Westminster Canterbury of Lynchburg — 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

Westminster Canterbury of Lynchburg was inspected 7 times between December 10, 2020 and May 26, 2026 by the Virginia Department of Social Services. 6 of those visits ended with violations cited and 1 with none. Across that history VDSS cited 15 violations under 12 distinct standards. 1 inspection was prompted by a complaint.

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

VDSS publishes inspections on a rolling window. 6 of these 7 are still on the state's site; the other 1 has since dropped off it and is 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

01/28/2028

Administrator

Lori Sweeney

Licensing inspector

Cynthia Ball

Inspector phone

(540) 309-2968

Approved for

Special Care Unit · Assisted Living · Non-Ambulatory

Inspection History

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

May 26, 2026Complaint survey0 violations

Inspection dates

05/26/2026

Areas reviewed

22VAC40-73 PERSONNEL22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES

Comments

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/26/2026 8:30am until 9:00am 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 03/20/2026 regarding allegations in the area(s) of: PERSONNEL, BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES Number of interviews conducted with staff: 5 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

January 8, 2026Inspection3 violations

Inspection dates

01/08/2026

Areas reviewed

22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS

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: 01/08/2026 9am until 2:30pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 54 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 4 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations

22VAC40-73-440-D

Based on resident record review, the facility failed to ensure that uniform assessment instruments (UAI) were completed as required.

Evidence

The record for resident 5 has documentation of a physician order dated 11/11/2025 that the resident is on a no concentrated sweet, puree diet. The UAI dated 10/22/2025 in the record for resident 5 is inconsistent as it has documentation that resident 5 does not require any assistance with eating/feeding.

Plan of correction

Assisted Living Manager corrected the UAI the date of survey (01/08/2026) to reflect resident was mechanical assistance with eating instead of independent due to being on a puree diet.

22VAC40-73-680-D

Based on resident record review, the facility failed to ensure that medications were administered in accordance with physician instructions.

Evidence

The record for resident 2 has a physician order for Midodrine 5mg by mouth three times daily for Hypotension, hold if systolic is greater than 110. The January 2026 medication administration record (MAR) for resident 2 has documentation that the residents blood pressure was 123/71 on 01/01/2026 for the 0630-1000 medication pass. Staff initials are present for the administration of the Midodrine 5mg on 01/01/2026 for the 0630-1000 medication pass even through physician orders are to hold the medication if resident 2’s systolic blood pressure is greater than 110.

Plan of correction

Assisted Living Manager will provide education to all RMA’s regarding administering medication with parameters as well as provide 1:1 education with staff member who made error.

22VAC40-90-30-B

Based on staff record review, the facility failed to ensure that a sworn statement or affirmation was completed for all applicants for employment.

Evidence

The record for staff person 6, hired on 09/30/2025, has a sworn statement or affirmation that is incomplete as it lacks documentation if the employee has been convicted of a law violation, is subject to pending criminal charges and is not signed or dated by the employee.

Plan of correction

Human Resources had staff person 6 sign a new sworn disclosure statement the date of survey (01/08/2026) and ran another background check. HR will assure all documents are signed before being placed in staff HR files.

April 28, 2025Inspection2 violations

Inspection dates

04/28/2025

Areas reviewed

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: 04/28/2025 9am until 2:30pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 54 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Number of staff records reviewed: 4 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations

22VAC40-73-440-D

Based on resident record reviews, the facility failed to ensure that private pay uniform assessment instrument (UAIs) were completed as required.

Evidence

The UAI dated 03/03/2025 for resident 2, the UAI dated 12/13/2024 for resident 3, the UAI dated 02/04/2025 for resident 4, the UAI dated 05/10/2024 for resident 5, the UAI dated 03/19/2025 for resident 6 and the UAI dated 12/30/2024 for resident 7 have documentation that medications are administered to these residents by professional nursing staff. The facility employees registered medications aides, who are considered laypersons on a UAI assessment, who also administer medications to residents that reside at the facility.

Plan of correction

Assisted Living Manager will correct all resident’s UAI’s from “Professional Nursing Staff” to “Lay Person” when pertaining to a Licensed Medication Aide.

22VAC40-73-680-K

Based on observations of the facility medication cart and resident record review, the facility failed to ensure that when medication aides administer PRN medications a detailed medication order was obtained from the physician that includes 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

The record for resident 1 has documentation of a signed physician order dated 11/06/2023 for Narcan 4mg/actuation nasal spray, spray Inhalation into one nostril once daily as needed for emergency due to Opioid Use. The order does not include symptoms that indicate the use of the medication, and directions as to what to do if symptoms persist.

Plan of correction

The Physician discontinued the PRN Narcan the date of the inspection (04/28/2025). Moving forward, a Narcan order will be more specific to include symptoms that indicate the use of the medication and directions as what to do if symptoms persist.

January 5, 2024Inspection1 violation

Inspection dates

01/05/2024

Areas reviewed

Comments

Type of inspection: Renewal Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 01/05/2024 9:00am until 2:00pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 45 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Number of staff records reviewed: 4 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations

22VAC40-73-960-B

Based on observations made of the facility physical plant, the facility failed to ensure that all required information was included on the posted facility fire and emergency evacuation drawings.

Evidence

The facility posted fire and emergency evacuation drawing located by the elevators on the 3rd, 4th and 5th floors did not contain information about areas of refuge or assembly areas on the day of inspection.

Plan of correction

The Administrator will discuss areas of refuge and assembly areas with the local Fire Marshall and will update the facility posted fire and emergency evacuation drawing to included all required items.

May 15, 2023Inspection3 violations

Inspection dates

05/15/2023

Areas reviewed

Comments

Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/15/2023 9:00am until 2:00pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 46 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 4 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations

22VAC40-73-440-D

Based on resident record reviews, the facility failed to ensure that private pay uniform assessment instruments (UAIs) were completed as required.

Evidence

The UAI dated 05/09/2023 in the record for resident 4 has documentation that the residents behavior pattern is wandering/passive less than weekly. A interdisciplinary note dated 03/21/2023 has documentation of the resident trying to spit, hit and becoming aggressive with staff. The UAI does not have documentation in the area for resident 4’s type of inappropriate behaviors.

Plan of correction

Resident Care Coordinator (RCC) corrected the UAI the date of the inspection (05/15/2023) to include the residents type of inappropriate behaviors.

22VAC40-73-680-D

Based on review of resident records and medication administration records (MARs), the facility failed to ensure that medications administered were consistent with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing.

Evidence

The record for resident 6 has a physician order for Ozempic 0.25mg sub-q every Wednesday for DMII. This medication is a non-insulin injection.
The May 2023 MAR for resident 6 has documentation of staff initials who are RMA’s for the administration of this medication.
Page 53 of the current 68 hour registered medication aide curriculum revised in 2022 has documentation that “Non-insulin injections a. Medication aides may not administer pursuant to 18VAC90-60-110(B)(5)”.

Plan of correction

Resident Care Coordinator (RCC) will provide education to all RMA’s and Charge Nurse’s (LPN) to ensure all medications administered are consistent with the standards in the medication aide curriculum. RMA’s are not to administer non-insulin injections.

22VAC40-73-860-I

Based on observations of the facility physical plant, the facility failed to ensure that cleaning supplies were stored in a locked area.

Evidence

The bottom cabinet to the right of the desk on the facility safe, secure unit was noted to be unlocked on the day of inspection. 2 containers of Clorox Bleach Germicidal wipes, 2 containers of Sani Wipes and a container of Prempt Wipes were observed sitting on the shelf in the unlocked cabinet.

Plan of correction

The Clorox Bleach Germicidal wipes, Sani Wipes and Prempt wipes (Cleaning supplies) were removed from the bottom cabinet the day of inspection (05/15/2023) and stored in a locked area. Resident Care Coordinator (RCC) will provide education to staff regarding the importance of storing all cleaning supplies in a locked area.

December 3, 2021Inspection4 violations

Inspection dates

12/03/2021

Areas reviewed

22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity32.1 Reported by persons other than physicians63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS

Comments

On 12/3/2021 two inspectors conducted a renewal study (9:10 am to 4:20 pm). Eight resident records and five staff records were reviewed. All new staff records were reviewed for background check information. A physical plant tour was done, medication pass was observed, and other documents were reviewed. An exit interview was conducted on-site.

Violations

22VAC40-73-220-A

Based on document review, the facility failed to have direct care or companion services provided by private duty personnel to meet identified needs reflected on the resident's individualized service plan.

Evidence

Staff 5 does private duty work for resident 3 and the exact duties she provides are not described on the individualized service plan (ISP). The ISP states, "Monitor to assure needs are met. on Mondays and Thursays (sic) from 1300-1700". The needs are not stated, and what is done is not specified.

Plan of correction

Residents ISP stated her Personal Care Aide assisted with laundry services. Resident Care Coordinator added other specific duties (walks, puzzles, empty trash can) the personal care aide does for the resident on her ISP.

22VAC40-73-650-A

Based on observation, staff and resident interviews and resident record review, the facility failed to ensure that no treatment was changed by the facility without a valid order from a physician or other prescriber.

Evidence

The record for resident 5 contained a physician’s order, dated 11/01/2021, for “Resident to wear R ankle brace when OOB (out of bed). Check skin when applying and removing R ankle brace for any signs or symptoms of skin breakdown – Every shift; (physician)”.
During on-site inspection, one licensing inspector observed the resident wearing a right ankle brace. Interview with the resident and staff revealed that the resident applies the brace herself and removes the brace herself. The physician’s order does not contain information that the resident may apply and remove the right ankle brace herself.

Plan of correction

Resident is very independent and her personal choice is to apply and remove the brace independently. On the day of inspection, the Charge Nurse received a clarification order from the resident’s physician. The order now reads, resident may apply and remove brace at any time of her choosing.

22VAC40-73-450-C

Based on resident record review, the facility failed to properly address a need on a comprehensive individualized service plan (ISP).

Evidence

The uniform assessment instrument (UAI) dated 11/1/2021 shows that resident 1 does not need help with doing laundry, and the ISP dated 11/1/2021 shows that the resident both needs help with laundry, and is independent with Laundry.

Plan of correction

Resident Care Coordinator corrected the ISP the day of inspection to show the resident does not need assistance with laundry services.

22VAC40-73-1150-B

Based on observation, the facility failed to have protective devices on the windows in the special unit sunroom to prevent windows from being opened wide enough for a resident to crawl through.

Evidence

The sunroom in the special care unit (memory care), accessible to the residents, had no protective devices on four large windows. They were able to be opened wide enough for residents to crawl through.

Plan of correction

All four windows lock, however, permanent locks were placed on all four windows the day of inspection.

December 10, 2020Inspection2 violations

Inspection dates

Dec. 10, 2020 and Dec. 14, 2020

Areas reviewed

22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity32.1 Reported by persons other than physicians63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS

Technical assistance

A link to the UAI User's manual was provided.

Comments

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 12/10/2020 and concluded on 12/14/2020. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 47. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed three (3) resident records, three (3) staff records, one companion record, staff schedules, fire drill records, background check review on new staff, health care oversight report, fire inspection report, and the health department report submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations

22VAC40-73-440-A

Based on resident record review, the facility failed to complete a uniform assessment instrument (UAI) in accordance with Assessment in Assisted Living Facilities (22VAC30-110).

Evidence

The UAI dated 10/1/2019 for resident 3 shows this resident is disoriented to some spheres, some of the time. The UAI does not indicate to which spheres the resident is disoriented.

Plan of correction

The UAI for resident 3 was corrected on, 12/15/2020, to reflect which spheres the resident is disoriented. The Resident Care Coordinator (RCC) or designee will assure UAI’s indicate which spheres are disoriented.

22VAC40-73-700-1

Based on document review, the facility failed to have a complete prescriber's order for a resident using supplemental oxygen.

Evidence

The oxygen order for resident 2 lacked information regarding the source of the oxygen, such as compressed gas or concentrators.

Plan of correction

The day of the inspection, 12/14/2020, this order was corrected with the source of the oxygen. The Resident Care Coordinator or Charge Nurse will assure the source of the oxygen is on all physician’s orders.