at 9:39 am to 3:35 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 09/08/2025 regarding allegations in the area(s) of: Resident Care and Related Services, Staffing and Supervision, and the Safe Secure Environment Number of residents present at the facility at the beginning of the inspection: 60 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: 4 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: An observation of the facility’s medication carts were completed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some but not all of the complaint of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact (Donesia Peoples), Licensing Inspector at (757) 353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-650-A
Based on the record review and staff interview 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
  1. The record for resident #1 contains the following: ? A physician order signed and dated 03/18/25 for Eliquis 2.5 mg, one tablet by mouth twice a day for a start date of 03/09/25. ? Resident’s March 2025 Medication Administration Record (MAR) includes instructions to take Eliquis 2.5mg one tablet by mouth twice a day with a start date of 03/09/25 and a discharge date of 03/25/25.
  2. The record for resident #1 did not contain a valid order from a physician or other prescriber to discontinue Eliquis 2.5mg one tablet twice a day.
  3. Upon request, and during an interview on 09/11/25 with staff #2, staff #2 was not able to provide a valid order to discontinue Eliquis 2.5mg for resident #1. Staff #2 confirmed a valid order to discontinue Eliquis 2.5mg was not in the resident’s record.
Plan of correction
What was done to correct? RCD/ARCD in serviced on Viva Medication Management policy How will the occurrence be Prevented? Monthly in-services for medication management will be provided to staff Person Responsible? RCD/ARCD
22VAC40-73-680-D
Based on the record review and staff interview the facility failed to ensure medications shall be administered in accordance with the physician's or other prescriber’s instructions.
Evidence
  1. The record for resident #1 contains a physician order and physician note dated 07/25/25 to increase Seroquel to 75mg at night and maintain 50mg in the morning for agitation/anxiety/aggression related to dementia.
  2. Resident #1’s July and August 2025 Medication Administrator Records (MARs) did not include instructions to take Seroquel 75 mg every night at bedtime starting 07/25/25. The instructions on the July and August 2025 MARs is to take Seroquel 50mg one tablet by mouth twice a day.
  3. During an interview on 09/11/25 with staff #2, staff #2 confirmed resident #1’s July and August 2025 MARs did not include instructions per the physician order dated 07/25/25 for the resident to start taking Seroquel 75mg at bedtime starting 07/25/25.
Plan of correction
What was done to correct? In-service for RMAs How will the occurrence be Prevented? Prescriber orders will be reviewed by the RCD/ARCD and sign off as received and verification of the medication in the EMR Person Responsible? RCD/ARCD
August 27, 2025Inspection1 violation
Inspection dates
Aug. 27, 2025 and Sept. 11, 2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced monitoring inspection took place on 08/27/2025 at 9:59 am to 4:20 pm and 09/11/2025 at 9:39 am to 3:35 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-report was received by VDSS Division of Licensing on 8/23/2025 and 08/26/2025 regarding allegations in the area(s) of: Resident Care and Related Services and the Safe Secure Environment Number of residents present at the facility at the beginning of the inspection: 60 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: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: An observation of the facility’s medication carts were completed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact (Donesia Peoples), Licensing Inspector at (757) 353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-640-A
Based on the facility’s incident report, record review, and staff interview, the facility failed to implement a written plan for medication management.
Evidence
  1. The facility’s medication management plan dated 09/01/24, documents that medications always need to be administered according to the “7 rights” (right person, right medication, right time, right route, right reason, and right record). 2.Staff #5 sent an incident report via email to the Licensing Inspector (LI) on 8/26/25 that included the following for a medication error that occurred on 08/20/25: Resident #1 was administered resident #2’s medications at 9am.
  2. During an interview on 08/27/25 with staff #1, staff #1 stated on 08/20/25 at 9am, staff #1 administered the following medications to resident #1 in error as these medications are prescribed to resident #2: ? Amlodipine 1mg for hypertension ? Aspirin 81 mg for blood thinner ? Calcium 600mg for supplement ? Ezetimbe 10mg for hyperlipidemia ? Pepcid/Famotidine 20 mg for Gerd ? Januvia 100mg for Diabetes ? Metformin 500mg for Diabetes ? Multivitamin for Supplement ? Omega Fish Oil for Dyslipidemia ? Ramipril 10mg for Hypertension
  3. Resident #1’s hospital visit summary dated 8/20/25 documents the reason for visit as drug overdose and the diagnoses as hypotension, hyperglycemia, medication administered in error, and accidental overdose. Lab tests were completed and the resident was treated with sodium chloride. Staff #1 stated resident returned to the facility on 08/20/25 with no new orders from the hospital.
  4. Staff #5 sent an incident report via email to the Licensing Inspector (LI) on 8/23/25 that included the following for a medication error that occurred on 08/22/25: ? Resident #3 was given resident #4’s medication.
  5. An email sent to the LI on 8/26/25 states that on 08/22/25, resident #3 was administered the following medications prescribed to resident #4: ? Atorvastation 40 mg for hyperlipidemia ? Lantus 38 units for diabetes ? Ativan/Lorazepam for dementia 0.5mg ? Metformin 500mg for diabetes
  6. Resident #3’s hospital documentation (pages 30-35) dated 08/22/25 through 08/24/2025 states the resident was admitted 08/22/25 through 08/24/25 for receiving another resident’s medication, insulin overdose, accidental or unintentional. The resident received IV dextrose for treatment and the resident’s blood sugar levels were monitored during the hospital stay.
Plan of correction
What was done to correct? RCD/ARCD in serviced on Viva Medication Management policy How will the occurrence be Prevented? Monthly in-services for medication management will be provided to staff Person Responsible? RCD/ARCD
August 27, 2025Complaint survey2 violations
Inspection dates
Aug. 27, 2025 and Sept. 11, 2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 08/27/2025 at 9:59 am to 4:20 pm and 09/11/25 at 9:39 am to 3:35 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by the VDSS Division of Licensing on 8/15/2025 regarding allegations in the area(s) of: Personnel, Staffing and Supervision, and Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 66 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 5 Number of staff records reviewed: 5 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Residents were observed completed an activity, and lunch was observed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the complaint 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 (Donesia Peoples), Licensing Inspector at (757) 353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-200-C
Based on the record review, collateral contact interview, and staff interview the facility failed to ensure direct care staff shall meet one of the requirements in this subsection. If the staff does not meet the requirement at the time of employment, he shall successfully meet one of the requirements in this subsection within two months of employment.
Evidence
  1. The record for Staff #1, (hire date of 07/16/25 and suspended on 09/25/25), contains a personal care aide (PCA) training certificate with a date of December 2024. During a phone interview on 09/24/25 with collateral contact #1, collateral contact #1 stated staff #1 did not enroll in and/or complete the personal care aide training program provided by collateral contact #1’s home health care agency. Collateral contact #1 stated the instructor listed on the PCA certificate does not provide instructor training for collateral contact #1’s PCA training program.
  2. Upon request on 09/24/25 for evidence of staff #1’s qualifications as a direct care staff, staff #3 sent the Licensing Inspector (LI) an email on 09/25/25 containing an email from collateral contact #1’s agency stating staff #1 has not completed the personal care aide training program with the agency.
  3. During a phone interview on 09/25/25, with staff #3, staff #3 stated staff #1 was suspended from the facility on 09/25/25 due to not providing evidence of qualifications as a direct care staff.
Plan of correction
What has been done to correct? Audit of employee files of direct care staff. How will occurrence be Prevented? Business Office Manager will obtain the credentials of the direct care staff upon hire and verify the validity. Business office manager will audit the employee file of the direct care staff quarterly. Person Responsible: Business Office Manager
22VAC40-73-490-A
Based upon staff interview the facility failed to ensure if a facility employs a licensed health care professional, who is onsite on a full time basis, a licensed health care professional, practicing within the scope of the health care professional’s profession, shall provide health care oversight at least every six months.
Evidence
  1. Upon request and during an interview on 08/27/25 with staff #3, staff #3 provided a health care oversight completed on 12/27/24. Staff #3 was not able to provide a healthcare oversight completed within six months after 12/27/24.
Plan of correction
What has been done to correct? The Regional Clinical Director has initiated completion of the healthcare oversight on 9/9, 9/10, and 9/11. How will occurrence be Prevented? A Healthcare Oversight will be provided every 6 months. Person Responsible: Resident Care Director and Regional Clinical Director
August 27, 2025Complaint survey0 violations
Inspection dates
Aug. 27, 2025 and Sept. 11, 2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 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 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 08/27/2025 at 9:59 am to 4:20 pm and 09/11/2025 at 9:39 am to 3:35 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by the VDSS Division of Licensing on 8/15/2025 regarding allegations in the area(s) of: Regulations for Background Checks for Assisted Living Facilities and Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 66 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 5 Number of staff records reviewed: 6 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: Resident were observed completing an activity in the common area. Additional Comments/Discussion: None 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 (Donesia Peoples), Licensing Inspector at (757) 353-0430 or by email at donesia.peoples@dss.virginia.gov Violation Notice Issued: Yes A copy of this document will be sent to the licensee/provider for signature.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
August 27, 2025Complaint survey3 violations
Inspection dates
Aug. 27, 2025 and Sept. 11, 2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 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 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 08/27/2025 at 9:59 am to 4:20 pm and 09/11/2025 at 9:39 am to 3:35 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by the VDSS Division of Licensing on 8/15/2025 regarding allegations in the area(s) of: Regulations for Background Checks for Assisted Living Facilities and Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 66 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 5 Number of staff records reviewed: 5 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: Resident were observed completing an activity in the common area. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the complaint 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 (Donesia Peoples), Licensing Inspector at (757) 353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-440-A
Based on the record review and staff interview the facility failed to ensure all residents of and applicants to assisted living facilities shall be assessed face to face using the uniform assessment instrument in accordance with Assessment in Assisted Living Facilities (22VAC30-110). The Uniform Assessment Instrument (UAI) shall be completed prior to admission, at least annually, and whenever there is a significant change in the resident's condition.
Evidence
  1. Resident #2’s UAI in the record is dated as completed on 03/20/24. The resident’s record did not contain an annual UAI completed after 03/20/24.
  2. Upon request and during an interview on 09/11/25 with staff #2, staff #2 was not able to provide an annual UAI completed after 3/20/24 for resident #2.
  3. Resident #4’s UAI in the record is dated as completed on 04/26/24. The resident’s record did not contain an annual UAI completed after 04/26/24.
  4. Upon request and during an interview on 09/11/25 with staff #2, staff #2 was not able to provide an annual UAI completed after 04/26/24 for resident #4.
Plan of correction
What has been done to correct? An audit of UAIs has been completed and UAIs have been updated. How will occurrence be prevented? The Resident Care Director/Assistant Resident Care Director will assess applicants face to face for admission prior to being admitted to the community. Resident Care Director/Assistant Resident Care Director will complete face-to-face assessments annually, and whenever there is a significant change in resident’s condition. The RCD/ARCD will use the Uniform Assessment Instrument to complete the face-to-face assessments prior to admissions, annually and when there is a significant change in resident’s condition. The RCD and ARCD will complete an audit of files every quarter. Person Responsible? Resident Care Director (RCD) and Assistant Resident Care Director (ARCD)
22VAC40-73-450-F
Based on the record review and staff interview the facility failed to ensure Individualized service plans (ISP) shall be reviewed and updated at least once every 12 months and as needed for a significant change of a resident’s condition.
Evidence
  1. Resident #2’s ISP in the record is dated as completed on 03/20/24. The resident’s record did not contain an ISP reviewed and updated at least 12 months after 03/20/24.
  2. Upon request and during an interview on 09/11/25 with staff #2, staff #2 was not able to provide an ISP completed after 3/20/24 for resident #2.
  3. Resident #4’s ISP in the record is dated as completed on 04/26/24. The resident’s record did not contain an ISP reviewed and updated at least 12 months after 04/26/24.
  4. Upon request and during an interview on 09/11/25 with staff #2, staff #2 was not able to provide an ISP
Plan of correction
What has been done to correct: Audit of resident files. ISPs updated. How will occurrence be prevented? An audit will be done at least once every 12 months and as needed for a significant change (greater than 30 days) of a resident’s condition. Person Responsible: Resident Care Director and Assistant Resident Care Director
22VAC40-90-40-B
Based on the record review and staff interview the facility failed to ensure the criminal history record report shall be completed within 30 days of employment for each employee.
Evidence
  1. The record for staff #8, hire date of 04/01/25, does not contain a criminal history report.
  2. Upon request and during an interview on 09/11/25 with staff #3, staff #3 was not able to provide a criminal history report for staff #8.
Plan of correction
What has been done to correct? An audit of employee files How will occurrence be prevented? A criminal history search will be completed at time of hire for each person who has been offered employment. The Business Office Manager and Executive Director will complete an employee file audit quarterly. Person Responsible? Business Office Manager and Executive Director
July 10, 2025Complaint survey0 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 IMPAIRMENTS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 07/10/2025 at 09:50 am to 12:00 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 06/30/2025 regarding allegations in the area(s) of: Staffing and Supervision, Resident Care and Related Services, Personnel, and the Safe Secure Environment. Number of residents present at the facility at the beginning of the inspection: 69 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: 3 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 6 Observations by licensing inspector: Observed residents participating in an activity. The facility’s staffing schedule was reviewed. A review of the facility’s policy and procedures for staff were reviewed. An observation of the facility’s food and snacks supply was completed. Additional Comments/Discussion: Family member interview was completed. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the complaint 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 (Donesia Peoples), Licensing Inspector at (757) 353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 27, 2025Complaint survey4 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 IMPAIRMENTS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 05/27/2025 at 11:00 am to 1:15 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by the VDSS Division of Licensing on 05/22/2025 regarding allegations in the area(s) of: Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 66 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Facility's incident reporting policy was reviewed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the complaint 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 (Donesia Peoples), Licensing Inspector at (757) 353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-70-A
Based on the record review and staff interview the facility failed to ensure each facility shall report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident.
Evidence
  1. The record for resident #1 contains a progress note dated 05/07/25 documenting the resident was drooling from his mouth, speechless, and seemed very weak. The facility staff contacted 911 and the resident was taken to the hospital.
  2. During an interview on 05/27/25 with staff #1, staff #1 acknowledged the facility did not notify the regional licensing office of resident’s #1 hospital admission on 05/07/25.
  3. The record for resident #2 contains a progress note dated 05/09/25 documenting the resident was sent to the hospital for evaluation of wound on resident’s leg. Resident’s #2 progress notes dated 05/12/25 and 05/13/25 documents the resident was admitted to the hospital for cellulitis of the right lower leg with wound to right lower leg.
  4. During an interview on 05/27/25 with staff #1, staff #1 acknowledged the facility did not notify the regional licensing office of resident’s #2 hospital admission on 05/09/25.
Plan of correction
Regional Director of Clinical Operations to revise policies 2.11 ( emergency/ 911) and 2.13 (incident report) to reflect notifying Licensing office. Executive Director and/or designee to in-service Nursing Team on the importance of reporting any major incidents that have a negative effect or threaten life, health, safety or welfare of any resident. To be corrected by 6/6/2025
22VAC40-73-325-B
Based on the record review and staff interview the facility failed to ensure the fall risk rating shall be reviewed and updated after a fall.
Evidence
  1. Resident’s #1 progress notes document the resident had a fall on the following dates: 03/06/25, 03/11/25, 04/06/15, 04/17/25, and 04/26/25. The resident’s record did not contain a fall risk rating completed after each fall that occurred on the following dates: 03/06/25, 03/11/25, 04/06/15, 04/17/25, and 04/26/25.
  2. Upon request, during an interview on 05/27/25 with staff #1, the facility did not provide documentation of a fall risk rating completed for resident #1 after each fall that occurred on the following dates: 03/06/25, 03/11/25, 04/06/15, 04/17/25, and 04/26/25.
Plan of correction
Assistant Resident Care Director and/or designee will be in-serviced on the importance of completing a fall risk rating after a fall. All incidents relating to falls will be reviewed for fall risk rating, and completed by 6/6/25
22VAC40-73-470-F
Based on the record review and staff interview the facility failed to ensure when the resident suffers serious accident, injury, illness, or medical condition, or there is reason to suspect that such has occurred, medical attention from a licensed health care professional shall be secured immediately. The circumstances involved and the medical attention received or refused shall be documented in the resident's record. The date and time of occurrence, as well as the personnel involved shall be included in the documentation. The resident's physician, if not already involved, next of kin, legal representative, designated contact person, case manager, and any responsible social agency, as appropriate, shall be notified as soon as possible but no later than 24 hours from the situation and action taken. A notation shall be made in the resident's record of such notice, including the date, time, caller, and person notified.
Evidence
  1. The record for resident #1 contains a progress note dated 05/07/25 documenting the resident was drooling from his mouth, speechless, and seemed very weak. The facility staff contacted 911 and the resident was taken to the hospital. The resident’s record did not contain documentation the resident’s legal representative was notified within 24 hours of the resident’s change in medical condition and transport to the hospital.
  2. During an interview on 05/27/25 with staff #1, staff #1 acknowledged the record for resident #1 did not contain documentation the resident’s legal representative was notified within 24 hours of the resident’s change in medical condition and transport to the hospital that occurred on 05/07/25.
Plan of correction
All registered medication aides to be in-service on documenting that the resident’s legal representative was notified within 24 hours of the resident’s change in medical condition and transport to the hospital. To be completed by: 6/6/25
22VAC40-73-680-I
Based on the record review the facility failed to ensure the medication administration record (MAR) shall include: any medication errors or omissions.
Evidence
  1. Resident’s #1 MAR did not include reason for omission of the following medications on the following dates: 04/07/25, Pravastatin, scheduled at 9:00 pm; 03/17/25, and 03/23/25, Risperidone, scheduled at 9:00 am; 03/17/25, and 03/23/25, Vitamin D3, scheduled at 9:00 am;
  2. Resident’s #2 MAR did not include reason for omission for the following medications on the dates of 03/21/25, 05/05/25 and 05/08/25 at 9:00 am: Aripiprazole, Lisinopril, Sertraline, Spiriva, and Clindamycin.
Plan of correction
All registered medication staff to be in-serviced on the importance of documenting omissions and exceptions with an explanation of why medication was not administered. To be completed by: 5/30/25
April 17, 2025Inspection8 violations
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced renewal inspection took place on 04/17/2025 from 8:22 am to 5:25 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: 64 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: 1 Number of interviews conducted with staff: 4 Observations by licensing inspector: Breakfast, Lunch and an activity were observed. A medication pass observation was completed for three residents. The following were reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, first aid kits, medication carts, fire inspection report, health inspection report. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-50-A
Based on the record review and staff interview the facility failed to ensure the assisted living facility shall prepare and provide a statement to the prospective resident and the prospective resident’s legal representative, if any, that discloses information about the facility. The statement shall be on a form developed by the department and shall: Disclose the following information which shall be kept current: name of the licensee.
Evidence
  1. Residents #1, disclosure statement did not include the name of the current licensee.
  2. Residents #2, #3. #4, and #5 disclosure statements were not updated to include the facility’s name change that became effective 10/16/2024.
  3. During an interview on 04/17/25 with staff #5, staff #5 acknowledged the disclosure statements for resident#1, #2, #3, #4, and #5 was not current to include the name of the licensee and name of the facility.
Plan of correction
What has been done to correct: Resident #1, #2, #3, #4 and #5 disclosure statement has been revised with correct licensee and facility name. Date: 5/14/25 What will be done to prevent recurrence: Executive Director and Sales Director will review all disclosure statements prior to resident placement. Business Office Manager to review prior to placement in business file.
22VAC40-73-250-D
Evidence
  1. The record for staff #2, hire date 10/13/20, did not contain an annual risk assessment for TB. The staff record contains a risk assessment for TB completed on 10/12/23.
  2. Upon request, during an interview with staff #5 on 04/17/25, the facility did not provide documentation of a completed annual TB risk assessment for staff #2.
Plan of correction
What has been done to correct: Staff #2 TB risk assessment was corrected on 4/18/25 What will be done to prevent recurrence: Business Office Manager and/or designee to review all employee files monthly for TB risk assessments
22VAC40-73-320-A
Based on the record review and staff interview the facility failed to ensure within the 30 days preceding admission, a person shall have a physical examination by an independent physician. The report of such examination shall be on file at the assisted living facility and shall contain the following: Date of the exam; Height, weight, and blood pressure; a statement that the individual does not have any of the conditions or care needs prohibited by 22VAC40-73-310 H.
Evidence
  1. Resident’s #1 physical examination dated 03/14/25 does not include a statement that the resident does not require continuous licensed nursing care.
  2. During an interview on 04/17/25 with staff #5, staff #5 acknowledged that resident’s #1 physical examination does not include a statement that the resident does not require continuous licensed nursing care.
  3. Resident’s #4 physical examination dated 07/02/24 does not include the date of the exam, the resident’s height, and the resident’s blood pressure.
  4. During an interview on 04/17/25 with staff #5, staff #5 acknowledged that resident’s #4 physical examination does not include the date of the exam, the resident’s height, and the resident’s blood pressure. Based on the record review and staff interview the facility failed to ensure the original agreement or acknowledgment shall be updated whenever there are changes to any of the policies or information referenced or identified in the agreement or acknowledgment and dated and signed by the licensee or administrator and the resident or the resident’s legal representative. Evidence:
  5. Resident’s #2, admission date of 08/27/24, admission agreement was not updated to include the facility’s name change that became effective 10/16/2024.
  6. Resident’s #3, admission date of 09/06/24, admission agreement was not updated to include the facility’s name change that became effective 10/16/2024.
  7. Resident’s #4, admission date of 07/08/24, admission agreement was not updated to include the facility’s name change that became effective 10/16/2024.
  8. Resident’s #5, admission date of 07/15/22, admission agreement was not updated to include the facility’s name change that became effective 10/16/2024. change that became effective 10/16/2024.
  9. During an interview on 04/17/25 with staff #5, staff #5 acknowledged the admission agreements for resident’s #2, #3, #4, and #5 was not updated to include the facility’s name change that became effective 10/16/24.
Plan of correction
What has been done to correct: Resident #1 page 2 of physical was corrected by in-house PCP on 4/22/25 to reflect resident does not require 24 hour licensed nursing care. What will be done to prevent recurrence: Resident Care Director, Assistant Resident Care Director and/or designee to review all history and physicals prior to all admissions for completion of height, weight and blood pressure. They will also ensure page 2 of physical is completed to reflect no prohibited conditions . Date: 5/30/25
22VAC40-73-390-C
Based on the record review and staff interview the facility failed to ensure within the 30 days preceding admission, a person shall have a physical examination by an independent physician. The report of such examination shall be on file at the assisted living facility and shall contain the following: Date of the exam; Height, weight, and blood pressure; a statement that the individual does not have any of the conditions or care needs prohibited by 22VAC40-73-310 H.
Evidence
  1. Resident’s #1 physical examination dated 03/14/25 does not include a statement that the resident does not require continuous licensed nursing care.
  2. During an interview on 04/17/25 with staff #5, staff #5 acknowledged that resident’s #1 physical examination does not include a statement that the resident does not require continuous licensed nursing care.
  3. Resident’s #4 physical examination dated 07/02/24 does not include the date of the exam, the resident’s height, and the resident’s blood pressure.
  4. During an interview on 04/17/25 with staff #5, staff #5 acknowledged that resident’s #4 physical examination does not include the date of the exam, the resident’s height, and the resident’s blood pressure. Based on the record review and staff interview the facility failed to ensure the original agreement or acknowledgment shall be updated whenever there are changes to any of the policies or information referenced or identified in the agreement or acknowledgment and dated and signed by the licensee or administrator and the resident or the resident’s legal representative. Evidence:
  5. Resident’s #2, admission date of 08/27/24, admission agreement was not updated to include the facility’s name change that became effective 10/16/2024.
  6. Resident’s #3, admission date of 09/06/24, admission agreement was not updated to include the facility’s name change that became effective 10/16/2024.
  7. Resident’s #4, admission date of 07/08/24, admission agreement was not updated to include the facility’s name change that became effective 10/16/2024.
  8. Resident’s #5, admission date of 07/15/22, admission agreement was not updated to include the facility’s name change that became effective 10/16/2024.
  9. During an interview on 04/17/25 with staff #5, staff #5 acknowledged the admission agreements for resident’s #2, #3, #4, and #5 was not updated to include the facility’s name change that became effective 10/16/24.
Plan of correction
What has been corrected: Page 3 of resident agreement for resident’s #2, #3. #4 and #5 have been revised to reflect facility’s name change as of 4/18/25. To be initialed and dated by responsible parties by 5/15/25. What will be done to prevent recurrence: Executive Director or Business Office Manager to review all existing resident agreements over the next 30 days for facility’s correct name.
22VAC40-73-440-A
Based on the record review and staff interview the facility failed to ensure all residents of and applicants to assisted living facilities shall be assessed face to face using the uniform assessment instrument in accordance with Assessment in Assisted Living Facilities (22VAC30-110). The UAI shall be completed prior to admission, at least annually, and whenever there is a significant change in the resident's condition.
Evidence
  1. The record for resident #5 did not contain an annual UAI. The UAI in the record is dated 02/22/24.
  2. Upon request, during an interview with staff #5 on 04/17/25, the facility did not provide documentation of an UAI completed annually after 02/22/24 for resident #5.
  3. The record for resident #6, admission date of 10/09/24, did not contain an UAI.
  4. Upon request, during an interview with staff #5 on 04/17/25, the facility did not provide documentation of an UAI completed for resident #6.
Plan of correction
What has been done to correct: Resident #5 annual UAI was updated and completed on 4/18/25. What will be done to prevent recurrence: Resident Care Director, Assistant Resident Care Director and/or designee to audit random charts monthly for completed UAI’s.
22VAC40-73-450-A
Based on the record review and staff interview the facility failed to ensure on or within seven days prior to the day of admission, a preliminary plan of care shall be developed to address the basic needs of the resident that adequately protects his health, safety, and welfare.
Evidence
  1. The record for resident #4, admission date of 07/08/24, does not contain a preliminary plan of care completed within seven days prior to admission. The resident’s record contains a preliminary plan of care dated 06/28/24, which is more than 7 days prior to the resident? s admission.
  2. During an interview on 04/17/25 with staff #5, staff #5 acknowledged resident’s #4 record does not contain a preliminary plan of care completed within seven days prior to the resident’s admission date of 07/08/24.
Plan of correction
Resident Care Director or Assistant Resident Care Director to ensure all preliminary plan of care to be completed no more than 7 days prior to admission or on admission. All existing resident preliminary plan of care to be audited monthly. Date: 5/30/25
22VAC40-73-450-C
Based on the record review and staff interview the facility failed to ensure the comprehensive individualized service plan (ISP) shall be completed within 30 days after admission and shall include a description of identified needs based upon the UAI.
Evidence
  1. The record for resident #2, admission date of 08/27/24, does not contain an ISP completed within 30 days after admission. The resident’s record contains a preliminary ISP dated as completed on 08/21/24 and an ISP dated as completed on 09/30/24.
  2. The record for resident #4, admission date of 07/08/24, does not contain an ISP completed within 30 days after admission. The ISP in the record is dated as completed on 10/14/24.
  3. During an interview on 04/17/25 with staff #5, staff #5 acknowledged resident’s #2 and resident’s #4 ISP was not completed within 30 days after admission.
Plan of correction
Resident Care Director and Assistant Resident Director will ensure all ISP’s will be completed within 30 days of admission. All existing resident ISP’s to be audited randomly monthly. 5/30/25 and ongoing
22VAC40-73-450-D
Based on the record review and staff interview 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. The record for resident #1 contains a hospice plan of care with an effective date of 03/14/25. The resident’s ISP dated 04/14/25 does not include the hospice care services the resident receives.
  2. During an interview on 04/17/25, with staff #5, staff #5 acknowledged that resident #1 receives hospice care services, and the resident’s ISP does not include the hospice care services the resident receives.
Plan of correction
What has been corrected: Resident #1 ISP was updated to reflect hospice services and who will provide services. Date: 4/18/25 What will be done to prevent recurrence: Resident Care Director and Assistant Resident Care Director to ensure all ISP’s are updated in a timely manner to reflect any change in condition and/or outside agency services and who will provide the services.
April 17, 2025Inspection2 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 IMPAIRMENTS
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced monitoring inspection took place on 04/17/2025 at 8:22 am to 5:25 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-report was received by VDSS Division of Licensing on 03/31/2025 regarding allegations in the area(s) of: Resident Care and Related Services and the Safe Secure Environment Number of residents present at the facility at the beginning of the inspection: 64 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: An observation and monitoring of the facility’s exit doors was completed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact (Donesia Peoples), Licensing Inspector at (757) 353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-460-D
Based on the record review and staff interview the facility failed to ensure the facility shall provide supervision of resident schedules, care, and activities, including attention to specialized needs, such as prevention of falls and wandering from the premises.
Evidence
  1. Resident’s #1 incident report dated 04/07/25 documents on the day of 03/31/25 at 6:42 am the resident was unable to be located in the facility’s safe secure unit. The resident was found at a location off the facility’s premises on 03/31/25 at 8:44 am.
  2. During an interview on 04/17/25 with staff #2 and staff #3, staff #2 and staff #3 acknowledged the following: Based on staff #2 and staff #3 review of the facility’s video footage, resident #1 exited the facility’s safe secure unit on 03/30/25 at 9:53 pm. The resident exited a secure door when staff #1 opened the door while entering the secured unit. Staff #1 did not observe the resident standing in the corner near the door and the resident exited through the door before it closed. The facility staff was not aware the resident exited the safe secure unit until the next day on 03/31/25 at 6: 42 am. Resident #1 was located by staff #2 at a location distanced 5 miles away from the facility.
Plan of correction
What has been done to correct: All staff were in-service on the importance of performing 2 hour rounds. Project Lifesaver was requested. Resident was placed on hourly rounds until Project Lifesaver was approved. Project Lifesaver was approved, and bracelet was placed on 5/1/25. RMA will be checking for placement daily. Record to be sent to Project Lifesaver monthly. What will be done to prevent recurrence: Resident Care Director, Assistant Resident Care Director to review daily placement log weekly. Daily checks has also been added to Medication Administration Record for RMA sign off. 5/1/25
22VAC40-73-930-D
Based on the record review and staff interview the facility failed to ensure for each resident with an inability to use the signaling device the following shall be met: a minimal frequency of daily rounds to be made; once the resident has gone to bed each evening until the resident has arisen each morning, at a minimum direct care staff shall make rounds no less than every two hours; the facility shall document the rounds that were made, which shall include the name of the resident, the date and time of the rounds, and the staff member who made the rounds.
Evidence
  1. Resident’s #1Individualized Service Plan (ISP) dated 5/20/24 includes the resident needs safety checks every 2 hours due to cognitive inability. The facility’s round logs did not include documentation 2-hour rounds were completed for resident #1 on the following dates: 03/08/25, 03/09/25, 03/10/25, 03/17/25, 03/20/25, 03/21/25, and 03/26/25.
  2. During an interview on 04/17/25 with staff #2 and staff #3, staff #2 and staff #3 acknowledged resident’s #1 March round logs did not include documentation 2-hour rounds were completed on the following dates: 03/08/25, 03/09/25, 03/10/25, 03/17/25, 03/20/25, 03/21/25, 03/26/25, and 03/30/25.
Plan of correction
What has been done to correct: All staff on each shift were in-service on the importance of performing 2 hour rounds. 3/31/25 What will be done to prevent recurrence: Resident Care Director and Assistant Resident Care Director to review 2-hour rounds log weekly for omissions. 4/30/25
January 16, 2025Complaint survey0 violations
Inspection dates
Jan. 16, 2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 01/16/2025 at 11:00am to 1:33 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 12/30/24 regarding allegations in the area(s) of: Staffing and Supervision, Resident Care and Related Services, and the Safe Secure Environment. Number of residents present at the facility at the beginning of the inspection: 64 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Observed residents participating in an activity. The facility’s staffing schedule was reviewed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the complaint 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 (Donesia Peoples), Licensing Inspector at (757) 353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
December 19, 2024Complaint survey2 violations
Inspection dates
Dec. 19, 2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced monitoring inspection took place on 12/19/2024 at 9:38 am to 1:25 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 12/12/2024 regarding allegations in the area(s) of: Resident Care and Related Services and the Safe Secure Environment Number of residents present at the facility at the beginning of the inspection: 64 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 2 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: An observation of residents was completed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the complaint 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 (Donesia Peoples), Licensing Inspector at (757) 353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-450-F
Based on the record review the facility failed to ensure Individualized service plans (ISP) shall be reviewed and updated at least once every 12 months and as needed for a significant change of a resident’s condition. The review and update shall be performed by a staff person with the qualifications specified in subsection B of this section and in conjunction with the resident and, as appropriate, with the resident's family, legal representative, direct care staff, case manager, health care providers, qualified mental health professionals, or other persons.
Evidence
  1. The record for resident #1, documents a hospice care start date of 8/06/24. Resident’s #1 ISP is dated as completed on 4/30/24. Resident’s #1 ISP was not reviewed and updated for the resident’s significant change in condition to include need for hospice care services.
Plan of correction
Resident Care Director or Assistant Resident Care Director to review all isp’s over the next 60 days for needed changes. All isp’s to be updated within real time of a change in condition
22VAC40-73-460-A
Based on the record review and staff interview the facility failed to assume general responsibility for the health, safety, and well-being of the residents.
Evidence
  1. The record for resident #1 contains an incident report dated 10/28/24 that documents the following for an incident that occurred on 10/09/24: “resident # 1 had fallen in her room;” “resident #1 was admitted to the hospital for a left hip fracture humerus;” “upon returning from the hospital, on 10/11/24, the resident’s left arm was in a sling orders were to follow up with PCP.” “hospice ordered a X ray, and a left hip fracture was noted. ”
  2. During an interview with staff #1, staff #1 stated the following: On 10/09/24 the facility’s carpet was cleaned and was wet. Staff #1 assisted resident #1 by walking resident #1 to resident’s #1 room. When resident #1 entered the room, after walking on the wet carpet, the resident encountered a fall. Staff #1 stated the bottom of resident’s #1 shoes were wet and staff #1 observed a wet streak mark from the entrance of the resident’s door frame to where the resident had fallen.
Plan of correction
Maintenance Director completed in-service with all housekeepers on procedures when performing carpet cleaning (11/15/24). To prevent future incidents of falls on wet floors, maintenance will conduct regular inspections of all areas to quickly address any spills or hazards on floors and ensuring that cleaning protocols specify the use of warning signage during wet cleaning procedures. Housekeeping will implement a system for immediate reporting of wet areas and will enhance training on safe cleaning practices. Staff will be educated on proactive measures including frequent monitoring of residents, providing assistance during ambulation, and using fall prevention protocols
August 8, 2024Complaint survey0 violations
Inspection dates
Aug. 8, 2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 8/08/24 at 10:07 am to 12:20 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 07/30/2024 regarding allegations in the area(s) of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 69 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: An observation of lunch was completed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the complaint 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 (Donesia Peoples), Licensing Inspector at (757) 353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
April 29, 2024Inspection5 violations
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE
Technical assistance
Emergency Placement
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced renewal inspection took place on 04/29/2024 from 8:17 am to 2:48 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: 66 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: 4 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 4 Observations by licensing inspector: Breakfast, Lunch and an activity were observed. A medication pass observation was completed for three residents. The following was reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, medication carts, fire inspection report, health inspection report. Water temperature was measured, and the call bell system was monitored. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-40-C
Based on the onsite record review the facility failed to ensure any person required to obtain a criminal history report shall be ineligible for employment if the report contains convictions of barrier crimes.
Evidence
  1. Staff #5, date of hire 11/07/23, criminal record report contains two convictions for barrier crimes (18.2-57 and 18.2- 51.2).
Plan of correction
Staff #5 is no longer employed with CSL. Business Office Manager and/or designee to review all background checks and barrier crime list prior to start date and ongoing.
22VAC40-73-260-A
Based on the record review the facility failed to ensure each direct care staff member who does not have current certification in first aid as specified in subdivision 1 of this subsection shall receive certification in first aid within 60 days of employment.
Evidence
  1. The record for staff #1, date of hire 07/26/23, contains a first aid certification completed on 04/29/24. The staff record did not contain a first aid certification completed within 60 days of employment.
Plan of correction
Staff #1 first aid certification is now on file dated for 4/29/24. Business Office Manager and/or designee will randomly review files monthly to ensure all first aid certifications are on file within the prospective timeline.
22VAC40-73-320-A
Based on the record review the facility failed to ensure within the 30 days preceding admission, a person shall have a physical examination by an independent physician.
Evidence
  1. The record for resident #3, admitted 04/19/24, contains a physical examination dated as completed on 02/28/24, which is more than 30 days prior to the resident’s admission to the facility.
Plan of correction
Resident Care Director, Assistant Resident Care Director and Executive Director to review all history and physicals prior to admission to community to ensure completion within 30 days prior to move in.
22VAC40-73-450-E
The individualized service plan (ISP) shall be signed and dated by the licensee, administrator, or his designee, and by the resident or his legal representative.
Evidence
  1. Resident’s #2 ISP dated 10/30/23 did not include the resident or legal representative signature.
  2. Resident’s #5 ISP dated 11/27/23 did not include the resident or legal representative signature.
  3. Resident’s #6 ISP dated 04/04/24 did not include the resident’s or legal representative signature.
Plan of correction
Resident #2, #5 and # 6 ISP to be signed by 05/31/2024. Resident Care Director, Assistant Resident Care Director and/or designee will randomly audit resident's ISP’s to ensure timely signature of ISP’s. If not signed by legal representative, documentation to be provided for justification of why ISP not signed.
22VAC40-73-660-A
Based on observation, it was determined that the facility did not ensure that medications shall be stored in a manner consistent with current standards of practice and the storage area shall be locked and the individual responsible for medication administration shall keep the keys to the storage area on his person.
Evidence
  1. During a tour of the facility with staff #6, the medication cart was observed to be unlocked and unstaffed.
Plan of correction
Inservice to be provided to discuss the importance of medication cart being locked and supervised. Resident Care Director, Assistant Resident Care Director and/or designee to perform random cart audits weekly to ensure that medication cart is locked and monitored by registered medication aide when in use.
July 27, 2023Inspection0 violations
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
A self-reported incident was received by VDSS Division of Licensing on 07/03/2023 regarding allegations in the area(s) of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 56 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: An observation of residents was completed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. 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 (Donesia Peoples), Licensing Inspector at (757) 353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
June 13, 2023Inspection1 violation
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced monitoring inspection took place on 06/13/2023 at 8:43 am to 10:50 am. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 05/03/2023 and 05/05/2023 regarding allegations in the area(s) of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 56 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: An observation of residents was completed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self- report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact (Donesia Peoples), Licensing Inspector at (757) 353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-460-A
Based on staff interview and record review the facility failed to assume general responsibility for the health, safety, and well-being of the residents.
Evidence
  1. The record for resident #1 contains an incident report dated 05/03/2023 that documents ?private duty sitter failed to provide assistance to resident when sitting on the ground.?
  2. Staff # 3 reported during an interview with this inspector to have observed the following: resident #1 sliding down to the ground and reach for assistance from staff #1, however staff #1 did not provide assistance to the resident.
  3. The record for resident #1 contains an incident report dated 05/04/2023 that documents ?resident’s private duty sitter was observed pushing resident back into a chair and restricting her from walking around freely.?
  4. Staff # 3 reported during an interview with this inspector to have observed the following: staff #2 pushed resident #1 down into the chair when the resident was attempting to stand up from out of the chair.
Plan of correction
Staff 1 and Staff 2 were both removed from caring for Resident #1 By 7/31/2023, the Executive Director/designee will provide training to current community staff and private duty staff, currently providing services at the community, on Resident Rights and Abuse and Neglect. BOM/designee will provide orientation to private duty staff prior to start of care to include, but not limited to, Resident Rights and Abuse and Neglect; private duty companies and families will be made aware of this needed orientation as warranted. The Executive Director/designee requests plan of care, from agency, prior to start of care to assure resident’s needs are being appropriately met. The Executive Director/designee will complete a review of private duty staff records at least quarterly to assure compliance with training requirements.
March 22, 2023Inspection1 violation
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced monitoring inspection took place on 03/22/2023 from 8:15am to 4:56pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A (self-reported incident) was received by VDSS Division of Licensing on (02/28/2023 and 03/08/2023) regarding allegations in the area(s) of: Personnel Number of residents present at the facility at the beginning of the inspection: 57 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: An observation of the resident and the resident’s room was completed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples. Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-110-1
Based on the staff interview and record review the facility failed to ensure all staff shall be considerate and respectful of the rights, dignity, and sensitiveness of persons who are aged, infirm, or disabled.
Evidence
  1. Staff #1 acknowledged hearing staff #2 communicate a curse word towards resident #1 while the staff was directing the resident to put her clothes on.
  2. Resident’s #1’s incident report dated 03/08/2023 documents staff # 1 communicated a curse word to the resident when directing the resident to put her shirt on.
Plan of correction
Staff #2 was immediately removed from situation. Current staff was provided retraining on Resident Rights and Abuse/Neglect in response to incident. Training was completed (03/07/2023). Moving forward, training on Resident Rights and Abuse/Neglect will continue to be completed for new and current staff at hire, annually and as needed. Staff attendance will be documented appropriately.
March 22, 2023Inspection6 violations
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Technical assistance
Weekly Breakfast Menu to be kept current
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced renewal inspection took place on 03/22/2023 from 8:15am to 4:56pm. 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: 57 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: 4 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: Breakfast, Lunch and an activity were observed. A medication pass observation was completed for four residents. The following was reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, medication carts, fire inspection report, health inspection report. Water temperature was measured, and the call bell system was monitored. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-430-H-1
Based on the record review the facility failed to ensure at the time of discharge, the assisted living facility shall provide to the resident, and as appropriate his legal representative and designated contact person a dated statement signed by the licensee or administrator that contains the following information: the resident’s destination.
Evidence
  1. The record for resident #8, contains a discharge statement dated 01/12/23 that does not include the resident’s destination.
Plan of correction
The Resident Care Director and/or designee will assure that discharge statements are completed, to include discharge destination, per regulatory standards. Monthly, the Executive Director/designee, will review residents discharged, during that month, to assure discharge statements are completed with appropriate information per regulatory requirements.
22VAC40-73-440-A
Based on the record review the facility failed to ensure the uniform assessment instrument (UAI) shall be completed whenever there is a significant change of the resident’s condition.
Evidence
  1. The record for resident #7 contains a physician order dated 02/15/2023 for a hospice admission and treatment. The UAI in the record is dated 01/16/23. The record does not contain a UAI completed when there was a significant change in the resident’s condition for the hospice admission and treatment.
Plan of correction
Resident Care Director and Assistant Resident Care Director have reviewed what constitutes a ?significant change of condition?. At least weekly, the Resident Care Director, Assistant Resident Care Director and Executive Director and/or designees will meet to discuss any significant changes in resident status/needs that would warrant an update to the UAI. UAI will be updated when appropriate.
22VAC40-73-450-C
Based on the record review the facility failed to ensure the Individualized Service Plan (ISP) includes a description of identified needs based upon the UAI.
Evidence
  1. Resident #2’s UAI dated 01/25/2023 documents mechanical & human help needs for dressing and mobility. The ISP dated 01/25/2023 does not include documentation of the mechanical supports needed for dressing and mobility.
  2. Resident #5’s UAI dated 02/23/2023 documents mechanical help needed for dressing. The ISP dated 02/23/2023 does not include documentation of the mechanical supports needed for dressing.
Plan of correction
Resident Care Director and Assistant Resident Care Director to complete audit of current ISPs to assure they include description of identified needs based on UAI. Moving forward, prior to ISP being signed by Executive Director/designee the ISP will be reviewed to assure that the ISP matches needs based on UAI. Resident #8’s isp was corrected on 3/23/2023.
22VAC40-73-450-D
Based on the record review 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 ISP.
Evidence
  1. The record for resident #7 contains a physician order dated 02/15/2023 for a hospice admission and treatment. The record does not contain an agreed upon coordinated plan between the facility and the hospice organization. The record does not contain an ISP to include services provided by the hospice organization.
Plan of correction
Resident Care Director and/or Assistant Resident Care Director will meet with hospice agency, at least weekly, to discuss care coordination to assure that the ISP includes services that hospice will be providing and how often these services are provided. The Executive Director will complete regular, random audits of those residents receiving hospice services to assure ISP speaks to current hospice services being provided to resident being reviewed.
22VAC40-73-450-E
Based on the record review, the facility failed to ensure the ISP shall be signed and dated by the resident or the legal guardian.
Evidence
  1. Resident #1’s ISP dated 01/19/2023 was not signed and dated by the resident or the legal guardian.
  2. Resident #2’s ISP dated 01/25/2023 was not signed and dated by the resident or the legal guardian.
  3. Resident #3’s ISP dated 01/12/2023 was not signed and dated by the resident or the legal guardian.
  4. Resident #5’s ISP dated 02/23/2023 was not signed and dated by the resident or the legal guardian.
  5. Resident #6’s ISP dated 02/07/2023 was not signed and dated by the resident or the legal guardian.
Plan of correction
Resident Care Director and Assistant Care Director will ensure all ISPs are signed prior to placement in chart. To assist in timely signature from family, the ISP will be emailed for review and signature by the POA/RP. RCD/ARCD will document attempts to obtain signature from POA/RP. The Executive Director, will complete a monthly review of ISPs completed during that month to assure appropriate signature/documentation of attempts to obtain signature.
22VAC40-73-640-A
Based on observation the facility failed to implement a written plan for medication management to include methods to prevent the use of outdated medications.
Evidence
  1. During observation with staff #5 the following expired medications was observed on the medication cart, and a locked refrigerator used for medication storage: Sertraline HCL tabs 25mg expired 05/27/2022; Morphine Sulfate 20mg/1ML SOLN expired 01/22/2023; Morphine Sulfate 20mg/1ML SOLN expired 12/20/2022; Morphine Sulfate 20mg/1ML SOLN expired 08/31/2022.
Plan of correction
Medication staff will be provided training to monitor expiration dates when meds are received and prior to administration. Resident Care Director or designee to audit medication cart weekly to assure expired medications are not available on cart. Executive Director/designee to audit medication cart monthly to review for expired medications. If expired medication will be ordered from pharmacy or D/C order will be requested if medication no longer needed.
November 15, 2022Inspection3 violations
Inspection dates
Nov. 15, 2022
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced monitoring inspection took place on 11/15/22 at 8:16 am to 12:30 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 11/03/2022 and 11/04/2022 regarding allegations in the area(s) of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 55 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 5 Number of staff records reviewed: 3 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: The following were reviewed: staffing schedule, plan for resident emergencies and practice exercises, and observation of the exit doors in the memory care unit. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self- report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact (Donesia Peoples), Licensing Inspector at (757) 353-0430 or by email at donesia. peoples@dss.virginia.gov
Violations
22VAC40-73-1150-A
Based on staff interview, the facility failed to ensure doors that lead to unprotected areas be monitored or secured through devices that conform to applicable building and fire codes, including door alarms, cameras, constant staff oversight, security bracelets that are part of an alarm system, pressure pads at doorways, delayed egress mechanisms, locking devices, or perimeter fence gates for residents residing in a safe, secure environment.
Evidence
  1. Staff # 1 and Staff #4 acknowledged resident #1 exited an exit door in the safe, secure unit that was unlocked and not working properly. The exit door leads to an unsecured parking lot outside of the facility.
  2. An incident report referencing Resident #1 dated 11/04/22 documents the ?exit doors was not working properly and was repaired on 11/04/22.?
Plan of correction
West wing exit door on right side of community, was repaired on November 4, 2022. Maintenance Director to check door weekly for operation failure.
22VAC40-73-450-C
Based on the onsite record review the facility failed to ensure the comprehensive individualized service plan (ISP) shall be completed within 30 days after admission.
Evidence
  1. .
  2. Resident #1 record documents an admission date of 3/18/22.
  3. Resident #1 record includes a Preliminary ISP dated 3/17/22. The Comprehensive ISP in the record is dated 09/17/22.
  4. Staff # 4 acknowledged the ISP for resident #1 documents a completed date of 09/17/22.
  5. Resident #2 record documents an admission date of 06/05/22. The record includes a Preliminary ISP dated 06/05/2022.
  6. Resident # 2 record did not include documentation of a Comprehensive ISP.
  7. Staff #4 acknowledged a Comprehensive ISP was not completed and included in the record for resident #2.
Plan of correction
Resident Care Director, Assistant Resident Care Director and Executive Director audit new resident charts monthly, to ensure all 30-day comprehensive ISP’s are completed in a timely manner.
22VAC40-73-460-D
Based on staff interview and the record review the facility failed to provide supervision of resident schedules, care, and activities including attention to specialized needs, and wandering from the premises.
Evidence
  1. An incident report referencing Resident #1 dated 11/04/2022 documents ? On 11/03/22 at 4:40 pm, the resident eloped out of the community and was missing for approximately 20 minutes.? The resident was located at 5:01pm by the police outside of a daycare center. The resident was returned to the facility by the police.
  2. Staff #1 and staff #4 acknowledged the staff on duty was not aware resident #1 exited the facility’s safe, secure unit until receiving a call stating the resident was returning to the facility by the police.
  3. Resident #1 physical exam report dated 03/16/22 documents a diagnosis of Alzheimer’s Disease and Dementia. The physical exam reports the resident is not oriented to time or place and his judgement and insight is impaired.
  4. Resident #1 record documents an approval for placement in the special care unit dated 03/17/2022.
Plan of correction
Resident #1 was placed on hourly rounds and staff were inserviced on missing persons, elopement protocols and the importance of knowing where the resident is located at all times.
July 8, 2022Complaint survey0 violations
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES
Comments
An unannounced non-mandated complaint inspection was initiated on 7/08/22- from 9:10 a.m. until 10:30a.m The Acknowledgement of Inspection form was signed and left at the facility for the date of the inspection. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
March 10, 2022Inspection1 violation
Inspection dates
March 10, 2022 and March 25, 2022
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity
Comments
An unannounced monitoring inspection was conducted on 3-10-22. The facility census was 50. An Exit meeting was conducted with the Administrator and the Acknowledgement Form was emailed. Please complete the columns for "description of action to be taken" and "date to be corrected" for each violation cited on the violation notice, and then return a signed and dated copy to the licensing office within 10 calendar days of receipt. You need to be specific with how the deficiencies either have been or will be corrected to bring you into compliance with the Standards. Your plan of correction must contain the following three points: 1. Steps to correct the noncompliance with the standard(s) 2. Measures to prevent the noncompliance from occurring again 3. Person(s) responsible for implementing each step and/or monitoring any preventive measure(s) Please provide your responses in a Word Document, if possible. POC due within 10 days: 4-11-22
Violations
22VAC40-73-1180-B
Based on record review and staff interview, the facility failed to ensue when there are indications that ordinary material or objects may be harmful to a resident, these materials or objects shall be inaccessible to the resident except under the staff supervision.
Evidence
  1. On 11-7-21 an incident report was received documenting, ?resident observed taking housekeeper’s handheld hand sanitizer and drinking a small amount?.
  2. Resident’s uniformed assessment instrument (UAI) dated 5-10-21 documented resident wanders. The individualized service plan (ISP) dated 6-9-21 was not updated to address resident’s two occasions of ingestion of foreign substance, 6-24-21 and 11-7-21 and what staff services were put in place to address resident’s safety concerns.
  3. On 3-25-22, staff #1 acknowledged resident’s ISP was not updated to address the resident accessing harmful objects on the safe, secure unit.
Plan of correction
Assistant Resident Director and Executive Director updated UAI to reflect residents' behavior, and ISP updated to reflect interventions to prevent resident from ingesting foreign objects. Staff in serviced on interventions to prevent all residents from ingesting foreign objects. April 15, 2022 and ongoing
March 10, 2022Inspection4 violations
Inspection dates
March 10, 2022 , March 11, 2022 and March 25, 2022
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 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity63.2 Protection of adults and reporting22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report
Comments
An unannounced renewal inspection was conducted by two inspector (PLO and ERO) on 3-10-22. the census was 50. A medication pass observation, breakfast meal, staff and resident records, emergency preparedness documents, interviews, water temperature, signaling observation and activities were observed. Violations were reviewed with the administrator throughout the inspection. A final exit interview was conducted with the administrator and staff on-site on 3-25-22. The acknowledgement forms were sent to the administrator via email. Please complete the columns for "description of action to be taken" and "date to be corrected" for each violation cited on the violation notice, and then return a signed and dated copy to the licensing office within 10 calendar days of receipt. You need to be specific with how the deficiencies either have been or will be corrected to bring you into compliance with the Standards. Your plan of correction must contain the following three points: 1. Steps to correct the noncompliance with the standard(s) 2. Measures to prevent the noncompliance from occurring again 3. Person(s) responsible for implementing each step and/or monitoring any preventive measure(s) Please provide your responses in a Word Document, if possible. POC due within 10 days: 4-11-22
Violations
22VAC40-73-320-A
Based on record reviewed and staff interviewed, the facility failed to ensure the physical examination included all required information for two of six residents? record.
Evidence
  1. Resident #3’s physical examination document dated 8-19-21 did not include the height information.
  2. Resident #4’s physical examination document dated 8-19-21 did not include the height information.
  3. On 3-25-22 staff #1 acknowledged the aforementioned resident’s physical did not include all required information.
Plan of correction
Executive Director and Assistant Resident Care Director to update resident 3 and 4 history and physical to reflect height. all history and physicals will be reviewed, to ensure that heights are included for regulatory compliance. April 15, 2022, Ongoing
22VAC40-73-450-C
Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) included all assessed needs for four of six residents? record. a assessed eeds o ou o s es de ts? eco d.
Evidence
  1. Resident #1’s uniformed assessment instrument (UAI) dated 10-18-21 documented wheeling need as not performed, the individualized service plan (ISP) did not document what and how services would be provided. Psychosocial need documented on the ISP. The ISP did not document what and how services would be provided- resident need documented as disruptive, aggressive- and service documented- may receive special tolerance or staff training.
  2. Resident #3’s UAI dated 1-13-22 documented wheeling need as not performed. The ISP dated 1-18-22 did not document what services and how it would be performed. The UAI documented behavior as appropriate. The ISP documented resident’s behavior as resistive to care.
  3. Resident #5’s UAI dated 2-18-22 documented toileting need as mechanical help. The ISP dated 2-18-22 documented use of grab bars and supervision. Behavior need documented abusive, agitation greater than weekly. The ISP did not document what staff should do/what services should be provided.
  4. Resident #6’s UAI dated 2-28-22 documented dressing need as mechanical help/supervision. The ISP dated 2-28-22 did not document what mechanical help was needed. Wheeling and stairclimbing need documented as not performed. The ISP did not document what/how services should be provided. Resident’s UAI documented disoriented in all spheres (time, place, and situation). The ISP did not document what services to be provided.
  5. On 3-25-22 staff #1 acknowledged the aforementioned residents? record did not include all assessed information.
Plan of correction
Executive Director and Assistant Resident Care Director to update resident's 1,3,5 and 6 UAI's to reflect all assessed needs of residents. Assistant Resident Care Director and Executive Director to audit uai's and isp's randomly monthly, to ensure regulatory compliance. Apr 15, 2022, ongoing
22VAC40-73-450-F
Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) shall be reviewed and updated at least once every 12 months and as needed for a significant change of a resident’s condition for two of six residents? record.
Evidence
  1. Resident #3’s record documented skilled nursing services with a start of service (SOC) date of 1-18-22 and another visit on 2-18-22. The record also documented physical therapy services on 1-20-22 (evaluation), 1-24-22 and 3-9-22. Resident’s record also documented mental health services from a provider, initial assessment dated 11-10-21. Another provider’s document was dated 2-9-22 with a follow-up in 3 months.
  2. Resident #4’s record documented physical therapy services discontinued on 10-14-21.
  3. On 3-25-22 staff #1 acknowledged the aforementioned residents? ISP did not document the therapy services and/or mental health services.
Plan of correction
Executive Director and Assistant Resident Care Director updated resident #3 ISP to reflect all documented services. Assistant Resident Care Director and Executive Director to audit uai's and isp's randomly monthly, to ensure regulatory compliance. April 15, 2022, Ongoing
22VAC40-73-680-I
Based on record reviewed and staff interviewed, the facility failed to ensure the facility medication administration record (MAR) included all required information for one of six residents? record.
Evidence
  1. Resident #1’s February 2022 medication administration record (MAR) did not include the initials of the direct care staff administering the following medications on 2-27-22 at 06:00: (a) Tylenol and (b) Depakote. Ativan not initials on the following dates and time: (a) 3-1-22 at 05:00, 11:00, 17:00 and 23:00; on 3-2-22 at 05:00 and 11:00; and 3-3-22 at 23:00, 3- 8-22 and 3-29-22 at 23:00.
  2. On 3-25-22, staff #1 acknowledged the aforementioned resident’s medication administration was blank, did not include the initials of the direct care staff who administered the medications.
Plan of correction
Assistant Resident Care Director and Executive Director reviewed controlled substance book, which reflected that Ativan medication was administered. After careful review of medication card, it was noted that Depakote and Tylenol were both administered. All Registered Medication Aides were in-serviced, on the impo1iance of signing off for all medication administrations. Assistant Resident Care Director to review Medication Administration Records for omissions randomly. Executive Director to review Medication Administration Records weekly for omissions. April 15, 2022, Ongoing
July 9, 2021Inspection1 violation
Inspection dates
July 9, 2021 , July 12, 2021 and July 21, 2021
Areas reviewed
22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity
Comments
A non-mandated, self-report, inspection was initiated on 7-9-21 and concluded on 8-10-21. A self-reported incident was received by the departed on 7-1-21 and revised on report received on 7-9-21 regarding allegations in the area of resident care on serious cognitive unit. The assistant resident care director was contacted by telephone to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the self-report of non-compliance with standards or law, and violations were issued. Any violations not related to the self-report but determined during the course of the investigation can be found on the violation notice.
Violations
22VAC40-73-1180-B
Based on record review and staff interview, the facility failed to ensue when there are indications that ordinary material or objects may be harmful to a resident, these materials or objects shall be inaccessible to the resident except under the staff supervision.
Evidence
  1. On 7-1-21 an incident report was received documenting resident #1, was observed by staff #4, "with a pink creamy substance around mouth."
  2. Interview with staff #4, staff stated the pink creamy substance was Resident #2’s calmoseptine barrier cream. According to staff #4, resident #1 had entered resident #2’s room while staff and resident were in the bathroom and retrieved the cream from the night stand.
  3. Staff #5 came and took resident #1 back to his unit. Staff #5 stated observing cream on resident’s hand.
  4. Collateral #1, instructed staff #5 to contact poison control, push fluids and monitor resident.
  5. On 8-10-21, during exit with staff #1, staff acknowledged resident obtained access to substance that should not have been accessible to resident #1.
Plan of correction
Resident Care Director, Assistant Resident Care Director and /or designee to perform room sweeps daily and continuously to ensure materials or objects that may be harmful, are inaccessible to residents except under the supervision of direct care staff. All direct care staff will be inserviced on materials and objects not permitted in resident rooms or within harms ways of resident. 07/26/2021 Ongoing
June 17, 2021Complaint survey1 violation
Comments
This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A complaint inspection was initiated on May 5, 2021 and concluded on June 17, 2021. A complaint was received by the department regarding allegations in the areas of resident care and related services. The Executive Director was contacted by telephone to conduct the investigation. The licensing inspector emailed the (person in charge) a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the allegation of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.
Violations
22VAC40-73-460-D
Based on record review and discussion, the facility failed to ensure attention to specialized needs for prevention of falls.
Evidence
  1. Resident #1 admitted on 04-19-2021. Resident experienced falls with hospitalizations on 04-26-2021 and 05-03-2021. The hospitalization on 05-03-2021 documented ?Closed head injury, initial encounter; traumatic hematoma of forehead, initial encounter; and fall, initial encounter“. Resident’s Progress Note dated 05-04-2021 documented, ”Resident continues to have falls??
  2. Resident #1’s Individualized Service Plan Addendum dated 04-26-2021 documented a soft helmet would be ordered for the resident as a fall risk intervention, but as of 05-04-2021 the helmet had not been ordered.
  3. Resident #1’s death certificate dated 05-08- 2021 documented the cause of death as “advanced dementia” and other significant conditions contributing to death as “acute head injury of uncertain significance”.
  4. Staff #1 confirmed the aforementioned falls occurred and the soft helmet had not been obtained prior to Resident #1’s death.
Plan of correction
Resident #1 helmet was supposed to be ordered by hospice company. Hospice company failed to notify community they were unable to order soft helmet. Resident Care Director and/or designee will ensure all interventions are put into place as falls occur and follow up accordingly with any outside agency for intervention. Resident Care Director and/or designee will ensure all intervention items are available prior to adding to individualized service plan. Executive Director, Resident Care Director and/or designee to meet monthly to discuss and review all high risk for falls residents monthly.
June 17, 2021Complaint survey1 violation
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A complaint inspection was initiated on May 5, 2021 and concluded on June 17, 2021. A complaint was received by the department regarding allegations in the areas of resident care and related services. The Executive Director was contacted by telephone to conduct the investigation. The licensing inspector emailed the (person in charge) a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the allegation of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.
Violations
22VAC40-73-460-D
Based on record review and discussion, the facility failed to ensure attention to specialized needs for prevention of falls.
Evidence
  1. Resident #1 admitted on 04-19-2021. Resident experienced falls with hospitalizations on 04-26-2021 and 05-03-2021. The hospitalization on 05-03-2021 documented ?Closed head injury, initial encounter; traumatic hematoma of forehead, initial encounter; and fall, initial encounter“. Resident’s Progress Note dated 05-04-2021 documented, ”Resident continues to have falls??
  2. Resident #1’s Individualized Service Plan Addendum dated 04-26-2021 documented a soft helmet would be ordered for the resident as a fall risk intervention, but as of 05-04-2021 the helmet had not been ordered.
  3. Resident #1’s death certificate dated 05-08-2021 documented the cause of death as “advanced dementia” and other significant conditions contributing to death as “acute head injury of uncertain significance”.
  4. Staff #1 confirmed the aforementioned falls occurred and the soft helmet had not been obtained prior to Resident #1’s death.
Plan of correction
Resident #1 helmet was supposed to be ordered by hospice company. Hospice company failed to notify community they were unable to order soft helmet. Resident Care Director and/or designee will ensure all interventions are put into place as falls occur and follow up accordingly with any outside agency for intervention. Resident Care Director and/or designee will ensure all intervention items are available prior to adding to individualized service plan. Executive Director, Resident Care Director and/or designee to meet monthly to discuss and review all high risk for falls residents monthly.
May 18, 2021Inspection3 violations
Inspection dates
May 18, 2021 , May 19, 2021 and May 20, 2021
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-90 The Sworn Statement or Affirmation
Comments
This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on May 18, 2021 and concluded on May 20, 2021. The Executive Director was contacted by telephone to initiate the inspection. The Executive Director reported that the current census was 48. The inspector emailed the Executive Director a list of items required to complete the inspection. The inspector reviewed 3 resident records, 3 staff records, health and fire inspections, fire and emergency drills, healthcare oversight, pharmacy oversight, activities calendar, staff schedules, menus submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliances with applicable standards or law, and violations were documented on the violation notice issued to the facility.
Violations
22VAC40-73-650-B
Based on record review and discussion, the facility failed to ensure physician’s orders identified the diagnosis, condition, or specific indications for administering each drug.
Evidence
  1. Resident #1’s physician’s orders dated 04-08-2021 did not identify the diagnosis, condition, or specific indications for administering Bupropion and Mirtazapine.
  2. Staff #1 confirmed during discussion that the diagnosis, condition, or specific indication for administering the aforementioned drugs were not included in the physician’s order.
Plan of correction
Resident Care Director and/or designee to review physician orders monthly for missing diagnosis and update accordingly. Resident #1’s physician orders have been updated to reflect diagnosis for the 2 medications sighted on this notice.
22VAC40-73-720-A
Based on record review and discussion, the facility failed to ensure Do Not Resuscitate (DNR) Order was included on the individualized service plan (ISP).
Evidence
  1. Resident #2’s hospice “Plan of Care Update Report” dated 02-24-2021 documented a DNR order was in place; however, the DNR was not documented on the resident’s ISP dated 12-30-20.
  2. Staff #1 confirmed the DNR orders were not included on the ISP.
Plan of correction
Resident Care Director and/or designee will ensure that each ISP is reviewed and updated every six months or if there is a change in the resident condition to include the assessed needs per UAI. Resident #2’s ISP was updated to reflect ill thl dit assessed needs. Executive Director or designee will complete random monthly audit of a minimum of 5 Comprehensive ISP’s to ensure ongoing compliance.
22VAC40-90-30-C
Based on record review and discussion, the facility failed to ensure any person making a materially false statement on the sworn statement shall be guilty of a Class 1 misdemeanor.
Evidence
  1. Staff #2 and Staff #3`s sworn statements documented “No” on the question ?Have you ever been convicted of a law violation(s) but excluding offenses committed before your eighteenth birthday that were finally adjudicated in a juvenile court or under a youth offender law??
  2. Staff #2’s and staff #3’s Criminal History Record documented convictions.
  3. Staff #1 confirmed the aforementioned staffs? sworn statements contained materially false statement contradicting the “Criminal History Request Response” received.
Plan of correction
Business Office Manager and/or designee to review all sworn disclosure statements upon hiring, and again after requesting criminal history record. Do to such a huge staffing challenge in the healthcare industry, staff #2 and #3 were given another sworn disclosure to complete and their criminal backgrounds processed again. They both were counseled on the verbiage of the sworn disclosure statement.
April 7, 2021Complaint survey2 violations
Inspection dates
April 7, 2021 , April 8, 2021 and April 9, 2021
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A complaint inspection was initiated on April 7, 2021 and concluded on April 9, 2021. A complaint was received by the department regarding allegations in the areas of resident care and related services, building and grounds, and staffing. The Executive Director was contacted by telephone to conduct the investigation. The licensing inspector emailed the Executive Director a list of documentation required to complete the investigation. The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law were determined; however, violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.
Violations
22VAC40-73-650-B
Based on record review and discussion, the facility failed to ensure prescriber orders included the diagnosis, condition, or specific indications for administering each drug.
Evidence
  1. Resident #2’s telephone orders dated 05-13-2020 and signed on 05-14-2020 documented Aspirin 81 mg, Diltiazem 120 mg, and Lidocaine 4% without diagnosis, condition, or specific indications for administering each drug.
  2. Resident #2’s written orders dated 02-05-2020 documented Lorazepam 0.5 mg and Coumadin 5 mg without diagnosis, condition, or specific indications for administering each drug.
  3. Staff #1 confirmed the aforementioned information was not included in the orders.
Plan of correction
Resident Care Director and/or designee to review all telephone medication orders weekly for missing diagnosis. Physician order sheets will be reviewed monthly for missing diagnosis. Ongoing.
22VAC40-73-680-E
Based on record review and discussion, the facility failed to ensure medical treatments ordered by a prescriber shall be provided according to his instructions.
Evidence
  1. Resident #1’s prescriber’s orders dated 03-19-2020 documented, “THERAFIRM 15-20 KH MED SUPPORT ” APPLY IN THE MORNING AND REMOVE AT BEDTIME FOR EDEMA Indicated For Edema?. 2 Resident #1’s March 2020 Medication Administration Record documented Therafirm was not applied and/or removed
  2. Resident #1’s March 2020 Medication Administration Record documented Therafirm was not applied and/or removed 25 times. Documented reasons were ?Other: unable to find stockings, Other: unable to find, Other: will call pharmacy, and Other: not available.?
  3. Staff #1 confirmed during discussion that Resident #1’s Therafirm were not applied/removed according to prescriber? s instructions.
Plan of correction
Resident Care Director and/or designee will review medication administration records daily for unavailable medications/treatments. All registered medication aides will be in-serviced on notifying Resident Care Director or Assistant Resident Care Director within 24 hours of not being available. Ongoing.
December 30, 2020Inspection2 violations
Inspection dates
Dec. 30, 2020 , Jan. 4, 2021 and Jan. 5, 2021
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A monitoring inspection was initiated on December 28, 2020 and concluded on January 5, 2021. The Executive Director was contacted by telephone to initiate the inspection. The Executive Director reported that the current census was 55. The inspector emailed the Executive Director a list of items required to complete the inspection. The inspector reviewed 5 resident records, along with policy documents submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility. Consultation was provided regarding administering medications according to a physician’s order and individualized service plans being updated accordingly.
Violations
22VAC40-73-550-D
Based on record review and discussion, the facility failed to establish written policies and procedures for implementing ? 63.2-1808 of the Code of Virginia.
Evidence
  1. A copy of the written policies and procedures for implementing ?63.2-1808 of the Code of Virginia [Rights and Responsibilities of Residents of Assisted Living Facilities] was requested.
  2. Staff #1 indicated that the facility did have the requested written policies and procedures; however, Staff #1 provided via email; a document titled, “Resident Programs- Section 14 Smile Standards” which documented, ?It is the responsibility of the Program Director to maintain and update the Residents Rights signatures every year?“ Staff #1 stated, ”This is the only policy I could find in reference to resident rights.?
Plan of correction
Executive Director contacted Regional Vice President. Regional Vice President notified Vice President of Resident Programs. A new policy was created and put in place for resident rights on February 12,2021.
22VAC40-73-680-I
Based on record review and discussion, the facility failed to ensure the Medication Administration Record (MAR) included initials of direct care staff administering the medications.
Evidence
  1. Residents? October, November, and December 2020 MARs did not contain the initials of direct care staff (DCS) who administered the following medications: A. Resident #1’s MARs did not have 68 sets of DCS? initials documented for Rosuvastatin Calcium, Fish Oil, Theratrum Complete, Olanzapine, Metoprolol, Aspirin, DOK Oral Capsule, Hydrochlorothiazide, Memantine and Omeprazole; B. Resident #2’s MARs did not have 28 sets of DCS? initials documented for Lorazepam, Amlodipine Besylate, Eliquis, Flecainide Acetate, Metoprolol, and Spironolactone; and C. Resident #3’s MARs did not have 3 sets of DCS? initials documented for Xiidra Ophthalmic Solution, and Simbrinza Ophthalmic Suspension.
  2. Staff #1 acknowledged during discussion that the aforementioned medications were not initialed by direct care staff who administered the medications. Staff #1 did not provide any additional documentation with the DCS? initials for the aforementioned MARs.
Plan of correction
Resident Care Director and/or designee will review Medication Administration Record daily for omitted initials. Paper medication records will be printed monthly to ensure that medications can be documented in the event of electronics failure. All registered medication aides will be in serviced on how to document medication passes, when electronic devices are not working properly.
September 17, 2020Inspection3 violations
Inspection dates
Sept. 17, 2020 , Sept. 18, 2020 , Sept. 21, 2020 and Sept. 22, 2020
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A monitoring inspection was initiated on 09-17-2020 and concluded on 09-22-2020. Several self-reported incidents were received by the department pertaining to Administration and Administrative Services and Resident Care and Related Services. The Administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the Administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the self-report of non-compliance with standards or law, and violations were issued. Any violations not related to the self-reports but identified during the course of the investigation can be found on the violation notice.
Violations
22VAC40-73-40-A
Based on record review and interview, the licensee failed to ensure compliance with the facility’s own policies and procedures.
Evidence
  1. On 08-31-2020, staff #2 emailed an incident report involving resident #1, which documented, ?[On 08-28-2020 at approximately 5:05 PM] Resident alledgedly [allegedly] repeatedly struck Direct Care Manger during ADL care being attempted. Another Direct Care Manager states that she saw 1st care giver [identified by staff #2 as “staff #3”] strike the resident on her right shoulder??
  2. Staff #1 provided a copy of the facility’s ?GP12- Abuse Prevention, Intervention, Reporting, and Investigation (10-30- 2019)“ which documented ”Should any resident experience abuse (by staff, residents, family, or others) or when abuse is suspected, staff is required to immediately notify the Resident Care Director or designee and any other persons/agencies as described in this policy“ Residents are to be free from ” physical, emotional/mental abuse“ at all times” If such incidents occur or are discovered after normal working hours, the Manager on Duty is notified? Resident and staff are to be protected during incident investigations by ensuring accused employees are removed from resident contact immediately and suspended pending investigation??
  3. Staff #1 provided signed and typed statements from staff #2, #3, #4 & #5 regarding the aforementioned incident involving resident #1: A. Staff #2’s statement dated 09-02-2020 documented “On 8/31/2020” staff #1 informed me that staff #4 had called her early that morning stating that she thinks she may have witnessed abuse to a resident at the hand of her co-worker? I called staff #4 and she explained that she saw staff #3 hit resident #1 in her right upper arm/shoulder area ...? B. Staff #4’s statement documented “On 08/28/2020 at approximately 5:04 pm” As I looked up, I saw staff #3 struck her [resident #1] in her right arm/shoulder area“ The resident” did say to me, ?Don’t let her touch me! How could you let her do this to me??“ After I went home for the weekend, I couldn’t get the situation off of my mind” So, on Monday morning I called staff #1 and told her what happened.? C. Staff #3’s statement documented “On 08/28/2020” We started changing her and she [resident #1] punched me in my eye. In a reflex, I hit her arm?? D. Staff #5’s statement documented ?On Friday evening staff #3 came up to me and told me that resident #1 had punched her in her eye“ She [staff #3] never mentioned that she had struck resident.”
  4. Staff #1 provided a copy of staff #3’s “Timecard Editor” [timesheet] that documented staff #3 worked from 2:52 PM until 11:02 PM on 08-28-2020. Staff #3 was not removed from resident contact immediately after the incident involving resident #1 that occurred on 08-28-2020 at approximately 5:05 PM; per the facility’s ?GP12-Abuse Prevention, Intervention, Reporting, and Investigation (10-30-2019)? policy.
  5. Staff #1 acknowledged, staff did not follow the facility’s policy labeled ?GP12-Abuse Prevention, Intervention, Reporting, and Investigation (10-30-2019)? with regard to the aforementioned incident.
Plan of correction
1. Staff #4 was educated on our reporting policies and being a mandated reporter. Completed 09/02/2020. 2. Staff # 5 was involved in a different self-report. Staff # 5 was involved in violation :22VAC40-73-(3)-130-A 3. Executive Director, Business Office Manager and/or designee to assign the following Relias training to all staff: a. Effective Communication b. Preventing, recognizing, and reporting abuse c. Handling Aggressive Behaviors d. Dementia Care: Preventing catastrophic reactions 4. Staff # 3 was immediately suspended pending investigation. Completed 8/31/2020
22VAC40-73-130-A
Based on record review and interview, the facility failed to ensure staff who are mandated reporters under ? 63.2-1606 of the Code of Virginia report suspected abuse of residents in accordance with that section.
Evidence
  1. On 09-17-2020, staff #2 emailed two incident reports which documented: A. ?On 09/17/2020 Direct Care Manager (staff #5) reported that she heard Direct Care Manager (staff #6) speaking loudly to resident [resident #3] in a disrespectful manner and felt that it was verbal abuse.? The documented date of the incident was “09/15/20.” B. ?On 09/17/2020 Direct Care Manger (staff #5) reported that she heard Direct Care Manager (staff #6) speaking loudly to resident [resident #4] in a disrespectful manner and felt that it was verbal abuse.? The documented date of the incident was “09/15/20.”
  2. Staff #1 acknowledged staff #5 did not report the aforementioned suspected verbal abuse involving resident #3 and resident #4 after the incident’s occurred.
Plan of correction
1. Staff #5 was educated on our reporting policies and being a mandated reporter. Completed 9/18/20 2. Executive Director, Business Office Manager and/or designee to assign the following Relias training to all staff: a. Effective Communication b. Preventing, recognizing, and reporting abuse c. Handling Aggressive Behaviors d. Dementia Care: Preventing catastrophic reactions 3. Staff # 6 was immediately suspended pending investigation. Investigation proved not valid; employee returned to work. Completed 9/17/2020
22VAC40-73-650-F
Based on record review and interview, the facility failed to ensure whenever a resident is admitted to a hospital for treatment of any condition, the facility should obtain new orders for all medications and treatments prior to or at the time of the resident's return to the facility.
Evidence
  1. On 08-20-2020, staff #2 emailed an incident report involving resident #2 which documented, ?[On 08-14-2020 at approximately 6:30 PM] Resident returned to community during the evening shift with no discharge summary. The only paperwork the resident had upon return was the unfilled COVID form, med list, hospital transfer form, and face sheet sent by [hospital]??
  2. Staff #1 provided a copy of resident #2’s hospital “After Visit Summary” dated 08-14-2020, which documented the resident, had a diagnosis of “Acute deep vein thrombosis (DVT) of femoral vein of right lower extremity” and started on ? Apixaban (Eliquis) 5mg. Take 1 tab by mouth two (2) times a day. 10mg BID daily for first 7 days. 5mg BID until stopped by primary care doctor...?
  3. Resident #2’s August 2020 Medication Administration Record (MAR) documented Eliquis was first administered by facility staff on 08-19-2020. The MAR did not document that facility staff administered Eliquis to the resident on 08-15- 2020 through 08-18-2020.
  4. Staff #1 provided a copy of resident #2’s “Notes” which documented: A. ?08/18/2020 3:58 PM- Late Entry for 8/17/2020 11:25 AM: RCD called [hospital] medical records to fax over discharge orders as resident did not have paperwork at time of coming back to community?? B. “08/18/2020 4:02 PM- ” received discharge summary via fax at 3:26 PM. Upon review of d/c [discharge] summary, it was discovered that resident had an order to start Eloquis [Eliquis]??
  5. Staff #2 stated resident #2 did not receive the Eliquis 5mg for “3 days” after returning from the hospital on 08-14-2020 however, the resident did not receive the medication for 4 days (8-15-20, 8-16-20, 08-17-20 & 08-18-20).
  6. Staff #1 acknowledged, ?the facility did not obtain the new Eliquis order for resident #2’s prior to or at the time resident #2 returned to the facility on 08-14-2020.?
Plan of correction
1. Resident Care Director, Assistant Resident Care Director and/or designee will ensure upon resident return to speak with medical transport about retrieving discharge paperwork prior to leaving community. Ongoing 2. Resident Care Director, Assistant Resident Care Director and/or designee to notify Emergency Room/ Hospital within 24 hours of resident return if discharge paperwork not received upon residents? return to community. Ongoing 3. Resident Care Director, Assistant Resident Care Director and/or designee will review Yardi (medication administration system) daily for new orders, to ensure all medications are started within 24 hours. Ongoing