Virginia DSS · Assisted Living Facility

Emily Green Shores

📍 500 Westmoreland Avenue, Portsmouth, VA, 23707

ID 8398Two Year licenseActive
16
Inspections
On record
12
With violations
Visits that cited something
4
Clean visits
Nothing cited
27
Violations cited
Individual findings
25
Standards cited
Distinct rules
9
Complaint visits
Prompted by a complaint

Emily Green Shores was inspected 16 times between February 4, 2021 and June 1, 2026 by the Virginia Department of Social Services. 12 of those visits ended with violations cited and 4 with none. Across that history VDSS cited 27 violations under 25 distinct standards. 9 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. 14 of these 16 are still on the state's site; the other 2 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
06/30/2027
Administrator
Maria Irlinger
Licensing inspector
Lanesha Allen
Inspector phone
757-715-1499
Approved for
Assisted Living · Non-Ambulatory

Inspection History

16

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

June 1, 2026Inspection2 violations
Inspection dates
06/01/2026
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 PREPAREDNESS63.2- (18) FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Technical assistance
22VAC40-73-250 22VAC40-73-550
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: 6/1/2026 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: 27 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: 2 Observations by licensing inspector: Breakfast lunch and tour of the facility occurred during onsite. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of these inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at Lanesha.allen@dss.virginia.gov
Violations
22VAC40-73-440-A
Based on the review of four resident records, it was determined that the facility did not ensure that the UAI shall be completed at least annually.
Evidence
  1. The record for Resident #4 contained an UAI dated 11/26/2024.
  2. Staff #4 confirmed that UAI for residents #4 was not updated annually.
Plan of correction
• Resident will be reassessed and the new UAI will be filed in their Clinical Chart • An audit of all Residents' charts will be done to ensure accuracy • The Compliance Nurse and/or designee will be responsible
22VAC40-73-450-F
Based on observation, interview and document review on 6/1/2026, the facility did not ensure that the Individualized service plan shall be reviewed and updated at least once every 12 months.
Evidence
  1. During the record review for Resident #4, the record did not contain an annual ISP. The last plan was dated 11/29/24. 2.Staff #4 states the plan was completed, however misfiled. Staff #4 was unable to provide the documentation during this onsite visit.
Plan of correction
• ISP's will be completed upon admission and updated annually and or if there's a significant change in Resident's condition • An audit was completed of all Residents' Clinical Charts to ensure accuracy • The Compliance Nurse and/or Designee will be responsible for completing ISP's accordingly. A tickler system will be created to assist in making sure ISP's are done annually
November 24, 2025Complaint survey0 violations
Inspection dates
11/24/2025
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Technical assistance
22VAC40-73-30
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: 11/24/2025 from 1:00 pm-2:30pm. 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 11/20/2025 regarding allegations in the area(s) of: Admission, Retention and Discharge Of Residents and Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 26 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:0 Number of interviews conducted with residents:0 Number of interviews conducted with staff: 2 Observations by licensing inspector: An activity were observed. The following was reviewed: resident records, Facility Admission policy. Additional Comments/Discussion: The evidence gathered during the investigation did not support the (allegation(s)/self-report) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at Lanesha.allen@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
August 25, 2025Complaint survey1 violation
Inspection dates
08/25/2025
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION
Comments
Type of inspection: Complaint An unannounced monitoring inspection took place on 08/25/2025 at 12:30 pm until 12:45 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-report was received by VDSS Division of Licensing on 08/25/2025 regarding allegations in the area of: Personnel Number of residents present at the facility at the beginning of the inspection: 21 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: none Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov. Should you have any questions, please contact Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at Lanesha.allen@dss.virginia.gov.
Violations
22VAC40-73-150-B
Based on the onsite record review the facility did not ensure that If an administrator becomes unable to perform his duties, the facility shall immediately employ a new administrator or appoint a qualified acting administrator so that no lapse in administrator coverage occurs.
Evidence
  1. During a onsite visit with staff #1 on 08/25/2025, staff #1 confirmed there was no administrator in place.
Plan of correction
Not published by VDSS.
May 15, 2025Inspection2 violations
Inspection dates
05/15/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE
Technical assistance
22VAC40-73-70
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: 05/15/2025 from 8:40 am-2:30pm. and 05/21/2025 from 7:30 a.m. to 8:00 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: 21 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 5 Number of staff records reviewed:3 Number of interviews conducted with residents:2 Number of interviews conducted with staff: 3 Observations by licensing inspector: Breakfast, lunch and an activity were observed. A medication pass observation was completed for three residents. The following was reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, medication carts, fire inspection report, health inspection report, and a staffing schedule. Water temperature was measured. Additional Comments/Discussion: 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 Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at Lanesha.allen@dss.virginia.gov
Violations
22VAC40-73-550-G
Based on the record review the facility did not ensure the rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each resident or his legal representative or responsible individual and each staff person.
Evidence
  1. of this review shall be the resident's, his legal representative's or responsible individual's, or staff person's written acknowledgment of having been so informed, which shall include the date of the review and shall be filed in the resident's or staff person's record. Evidence:
  2. The record for resident #2 contains a Resident Rights dated 1/5/2022. The record did not contain an annual Resident Rights Review at the time of inspection.
  3. The record for resident #3 contains a Resident Rights dated 12/28/2016. The record did not contain an annual Resident Rights Review at the time of inspection.
  4. The record for staff #5 did not contain an annual Resident Rights Review at the time of inspection.
Plan of correction
The Administrator and the Administrative Assistant reviews Resident’s Rights to all residents and staff once a year in January and the files are kept in a different place in the office. The Administrative Assistant will ensure they are available for review for the State inspections. Date to be corrected: 5-27-2025
22VAC40-90-40-B
Based on the record review the facility did not ensure the criminal history record report shall be obtained on or prior to the 30th day of employment for each employee.
Evidence
  1. The record for staff #7 contains a Sworn Disclosure dated 10/13/2024. The date of hire for staff was 08/20/2024, which is greater than 30 days of employment.
Plan of correction
The Administrator and the Administrative Assistant will ensure that documents are double checked on all new employees the day they are hired. Date to be corrected: 5-27-2025
January 31, 2025Complaint survey0 violations
Inspection dates
01/31/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 1/31/2025 from 3:00pm-3:30pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 12/30/2024 regarding allegations in the area(s) of: Resident Care And Related Services Number of residents present at the facility at the beginning of the inspection: 28 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed:0 Number of interviews conducted with residents:0 Number of interviews conducted with staff: 1 Observations by licensing inspector: 0 Additional Comments/Discussion: 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 Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at Lanesha.allen@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
November 26, 2024Complaint survey1 violation
Inspection dates
11/26/2024
Areas reviewed
22VAC40-73 BUILDINGS AND GROUND
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: 11/26/24 from12:45pm-12:50pm. 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 11/15/24, 11/18/24, and 11/20/24 regarding allegations in the area(s) of: Buildings and Grounds Number of residents present at the facility at the beginning of the inspection: 29 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed:0 Number of interviews conducted with residents:0 Number of interviews conducted with staff: 1 Observations by licensing inspector: 0 Additional Comments/Discussion: The evidence gathered during the investigation supported the allegation(s) of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaints 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 Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at Lanesha.allen@dss.virginia.gov
Violations
22VAC40-73-870-D
Based on the report received from the facility, the facility did not ensure the buildings shall be kept free of infestations of insects and vermin. The grounds shall be kept free of their breeding places.
Evidence
  1. A complaint was received by licensing inspector that the facility has bed bugs.
  2. Staff #1 confirms the presence of bed bugs presently at the facility.
  3. Staff #1 provided to licensing inspector reports received from Orkin. Orkin report shows treatment to the facility on the following dates: 7/1/24, 8/26/24, 9/5/24, 9/16/24, 10/7/24, 10/21/24, 11/4/24, 11/18/24.
Plan of correction
Maintenance Supervisor/Director of Housekeeping will continue to follow Orkin Pest Control instructions to complete daily inspections in various rooms and common areas. Orkin and Maintenance Supervisor/Director of Housekeeping will continue to alternate on a (7) day cycle to inspect and treat infected areas with preferred pesticide by Orkin until all evidence of bed bugs are exterminated. Date to be corrected: March 30th., 2025
May 29, 2024Inspection1 violation
Inspection dates
05/29/2024
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 PREPAREDNESS
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced monitoring inspection took place on 05/29/24 from 8:22 am to 4:05 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-report was received by VDSS Division of Licensing on 04/25/24 regarding allegations in the areas of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 31 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Medication carts and availability of medications. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegations area of non-compliance with standard(s) or law were: Resident Care and Related Services. A violation notice was issued; any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-680-D
Based on the record review the facility failed to ensure medications shall be administered in accordance with the physician’s or other prescriber’s instructions.
Evidence
  1. The record for resident #1 contains a physician order dated 03/22/24 and 04/03/24 that includes “Raloxifene 60 mg 1 tab daily every AM, and Vitamin D3 5000 IU plus Vitamin K2 100 mcg, take 1 capsule by mouth daily.” Resident’s #1 incident report documents that the resident was not administered Raloxifene and Vitamin D3 plus Vitamin K2 the dates of 03/22/24 through 04/24/2024. Resident’s #1 MAR record documents the medications (Raloxifene, and Vitamin D3 plus K2) was administered starting 04/25/24.
Plan of correction
Medication Aide will ensure that anytime a resident returns from a physician's appointment they will obtain the visit's paperwork and any written orders the physician prescribed for the resident. They will fax orders to the pharmacy then transcribe them onto M.A.R. RCC/Compliance Nurse will review physician's orders and M.A.R.'s weekly for documentation.
May 29, 2024Inspection2 violations
Inspection dates
05/29/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced renewal inspection took place on 05/29/2024 from 8:22 am to 4:05 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 31 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: A medication pass observation was completed for three residents. The following was reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, medication carts, fire inspection report, health inspection report, and a staffing schedule. Water temperature was measured, and the call bell system was monitored. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-250-D
Based on the record review it was determined that the facility failed to ensure each staff person on or within 7 days prior to the first day of work at the facility prior to coming in contact with residents shall submit the results of a risk assessment documenting the absence of tuberculosis (TB) in a communicable form as
Evidence
  1. d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. The risk assessment shall be no older than 30 days. Evidence:
  2. The record for staff #2, date of hire 06/16/23, does not contain documentation of a risk assessment for TB completed on or within 7 days prior to the first day of work. 2.The record for staff #2 contains a risk assessment for TB dated 03/03/23, which is more than 30 days prior to the staff’s hire date of 06/16/23.
Plan of correction
Compliance Nurse and Resident Care Coordinator will review all new hire nursing personnel's risk assessment form for T.B. screening to be sure it is completed on/or within 7-days prior to the first day of work.
22VAC40-90-40-B
Based on the staff 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 staff person.
Evidence
  1. The record for staff # 2, date of hire 06/16/23, does not contain a criminal history report completed for staff #2.
Plan of correction
Administrator/Administrator Assistant will review all new hired employees records to ensure the criminal history record is completed with correct information and filed in employee's file.
May 29, 2024Complaint survey0 violations
Inspection dates
05/29/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 05/29/24 from 8:22 am to 4:05 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 05/22/2024 regarding allegations in the area of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 31 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: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: The following was reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, medication carts, fire inspection report, health inspection report, and a staffing schedule. Water temperature was measured, and the call bell system was monitored. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at Donesia.peoples@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
August 10, 2023Complaint survey0 violations
Inspection dates
08/10/2023
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 08/10/23 from 8:50 am to 9:47 am. 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 08/07/2023 regarding allegations in the area(s) of: Building and Grounds Number of residents present at the facility at the beginning of the inspection: 30 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: An observation of building and grounds to include flooring, restrooms, and resident rooms. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 31, 2023Inspection4 violations
Inspection dates
05/31/2023
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced renewal inspection took place on 05/31/2023 from 8:30 am to 4:00 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 28 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: A medication pass observation was completed for three residents. The following was reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, medication carts, fire inspection report, health inspection report, and a staffing schedule. Water temperature was measured, and the call bell system was monitored. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-310-H
Based on the record review the facility failed to ensure in accordance with 63.2-1808 of the Code of Virginia, assisted living facilities shall not admit or retain individuals with any of the following conditions or care needs: psychotropic medications without appropriate diagnosis and treatment plans.
Evidence
  1. The record for resident #5 contains a physician order dated 05/08/23 to include “Quetiapine 25mg, take one tablet by mouth every day for schizophrenia; Lorazepam 0.5mg take one table by mouth three times daily as needed for anxiety.” The record does not contain documentation of a treatment plan for the psychotropic medications, Quetiapine and Lorazepam.
Plan of correction
RCC & Compliance, LPN will review all resident charts who are taking psychotropic medications quarterly to ensure their physician has reviewed chart and updated treatment plan
22VAC40-73-640-A
Based on observation the facility failed to implement a written plan for medication management to include methods to prevent the use of outdated medications.
Evidence
  1. During the medication cart observation with staff # 5 the following expired medications were observed on the medication cart: Cetirizine Hydrochloride 10mg expired 01/2023 for resident #7. 2.The resident’s Medication Administration Record documents the resident was administered Cetirizine Hydrochloride 10mg the dates of 05/25/23 through 05/31/23. Staff #5 confirmed the Cetirizine Hydrochloride administered to the resident was from the bottle labeled with an expiration date of 01/2023.
Plan of correction
Compliance Nurse, LPN orientated RCC and Medication Aides to comply with medication policy to review all medications upon new arrival and medication administration for expiration dates
22VAC40-73-490-A-2
Based on the record review the facility failed to ensure for residents who meet the criteria for assisted living, a licensed health care professional shall provide health care oversight at least every three months and all residents shall be included at least annually in healthcare oversight.
Evidence
  1. The record for resident #1, does not contain documentation of a health care oversight completed during the timeframe of 05/12/22- 05/31/23. The resident’s Uniform Assessment Instrument (UAI) dated 11/23/22 documents the resident meets the criteria for assisted living care.
  2. The record for resident #3, does not contain documentation of a health care oversight completed during the timeframe of 05/12/22- 05/31/23. The resident’s Uniform Assessment Instrument (UAI) dated 12/16/22 documents the resident meets the criteria for assisted living care.
  3. The facility’s health care oversight dated 06/15/22 and 01/09/23 did not include documentation the health care oversight included the record review for residents #1 and #3. 4.During an interview with staff #4, the staff confirmed the facility does not employ a licensed health care professional on a full-time basis and the dates of the most recent health care oversight completed are 06/15/22 and 01/09/23.
Plan of correction
Administrator contracted new oversite nurse to provide oversites quarterly to ensure all Residents charts are reviewed
22VAC40-73-380-B
Based on the record review the facility failed to ensure the personal and social information required in subsection A of this section (allergies, and information concerning Do Not Resuscitate (DNR) Orders shall be placed in the person's record and kept current.
Evidence
  1. Resident #1’s personal and social information documented “N/A” in the section for DNR status. The resident’s record contains a DNR order dated 05/27/21.
  2. Resident #4’s personal and social information documented the resident’s allergies as “none known.” The resident’s ISP dated 08/12/22 documents the resident is allergic to adhesive tape. The resident’s physical exam dated 08/10 22 documents the resident is allergic to tape.
Plan of correction
RCC & Compliance will review and ensure all Resident’s social data forms are updated with any changes to status codes, allergies, contact information and change of physician quarterly to ensure accuracy
March 20, 2023Complaint survey3 violations
Inspection dates
03/20/2023
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 GROUND22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 03/20/2023 at 8:17 am to 12:50 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 11/09/2022 regarding allegations in the areas of: Personnel, Resident Care and Related Services, 28 Number of residents present at the facility at the beginning of the inspection: 28 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 5 Observations by licensing inspector: Breakfast was observed, and a medication pass observation was completed for one resident. The following documents were reviewed: staffing schedule, resident council meeting minutes, and staff training records. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations area of non-compliance with standard(s) or law were issued.: 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-460-A
Based on the record review the facility did not assume responsibility for the health, safety, and well-being of resident #1.
Evidence
  1. The record for resident #1 contains a note dated 02/27/23 by the hospice nurse to include “patient’s condom catheter was applied tightly causing an unstageable pressure ulcer.”
  2. A physician order dated 02/27/23 documents “wound care-penile- cleanse with wound cleaner, pat dry, apply calmoseptine daily and as needed.” 3 Staff #1 confirmed during an interview with this inspector on 03/20/2023 that staff #3, a certified nurse assistant, applied the condom catheter tightly, which resulted in the resident’s need for penile wound care.
Plan of correction
Administrator reiterated verbally and in writing the importance of following physician’s orders and practicing within the scope of practice and training with all direct care staff to ensure the safety and wellbeing of all residents.
22VAC40-73-680-E
Based on the record review the facility failed to ensure medical procedures or treatments ordered by a physician or other prescriber shall be provided according to his instructions and documented. The documentation shall be maintained in the resident’s record.
Evidence
  1. The record for resident #1 contains a physician order dated 01/11/2023 which includes instructions to reposition the resident in bed every 2-3 hours. The resident’s record and medication administration record (MAR) for January, February, and March 2023 did not include documentation the resident is repositioned in bed every 2- 3 hours.
  2. The record for resident #1 contains a physician order dated 01/24/2023 to include the following instructions: “apply skin prep to reddened area of sacrum area daily with AM care” and “apply barrier ointment to reddened area of sacrum twice a day in the afternoon and bedtime.” The resident’s record and MAR did not include documentation skin prep was applied to the reddened area of the sacrum on the following dates: 02/18/23; 02/19/23; 02/24/23. The resident’s record and MAR did not include documentation barrier ointment was applied to the reddened area of sacrum twice a day in the afternoon and bedtime on the following dates and times: 02/01/23-02/03/23 at 8pm; 02/06/23-02/09/23 at 8pm; 02/11/23-02/12-23 at 8pm; 02/18/23-02/19/23 at 12pm; 02/23/23-02/24/23 at 12pm.
  3. The record for resident #1 contains a physician order dated 02/27/23 that include instructions to “change resident every 2 hours to ensure he is dry.” The resident’s record and MAR did not include documentation the resident is changed every 2 hours.
Plan of correction
Resident Care Coordinator will monitor to ensure that the medication aides are following written physician’s orders as instructed and documenting at time treatment is completed. A scheduled turn and check for incontinence chart will be kept in Resident’s room and initialed by the direct care staff at time of scheduled turn/repositioning and continence check then file in Resident’s chart monthly as completed.
22VAC40-73-200-B
Based on the record review the facility failed to ensure direct care staff who are responsible for caring for residents with special health care needs shall only provide services within the scope of their practice and training.
Evidence
  1. Staff #1 acknowledged that on 02/27/23, staff #3 a certified nurse’s aide, removed and placed the condom catheter for resident #1.
  2. Placement and removal of a condom catheter is outside the scope of practice for a certified nurse assistant.
Plan of correction
Administrator verbally instructed direct care staff to follow orders and to practice only within the scope of their practice and training and follow physician’s orders to ensure the safety and wellbeing of all residents.
November 16, 2022Complaint survey2 violations
Inspection dates
11/16/2022
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 11/16/22 at 8:35 am to 12:55 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 11/09/2022 regarding allegations in the areas of: Admission, Retention, and Discharge of Residents and Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 33 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: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: The following additional items were reviewed, staffing schedule, emergency preparedness drills, and practice plan for resident emergencies. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations area of non-compliance with standard(s) or law were: Resident Care and Related Services. A violation notice was issued; any violation(s) not related to the complaint) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-470-F
Based on the onsite record review the facility failed to ensure when a resident suffers serious accident, injury, illness or medical condition, or there is reason to suspect that such has occurred, the circumstances involved and the medical attention received or refused shall be documented in the resident’s record. The resident’s next of kin, legal representative, and designated contact person shall be notified as soon as possible but no later than 24 hours from the situation and action taken, or if applicable, the resident’s refusal of medical attention.
Evidence
  1. The record of Resident #1 contains a progress note dated 10/06/2022 which documents “the resident has been in bed all morning, refused breakfast and lunch for three days, vital signs were BP 76/50, Pulse 57, and temperature 97.1, and the Resident Care Coordinator contacted the doctor.” There is no documentation in the record that includes the medical attention received or refused.
  2. Staff # 1 acknowledged the resident refused to go to the ER on 10/06/22 however the refusal was not documented in the resident’s record.
  3. Staff #1 acknowledged the staff on duty did not notify the resident’s legal representative and designated contact person within 24 hours of the resident’s refusal of medical attention.
Plan of correction
Administrator met with Medication Aides reviewed company policy to always notify Responsible Party, POA, and Designated Person regarding any change of status at time physician is notified and to always document in Resident’s chart the event that occurred, if vitals not within normal range to always call 911 for professional assistance and document the outcome. On 11/30/2022 Administrator reviewed the Resident’s change of status policy and procedure with all of the nursing team. They are always call the RCC for instructions. The RCC will monitor the direct care staff to ensure they are following said instructions.
22VAC40-73-325-B
Based on the record review the facility failed to ensure the Fall Risk Rating (FRR) shall be reviewed and updated when the condition of the resident changes, and after a fall.
Evidence
  1. The record for Resident #1 contains a FRR dated 01/09/20. The record did not include documentation of a FRR annually for 2021, 2022, and when the condition of the resident changed to hospice treatment on 10/13/22.
Plan of correction
RCC/Administrator will ensure that the Fall Risk Rating is updated with any fall when Hospice Care need is determined and annually.
May 12, 2022Inspection5 violations
Inspection dates
05/12/2022, 05/16/2022
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS
Violations
22VAC40-73-680-I
Based on documentation review, the facility failed to include all required documentation on the Medication Administration Record (MAR).
Evidence
  1. Resident #1 has a physician’s order for Novolog Flex 100u/ml to be administered on a sliding scale. The March 2022 MAR spaces for 3/7, 3/11, 3/19, 3/20, and 3/26 were blank and there was no information documented on the back on the MAR.
  2. Resident #1 has a physician’s order to monitor blood sugar four times a day before meals and at bedtime to check blood sugar for diabetes. The March 2022 MAR spaces for 3/7 and 3/12 were blank and there was no information documented on the back on the MAR.
Plan of correction
Administrator met with all Medication Aids to consult them on the policy and procedure for drawing blood sugars and administrating sliding scale insulin and recording at time the procedure is done. Resident Care Coordinator will review M.A.R.s weekly to ensure all sliding scale medications are being signed off at time of administration and blood sugar results are recorded as per written physician’s orders. Administrator will audit M.A.R.s throughout month for accuracy.
22VAC40-73-490-A
Based on record review and staff interview, the facility failed to ensure that health care oversight was provided at least every six months.
Evidence
  1. Staff#1 acknowledged the facility’s last documentation of health care oversight was dated 3/15/21.
Plan of correction
Administrator contracted a new Health Care Oversite Nurse. Resident Care Coordinator/Administrator will mark calendar to schedule the Health Care Oversite to ensure it is completed every six months.
22VAC40-73-940-A
Based on a review of the facility documentation the facility failed to ensure that an annual fire inspection was conducted by the appropriate fire official.
Evidence
  1. Staff #1 acknowledged the last documented fire inspection for the facility was 4/8/21.
Plan of correction
Administrator notified Fire Marshall to remind him that the annual inspection was past due. Maintenance Supervisor/Administrator will continue to mark the calendar to notify Fire Marshall one month in advance then call weekly until he arrives to ensure the Fire Marshall completes annual inspection within the annual timeline.
22VAC40-73-620-A
Based on documentation review and interview, the facility failed to ensure dietary oversight was conducted every six months for special diets by a dietitian or nutritionist.
Evidence
  1. The last oversight review for special diets was dated 8/8/21.
Plan of correction
Administrator contracted a new Registered Dietitian Nutritionist to conduct dietary oversite. Resident Care Coordinator/Administrator will date calendar to call a month in advance to ensure dietary oversites are conducted at least every six months.
22VAC40-73-610-B
Based on observations made on the posted menu, the facility failed to have any menu substitutions recorded on the posted menu.
Evidence
  1. The breakfast menu posted for 5/12/22 was scrambled eggs, biscuits, cold or hot cereal, fruit, juice, and milk. Licensing Inspectors observed the residents eating pancakes as a substitution for biscuits. The substitution was not noted on the menu.
  2. The dinner menu posted on 5/16/22 was peppered pork loin, rice, and broccoli. Licensing Inspectors observed the residents eating fried chicken and sweet potatoes as substitutions for peppered pork loin and rice. The substitutions were not noted on the menu.
Plan of correction
Dietary Manager will ensure all menu changes will be posted on the menu to match the changes made to the menu board in the dining-room. Dietary Manager responsible for reviewing all menu changes then report changes to the Administrator. Administrator will conduct Radom audits weekly to ensure proper posting of all menu changes.
May 11, 2021Inspection3 violations
Inspection dates
May 11, 2021 and May 12, 2021
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-90 The Criminal History Record Report
Comments
This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on May 11, 2021 and concluded on May 12, 2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 26. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 3 resident records, 3 staff records, activities calendar, staff schedules, menu, fire and emergency drills, criminal record checks submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliances with applicable standards or law, and violations were documented on the violation notice issued to the facility.
Violations
22VAC40-73-290-A
Based on record review and discussion, the facility failed to maintain a written work schedule that included the names and job classifications of all staff working each shift.
Evidence
  1. The April 2021 "Med Tech [Medication Technician]" and "Direct Care" staff schedules did not identify which staff were working each shift.
  2. Staff #1 confirmed during discussion that the times of each shift were not specified on the schedules.
Plan of correction
RCC will ensure that the staff schedules will be colored coded with shift hours to reflect which staff will be working each shift.
22VAC40-73-680-I
Based on record review and discussion, the facility failed to ensure the Medication Administration Record (MAR) included the diagnosis, condition, or specific indications for administering the drug.
Evidence
  1. Resident #2’s March 2021 MAR was missing the diagnosis, condition, or specific indications for administering the drug for the following medications: Cyanocobalamin 1000mg, Namenda XR 28 mg, and Neurontin 100 mg.
  2. Staff #1 confirmed Resident #2's March 2021 MAR was missing the diagnoses, conditions, or specific indications for administering the drug for the three medications.
Plan of correction
RCC will review MAR's weekly to ensure each MAR has the appropriate documentation to include the indications.
22VAC40-90-40-C
Based on record review and discussion, the facility failed to ensure any person required by this chapter to obtain a criminal history record report shall be ineligible for employment if the report contains convictions of the barrier crimes.
Evidence
  1. Staff #4’s dates of employment were 03-16-2021 to 04-21-2021 as housekeeping staff. Staff #4’s criminal history record report dated 03-16-2021 contained a barrier crime that made staff ineligible for employment.
  2. Staff #1 confirmed dates of employment and that Staff #4 was employed despite ineligibility due to barrier crime conviction.
Plan of correction
Administrator will continue to terminate any employee who has a barrier crime record upon receipt of the criminal background check.
February 4, 2021Complaint survey1 violation
Inspection dates
Feb. 4, 2021 and Feb. 12, 2021
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A complaint inspection was initiated on February 4, 2021 and concluded on February 12, 2021. A complaint was received by the department regarding allegations in the areas of release of information. The Director of Nursing was contacted by telephone to conduct the investigation. The licensing inspector emailed the Administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the allegation of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.
Violations
22VAC40-73-570-C
Based on record review and discussion, the facility released information regarding the resident’s personal affairs written permission of the resident or his legal representative.
Evidence
  1. An email dated 12-21-2020 documented Resident #1’s “base rent” information and was sent to an individual.
  2. Resident #1’s “Release of Information” dated 11-11-2020 not specify any individual was given authorization to access resident’s information.
  3. Staff #1 confirmed that a release of Resident #1’s information to the specific individual receiving the information was not completed by a resident or his legal representative, and the information was sent in error.
Plan of correction
Administrator will ensure all emails with attachments will be double checked for accurate recipient information before sending to reduce risk of releasing personal information to unintended recipient.