Virginia DSS · Assisted Living Facility

Marian Manor of Stafford

📍 177 Old Potomac Church Road, Stafford, VA, 22554-7258

ID 8315Three Year licenseActive
7
Inspections
On record
4
With violations
Visits that cited something
3
Clean visits
Nothing cited
16
Violations cited
Individual findings
16
Standards cited
Distinct rules
1
Complaint visits
Prompted by a complaint

Marian Manor of Stafford was inspected 7 times between March 21, 2022 and June 8, 2026 by the Virginia Department of Social Services. 4 of those visits ended with violations cited and 3 with none. Across that history VDSS cited 16 violations under 16 distinct standards. 1 inspection was prompted by a complaint.

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

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

Provider Information

Facility type
Assisted Living Facility
License type
Three Year
License expires
02/14/2026
Administrator
Sharlene Jackson
Licensing inspector
Sarah Pearson
Inspector phone
(540) 680-9469
Approved for
Assisted Living · Non-Ambulatory

Inspection History

7

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

June 8, 2026Inspection2 violations
Inspection dates
06/08/2026
Areas reviewed
22VAC40-73 Administration and Administrative Services22VAC40-73 Personnel22VAC40-73 Staffing and Supervision22VAC40-73 Admission, Retention and Discharge of Residents22VAC40-73 Resident Care and Related Services22VAC40-73 Resident Accommodations and Related Provisions22VAC40-73 Building and Grounds22VAC40-73 Emergency Preparedness22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 Sworn Statement
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: 6/8/2026, 10:49am to 3:45pm. 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: 37 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 3 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: The LI observed residents participating in activity programs and eating lunch. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. 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 Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov
Violations
22VAC40-73-450-F
Based on resident record review and staff interview, the facility failed to develop an Individualized Service Plan (ISP) that was updated as needed for a significant change.
Evidence
  1. Resident 4 admitted 2/4/2021 had an order written 2/20/2026 to cleanse coccyx and upper buttocks with soap and water, dry thoroughly and apply remedy barrier cream Q shift (per shift) and PRN (as needed) hospice will provide.
  2. The ISP for resident 4 dated 3/30/2026 did not include the need for wound care.
  3. Staff 4 acknowledged the ISP for resident 4 did not include a need for wound care.
Plan of correction
The Administrator and DON will audit ISP’s to ensure each are comprehensive and person centered on or before June 30,2026.
22VAC40-73-350-B
Based on resident record review and staff interview, the facility failed to, prior to admission, whether a potential resident is a registered sex offender.
Evidence
  1. Resident 3 admitted 5/19/2026 had a Virginia State Police search results for All Offenders on file dated 5/20/2026.
  2. Staff 4 acknowledged the report was run the day after resident 3 moved into the assisted living facility.
Plan of correction
The Administrator will ensure all future criminal and sex offender searches are completed before admission or on day of admission. Date of Correction June 15,2026.
December 30, 2025Inspection8 violations
Inspection dates
12/30/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND
Technical assistance
Ensure an alternative method to the door alarms such as turning down the volume or using alternative methods to monitor the doors. Strongly encourage submitting infection control program and the medication management plan to be reviewed by the department.
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: 12/30/2025 9am-3:07pm 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 regarding allegations in the area(s) of: Staffing and Supervision. Number of residents present at the facility at the beginning of the inspection: 37 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:3 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: During the inspection LI experienced the facility dog pawing/scratching at LI’s leg during the facility tour. Additional Comments/Discussion: Please refer to the technical assistance provided. 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 Alexandra Roberts, Licensing Inspector at 804-845-6956 or by email at Alexandra.n.roberts@dss.virginia.gov
Violations
22VAC40-73-860-I
Based on observation, the facility failed to ensure that cleaning supplies and other hazardous materials in a locked area.
Evidence
  1. During facility tour on 12/30/2025, disinfectant spray was observed in the unlocked first floor hallway closet.
  2. Photo evidence obtained.
Plan of correction
All housekeeping supplies are to be in the locked closet unless they are in use. Administrator will ensure all supplies remain in locked closets. Housekeeping and nursing Inservice held on January 23, 2026.
22VAC40-73-870-E
Based on observation, the facility failed to ensure that all furnishings, fixtures, and equipment, including furniture, window coverings, sinks, toilets, bathtubs, and showers, shall be kept clean and in good repair and condition, except that furnishings and equipment owned by a resident shall be, at a minimum, in safe condition and not soiled in a manner that presents a health hazard.
Evidence
  1. During inspection on 12/30/2025, chair in the front left office space that licensing staff was sitting in was unsteady and the arm rest broke while in use at 10:36 a.m.
  2. During facility tour on 12/30/2025 with Staff 1, two licensing staff observed facility air vents to have dust collected, medication cart with an unknown brown substance running down the right side, wall attached cooling system to have unknown brown substance on the control panel, brown and black substance in the wall attached cooling system, floor vents in residents rooms to be bent and broken and not clean, rusted floor pan underneath a water dispenser in first floor sitting area, and shared bathrooms to have orange, black and brown colored stains in the showers, bathroom floor and toilet.
  3. During facility tour on 12/30/2025, fire exits on the upper and lower level were blocked by various items such as hoyer lifts as well as covered by a curtain.
Plan of correction
The LI arrived at facility at 9 AM, noting the arm rest broke at 10:36AM and it is unclear how the arm became dislodged since all 4 office chairs are less than a year old. However, due to the potential for this defect in these chairs to happen again, 4 new chairs have been ordered from a different manufacturer. The medication cart was cleaned by nursing staff. Housekeeping has cleaned all spills including chocolate pudding on the unit. The one floor vent noted has been replaced. The drip pan for the Water Cooler rental has been ordered and will be replaced. The orange shade on the bathroom tile is from well water. Current solution to restore tile will be found and will be completed by Feb.10th, 2026. The sheer curtain decorations on 2 of 6 fire doors has been removed. All staff have been inserviced to not block fire doors. The Administrator will round throughout facility daily to ensure compliance is maintained. Date of completion Feb 10,2026.
22VAC40-73-260-A
Based on record review and interview, the facility failed to ensure that each direct care staff member shall maintain current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute.
Evidence
  1. Staff 3’s record (hired 3/7/2025) contained First Aid/CPR certification from National CPR Foundation which is not an approved provider.
  2. Staff 4’s record (hired 11/15/2017) included First Aid/CPR certification from American Red Cross that expired on 8/16/2018.
  3. Staff 1 confirmed that Staff 3 and Staff 4 do not have First Aid/CPR certification that is current and/or from an approved provider.
  4. Photo evidence obtained.
Plan of correction
Marian Manor has licensed nurses on duty that do not require FA. There is always at least one person on duty with CPR which meets VAC 40-73-260A -4. All staff will have AHA or Red Cross CPR and or FA by Feb.26, 2026.
22VAC40-73-320-A
Based on record review and interview, the facility failed to ensure that within the 30 days preceding admission, a person shall have a physical examination by an independent physician and included all required information.
Evidence
  1. Resident 1’s physical examination (admitted 01/15/2025) dated as completed on 01/15/2025 did not include height, weight, general physical condition, including a systems review as is medically indicated, any diagnosis or significant problems; any known allergies and description of the person's reactions, any recommendations for care including medication, diet, and therapy, results of a risk assessment documenting the absence of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it, and the signature of the examining physician or his designee.
  2. Staff 1 confirmed that the physical examination did not contain all required information and was missing page 3 of the physical examination report.
  3. Photo evidence obtained.
Plan of correction
The Physician did not record height and weight upon admission. All other documentation was present in the chart. Page 3 was located under Physician Orders since it had all medications listed on it. Document was provided to LI on 1/26/26. All charts will be audited by Feb.5th, 2026.
22VAC40-73-450-E
Based on record review and interview, the facility failed to ensure that the individualized service plan shall be signed and dated by the licensee, administrator, or his designee, (i.e., the person who has developed the plan), and by the resident or his legal representative.
Evidence
  1. Resident 1’s record contained two individualized service plans (ISP) dated 01/15/2025 and 04/05/2025 that indicated “resident unable to sign” and did not have a signature and date by the resident or his legal representative.
  2. Staff 1 confirmed that Resident 1’s legal representative did not sign or date either of the ISPs.
Plan of correction
A complete audit of all ISP’s was completed on January 23rd, 2026 by the facility Administrator. ISP’s are emailed to RPs that are not local to area with hopes of signatures and return of ISP. If the document is not returned or signed, a copy of the sent email will be attached to the ISP as evidence of the attempt. This will be implemented on January 23,2026 by the Administrator.
22VAC40-73-460-D
Based on record review and interview, the facility failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs, such as prevention of falls and wandering.
Evidence
  1. During the onsite inspection on 12/30/2025, licensing staff reviewed facility documentation that detailed that on 03/22/2025, Resident 1 was outside walking the courtyard at 7:30pm. Resident 1 was still outside at 8:14pm per provided report. Staff attempted to locate the Resident within the facility and its premises including the courtyard. Staff then contacted Staff 1 and the local sheriff’s department was called after 9pm.
  2. Resident 1 is diagnosed with dementia with behavioral disturbances and is non-ambulatory per physical examination dated 01/15/2025.
  3. Resident 1's individualized service plan (ISP) dated 01/15/2025 details a description of need that Resident 1 is disoriented, and “monitor for safety while walking outside. Elopement risk is elevated due to Dementia…" The ISP continues to detail that the services to be provided would include “Staff to monitor whereabouts when resident is outside” with the expected goal detailed to be “Resident will remain safe while walking outside…”
  4. Staff 1 acknowledged Resident 1's ISP dated 01/15/2025 need for monitoring while walking outside. Staff 1 also confirmed Resident 1 was located outside on 03/22/2025 alone on the ground in the fenced courtyard between two bushes after being located with the help of the local sheriff department.
Plan of correction
This was a self-reported incident. A VDSS Licensing Inspector was at Marian Manor on May 20,2025 and did not choose to investigate this even though it was self-reported on March 24th, 2025. Resident did not wander- he was inside of our secure courtyard walking as he does daily. Cameras record all activity inside of the area. He was last seen on camera at 815 PM and 830 PM. 911 was activated at 9:11 pm. Resident was indeed monitored by staff and visual aids as documented in the self-report. There were no injuries noted. Resident has a Project Lifesaver Bracelet provided by SCSO, whereas protocol requires facility to call 911 immediately if he is not accounted for. It is evident that Resident was monitored, otherwise no action would have been taken. The ISP states “resident will be monitored” which he was. Marian Manor staff will continue to monitor all residents inside and, in the courtyard, using the above methods. There was no negative outcome to this event. All residents will be monitored whether inside or out. January 23,2026.
22VAC40-73-660-A-1
Based on observation and interview, the facility failed to ensure that the medication and dietary supplements administered by the facility are stored in a locked area.
Evidence
  1. During facility tour on 12/30/2025 with Staff 1, two licensing staff observed an unattended and unlocked storage cart on the lower level of the facility in the hallway that contained 10% Povidone Iodine Topical Solution, Calazime skin protectant paste, Calprotect Ointment/Menthol/Zinc Oxide and Nystatin Topical Powder, USP in the pharmacy containers with resident information.
  2. During facility tour on 12/30/2025 with Staff 1, two licensing staff observed Resident 2’s Sodium Chloride 0.9% IRR unsecured and on a shelf above the unlocked storage cart on the lower level hallway.
  3. Staff 1 acknowledged the unsecured medications and unlocked storage cart.
  4. Photo evidence obtained.
Plan of correction
All medications will be maintained in the locked medication cart. DON held Inservice held on January 23,2026.
22VAC40-73-870-B
Based on observation, the facility failed to ensure that all buildings shall be well-ventilated and free from foul, stale, and musty odors.
Evidence
  1. Upon entrance into the facility on 12/30/2025 at 9:00 a.m., two licensing staff noted a foul odor that smelled of urine.
  2. During the facility tour on 12/30/2025 at 11 a.m. with Staff 1, two licensing inspectors toured the lower-level floor of the facility and noted a more potent and stronger foul odor that smelled of urine.
Plan of correction
All furnishings were immediately disinfected whereas a resident had an episode of urinary incontinence. The lower-level source of odor was located in trash can in a resident room. The nursing staff will monitor certain residents more frequently. A poll was taken of 6 family members visiting on day of inspection from 3:30PM- 5:30 PM. No guest noted any odors. Housekeeping staff will check certain resident rooms trash cans every two hours to ensure no odor is present. Inservice held on January 23rd, 2026.
May 20, 2025Complaint survey1 violation
Inspection dates
05/20/2025
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 5/20/2025 11:00 a.m. – 3:30 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 3/15/2025 regarding allegations in the area(s) of: resident care, staffing, and supplies. Number of residents present at the facility at the beginning of the inspection: 39 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: Building and grounds and resident care. Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. However, violation(s) 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 Jeff Marnien, Licensing Inspector at (540) 571-0189 or by email at Jeffrey.marnien@dss.virginia.gov
Violations
22VAC40-73-460-H
Based on record review and staff interviews, 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. During a record review conducted by the Licensing Inspector (LI) on 5/20/2025, resident 3’s Individualized Service Plan (ISP), dated 4/5/2025, indicated that the resident would receive two showers or baths per week, with staff assistance, due to a diagnosis of dementia. The Uniform Assessment Instrument (UAI), dated 4/10/2025, stated that the resident required supervised assistance with bathing. A psychiatric assessment, dated 1/29/2025, noted that the resident experienced intermittent paranoia related to showering. A shower schedule was provided, designating resident 3 for showers on Tuesdays and Fridays during the 11 p.m. to 7 a.m. shift.
  2. On 5/20/2025, the LI interviewed staff 3 who stated resident 3 requires supervision otherwise they will only wash their belly.
  3. During the month of May 2025 there were two instances documented when resident 3 received showers, 5/1/2025 and 5/15/2025. 4 Staff 1 and staff 2 confirmed documentation doesn’t demonstrate resident 3 is receiving the number of showers according to their ISP.
Plan of correction
An audit of all ISP’s will be conducted by the Administrator and DON to ensure ADL care needs are identified in conjunction with the UAI. Direct care staff have been educated on the importance of completing documentation accurately and in a timely manner. Audits will be conducted daily by Charge Nurse to ensure all direct care paperwork is completed at end of shift.
November 25, 2024Inspection5 violations
Inspection dates
11/25/2024, 11/26/2024
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS63.2- (17) LICENSURE AND REGISTRATION PROCEDURES63.2- (18) FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
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: 11/25/2024 11:30am – 4:50pm, 11/26/2024 10:30am – 3:00pm 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: 37 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 3 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Building and grounds, lunch and dinner services, medication pass 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. 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 (Jeff Marnien), Licensing Inspector at (540) 571-0189 or by email at Jeffrey.marnien@dss.virginia.gov
Violations
22VAC40-73-250-D
Based on record review and staff interview the facility failed to ensure employee health information was maintained at the facility and included in the staff record for each staff person.
Evidence
  1. During an interview on 11/25/2024 with staff 1, LI requested the tuberculosis (TB) examination report for staff 4.
  2. Staff 1 reviewed staff 4’s record with LI and observed the TB evaluation report was not in staff 4’s record.
  3. Staff 1 confirmed the TB evaluation report was not in staff 4’s record and available for review.
Plan of correction
An internal audit of all employee files has been conducted by the Administrator. Every employee has a current TB exam/report. The Administrator will review all employee files quarterly and create a spreadsheet for annual updates to ensure compliance with VDSS Standards.
22VAC40-73-930-D
Based on observation and staff interview the facility failed to document rounds for each resident with an inability to use the signaling device.
Evidence
  1. During an interview on 11/25/2024 with staff 1, LI asked if there were residents unable to use the pull cord or pendent alert system. Staff 1 stated all the residents were unable to use the call system due to cognitive impairment.
  2. LI requested documentation of rounds that were made for the residents unable to use the call system.
  3. Staff 1 and staff 2 stated that documentation of rounds was not being documented and cannot be submitted for review.
Plan of correction
Rounds are conducted every hour. The DON and Administrator created a specific document which was implemented on the day of inspection. DON will monitor and audit monthly.
22VAC40-73-120-A
Based on record review and staff interview the facility failed to ensure the orientation and training of new staff occurred within the first seven working days of employment.
Evidence
  1. During an interview on 11/25/2024 with Staff 1, LI requested documentation of orientation and training for staff 3.
  2. Staff 1 reviewed staff 3 record with LI and observed documentation of receiving orientation and training was not in staff 3’s record.
  3. Staff 1 confirmed the documentation was not available for review.
Plan of correction
An internal audit of all employee files has been conducted by the Administrator. Every employee has orientation documentation on file. The Administrator will conduct quarterly audits to maintain compliance with VDSS Standards.
22VAC40-73-840-A
Based on record review, observation, and staff interview the facility failed to ensure they maintained a policy regarding pets living on the premises that ensured the safety and well-being of all residents and staff.
Evidence
  1. Licensing Inspector (LI) observed two dogs and one cat living on the premises.
  2. During interview on 11/25/2024 with staff 1, LI asked who the owners were of the animals. Staff 1 stated the dog belonged to resident 8 and the other dog and cat belonged to the facility.
  3. LI requested the pet policy. Staff 1 provided the resident agreement. In section 27 it states, “Residents are not allowed pets of any type in the facility. Family members are invited to bring pets into the facility, with prior permission from the Administrator. All pets must have current shots, proof of current shots and be in good health, and leashed/crated, or contained, if applicable always.”
  4. Staff 1 confirmed the pet policy, within the resident agreement, needed updated since they do allow pets to live at the facility.
Plan of correction
The Resident Agreement was updated by the Administrator during the inspection which now reads “Pets are allowed on a case by case basis”.
22VAC40-73-200-D
Based on record review and staff interview the facility failed to obtain a copy of documentation indicating that direct care staff have met one of the requirements to be a direct care provider and retain the documentation with the staff member's record.
Evidence
  1. During an interview on 11/25/2024 with Staff 1, LI requested the direct care aide documentation for staff 4.
  2. Staff 1 reviewed staff 4’s record with LI and observed criteria to be a direct care provider was not in staff 4’s record.
  3. Staff 1 confirmed the documentation was not available for review.
Plan of correction
An internal audit of all employee files has been conducted by the Administrator. Every employee has a copy of the training certificate or CNA license on file. The Administrator will conduct a quarterly review of all employee files to ensure compliance with VDSS Standards.
February 21, 2024Inspection0 violations
Inspection dates
02/21/2024
Areas reviewed
Administration and Administrative ServicesPersonnelStaffing and SupervisionAdmission, Retention and Discharge of ResidentsResident Care and Related ServicesBuildings and GroundsEmergency PreparednessMixed Population
Comments
Date of Inspection: February 21, 2024 Type of Inspection: Monitoring Inspection If you have any questions or email changes, please do not hesitate to contact me at laura.lunceford@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov. Census 35 Number of records reviewed and interviews conducted- 8 records (staff and residents),7 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. The Licensing Inspector observed the residents during activities and meals. The Licensing Inspector reviewed the following at the time of inspection: fire drills, menus, activity calendars, physical plant and healthcare oversight.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
January 20, 2023Inspection0 violations
Inspection dates
01/20/2023
Areas reviewed
Administration and Administrative ServicesPersonnelStaffing and SupervisionAdmission, Retention and Discharge of ResidentsResident Care and Related ServicesBuildings and GroundsEmergency PreparednessAdditional Requirements for Facilities that Care for Adults with Serious Cognitive ImpairmentMixed Population
Comments
Date of Inspection: January 20, 2023 Type of Inspection: Renewal Inspection If you have any questions or email changes, please do not hesitate to contact me at laura.lunceford@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov. Census 37 Number of records reviewed and interviews conducted- 4 resident records and 4 staff records, 5 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. The Licensing Inspector observed the residents during activities and meals. The Licensing Inspector reviewed the following during the inspection: fire drills, dietician report, pharmacy review and health care oversight.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
March 21, 2022Inspection0 violations
Inspection dates
03/21/2022
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Date of Inspection: March 21, 2011 Type of Inspection: Monitoring Inspection If you have any questions or email changes, please do not hesitate to contact me at laura.lunceford@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov. Census 38 Number of records reviewed and interviews conducted- 3 resident records and three staff records records, 5 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. The residents were observed during lunch and activities. The pharmacy review report, dieticians report and health care oversight were all reviewed at the time of inspection.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.