Virginia DSS · Assisted Living Facility

Babcock Manor, Inc.

📍 State Route 691, Appomattox, VA, 24522

ID 9047One Year licenseActive
8
Inspections
On record
7
With violations
Visits that cited something
1
Clean visits
Nothing cited
59
Violations cited
Individual findings
44
Standards cited
Distinct rules
2
Complaint visits
Prompted by a complaint

Babcock Manor, Inc. was inspected 8 times between June 21, 2022 and June 10, 2026 by the Virginia Department of Social Services. 7 of those visits ended with violations cited and 1 with none. Across that history VDSS cited 59 violations under 44 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.

Every inspection listed here is currently published on the VDSS site.

Provider Information

Facility type
Assisted Living Facility
License type
One Year
License expires
08/26/2026
Administrator
Patricia House
Licensing inspector
Cynthia Ball
Inspector phone
(540) 309-2968
Approved for
Assisted Living · Non-Ambulatory

Inspection History

8

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

June 10, 2026Inspection10 violations
Inspection dates
06/10/2026
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY32.1- (37) REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2- (1) GENERAL PROVISIONS63.2- (16) PROTECTION OF ADULTS AND REPORTING63.2- (17) LICENSURE AND REGISTRATION PROCEDURES63.2- (18) FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/10/2026 8:00am until 1:30pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 24 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Violations
22VAC40-73-210-B
Based on staff record review, the facility, licensed for both residential and assisted living, failed to ensure that direct care staff attended at least 18 hours of training annually.
Evidence
  1. The record for staff person 1, hired 11/20/1998, did not contain documentation that the employee received 18 hours of annual training from 11/2024 through 11/2025.
Plan of correction
The Administrator will audit all staff records to ensure that all annual training is completed as required.
22VAC40-73-250-C
Based on staff record review, the facility failed to maintain all required information in staff records.
Evidence
  1. The record for staff person 3, hired on 04/28/2025, does not contain verification that the employee received a copy of their job description.
Plan of correction
The Administrator will audit all staff records to ensure that all required information is included in employee files.
22VAC40-73-610-B
Based on observations of the facility physical plant, the facility failed to ensure that the current weeks menu was posted.
Evidence
  1. On the day of on-site inspection, the licensing inspector (LI) observed that a current weeks menu was not posted in the facility at the time of inspection
Plan of correction
The Administrator will ensure that the current weeks menu is posted in the facility.
22VAC40-73-440-D
Based on resident record review, the facility failed to ensure that private pay uniform assessment instruments (UAIs) were completed as required.
Evidence
  1. The UAI dated 08/04/2025 in the record for resident 1 is incomplete as the area to assess the residents level of orientation is blank.
  2. The UAI dated 03/15/2026 in the record for resident 4 is incomplete as the area to assess the residents behavior is blank.
Plan of correction
The Administrator will review UAI’s to ensure that they are completed as required.
22VAC40-73-680-C
Based on observations of the facility morning medication pass and resident record review, the facility failed to ensure that medication were administered no later than 1 hour after the facility standard dosing schedule.
Evidence
  1. The June 2026 medication administration record (MAR) for resident 1 has documentation that the residents morning medications are to be administered at 7am. During the morning medication pass observed on 06/10/2026, the licensing inspector (LI) noted that staff person 1 administered resident 1’s 7am medication at 8:40am.
Plan of correction
The Administrator will review resident medication times and adjust to ensure that medications are administered within time frames.
22VAC40-73-450-F
Based on resident record review, the facility failed to ensure that individualized service plans (ISPs) were updated as required.
Evidence
  1. The record for resident 1 has a fall risk assessment form dated 08/05/2025 that indicates that the resident is at risk for falls. The ISP dated 08/05/2025 in the record for resident 1 does not address the need for fall risk.
  2. The history and physical dated 07/07/2023 in the record for resident 2 has documentation that the resident has an allergy to fish. The ISP dated 05/27/2026 in the record for resident 2 does not address the residents allergy to fish.
  3. The record for resident 3 has a fall risk assessment form dated 05/26/2026 that indicates that the resident is at risk for falls. A diet sheet signed by the physician dated 05/19/2026 has that resident 3 is prescribed an ADA, diabetic, vegetarian diet. The ISP dated 05/26/2026 in the record for resident 1 does not address the need for fall risk and has that the resident is on a regular diet.
Plan of correction
The Administrator will review ISPs to ensure that all identified needs are addressed.
22VAC40-73-550-G
Based on staff and resident record reviews, the facility failed to ensure that a review of resident rights was completed with all residents and all staff annually.
Evidence
  1. The records for staff persons 1, 2 and 3 do not contain documentation that an annual review of resident rights was completed with these employees.
  2. The record for residents 2 and 4 do not contain documentation that an annual review of resident rights was completed with these residents.
Plan of correction
The Administrator will schedule an annual review of resident rights with all residents and all staff.
22VAC40-73-620-A
Based on review of facility documentation and staff interviews, the facility failed to ensure that a oversight of special diets was completed by a dietician at least every six months.
Evidence
  1. The licensing inspector (LI) requested to review the most recent oversight of special diets on the day of on0site inspection. In an interview with staff person 2 it was reported that they were unable to locate the documentation from the last oversight.
Plan of correction
The Administrator has reached out to the dietician and requested that a copy of the special diet review be sent to the facility. The Administrator will ensure that all copies of special diet oversights are retained at the facility.
22VAC40-73-210-F
Based on staff record review, the facility failed to ensure that direct care staff received at least 2 hours training in infection control annually.
Evidence
  1. The record for staff person 2, hired in April 1989, did not contain documentation that the employee received 2 hours of training in infection control from 4/2025 through 4/2026.
Plan of correction
The Administrator will audit all staff records to ensure that all annual training is completed as required.
22VAC40-73-680-I
Based on resident record review, the facility failed to ensure that all required information was included on resident medication administration records (MARs).
Evidence
  1. The June 2026 MAR for resident 1 does not contain a diagnosis for numerous prescribed medications listed on the MAR.
Plan of correction
The Administrator will contact resident physician and pharmacy to have all diagnoses put on residents MARs.
October 24, 2025Complaint survey2 violations
Inspection dates
10/24/2025
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
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: 10/24/2025 9:30am until 11:00am The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 10/14/2025 regarding allegations in the area(s) of: Personnel, staffing, resident care and related services, building and grounds and additional requirements for facilities that care for resident with serious cognitive impairments. 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: 4 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the (allegation(s); area(s) of non-compliance with standard(s) or law were: additional requirements for facilities that care for resident with serious cognitive impairments. 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Violations
22VAC40-73-890-B
Based on observations of the facility physical plant, the facility failed to ensure that interior areas were adequately lighted for the safety and comfort of residents and staff.
Evidence
  1. At approximately 9:38am on the day of on-site inspection the lighting in the bathroom upstairs by room 3 was noted to be inoperable.
Plan of correction
The lights were fixed during the inspection. The Administrator will ensure that all staff monitor lights in the facility to make sure they are working properly.
22VAC40-73-1040-B
Based on observations of the facility physical plant, the facility failed to ensure that protective devices were on windows in common areas to prevent residents with serious cognitive impairments from opening windows wide enough to be able to crawl through.
Evidence
  1. The window to the right in the downstairs common area did not contain a protective device to prevent the window from opening wide enough for a resident to crawl through on the day of on-site inspection. The facility houses a mixed population of residents of which includes residents with a serious cognitive impairment.
Plan of correction
The facility Administrator will have all windows checked for proper protective devices and will ensure that staff monitor windows regularly
June 4, 2025Inspection13 violations
Inspection dates
06/04/2025
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 PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/04/2025 9am until 2:30pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 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: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Violations
22VAC40-73-950-E
Based on review of facility documentation, the facility failed to ensure that a review of the facility emergency preparedness plan was completed semi-annually with all residents.
Evidence
  1. The facility documentation of review of their emergency preparedness plan with residents had documentation that the last date completed was in December 2023.
Plan of correction
The facility Administrator will schedule a review of the facility preparedness and response plan with all resident and will ensure that it is completed semi-annually.
22VAC40-73-620-B
Based on review of the facility oversite of special diets, the facility failed to ensure that the oversite of special diets was signed and dated by the dietician or nutritionist.
Evidence
  1. The oversite of special diets report provided to the licensing inspector for review on the day of on-site inspection did not contain documentation of the date that the oversite was completed or the signature of the dietician or nutritionist who completed the oversite.
Plan of correction
The facility Administrator will discuss with the dietician and ensure that oversites of special diets are signed and dated.
22VAC40-73-250-B
Based on staff record review and staff interview, the facility failed to retain records for all staff at the facility.
Evidence
  1. The LI requested to review the record for staff person 4 on the day of on-site inspection. In an interview with staff person 5 during the inspection, staff person 5 expressed that they were unable to locate staff person 4’s record for the LI to be able to review.
Plan of correction
The facility Administrator will attempt to locate the record for staff person 4. If the record is not located the facility Administrator will develop a new record for staff person 4 to include all required information
22VAC40-73-250-D
Based on staff record review, the facility failed to ensure that a screening for tuberculosis was completed on or within seven days prior to the first day of work.
Evidence
  1. The record for staff person 3, whose first day of work is documented as 04/28/2025, has documentation that a screening for tuberculosis was not completed until 06/02/2025.
Plan of correction
The facility Administrator will ensure that all new employees received a screening for tuberculosis as required
22VAC40-73-550-G
Based on resident and staff record review, the facility failed to ensure that an annual review of resident rights was completed with staff and residents.
Evidence
  1. The record for resident 3 has documentation that the last review of resident rights was completed with this resident on 11/02/2023.
  2. The records for staff person 1, hired 11/20/1998, and staff person 2, hired 11/18/2019, do not have documentation of a re4view of resident rights being completed annually for these employees.
Plan of correction
The facility Administrator will schedule a review of resident rights for all residents and staff and ensure that a review is completed annually
22VAC40-73-700-2
Based on observation of the facility physical plant, the facility failed to post a “No-Smoking Oxygen in Use” on all rooms where oxygen is being used.
Evidence
  1. At 9:48am o the day of on-site inspection, the licensing inspector (LI) observed resident 5 in his room (room 2) with oxygen in use via a oxygen concentrator and nasal cannula. The room did not contain a “No-Smoking Oxygen in Use” posting.
Plan of correction
The facility Administrator had a sign posted on the day of inspection.
22VAC40-73-320-A
Based on resident record review, the facility failed to ensure that resident physical examinations contained a statement that the individual does not have any prohibited conditions or care needs.
Evidence
  1. The record for resident 3, admitted on 11/02/2023, has a physical examination dated 10/30/2023 that has documentation that the resident requires continuous licensed nursing care, which is a prohibited condition for admission to an Assisted Living Facility.
Plan of correction
The facility Administrator will have resident 3 re-assessed and have the physical examination updated correctly.
22VAC40-73-860-I
Based on observations of the facility physical plant, the facility failed to ensure that cleaning supplies were stored in a locked area.
Evidence
  1. Room 6 located downstairs in the facility was noted to contain a container of Member Mark Disinfecting Wipes and a bottle of Clorox Multi Surface Cleaner with Bleach sitting out on a wheelchair in the room. The door to the room was open. In an interview with staff person 5 on the day of inspection, staff person 5 expressed that resident 6, who resides in this room, is currently in the hospital.
Plan of correction
The facility Administrator removed the cleaning supplies from the room on the day of inspection.
22VAC40-73-325-B
Based on resident record review, the facility failed to ensure that a fall risk rating was completed after a resident fell for resident who are assessed as assisted living level of care.
Evidence
  1. The record for resident 1 has documentation that the resident sustained a fall on 03/10/2025 and was sent to the local emergency room for evaluation. The record does not contain documentation that a fall risk rating was completed for this fall. The uniform assessment instrument (UAI) dated 03/03/2025 has documentation that resident 1 is assessed as assisted living level of care.
Plan of correction
The facility Administrator will ensure that fall risk ratings are completed as required for resident who have a fall.
22VAC40-73-310-B
Based on resident record review, the facility failed to ensure that a documented interview was completed prior to or on the day admission.
Evidence
  1. The record for resident 1, admitted on 03/04/2025 did not contain documentation of an interview with the resident prior to or at the time of the residents admission to the facility.
Plan of correction
The facility Administrator will ensure that a documented interview is completed for new residents prior to their admission and placed in their record.
22VAC40-73-1040-A
Based on observations of the facility physical plant, the facility failed to ensure that doors leading to the outside had a system of security monitoring of residents with serious cognitive impairments.
Evidence
  1. The doors leading to the outside downstairs in the hallways beside rooms 1 and 6 were noted to have alarm devices that were inoperable at the time of inspection. The licensing inspector (LI) opened both doors several times and noted that the alarm did not sound.
Plan of correction
The facility Administrator had maintenance replace the batteries in both door alarms on the day of inspection.
22VAC40-73-210-F
Based on staff record review and staff interview, the facility failed to ensure that direct care staff received at least two hours of training in infection control and prevention annually.
Evidence
  1. The record for staff person 1, hired 11/20/1998, and staff person 2, hired 11/18/2019, did not contain documentation that these employees have received annual training in infection control and prevention. Staff person 5 confirmed in interview on day of inspection that infection control training has not been completed.
Plan of correction
The facility Administrator will schedule infection control training for all staff and will ensure that training occurs annually
22VAC40-73-690-B
Based on resident record review, the facility failed to ensure that residents assessed as assisting living level of care received a medication review every six months.
Evidence
  1. The record for resident 2, admitted to the facility on 07/11/2024, did not contain documentation that a medication review has been completed for this resident. The uniform assessment instrument (UAI) dated 07/08/2024 in the record for resident 2 has documentation that the resident is assessed as assist4ed living level of care.
Plan of correction
The facility Administrator had a medication review completed for resident 2 on 6/4/25. The Administrator will ensure that medication reviews are completed as required.
August 12, 2024Complaint survey0 violations
Inspection dates
08/12/2024
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 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: 08/12/2024 9:45am until 1:00pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 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: 1 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
August 12, 2024Inspection4 violations
Inspection dates
08/12/2024
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 PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 08/12/2024 9:45am until 1:00pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 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: 4 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Violations
22VAC40-73-450-F
Based on resident record review, the facility failed to ensure that Individualized service plans (ISP) were updated as needed for a significant change of a resident’s condition.
Evidence
  1. The record for resident 1 has documentation that the resident is a high fall risk from the 07/05/2024 fall risk assessment form. The ISP dated 05/27/2024 in the record for resident 1 does not have documentation to address this identified needsor of any services being provided.
  2. The record for resident 2 has documentation that the resident is receiving wound care through Hospice services and is a fall risk from the 04/11/2024 fall risk assessment form. The ISP dated 08/06/2023 in the record for resident 2 does not have documentation to address these identified needs or of any services being provided.
  3. The record for resident 3 has a physician order dated 07/13/2023 for fall mats and a physician order dated 03/01/2024 for the resident to be in bad at all times. The record also has documentation that Hospice is providing wound care services for a wound to the residents coccyx and right heel. The ISP dated 12/17/2023 in the record for resident 3 does not have documentation to address these identified needs or of any services being provided.
  4. The record for resident 4 has a physician order dated 07/13/2023 to use fall mats at all times when resident is in bed and half length bed rails. The record also has documentation that resident 4 is a high fall risk on a fall risk assessment form dated 02/02/2024.The ISP dated 02/02/2024 in the record for resident 24does not have documentation to address these identified needs or of any services being provided.
Plan of correction
The administrator will review and update resident ISPs to include all identified needs.
22VAC40-90-30-B
Based on staff record reviews, the facility failed to ensure that a sworn statement or affirmation was completed for all applicants for employment.
Evidence
  1. The record for staff person 3, who is currently employed at the facility, did not contain documentation of a sworn statement or affirmation.
Plan of correction
The administrator will ensure that all new employees complete a sworn disclosure statement prior to employment.
22VAC40-73-120-A
Based on staff record review and staff interviews, the facility failed to ensure that new staff received orientation and training within the first seven working days of employment.
Evidence
  1. The record for staff person 3 did not contain documentation of this employee receiving orientation and training to the facility. In an interview with staff person 4 conducted on the day of inspection, staff person 4 expressed that this employee has been employed for several months.
Plan of correction
The administrator will ensure that new employees receive orientation and training as required.
22VAC40-73-250-C
Based on staff record reviews, the facility failed to ensure that all personal and social data was maintained in staff records,
Evidence
  1. The record for staff person 3 did not include the date of hire for this employee or documentation/receipt of the employees job description.
Plan of correction
The Administrator will ensure that all employee records contain all required information.
May 24, 2024Inspection10 violations
Inspection dates
05/24/2024
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 PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/24/2024 7:45am until 1:00pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 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: 5 Number of staff records reviewed: 0-Not available for review. Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Violations
22VAC40-73-690-B
Based on resident record review, the facility failed to ensure that residents assessed as assisted living level of care received a mediation review at least every 6 months.
Evidence
  1. The record for resident 2, assessed as assisted living level of care on their uniform assessment instrument dated 08/06/2023, has documentation that the last medication review was completed on 08/23/2023 for this resident.
  2. The record for resident 3, assessed as assisted living level of care on their uniform assessment instrument dated 12/17/2023, has documentation that the last medication review was completed on 05/11/2023 for this resident.
Plan of correction
The Administrator will reach out to have a medication review completed for these residents.
22VAC40-73-1040-A
Based on observations of the facility physical plant, the facility failed to ensure that a system of security monitoring was on all doors leading to the outside for monitoring of resident with serious cognitive impairments.
Evidence
  1. The 3 doors downstairs that lead to the outside were noted to have inoperable door alarms during the on-site inspection on 05/24/2024. The house houses a mixed population of residents such as resident 4, who has a diagnosis of dementia and is assessed with disorientation to some spheres some of the time with date and day being the spheres affected on the uniform assessment instrument completed on 12/17/2023.
Plan of correction
New batteries were placed in the door alarms on the day of inspection. The Administrator will in-service all staff on routine monitoring of all door alarms.
22VAC40-73-710-C
Based on observations, resident record review and staff interviews, the facility failed to ensure that a physician's written order was obtained that specifies the condition, circumstances, and duration under which the restraint is to be used.
Evidence
  1. Resident 1 was observed by the LI at 8:09am on 05/24/2024 to be sitting in a Geri Chair with a tray that was secured over top. Documentation in Hospice notes dated 05/06/2024 has that “During the day they sit her in a geri chair for her safety to prevent her from ambulating without assistance”. The record for resident 1 did not contain documentation of a physicians written order for the use of a Geri Chair with a secured tray that includes the condition, circumstances, and duration under which the restraint is to be used. In an interview with staff person 1 on 05/24/2024, staff person 1 confirmed they were not able to locate a physician order for the use of a Geri Chair in the record for resident 1.
Plan of correction
The Administrator has had the restraint discontinued for this resident.
22VAC40-73-650-E
Based on resident record reviews, the facility failed to ensure that physician orders were maintained in resident records.
Evidence
  1. The record for resident 2 has documentation that the resident was admitted to Hospice services on 04/10/2024 and that Hospice is providing wound care services for a wound on the residents left ankle. In an interview with staff person 1 conducted on 05/24/2024, staff person 1 expressed that this is correct. The record for resident 2 does not have documentation of the physicians order for the treatment/wound care being provided to resident 2’s left ankle.
  2. The record for resident 3 has documentation that the resicnet is receiving wound care services from Hospice from a wound on the residents coccyx and right heel. In an interview with staff person 1 conducted on 05/24/2024, staff person 1 expressed that this is correct. The record for resident 3 does not have documentation of the physicians order for the treatment/wound care being provided to resident 3’s coccyx and right heel.
Plan of correction
The Administrator has obtained physicians orders for these residents and will ensure that all physicians orders are in resident records.
22VAC40-73-40-B
Based on observations and staff interviews, the licensee failed to ensure that at all times the department's representative is afforded reasonable opportunity to inspect all of the facility's buildings, books, and records as specified in § 63.2-1706 of the Code of Virginia.
Evidence
  1. During the on-site inspection conducted on 05/24/2024, staff person 1, the designated person in charge, did not have access to staff records, staff and resident review of the emergency preparedness plan and staff review and practice of resident emergencies. This documentation was not available for the LI to review during the on-site inspection.
Plan of correction
The Administrator will speak with all staff persons in charge and develop a plan to ensure that they have access to all records when the Administrator is out of the building.
22VAC40-73-440-A
Based on resident record review, the facility failed to ensure that a uniform assessment instrument (UAI) was completed/updated whenever a significant change in a resident was observed.
Evidence
  1. The UAI dated 07/07/2023 in the record for resident 1 has documentation that the resident is independent with the ADLs for dressing, transferring, eating/feeding, walking, wheeling and mobility. Hospice notes dated 03/08/2023, 09/10/2023 and 12/09/2023 have documentation that resident 1 is dependent with these ADL needs. In an interview with staff person 1 on 05/24/2024, staff person 1 expressed that Hospice notes are correct and that the UAI has not been updated to reflect resident 1’s current ADL needs.
Plan of correction
The Administrator will have the UAI for resident 1 updated to reflect accurate ADL needs.
22VAC40-73-940-A
Based on observations of facility documentation, the facility failed to ensure compliance with the Statewide Fire Prevention Code (13VAC5-51) by ensuring a inspection by the appropriate fire official at least annually.
Evidence
  1. Facility documentation made available for review during the on-site inspection show that the last fire inspection was completed at the facility on 06/13/2022.
Plan of correction
The Administrator has made contact with the fire official and an inspection has been scheduled for the week on June 3, 2024
22VAC40-73-860-I
Based on observations of the facility physical plant, the facility failed to ensure that cleaning supplies and other hazardous materials were stored in a locked area.
Evidence
  1. The laundry room located downstairs in the facility was observed to be unlocked at 8:13am on 05/24/2024. A bottle of Scrubbing Bubbles Mega Shower Foamer, a can of Favor Furniture Polish, a can of Comet with Bleach Cleaner, a bottle of Great Value Glass Cleaner, a bottle of Great Valus All Purpose Cleaner with Bleach and a bottle of First Choice Lavender Cleaner were observed sitting out on a table in the laundry room.
Plan of correction
The laundry room door was locked on the day of inspection. The Administrator will in-service all staff on the proper storage of cleaning supplies.
22VAC40-73-710-D
Based on observations, resident record review and staff interviews, the facility failed to ensure that direct care staff kept a record of restraint usage, outcomes, checks, and any assistance required in subdivision 4 of this subsection and shall note any unusual occurrences or problems if any.
Evidence
  1. Resident 1 was observed by the LI at 8:09am on 05/24/2024 to be sitting in a Geri Chair with a tray that was secured over top. Documentation in Hospice notes dated 05/06/2024 has that “During the day they sit her in a geri chair for her safety to prevent her from ambulating without assistance”. In an interview with staff person 1 on 05/24/2024, staff person 1 expressed that there was not documentation of a restraint record to include the usage, outcomes, checks or any assistance required for the Geri chair use for resident 1.
Plan of correction
The Administrator has had the restraint discontinued for this resident.
22VAC40-73-450-F
Based on resident record review, the facility failed to ensure that Individualized service plans (ISP) were updated as needed for a significant change of a resident’s condition.
Evidence
  1. The record for resident 1 has documentation that the resident has an allergy to Latex, is receiving hospice services, is a high fall risk from the 07/07/2023 fall risk assessment and has documentation in hospice notes that a Geri Chair is used to prevent the resident from ambulating without assistance. The ISP dated 07/07/2023 in the record for resident 1 does not have documentation to address these identified needs or of any services being provided.
  2. The record for resident 2 has documentation that the resident is receiving wound care through Hospice services and is a fall risk from the 04/11/2024 fall risk assessment. The ISP dated 08/06/2023 in the record for resident 2 does not have documentation to address these identified needs or of any services being provided.
  3. The record for resident 3 has a physician order dated 10/03/2023 for the resident to be on a puree diet, a physician order dated 07/13/2024 for fall mats and a physician order dated 03/01/2024 for the resident to be in bad at all times. The record also has documentation that Hospice is providing wound care services for a wound to the residents coccyx and right heel. The ISP dated 12/17/2023 in the record for resident 3 does not have documentation to address these identified needs or of any services being provided.
Plan of correction
The Administrator will update resident ISPs to reflect all identified needs.
June 26, 2023Inspection11 violations
Inspection dates
06/26/2023
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 PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Comments
Type of inspection: Renewal Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/26/2023 9:30am until 2:30pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 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: 6 Number of staff records reviewed: 4 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 4 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Violations
22VAC40-73-680-E
Based on resident record review and staff interview, the facility failed to ensure that medical procedures or treatments ordered by a physician or other prescriber were provided according to his instructions and documented and the documentation is to be maintained in the resident’s record.
Evidence
  1. The record for resident 2 contains a signed order, dated 12/28/2022, to hold the resident’s prescribed Carvedilol 3.125 MG when the resident’s systolic blood pressure is less than 110. Interview with staff 2 revealed that staff document the resident’s blood pressure on the back of the medication administration record (MAR). The 05/21/2023 through 06/20/2023 MAR for resident 2 indicates that the resident was administered Carvedilol 3.125 MG at 7:00AM on 05/28/2023 and 06/20/2023; however, the MAR did not include documentation of what the resident’s blood pressure was. Interview with staff 2 confirmed that this was accurate and could not locate the blood pressure readings for the resident at 7:00AM on 05/28/2023 and 06/20/2023 during the on-site inspection.
  2. The record for resident 5 contains the following orders for oxygen: Use two liters of oxygen, dated 01/06/2023, at all times to keep oxygen status greater than 89%; keep using oxygen as much as needed, dated 04/17/2023, oxygen goal for the resident is 89% - 93%; and hospital discharge instructions signed by a physician, dated 06/12/2023, continuous oxygen at three liters via nasal cannula. During on-site inspection on 06/26/2023, one licensing inspector (LI) spoke with staff 2 regarding documentation by staff to ensure that the resident is using oxygen continuously. Staff 2 stated that staff are not documenting resident 5’s oxygen usage.
Plan of correction
The administrator will have an in-service for all medications aids on proper documentation and following physician orders.
22VAC40-73-610-D
Based on resident record review and staff interview, the facility failed to ensure that when a diet is prescribed for a resident by his physician or other prescriber, that it is prepared and served according to the physician’s or other prescriber’s orders.
Evidence
  1. The record for resident 2 contains a signed order, dated 12/28/2022, for the resident to be on a fluid restriction of 64 ounces daily. Interview with staff 2 revealed that staff are not ensuring that the resident only receives 64 ounces of fluid daily. Interview with staff 3 revealed that she was not aware of the order for the resident to only receive 64 ounces of fluid daily.
  2. The most recent dietitian oversight was dated 04/06/2023 and lists 13 residents with a special diet. A list of special diets was not observed in the kitchen on the day of inspection. Interview with staff person 3 expressed that everyone receives the same meals and was not aware of special diet orders for any resident.
Plan of correction
The administrator had the fluid restriction diet for resident 2 discontinued as the resident is on hospice. The administrator will review all current special diets and ensure that an updated posting is in the kitchen. The administrator will in-service all dietary and direct care staff on the importance of preparing and serving special diets.
22VAC40-73-450-E
Based on resident record review, the facility failed to ensure that individualized service plans (ISPs) were signed and dated by the resident or his legal representative.
Evidence
  1. The ISP’s for resident 1, dated 07/19/2022, resident 2, dated 12/17/2022, resident 3, dated 02/10/2023 and the ISP for resident 5, dated 04/01/2023, were not signed and dated by the resident or his legal representative.
Plan of correction
The administrator will have residents/families sign ISPs.
22VAC40-73-250-D
Based on review of staff records, the facility failed to ensure a screening for tuberculosis was completed on or within seven days prior to the first day of work for new employees.
Evidence
  1. The record for staff person 5, hired on 04/10/2023, has documentation that a screening for tuberculosis was not completed until 06/02/2023.
Plan of correction
The administrator will ensure that new employees have a screening for tuberculosis prior to the first day of work.
22VAC40-73-870-A
Based on observation during a tour of the physical plant, the facility failed to ensure that the interior of the building is maintained in good repair.
Evidence
  1. The baseboard heater across from room 2 was noted to be separating from the wall.
  2. The floor in the hallway next to the dining room was noted to have several cracks/gaps between the floor boards.
  3. The public restroom upstairs by the nursing office was noted to have an inoperable door knob on the day of inspection as the door would not stay closed.
  4. The door frame around the door to room 10 was noted to be broken/cracked on the day of inspection.
Plan of correction
The administrator has talked with maintenance and will have physical plant repairs completed.
22VAC40-73-680-D
Based on resident record review, the facility failed to ensure that medications are administered in accordance with the physician’s or other prescriber’s instructions.
Evidence
  1. The record for resident 2 contains a signed order, dated 12/28/2022, to hold the resident’s prescribed Carvedilol 3.125 MG when the resident’s systolic blood pressure is less than 110. The 05/21/2023 through 06/20/2023 medication administration record (MAR) for resident 2 contains documentation that the resident’s blood pressure was 108/65 on 06/08/2023; however, the MAR contains documentation that Carvedilol 3.125MG was administered to the resident when it should have been held.
Plan of correction
The administrator will have an in-service for all medications aids on proper documentation and following physician orders.
22VAC40-73-550-G
Based on a review of resident and staff records, the facility failed to ensure that am annual review of resident rights was completed with residents and staff.
Evidence
  1. The records for residents 2, 3, 5 and 6 and the records for staff 2 and 3 did not contain documentation that these individuals received an annual review of residents rights.
Plan of correction
The administrator will ensure that an annual review of resident rights is completed with all residents and all staff.
22VAC40-73-200-C
Based on review of staff records, the facility failed to ensure that the direct care staff met the required training requirements
Evidence
  1. The record for staff person 5, hired on 04/10/2023, did not contain documentation that this employee has direct care certification/training. An interview was conducted with staff person 6 who expressed that this employee, who works the 3rd shift as a care aid, has not completed direct care staff training.
Plan of correction
The administrator will have this individual enroll and complete a direct care training program.
22VAC40-90-40-B
Based on review of staff records, the facility failed to ensure that a completed criminal history report was received within the first 30 days of employment.
Evidence
  1. The record for staff person 5, hired on 04/10/2023 did not contain documentation of a completed criminal history report on the day of inspection.
Plan of correction
The administrator will ensure that all new staff have a completed criminal history report within 30 days of the day of employment. Employee 5’s criminal report has been requested and the administrator is awaiting the results.
22VAC40-73-710-C
Based on observations and resident record review, the facility failed to ensure that a restraint was only used in accordance with physician orders/instructions.
Evidence
  1. During a tour of the facility physical plant, both LI’s in the presence of staff person 1 observed resident 3 lying in bed with half rails up on both sides. The back of a recliner chair was placed at the side of the bed from the end of the half rail towards the foot of the bed and a wheelchair was placed at the side of the bed towards the end of the bed. Interview with staff person 1 expressed that this is done to keep resident 6 from trying to climb out of the bed. A review of the record for resident 6 noted that there is not a physician order for a restraint to keep resident 6 from climbing out of bed.
Plan of correction
The administrator has in-serviced all direct care staff on the proper use of recliner chairs and wheelchairs. The administrator will consult with the resident’s physician on the residents needs for half rails and bed mats and will obtain proper physician orders.
22VAC40-73-450-C
Based on resident record review and staff interview, an individualized service plan (ISP) was not completed as required.
Evidence
  1. The uniform assessment instrument (UAI) for resident 2, dated 12/17/2022, indicates that the resident is disoriented some spheres, some of the time to date and day; however, the ISP for resident 2, dated 12/17/2022, does not indicate the aforementioned information. Interview with staff 2 confirmed that the UAI is correct and this information needs to be included on the resident’s ISP.
  2. The UAI dated 05/02/2023 in the record for resident 6 has documentation that the resident is disoriented to some spheres some of the time with time being the sphere affected. The ISP dated 05/02/2023 in the record for resident 6 does not address this identified need.
Plan of correction
The administrator will update ISPs to reflect identified needs.
June 21, 2022Inspection9 violations
Inspection dates
06/21/2022
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 PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Comments
Type of inspection: Renewal Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/21/2022 9:30am until 2:30pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 25 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 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov
Violations
22VAC40-73-560-I
Based on a review of resident records, the facility failed to ensure that a current resident photo was available for identification purposes.
Evidence
  1. The record for resident 2, admitted on 04/29/2022 did not contain a current photo on the day of inspection.
Plan of correction
The Administrator will ensure a current photo for all residents are obtained
22VAC40-73-700-2
Based on observations of the facility physical plant, the facility failed to post a “No Smoking-Oxygen in Use” sign at all rooms where oxygen is in use.
Evidence
  1. Room 9 upstairs was noted to have an oxygen concentrator sitting by the first bed in the room. The room did not have a “No Smoking –Oxygen in Use” sign posted.
Plan of correction
A No Smoking sign will be posted on room 9.
22VAC40-73-350-B
Based on a review of resident records, the facility failed to ascertain prior to admission whether a potential resident was a registered sex offender.
Evidence
  1. The record for resident 2, admitted on 04/29/2022 has documentation that a sex offender screening was not admitted until 05/03/2022.
  2. The record for resident 3, admitted on 11/15/2022 has a sex offender screening that does not have a date of completion.
Plan of correction
The Administrator will ensure that all new admissions receive a sex offender screening prior to their admission.
22VAC40-73-50-A
Based on a review of resident records, the facility failed to ensure that the statement prepared and provided to the prospective resident and his legal representative, if any, that discloses information about the facility included all required components.
Evidence
  1. The record for resident 2, admitted on 04/29/2022 and resident 3, admitted on 11/15/2022 had a “Assisted Living Facility Disclosure Statement” that did not include a statement of whether or not the facility has an on-site emergency electrical power source for the provision of electricity during an interruption of the normal electric power supply.
Plan of correction
The Administrator will print off the new Disclosure Statement form from the DSS website and will begin using it.
22VAC40-73-980-A
Based on observations of the facility first aid kit, the facility failed to ensure that expiration dates have not passed on items inside the kit.
Evidence
  1. The facility first aid kit was noted to have a bottle of Betadine with an expiration date of 12/2020.
Plan of correction
The Betadine was removed from the first aid kit and expiration dates will be checked monthly.
22VAC40-73-550-G
Based on a review of staff records, the facility failed to ensure annual training on resident rights and responsibilities with all staff.
Evidence
  1. The records for staff persons 2 and 3 have documentation that the last training in resident rights and responsibilities was completed on 12/15/2020.
Plan of correction
The Administrator will schedule an annual review of resident rights will all staff.
22VAC40-73-610-D
Based on a review of resident records and interview with staff, the facility failed to ensure that special diets prescribed to residents were prepared and served according to physician instructions.
Evidence
  1. The record for resident 2 has documentation of a controlled carbohydrate diet. The record for resident 4 has documentation that the resident is on a regular soft food diet.
  2. On the day of inspection it was observed that a special diet list was not available in the facility kitchen. Interview with staff person 1, who was preparing the lunch meal, expressed that there are currently no special diets and that all residents receive the same diet/food.
Plan of correction
The Administrator will ensure that a diet list for all residents who are on a special diet is kept current in the facility kitchen. The Administrator will in-service all staff on the diet list location.
22VAC40-73-450-F
Based on a review of resident records, the facility failed to ensure that all identified needs were reflected on resident individualized service plans (ISPs).
Evidence
  1. The record for resident 1 has documentation that the resident is receiving mental health services. The ISP dated 04/01/2022 does not reflect this identified need.
  2. The record for resident 2 has documentation that the resident is receiving mental health services. The uniform assessment instrument (UAI) dated 12/14/2021 in the record for resident 2 has documentation that the resident is disoriented some spheres some of the time with time and situation being the spheres affected and that the residents behavior pattern is abusive/aggressive/disruptive less than weekly. The ISP dated 04/29/2022 in the record for resident 2 does not reflect these identified needs.
  3. The record for resident 3 has a fall risk dated 11/15/2021 that rates that resident at an increased risk for falls. The UAI dated 11/11/2021 in the record for resident 3 has that the resident is disoriented to all spheres some of the time. The ISP dated 11/15/2021 for resident 3 does not reflect these identified needs.
Plan of correction
The Administrator will review these ISP’s and will update to reflect all identified needs.
22VAC40-73-270-4
Based on a review of staff records, the facility failed to ensure all staff received annual training in methods of dealing with residents who have a history of aggressive behaviors or dangerously agitated states.
Evidence
  1. The record for staff person 2, hired on 01/15/2020 and staff person 3, hired in 4/1989 have documentation that the last training for aggressive behaviors was conducted in 2020.
Plan of correction
The Administrator will schedule a training in aggressive behaviors for all direct care staff.