Friendship Assisted Living, Inc. — Virginia Inspection Report

Inspections

On record

With violations

Visits that cited something

Clean visits

Nothing cited

Violations cited

Individual findings

Standards cited

Distinct rules

Complaint visits

Prompted by a complaint

Friendship Assisted Living, Inc. was inspected 6 times between June 14, 2021 and April 9, 2026 by the Virginia Department of Social Services. 5 of those visits ended with violations cited and 1 with none. Across that history VDSS cited 18 violations under 14 distinct standards.

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. 5 of these 6 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

05/31/2028

Administrator

Alex Parker

Licensing inspector

Holly Copeland

Inspector phone

(540) 309-5982

Approved for

Assisted Living · Non-Ambulatory

Inspection History

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

April 9, 2026Inspection2 violations

Inspection dates

04/09/2026

Areas reviewed

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: 04/09/2026 from 07:45 AM to 03:00 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: 83 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 9 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of these inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem-solving conference. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov

Violations

22VAC40-73-450-C

Based on record review and staff interview, the facility failed to ensure that the comprehensive individualized service plan (ISP) shall include a description of identified needs and date identified based on various sources, including the uniform assessment instrument (UAI).

Evidence

On the date of inspection, the record for resident 5 contained a UAI that had been most recently updated on 10/17/2025 and an ISP with a most recent update on 01/05/2026.
The UAI for resident 5 indicated that the resident is oriented to all cognitive spheres, with an identified date of 10/11/2025. Alternately, the ISP for resident 5 indicated that the resident is disoriented to some spheres (time) some of the time, with an identified date of 10/11/2025.
An interview with staff 4 on the date of inspection revealed that resident 5 is oriented to all cognitive spheres; therefore, the UAI for resident 5 is correct and the ISP was incorrect, as it did not accurately reflect the resident’s identified needs as indicated on the UAI.

Plan of correction

Resident #5’s ISP was immediately reviewed and corrected on 4/10/25 to accurately reflect the cognitive status documented in the UAI. A 100% audit of all resident records was conducted to ensure ISPs are consistent with the most current UAI, and any discrepancies were corrected. Staff responsible for completing ISPs were re-educated on ensuring care plans accurately reflect assessed needs, and a second-level review process has been implemented prior to finalization.

22VAC40-73-720-A

Based on record review and staff interview, the facility failed to ensure that the Do Not Resuscitate Order (DNR) in a resident’s record was a valid written order that was issued by the resident’s attending physician.

Evidence

On the date of inspection, the record for resident 6 contained a DURABLE DO NOT RESUSCITATE ORDER form, dated 04/04/2019, that had been signed by all parties but had not been completed.
An interview with staff 4 on the date of inspection was unsuccessful in locating a complete DNR form for resident 6.

Plan of correction

Resident #6’s record was corrected by obtaining a valid, fully completed physician-signed DNR order on 4/15/26. A 100% audit of all resident records was conducted to ensure all DNR forms are complete and properly signed by a physician. Staff were re-educated on requirements for valid DNR documentation, and a checklist has been implemented to ensure forms are reviewed for completeness upon admission and during routine record reviews.

March 20, 2025Inspection1 violation

Inspection dates

03/20/2025

Areas reviewed

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: 03/20/2025 from 08:30 AM to 03:00 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 Holly Copeland, Licensing Inspector at (540) 309-5982 or by email at holly.copeland@dss.virginia.gov

Violations

22VAC40-73-640-A

Based on observation, staff interview, and record review, the facility failed to implement a portion of its medication management plan regarding its methods to prevent the use of outdated, damaged, or contaminated medications.

Evidence

On page 6, section F of the facility’s most current medication management policy and procedures, last updated 03/07/2025, point #1 indicates that all bulk and non-packaged medication must be dated when placed on the cart by the medication person who opens the medication, which includes insulins, drops, patches, creams, treatments, and bottled medication. Point #4 of section F indicates that when a medication person opens a multidose parenteral vial that has been labeled by the pharmacy provider, the medication person will date the vial and designate an expiration date.
On the date of the renewal inspection at approximately 09:00 AM, LI performed a medication cart audit for the 2nd floor of the facility. While reviewing the 2nd floor A-cart, LI observed in the top drawer of that cart a HUMALOG 100 UNITS/ML KWIK pen (insulin) belonging to resident 3 in a clear plastic bag with pharmacy label attached. The bag indicated to refrigerate until the pen is opened, and the pen inside of the bag contained a blank expiration date sticker.
An interview with staff 2, who was assigned to that medication cart at that time was unsuccessful at determining exactly when the pen was opened nor why it had not been labeled with an expiration date.
At 09:27 AM, LI performed a medication cart audit for the 4th floor of the facility. While reviewing the 4th floor A-cart, LI observed in the top drawer of that cart a TRESIBA FlexTouch 100 units/mL insulin pen belonging to resident 10 in a clear plastic bag with pharmacy label attached. The bag indicated to refrigerate until the pen is opened, and the pen inside of the bag contained a blank expiration date sticker.
An interview with staff 1, who was assigned to that medication cart at that time was unsuccessful at determining exactly when the pen was opened nor why it had not been labeled with an expiration date.
At 09:43 AM, LI performed a medication cart audit for the 5th floor of the facility. While reviewing the 5th floor A-cart, LI observed in the top drawer of that cart an Insulin Lispro Injection KwikPen U-100 pen belonging to resident 11 in a clear plastic bag with pharmacy label attached. The pen inside of the bag contained a blank expiration date sticker.
An interview with staff 4, who was assigned to that medication cart at that time was unsuccessful at determining exactly when the pen was opened nor why it had not been labeled with an expiration date.

Plan of correction

This Plan of Correction is our written allegation of compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by state law. Director of Nursing, upon notice on 3/20/25 of the unlabeled pens, discarded of them and performed an additional cart audit with no other findings. Director of Nursing will conduct a staff meeting with all medication administration staff to review the updated policy and revisions that were made to medication management policy on 3/7/25 to ensure their understanding of the guidelines to properly date bulk and non-packaged medication when it is opened. Further, the medication management policy, specifically relating to properly date bulk and non-packaged medication when it is opened, will be reviewed monthly at the monthly pharmacy meeting until the committee is satisfied procedures are being properly followed.

April 30, 2024Inspection1 violation

Inspection dates

04/30/2024

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: 04/30/2024 from 09:00 AM until 03:15 PM 05/01/2024 from 08:15 AM until 12:00 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov

Violations

22VAC40-73-680-B

Based on record review and staff interview, the facility failed to ensure that medications shall remain in the pharmacy issued container, with the prescription label attached, until administered to the resident.

Evidence

While performing an audit of the 4th floor medication cart on 05/01/2024, LI observed a round pink pill laying on the bottom of the 3rd drawer, at the back of the left row.
The loose pill was also observed by staff 2 and was matched to the VITAMIN B-12 medication card belonging to resident 10.
While performing an audit of the 3rd floor medication cart on 05/01/2024, LI observed two round white pills which were stamped with 54|27 laying on the bottom of the 3rd drawer at the back of the middle row.
The loose pills were also observed by staff 3 and were matched to the ACETAMINOPHEN 500 MG medication card for resident 11.

Plan of correction

1. Perform chart checks daily to determine if there are any cards with loose pills and send back to Pharmacy for repackaging. 2. Educate all RMA’s and Nurses that administer medication to: check the cards when being used to ensure sufficient packaging, and how to send back for repackaging. 3. Track and report all instances to Pharmacy. 4. Check all medication cards when they arrive.

April 27, 2023Inspection6 violations

Inspection dates

04/27/2023

Areas reviewed

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: 04/27/2023 from 09:00 AM until 02:00 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov

Violations

22VAC40-73-200-B

Based on resident record review, the facility failed to ensure that direct care staff who are responsible for caring for residents with special health care needs only provide services within the scope of their practice and training.

Evidence

The record for resident 10 contains a physician’s order, dated 01/15/2023, for the following: “Cleanse lesion to right side of face (post skin cancer removal) with soap and water, pat dry, apply Vaseline ointment using a q-tip and cover with non-stick dressing or band-aid Change dressing one time daily *start on 1/21/23 48 hours post skin cancer removal* every day shift for treatment of lesion s/p skin cancer removal until healed”.
Interview with staff person 7 revealed that the resident’s incision area regarding the skin cancer removal contained sutures.
The January 2023, February 2023, March 2023, and April 2023 medication administration records (MARs) for resident 10 contain initials of registered medication aides (RMAs) numerous days each month as providing the aforementioned treatment to the resident’s wound; however, providing wound treatment is out of an RMA’s scope of practice.

Plan of correction

Educate all RMA’s/LPN’s on their scope of practice. Enhabit Home Health and Hospice will provide updated Wound/Lesion Care In-Service to all Licensed staff. Will update all Wound/Lesion treatments to assign: LPN will do. DON and ADON will complete random audits of all new treatment orders and ensure assignment of treatments.

22VAC40-73-860-I

Based on observation during a tour of the physical plant, the facility failed to ensure that hazardous materials were stored in a locked area.

Evidence

At approximately 10:07AM during the on-site inspection, collateral 1 observed a small round dark red pill on the floor in the hallway outside of room 402. The pill was also observed by staff 4.

Plan of correction

In-Service for all LPN’s and RMA”s to ensure all medications are taken by each resident as appropriate.

22VAC40-73-680-D

Based on observation of a medication pass, observation during an audit of a medication cart, and resident record review, the facility failed to ensure that a medication was administered in accordance with the physician’s or other prescriber’s instructions.

Evidence

The record for resident 10 contains a physician’s order, dated 03/07/2023, to decrease Lasix (Furosemide) to 10 MG once a day “half 20MG to Equal 10MG”.
The March 2023 medication administration record (MAR) (starting 03/08/2023) and the April 2023 MAR for the resident includes Lasix Tablet 20 MG (Furosemide) give 0.5 tablet by mouth in the morning for edema - take half of 20 MG to equal 10 MG. The description of Lasix (Furosemide) 20 MG tablet that is located on the packaging for resident 10’s medications stated that Furosemide 20MG is a “tablet round, white txt: ep:116” and the tablet located in the packaging was whole. This was also noted by staff persons 2 and 6 and collaterals 1 and 2 during the medication cart audit that contains resident 10’s medications.
Collateral 1 noted during observation of resident 10’s morning medication pass during on-site inspection on 04/27/2023 that staff 9 did not cut the Lasix (Furosemide) 20MG tablet in half therefore the resident received a whole Lasix (Furosemide) 20MG tablet.

Plan of correction

Pharmacist will start auditing and compare medication orders to PCC and compare to bubble pack bingo card packaging prior to delivery. Will provide education to all licensed staff (LPN’s and RMA’s) to ensure proper medication administration. Will provide in-service to all staff on Medication Management Policy.

22VAC40-73-870-E

Based on observations of the facility’s physical plant, the facility failed to ensure that all furnishings, fixtures, and equipment, including furniture, window coverings, sinks, toilets, bathtubs, and showers, shall be kept clean and in good repair and condition.

Evidence

The mini blinds on the window in room 312 were noted to have several panels that were broken off and lying on the windowsill.

Plan of correction

Place work order for Maintenance to replace all missing blinds on 4/27/23.

22VAC40-73-640-A

Based on observation, staff interview, and policy review, the facility failed to implement a part of its medication management plan regarding methods to prevent the use of outdated, damaged, or contaminated medications.

Evidence

The facility’s medication management plan, updated 08/26/2022, states that routine medication pass observations and medication cart audits will be conducted by an individual working within their scope of practice, to include all medication administration staff, to ensure conformance of the medication management plan. The plan further states that medication cart audits include observation for any expired, damaged, contaminated, or discontinued medications.
On the date of inspection, LI completed an audit of the 2nd floor medication cart-A. At that time, LI observed a Novolog Flex Pen prefilled syringe that appeared to have been opened as the plunger was down near the bottom of the pen; however, there was no open date on the unit to ensure that the Novolog Flex Pen prefilled syringe will be discarded 28 days after opening per manufacturer’s instructions.
Upon interviewing staff 6 during the cart audit, staff 6 stated that she could determine that the Novolog Flex Pen prefilled syringe had been opened/used based on its appearance, but she could not be certain when it was opened because there was no open date indicated; therefore, she was not able to determine when to discard the pen.

Plan of correction

Discarded Novolog Flex Pen on this date 4/27/23. DON and ADON will provide education to add Open Date and Expiration Date on all insulin pens. DON and ADON will do random audits to check for Open Date and Expiration Date on all open pens.

22VAC40-73-450-C

Based on resident record review, the facility failed to ensure that all identified needs were addressed on individualized service plans (ISPs).

Evidence

The uniform assessment instrument (UAI) for resident 8, dated 10/14/2022, indicates that the resident requires physical assistance with walking and wheeling.
An interview with staff 7 confirmed that this is correct; however, the ISP for resident 8, dated 10/14/2022, does not address these identified needs.

Plan of correction

Sonja Johnson, ADON updated/corrected ISP on 4/27/23. Kim Novak, LPN will continue to provide Healthcare Oversight and will complete random audits. Ashley Davis, LPN will continue ISP random audits.

April 19, 2022Inspection8 violations

Inspection dates

04/19/2022

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 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 4/19/2022 two inspectors conducted an annual monitoring visit (8:45 am to 4:27 pm). 84 residents were in care. Ten resident files, five staff files, and other documents were reviewed. A medication pass was observed, activities were observed, and a physical plant tour was done. An informal exit interview was held onsite the day of the inspection, and the facility was given an opportunity to provide additional documentation, if needed. A telephone exit interview was held on 4/22/2022.

Violations

22VAC40-73-860-I

Based on observation, the facility failed to have cleaning supplies stored in a locked area.

Evidence

The laundry was unlocked an unattended on a floor residents were using. The following cleaning products were stored in the laundry room: Comet, Shout, bleach, Downey Fabric Softener, and several brands of laundry detergent.

Plan of correction

The laundry will be locked at any time a staff member is not in attendance. A locked cabinet will also be added to the laundry room for all chemicals to be stored in. The Director of Housekeeping will be responsible for assuring that chemicals are no longer unsecured in the laundry.

22VAC40-73-680-D

Based on observation and resident record review, the facility failed to ensure that a medication was administered in accordance with the physician's order.

Evidence

Resident 12 has an order signed on 4/12/2022 for Vitamin D3 1.25 mg (50000 UT) (Cholecalciferol) to be given one time a day every Tuesday. This is not in the medication cart - resident 12 is being administered Vitamin D2 (Ergocalciferol) instead.

Plan of correction

The pharmacy was contacted upon discovery of error and was corrected on day of inspection; Going forward the pharmacy staff will double check all orders when filling medications prior to delivery; the staff member in charge during the shift medications are received will review each medication for accuracy prior to being stored on the medication cart.

22VAC40-73-325-B

Based on resident record review and staff interview, the facility failed to ensure that the fall risk rating was reviewed and updated annually for each resident who meets the criteria for assisted living care.

Evidence

The uniform assessment instrument (UAI) for resident 3, dated 11/20/2021, identified the resident as assisted living level of care. The record for resident 3 contained documentation that the last fall risk rating for the resident was conducted on 11/21/2020. Interview with staff 6 confirmed that this was the most recent fall risk rating for the resident.

Plan of correction

Education and reminders will be provided to staff members who are responsible for completing fall risk ratings; the Director of Nursing or designee will complete monthly audits to ensure all fall risk ratings are completed as required .

22VAC40-73-550-G

Based on staff record review, the facility failed to ensure that a staff person had annual training in resident rights and responsibilities.

Evidence

The record for staff 4 has no documentation to support that annual training in residents rights and responsibilities was done during the training year of 2/3/2021 through 2/2/2022.

Plan of correction

Staff member 4’s last day of employment is 4/28/2022. Going forward the Director of Nursing or designee will complete routine audits to ensure education/training requirements are met up to date. Staff members that are not current with education will be removed from the schedule until education requirements are met. Further disciplinary action will be taken for staff who continue to not meet education requirements.

22VAC40-73-270-4

Based on staff record review, the facility failed to ensure that a staff person had annual refresher training in methods of dealing with agitated or aggressive residents.

Evidence

The record for staff 4 shows that there was no refresher training in methods of dealing with agitated or aggressive residents in the training year 2/3/2021 to 2/2/2022. Residents 2 and 5 have documentation in their charts showing they have agitated or aggressive behavior at times.

Plan of correction

22VAC40-73-210-B

Based on review of staff records, the facility failed to ensure that a direct care staff person had at least 18 hours of training annually.

Evidence

Staff 4 has documentation to support that 3.75 hours of training were obtained in the time period from 2/3/2021 through 2/2/2022.

Plan of correction

22VAC40-73-440-A

Based on resident record review and staff interview, the facility failed to complete the uniform assessment instrument (UAI) as required.

Evidence

The UAI for resident 6, dated 08/22/2021, indicated that the resident is assisted living level of care; however, interview with staff determined that the resident is residential living level of care.

Plan of correction

Education to staff members responsible for completing the UAI and refresher course on UAI training will be completed within 30 days; Administrator or designee will review UAI’s for accuracy upon completion.

22VAC40-73-680-M

Based on observation and resident record review, the facility failed to have a PRN medication available for a resident.

Evidence

Resident 11 has an order signed 12/20/2021 for Tums, two tablets as needed for GI complaint. This medication is on the medication administration record (MAR), and the medication cart did not have them for this resident.

Plan of correction

Director of Nursing or designee will complete routine cart audits with comparison to MAR to ensure PRN (as needed) medications are available on the medication cart to be administered as ordered.

June 14, 2021Inspection0 violations

Inspection dates

June 14, 2021 and June 17, 2021

Areas reviewed

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 6/14/2021 and concluded on 6/17/2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 78. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed four (4) resident records, four (4) staff records, staff schedules, fire drill records, background check review on new staff, health care oversight report, fire inspection report, health department report, infection control policy and medication management plan submitted by the facility to ensure documentation was complete. The information gathered during the inspection determined no violations with applicable standards or law. No violations were issued.

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.