Hilton Plaza, Inc. — Virginia Inspection Report

Inspections

On record

With violations

Visits that cited something

Clean visits

Nothing cited

Violations cited

Individual findings

Standards cited

Distinct rules

Complaint visits

Prompted by a complaint

Hilton Plaza, Inc. was inspected 18 times between June 25, 2021 and May 11, 2026 by the Virginia Department of Social Services. 11 of those visits ended with violations cited and 7 with none. Across that history VDSS cited 95 violations under 56 distinct standards. 5 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. 15 of these 18 are still on the state's site; the other 3 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

Two Year

License expires

06/30/2028

Administrator

Nina Taylor

Licensing inspector

Darunda Flint

Inspector phone

(757) 807-9731

Approved for

Assisted Living · Ambulatory Only

Inspection History

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

May 11, 2026Inspection0 violations

Inspection dates

05/11/2026

Areas reviewed

22VAC40-73 PERSONNEL

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: 05/11/2026 arrival 8:11 a.m. / departure 1:09 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 10/24/2025 regarding allegations in the area(s) of: Personnel Number of residents present at the facility at the beginning of the inspection: 40 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: 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 Darunda Flint, Licensing Inspector at (757) 807-9731 or by email at darunda.a.flint@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

May 11, 2026Inspection0 violations

Inspection dates

05/11/2026

Areas reviewed

22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

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: 05/11/2026 ( arrival 8:11 a.m. / departure 1:09 p.m.) The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 40 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: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: Breakfast was observed. A medication pass observation was completed for three residents. The following were reviewed: emergency preparedness drills, fire drills, fire inspection report, health inspection report, first-aid kit, and water temperatures were measured. 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 Darunda Flint, Licensing Inspector at (757) 807-9731 or by email at darunda.a.flint@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

June 2, 2025Inspection0 violations

Inspection dates

06/02/2025

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 PREPAREDNESS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSING PROCESS

Comments

Type of inspection: Renewal An unannounced mandated renewal inspection was conducted on 6-2-25 (Ar. 07:53 a.m./Dep 1:15 p.m.) The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 58 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Yes Number of resident records reviewed: 7 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 4 Observations by licensing inspector: medication pass observation, water temperature, emergency food, signaling check, breakfast meal. 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 Willie Barnes, Licensing Inspector at 757-439-6815 or by email at willie.barnes@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

April 14, 2025Inspection4 violations

Inspection dates

04/14/2025

Areas reviewed

Comments

Type of inspection: Monitoring An unannounced non-mandated monitoring inspection was conducted on 4-14-25. (Ar. 08:35 a.m./Dep 12:05 p.m.). The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 62 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Yes Number of resident records reviewed: 4 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: Medication pass observation, first aid kit check, water temperature and observation of breakfast meal. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov

Violations

22VAC40-73-310-H

Based on record reviewed and staff interviewed, the facility failed to ensure it did not admit or retain individuals with psychotropic medications without appropriate diagnosis and treatment plans for a resident.

Evidence

On 4-14-25, resident #2’s physician’s order dated 2-27-25 and April 2025 medication administration record (MAR) noted resident prescribed psychotropic medication Haloperidol. Resident’s April 2025 MAR and physician order dated 9-26-24 noted resident prescribed Hydroxyzine.
Staff #1 acknowledged the resident’s record did not have a treatment plan for the psychotropic medications prescribed.

Plan of correction

Staff will ensure that no individuals will be admitted without appropriate psychotropic treatment plans and that the plans will be updated when medication changes are made. Date of Correction: 04/14/2025

22VAC40-73-860-G

Based on observation by staff and inspector, the facility’s hot water at taps available was not maintained within a range of 105 degrees Fahrenheit (F) to 120 degrees Fahrenheit.

Evidence

On 4-14-25 during a tour of the facility with staff #2, the water temperature by the door in the men’s bathroom on the second floor had a temperature reading of 99.1 degrees F.
The water temperature at the sink in the shower/tub room on the first floor across from room #104 had a reading of 101 F. The bathtub reading in the same room had a temperature reading of 94.8 F.
Staff #2 acknowledged the water temperatures in the bathrooms were not within a range of 105 degrees F to 120 degrees F.

Plan of correction

Supervisor of staff will ensure that hot water taps available to residents will be maintained within a range of 105 degrees to 120 degrees F. Date Of Correction: 05/14/2025

22VAC40-73-410-A

Based on document reviewed and staff interviewed, the facility failed to ensure acknowledgment of having received the orientation was signed and dated by the resident, as appropriated, resident’s legal representative.

Evidence

On 4-14-25, resident #3’s orientation document to the facility did not include date orientation was signed and did not include signature of resident’s legal representative.
Staff #1 acknowledged the resident’s orientation document did not include the date of acknowledgment of the orientation to the facility.

Plan of correction

Staff will ensure that no individuals will be admitted without all documents being dated and complete. Date of Correction: 04/14/2025

22VAC40-73-310-D

Based on document reviewed and staff interviewed, the facility failed to ensure the written assurance was provided to the resident that the facility has the appropriate license to meet the resident’s care needs at the time of admission.

Evidence

On 4-14-25, resident #3’s written assurance document did not include a date. The resident’s physician’s order dated 3-20-25 noted date of admit as 3-5-25.
Staff #1 acknowledged the resident’s written assurance document did not include a date.

Plan of correction

Staff will ensure that no individuals will be admitted without all documents being dated and complete. Date of Correction: 04/14/2025

February 24, 2025Inspection3 violations

Inspection dates

02/24/2025

Areas reviewed

Comments

Type of inspection: Monitoring An on-site non-mandated monitoring was conducted on 2-24-25 (Ar: 07:05/ Dep 12:40 a.m.) The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 59 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Yes Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: Number of interviews conducted with staff: 3 Observations by licensing inspector: medication pass; breakfast meal, first aid kit check, water temperature check; tour of facility. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov

Violations

22VAC40-73-450-C

Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) included all assessed needs for two of six records.

Evidence

On 2-24-25, resident #3’s uniform assessment instrument (UAI) dated 12-30-24 and resident’s history and physical dated 1-13-25 noted resident’s abusive behavior and aggressive behavior and wandering. These assessed needs were not noted on the resident’s ISP.
Resident #2’s UAI dated 12-6-24/2-6-25 noted resident’s wandering behavior and short-term memory/dementia. These assessed needs were note noted on the resident’s ISP.
Staff #1 and #2 acknowledged the residents’ needs not documented on the residents’ ISP.

Plan of correction

LALFA and Supervisor of staff will ensure that comprehensive ISPs will be completed within 30 days and will include all assessed needs for residents.

22VAC40-73-310-H

Evidence

On 2-24-25, resident #4’s physician’s order dated February 2025 medication administration record (MAR), and physician’s order dated 1-23-25 and 10-30-24 noted resident prescribed psychotropic medication, Lacosamide.
Resident #6’s February 2025 MAR and physician’s orders dated 1-29-25 noted resident prescribed Trazadone.
Staff #1 and #2 acknowledged the resident’s record did not have a treatment plan for the psychotropic medications.

Plan of correction

Staff will ensure that no individuals will be admitted without appropriate psychotropic treatment plans and that the plans will be updated when medication changes are made.

22VAC40-73-870-A

Based on observation, the facility failed to ensure the interior of the building was maintained in good repair.

Evidence

On 2-24-25, during a tour of the facility with staff #2, the wallpaper on the wall on the first floor, back hallway was observed peeling from the baseboard area of the wall.
The female bathroom on the second floor, first toilet stall’s pilaster and pilaster shoe were observed to be crumbling and in need of repair.
Staff #2 acknowledged the bathroom’s stall/pilaster base was in need of repair.

Plan of correction

December 12, 2024Inspection2 violations

Inspection dates

12/12/2024

Areas reviewed

Comments

Type of inspection: Monitoring An on-site unannounced non-mandated monitoring was conducted on 12-12-24. (Ar 07:35 a.m./Dep 12:25 p.m.) The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 62 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Yes Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 4 Observations by licensing inspector: Breakfast-lunch-activity with church-medication pass Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov

Violations

22VAC40-73-450-A

Based on record reviewed and staff interviewed, the facility failed to ensure the preliminary plan of care include what services staff were to provide for the residents.

Evidence

On 12-12-24, resident #1’s uniformed assessment instrument (UAI) dated 8-29-24 noted resident’s bathing noted as mechanical help; dressing noted as human help/physical assistance; toileting noted as mechanical help; transferring noted as mechanical help; bladder noted as greater than weekly and walking noted as mechanical help. The narrative noted resident need for assistance with stairclimbing. The resident’s preliminary plan of care dated 11-14-24 did not include what and how staff would provide service to assist resident with assessed needs noted on the UAI.
Resident #2’s UAI dated 10-29-24-bowel incontinence less than weekly and bladder incontinence greater than weekly. Resident assessed as disoriented some time, some spheres (Situation and time) and assessed as having judgement problems. The narrative noted resident requires prompting to take showers and toilet. The preliminary plan of care dated 11-18-24 did not include what and how staff would provide services to assist resident with assessed needs noted on the UAI.
Staff #1 and #2 acknowledged the resident’s preliminary plan of care did not include how and what services would be provided and did not include a review date of services.

Plan of correction

Staff will ensure that the preliminary plan of care will include what services staff will provide for the residents. Correction Date: 12/28/2024

22VAC40-73-750-B

Based on observations and interviews during a tour of the facility, residents’ rooms did not have pillows on the bed. There were rooms that did not have enough chairs for the number of residents assigned to the room.

Evidence

On 12-12-24 during a tour of the facility with staff #2, rooms #208, #209, #216 and #201 had four residents assigned and three chairs in the room.
Rooms #205 and #214 was missing pillows from two beds in each room.
Room #210 missing pillowcases from pillows on bed.
There was no toilet paper in the stall near the window in male bathroom with tub upstairs.
Staff #2 acknowledged the rooms did not have all required resident accommodations, chairs and/or pillows and pillowcases.

Plan of correction

Housekeeping staff will have additional training and ensure that each bed has a pillow and each room has correct number of chairs Correction Date: 12/27/2024

October 15, 2024Inspection5 violations

Inspection dates

10/15/2024

Areas reviewed

Comments

Type of inspection: Monitoring An on-site non-mandated monitoring inspection was conducted on 10-15-24 (Ar 07:38 a.m/ Dep 13:20 p.m.) The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 62 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Yes Number of resident records reviewed: 7 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 4 Observations by licensing inspector: breakfast meal, water temperature, first aid kit Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact (Willie Barnes), Licensing Inspector at (757-439-6815 or by email at willie.barnes@dss.virginia.gov

Violations

22VAC40-73-310-H

Based on record reviewed and staff interviewed, the facility failed to ensure it did not admit or retain individuals with psychotropic medical condition without a diagnosis and treatment.

Evidence

On 10-15-24, resident #4’s October 2024 medication administration record (MAR) and prescriber’s order fax dated 6-20-24 noted resident prescribed Aripiprazole (Abilify) and Benztropine (Cogentin). The resident’s record did not include a psychotropic treatment plan for this psychotropic medication.
Staff #1 acknowledged the residents’ record did not include a psychotropic treatment plan for the prescribed psychotropic medication.

Plan of correction

LALFA will be responsible for monitoring psychotropic treatment plans for all existing and new psychotropic medications. Date to be corrected: 10/21/2024

22VAC40-73-450-F

Based on record reviewed and staff interviewed, the facility failed to ensure that the resident’s individualized service plan (ISP) included all assessed needs for a resident.

Evidence

On 10-15-24, resident #4’s uniformed assessment instrument (UAI) dated 8-19-24 noted resident needed assistance with bathing. The narrative in the document noted resident required supervision with bathing. Staff #2 stated resident required verbal prompting/reminders for bathing and sometimes physical assistance. The individualized service plan (ISP) dated 8-19-24 did not include this assessed need.
Staff #1 acknowledged the resident’s ISP did not include all assessed needs.

Plan of correction

LALFA and Supervisor of staff or designee will ensure that the individualized service plan (ISP) will be reviewed and updated at least once every 12 months and as needed as the condition of the resident changes. Date to be corrected: 10/21/2024

22VAC40-73-680-M

Based on observation, record reviewed, and staff interviewed, the facility failed to ensure medications ordered for PRN (as needed) administration was available, properly labeled for the specific resident, and properly stored at the facility.

Evidence

On 10-15-24, following medication pass observation with staff #3, the prescribed PRNs noted on resident #3’s physician’s orders dated 8-29-24 were not available. Ondansetron (Zofran) and Hydrocortisone cream were not available in the facility.
Staff #1 and #3 acknowledged resident #3’s PRN s were not available in the facility.

Plan of correction

RMA’s will audit carts monthly to ensure that all PRN’s are available. Date to be corrected: 10/21/2024

22VAC40-73-680-K

Based on record reviewed and staff interviewed, the facility failed to ensure when medication aides administer the PRN (as needed) medication when the facility has obtained from the resident’s physician or other prescriber a detailed medical order, the order included all required information. The order shall include the symptoms that indicate the use of the medication, exact dosage, the exact time frames the medication is to be given in a 24-hour period and directions as to what to do if symptoms persist.

Evidence

On 10-15-24, during the medication pass observation with staff #3, resident #7’s prescribed PRN Naloxone noted nasal spray may be given every 2-3 minutes until assistance arrives.
Staff #1 and #3 acknowledged the PRN dosage was every 2-3 minutes and not exact time.

Plan of correction

RMA’s will not accept orders that do not have specific directions. Date to be corrected: 10/21/2024

22VAC40-73-860-G

Based on observation and staff interviewed, the facility failed to ensure hot water at taps available to residents shall be maintained within a range of 105 degrees Fahrenheit (F) to 120 degrees F.

Evidence

On 10-15-24 during a tour of the facility with staff #2, the water temperature at the faucet in the bathtub in the tub room on the first floor near the laundry room at 12:40 p.m. was 91.9.
Staff #2 acknowledged the water temperature in the tub room on the first floor was not within the required range.

Plan of correction

Supervisor of staff will ensure that hot water taps available to residents will be maintained within a range of 105 degrees to 120 degrees F. Date to be corrected: 10/21/2024

August 5, 2024Inspection10 violations

Inspection dates

08/05/2024

Areas reviewed

22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments

Type of inspection: Monitoring An unannounced non-mandated monitoring inspection was conducted on 8-5/24 with two inspectors from the Peninsula Licensing Office. AR 07:20/Dep 12:05. Facility census was 61. The administrator was not present. Preliminary exit conducted with administrator via telephone conference with inspectors, staff person in charge and administrator. 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: 61 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Yes Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: AC unit not working, ventilation extension through window upon arrival. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov

Violations

22VAC40-73-880-C

Based on observation and staff and residents interviewed, the facility failed to ensure the air conditioning (AC) system for all areas used by residents, including residents’ bedrooms and common areas that the temperatures in these areas did not exceed 80 degrees Fahrenheit (F).

Evidence

On 8-5-24, during a tour of the facility, the temperature in the common area/dining area was measured using a moveable thermometer and the reading was 83 to 85 degrees F. The temperature in resident room #202 was 87.3 F. The reading in the upstairs hallway to the right of the elevator was 87 degrees. The reading in the residents’ room #213 was 87.6 This room was observed with two long aluminum-colored ducts in the windows and connected to a cooling system in the hallway. The ducts prevented the bedroom door from being closed, thereby preventing the residents from having privacy in their bedroom.
The Accu Weather for Newport News noted temperature of 92 degrees on 8/2/24; 90 degrees on 8/3/24; 85 degrees on 8/4/24 and 87 degrees on 8/5/24.
Staff #2 acknowledged the temperature in the facility exceeded 80 degrees F in areas utilized by the residents.

Plan of correction

Supervisors or designee will ensure all furnishings, fixtures, and equipment will be kept clean and in good repair and condition. Maintenance will correct any as soon as it is reported to Administrator or to maintenance. Correction Date: 08/19/2024

22VAC40-73-310-D

Based on record reviewed and staff interviewed, the facility failed to ensure upon review of the UAI and prior to admission of a resident, the facility administrator shall provide written assurance to the resident that the facility has the appropriate license to meet the resident’s care needs at the time of admission. A copy of the signed document by the resident or legal representative shall be kept in the resident’s record.

Evidence

On 8-5-24, resident #4’s record did not include a copy of the signed and dated written assurance. The resident’s date of admission was noted as 7-15-24.
Staff #2 acknowledged the resident’s record did not include the signed and dated acknowledgement of the facility’s written assurance.

Plan of correction

Staff will ensure that a signed and dated written assurance is put into the resident prior to admission. Correction Date: 08/19/2024

22VAC40-73-550-G

Based on record reviewed the facility failed to ensure the rights and responsibilities of residents in assisted living facility was reviewed with staff.

Evidence

. 1.Staff #5’s date of hire noted as 6-20-24. The record did not have documentation of a signed and dated copy of the resident’s rights.
Staff #2 acknowledged the staff member records did not include signed and dated initial or annual resident’s right review.

Plan of correction

Staff will ensure that the rights and responsibilities will be reviewed and updated at least once every 12 months.. Correction Date: 08/19/2024

22VAC40-73-450-F

Based on record reviewed, the facility failed to ensure the individualized service plan reviewed and updated included all assessed needs.

Evidence

On 8-5-24, resident #3’s application dated 1-13-23 noted allergy to strawberry. The resident’s physician order dated 7-26-24 also noted resident’s allergy to strawberry and Ascorbic acid. These assessed needs were not documented on the resident’s individualized service plan (ISP) dated 4-22-24.
Staff 2 acknowledged the resident’s ISP did not include all assessed needs.

Plan of correction

Staff will ensure that the ISP’s shall be reviewed and updated at least once every 12 months as needed. Correction Date: 08/19/2024

22VAC40-73-70-A

Based on interview and observation, the facility failed to ensure it reported to the 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

On 8-5-24, upon entering the facility, the inspectors inquired of staff #2 the reason for the aluminum-colored ducts observed hanging on the outside of the building and the windows opened on the second floor. Staff stated the facility’s air conditioning system was not working. Staff was asked when this occurred, and it was stated the past Friday, (August 2nd).
The facility’s AC system not working was not reported to the licensing department.
Staff #1 acknowledged the AC system not working was not reported to the licensing office.

Plan of correction

Administrator will report within 24 hours to the licensing office any major incident. Correction Date: 08/26/2024

22VAC40-73-120-A

Based on record reviewed and staff interviewed, the facility failed to ensure the orientation and training required for staff occurred within the first seven working days of employment.

Evidence

On 8-5-24, staff #5’s orientation and training documents (including job description, organizational chart) did not include the date the training and documents were received/reviewed by staff.
Staff #2 acknowledged the staff’s documents did not include a date of receipt.

Plan of correction

Administrator will ensure all staff beginning their new position will have required training within 7 days of employment. Correction Date: 08/19/2024

22VAC40-73-250-D

Based on record reviewed and staff interviewed, the facility failed to ensure health information required by the standards was conducted within the required timeframe.

Evidence

On 8-5-24, staff #3’s record noted staff’s date of hire as 7-10-2023. The tuberculosis (TB) screening in the record was dated 8-18-23, not on or within seven days prior to the first day of work at the facility.
Staff acknowledged staff’s TB was not within the required timeframe.

Plan of correction

Administrator will ensure all staff beginning their new position will have a negative TB test provided prior to the start date. Correction Date: 08/19/2024

22VAC40-73-310-H

Based on record reviewed and staff interviewed, the facility failed to ensure it did not admit or retain individuals with psychotropic medications without appropriate diagnosis and treatment plans.

Evidence

On 8-5-24, resident #6’s July 2024 medication administration record (MAR) included Depakote, a psychotropic medication. The record did not include a psychotropic treatment plan for this prescribed medication.
Staff #2 acknowledged the resident’s record did not include a treatment plan for the prescribed psychotropic medication Depakote for mood.

Plan of correction

Staff will ensure that no individuals will be admitted without appropriate psychotropic treatment plans. Date of Correction: 08/19/2024

22VAC40-73-310-B

Based on record reviewed and staff interviewed, the facility failed to ensure the documented interview between the administrator or a designee responsible for admission and retention decisions, the individual and or legal representative, if applicable was in the resident’s record and included the mental health screening.

Evidence

On 8-5-24, resident #4’s record included a copy of the interview and mental health screening document; however, the documents did not include a date and there was no name of the documents.
Staff #2 acknowledged the mental health and interview document in the resident’s record did not include signatures, dates or names.

Plan of correction

Staff interviewing prospective resident will ensure that documentation of the interview will be stored as a matter of record prior to the date of actual admission. Correction Date: 08/19/2024

22VAC40-73-290-A

Based on observation and staff interviewed, the facility failed to ensure it maintain a written work scheduled that included the names and job classification of all staff working each shift with an indication of whomever is in charge at any given time.

Evidence

On 8-5-24, the staff scheduled posted with the names of staff on duty and staff in charge was dated July 21, 2024, to August 3, 2024.
Staff #2 acknowledged the posted schedule for staff and administrator was not current.

Plan of correction

Administrator will review posted schedule weekly to ensure that it is correct and up to date. Correction Date: 08/19/2024

June 12, 2024Inspection10 violations

Inspection dates

06/12/2024

Areas reviewed

Comments

Type of inspection: Renewal An unannounced renewal inspection was conducted on 6-12-24 with two licensing inspectors from the Peninsula Licensing Office. Ar 07:45 a.m./Dep 13:15 p.m.) The facility census was 54. 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: 54 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Yes Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: Medication pass/ breakfast meal Additional Comments/Discussion: psychotropic medication/ infection control policy 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 (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov

Violations

22VAC40-73-750-E

Based on observation and staff interviewed, the facility failed to ensure the bed linen for a resident was clean.

Evidence

On 6-12-24, during a tour of the facility with staff #1, the box spring cover on a resident’s bed in room #211 was observed with have light grey- and orange-colored stains.
Staff #1 acknowledged the box spring cover was not clean.

Plan of correction

Supervisors or designee will ensure all furnishings, fixtures, and equipment will be kept clean and in good repair and condition. Mattress and box-spring covers will be monitored weekly and washed or replaced if dirty or stained. Correction Date: 6/12/2024

22VAC40-73-240-D

Based on document reviewed and staff interviewed, the facility failed to ensure subsequent tuberculosis (TB) evaluation and reports were completed for one of three staff records reviewed.

Evidence

On 6-12-24, staff #1’s tuberculosis assessment was dated 5-4-23. The staff’s date of hire noted as 8-25-20.
Staff #1 acknowledged the tuberculosis assessment was not current.

Plan of correction

Administrator will ensure that current risk assessments are completed annually by using the date of hire as a guideline by staff, who will monitor and report this information to the Administrator. Administrator will monitor assessments to ensure that the assessor uses the correct date on the form. Correction Date: 6/17/2024

22VAC40-73-650-B

Based on document reviewed and staff interviewed, the facility failed to ensure all physician or other prescriber orders, both written and oral, for administration of all prescription and over-the-counter medications and dietary supplements shall include, the name of the resident, the date of the order, the name of the drug, route, dosage, strength, how often the medication is to be given, and identify the diagnosis, condition, or specific indications for administering each drug.

Evidence

On 6-12-24, resident # 1’s physician’s orders sheet (POS) dated 4-11-24 did not include a diagnosis for Ibuprofen.
Resident #3’s physician’s telephone order signed and dated 4-26-24 did not include a diagnosis for Mobic and HCTZ. The physician order dated 4-26-24 did not include a diagnosis for Quetiapine Fumarate.
Staff #1 acknowledged; the resident’s physician’s orders did not include the diagnosis for the prescribed medication.

Plan of correction

The RMA’s will ensure that physician or other prescriber’s orders identify the diagnosis, condition, or specific indications for administering each drug. RMA’s and administrator will monitor MAR’s and PO’s monthly and as needed. Correction Date: 7/12/2024

22VAC40-73-100-C-1

Based on observation and staff interviewed, the facility failed to ensure that staff followed the facility’s policies and procedures for hand hygiene.

Evidence

On 6-12-24 during the medication pass observation with staff #2, staff was observed using the facility’s hand sanitizer. The hand sanitizer was dated 6-2023. Staff #2 stated not knowing that hand sanitizers had an expiration date.
Staff #1 was informed of the expiration date on the bottle of the hand sanitizer used by staff #1 during the medication pass. Staff #1 stated the staff should be washing hands between medication pass in accordance with the facility’s policies and procedures.
The facility policies and procedures documented handwashing and the use of hand sanitizer.
The hand sanitizer used by the facility during the medication pass noted an expiration date of 6-2023.
Staff #1 and #2 acknowledged the hand sanitizer was expired.

Plan of correction

Administrator will ensure that hand sanitizer is available at all times and will ensure that the expiration date is current. Correction Date: 6/12/2024

22VAC40-73-450-F

Based on record reviewed and staff interviewed, the facility failed to ensure the resident’s annual/reassessed individualized service plan (ISP) included all assessed needs.

Evidence

On 6-12-24, resident #2’s uniformed assessment instrument (UAI) dated 2-7-24 noted the resident receive mental health services from a community services board. The resident record included mental health progress reports from a community service board. The resident’s psychotropic treatment plan noted the resident is administered Risperdal Consta intramuscularly every 14 days and Uzedy ER injection under the skin once a month by the community service board. These services were not on the resident’s ISP dated 2-8-24.
Resident #3’s UAI dated 8-16-23 noted resident incontinent of bladder and psychosocial assessed as having judgement problems. The ISP dated 8-17-23 did not include these assessed needs.
Staff #1 acknowledged the aforementioned residents’ ISP did not include all assessed needs.

Plan of correction

Administrative staff will ensure that the ISP includes all assessed needs for client and Administrator will double check each ISP as they are completed. Correction Date: 7/12/2024

22VAC40-73-320-B

Based on record reviewed and staff interviewed, the facility failed to ensure that it had a physical examination for a resident within 30 days preceding the resident’s admission.

Evidence

On 6-12-24, resident #5’s record noted the resident’s physical examination was dated 12-4-23. The resident’s date of admission to the facility was noted as 9-14-23.
Staff #1 acknowledged the resident physical was completed 12-4-23, after the resident’s admission date.

Plan of correction

Staff will ensure that no resident is admitted without proper documentation of a physical exam prior to admission – dated within 30 days. Correction Date: 6/12/2024

22VAC40-73-870-E

Based on observations and staff interviewed, 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.

Evidence

On 6-12-24 during a tour of the facility with staff #1, the front sink near a stall, had a slow drain. The male restroom in the common area was observed with a slow drain. The window blind in room #211 was observed to have an approximate 8 x 8-inch cutout section. The window blind in the far-right corner in room #209 was in need of repair. The commode top in the corner bathroom down the hall from the kitchen and next to the storage room, extended beyond the commode (did not fit).
Staff #1 acknowledged the building and equipment items needed repair.

Plan of correction

Supervisors or designee will ensure all furnishings, fixtures, and equipment will be kept clean and in good repair and condition. Maintenance and plumbing will correct any issues with slow draining sinks and toilet lids that become broken as they are reported to Administrator or to maintenance. Maintenance will correct any issues blinds as soon as it is reported to Administrator or to maintenance. Correction Date: 6/12/2024

22VAC40-73-680-I

Based on documents reviewed and staff interviewed, the facility failed to ensure the facility’s medication administration record (MAR) for a resident included all requirements.

Evidence

On 6-12-24, resident #1’s June 2024 MAR did not include diagnosis, condition, or specific indications for administering the following drug or supplement: (a) Amlodipine, (b) Atorvastatin, (c) Carvedilol, (d) Fluticasone, (e) Furosemide, (f) Multivitamin-Mineral, (g) Vitamin D3 and (h) Cromolyn eye drops.
Staff #1 and #2 acknowledged the resident’s MAR did not include diagnosis, condition, or specific indications for the drug or supplement.

Plan of correction

22VAC40-73-660-A-7

Based on observation and staff interviewed, the facility failed to ensure that single-use and dedicated medical supplies and equipment shall be appropriately labeled and stored.

Evidence

On 6-12-24, during the medication pass observation with staff #2, resident #7’s blood sugar glucometer was observed to not be labeled.
Staff #2 acknowledged the resident’s blood sugar glucometer was not labeled.

Plan of correction

RMA’s will ensure that all dedicated medical supplies and equipment are appropriately labeled. Administrator and HCO nurse will monitor compliance with this monthly and quarterly. Correction Date: 6/12/2024

22VAC40-73-450-C

Based on record reviewed and staff interviewed, the facility failed to ensure that the resident’s individualized service plan (ISP) included all assessed needs for a resident.

Evidence

On 6-12-24 resident #5’s uniformed assessment instrument (UAI) dated 7-8-23 documented resident was disoriented some spheres sometime and assessed as having aggressive/abusive behaviors. These assessed needs were not documented on the resident’s ISP dated 10-13-23. The resident’s mental health progress notes documented the resident receiving services from a community service provider. This need was not documented on the resident's ISP.
Staff #1 acknowledged the aforementioned resident’s ISP did not include all assessed needs.

Plan of correction

Administrative staff will ensure that the ISP includes all assessed needs for client and Administrator will double check each ISP as they are completed. Correction Date: 7/12/2024

February 14, 2024Complaint survey0 violations

Inspection dates

02/14/2024;02/15/2024

Areas reviewed

Comments

Type of inspection: Complaint An unannounced complaint inspection was conducted on 2-14-24; Ar 09:30 a.m./ dep 11:55 a.m. The facility census was 64. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 1-24-24 regarding allegations in the health safety and welfare and resident care. Number of residents present at the facility at the beginning of the inspection: 64 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 2 Number of interviews conducted with residents: 2 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 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 (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

March 27, 2023Complaint survey4 violations

Inspection dates

03/27/2023,03/30/2023,04/06/2023,04/19/2023,05/09/2023,06/02/2023

Areas reviewed

Comments

Type of inspection: Complaint An unannounced on-site complaint inspection conducted on 3-27-23, 3-30-23 and 4-6-23. 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 2-13-23 regarding allegations in the resident care, neglect and the building. Number of residents present at the facility at the beginning of the inspection: 62 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. yes Number of resident records reviewed: 3 Number of staff records reviewed: 0 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations area(s) of non-compliance with standard(s) or law were not in compliance. 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 Willie Barnes, Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov

Violations

22VAC40-73-70-A

Based on record reviewed, policy reviewed, and staff interviewed, the facility failed to ensure it reported 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

On 3-27-23, during the renewal inspection it was revealed that incident reports involving residents’ health, safety and welfare were not reported to the licensing department.
On 2-21-23, resident #1’staff observed resident’s right arm to be red and swollen; resident refused to go to ER. There was no documentation of resident’s physician being notified. On 3-1-23, resident #1 was admitted to the hospital with shoulder and elbow fractures on 3-1-23.
Resident #2 was reported missing on 1-24-23. Resident was later located in a hospital in Petersburg Virginia. Individual reported to EMS, picking up resident three days prior in Newport News. Resident’s discharge statement, 2-25-23, noted resident “presented to the emergency room due to recurrent seizures that were not control by the EMS crew”. On 3-20-23, the local EMT notified the facility of resident being found in a field in the community and was intoxicated and had high blood sugar. Resident was admitted to a local hospital in Newport News for seizure and hyperglycemia.
Resident #3 notified staff of fall on right arm on 3-2-23, resident was not seen for treatment. On 3-12-23 resident complained of right arm- not able to move arm; resident sent to local hospital and admitted. Discharge summary noted, diagnoses of fall, right elbow pain and infestation by bed bug.
On 1-21-23, resident #4 was reported missing to the local police station.
On 3-20-23, resident #5, fell to floor, right side of face, large amount of blood on floor, face, and bed. Resident continued to have seizure, 911 called, resident transported to hospital.

Plan of correction

An incident report training will be completed by ALFs trainer at next staff meeting. Staff members have been informed by Administrator not to repeat this violation and to report within 24 hours. Correction Date: 6/14/23

22VAC40-73-325-B

Based on record reviewed and staff interviewed, the facility failed to ensure a subsequent risk assessment for tuberculosis (TB) was completed annually on each reach as

Evidence

d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence:
On 3-30-23, resident #1’s TB documents in the record were dated 2-7-18, 2-5-19, 1-31-20 and 3-8-21. The resident’s date of admission noted as 5-23-01. The record did not include a current risk assessment documenting the absence of TB.

Plan of correction

Staff will use the current screening form to ensure current risk assessments are completed annually by using the date of admission as a guideline by staff, who will monitor and report this info to whom Administrator Correction date 6/1/2023

22VAC40-73-450-F

Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) shall be reviewed and updated at least once every 12 months and as needed as the condition of the resident changes.

Evidence

On 4-6-23, resident #1’s ISP dated 4-28-22 was not updated to document the resident’s significant change of condition. The ISP did not document therapy services Resident #1 was admitted to a local hospital on 3-1-23 and discharged on 3-8-23, the discharge summary noted, “humeral head fracture, left, closed, closed fracture of right proximal humerus, forearm laceration, right, severe malnutrition, vascular dementia, underweight and contusion of front wall of thorax. “Wound care: weekly dressing changes, may be changed sooner as needed for soiling or saturation. Please change with 4 x 4 and Tegaderm/Medipore tape or simple island dressing. Keep incision dry, no creams or lotions.” Resident also discharge with home health needs: “physical therapy assessment -patient has weakness and decreased mobility resulting from a recent injury, illness, or surgery; occupational therapy also ordered.
On 3-30-23, resident #1 stated being in the hospital and had injury to shoulder and elbow. The resident stated getting dress was painful but took time- and slowly able to get dress and bath. Resident stated informing staff about an altercation with a staff member, but nothing was done. Interview with staff #4, staff not aware of any incident and provided staff with the resident’s discharge documents.
On 3-27-23, the inspector interviewed the occupational therapist (OT), who was at the facility. The OT stated the cause of resident’s injury was unclear; resident schedule to receive physical and occupational therapy for the fractured shoulder and elbow.

Plan of correction

The facility shall ensure that the ISPs will be reviewed and updated annually by administrator and staff who will monitor and report this info to administrator Correction date 6/14/2023

22VAC40-73-650-B

Based on document reviewed and staff interviewed, the facility failed to ensure the physician or other prescriber orders, both written and oral, for administration of all prescription and over-the-counter medications and dietary supplements shall include the name of the resident, the date of the order, the name of the drug, route, dosage, strength, how often medication is to be given, and identify the diagnosis, condition, or specific indications for administering each drug.

Evidence

On 4-6-23, resident #3’s physician’s order provided to the inspection by staff #4, did not include the diagnosis, condition, or specific indications for the following medications: (a) Cinacalcet (b) Entresto (c) Isosorbide (d) Nifedipine (e) Sevelamer Carbonate (f) Spriva Respimat and (g) Compression Stockings.

Plan of correction

The facility will ensure that physician or other prescriber orders identify the diagnosis, condition, or specific indications for administering each drug. Medication Aides and Administrator who will monitor and report this info to whom administrator Correction date 6/14/2023

March 27, 2023Inspection39 violations

Inspection dates

03/27/2023,03/30/2023,04/06/2023,04/19/2023

Areas reviewed

Comments

Type of inspection: Renewal On-site renewal inspection: 3-27-23 (Ar 07:13/dep 5:30 p- day 1, census was 62, administrator not present. Day 2 (10:30 a.m./dep 11:25 a.m.- administrator not present-staff person in charge on schedule arrived later during visit); day 3 on-site on 4-6-23 (ar 09:00- dep 11:40 a.m.) visit on day with licensing administrator and director of operations. The administrator was not present initially but arrived prior to DSS departure. The Acknowledgement of Inspection form was signed and left at the facility on day 1 (signed and dated by facility representative). Day 3- signed and dated by administrator. 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 Willie Barnes, Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov

Violations

22VAC40-73-820-C

Based on observations and staff interviewed, the facility failed to ensure residents did not smoke in or on their beds.

Evidence

On 4-6-23, during a tour of the facility, cigarette butts were observed in residents’ rooms. (Room 207, 208).

Plan of correction

Supervisor of staff or designee will ensure that residents will not smoke in or on their beds. Staff will immediately remove cigarettes, ash trays, remind residents that they are breaking a rule that could possibly get them discharged and will report to the supervisor that resident had paraphernalia or was caught smoking. Date to be corrected: 7/14/23

22VAC40-73-820-C

Based on observations and staff interviewed, the facility failed to ensure residents did not smoke in or on their beds.

Evidence

On 4-6-23, during a tour of the facility, cigarette butts were observed in residents’ rooms. (Room 207, 208).

Plan of correction

22VAC40-73-860-I

Based on observation and staff interviewed, the facility failed to ensure it stored cleaning supplies and other hazardous materials in a locked area.

Evidence

On 4-6-23, during the facility tour with staff #7, cleaning supplies and other hazardous materials were observed in the first floor maintenance closet. Disinfectant spray was observed on top of a paper towel holder in a second floor restroom.

Plan of correction

Supervisor of staff or designee will ensure that all cleaning supplies and other hazardous materials will be kept in a locked area when staff members are not using them. All staff not just housekeepers, will be held accountable for maintaining this regulation. Date to be corrected: 7/14/23

22VAC40-73-325-B

Based on record reviewed and staff interviewed, the facility failed to ensure the fall risk rating shall be reviewed and updated at least annually.

Evidence

On 3-27-23, resident #4’s record documented the fall risk was completed 2-5-20 with a score of 12. According to the facility’s document, the resident’s score was based on the resident’s visual impairment and prescription for psychotropic medications and predisposing conditions. The record did not include a current fall risk rating. The resident’s date of admit was noted as 8-14-19.

Plan of correction

325.B-LALFA will be responsible for obtaining a fall risk rating on new residents and annually. Date to be corrected: 8/16/23

22VAC40-73-990-C

Based on document reviewed and staff interviewed, the facility failed to ensure at least once every six months, all staff currently on duty on each shift shall participate in an exercise in which the procedures for resident emergencies are practiced.

Evidence

On 3-27-23, there was no documentation of the staff receiving training or practice the requirements of 22VAC40-73-990, resident emergency practice

Plan of correction

Supervisor of staff or designee will ensure that at least once every six months, all staff currently on duty on each shift will participate in an exercise in which the procedures for resident emergencies are practiced. Date to be corrected: 7/26/23

22VAC40-73-610-B

Based on observation and staff interviewed, the facility failed to ensure that menu with meals and snacks for the current week shall be posted.

Evidence

On 3-27-23, the menu for the current week was not posted. The week posted was dated 3-19-23 thru 3-25-23. According to staff #2, the current menu is posted on Sunday.
On 3-30-23, the same menu was posted in the facility. The current menu was not posted as required.

Plan of correction

The food service supervisor shall ensure that menu with meals and snacks for the current week will be posted. Date to be corrected: 7/14/23

22VAC40-73-210-B

Based on record reviewed and staff interviewed, the facility failed to ensure two of four direct care staff attended at least 18 hours of training annually.

Evidence

On 4-6-23, staff #1’s record documented, 3.5 hours of annual training (.5 dementia; 1.0 infection control and 2.0 professional ethics). Staff’s date of hire noted as 8-25-20.
Staff #2’s record did not include annual training required hours. Staff’s date of hire noted as 10-1-20.

Plan of correction

The ALF contracted a master trainer in many entities that is also a consultant. Date to be corrected: April 26, 2023

22VAC40-73-160-E

Based on record reviewed and staff interviewed, the facility failed to ensure the administrator who supervises the medication aides shall be required to annually have four hours of training in medication administration specific to the facility population or a refresher course in medication administration offered by a Virginia Board of Nursing approved program.

Evidence

On 4-6-23, staff #1’s record did not have documentation of 4 hours of training in medication administration. The medication refresher course in the record was dated 8-13-21.

Plan of correction

Administrator Annual Med Training-We were only given 30 minutes to view the draft of the violations that stated the administrator did not have 4 hours of annual med refresher training. The administrator completed his annual med training on 4/18/23. I feel that this is an incorrect regulation indicating the med aide did not have 4 hours annual refresher training. {Regs: 210, 250 and 670) Date to be corrected: LALFA will get the RMAs their annual med refresher by 8/15/23.

22VAC40-73-150-F

Based on document reviewed, the facility failed to ensure the administrator for a facility licensed for both residential and assisted living care served on a full-time basis as the on-site agent of the licensee and shall be responsible for the day-to-day administration and management of the facility.

Evidence

On 4-6-23, the administrator’s schedule provided noted the administrator, staff #1 was available from 10a to 6 p for March 9, 2023 thru April 7, 2023. The inspector was on-site on 3-27-23 from 7:13 am to 5:30 pm. The administrator was not present on site. The inspector was also at the facility on 3-30-23 from 10:30 am to 11:25 am. The administrator was not present on-site.

Plan of correction

The administrator-of-record will be on-site, sharing with another qualified LALFA, and/or acting administrator for 40 hours/week, guaranteeing qualified staff on-site. The requested acting administrator/designated assistant administrator will be on-site for 90 days to cover the other LALFA who was recently hospitalized twice. Date to be corrected: Implemented ASAP, 7/14/23 The administrator-of-record will be on-site, sharing with another qualified LALFA, and/or acting administrator for 40 hours/week, guaranteeing qualified staff on-site. The requested acting administrator/designated assistant administrator will be on-site for 90 days to cover the other LALFA who was recently hospitalized twice. Date to be corrected: Implemented ASAP, 7/14/23 The administrator-of-record will be on-site, sharing with another qualified LALFA, and/or acting administrator for 40 hours/week, guaranteeing qualified staff on-site. The requested acting administrator/designated assistant administrator will be on-site for 90 days to cover the other LALFA who was recently hospitalized twice. Date to be corrected: Implemented ASAP, 7/14/23 LALFA, will be going to Hilton Plaza for 40 hours a week. (rec 7/24/23 email)

22VAC40-73-750-E

Based on observations and staff interviewed, the facility failed to ensure bed linens were clean and in good repair for residents.

Evidence

On 4-6-23, during the LA and senior licensing assistant’s tour of the facility with staff #7, various resident bedrooms did not have clean sheets and pillowcases in good repair. There was various mattress with stains. (Room 207, 208)

Plan of correction

Supervisor of staff or designee will ensure that bed linens will be clean and in good repair for residents to use by having staff to clean linen weekly and replace, if applicable. Date to be corrected: 7/14/23

22VAC40-90-40-B

Based on the employee record review, the facility failed to ensure the criminal history record report was obtained on or prior to the 30th day of employment for each employee.

Evidence

On 4-6-23, staff #3’s record did not contain documentation of a criminal history record report. Staff #3’s date of hire was noted as 2-27-23. This staff was observed working without the supervision of someone with a criminal record check on 3-27-23. The inspector conducted the medication pass observation with this staff on 3-27-23.
Staff #4’s date of hire was noted as 5-13-22, no background check was provided for staff.
Staff #5’s date of hire was noted as 6-23-22, no background check was provided for staff.
Staff #13’s date of hire was noted as 6-21-22, the background check was dated 8-25-22.

Plan of correction

LALFA will ensure that criminal history record reports will be obtained on or prior to the 30th day of employment for each employee. The computer program has been set back up to ensure compliance with this regulation. Date to be corrected: 7/14/23

22VAC40-73-290-A

Based on observation and staff interviewed, the facility failed to ensure the written work scheduled included the names, job classification, of all staff working. The schedule should include any absences, substitutions, or other changes that should be noted.

Evidence

On 3-27-23, 3-30-23 and 4-6-23, the facility written schedule posted noted staff #2’s position as an (AIT)- administrator in training. According to staff #1, staff #2 is not enrolled in the AIT program.
Staff #12’s name is listed on the schedule dated 3-26-23 through 4-1-23. According to staff #1, staff #12 did not return after 3-27-23. The staff’s name was not removed from the schedule posted on 4-6-23. Information for all new staff members since the lasted inspection was not provided.
The administrator’s schedule provided noted staff #1 worked 10 a.m to 6 p.m (March 27-March 31). The inspector was on site on 3-27-23 from 7:13 a.m. to 5:30 p.m. and the inspector did not see nor engage with staff #1. The inspector was also on-site on 3-30-23 from 10:30 to 11:40 a.m. and did not see or engage with staff #1.

Plan of correction

Supervisor of staff will be responsible for monitoring and completing the work schedule and will ensure compliance with state regulations. Date to be corrected: 7/16/23

22VAC40-73-310-B

Based on record reviewed and staff interviewed, the facility failed to ensure a documented interview between the administrator or a designee responsible for admission and retention-decisions, the individual, and legal representative, if applicable for two of eight resident records reviewed.

Evidence

On 3-27-23, resident #5’s record included the interview document, but it did not include the date.
Resident #7’s interview document did not include the date of the interview and did not include the signature and date of the facility staff.

Plan of correction

Supervisor of staff will be responsible for monitoring the interviews of residents upon admission. Date to be corrected: 7/16/23

22VAC40-73-50-B

Based on record reviewed and staff interviewed, the facility failed to ensure written acknowledgement of the receipt of the disclosure by the resident or legal representative shall be retained in the resident’s record.

Evidence

On 3-27-23, resident #6’s record did not have documentation of a signed and dated disclosure statement. Resident’s date of admission noted as 9-28-22 and resident agreement signed and dated 9-25-22.

Plan of correction

Licensed Assisted Living Facility Administrator (LALFA) will ensure that all disclosures are signed before the admission date but definitely no later than the date of admission with an explanation of why it occurred on the date of admission. Date to be corrected: 7/26/23

22VAC40-73-310-D

Based on record reviewed and staff interview, the facility failed to ensure the administrator provided written assurance to the resident that the facility had the appropriate license to meet the care needs at the time of admission for two of eight resident record reviewed.

Evidence

On 3-27-23, resident #5’s record included the written assurance document, however, the document was not signed and dated by the resident or the legal representative. The resident’s date of admit noted as 3-21-23.
Resident #7’s written assurance document did not include the facility representative’s signature and date. The resident’s date of admit noted as 11-16-22.

Plan of correction

LALFA will be responsible for monitoring written assurances of residents upon admission. Date to be corrected: 7/16/23

22VAC40-73-430-H-1

Based on record reviewed and staff interviewed, the facility failed to ensure the discharge statement included all required information.

Evidence

On 3-27-23, resident #8’s discharge statement did not include the date the resident was notified of discharge, the method of notification and not signed by the licensee and/or administrator

Plan of correction

Supervisor of staff will ensure that discharge statements will include all required information in residents' charts/records. Same will be documented. Date to be corrected: 8/16/23

22VAC40-73-320-A

Based on record reviewed and staff interviewed, the facility failed to ensure a person shall have a physical examination by an independent physician within 30 days preceding admission and include the results of a risk assessment documenting the absence of tuberculosis (TB) in a communicable form as

Evidence

d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence:
On 3-27-23, resident #6, date of admission was noted as 9-28-22 with an individual service plan dated 9-30-22. The physical in the record was dated 7-13-22. The tuberculosis risk assessment in the record was dated 7-20-22. Both admitting requirement documents were more than 30 days preceding the resident’s admit date of 9-28-22. There was not documentation of a review or update of these documents prior to admission.

Plan of correction

LALFA will be responsible for monitoring physical examination and TB results of residents upon admission to ensure compliance with state regulations guideline dates. Date to be corrected: 7/16/23

22VAC40-73-320-A

Evidence

d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence:
On 3-27-23, resident #6, date of admission was noted as 9-28-22 with an individual service plan dated 9-30-22. The physical in the record was dated 7-13-22. The tuberculosis risk assessment in the record was dated 7-20-22. Both admitting requirement documents were more than 30 days preceding the resident’s admit date of 9-28-22. There was not documentation of a review or update of these documents prior to admission.

Plan of correction

LALFA will be responsible for monitoring physical examination and TB results of residents upon admission to ensure compliance with state regulations guideline dates. Date to be corrected: 7/16/23

22VAC40-73-890-B

Based on observation and staff interviewed, the facility failed to ensure all interior and exterior areas shall be adequately lighted for the safety and comfort of residents and staff.

Evidence

On 4-6-23, during a tour of the facility with staff #7, the second-floor hallway was not adequately lighted.

Plan of correction

Supervisor of staff or designee will ensure all interior and exterior areas shall be adequately lighted for the safety and comfort of residents and staff. All wattage of light bulbs has been increased and areas have been repainted to provide better reflection of lights in areas cited. Pictures have been sent to state licensing proving the correction of this regulation. Supervisor or designee will check areas weekly to ensure compliance of this regulation. Date to be corrected: 7/14/23

22VAC40-73-925-A

Based on observations and staff interviewed, the facility failed to ensure it had an adequate supply of toilet tissue accessible to each commode and soap accessible to each face/hand washing sink and each bathtub or shower.

Evidence

On 4-6-23, during a tour of the facility, the face/hand washing sink in the common bathroom and resident’s bathroom did not have liquid soap for handwashing. 2 .The common bathroom and various toilet stalls did not have toilet tissue available.

Plan of correction

Supervisor of staff or designee will ensure that there is an adequate supply of toilet tissue accessible to each commode and soap accessible to each face/hand washing sink and each bathtub or shower. A walk-through of the building per shift will occur by person-in-charge and anything missing will be immediately replenished. Date to be corrected: 7/14/23

22VAC40-73-930-A

Based on observation, demonstration and staff interviewed, the facility failed to ensure the signaling device in the facility was operable.

Evidence

On 4-6-23, during a tour of the facility, the signaling device on the second floor was not working. The system did not have a button or cord to pull for assistance.
The call bell in room 108 was activated, no alarm sounded in the medication room and no light outside the room was visible for staff to determine the origin. The call system which terminated in the medication room was not operable, therefore staff was not to know that call bell had been activated.

Plan of correction

Supervisor of staff or designee will ensure that signaling devices in the facility are operable. Proof of compliance has been sent to state licensing. Any inoperable signaling devices will be reported immediately to the person-in-charge by all staff every day. Date to be corrected: 7/14/23

22VAC40-73-450-E

Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) was signed and dated by the licensee, administrator, or his designee, and the resident or the legal representative for two of eight resident records reviewed.

Evidence

On 3-27-23, resident #2’s ISP dated 8-22-22 was not signed by the resident and/or legal representative.
Resident #7’s ISP dated 11-16-22 did not include a signature of the developer. It also did not include the signature and date of the resident and/or representative.

Plan of correction

LALFA and Supervisor of staff will ensure that individualized service plan (ISP) will be signed and dated by a qualified designee and with signatures of the resident or the legal representative of the resident. Date to be corrected: 9/1/23

22VAC40-73-860-G

Based on observation and staff interviewed, the facility failed to ensure hot water at taps available to residents shall be maintained within a range of 105 degrees Fahrenheit(F) to 120 degrees F.

Evidence

On 3-27-23, during the facility tour with staff #5, the water temperature in the bathroom on the first floor across from the private rooms was 100.5 degrees F. The men’s restroom in the common area was 91.9 F. The hot water in the ladies restroom in the common area was not working. The restroom in the back hallway on the first floor was 93.0 F. The men’s bathroom upstairs on the second floor was 84.0 F.

Plan of correction

Supervisor of staff will ensure that hot water taps available to residents will be maintained within a range of 105 degrees to 120 degrees F. This has already been corrected. Date to be corrected: 7/14/23

22VAC40-73-450-F

Evidence

On 3-27-23, resident #3’s ISP dated 7-8-22 did not include the resident’s allergy to Amoxicillin. The document from a local mental health agency noted resident’s allergy; document printed 9-22-22 also noted resident’s psychotropic medications. The resident’s date of admit noted as 7-20-18.

Plan of correction

22VAC40-73-870-B

Based on smell and staff interviewed, the facility failed to ensure the building was well-ventilated and free from foul, stale, and musty odors.

Evidence

On 4-6-23 during a tour of the facility, the first floor men’s bathrooms smelled of urine.

Plan of correction

Supervisor of staff or designee will ensure that the building will be well-ventilated and free from foul, stale and musty odor. The supervisor or designee will walk the building daily to ensure compliance with this regulation. Date to be corrected: 7/14/23

22VAC40-73-960-B

Based on observation and staff interview, the facility failed to the fire and emergency evacuation drawing was posted in a conspicuous place on each floor of the building used by residents.

Evidence

On 3-27-23 during a tour of the facility, the inspector noticed the evacuation poster was not on the first floor. On 3-30-23, staff #7 and the inspector looked for the evacuation poster on the first floor and could not locate the required evacuation posting.

Plan of correction

Supervisor of staff or designee will post the fire and emergency evacuation drawing in a conspicuous place on each floor of the building used by residents. The emergency evacuation drawing that was removed by a resident has been replaced and will be monitored by all staff on each shift. Date to be corrected: 7/14/23

22VAC40-73-870-E

Based on observations and staff interviewed, the facility failed to ensure all furnishings, fixtures, and equipment, bathtub and showers, shall be kept clean and in good repair and condition.

Evidence

On 3-27-23 during a tour of the facility with staff #5.
On 4-6-23 during a tour with staff #7, the following were observed: the toilet in the bathroom on second floor was not clean and shower stall was stained with a brown colored matter. Tiles were missing from the bottom of the wall in the bathroom on the second floor. The base of the privacy stalls in the men’s restroom on the second floor were observed to be heavily rusted and paint chips coming off. The base of the commode observed to be surrounded with brown/black matter in the men’s and women’s restroom on the second floor. Missing tiles on the floor and wall around the toilets and showers in the men’s and women's restrooms on the second floor. No tank top on the toilet in the men’s bathroom on the second floor and the toilet seating is poorly fitted. The tank top on the toilet in the restroom on the first floor is poorly fitted. The hand sink in the women’s restroom (common area) contained standing water.
Heavy build-up of black substance observance on the vents in the female restroom (common area). The trash can in the men’s common area restroom observed to be rusted. The door hinge to the room on the private room hallway, (men’s #2) observed to be loosed and rusted. The stall hinge in the female bathroom on the second floor is pulling away from the wall.
The fire alarm box on the door near the kitchen leading to the outdoor patio/courtyard is missing from the covering. The metal chairs in the break room were not secured to the frame. There were excess wiring cords not secured safely in break room. The ceiling in the laundry room was observed to have a black/brown substance on the vent. The vent and ceiling in the women’s bathroom on the second floor observed to have black/grey substance. A cord observed through the closed door of bedroom on the second floor. (Room 208)
The dresser in the resident’s room upstairs observed with fluid running down the side of the dresser. The top of the dresser was observed to have a heavy dark brown substance on the top. A coffee jar used as a tobacco spittoon was also on top of the dresser. Furniture in the rooms of the residents observed to be scratched (dressers) and a dresser missing the knobs (white colored). A resident’s mattress and box spring observed with bodily fluid since March 2023 (208). (Room 207, 208, 209, 210

Plan of correction

Supervisor of staff or designee will ensure all furnishings, fixtures, and equipment, bathtubs and showers will be kept clean and in good repair and condition. Pictures have been sent to state licensing proving the correction of this regulation. Staff will take pictures of any repairs that may be needed and report to the LALFA. Date to be corrected: 7/14/23

22VAC40-73-680-D

Based on record reviewed and staff interviewed, the facility failed to ensure medications shall be administered in accordance with the physician’s or other prescriber’s instruction and consistent with the standards of practice outlined in the current medication aide curriculum approved by the Virginia Board of Nursing.

Evidence

On 3-27-23 during the medication pass observation with staff #3, resident #3’s Vitamin B-12 could not be located for administration. There was no documentation to discontinue the Vitamin B-12. The physician order dated 3-8-23 included the Vitamin-12.

Plan of correction

LALFA or designee will ensure that medications will be administered in accordance with the physician's or other prescriber's instruction and consistent with the standards of practice outlined in the current medication aide curriculum approved by the Virginia Board of Nursing. Date to be corrected: 7/14/23

22VAC40-73-450-B

Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) was completed by the licensee, administrator or designee who has successfully completed the department-approved individualized service plan (ISP) training for residents.

Evidence

On 3-27-23, residents #3, # 4 and #6 ISPs were completed by staff #2, who was not qualified to complete the resident’s ISP. Staff #2’s record did not have documentation of ISP training. According to staff #1, staff #2 did not have ISP training.

Plan of correction

September 1 as a deadline to update ISPs instead of September 16 LALFA who is qualified to complete ISPs will assist with updating them. Supervisor of staff completed the ISP training successfully 7/14/23, and will assist to update ISPs and document same. Date to be corrected: 9/16/23

22VAC40-73-550-G

Based on record reviewed and staff interviewed, the facility failed to ensure the rights and responsibilities of residents in assisted living facilities was reviewed annually with each resident or his legal representative or responsible individual….and each staff person.

Evidence

of this review shall be the resident’s or staff person’s written acknowledgement of having been informed, which shall include the date of the review and filed in the resident’s or staff person’s record. Evidence:
On 3-27-23, the current residents’ rights and responsibilities roster signature provided did not include resident #2’s signature. The record noted the last rights was dated 1-12-21. The resident’s date of admit noted as 9-1-16.
Resident #3’s signature was not on the current rights and responsibilities roster. The record noted the lasted rights was dated 1-12-21. The resident’s date of admit noted as 7-20-18.
Resident #4’s record did not have documentation of resident rights being reviewed. The current rights and responsibilities roster provided did not have resident #4’s signature. The resident’s date of admit noted as 8-14-19.

Plan of correction

LALFA will ensure the rights and responsibilities of residents in assisted living facilities will be reviewed annually with each resident or his legal representative or responsible individual. and each staff person. Evidence of this review shall be the resident's or staff person's written acknowledgement of having been informed, which shall include the date of the review and filed in the resident's or staff person's record. Date to be corrected: 7/26/23

22VAC40-73-380-B

Based on record reviewed and staff interviewed, the facility failed to ensure the personal and social information document was kept current for three of eight resident records reviewed.

Evidence

On 3-27-23, resident #3’s personal and social data was not updated to include resident’s allergy to Amoxicillin.
Resident #5’s personal and social data did not include resident’s hobbies, the following areas were blank, life vocation, military services, advance directives, legal representatives, responsible individuals, next of kin, if known, clergy-place of worship, and designated contact person.
Resident #7’s personal and social data did not include resident’s birthplace, date of admission, vocation, advanced directive and previous mental health history.

Plan of correction

LALFA will be responsible for obtaining the personal and social information data and will keep this information current by checking same quarterly. Date to be corrected: Ongoing and by 8/16/23

22VAC40-73-410-A

Based on record reviewed and staff interviewed, the facility failed to ensure upon admission, it would provide an orientation for new residents and their legal representatives. Acknowledgement of having received the orientation shall be signed and dated by the resident and, as appropriate, his legal representative, and such documentation shall be kept in the resident’s record for two of eight records reviewed.

Evidence

On 3-27-23, resident #6’s record did not have documentation of having received orientation for new residents. The resident’s date of admit was noted as 9-28-22.
Resident #7’s record did not include documentation of having received orientation for new residents. The resident’s date of admit was noted as 11-16-22.

Plan of correction

Supervisor of staff will ensure upon admission, that orientation for new residents and their legal representatives will occur; same will be documented by acknowledging receipt. Date to be corrected: Ongoing and by 8/16/23

22VAC40-73-350-B

Based on record reviewed and staff interviewed, the facility failed to ascertain, prior to admission, whether a potential resident is a registered sex offender if the facility anticipates the potential resident will have a length of stay greater than three days or in fact stays longer than three days and shall document in the resident’s record that this was ascertained and the date the information was obtained.

Evidence

On 3-27-23, resident #5’s record did not include documentation sex offender information had been ascertained prior to the resident’s admission. The resident’s date of admit was noted as 3-21-23.

Plan of correction

LALFA will be responsible for obtaining sex offender's information on a potential resident within the date guidelines of the state regulations to maintain compliance and will document same. Date to be corrected: Ongoing and by 8/16/23

22VAC40-73-870-A

Based on observation and staff interviewed, the facility failed to ensure the interior of the building was maintained in good repair and kept clean and free of rubbish.

Evidence

Based on observation and staff interviewed, the facility failed to ensure the interior of the building was maintained in good repair and kept clean and free of rubbish. Evidence:
On 4-6-23 during a tour of the facility, the patio area at the rear of the building was not maintained in good repair. The courtyard/outdoor area was observed with grass growing through cracks in the concrete area, the fence was a missing slat, staining on the concrete and a broken metal bedframe. The floors in the hallway on the first and second floors was observed with accumulated dirt and debris. The recreation room missing a portion of the baseboard molding. The first-floor shower room contained stacks of multiple walkers. There were bags of soiled linen on the floor near the laundry room. The wall in the elevator and the second floor was observed with stains and in need of cleaning. There was a wet area on the floor in an upstairs bedroom (215). Staff #7 stated it was urine.
Various resident’s rooms upstairs were observed with piles of clothing on the floor, in the corner of the room and/or middle of the floor. Residents’ clothing was not in a dresser or closet (Rooms 109, 207, 208, 209 and 211). The laundry room was observed with stacks of clothing of clothing and baskets of clothing in the room.
Trash, soda bottles and cups observed in the room, on top of the dresser and windowsills of various residents’ rooms. (Room 208)

Plan of correction

Supervisor of staff or designee will ensure the interior of the building will be maintained in good repair and kept clean and free of rubbish. The supervisor or designee will walk the building daily to ensure compliance with this regulation. Pictures will be taken as proof of compliance or if applicable, or taken as repair needed. Pictures have been sent to the state licensing inspector to prove that all of the repairs and cleaning have occurred and will be maintained. Date to be corrected: 7/16/23

22VAC40-73-250-D

Based on record reviewed and staff interviewed, the facility failed to ensure two of four staff person within seven days prior to the first day of work at the facility submitted the results of a risk assessment, documenting the absence of tuberculosis (TB) in a communicable form as

Evidence

d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence:
On 4-6-23, staff #3’s TB screening information was dated 3-7-23. The staff’s date of hire was noted as 2-27-23.
Staff #4’s TB screening was dated 6-6-22. The staff’s date of hire was noted as 5-13-22.

Plan of correction

LALFA will monitor staff charts/records for PPD upon hire and quarterly to ensure compliance with state regulations. Date to be corrected: 7/26/23

22VAC40-73-680-I

Based on record reviewed and staff interviewed, the facility failed to ensure that the medication administration record (MAR) included all required information.

Evidence

On 4-6-23, resident #5’s medication administration record (MAR) did not include the initials of the direct care administering the medication at 8:00 a.m. on 3-27-23 for the following medications: Cogentin, Thorazine, Haldol, Vistaril, Risperdal and Vitamin D3.

Plan of correction

LALFA will ensure that the medication administration record (MAR) will include all required information by checking the MARs monthly as they come in. Date to be corrected: 7/16/23

22VAC40-73-750-B

Based on observations and staff interviewed, the facility failed to ensure residents’ bedrooms included all required items.

Evidence

On 4-6-23, during the licensing administrator and senior licensing assistant’s tour of the facility with staff #7, a resident bedroom did not have light bulb in the bedside lamps (Room 208). There were three chairs in the bedroom occupied by four residents (202). A black and white sheet at the window used for privacy. (211)
Room 104 did not have a chair.

Plan of correction

Supervisor of staff will ensure residents' bedrooms will include all required items by having staff to report weekly of any missing items. Date to be corrected: 7/14/23

22VAC40-73-870-D

Based on observations and staff interviewed, the facility failed to ensure the building was kept free of infestations of insects and vermin.

Evidence

On 4-6-23, during a tour of the facility with staff #7, bed bugs contaminants were observed on various beds (box spring- and mattresses) and on the floor and walls in residents’ room on the second floor. Live and dead bed bugs remnants were observed on bedding in residents’ room (Rooms 202, 207, 209 and 216).

Plan of correction

Supervisor of staff or designee will ensure the building will be kept free of insects. The supervisor or designee will walk the building daily to ensure compliance with this regulation. Exterminating and painting have occurred. Pictures have been sent to state licensing to prove compliance with this regulation. Date to be corrected: 7/14/23

22VAC40-73-450-C

Based on record reviewed and staff interviewed, the facility failed to ensure the comprehensive individualized service plan (ISP) was completed within 30 days and included all assessed needs for three of eight resident record reviewed.

Evidence

On 3-27-23, resident #5’s record did not include a preliminary plan of care, neither did it contain a comprehensive individualized service plan. The resident’s date of admit noted as 3-21-23.
Resident #6’s ISP was dated 9-30-22. The resident’s date of admission was noted as 9-28-22. According to staff, the facility conducts a comprehensive ISP for all residents prior to admission.
Resident #7’s ISP dated 11-16-22 did not include the resident’s discharge assistance program (DAP) information. The resident’s date of admit noted as 11-16-22.

Plan of correction

LALFA and Supervisor of staff will ensure that comprehensive ISPs will be completed within 30 days, and will include all assessed needs for residents. Date to be corrected: 9/1/23

June 28, 2022Inspection16 violations

Inspection dates

06/28/2022,07/05/2022,07/12/2022

Areas reviewed

22VAC40-73 PERSONNEL22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments

Type of inspection: Renewal An unannounced on-site renewal inspection was conducted by two inspectors from the Peninsula Licensing Office on 6-28-22 (AR 07:10 a.m./dep 2:30 p.m.) The facility census was 62. A tour of the facility was conducted, emergency preparedness standards were reviewed and observed, first aid kit check, breakfast meal observed, medication pass observation conducted, staff and resident interviews and records were reviewed. An exit meeting was conducted with the administrator in charge. The Acknowledgement of Inspection form was sent via email for the Administrator to review and sign on 6-23-22.The final exit meeting will be conducted on 7-22.22. 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 Willie Barnes, Licensing Inspector at 757-439-6815 or by email at willie.barnes@dss.virginia.gov

Violations

22VAC40-73-870-A

Based on observation and staff interviewed, the facility failed to ensure the interior of the building was maintained in good repair and kept clean and free of rubbish.

Evidence

On 6-28-22, during a tour of the facility with staff #2, the following was observed in areas of the building: (a) the ceiling vents in resident rooms (108, 210 and 202) contained black substance of some kind; (b) the first floor men’s bathroom (common area)’s sink did not have hot water; (c) the second floor men’s bathroom had large grey substance on the ceiling and the ceiling vent was also covered with a grey substance; (d) the second floor men’s bathroom tub contained brown colored areas; (e) the second floor men’s toilet was inoperable; (f) the second floor men’s bathroom divider was shaky, not stable and rusted and the base; (g) the second floor stairwell door was covered with a brown colored substance and (h) the male and female residents’ bedroom floors contained brown and black substance, particularly around the floor baseboards.
On 6-28-22, staff #2 acknowledged the building was not kept clean and items were determined to be in need of repair.

Plan of correction

Floor supervisor will ensure that the floor staff at the facility keeps the building in good repair, clean and free of any rubbish.

22VAC40-73-640-A

Based on observation, record reviewed, document reviewed, and staff interviewed, the facility failed to implement its medication management plan to ensure a resident’s prescription medication was filled and refilled in a timely manner to avoid missed dosages.

Evidence

On 6-28-22, during the medication pass observation with staff #3, resident #1’s 8:00 a.m. prescribed dosage of Paliperidone was not available to administer at 7:34 a.m.
Staff #3 and #1 acknowledged the aforementioned resident’s prescribed medication was not available to administer at the prescribed time and day.

Plan of correction

Registered Med-Aides will ensure that all prescriptions are filled and refilled to avoid missed dosages.

22VAC40-73-380-B

Based on record reviewed and staff interviewed, the facility failed to ensure the personal and social information document was kept current.

Evidence

On 6-28-22, resident #1, #2, and #3’s personal and social information form in the residents’ record was not completed, the form was blank.
On 6-28-22 and 7-11-22, staff #1 acknowledged the aforementioned residents’ personal and social information was not completed.

Plan of correction

Staff will ensure that the personal and social information is documented and kept current.

22VAC40-73-250-D

Based on record reviewed and staff interviewed, the facility failed to ensure a staff person within seven days prior to the first day of work at the facility submitted the results of a risk assessment, documenting the absence of tuberculosis (TB) in a communicable form as

Evidence

d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence:
On 6-28-22, staff #3’s record documented staff’s TB was dated 9-8-21. Staff’s record noted a date of hire of 6-2-22.
On 6-28-22 and 7-12-22, staff #1 acknowledged the aforementioned staff’s TB was not within seven days prior to the first day of work.

Plan of correction

Administrator going forward will ensure all staff beginning their new position will have a negative TB test provided prior to the start date.

22VAC40-73-450-C

Based on record reviewed and staff interviewed, the facility failed to ensure the comprehensive individualized service plan (ISP) was completed within 30 days and included all assessed needs.

Evidence

On 6-28-22, resident #1 and #2’s record did not include an ISP. The residents’ date of admission was documented as 1-25-22.
On 6-28-22 and 7-12-22, staff #1 acknowledged the aforementioned residents’ record did not include an ISP.

Plan of correction

Staff will ensure that a comprehensive ISP is completed within 30 days including all assessed needs.

22VAC40-73-440-G

Based on record reviewed and staff interviewed, the facility failed to ensure when a resident moves to an assisted living facility from another assisted living facility or other long-term care setting that use the UAI, the previous assessment is no more than 12 months old.

Evidence

On 6-28-22, resident #1’s UAI was dated 9-30-20 and reassessed on 10-7-20. The resident’s date of admission to the facility was documented as 1-25-22.
On 6-28-22 and 7-12-22, staff #1 acknowledged the aforementioned resident did not have a UAI that was no more than 12 months upon admission.

Plan of correction

Staff will ensure that each resident has a current UAI prior to admission.

22VAC40-73-610-E

Based on staff interviewed, the facility failed to ensure a copy of a diet manual containing acceptable practices and standards for nutrition was kept current and readily available to personnel responsible for food preparation.

Evidence

On 66-28-22, during an inspection of the facility, staff #7 was not able to provide a copy of a diet manual containing acceptable practices and standards for nutrition readily available to personnel responsible for food preparation.
On 6-28-22 and 7-12-22, staff #1 acknowledged the facility did not have a diet manual available.

Plan of correction

Food service manager will ensure that a current copy of the diet manual is available for the food prep staff.

22VAC40-73-450-F

Evidence

On 6-28-22, resident #2’s ISP was dated 1-25-22 and had a review date (end date) of 4-22-22.
Resident #4’s ISP in the record was dated 6-19-19.
Resident #7’s ISP in the record was dated 8-21-20.
On 6-28-22 and 7-12-22, staff #1 acknowledged, the aforementioned residents’ ISP was not updated at least once every 12 months or when the review period ended.

Plan of correction

Staff will ensure that the ISP’s shall be reviewed and updated at least once every 12 mos. as needed.

22VAC40-73-210-B

Based on record reviewed and staff interviewed, the facility failed to ensure direct care staff attended at least 18 hours of training annually.

Evidence

On 6-28-22, staff #2’s record documented 5 of the required 18 hours of training. There was not documentation of the required 4 hours of mental health training. Staff’s date of hire documented as 10-1-20.
Staff #5’s record documented 7 of the required 18 hours of training. There was no documentation of the required 4 hours of mental health training. Staff’s date of hire documented as 5-19-21.
On 6-28-22 and 7-12-22, staff #1 acknowledged the aforementioned staff records did not have the required annual training hours.

Plan of correction

Administrator will require twice weekly hour-long training until each direct care staff member is caught up.

22VAC40-90-40-B

Based on the employee record review, the facility failed to ensure the criminal history record report was obtained on or prior to the 30th day of employment for each employee.

Evidence

On 6-28-22 staff #6’s record documented staff’s date of hire as 9-27-21 and there was no Virginia State Police Criminal history check in the employee file.
On 6-28-22 and 7-12-22 #1 acknowledged the file did not contain a Virginia State Police Criminal history check.

Plan of correction

Administrator will ensure that no employee starts work until the criminal background history report is obtained prior to the new employee starts work at the facility.

22VAC40-73-310-B

Based on record reviewed and staff interviewed, the facility failed to ensure it documented the interview between the administrator or a designee responsible for admission and retention decisions, the individual, and the legal representative, if any. In some cases, conditions may create special circumstances that make it necessary to hold the interview on the date of admission.

Evidence

On 6-28-22, residents’ # 1, #2, and #3’s record did not included documentation of an interview and the date of the interview. The residents’ date of admission documented as 1-25-22.
On 6-28-22 and 7-12-22, staff #1 acknowledged the aforementioned residents’ records did not included a documented and dated interview.

Plan of correction

Staff interviewing prospective resident will ensure that documentation of the interview will be stored as a matter of record prior to the date of actual admission

22VAC40-73-410-A

Evidence

On 6-28-22, resident #1, #2, #3 and #5’s record did not have documentation of the resident’s orientation to the facility by facility representative, no signature and date of facility provided on document. Residents’ #1, #2 and #3 date of admission was documented as 1-25-22. Resident #5’s date of admission was documented as 9-27-19.
On 6-28-22 and 7-12-22, staff #1 acknowledged the aforementioned residents’ orientation to the facility’s document was not signed and documented by facility representative.

Plan of correction

Staff will ensure that a proper orientation is provided, signed and documented in the resident’s record for both the resident and, as appropriate, his legal representative.

22VAC40-73-390-B

Based on record reviewed and staff interviewed, the facility failed to ensure the resident agreement/acknowledgement was signed and dated.

Evidence

On 6-28-22, resident #1, #2 and #3’s resident agreement/acknowledgement form in the record was not signed and dated by the facility.
On 6-28-22 and 7-12-22, staff #1 acknowledged the aforementioned residents’ agreement/acknowledgement form was not signed and dated by the facility.

Plan of correction

Staff will ensure that the resident agreement/acknowledgement will be signed and dated upon admission going forward.

22VAC40-73-320-A

Evidence

d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence:
On 6-28-22, resident #1 and #2’s physical examination and TB document in the record was dated 3-25-21. The residents’ date of admission was documented as 1-25-22.
Resident #3’s physical examination and TB in the record was dated 3-4-21. The resident’s date of admission was documented as 1-25-22.
On 6-28-22 and 7-12-22, staff #1 acknowledged the aforementioned resident’s physicals and TBs were not within 30 days of admission.

Plan of correction

Staff will ensure that a physical exam and negative TB test result will be documented within 30 days preceding admission.

22VAC40-73-580-A

Based on document reviewed and staff interviewed, the facility failed to ensure when any portion of the facility is subject to inspection by the Virginia Department of Health, the facility shall be in compliance with those regulation, as

Evidence

d by an annual report from the Virginia Department of Health. Evidence:
On 6-28-22, the date of the facility’s last health inspection was dated 2-28-20.
Staff #1 acknowledged the facility did not have a current (annual) health inspection.

Plan of correction

Facility will work directly with VDH to ensure the facility stays in compliance with the annual inspections and documents the report.

22VAC40-73-310-D

Evidence

On 6-28-22, residents, #1, #2, and #3’s included a copy of the written assurance, however, the document was not signed and dated by the facility representative.
On 6-28-22 and 7-12-22, staff #1 acknowledged the aforementioned resident’s record did not include a signed and dated written assurance.

Plan of correction

Staff will ensure that a signed and dated written assurance is put into the resident prior to admission.

June 3, 2022Complaint survey1 violation

Inspection dates

06/03/2022,07/10/2022,07/12/2022

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES

Comments

Type of inspection: Complaint An unannounced complaint inspection was conducted on 6-3-22, (AR 08:30/dep 12:30). The census was 68. The Acknowledgement of Inspection form was sent to the Administrator. A complaint was received by VDSS Division of Licensing on 5-24-22 regarding allegations in the area of administration and administrative services. The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Willie Barnes, Licensing Inspector at 757-439-6815 or by email at willie.barnes@dss.virginia.gov

Violations

22VAC40-73-80

Based on record reviewed and staff interviewed, the facility failed to ensure resident’s funds was made available to the resident upon request.

Evidence

On 6-3-22 during a complaint inspection regarding resident #1 not receiving personal funds, three records were reviewed for personal spending disbursement. Resident #1, #2 and #3’s written documentation of accounting of personal funds provided by staff #1 documented residents last received personal spending money on 3-10-22. There was no documentation of residents’ receiving personal spending money for the months of April and May of 2022.
On 6-3-22, staff #1 acknowledged the facility could not provide to the inspectors documentation of resident #1 signing for personal spending money for April and May 2022.

Plan of correction

Facility will ensure that the signed documentation whereby the resident received his money is kept onsite.

June 3, 2022Complaint survey1 violation

Inspection dates

06/03/2022,06/10/2022,07/12/2022

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

Type of inspection: Complaint An unannounced complaint inspection was conducted on 6-3-22 (AR 08:30 a.m./dep 12:30 p.m.) The Acknowledgement of Inspection form was sent to the Administrator for signature A complaint was received by VDSS Division of Licensing on 5-24-22 regarding allegations in the area of resident care and resident care. The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Willie Barnes, Licensing Inspector at 757-439-6815 or by email at willie.barnes@dss.virginia.gov

Violations

22VAC40-73-460-D

Based on record reviewed, documentation and staff interviewed, the facility failed to ensure it provided supervision of a resident schedules, care and activities, including attention to specialized needs, such as prevention of falls and wandering from the premises.

Evidence

On 6-3-22, a-site visit was conducted for a complaint inspection of resident #1 being out of the facility and located in a neighboring city approximately 6.6 miles from the facility on a wet rainy day May 24, 2022. The resident was noted to be wet when picked up and returned to the facility. According to interview with staff #1, resident #1 frequently would leave the facility and would be gone sometimes for days at time. Staff also stated the resident would leave and is usually headed north and trying to go to northern Virginia area. This is the area the resident resided prior to coming to this facility. Staff also stated facility staff would go searching in the community to locate resident and return resident to the facility. According to staff #1, resident also is known to eat out of the trash can. The resident’s uniformed assessment instrument (UAI) dated 2-9-22 documented resident disoriented to time and date and also have problems with judgement. Also noted on the UAI -resident assessed as having long-term and short-term memory problems.
A request was made for documentation in the resident’s record of times/dates the resident leaves the facility and did not return. There were no documentation in the resident’s record provided. The facility’s communication log book noted resident out of facility, but the dates and times were not specific for leaving and returning. The resident’s May 2022 medication administration record documented times when the resident was out of the facility and did not receive medication. The times were not clear as some staff document refusal as out of facility and others documented out of facility as when resident was out per that particular staff’s documentation. According to interviews with other facility staff, the resident would leave the facility and staff would be gone for different periods of time.
On 6-23-22, staff #1 acknowledged resident #1 did leave the facility and was gone and was wet when the resident returned.

Plan of correction

Facility staff will take measures to relocate any resident whereby wandering becomes an issue with the safety of said resident and maintain schedules for care and activities

June 29, 2021Inspection0 violations

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS

Comments

The inspection was conducted by Licensing Staff using alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A monitoring inspection was initiated on 06/29/2021 and concluded on 06/29/2021. The director in-charge person was contacted by telephone to initiate the inspection. The inspector reviewed resident and staff records and additional documentation provided by the facility to ensure compliance. The information gathered during the inspection determined no violations with applicable standards or law. no violations were issued.

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

June 29, 2021Complaint survey0 violations

Areas reviewed

22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS

Comments

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A complaint inspection was initiated on 06/29/2021 and concluded on 06/29/2021. The Administrator was contacted to initiate the inspection. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed resident and staff records and additional documents submitted by the facility to ensure compliance. The information gathered during the inspection determined no violations with applicable standards or law. No violations were issued.

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

June 25, 2021Inspection0 violations

Areas reviewed

22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS22VAC40-73 EMERGENCY PREPAREDNESS

Comments

The inspection was conducted by Licensing Staff using alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 06/25/2021 and concluded on 06/25/2021. The director or in-charge person was contacted by telephone to initiate the inspection. The inspector reviewed 3 resident and 3 staff records and additional documentation provided by the facility to ensure compliance. The information gathered during the inspection determined no violations with applicable standards or law. no violations were issued.

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.