Virginia DSS · Assisted Living Facility

Shenandoah Valley Westminster-Canterbury

📍 300 Westminster Canterbury Drive, Winchester, VA, 22603

ID 8912Two Year licenseActive
9
Inspections
On record
3
With violations
Visits that cited something
6
Clean visits
Nothing cited
15
Violations cited
Individual findings
14
Standards cited
Distinct rules
2
Complaint visits
Prompted by a complaint

Shenandoah Valley Westminster-Canterbury was inspected 9 times between December 8, 2020 and November 20, 2025 by the Virginia Department of Social Services. 3 of those visits ended with violations cited and 6 with none. Across that history VDSS cited 15 violations under 14 distinct standards. 2 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. 8 of these 9 are still on the state's site; the other 1 has since dropped off it and is reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type
Assisted Living Facility
License type
Two Year
License expires
01/01/2027
Administrator
Andrew Heishman
Licensing inspector
Margaret Woods-Kane
Inspector phone
(804) 724-9618
Approved for
Assisted Living · Non-Ambulatory · Special Care Unit

Inspection History

9

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

November 20, 2025Inspection0 violations
Inspection dates
11/20/2025
Areas reviewed
Resident Care and Related Services
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: 11/20/2025 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 10/30/2024 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: 52 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: NA Number of interviews conducted with staff: 1 Observations by licensing inspector: NA Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the 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 Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
September 18, 2025Inspection3 violations
Inspection dates
09/18/2025
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 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS for FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY63.2- (1) General Provisions
Comments
Type of inspection: Monitoring A self-reported incident was received by VDSS Division of Licensing on 9/10/2025 regarding allegations in the area(s) of: Resident care and related services Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 9/18/2025 from 10:15 a.m. until 1:30 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 11 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: 5 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: Licensing inspector reviewed resident record, roam alert wanderer monitoring system policy, missing resident policy, 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 the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-reported incident 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 Angela Via, Licensing Inspector at (540) 682-1739 or by email at Angela.Via@dss.virginia.gov
Violations
22VAC40-73-460-A
Based on resident record review and staff interviews, the facility failed to assume general responsibility for the health, safety, and well-being of the resident.
Evidence
  1. The regional licensing office received a self-reported incident on 09/10/2025 indicating that on 09/9/2025 resident 1 did not return with the group to Blue Ridge Hall (memory support) following an activity off of the unit in Lawrence Hall. The self-report indicated that resident 1 was unaccounted for from 11:49 a.m. until 12:08 p.m.
  2. Staff 6 and 7 showed licensing inspector (LI) Lawrence Hall, where the activity was held, and the location of where resident 1 was found, which was outside of their former apartment on Winchester Hall in independent living, at 12:08 p.m. Resident 1 had walked down two hallways and took the elevator or the stairs to get from Lawrence Hall to Winchester Hall.
  3. Staff 4 confirmed that on 09/09/2025, resident 1 was found by security cameras outside of her former apartment, and staff 4 accompanied resident 1 back to memory support.
  4. During an interview, LI asked staff 4 if certain residents were assigned to certain staff members when off of the memory support hall. Staff 4 stated, “There is usually a group, and one staff member leads and one is behind, and the 2 to 3 staff, depending, help watch everyone.”
Plan of correction
1. It is duly noted that Resident #1 did not return with their group to the memory support neighborhood following an off-neighborhood activity. Resident #1 suffered no adverse effects due to the incident and did not leave the community’s main building. 2. The community will provide the appropriate number of staff to assist with off-neighborhood activities to ensure resident’s health, safety, and well-being. 3. Community staff were re-educated to include appropriate numbers of staff to assist with off-neighborhood activities to ensure residents’ health, safety, and well-being. 4. The community will review resident incidents at the monthly QAPI meetings.
22VAC40-73-390-A
Based on record review and staff interview, the facility failed to ensure at or prior to the time of admission, there was a written agreement or acknowledgment of notification, dated and signed by the resident or applicant'for admission or the appropriate legal representative and by the licensee or'administrator.
Evidence
  1. '
  2. Resident 1 admitted 7/22/2025 did not have a resident agreement in the resident record.
  3. Upon request, the facility did not provide a resident agreement for admission to Blue Ridge Hall (memory support) for resident 1.
  4. During an interview with staff 6, when asked if there was a resident agreement for resident 1’s admission to memory support, staff 6 stated, “I would say no; we have an admission agreement for when they moved into independent living”.'
  5. During an interview with staff 4, when asked if there was a resident agreement for resident 1’s admission to memory support, staff 4 stated, “No, not an admission agreement with the information you described”.
Plan of correction
1. All residents of the community sign a comprehensive admission agreement covering all levels of care. The community will audit the Assisted Living move-in checklist that is completed during an admission to Assisted Living to include the memory support neighborhood. 2. The community will complete the new Assisted Living move-in checklist for residents residing on the memory support neighborhood. 3. Community staff were educated to complete the new Assisted Living move-in checklist when a resident admits to the memory support neighborhood. 4. The community will complete admissions records of newly admitted residents to the memory support neighborhood to ensure the resident’s admission records includes completion of the new checklist. Results will be reviewed at monthly QAPI meetings.
22VAC40-73-560-A
Based on resident record review and staff interview, the facility failed to ensure procedures for documentation and recordkeeping to ensure that the information in resident record was accurate and clear and that the records were well-organized.
Evidence
  1. Resident 1’s record did not contain documentation of the elopement on 09/09/2025 or notification to the family of the elopement.
  2. During an interview with staff 6, when asked if there was documentation of resident 1’s elopement or speaking with the family following the incident, staff 6 stated, “No documentation and no wander assessment after incident”.
Plan of correction
1. The elopement and notification to the POA was documented on 9/18/2026. 2. The community reviewed all elopement incidents in the prior 6 months to ensure that the elopement and notification to the POA were documented. 3. Community staff were re-educated on notifying POAs of incidents as they occur and including notification in the incident documentation within the resident’s medical records. 4. The community will review resident incidents at the monthly QAPI meetings.
November 20, 2024Inspection2 violations
Inspection dates
11/20/2024
Areas reviewed
Administration and Administrative ServicesPersonnelStaffing and SupervisionAdmission, Retention and Discharge of ResidentsResident Care and Related ServicesResident Accommodations and Related ProvisionsBuilding and GroundsEmergency PreparednessAdditional Requirements for Facilities that Care for Adults with Cognitive ImpairmentsBackground Checks for Assisted Living FacilitiesSworn Statement
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: November 20-21, 2024 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: 52 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: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: LI observed residents participating in activity programs and eating meals. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov
Violations
22VAC40-73-450-C
Based on resident records review, the facility failed to develop and Individualized Service Plan (ISP) that identified needs of the resident.
Evidence
  1. Resident 2 had order for Occupational Therapy dated 9/4/2024 and the Individualized Service Plan (ISP) developed on 6/8/2024 did not include his need for these services.
  2. Resident 4 had a SV Morse Fall Scale assessment completed on 9/4/2023 that indicated a score of 85, which according to the assessment scale is a high risk for falls. The ISP developed on 5/6/2024 did not identify Resident 4 as a high risk for falls.
  3. Resident 4 had a physician’s order dated 9/6/2024 for minced and moist meats. Resident 4’s ISP developed on 5/6/2024 did not identify his need for the ordered diet.
  4. Resident 4 wears a wander management device and the ISP developed on 5/6/2024 did not identify his need to wear such device.
  5. Resident 6 had a SV Morse Fall Scale assessment completed on 9/25/2024 that indicated a score of 80, which according to the assessment scale which is a high risk for falls. The ISP developed on 3/25/2024 did not identify Resident 6 as a high risk for falls.
Plan of correction
The noted deficient practice was corrected on 11/21/2024. Resident 2’s ISP was revised to include the resident’s Occupational Therapy needs. Resident 4’s ISP was revised to include the resident’s high risk for falls, the resident’s need for an ordered diet for minced and moist meats, and the resident’s need to wear a wander management device. Resident 6’s ISP was revised to include the resident’s high risk for falls. Resident’s that have therapy needs, have been identified as “high risk” for falls, have specialty ordered diets, or that wear a wander management device have had their ISP reviewed and revised as necessary to ensure that residents have an ISP that identifies the needs of the resident.
22VAC40-73-560-F
Based on observation and staff interview, the facility failed to ensure that all records are treated confidentially.
Evidence
  1. During tour of the facility the LI observed a door to a room containing resident records was left unattended. LI asked Staff 4 if the door was normally left open and unattended and she said yes.
Plan of correction
The noted deficient practice was corrected on 11/20/2024. The door noted to be open was closed. Community staff were re-educated on closing doors to rooms containing resident records when the rooms are unattended to ensure that all records are treated confidentially.
June 13, 2024Complaint survey0 violations
Inspection dates
06/13/2024
Areas reviewed
Resident Care and Related Services
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: 06/13/2024 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: 53 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: 1 Number of interviews conducted with residents: Number of interviews conducted with staff: 2 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the 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 Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
June 13, 2024Complaint survey0 violations
Inspection dates
06/13/2024
Areas reviewed
Resident Care and Related Services
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: 06/13/2024 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: 53 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: Number of interviews conducted with residents: Number of interviews conducted with staff: 2 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the 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 (name), Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
December 7, 2023Inspection0 violations
Inspection dates
12/07/2023
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 PREPAREDNESSARTICLE 1 – SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE 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: LI entered the facility at 8:38 am on 12/7/2023 and exited at 2:55 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: 54 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 4 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: LI observed medication administration. LI observed residents eating breakfast. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jamie Eddy, Licensing Inspector at (703) 479-5247 or by email at jamie.eddy1@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 24, 2023Inspection10 violations
Inspection dates
05/24/2023
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 PREPAREDNESS32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/24/2023 from approximately 9:30am until 7:45pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 54 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed:4 Number of interviews conducted with residents:4 Number of interviews conducted with staff: 3 Observations by licensing inspector: postings, fire drills, menus, resident council, activities calendar, meals, pharmacy review, dietary review, staff interactions, health care oversight, first aid kits etc. Additional Comments/Discussion: A preliminary review of the violations was completed with the administrator at the end of the inspection. Opportunity was given to ask questions and to provide any additional information related to the violations. 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 Rhonda Whitmer, Licensing Inspector at (540) 292-5932 or by email at rhonda.whitmer@dss.virginia.gov
Violations
22VAC40-73-950-E
Based on document review and an interview, the facility failed to ensure a semi-annual review on the emergency preparedness and response plan was completed for all staff, residents, and volunteers.
Evidence
  1. There was no documentation indicating a semi-annual review of the emergency preparedness and response plan had been completed with staff, residents, and volunteers.
  2. The LI interviewed the administrator on 05/24/2023 who confirmed a review a had not been completed and was unable to confirm the date of the previous review.
Plan of correction
A) Residents/Staff affected- all. Schedule to educate on our emergency preparedness plan has been put into place. B) Potential for residents/staff to be affected- all. Schedule to educate on our emergency preparedness plan has been put into place. C) Systems Change- residents will be educated twice a year during their scheduled resident council meetings. They will sign in confirmation they received this education. Staff will receive training twice a year on their annual education day as well as a subsequent staff town hall which we have quarterly. Sign in sheets will be utilized. We currently do not use volunteers in Assisted Living. D) Monitoring- periodic audits to make sure the sign in sheets reflect 100% compliance with this requirement. E) Date of completion- 6/30/2023.
22VAC40-73-410-A
A) Residents affected- 4 and 5 residents now have resident orientation forms in their charts. B) Potential for all residents to be affected- a complete audit will be conducted to ensure all orientation forms are in each resident’s chart. C) Systems change- a second check of the resident’s chart to ensure the orientation form is complete will take place at the time of admission. D) Monitoring a periodic audit of residents’ charts to ensure the orientation forms are present. E) Date to be completed- 6/30/2023.
Plan of correction
A) Residents affected- 4 and 5 residents now have resident orientation forms in their charts. B) Potential for all residents to be affected- a complete audit will be conducted to ensure all orientation forms are in each resident’s chart. C) Systems change- a second check of the resident’s chart to ensure the orientation form is complete will take place at the time of admission. D) Monitoring a periodic audit of residents’ charts to ensure the orientation forms are present. E) Date to be completed- 6/30/2023.
22VAC40-73-380-A
Based on review of residents’ records the facility failed to ensure prior to or at the time of admission, the required personal and social data information was obtained.
Evidence
  1. The records for residents #2, #3, #4, #5, #6, #7, and #8 did not contain information regarding previous mental health or intellectual disability services history, if any, and if applicable for care or services.
  2. The records for residents #2, #3, #4, #5, #6, #7 and #8 did not contain information regarding current behavioral and social functioning, strengths, and problems.
  3. The records for residents #2, #3, #4, #5, #6, #7 and #8 did not contain information regarding substance abuse history if applicable for care or services.
Plan of correction
A) Residents affected- 2,3,4,5,6 and 7. Now have social data sheets (DSS model forms) in their charts. The data forms now address all mental health and intellectual disabilities history and any applicable care for these needs. The data forms also address current behavior and social functioning strengths and problems. The data forms also reflect any substance abuse history and applicable care or services. B) Potential for all residents to be affected- A complete audit will be done so each resident has a social data sheet in their chart to address the above stated conditions. C) Systems Change- all residents upon admission to Assisted Living will have the social data form completed. D) Monitoring. Periodic audits will be performed to make sure all residents have social data forms in their charts. E) Date to be completed- 6/30/2023.
22VAC40-73-490-B
Based on document review, the facility failed to ensure the health care professional provided health care oversight for the required components and recommendations for change as needed.
Evidence
  1. A review of the on-site health care oversite completed on 03-31-2023 did not include the date oversight was provided, signature of the licensed health care professional(s) and recommendations for change for the following: Monitor conformance to the facility’s medication management plan and the maintenance of required medication reference materials; Evaluate the ability of residents who self-administer medications to continue to safely do so; Observe infection control measures and consistency with the infection control program of the facility.
Plan of correction
A) Residents affected-all. Staff reeducation to complete and sign off on all areas of the healthcare oversight process to include medication management guidelines. B) Potential for residents to be affected-all. Staff reeducation to complete and sign off on all areas of the healthcare oversight process to include medication management guidelines. C) Systems change- Our Director of nursing will ensure complete compliance on the day the Healthcare oversight is completed. D) Monitoring- quarterly compliance audit will be conducted. E) Date of completion- 6/30/2023.
22VAC40-73-860-I
Based on observation, the facility failed to ensure cleaning supplies and other hazardous materials are in a locked area.
Evidence
  1. During a walk-though of the third floor, the LI observed the mechanical room door propped open and unattended. A shelf in the room contained multiple containers of cleaning supplies and chemicals.
Plan of correction
A) Residents affected- all. Facility Administrator reeducated the contracted employee to always keep closet doors shut and locked when not in them. Contracted employee agreed to do this. B) Potential for residents to be affected- all. Facility Administrator reeducated the contracted employee to always keep closet doors shut and locked when not in them. Contracted employee agreed to do this. C) Systems change- a memo will go out to all contracted companies educating their employees who come on site that all closets must be shut and locked when the contracted employee is not in that room even if they leave for just a few minutes. D) Monitoring- staff will remind contracted employees to keep doors shut and locked when not in use. Staff will periodically test doors on their floor to ensure compliance. E) Date of completion- 6/30/2023.
22VAC40-90-40-B
Based on review of staff records and an interview, the facility failed to ensure a criminal history record report was obtained on or prior to the 30th day of employment.
Evidence
  1. The file for staff #19, hired on 06/14/2022, did not contain a criminal history record report.
  2. The LI interviewed the administrator who stated “the criminal history report could not be located for staff #19.”
Plan of correction
A) Residents affected- all. The HR director will ensure all VSP background checks are fully completed monthly. B) Potential for residents to be affected- all. The HR director will ensure all VSP background checks are fully completed monthly. C) Systems change- HR generalist will make sure all VSP background checks are completed and stored in the employee’s file. HR Director to audit monthly. D) Monthly audit by HR Director. E) Date of completion- 6/30/2023.
22VAC40-73-250-D
Based on review of staff records, the facility failed to ensure an annual tuberculosis risk assessment documenting the individual is free of tuberculosis in a communicable form as
Evidence
  1. d by the completion of the current screening form published by the Virginia Department of Health of a form consistent with it. EVIDENCE:
  2. The risk assessment form for staff #3 hired on 06/15/2021 was incomplete.
  3. The risk assessment form for staff #4 hired on 06/16/2021 was incomplete.
Plan of correction
A) Residents affected- all. The clinic staff who complete the TB tests and assessments will reconcile at the end of each week who is still outstanding for the completion of this requirement. They will then email the respective department heads and our Administrator and DON who is out of compliance. B) Potential for residents to be affected- all. The clinic staff who complete the TB tests and assessments will reconcile at the end of each week who is still outstanding for the completion of this requirement. They will then email the respective department heads and our Administrator and DON who is out of compliance. C) Systems change- Our clinic nurse will also attend Education Day each month to get the TB assessments completed with the employees that attend for their annual work anniversary that corresponds with the TB assessment due that same month. D) Monitoring- the above stated weekly reconciliation with a notification email sent to Department heads, the administrator and our DON. E) Date of completion- 6/30/2023.
22VAC40-73-680-I
Based on review of resident’s Medication Administration Record (MAR), the facility failed to ensure the MAR included all required information.
Evidence
  1. Resident 9 has the following order: Tramadol HCL Oral tablet 50mg: Give one tablet by mouth every 6 hours as needed for severe pain.
  2. Documentation in the MAR indicates medication was administered on 05/16/2023 at 6:02am and was not effective. There is no documentation of follow-up.
  3. Documentation in the MAR indicates medication was administered on 05/20/2023 at 8:40am and was not effective. There is no documentation of follow-up.
Plan of correction
A) Resident affected- #9, reeducation of staff to follow up with investigation and proper documentation showing further treatment both pharmacological and non-pharmacological interventions. B) Potential for residents to be affected- any resident on pain medications. Reeducation of staff to follow up with investigation and proper documentation showing further treatment both pharmacological and non-pharmacological interventions. C) Systems Change- Staff reeducation, periodic spot checking for compliance by the Assisted Living care coordinator for compliance. Reeducation to include interventions to be discussed during report at change of shift. D) Monitor- spot audits weekly. E) Date of completion 6/30/2023.
22VAC40-73-970-A
Based on document review, the facility failed to ensure fire and emergency evacuation drill frequency and participation are in accordance with the current edition of the Virginia Statewide Fire Prevention Code (13VAC5-51). The drills required for each shift in a quarter shall not be conducted in the same month.
Evidence
  1. Documentation of fire drills indicate a fire drill was conducted on 02/28/2023 at 11:06pm; 03/29/2023 at 11:35pm and 04/27/2023 at 9:45pm.
  2. Documentation of a day shift fire drill is 12/30/2022 at 1:54pm.
Plan of correction
A) Residents affected- all. The Life safety manager will ensure there is a fire drill on each 8-hour shift and will conduct the drills at different times on each shift. B) Potential for residents to be affected- all. The Life safety manager will ensure there is a fire drill on each 8-hour shift and will conduct the drills at different times on each shift. C) Systems change- A calendar of fire drills will be scheduled each quarter to reflect occurrence on each shift and at different times on those shifts. D) Administrator to review monthly for adherence to this schedule. E) Date of completion 6/30/2023.
22VAC40-73-450-C
Based on review of residents’ records, the facility failed to ensure the comprehensive Individualized Service Plan (ISP) contained all assessed needs.
Evidence
  1. The Uniform Assessment Instrument (UAI) for resident #2, dated 12/11/2022 indicates resident requires physical assistance with dressing. This is not indicated on the ISP dated 12/11/2022.
  2. The Uniform Assessment Instrument for resident #6 dated 05/04/2023 indicates mechanical assistance is needed with walking. The type of mechanical support is not identified on the ISP dated 05/04/2023.
Plan of correction
A) Residents affected- 2 and 6 their ISPs have been updated to reflect the specific needs regarding dressing assistance for resident 2. For resident 6 the Isp now reflects the specific mechanical help required for walking. B) Potential for all residents to be affected- All ISPs will be audited to ensure the specific types of assistance required will be documented. C) Systems Change- upon completion of the comprehensive ISP the nurse will specify the exact type of assistance required with each ADL task. D) Monitoring- Monthly audits will be conducted to ensure all ISPs have specific assistance types noted. E) Date of Completion 6/30/2023.
December 21, 2021Inspection0 violations
Inspection dates
12/21/2021
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS63.2 Protection of adults and reporting22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report
Technical assistance
The following topics were discussed: 1. Medication administration to be indicated as lay person on UAI to include RMAs 2. Update disaster planning manual to reflect current photo of all residents who wear roam alerts.
Comments
An unannounced renewal inspection was conducted by two LIs on 12/21/2021. There were 54 residents in care. A walk through was completed and the facility was clean and free from any foul odors. The following were reviewed: Eight resident and four staff records, emergency preparedness plan, fire and resident emergency drills, dietary and health care oversights and resident council minutes. There were no violations during this renewal inspection. If you have any questions, please contact the licensing inspector at (540) 332-2300 or email rhonda.whitmer@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
December 8, 2020Inspection0 violations
Inspection dates
Dec. 8, 2020
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity63.2 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 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 monitoring inspection was initiated on 12/08/20 and concluded on 12/23/20. The administrator was contacted to initiate the inspection. The administrator reported that the current census was 52. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed four resident records, four staff records, staff schedules, fire and health inspection in addition to certifications, 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.