Virginia DSS · Assisted Living Facility

Hunters Woods at Trails Edge

📍 2222 Colts Neck Road, Reston, VA, 20191

ID 53004Conditional licenseActive
22
Inspections
On record
15
With violations
Visits that cited something
7
Clean visits
Nothing cited
39
Violations cited
Individual findings
31
Standards cited
Distinct rules
6
Complaint visits
Prompted by a complaint

Hunters Woods at Trails Edge was inspected 22 times between February 11, 2021 and May 27, 2026 by the Virginia Department of Social Services. 15 of those visits ended with violations cited and 7 with none. Across that history VDSS cited 39 violations under 31 distinct standards. 6 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. 2 of these 22 are still on the state's site; the other 20 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
09/26/2026
Administrator
Carla Shipley
Licensing inspector
Amanda Velasco
Inspector phone
(703) 397-4587
Approved for
Assisted Living · Non-Ambulatory · Special Care Unit

Inspection History

22

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

May 27, 2026Inspection7 violations
Inspection dates
05/27/2026
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 LICENSING PROCESS
Technical assistance
22VAC40-73-870-A: Buildings and Grounds; Upcoming refresh in safe, secure unit. 22VAC40-73-640-A: Medication Management Plan 22VAC40-73-260-A: First Aid Certifications 22VAC40-73-200-C: Qualifications Hire Dates/Admit Dates Re: CHOW
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: 05/27/2026 9:25 AM to 3:55 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 118 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: 6 Observations by licensing inspector: Medication Pass, Activities, and Meals/Snacks in both Memory Care and Assisted Living Units. Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of these inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov.Should you have any questions, please contact Amanda “AJ” Velasco, Licensing Inspector at (703) 397 4587 or by email at amanda.velasco@dss.virginia.gov.
Violations
22VAC40-73-640-A
Based on resident record review and staff interview, the facility failed to ensure a written plan for medication management was kept current, implemented, and addressed procedures for administering medication including required components.
Evidence
  1. In an interview with the LI on 05/27/2026, Staff 1 confirmed that the medication plan submitted and approved in March of 2026 was still the most up to date copy being used in the facility.
  2. Page 319 of the Medication Management Plan states that all orders will be transcribed to the EMAR within 24 hours of receipt.
  3. Resident 1’s record contains an order for Lactin Lotion, dated 05/02/2026, that states to apply topically to affected skin of feet and lower legs
  4. Resident 1’s Medication Administration Record (MAR) for May of 2026 indicates that despite the start date of 05/02/2026, the Lactin Lotion was not started on the MAR until 05/22/2026. It was marked as administered on 05/22/2026, but not administered and pending delivery on 05/23/2026 and 05/24/2026.
  5. In an interview with the LI on 05/27/2026, Staff 1 confirmed that the facility’s medication management plan was not followed.
Plan of correction
Resident 1 had their medication order transcribed on May 2, 2026. Due to delays in the family providing the lotion was unable to be administered. The lotion was administered on May 23, 2026. The ADNS will check all residents who have orders for lotion to ensure that the lotion is available for use as ordered. If they find that the lotion is not available, the product will be immediately obtained and provided for use. Education will be provided to the Med Techs by the Director of Wellness or their designee on checking resident rooms, and contacting the family to provide lotions to the community as needed. In addition, they will be educated on the need to communicate with the Director or Wellness or the Assistant Director of Wellness when lotion is not available so that lotion can be obtained. Weekly for 4 weeks, The ADNS will check all residents who have orders for lotion to ensure that the lotion is available for use as ordered. If they find that the lotion is not available, the products will be immediately obtained and provided for use.
22VAC40-73-220-A
Based on resident record review and staff interview, the facility failed to ensure that the direct care or companion services provided by private duty personnel to meet identified needs were reflected on the resident’s individualized service plan.
Evidence
  1. In an interview with the LI on 05/27/2026, Staff 2 confirmed that Resident 3 receives direct care or companion services provided by private duty personnel.
  2. Resident 3’s ISP, dated 11/11/2025, did not include documentation of the direct care or companion services provided by private duty personnel.
  3. In an interview with the LI on 05/27/2026, Staff 1 and Staff 2 confirmed that the direct care or companion services provided by private duty personnel were not listed on Resident 3’s ISP.
Plan of correction
The PDA services were added to Resident 3’s ISP by the Director of Wellness or their designee by 6/30/26. All residents who have hired a PDA will have their ISP checked to ensure that the ISP indicates the use of a PDA. If the ISP is found not to have a PDA indicated, it will be added to the ISP. As PDA’s are hired by residents, the ISP will be updated to indicate use of PDA. Weekly for 4 weeks, the ADNS will check all ISPs for residents who have hired a PDA to ensure the ISP has been updated. If they find that the ISP is not updated, they will update it at that time.
22VAC40-90-40-H
Based on staff record review and staff interview, the facility failed to ensure that employees with convictions of barrier crimes did not maintain employment.
Evidence
  1. During a criminal history record report and sworn statement of affirmation review, Staff 12’s record was reviewed. Staff 12 was hired on 05/06/2026. Staff 12’s Criminal Record Report, dated 05/01/2026, contained two barrier crime convictions dated 06/26/1992, 01/19/1993, and 11/13/2002.
  2. In an interview with the LI on 05/27/2026, Staff 1 confirmed that Staff 12 remained employed despite conviction of multiple barrier crimes.
Plan of correction
Staff member 12 was terminated on May 27, 2026, by the Executive Director. An audit will be conducted of all employee files by the Executive Director or their designee to ensure that all staff members are cleared to work at the community in accordance with the regulations. If issues are identified, immediate termination will be taken. Weekly for 4 weeks, and prior to start date, the Executive Director or their designee will audit all new hire files to ensure compliance with the regulation. If issues are identified, the employee will not be hired.
22VAC40-73-750-C
Based on direct observation, resident record review, and staff interview, the facility failed to ensure that the written specification not to have an item or items listed in subsection B was maintained in the resident’s record.
Evidence
  1. During a medication pass observation between Resident 1 and Staff 7, the LI observed that Resident 1’s room did not have a bed.
  2. Resident 1’s record did not include written approval for Resident 1’s room not to have a bed.
  3. In an interview with the LI on 05/27/2026, Staff 1 confirmed that written specification to not have a bed, as listed in subsection B, was maintained in Resident 1’s record.
Plan of correction
On May 28, 2026, an email was obtained by the Director of Wellness from the family stating that Resident 1 prefers to sleep in his recliner and a bed as not necessary for his room. This email was added to the medical record on May 28, 2026, and the resident’s ISP was updated on June 10, 2026, by the Director of Wellness to reflect his preference in sleeping in his recliner. All resident rooms will be inspected by the Memory Care Director, the Assisted Living Manager or their designee to identify any rooms where a bed is missing. If one is identified, a statement from the residents or their responsible party will be obtained stating that they prefer not to sleep in a bed or a bed will be provided. The ISP will also be updated to reflect the same. Prior to admission, all rooms will be checked to ensure that a bed is available. If a resident prefers not to have a bed in their room, written consent will be obtained and ISP updated to reflect the same. Weekly for 4 weeks, the Memory Care Director, Assisted Living Manager, or their designee will conduct weekly rounds to ensure that a bed is available in every resident room, unless the resident prefers not to have the bed in their room. They will then check the ISP to ensure that it reflects their preference.
22VAC40-73-680-D
Based on resident record review and staff interview, the facility failed to ensure medication was administered in accordance with the physician or other prescribers' instructions.
Evidence
  1. Resident 1’s record contains an order for Lactin Lotion, dated 05/02/2026, that states to apply topically to affected skin of feet and lower legs.
  2. Resident 1’s Medication Administration Record (MAR) for May of 2026 indicates that despite the start date of 05/02/2026, the medication was not started on the MAR until 05/22/2026. It was marked as administered on 05/22/2026, but not administered and pending delivery on 05/23/2026 and 05/24/2026.
  3. Resident 6’s record contains an order for Cod Oil, dated 04/13/2026, that states take one capsule by mouth every day.
  4. Resident 6’s MAR for May of 2026 indicates that the Cod Oil was not administered on 05/11/2026 because it was discontinued; however, medication administration resumed on 05/12/2026. Resident 6’s record did not include a discontinuation order for Cod Oil.
  5. In an interview with the LI on 05/27/2026, Staff 2 stated that the RX number changed by the pharmacy, so the barcode of the medication was pulling an error code, as if the medication was discontinued – despite not being discontinued.
  6. In an interview with LI on 05/27/2026, Staff 1 and Staff 2 confirmed that the medication for Resident 1 and Resident 6 were not administered per physician instructions.
Plan of correction
On May 23, 2026 the lotion needed for Resident 1 was provided by the family and was applied to Resident 1. On May 12, 2026, Resident 6 received their cod oil. The ADNS will check all residents to ensure that items are available for use as ordered. If they find that items are not available, the items will be obtained and provided for use. Education will be provided by the Director of Wellness or their designee to the Med Techs on how to update the pharmacy bar codes so that the error messages will not appear. Weekly for 4 weeks, the ADNS will check all residents to ensure that items are available for use as ordered. If they find that the items are not available, the products will be obtained and provided for use.
22VAC40-73-325-B
Based on resident record review and staff interview, the facility failed to ensure the fall risk rating was reviewed and updated annually, when the resident condition changes, and after a fall.
Evidence
  1. Resident 1’s records include documentation of a fall that occurred on 05/22/2026. Resident 1’s record does not contain a fall risk rating.
  2. Resident 2’s, admitted 11/01/2024, record contains a fall risk rating completed 11/18/2024. Resident 2’s record did not contain completion of an annual fall risk rating.
  3. In an interview with the LI on 05/27/2026, Staff 2 stated that Resident 1’s fall risk rating for Resident 1’s fall on 05/22/2026 was in progress but not completed. Staff 2 confirmed that Resident 2’s fall risk rating was not completed annually.
Plan of correction
The fall risk assessment will be completed for residents 1 and 2 by the Director of Wellness or their designee by 6/30/26. An audit will be completed by the Director of Wellness or their designee to ensure that all residents have had an annual fall risk assessment completed at the time of fall and annually. If it is found that one is needed, it will be completed at that time. Education will be provided to staff who complete the fall risk assessment by the Director of Wellness regarding completion of the fall risk assessment at the time of fall and annually. After a fall the ADNS or their designee will check to see that a fall risk assessment has been completed. If it has not been completed, they will complete one at that time. In addition, fall risk assessments will be completed annually for all residents at the time when their annual ISP is completed. Weekly for 4 weeks, The ADNS will check all residents who have fallen to ensure a fall risk assessment has been completed, and that annual fall risk assessments have been completed. If they find that the assessments have not been completed, they will complete one at that time.
22VAC40-73-930-D
Based on resident record review and staff interview, the facility failed to ensure that the information was included in the resident's individualized service plan when the resident has an inability to use the signaling device.
Evidence
  1. Resident 6 was admitted to the facility on 01/31/2024.
  2. Resident 7 was admitted to the facility on 06/10/2024.
  3. Both Resident 6 and Resident 7 reside in the safe, secure unit. In an interview with the LI on 05/27/2026, Staff 2 stated that both Resident 6 and Resident 7 require rounding due to an inability to use the signaling device.
  4. Resident 6’s ISP, dated 05/12/2026, and Resident 7’s ISP, dated 01/21/2026, do not include the resident’s inability to use the call bell device.
  5. In an interview with the LI on05/27/2026, Staff 1 and Staff 2 confirmed that the ISP’s of Resident 6 and Resident 7 do not include the inability to use the signaling device.
Plan of correction
The ISPs for residents 6 and 7 was updated by the Director of Wellness by 5/28/26. All residents who cannot use the signaling device will have their ISP checked and updated to indicate the same. As ISPs are developed for those who cannot use the signaling device the need for rounding will be added to their ISP by the Director of Wellness or their designee. Weekly for 4 weeks, The ADNS will check the ISPs of the residents who cannot use the signaling device to ensure that their ISP has been updated to reflect the need for rounding. If they find that the ISP is not updated, they will update it at that time.
March 5, 2026Inspection0 violations
Inspection dates
03/05/2026
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS
Technical assistance
The following documents should be maintained for residents: physical examination report, mental health screening, sex offender checks, and any safe, secure unit documents (appropriateness, approval, and assessment). The most current TB screening, resident rights review, UAI, and ISP should be maintained. The only document that should be maintained for staff records is the TB screening.
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: 03/05/2026 11:00 AM to 1:06 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: 121 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Resident Rooms, Common Areas (Assisted Living and Safe, Secure Unit) Additional Comments/Discussion: Discussed resident room door locks (freedom of movement) and building evaluation follow-up. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website should the facility be issued a license to operate. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of a licensed facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov. Should you have any questions, please contact Amanda “AJ” Velasco, Licensing Inspector at (703) 397 4587 or by email at amanda.velasco@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
August 19, 2025Inspection2 violations
Inspection dates
Aug. 19, 2025
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 08/19/2025, 10:00 a.m. to 1:20 p.m. The Acknowledgement of Inspection form was signed and lef t at the facility for each date of the inspection. A self -reported incident was received by VDSS Division of Licensing on 08/02/2025, regarding allegations in the area(s) of: Resident Care and Related Services and Staf f ing and Supervision. Number of residents present at the facility at the beginning of the inspection: 107 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 staf f records reviewed: 3 Number of interviews conducted with residents: 0 Number of interviews conducted with staf f : 2 Observations by licensing inspector: None Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection f indings. 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 identif ied 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 conf idential information, and (V) return to the licensing inspector by email within f ive (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 f indings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these f indings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing of f ice 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 f indings are subject to public disclosure. Please Note: A copy of the f indings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017 or by email at Jacquelyn.Kabiri@dss.virginia.gov
Violations
22VAC40-73-40-A
Based on record review and interview, the facility failed to assume general responsibility for the health, safety, and well- being of a resident in their care.
Evidence
  1. On 08/02/2025, the LI received a written incident report for an elopement from the secure unit at the facility. 2.The facility’s written incident report and the egress door’s alarm records show that Staff 3 cleared the door alarm at 3:47 a.m. after hearing it; however, Staff 3 did not check for or notice that Resident 1 (admitted 07/15/2024) had exited through the same door leading outside of the safe, secure environment.
  2. During routine safety rounds at 4:45 a.m., Staff 5 observed that Resident 1 was not in their room. A search was initiated within the entire facility and Resident 1 was not located.
  3. The police located Resident 1 at 6:20 a.m. and returned them to the facility.
  4. Staff 1 confirmed the details in the incident report regarding the elopement and acknowledged that Resident 1’s health, safety, and well-being were potentially compromised by being outside the secure environment.
Plan of correction
The resident was safely returned to the community on 8/2/25 and a head-to-toe assessment was completed immediately by The Wellness Director. The responsible party and attending physician were notified of the incident by the Wellness Director. There were no new orders given at that time. The resident was escorted to the emergency room by daughter, and no new orders were received. The resident was placed on 1:1 monitoring for following her return. The resident was identified as a high risk for elopement and was placed on protocol for elopement risk. Resident’s care plan was updated to reflect above information and meeting held with family to discuss new interventions. The staff involved in this incident were counseled on the need to closely monitor all residents who are at risk of leaving and immediately respond to any egress alarms on 8/6/25 by the Wellness Director. On 8/11/25 the Director of Facilities increased the timing of the egress alarm from a 30 second delay to no delay, increased the door alarm volume, and added additional signage to the exit door to deter exiting. In addition, the Director of Facilities also changed the alarm silencing function so that it requires a key to be turned off. Staff were Inservice on elopement policies, the need to keep all residents who live in the secure unit safe, and to answer all alarms immediately. This was conducted by the Memory Care Director and Wellness Director on 8/4/25 and continued through 8/14/25. and additional elopement drills were conducted for all three shifts on 8/11/25 and 8/12/25 by the Memory Care Director. Resident remains on hourly checks and 1:1 supervision during periods of agitation and overnight. On a weekly basis, the Wellness Director or their designee will do weekly documentation checks to ensure monitoring is occurring. In addition, the Memory Care Director will conduct monthly elopement drills and educate as needed. Any violations will result in corrective actions.
22VAC40-73-460-D
Based on a review of a self-reported incident and staff interview, the facility failed to ensure supervision of resident schedules, care, and activities was provided including prevention of wandering from the premises.
Evidence
  1. On 08/02/2025, the facility submitted a written incident report stating that Resident 1 had eloped around 3:50 a.m. and was found outside the Safe, Secure Unit off premises on 08/02/2025 around 6:20 a.m.
  2. Communication log completed by staff 5 on 08/02/2025 states that Resident 1 was not seen in their room during the round checks at 4:45 a.m.
  3. According to data from the nearest weather station at Washington Dulles International Airport (KIAD), the weather in Reston, VA, at 4:52 a.m. on Saturday, August 2, 2025, was clear with a temperature of 61°F.
  4. Based on Google Maps, the distance from the facility to the Safeway where Resident 1 was found is approximately a 6-minute walk. The route passes through a primarily residential area and involves crossing one road, Colts Neck Road, which has a crosswalk and is located in front of the shopping center adjacent to the residential neighborhood.
  5. In an interview conducted with the Licensing Inspector (LI) on 08/19/2025, Staff 1 confirmed that resident 1 eloped off premises during the early morning of 08/02/2025 potentially through a fire door equipped with delayed egress. Staff 1 also indicated that the police located the resident at approximately 6:20 a.m. at the Safeway grocery store located .03 miles from the facility and returned the resident to the facility around 6:36 a.m.
Plan of correction
The resident was safely returned to the community on 8/2/25 and a head-to-toe assessment was completed immediately by The Wellness Director. The responsible party and attending physician were notified of the incident by the Wellness Director. There were no new orders given at that time. The resident was escorted to the emergency room by daughter, and no new orders were received. The resident was placed on 1:1 monitoring for following her return. The resident was identified as a high risk for elopement and was placed on protocol for elopement risk. Resident’s care plan was updated to reflect above information and meeting held with family to discuss new interventions. The staff involved in this incident were counseled on the need to closely monitor all residents who are at risk of leaving and immediately respond to any egress alarms on 8/6/25 by the Wellness Director. On 8/11/25 the Director of Facilities increased the timing of the egress alarm from a 30 second delay to no delay, increased the door alarm volume, and added additional signage to the exit door to deter exiting. In addition, the Director of Facilities also changed the alarm silencing function so that it requires a key to be turned off. Staff were Inservice on elopement policies, the need to keep all residents who live in the secure unit safe, and to answer all alarms immediately. This was conducted by the Memory Care Director and Wellness Director on 8/4/25 and continued through 8/14/25. Additional elopement drills were conducted for all three shifts on 8/11/25 and 8/12/25 by the Memory Care Director. Resident remains on hourly checks and 1:1 supervision during periods of agitation and overnight. On a weekly basis, the Wellness Director or their designee will do weekly documentation checks to ensure monitoring is occurring. In addition, the Memory Care Director will conduct monthly elopement drills and educate as needed. Any violations will result in corrective actions.
July 29, 2025Complaint survey1 violation
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-80 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: 07/29/2025, 9:45 a.m to 1:00 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 07/06/2025 regarding allegations in the area(s) of: Resident Care and Related Services, Buildings and Grounds. Number of residents present at the facility at the beginning of the inspection: 119 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: Activities Additional Comments/Discussion: Collateral contact interviewed. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s); area(s) of non-compliance with standard(s) or law were: Direct Care and Related Services, Buildings and Grounds. A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017 or by email at Jacquelyn.Kabiri@dss.virginia.gov
Violations
22VAC40-73-870-A
Based on observation, the facility failed to ensure the interior of the building was maintained in good repair and kept clean.
Evidence
  1. On 07/29/2025, the LI observed resident 1’s apartment, specifically noting the condition of the carpet surrounding the lti l sofa area. The carpet had multiple stained and worn spots by the sofa area.
  2. Staff 2 acknowledged the appearance and condition of the carpet.
  3. Photo evidence taken.
Plan of correction
What has been done to correct? Upon discovery that resident 1’s apartment carpet condition had stains in it, the Director of Housekeeping immediately deep-cleaned the apartment and shampooed the carpet resident 1 on 7/29/25. This deep- cleaning and shampooing cleaned the carpet, but there are still minor discoloration in the carpet particularly around the area of resident 1’s sofa. For this reason, we received a quote from our flooring vendor to replace the carpet, and we have scheduled with the vendor to have resident 1’s carpet replaced on 8/13/25. How will recurrence be prevented: Ongoing cleaning and routine checks to ensure we remain in compliance with regulation 22Vac40-73-870.A. Person responsible: Director of Housekeeping services or Designee.
March 26, 2025Complaint survey1 violation
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 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: 03/26/2025, 3:30 p.m. to 4:30 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 02/18/2025 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: 118 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: Resident’s apartment Additional Comments/Discussion: 3 Collateral interviews conducted An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s); area(s) of non-compliance with standard(s) or law were: Resident Care and related services. A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. The department's inspection findings are subject to public disclosure. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017 or by email at Jacquelyn.Kabiri@dss.virginia.gov
Violations
22VAC40-73-460-B
Based on documentation and interview, the facility failed to ensure a prompt response by staff to resident needs as reasonable to the circumstances.
Evidence
  1. The facility’s call bell documents were reviewed during the inspection. From 03/04/2025 to 03/23/2025, there were 7 call bell response times for resident 1 that exceeded 20 minutes. ith th LI 05/22/2025 St ff 1 t t d ?Th f ilit d
  2. In an email exchange with the LI on 05/22/2025, Staff 1 stated. ?The facility does not have a set policy specifying an exact time frame for responding to call bells, our internal practice emphasizes timely and efficient responses as a standard of quality care.?
Plan of correction
Resident 1’s delayed call bell responses were addressed immediately. Staff were re-educated on the importance of prompt response times, with an internal goal of responding within 10 minutes. A written policy establishing expectations for response times was implemented on 5/28/2025. Daily audits of call bell logs are being conducted by the Nurse Manager, and any response over 15 minutes is reviewed and corrected. Additional staff coverage during peak hours has been arranged. Results will be tracked and discussed weekly in QAPI. Completion date: 6/10/2025. Responsible party: Executive Director and Health & Wellness Director.
February 26, 2025Inspection1 violation
Inspection dates
Feb. 26, 2025
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS
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: 02/26/2025, 12:30 p.m. to 3:00 p.m. 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 02/09/2025 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: 120 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: 3 Observations by licensing inspector: Bingo and activities 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. However, violation(s) not related to the self-report but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017 or by email at Jacquelyn.Kabiri@dss.virginia.gov
Violations
22VAC40-73-450-C
Based on documentation review, the facility failed to ensure the Individualized Service Plan (ISP) shall include a written description of what services will be provided to address identified needs and who will provide them.
Evidence
  1. Staff 1 acknowledged resident 1’s most current ISP was completed on 07/08/2024 during the onsite inspection on 02/26/2025.
  2. Upon review of resident 1’s record, it contained fall risk assessments completed after resident 1 fell 02/05/2025.
  3. Resident 1’s ISP dated 07/08/2024 was not updated after fall risk assessments completed on 02/05/2025 and on 02/09/2025, to indicate any intervention put into place.
Plan of correction
Resident 1’s ISP was updated on 2/27/2025 to reflect fall risk assessments from 2/5/2025 and 2/9/2025, including specific interventions and assigned staff responsibilities. A 90-day audit of all residents' ISPs is underway to ensure updates after significant changes. Staff were retrained on timely ISP revisions. ISPs will now be reviewed within 48 hours of any incident. Weekly audits will occur for 90 days, reported in QAPI. Completion date: 3/15/2025. Responsible: Health & Wellness Director
February 5, 2025Complaint survey0 violations
Inspection dates
Feb. 5, 2025
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 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: 02/05/2025, 10:45 AM- 2:00 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 01/10/2025 regarding allegations in the area(s) of: Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 107 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents:0 Number of interviews conducted with staff: 3 Observations by licensing inspector: Bingo 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 Jacquelyn Kabiri, Licensing Inspector, at 703-397-3017, or by email at Jacquelyn.Kabiri@dss.virginia.gov Violation Notice Issued: “No”
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
October 16, 2024Inspection2 violations
Inspection dates
Oct. 16, 2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND
Comments
Type of inspection: “Monitoring” Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/16/2024,12:01 p.m. to 2:00 p.m. 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 9/30/2024 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: 106 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Lunch 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 Jacquelyn Kabiri, Licensing Inspector at (703) 397- 3017 or by email at Jacquelyn.kabiri@dss.virginia.gov
Violations
22VAC40-73-40-A
Based on the review of facility records and interview conducted, the facility failed to follow their own policies and procedures.
Evidence
  1. Facility policy dated 4/17/2023, stated, “Telephone orders will not be accepted for new medications”, ?Telephone orders may be accepted for changes to existing medications and must be properly documented.?
  2. On 9/27/2024, staff 2 took a telephone order for a new medication, Lisinopril, for Resident 1
  3. Staff 1 confirmed that taking a verbal telephone order for a new medication was not following the facility’s written policy.
Plan of correction
The facility’s policy on telephone orders was reviewed, and all staff received re-education to ensure full compliance with the policy. Any deviations from the policy were immediately corrected, and a designated staff member was assigned to verify that proper documentation is completed for medication changes. To ensure ongoing adherence to the policy, a monthly audit of telephone orders will be conducted for the next three months. Staff in question were specifically re- educated on the telephone order policy, and the improper telephone order was corrected promptly. To prevent recurrence, all nursing staff will complete mandatory training on medication order policies with a focus on the restriction of telephone orders for new medications. A verification system has been put in place, requiring a second staff member to review and confirm all medication orders before they are processed. Monthly audits will continue for three months, and immediate corrective action will be taken if any violations are identified. The Director of Nursing will oversee the training, ensure compliance, and review the audit findings to maintain policy adherence.
22VAC40-73-680-D
Based on record review and interview, the facility failed to ensure medications were administered in accordance with the physician's or other prescriber’s instructions.
Evidence
  1. Resident 1’s record had a telephone order form dated 9/27/2024 to, ?* DC amlodipine and HCTZ once lisinopril is available to administer, *DC Lasix.? The new medication was (Lisinopril). The form was signed by staff 2. On 9/27/2024, the Medication Administration Record (MAR) for resident 1 indicated Lisinopril 10 mg was administered at 8:00 a.m. and amlodipine 10 mg, Hydrochlorothiazide (HCTZ) 20 mg and Furosemide 20 mg were administered at 9:00 a.m.
  2. Staff 1 confirmed there was a medication error by not discontinuing the amlodipine and HCTZ before starting the Lisinopril.
Plan of correction
1.Resident 1’s MAR and telephone order form were immediately reviewed, and corrections were made to ensure proper documentation. Staff received re-education on medication transcription, order verification, and MAR updates. A double- check system is now in place for new orders to prevent discrepancies. Monthly audits will be conducted for three months to ensure compliance. The Director of Nursing will oversee corrections and training. 2.The medication error was immediately addressed, and Resident 1’s medication regimen was corrected. Staff received re-education on proper medication discontinuation procedures and order verification. A double-check system was implemented to ensure accuracy when updating MARs. Monthly medication audits will be conducted for three months. The Director of Nursing will oversee compliance and staff training.
October 16, 2024Inspection3 violations
Inspection dates
Oct. 16, 2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS
Comments
Type of inspection: “Monitoring” Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/16/2024, 10:05 a.m. to 12:00 p.m. 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 9/29/2024 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: 110 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: 1 Number of interviews conducted with residents:1 Number of interviews conducted with staff: 2 Observations by licensing inspector: Activities and lunch 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 noncompliance with standard(s) or law. However, violations not related to the complaint but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jacquelyn Kabiri, Licensing Inspector at (703) 397-3017 or by email at Jacquelyn.Kabiri@dss.virginia.gov
Violations
22VAC40-73-410-A
Based on record review and interview, the facility failed to ensure the resident’s acknowledgment of having received orientation upon admission (to include emergency response procedures, mealtimes, and use of the call system) was signed and dated by the resident.
Evidence
  1. Resident 1 (admitted on 8/5/2024) had an orientation form in the record; however, it was not signed or dated by the resident.
  2. Staff 1 confirmed that the orientation form was not signed by resident 1.
Plan of correction
Orientation form was immediately reviewed, and the required signature and date were obtained. To prevent recurrence, all new admissions will be completed and sign orientation forms upon admission. A designated staff member will verify signatures before finalizing records. Staff (Move-in coordinator and Resident Care Coordinator) responsible for admissions will receive training in documentation requirements. Monthly audits will ensure compliance, and the Executive Director will oversee implementation
22VAC40-73-450-E
Based on record review and an interview, the facility failed to ensure the individualized service plan (ISP) was signed and dated by the resident or his legal representative.
Evidence
  1. Resident 1’s record had an ISP dated 8/5/2024 that was not signed or dated by resident 1 or their legal representative.
  2. Staff 1 confirmed in an interview that the ISP was not signed by resident 1 or the legal representative.
Plan of correction
Resident 1’s ISP was immediately reviewed, and the required signature was obtained from the resident or legal representative. To prevent recurrence, staff responsible for ISP documentation will be trained in obtaining signatures before finalizing ISPs. A designated staff member will review all ISPs for compliance, and monthly audits will be conducted for three months. The Executive Director will oversee compliance.
22VAC40-73-550-G
Based on staff record review and staff interview, the facility failed to ensure the written acknowledgment of the Resident? s rights and responsibilities training was signed and dated by staff.
Evidence
  1. The resident’s rights and responsibilities for staff 2 (hired 4/2/2024) was not signed or dated to indicate the completion of training.
  2. In an interview, staff 1 confirmed the resident’s rights and responsibilities training acknowledgement was not signed and dated.
Plan of correction
Resident Rights and Responsibilities training was immediately reviewed, and the required signature and date were obtained. To prevent recurrence, all new hires will be required to sign and date training acknowledgments before starting duties. HR will verify completion during onboarding, and monthly audits will ensure compliance. The Executive Director will oversee implementation.
April 25, 2024Inspection7 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 GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 ? SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Technical assistance
To ensure that the facility has a thorough understanding of the standards, the licensing inspectors had a discussion with the executive director, the director of wellness and the associate executive director regarding the following standards: 22VAC40-73-100, 22VAC40-73-120, 22VAC40-73-440, 22VAC40-73-450-E, 22VAC40-73-530-C, 22VAC40-73-640 and 22VAC40-73-990.
Comments
Type of inspection: Renewal Date of inspection and time the licensing inspectors were on-site at the facility for each day of the inspection: 04/25/2024 7:41AM until 4:00PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 88 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 4 Observations by licensing inspector: morning medication administration, noon-time meal, medication cart audit 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-1180-B
Based on observation of the facility’s physical plant, the facility failed to ensure when there are indications that ordinary materials or objects may be harmful to a resident, these materials or objects shall be inaccessible to the resident except under staff supervision.
Evidence
  1. At approximately 8:17AM during the walk through of the facility’s memory care unit, there was an operable long-stem lighter with an orange base located in the unlocked top far right drawer of the cabinet on the same wall as the refrigerator in the country kitchen which is accessible to residents. This was also observed by staff person 4.
Plan of correction
Executive Director conducted a mandatory all staff meeting on ordinary objects or materials that may be harmful to residents. A full and thorough inspection of each resident’s apartment and common areas were conducted during the meeting by the Executive Director, to ensure any potential harmful materials or objects are removed.
22VAC40-73-450-D
Based on resident record review and staff interview, the facility failed to ensure that when hospice care is provided to a resident, the assisted living facility and the licensed hospice organizations shall communicate and establish an agreed upon coordinated plan of care for the resident and the services provided by the hospice organization shall be included on the individualized service plan (ISP).
Evidence
  1. The ISP for resident 2, dated 02/29/2024, indicates that the resident is receiving hospice/palliative care and that the resident is receiving end of life comfort care services through collateral 2; however, the ISP does not include information of what services are being provided by Collateral 2 to the resident.
  2. Staff persons 4 and 5 verified that the resident is receiving hospice services from Collateral 2.
Plan of correction
Resident individualized service plan has been updated to include the hospice/ palliative care with information of services provided by the hospice team. This care plan will be updated when ever there is a change of service.
22VAC40-73-450-F
Based on resident record review, the facility failed to ensure that individualized service plans (ISPs) were updated at least once every 12 months or as needed for a change in a resident’s condition.
Evidence
  1. The uniform assessment instrument (UAI) dated 02/13/2024 in the record for resident 1 has documentation that the resident has a supra-pubic catheter. The ISP dated 02/13/2024 does not have a written description of services to be provided for this identified need. The ISP also does not have any time frames listed for expected outcomes for any of resident 1’s identified needs.
  2. The record for resident 5 has a signed Do Not Resuscitate Order (DNR) dated 04/16/2024. The ISP dated 04/20/2024 in the record for resident 5 does not include resident 5’s DNR status and has documentation of “CPR” located under the photo for resident 5 on the first page. The ISP also does not have any time frames listed for expected outcomes for any of resident 5’s identified needs.
  3. The ISP for resident 2, updated 02/29/2024, and the ISP for resident 3, updated 04/05/2024, do not have any time frames listed for expected outcomes for any of resident 2 or 3’s identified needs.
Plan of correction
Resident UAI and ISP has been updated to include time frame and outcome with services to be provided to resident 1. Code status on residents has been reviewed and corrected to reflect on their face sheet and individualized service plan with time frames.
22VAC40-73-610-D
Based on resident record review, staff interviews and observation of the noon-time meal, the facility failed to ensure that when a diet is prescribed for a resident by his physician or other prescriber, it shall be prepared and served according to the physician’s or other prescriber’s orders.
Evidence
  1. The record for resident 1 has physician orders signed on 10/02/2023 that include that resident 1 has been ordered a diabetic diet. The special diet book located in the facility kitchen has documentation that resident 1 is on a regular diet. Interviews by two licensing inspectors (LIs) and staff persons 8 and 9 conducted on 04/25/2024 expressed that they were not aware of the physician order for a diabetic diet for resident 1 and have been providing a regular diet to the resident.
  2. The record for resident 2 has physician orders signed on 03/27/2024 that indicate for the resident’s current diet to be discontinued and to start the resident on a pureed diet with thin liquids. The special diet book located in the facility kitchen has documentation that resident 2 is on a low sodium diet with thin liquids. In addition, observation of the noon-time meal during the on-site inspection, the two LIs along with staff persons 8 and 9 observed that the resident was being served lunch entree 2 which was a chicken salad sandwich on white bread with lettuce, tomato, and onion with house made potato chips. Staff persons 8 and 9 expressed that they were not aware of the physician order for the resident to be served a pureed diet and have been providing a regular diet to the resident.
Plan of correction
Director of Nursing and Dining Director will ensure that residents receive diets that have been prescribed by their Physician or dietitian. Staff will ensure that when a diet is prescribed for a resident by the dietitian (and approved by NP) it shall be prepared and served according to the physician’s orders.
22VAC40-73-640-A
Based on observations of the facility medication carts, the facility to ensure that the facility medication management plan was implemented in regard to outdated, damaged or contaminated medications.
Evidence
  1. The facility medication management plan has documentation under Med 14- Outdated, Damaged or Contaminated Medications that “2. All RMAs are to confirm expirations dates of medications during the medication pass” and under Med 22-Administering and Assisting with Injections that ?10. Note the expiration dates for injectables and discard upon expiration “and ”11. Once an injectable medication is opened follow the expiration date according to manufacturer’s instructions?.
  2. An opened Lantus Insulin pen was observed by two licensing inspectors (LIs) in the presence of staff person 5 in the memory care medication cart for resident 3. The pen did not have a date that the Insulin was opened or a date to discard the insulin to be able to follow manufacturer’s instructions which is to discard a Lantus Insulin pen 28 days following the first use.
Plan of correction
RMA’s and LPNs shall ensure that all medications have a manufacturing date and expiration date. All bottled medications and Insulins shall date on which they were opened to know the date they need to be discarded. Facility medication management plan has been reviewed with all RMA’s and LPN to ensure adherence to the policy
22VAC40-73-680-H
Based on resident record review and staff interview, the facility failed to ensure at the time the medication is administered, the facility shall document on a medication administration record (MAR) all medications administered to residents, including over-the-counter medications and dietary supplements.
Evidence
  1. The record for resident 3 contains a signed physician’s order, dated 04/15/2024, for potassium chloride 20MG tablet take one tablet by mouth every day for two days for a total of two doses.
  2. The April 2024 MAR for resident 3 includes documentation that the mediation was only administered on 04/18/2024 at 8:00AM.
  3. Interview with staff person 5 revealed that the medication was administered to the resident per the physician’s order for a total of two doses; however, staff person 5 was unable to find MAR documentation of the second dose of the aforementioned medication that was administered to resident 3.
Plan of correction
Director of Nursing/ assistant Director of Nursing have in serviced all RMAs and LPNs to document all medications administered. Periodic audit of med pass and chart review shall be conducted by DON/ ADON and designee.
22VAC40-90-40-B
Based on staff record review, the facility failed to ensure that a criminal history record report was obtained on or prior to the 30th day of employment for each employee.
Evidence
  1. The records for staff person 10, date of hire 09/19/2023, and staff person 11, date of hire 08/08/2023, did not contain documentation of a criminal history record report being completed on or prior to their 30th day of employment. In an interview conducted with staff person 7 on the day of inspection, staff person 7 expressed that this was correct and that criminal history reports could not be found for these employees.
  2. The record for staff person 12, date of hire 09/19/2023, has documentation of a criminal history record report being processed on 10/25/2023 but the report has documentation that the transaction is being processed. The record for staff person 12 does not have a completed criminal history record report. In an interview conducted with staff person 7 on the day of inspection, staff person 7 expressed that this was correct and that a completed criminal history report could not be found for this employee.
  3. The record for staff person 13, date of hire 09/05/2023, has documentation that a criminal history record report was not completed until 11/02/2023 for this employee.
  4. The record for staff person 14, date of hire 09/19/2023, has documentation that a criminal history record report was not completed until 10/30/2023 for this employee.
Plan of correction
A criminal record check has been run on staff 10, 11, and 12 and a copy of their completed report is placed in their respective files. The Executive Director or designee shall sign off all new hire documents to ensure that the criminal history record report for each employee is obtained on or prior to the 30th day of employment.
March 16, 2023Inspection0 violations
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 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: LI entered the facility at 10:51 am on 3/16/2023 and exited at 12:51 pm on 3/16/2023. 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 3/8/2023 regarding allegations in the area(s) of staffing and supervision, resident care and related services, buildings and grounds, and additional requirements for facilities that care for adults with serious cognitive impairments. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: LI walked the physical building, including the pathway that resident took when leaving the building. LI observed video footage of the incident. Additional Comments/Discussion: 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 Jamie Eddy, Licensing Inspector at (703) 479-5247 or by email at jamie.eddy@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
February 23, 2023Inspection0 violations
Inspection dates
Feb. 23, 2023
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 ? SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS
Technical assistance
A completed Renewal Application must be submitted prior to the expiration of the current license. The facility should receive an application in the mail, however if an application has not been received one can be obtained from the DSS web site or by calling the main office at (276) 206-0492.
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: LI entered the facility at 8:37 am on 2/23/2023 and exited at 4:15 pm on 2/23/2023. 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: 86 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 5 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 0 Observations by licensing inspector: LI observed medication administration. LI observed residents eating lunch. LI walked the physical plant. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (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 Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jamie Eddy, Licensing Inspector at (703) 479-5247or by email at jamie.eddy@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
February 23, 2023Inspection0 violations
Inspection dates
Feb. 23, 2023
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: LI entered the facility at 8:37 am on 2/23/2023 and exited at 3:35 pm on 2/23/2023. 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: 86 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: LI observed the doors in the memory care unit to ensure they were secured and working properly. There was an adequate number of staff working on the memory care unit. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jamie Eddy, Licensing Inspector at (703) 479-5247or by email at jamie.eddy@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
January 17, 2023Inspection1 violation
Inspection dates
Jan. 17, 2023
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: LI entered the facility at 1:10 pm on 1/17/2023 and exited at 2:30 pm on 1/17/2023. 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 12/21/2022 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: 85 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: LI walked the memory care unit and observed camera footage from 12/20/2022. Additional Comments/Discussion: 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 Jamie Eddy, Licensing Inspector at (703) 479-5247 or by email at jamie.eddy@dss.virginia.gov
Violations
22VAC40-73-460-D
Based upon a review of records, interviews, and review of camera footage by licensing inspector, the facility failed to ensure that the facility provides supervision of resident schedules, care, and activities, including attention to specialized needs, such as wandering from the premises.
Evidence
  1. Resident #1 was admitted to the safe, secure environment on 12/12/2022. 2. Interviews with administrative staff conducted on 1/17/2023 revealed that Resident #1 was able to exit the safe, secure environment through an egress door that exits next to the administrative offices and then exited the building through the main doors at approximately 8:36 pm on 12/20/2022. According to the information provided by the administrative staff, after someone pushes on the door for 15 seconds, the door will open, and an alarm is to sound. The Community Executive Operations Officer (CEOC) confirmed that the concierge had already left for the day so there was no one sitting at the front desk. 3. Using the CEOC? s cellular phone, LI was able to observe camera footage from 12/20/2022 that showed Resident #1 standing outside the main entrance to the building at approximately 8:36 pm on 12/20/2022. According to the CEOC, at approximately 8:41 pm, a resident on the independent living (IL) area of the building reported that Resident #1 had been given access into the IL area of the building, where staff later found Resident #1’s handbag but Resident #1 had exited the IL part of the building. 4. According to the self-reported incident report, Resident #1 was last seen by staff at approximately 8:00 pm ? walking back and forth within the memory care neighborhood,? staff provided care to another resident and when the staff went back to the room of Resident’s #1, the resident was not in the room. According to the self-reported incident report, staff searched throughout the entire memory care neighborhood but “did not find resident,” at approximately 9:30pm the search was expanded to include surrounding external environment. The self-reported incident report staff located Resident #1 at a Burger King located across the street from the facility at 2270 Hunters Woods Plaza, at approximately 9:30 pm on 12/20/2022. According to the LI’s map application on LI’s Apple Phone, the Burger King is located approximately 800 feet from the facility.
Plan of correction
Staff members involved in the incident were re-educated by the Resident Wellness Director on the elopement of the resident immediately following the incident. Other departments, housekeeping, dining, activities, and maintenance received additional training on policies and procedures regarding the elopement of residents to ensure they have adequate knowledge, skills, and abilities to keep our residents safe. The community shall intensify rounding to ensure resident’s safety. All high-elopement-risk residents now have a wander guard.
December 16, 2022Inspection0 violations
Inspection dates
Dec. 16, 2022
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: LI entered the facility at 11:06 am on 12/16/2022 and exited at 1:00 pm on 12/16/2022. 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 11/25/2022 regarding allegations in the area(s) of: personnel and resident care and related services. Number of residents present at the facility at the beginning of the inspection: 80 Number of resident records reviewed: 2 Number of staff records reviewed: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jamie Eddy, Licensing Inspector at (703) 479-5247or by email at jamie.eddy@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
June 13, 2022Inspection2 violations
Inspection dates
June 13, 2022 and June 13, 2022
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 ? SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE
Technical assistance
If the person signing the UAI is an employee of the facility, the administrator or designee, who has completed UAI training, must also sign the UAI.
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: Licensing Inspector entered the facility at 9:05 am and left on 6/13/2022 at 5:30 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: 67 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 5 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 0 Observations by licensing inspector: Medication administration and tour of the physical building. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jamie Eddy, Licensing Inspector at (703) 479-5247 by email at jamie.eddy@dss.virginia.gov
Violations
22VAC40-90-30-B
Based upon a review of records, the facility failed to ensure that applicants for employment at assisted living facilities provide the hiring facility with a sworn statement of affirmation.
Evidence
  1. The Sworn Statement of Affirmation for the following employees were incomplete (questions were not answered): Staff #16, #35, #55, #56, #60, #61, #82, #86, #89, and #90.
Plan of correction
Sworn Statement affirmation for all applicants will be audited by Administrative Services Director and signed off by Assistant Executive Operations Officer to ensure that all questions have been answered and signed by the applicant. Administrative Services Director and Assistant Executive Operations Officer would audit 15% of employees file monthly to ensure compliance.
22VAC40-90-40-B
Based upon a review of records, the facility failed to ensure that criminal history record reports are obtained on or prior to the 30th day of employment for each employee.
Evidence
  1. According to documentation reviewed in the employee’s records, the following employee’s criminal history record reports were completed beyond the 30th day of employment. The criminal history record report for Staff #1, who was hired on 1/11/2022, was completed on 6/13/2022. The criminal history record report for Staff #2, who was hired on 4/13/2021, was completed on 6/30/2021. The criminal history record report for Staff #3, whose date of hire was 3/16/2021, was completed on 6/30/2021.
Plan of correction
All new hires will have a criminal history record report obtained by the Administrative Services Director prior to the 30th day of employment. All application will be audited for compliance and signed off by Assistant Executive Operations Officer before any new hire will be allowed to begin orientation.
July 16, 2021Complaint survey0 violations
Inspection dates
July 16, 2021 and Aug. 20, 2021
Areas reviewed
22VAC40-73 PERSONNEL63.2 Facilities and Programs
Comments
Licensing Inspector (LI) conducted an announced complaint investigation on 7/16/2021, 8/20/2021 and 11/27/2021 regarding resident rights and exploitation. LI reviewed resident records and other documentation. Residents and staff inteviewed. Exit interview with Executive Director.. Complaint is deemed not valid as a preponderance of evidence gathered during the investigation did not support the allegations. Thank you for your cooperation and if you have any questions please call (703) 895-5627 or contact me via e-mail at jeannette.zaykowski@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
July 7, 2021Complaint survey1 violation
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
A non-mandated complaint inspection was initiated on 7/07/2021 and concluded on 9/29/2021. A complaint was received by the department regarding allegations in the areas of staffing and resident care. The Executive Director was contacted by telephone to conduct the investigation. The licensing inspector emailed a list of documentation required to complete the investigation. The licensing inspector conducted an on-site observation at the facility on 7/07/2021. The evidence gathered during the investigation supported the allegation of non-compliance with standards or law, and violations were issued. Any violation not related to the complaint but identified during the course of the investigation can be found on the violation notice. Exit interview with the Administrator. Areas of non-compliance are identified on the violation notice. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word "corrected" is not acceptable. The plan of correction must contain: 1) steps to correct the non-compliance with the standard(s), 2) measures to prevent the non-compliance from occurring again, 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s), and 4) date that that plan of correction will be completed. Thank you for your cooperation and if you have any questions please call (703) 895-5627 or contact me via e-mail at jeannette.zaykowski@dss.virginia.gov.
Violations
22VAC40-73-450-H
Based on documentation review, interviews, and observation, the facility failed to ensure that the care and services specified in the Individualized Service Plan (ISP) are provided to each resident.
Evidence
  1. The ISP for Resident 1,dated (05/04/2021) showed staff are to assist resident with hearing aids and will turn on/off as needed, place/remove them in ears daily, remind resident to leave them in ears, and place them in the charger at night.
  2. Interviews with and emails from Collateral 2 and Collateral 3 revealed upon their visits with resident 1 on 06/14/2021, 06/12/2021, 06/10/2021, 06/8/2021, 06/07/2021, 06/06/2021, 06/01/2021, 05/31/2021, 05/20/2021, 05/19/2021, 05/16/2021, 05/15/2021, 05/14/2021, 04/14/2021, 04/10/2021, 03/31/2021 the hearing aids were not in ears or were not turned on.
  3. The LI observed hearing aids in the ears of Resident 1 on 07/07/2021; however the hearing aids were not turned on. The LI asked the resident to demonstrate turning the aids off and the resident was unable to do so.
Plan of correction
Not published by VDSS.
June 30, 2021Inspection2 violations
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
On 06/30/2021 Licensing Inspector (LI) conducted unannounced inspection in response to self-reported incident. Reviewed resident records and other documentation. Conducted resident and staff interviews. Exit interview conducted with the Executive Director. Violation notice issued and assessed risk assigned to violations. Areas of non-compliance are identified on the violation notice. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word "corrected" is not acceptable. The plan of correction must contain: 1) steps to correct the non-compliance with the standard(s), 2) measures to prevent the non-compliance from occurring again, 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s), and 4) date that that plan of correction will be completed. Thank you for your cooperation and if you have any questions please call (703) 895-5627 or contact me via e-mail at jeannette.zaykowski@dss.virginia.gov.
Violations
22VAC40-73-70-A
Based on record and documentation review and interviews, facility failed to ensure that 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. Resident 1 wandered from the facility on 05/28/2021 and the facility emailed an incident report to the Licensing Inspector on 05/30/2021 at 1:09 a.m.
Plan of correction
Not published by VDSS.
22VAC40-73-460-D
Based on record review, documentation and interview, facility failed to ensure that the facility shall provide supervision of resident schedules, care, and activities, including attention to specialized needs, such as the prevention of wandering from the premises.
Evidence
  1. Facility incident report dated 05/29/2021 and resident caregiver notes dated 05/29/2021 document that Resident 1 was returned to the facility by the daughter and the police on 05/28/2021 at about 9:40 p.m. after he had been observed wandering unaccompanied in the neighborhood and facility was not aware that the resident had left the facility.
  2. Resident 1 interviewed on 06/30/2021 stated "I normally like to take a walk at night but I was on the trail and then came to a street corner and it was dusk and I didn't know where to go. I am new here." Resident signed the Resident Handbook on 05/24/2021 that includes the procedure to sign in and out of the building and when asked about the procedure stated o 05/ t at c udes ocedu e stated "I don't recall that book but I am probably not able to do it because I sometimes forget things which is why I need to live here".
  3. Resident 1's Uniform Assessment Instrument dated 05/1/2021 documents "appropriate" and Resident 1's Individual Service Plan onset date 05/24/2021 documents resident "enjoys going for walks/exercise" and "Direct Care Staff, Community Staff or private companion will accompany (resident) when he leaves the building."
  4. Staff interviews on 06/30/2021 stated no knowledge of wandering behavior for Resident 1 prior to this incident.
Plan of correction
Not published by VDSS.
June 30, 2021Inspection1 violation
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
On 06/30/2021 Licensing Inspector (LI) conducted unannounced inspection in response to self-reported incident. Reviewed resident records and other documentation. Conducted resident and staff interviews. Exit interview conducted with the Executive Director. Violation notice issued and assessed risk assigned to violation. Areas of non-compliance are identified on the violation notice. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word "corrected" is not acceptable. The plan of correction must contain: 1) steps to correct the non-compliance with the standard(s), 2) measures to prevent the non-compliance from occurring again, 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s), and 4) date that that plan of correction will be completed. Thank you for your cooperation and if you have any questions please call (703) 895-5627 or contact me via e-mail at jeannette.zaykowski@dss.virginia.gov.
Violations
22VAC40-73-460-D
Based on record review, documentation and interview, facility failed to ensure that the facility shall provide supervision of resident schedules, care, and activities, including attention to specialized needs, such as the prevention of wandering from the premises.
Evidence
  1. The facility's incident report dated 05/16/2021 and resident caregiver notes dated 05/15/2021 and 05/17/2021 document that on 05/15/2021 at 4:20 p.m. Resident 1's Private Duty Aid notified staff that Resident 1 could not be found, premises and surrounding areas were searched, police and family were notified for assistance. Documentation shows that Resident 1 was returned to the facility in a private car driven by his previous neighbor who had seen Resident 1 on the deck of his home.
  2. Tracking devices were reviewed and video showed Resident 1 walking out of the building behind someone pushing a wheelchair.
  3. Resident 1 interviewed on 06/30/2021 stated that "I can walk a long way; I walked all over the world and know how to read maps so I never got lost" and he recalled "a nice man gave me a ride back". Resident signed the Resident Handbook on 07/15/2019 that includes the procedure to sign in and out of the building and was unable to recall this requirement during interview. Wander device was observed on resident's left ankle during interview.
  4. Resident 1's Uniform Assessment Instrument dated 04/5/2021 documents "wandering/passive weekly or more"; ISP dated 04/12/2021 documents resident "wears a wander guard" and "Private Duty Aide (PDA) walks with (resident) outside of building for safety and supervision".
  5. Staff interview stated on 06/30/2021 that the facility learned after the incident that when the doors are already opened then the wander device is not activated so the facility was not alerted that the resident had exited.
Plan of correction
Not published by VDSS.
June 30, 2021Complaint survey6 violations
Inspection dates
June 30, 2021 and July 7, 2021
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
A non-mandated complaint inspection was initiated on 6/30/2021 and concluded on 9/30/2021. Additional review of medication orders conducted week of 10/25/2021. A complaint was received by the department regarding allegations in the areas of staffing and resident care. The Executive Director was contacted by telephone to conduct the investigation. The licensing inspector emailed a list of documentation required to complete the investigation. The licensing inspector conducted an on-site observation at the facility on 6/30/2021 and 7/07/2021. The evidence gathered during the investigation supported the allegation of non-compliance with standards or law, and violations were issued. Any violation not related to the complaint but identified during the course of the investigation can be found on the violation notice. Exit interview with the Administrator. Areas of non-compliance are identified on the violation notice. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word "corrected" is not acceptable. The plan of correction must contain: 1) steps to correct the non-compliance with the standard(s), 2) measures to prevent the non-compliance from occurring again, 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s), and 4) date that that plan of correction will be completed. Thank you for your cooperation and if you have any questions please call (703) 895-5627 or contact me via e-mail at jeannette.zaykowski@dss.virginia.gov.
Violations
22VAC40-73-50-A
Based on document review, the facility failed to provide a statement to the prospective resident and his legal representative that discloses information fully and accurately in plain language about the facility.
Evidence
  1. The facility's disclosure statement documents staff per shift as "RN, LPN" between the hours of 7:00 am -11:00 pm and did not disclose fully and accurately that the staff per shift would be an RN and/or LPN; only an LPN worked at the facility at the time of the inspection.
Plan of correction
Not published by VDSS.
22VAC40-73-460-H
Based on interview and document review, the facility failed to ensure that personal assistance and care are provided to each resident as necessary so that the needs of the resident are met, including assistance or care with bathing at least twice a week, but more often if needed or desired.
Evidence
  1. Resident 1's most recent ISP dated 05/13/2021 documents resident "requires mechanical and physical EVIDENCE: Resident 1s most recent ISP dated 05/13/2021 documents resident requires mechanical and physical assistance with bathing task". The facility was able to provide a shower log for residents however Resident 1 was not listed. Interview with Staff 3 confirmed that there was no documentation to show that Resident 1 received showers.
Plan of correction
Not published by VDSS.
22VAC40-73-470-F
Based on record review, the facility failed to ensure that when the resident suffers serious accident, injury, or medical condition, medical attention from a licensed health care professional shall be secured immediately and the circumstances involved and the medical attention received 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 and a notation shall be made in the resident's record.
Evidence
  1. An incident report was created regarding Resident 1's hospitalization on 05/22/2021-05/23/2021 and Resident 1's record did not include a progress note regarding the hospitalization and circumstances.
Plan of correction
Not published by VDSS.
22VAC40-73-530-C
Based on observation and interview, the facility failed to provide freedom of movement for the residents to their personal spaces and residents in the Safe, Secure Unit (SSU) were locked out of their rooms.
Evidence
  1. Locked doors require residents to have a key fob to unlock the doors and licensing inspector observed residents without the fobs. Interviews with staff confirmed that the residents in the SSU do not have the fobs.
Plan of correction
Not published by VDSS.
22VAC40-73-640-A
Based on record review, the facility failed to implement a written plan for medication management that shall include methods to ensure that each resident's prescription medications ordered for the resident are filled and refilled in a timely manner to avoid missed dosages, and methods for verifying that medication orders have been accurately transcribed to medication administration records (MARs) within 24 hours of receipt of a new order.
Evidence
  1. Resident 1's MAR showed that Clonazepam 0.5 MG Tab ordered on 03/4/2021 was not available on 03/6/2021, 03/08/2021, 03/09/2021 and 03/10/2021.
  2. Resident 1's MAR showed an as needed (PRN) medication Acetaminophen 325 MG Tab was not available on 05/25/2021, 05/29/2021 and 05/30/2021.
  3. Hospital discharge order dated 05/22/2021 for Acetaminophen 325 MG Tab 650 MG oral every 6 hours 7 days was not accurately transcribed to Resident 1's MAR.
Plan of correction
Not published by VDSS.
22VAC40-73-720-B
Based on record review and interview, the facility failed to have a system to ensure that all staff are aware of residents who have a valid Do Not Resuscitate (DNR) Order.
Evidence
  1. Non-direct care staff interviewed stated to go to the direct care staff for the code status and the direct care staff interviewed stated to look in the resident record for the code status.
  2. The record for Resident 1 included a DNR dated 01/06/2021.
  3. The Individualized Service Plan (ISP) for Resident 1 dated 05/13/2021 showed a DNR.
  4. A Physician Order dated 06/26/2021 shows code status as "FULL CODE".
Plan of correction
Not published by VDSS.
February 11, 2021Inspection2 violations
Inspection dates
Feb. 11, 2021 and Feb. 15, 2021
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 ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE
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 inspection was initiated on 2/11/2021 and concluded on 2/15/2021. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 60. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed 4 resident records and 4 staff records. Criminal record checks and sworn statements of all staff hired since last inspection and other documentation submitted by the facility was reviewed 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. Exit interview with the Administrator. Areas of non-compliance are identified on the violation notice. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word "corrected" is not acceptable. The plan of correction must contain: 1) steps to correct the non-compliance with the standard(s), 2) measures to prevent the non-compliance from occurring again, 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s), and 4) date that that plan of correction will be completed. Thank you for your cooperation and if you have any questions please call (703) 895-5627 or contact me via e-mail at jeannette.zaykowski@dss.virginia.gov.
Violations
22VAC40-73-1090-A
Based on record review, facility failed to ensure the resident shall have been assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare. The physician shall be board certified or board eligible in a specialty or subspecialty relevant to the diagnosis and treatment of serious cognitive impairments.
Evidence
  1. Resident #3 was admitted to a Safe, Secure Unit (SSU) on 2/25/2020 with an Assessment of Serious Cognitive Impairment (ASCI) form dated 3/02/2020, after admission. Resident #4 was admitted to a SSU on 1/15/2021 with an ASCI form completed on 1/11/2021 and documented that the resident does not have a serious cognitive impairment due to a primary psychiatric diagnosis of dementia and also answered "No" to the question "is the individual unable to recognize danger or protect her own safety and welfare".
Plan of correction
Resident #3 was an emergent internal transfer from Assisted Living because the resident does not recognizing danger. Resident Wellness Director (RWD) will work with wellness team to ensure that all admissions to a Safe, Secure Unit (SSU) have a Serious Cognitive Impairment (ASCI) form prior to admission, including during an emergent transfer. In addition, the RWD will ensure that the form is completed accurately and in its entirety.
22VAC40-90-30-C
Based on record review, facility failed to ensure that any person making a maerially false statement on the sworn statement or affirmation shall be guilty of a Class 1 misdemeanor.
Evidence
  1. Staff #13's sworn statement signed and dated 12/8/2020 documents not convicted of a law and criminal record report dated 12/30/2020 documents a conviction dated 12/12/2006.
Plan of correction
Staff #13 believed the non-barrier misdemeanor from 15 years ago to be expunged from her record and a late entry is now noted on that staff's sworn statement. Administrative Services Director will provide a more detailed review with staff during the pre-hire paperwork signing and the Executive Operations Officer will audit pre-hire sworn statements.