Lakewood Manor Baptist Retirement Community — Virginia Inspection Report

Inspections

On record

With violations

Visits that cited something

Clean visits

Nothing cited

Violations cited

Individual findings

Standards cited

Distinct rules

Complaint visits

Prompted by a complaint

Lakewood Manor Baptist Retirement Community was inspected 13 times between June 24, 2021 and August 5, 2025 by the Virginia Department of Social Services. 7 of those visits ended with violations cited and 6 with none. Across that history VDSS cited 34 violations under 24 distinct standards. 5 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. 12 of these 13 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

One Year

License expires

09/01/2026

Administrator

Jennifer Koeniger

Licensing inspector

Kimberly Davis

Inspector phone

(804) 356-3572

Approved for

Non-Ambulatory · Special Care Unit · Assisted Living

Inspection History

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

August 5, 2025Inspection8 violations

Inspection dates

08/05/2025,08/12/2025

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 PROCESS

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: 8-5-25 from 10:15 a.m.- 3:45 p.m. and 8-12-25 from 8:45 a.m.-12:15 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: 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: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 4 Additional Comments/Discussion: The following items were also reviewed/observe during the inspection-facility documentation, facility postings, first aid kit, medication pass, physician’s orders, medication administration records, lunch meal/menu. An exit meeting was 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 Kimberly Davis, Licensing Inspector at (804) 356-3572 or by email at Kimberly.M.Davis@dss.virginia.gov

Violations

22VAC40-73-120-C

Based on a review of staff records the facility failed to ensure that all staff shall be trained in the relevant laws, regulations, and the facility's policies and procedures sufficiently to implement: 1. Emergency and disaster plans for the facility; 2. Procedures for the handling of resident emergencies; 3. Use of the first aid kit and knowledge of its location; 4. Handwashing techniques, standard precautions, infection risk-reduction behavior, and other infection control measures specified in 22VAC40-73- 100; 5. Confidential treatment of personal information; 6. Requirements regarding the rights and responsibilities of residents; 7. Requirements and procedures for detecting and reporting suspected abuse, neglect, or exploitation of residents and for mandated reporters, the consequences for failing to make a required report, as set out in § 63.2- 1606 of the Code of Virginia; 8. Procedures for reporting and documenting incidents as required in 22VAC40-73- 70; 9. Methods of alleviating common adjustment problems that may occur when a resident moves from one residential environment to another; and 10. For direct care staff, the needs, preferences, and routines of the residents for whom they will provide care.

Evidence

The record for Staff # 2 (date of hire: 6-21-22) contained initial orientation and training that did not address all required topics. This was confirmed by facility staff.

Plan of correction

Not published by VDSS.

22VAC40-73-450-E

Evidence

The record for Resident # 4 (admit date: 8-20-24) contained an ISP dated 4-7-25 that was not signed or dated at all. This was confirmed by staff.

Plan of correction

Not published by VDSS.

22VAC40-73-950-E

Based on a review of resident records the facility failed to ensure that it shall develop and implement an orientation and semi-annual review on the emergency preparedness and response plan for all staff, residents, and volunteers, with emphasis placed on an individual's respective responsibilities. The review shall be documented by signing and dating. The orientation and review shall cover responsibilities for: 1. Alerting emergency personnel and sounding alarms; 2. Implementing evacuation, shelter in place, and relocation procedures; 3. Using, maintaining, and operating emergency equipment; 4. Accessing emergency medical information, equipment, and medications for residents; 5. Locating and shutting off utilities; and 6. Utilizing community support services.

Evidence

The facility was unable to provide documentation of a semi-annual review on the emergency preparedness and response plan for all staff. This was confirmed by facility staff.

Plan of correction

Not published by VDSS.

22VAC40-73-260-A

Based on a review of staff records the facility failed to ensure that each direct care staff member shall maintain current certification in first aid.

Evidence

-The record for Staff # 2 (date of hire: 6-21-22) and Staff # 3 (date of hire: 10-8-24) did not contain documentation of first aid certification. This was confirmed by facility staff.

Plan of correction

Not published by VDSS.

22VAC40-73-325-A

Based on a review of resident records the facility failed to ensure that for residents who meet the criteria for assisted living care, by the time the comprehensive ISP is completed, a written fall risk rating shall be completed.

Evidence

The record for Resident # 4 (admit date: 8-20-24) did not contain a fall risk assessment at all. This was confirmed by facility staff.

Plan of correction

Not published by VDSS.

22VAC40-73-50-B

Based on a review of resident records the facility failed to ensure that written acknowledgment of the receipt of the disclosure by the resident or the resident’s legal representative shall be retained in the resident's record.

Evidence

The record for Resident # 4 (admit date: 8-20-24) did not contain written acknowledgment of the receipt of the disclosure. This was confirmed by facility staff.

Plan of correction

Not published by VDSS.

22VAC40-73-1090-A

Based on a review of resident records the facility failed to ensure that prior to his/her admission to a safe, secure environment, the resident shall have been assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare. The physician shall be board certified or board eligible in a specialty or subspecialty relevant to the diagnosis and treatment of serious cognitive impairments (e.g., family practice, geriatrics, internal medicine, neurology, neurosurgery, or psychiatry). The assessment shall be in writing and shall include the following areas: 1. Cognitive functions (e.g., orientation, comprehension, problem-solving, attention and concentration, memory, intelligence, abstract reasoning, judgment, and insight); 2. Thought and perception (e.g., process and content); 3. Mood/affect; 4. Behavior/psychomotor; 5. Speech/language; and 6. Appearance.

Evidence

The record for Resident # 4 (admit date: 8-20-24) did not contain an assessment for serious cognitive impairment. This was confirmed by staff.

Plan of correction

Not published by VDSS.

22VAC40-73-410-A

Based on a review of resident records the facility failed to ensure that upon admission, the assisted living facility shall provide an orientation for new residents and their legal representatives, including emergency response procedures, mealtimes, and use of the call system. If needed, the orientation shall be modified as appropriate for residents with cognitive impairments. Acknowledgment of having received the orientation shall be signed and dated by the resident and, as appropriate, his/her legal representative, and such documentation shall be kept in the resident's record.

Evidence

The record for Resident # 4 (admit date: 8-20-24) did not contain documentation of the acknowledgment of having received the orientation. This was confirmed by facility staff.

Plan of correction

Not published by VDSS.

April 15, 2025Inspection1 violation

Inspection dates

04/15/2025

Areas reviewed

22VAC40-73 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: 4-15-25 from 10:35 a.m.-11:25 a.m. 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 regarding allegations in the area(s) of: resident care Number of residents present at the facility at the beginning of the inspection: 51 Number of resident records reviewed: 1 Number of interviews conducted with staff: 2 An exit meeting was 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-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Kimberly Davis, Licensing Inspector at (804) 356-3572 or by email at Kimberly.M.Davis@dss.virginia.gov

Violations

22VAC40-73-680-E

Based on a self-report received from the facility and a review of the resident’s record the facility failed to ensure that medical procedures or treatments ordered by a physician or other prescriber shall be provided according to his instructions and documented.

Evidence

-The record for Resident # 1 contained charting notes that documented that the resident had a fall on 8-19-24 and went to the emergency room where she received staples in her scalp and returned to the facility. -The record for Resident # 1 contained a physician’s order dated 8-20-24 that stated, ”Remove staples from posterior scalp, 8-26-24.” -According to the self-report received from the facility, “the physician’s order was filed in the resident’s paper chart but was not entered into the electronic record.” -Charting notes dated 10-29-24 for Resident # 1 documented that upon assessment by staff, about six staples were noted on the left side back of the resident’s head. Charting notes dated 10-30-24 documented that the staples were removed from the resident’s left posterior scalp on 10-30-24 by the Nurse Practitioner.

Plan of correction

Not published by VDSS.

December 10, 2024Inspection13 violations

Inspection dates

12/10/2024,12/12/2024

Areas reviewed

Comments

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12-10-24 from 9:47 a.m.- 2:35 p.m. and 12-12-24 from 10:41 a.m.- 3:10 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: 51 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 interviews conducted with residents: 2 Number of staff records reviewed: 3 Number of interviews conducted with staff: 3 Additional Comments/Discussion: The following items were also reviewed/observed during the inspection: facility documentation, facility postings, first aid kit, medication pass, physician’s orders, medication administration records, lunch meal/menu. An exit meeting was 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 Kimberly Davis, Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov

Violations

22VAC40-73-210-B

Based on a review of staff records the facility failed to ensure that in a facility licensed for both residential and assisted living care, all direct care staff shall attend at least 18 hours of training annually. EXCEPTION: Direct care staff who are licensed health care professionals or certified nurse aides (CNA) shall attend at least 12 hours of annual training.

Evidence

The record for Staff # 3 (date of hire: 1-3-23), who is a CNA, did not contain documentation of annual training. This was confirmed by facility staff.

Plan of correction

An audit of personnel training records will be conducted to ensure that all employees have attended at least 12 hours of training annually. Moving forward, the Administrator will have access to employee’s Relias to monitor ongoing compliance with training.

22VAC40-73-430-H-2

Based on a review of resident records the facility failed to ensure that a copy of the written discharge statement shall be retained in the resident's record.

Evidence

The record for Resident # 6 (discharge date: 10-8-24) did not contain a written discharge statement. This was confirmed by facility staff.

Plan of correction

The Administrator or designee will ensure that all residents and/or responsible parties will be provided with a discharge statement upon discharge from the facility.

22VAC40-73-350-B

Based on a review of resident records the facility failed to ensure that it shall ascertain, prior to admission, whether a potential resident is a registered sex offender if the facility anticipates the potential resident will have a length of stay greater than three days or in fact stays longer than three days and shall document in the resident's record that this was ascertained and the date the information was obtained.

Evidence

The record for Resident # 1 (admit date: 11-25-24) did not contain a sex offender screening. This was confirmed by facility staff.

Plan of correction

The Administrator or designee will ensure that the sex offender registry is checked for all admissions prior to admission.

22VAC40-73-50-B

Evidence

The record for Resident # 1 (admit date: 11-25-24) and Resident # 2 (admit date: 10-30-24) did not contain written acknowledgment of the receipt of the disclosure. This was confirmed by facility staff.

Plan of correction

All pre-admission and admission paperwork will be reviewed for accuracy by the Administrator or designee prior to admission to ensure that all required admission paperwork is complete.

22VAC40-73-260-A

Based on a review of staff records the facility failed to ensure that each direct care staff member shall maintain current certification in first aid.

Evidence

The record for Staff # 3 (date of hire: 1-3-23) did not contain documentation of first aid certification. This was confirmed by facility staff.

Plan of correction

An audit of personnel files will be conducted by the Administrator or designee to ensure that each direct care staff member maintains current certification in first aid.

22VAC40-73-1100-A

Based on a review of resident records the facility failed to ensure that prior to placing a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia in a safe, secure environment, the facility shall obtain the written approval of one of the following persons, in the following order of priority: 1. The resident, if capable of making an informed decision; 2. A guardian or other legal representative for the resident if one has been appointed; 3. A relative who is willing and able to take responsibility to act as the resident's representative, in the following specified order: (i) spouse, (ii) adult child, (iii) parent, (iv) adult sibling, (v) adult grandchild, (vi) adult niece or nephew, (vii) aunt or uncle; or 4. If the resident is not capable of making an informed decision and a guardian, legal representative, or relative is unavailable, an independent physician who is skilled and knowledgeable in the diagnosis and treatment of dementia.

Evidence

The record Resident # 3, who resides on the secure unit, did not contain written approval of placement in a secure environment. This was confirmed by facility staff.

Plan of correction

A chart audit will be conducted by the Administrator or designee to ensure that all residents residing in the safe, secure environment have the written approval of one of the following persons, in the following order of priority: 1. The resident, if capable of making an informed decision; 2. A guardian or other legal representative for the resident if one has been appointed; 3. A relative who is willing and able to take responsibility to act as the resident's representative, in the following specified order: (i) spouse, (ii) adult child, (iii) parent, (iv) adult sibling, (v) adult grandchild, (vi) adult niece or nephew, (vii) aunt or uncle; or 4. If the resident is not capable of making an informed decision and a guardian, legal representative, or relative is unavailable, an independent physician who is skilled and knowledgeable in the diagnosis and treatment of dementia.

22VAC40-73-450-E

Based on a review of resident records the facility failed to ensure that the individualized service plan (ISP) shall be signed and dated by the licensee, administrator, or his designee, (i.e., the person who has developed the plan), and by the resident or his legal representative. The plan shall also indicate any other individuals who contributed to the development of the plan, with a notation of the date of contribution. The title or relationship to the resident of each person who was involved in the development of the plan shall be included. These requirements shall also apply to reviews and updates of the plan.

Evidence

-The record for Resident # 1 contained an ISP with the creation date of 11-25-24 that was not signed or dated by the licensee, administrator, or his/her designee and was signed but not dated by the resident. -The record for Resident # 3 contained an ISP with a creation date of 8-19-24 that was signed and dated by staff but was not signed/dated by the resident or his/her legal representative. -The record for Resident # 4 contained an ISP with a creation date of 5-23-24 that was not signed or dated at all. This was confirmed by facility staff.

Plan of correction

The Administrator or designee will ensure that all individualized service plans are signed and dated by the resident and/or responsible party, as well as by the Administrator and/or designee.

22VAC40-73-1090-A

Based on a review a review of resident records the facility failed to ensure that prior to his/her admission to a safe, secure environment, the resident shall have been assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare.

Evidence

The record for Resident # 3, who resides on the secure unit (admit date: 1-20-23) did not contain an assessment for serious cognitive impairment. This was confirmed by facility staff.

Plan of correction

A chart audit will be conducted to ensure that all residents residing in the safe, secure environment have been assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare. To maintain future compliance, the Administrator or designee will review all paperwork prior to admission to ensure all required documents have been received.

22VAC40-73-440-A

Based on a review of resident records the facility failed to ensure that the Uniform Assessment Instrument (UAI) shall be completed prior to admission, at least annually, and whenever there is a significant change in the resident's condition.

Evidence

The record for Resident # 4 (admit date: 1-25-23) did not contain a UAI. This was confirmed by facility staff.

Plan of correction

The Administrator or designee will ensure that all new residents and/or their legal representative, will receive orientation including emergency response procedures, mealtimes, and use of the call system, and that acknowledgement of having received the orientation is signed and dated by the resident and his legal representative.

22VAC40-73-550-G

Based on a review of resident and staff records the facility failed to ensure that the rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each resident or his legal representative or responsible individual and each staff person.

Evidence

of this review shall be the resident's, his legal representative's or responsible individual's, or staff person's written acknowledgment of having been so informed, which shall include the date of the review and shall be filed in the resident's or staff person's record. Evidence: -2 of 3 staff records did not contain a written acknowledgment of a review of the rights and responsibilities of residents in assisted living facilities. -4 of 6 resident records did not contain a written acknowledgment of a review of the rights and responsibilities of residents in assisted living facilities. This was confirmed by facility staff.

Plan of correction

The Administrator or designee will ensure that the rights and responsibilities of residents in an assisted living facility will be reviewed annually with all staff and resident’s (or legal representative).

22VAC40-73-1110-B

Based on a review of resident records the facility failed to ensure that six months after placement of the resident in the safe, secure environment and annually thereafter, the licensee, administrator, or designee shall perform a review of the appropriateness of each resident's continued residence in the special care unit.

Evidence

The record for Resident # 3, who resides on the secure unit, did not contain a review of the appropriateness of the resident's continued residence in the special care unit. This was confirmed by facility staff.

Plan of correction

A chart audit will be conducted by the Administrator or designee to ensure that all residents residing in the safe, secure environment have a review of appropriateness for continued placement six months after placement and annually thereafter.

22VAC40-73-410-A

Based on a review of resident records the facility failed to ensure that upon admission, the assisted living facility shall provide an orientation for new residents and their legal representatives, including emergency response procedures, mealtimes, and use of the call system. If needed, the orientation shall be modified as appropriate for residents with cognitive impairments. Acknowledgment of having received the orientation shall be signed and dated by the resident and, as appropriate, his legal representative, and such documentation shall be kept in the resident's record.

Evidence

The record for Resident # 1 (admit date:11-25-24) and Resident # 2 (admit date: 10-30-24) did not contain acknowledgment of having received the orientation. This was confirmed by facility staff.

Plan of correction

22VAC40-73-320-A

Based on a review of resident records the facility failed to ensure that within the 30 days preceding admission, a person shall have a physical examination by an independent physician. The report of such examination shall be on file at the assisted living facility and shall contain the following: 1. The person's name, address, and telephone number; 2. The date of the physical examination; 3. Height, weight, and blood pressure; 4. Significant medical history; 5. General physical condition, including a systems review as is medically indicated; 6. Any diagnosis or significant problems; 7. Any known allergies and description of the person's reactions; 8. Any recommendations for care including medication, diet, and therapy; 9. Results of a risk assessment documenting the absence of tuberculosis in a communicable form as

Evidence

d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it;
A statement that the individual does not have any of the conditions or care needs prohibited by 22VAC40-73-310 H;
A statement that specifies whether the individual is considered to be ambulatory or nonambulatory as defined in this chapter;
A statement that specifies whether the individual is or is not capable of self- administering medication; and
The signature of the examining physician or his designee. Evidence: The record for Resident # 2 contained a Report of Physical Examination dated 10-15-24 that did not include all of the required items. This was confirmed by facility staff.

Plan of correction

The Administrator or designee will review all paperwork prior to admission to ensure the paperwork contains all of the information required by the Standards.

July 3, 2024Complaint survey1 violation

Inspection dates

07/03/2024

Areas reviewed

22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 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: 7-3-24 from 9:40 a.m.-2:00 p.m. 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 6-4-24 regarding allegations in the area(s) of: resident care. Number of residents present at the facility at the beginning of the inspection: 52 Number of resident records reviewed: 1 Number of interviews conducted with staff: 4 An exit meeting was 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: A violation notice was issued; any violation(s) not related to the complaint(s) 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 Kimberly Davis, Licensing Inspector at (804) 662-x or by email at Kimberly.M.Davis@dss.virginia.gov

Violations

22VAC40-73-325-B

Based on a review of the resident’s record the facility failed to ensure that the fall risk rating shall be reviewed and updated under each of the following circumstances: 1. At least annually; 2. When the condition of the resident changes; and 3. After a fall.

Evidence

The record for Resident # 1 contained charting notes that documented that the resident had two falls on 5-12-24 and one fall on 5-11-24. However, the resident’s record contained only one fall risk evaluation, dated 5-11-24.

Plan of correction

1. The resident sampled was missing a post fall assessment on May 11, 2024. The resident has since been discharged, but the post fall assessment was completed on July 3, 2024. 2. All residents have the potential to be affected by the deficient practice. A 100% audit of all current Assisted Living and Memory Support residents who have experienced falls was completed to ensure that post fall assessments had been completed. Any assessments within the last year that had not been completed were done. 3. All team members will be educated by July 26, 2024, on when to complete a post fall assessment on a resident: at least annually, when the condition of the resident changes, and after a fall. 4. AL Nurse Manager or designee will audit post fall assessments for their completion once a week for 4 weeks, then twice a month for two months and then quarterly for two quarters. Identified areas of concern will be corrected and re-education completed.

June 14, 2024Complaint survey0 violations

Inspection dates

06/14/2024

Areas reviewed

22VAC40-73 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: 6-14-24 from 10:55 a.m.- 11:30 a.m. 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 regarding allegations in the area(s) of: resident care. Number of residents present at the facility at the beginning of the inspection: 45 Number of resident records reviewed: 1 Number of interviews conducted with staff: 2 An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Kimberly Davis, Licensing Inspector at (804) 662-757 or by email at Kimberly.M.Davis@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

March 1, 2024Inspection0 violations

Inspection dates

03/01/2024

Areas reviewed

22VAC40-73 BUILDINGS AND GROUND

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: 3-1-24 from 10:00 a.m.-11:10 a.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Additional Comments/Discussion: An unannounced monitoring inspection was conducted by licensing staff on 3-1-24 to observe the facility’s memory care unit renovations. A tour was completed and measurements were taken. The facility is not requesting an increase in its licensed capacity. An exit meeting was 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 Kimberly Davis, Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

January 11, 2024Inspection0 violations

Inspection dates

01/11/2024

Areas reviewed

22VAC40-73 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: 1-11-24 from 10:20 a.m.-11:40 a.m. 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 12-8-23 regarding allegations in the area(s) of : resident care. Number of residents present at the facility at the beginning of the inspection: 53 Number of resident records reviewed: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: The identified resident was observed participating in a memory care activity. An exit meeting was 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 Kimberly Davis, Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

August 10, 2023Inspection3 violations

Inspection dates

08/10/2023,08/15/2023

Areas reviewed

Comments

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 8-10-23 from 11:35 a.m.- 4:15 p.m. and 8-15-23 from 9:35 a.m.- 2:55 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: 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: 5 Additional Comments/Discussion: The following items were also reviewed/observed during the inspection: facility documentation, facility postings, first aid kit, physician’s orders, medication administration records, med pass, emergency food and water. An exit meeting was 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 Kimberly Davis, Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov

Violations

22VAC40-73-260-A

Based on a review of staff records the facility failed to ensure that each direct care staff member shall maintain current certification in first aid.

Evidence

The record for Staff # 4 did not contain documentation of first aid certification.

Plan of correction

Not published by VDSS.

22VAC40-73-120-C

Based on a review of staff records the facility failed to ensure that all staff shall be trained in the relevant laws, regulations, and the facility's policies and procedures sufficiently to implement: 1. Emergency and disaster plans for the facility; 2. Procedures for the handling of resident emergencies; 3. Use of the first aid kit and knowledge of its location; 4. Handwashing techniques, standard precautions, infection risk-reduction behavior, and other infection control measures specified in 22VAC40-73-100; 5. Confidential treatment of personal information; 6. Requirements regarding the rights and responsibilities of residents; 7. Requirements and procedures for detecting and reporting suspected abuse, neglect, or exploitation of residents and for mandated reporters, the consequences for failing to make a required report, as set out in § 63.2-1606 of the Code of Virginia; 8. Procedures for reporting and documenting incidents as required in 22VAC40-73- 70; 9. Methods of alleviating common adjustment problems that may occur when a resident moves from one residential environment to another; and 10.For direct care staff, the needs, preferences, and routines of the residents for whom they will provide care.

Evidence

4 of 4 staff records reviewed did not contain documentation that included all of the required items for initial staff training.

Plan of correction

Not published by VDSS.

22VAC40-73-550-G

Based on a review of staff records the facility failed to ensure that the rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each staff person.

Evidence

of this review shall be the staff person's written acknowledgment of having been so informed, which shall include the date of the review and shall be filed in the staff person's record. Evidence: The record for Staff # 4 (date of hire:10-8-2001) did not contain acknowledgment of an annual review of the rights and responsibilities of residents in assisted living facilities.

Plan of correction

Not published by VDSS.

August 10, 2023Complaint survey0 violations

Inspection dates

08/10/2023

Areas reviewed

22VAC40-80 COMPLAINT INVESTIGATION

Comments

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 8-10-23 from 9:53 a.m.- 11:35 a.m. 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 July 3, 2023 regarding allegations in the area(s) of: personnel. Number of residents present at the facility at the beginning of the inspection: 54 Number of staff records reviewed:1 Number of interviews conducted with staff:1 An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Kimberly Davis, Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

April 14, 2023Complaint survey0 violations

Inspection dates

04/14/2023,08/15/2023

Areas reviewed

22VAC40-80 COMPLAINT INVESTIGATION

Comments

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 4-14-23 from 1:05 p.m.- 3:20 p.m. and 8-15-23 from 2:55 p.m.- 3:40 p.m. 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 regarding allegations in the area(s) of: resident care and personnel. Number of residents present at the facility at the beginning of the inspection: 50 Number of resident records reviewed: 1 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Additional Comments/Discussion: Facility documentation, staff schedules, and time cards were also reviewed. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Kimberly Davis, Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

April 14, 2023Complaint survey1 violation

Inspection dates

04/14/2023

Areas reviewed

22VAC40-80 COMPLAINT INVESTIGATION

Comments

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 4-14-23 from 10:15 a.m.-1:05 p.m. 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 1-23-23 regarding allegations in the area(s) of: resident care and personnel. Number of residents present at the facility at the beginning of the inspection: 50 Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with staff: 3 An exit meeting was 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: resident care 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 Kimberly Davis, Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov Violation Notice Issued: Yes

Violations

22VAC40-73-460-E

Based on a review of resident records the facility failed to ensure that the facility shall regularly observe each resident for changes in physical, mental, emotional, and social functioning. 1. Any notable change in a resident's condition or functioning, including illness, injury, or altered behavior, and any corresponding action taken shall be documented in the resident's record. 2. The facility shall provide appropriate assistance when observation reveals unmet needs.

Evidence

-The facility’s electronic “Daily Charting” for Resident # 1 (admit date: 7-20-2020) did not contain any documentation at all by staff during the 11-7 shift on 11-6-23 to indicate whether the resident had been observed or assisted by staff. -According to the administrator Resident # 1 was observed by staff to have a skin tear on her lower left arm at approximately 4:00 a.m. on 11-6-23. However, this was not noted on the “Daily Charting” for resident.

Plan of correction

a. All direct care team members will be re-educated by Staff Development Coordinator, or designee on daily charting requirements for each resident on each shift. New hire orientation for direct care team members will also ensure charting requirements are reviewed and competency is validated. b. Education will include notifying the charge nurse of any notable change in a resident’s condition or functioning noted during shift to include changes in skin such as a skin tear, the process if electronic charting on residents is not available, then the use of paper documentation, and proper filing of paper documentation into the resident record. c. The Nurse Manager or designee will audit “daily charting” once a week for two weeks, once a month for two months and once a quarter for two quarters. Audit results will be reviewed by the Associate Executive Director and re-education/team member counseling will occur immediately if omissions are found. Audit results will also be reported to the Quality Assurance Committee for continued review and oversight. d. Date of Compliance: July 15, 2023

August 19, 2022Inspection7 violations

Inspection dates

08/19/2022

Areas reviewed

Comments

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 8-19-22 from 9:48 a.m.- 4:45 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: 61 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 Additional Comments/Discussion: The following items were reviewed/observed during the inspection: facility postings, facility documentation, criminal records checks, tour of the facility, first aid kit and emergency food/water supplies, medication pass/physician’s orders/Medication Administration Records (MARs). Residents and staff were also interviewed. An exit meeting was 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 Kimberly Davis, Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov

Violations

22VAC40-73-450-C

Based on a review of resident records the facility failed to ensure that the individualized service plan (ISP) contained a written description of what services will be provided to address all identified needs on the Uniform Assessment Instrument (UAI).

Evidence

The ISP dated 8-2-2022 for Resident # 6 (admit date: 8-2-22) indicated “No help needed” for the following activities: dressing, toileting, transferring, eating/feeding. However, the resident’s UAI (dated: 8-6-2022) indicates that resident “Needs help” with those same activities.

Plan of correction

a. Resident #6’s ISP was revised to coincide with the resident’s UAI. The resident’s needs are reflected in the ISP and the ISP is up to date. b. Nurse Manager or designee will provide an audit of all residents’ ISP’s and UAI’s to ensure that the ISP contains a written description of what services will be provided to address all identified needs on the UAI. c. The Administrator of Assisted Living will educate all nurses conducting ISP’s and UAI’s on the important of making sure that the information provided by both tools coincides with one another. d. The administrative nurse or designee will audit newly admitted residents UAI’s and ISP’s for consistency once a week for two weeks, once a month for two months, and once a quarter for two quarters. Audit findings will be reported to the Administrator of Assisted Living and the Administrator of Health Services. Any areas of concern will be addressed.

22VAC40-73-250-D

Based on a review of staff records the facility failed to ensure that each staff person shall annually submit the results of a risk assessment, documenting that the individual is free of tuberculosis in a communicable form as

Evidence

d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: -The record for Staff # 3 (date of hire: 10- 3-2017) contained a TB screening last dated 5-20-21. -The record for Staff # 1 (date of hire: 3- 24-2009) contained a TB screening last dated 5-20-21. -The record for Staff # 4 (date of hire: 11- 3-2003) contained a TB screening last dated 6-21-21. -The administrator had staff to check the records for current TB screenings for Staff #3, #1, and #4, but no current documentation could be found.

Plan of correction

a. An audit of personnel files was completed and found that the risk screenings were often out of date or not documented. b. All staff with a missing or out of date screening form has been contacted and notified that the TB screening form must be completed no later than 10/14/2022 and returned to the Human Resources Director or Administrator of Assisted Living c. The Administrator of Assisted Living will educate the Human Resources Director on the requirements of Regulation 22VAC73-250-D in regard to TB screening. The Human Resources Director will audit personnel files to confirm all screening forms have been collected and are complete no later than 10/31/2022. The Human Resources Director will maintain a copy of records of TB screenings in her office in a secure binder annually for all team members effective 1/15/2023. d. The Human Resources Director or designee will audit files for annual TB screening/risk assessment once a week for two weeks, once a month for two months, and once a quarter for two quarters. Audit findings will be reported to the Administrator of Assisted Living and the Administrator of Health Services. Any areas of concern will be addressed.

22VAC40-73-980-A

Based on a review of the facility’s first aid kit the facility failed to ensure that the first aid kit contained all required items.

Evidence

-The first aid kit did not contain the First Aid instructional manual. Staff # 6 stated that she was not sure why the instructional manual was not in the first aid kit and would make sure it was replaced.

Plan of correction

a. The first aid kit cited now contains the First Aid instructional manual. b. The Administrator of Assisted Living audited all 5 first aid kits used in the assisted living area and ensured that the kits were complete. Administrator of Assisted Living placed content list on the top of each first aid kit. c. The Administrator of Assisted Living or designee will educate all assisted living team members regarding the first aid kits located on each floor and the required contents. The Administrative Nurse will be responsible for checking the kits on a monthly basis and documenting findings in a log maintained with each first aid kit. d. The Administrative Nurse or designee will audit the first aid kits once a week for two weeks, once a month for two months and once a quarter for two quarters. Audit findings will be reported to the Administrator of Assisted Living and the Administrator of Health Services and any areas of concern will be addressed.

22VAC40-73-550-G

Based on a review of resident records the facility failed to ensure that the rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each resident or his legal representative or responsible individual.

Evidence

of this review shall be the resident’s, his legal representative’s or responsible individual’s written acknowledgment of having been so informed, which shall include the date of review and shall be filed in the resident’s record. Evidence: The record for Resident # 8 (admit date: 7-28-2021) did not contain written acknowledgment of annual review of resident rights. Staff # 7 looked for it in the resident’s record but did not find it.

Plan of correction

a. Resident #8 was provided with a copy of rights and responsibilities by Medical Social Worker on October 5, 2022. Written acknowledgement was obtained and placed in the resident’s record on October 5, 2022. b. An audit of all resident files was completed on August 22, 2022 by the Medical Social Worker to ensure that review of the rights and responsibilities of residents in assisted living has been completed annually. Twelve resident files were identified as missing annual review of rights and responsibilities. Eleven of those files are now updated and written acknowledgement was placed in each resident’s record. The remaining resident file will be updated and documented by 10/7/2022. c. The Medical Social Worker will complete a review of resident’s annual rights and responsibilities on the resident’s move in date anniversary, yearly. This calendar will be kept up to date by the Medical Social Worker. d. The Administrator of Assisted Living or designee will educate the Medical Social Worker on the requirement to review all resident’s annual rights and responsibilities every year on their move in anniversary, with each resident or their legal representative or responsible individual. The administrative nurse or designee will audit resident files for an annual rights and responsibilities once a week for two weeks, once a month for two months and once a quarter for two quarters. Audit findings will be reported to the Administrator of Assisted Living and the Administrator of Health Services and any areas of concern will be addressed.

22VAC40-90-40-C

Based on a review of staff records the facility failed to ensure that any person required to obtain a criminal history record report shall be ineligible for employment if the report contains convictions of the barrier crimes.

Evidence

The record for Staff # 5 (date of hire: 9-14-2021) contained a criminal history report dated 8-30-2021 with a barrier crime of Misdemeanor Assault per VA Code Section 18.2-57. The administrator stated that the staff member would be terminated.

Plan of correction

a. Staff member #5 was terminated August 24, 2022. b. All personnel files for assisted living team members have been reviewed to ensure that no team member has a barrier crime. All background checks were in place and no barrier crimes were identified. c. The Administrator of Assisted Living will educate the Human Resources Director on barrier crimes and that team members cannot begin resident care until their background has come back and it does not include any barriers crimes. Administrator of Assisted Living will educate using the DSS update dated August 5, 2022, which described “barrier crimes.” The Human Resources Director will provide the Administrator of Assisted Living with background reports of potential new assisted living employees which show any criminal background information for the Administrator’s approval/denial before employment begins. The Administrator of Assisted Living will initial and date upon review. The Administrator of Assisted Living or designee will complete a 100% audit of Annual Sworn Statement or Affirmation shall be made of each assisted living employee’s file by October 31, 2022 d. The Administrator of Assisted Living or designee will conduct an audit of all new hire personnel files once a week for two weeks, once a month for two months and once a quarter for two quarters. Audit results will be reviewed by the Administrator of Health Services and any areas of concern will be addressed.

22VAC40-73-440-A

Based on a review of resident records the facility failed to ensure that all residents of and applicants to assisted living facilities shall be assessed face to face using the uniform assessment instrument (UAI) in accordance with Assessment in Assisted Living Facilities (22VAC30-110). The UAI shall be completed prior to admission, at least annually, and whenever there is a significant change in the resident’s condition.

Evidence

The record for Resident # 6 (admit date: 8-2-22) contained a UAI (dated: 8-6-22) that was not completed prior to the resident’s admission.

Plan of correction

a. The UAI of Resident #6 has been reviewed and is accurate and up to date. b. An audit of all assisted living residents will be completed by the Nurse Manager to determine if the UAI was completed prior to their admission in order to determine if this was an isolated incident or if a process change is needed for admission c. The Administrator of Assisted Living or designee will educate all nurses who complete the UAI on the appropriate time frame of completion regarding new residents. d. The administrative nurse or designee will audit all newly admitted resident files once a week for two weeks, once a month for two months and once a quarter for two quarters to ensure that the UAI was completed prior to admission. Audit findings will be reported to the Administrator of Assisted Living and the Administrator of Health Services and any areas of concern will be addressed

22VAC40-73-210-F

Based on a review of staff records the facility failed to ensure that at least two hours of direct care staff annual training shall focus on infection control and prevention.

Evidence

The training record for Staff # 1 (date of hire: 3-24-2009) contained only one hour of infection control and prevention training last dated 8-20-2021.

Plan of correction

a. Staff member #1 will complete 2 hours of infection control and prevention training by October 31, 2022, to include Infection Control and Prevention (1 hour), Infection Control – Essential Principles (30 min) and Infection Control – Isolating and Cohorting. b. All assisted living staff personnel files will be audited to ensure compliance with the necessary infection control and prevention training hours. Those staff members that do not have 2 hours of infection control education will complete the necessary hours by October 31, 2022. All new hires will receive the 2 hours of infection control training during their first week of hire and education on infection control will be conducted annually in the month of October. c. The Administrator of Assisted Living or designee will provide education to the Staff Development Coordinator and Human Resources Director on the requirements for all staff to obtain two hours of infection control and prevention training, annually. d. The Administrator of Assisted Living or designee will audit all new hire personnel files to ensure training is completed prior to resident care, once a week for 2 weeks, once a month for two months and once a quarter for two quarters. Audit results will be reviewed by the Administrator of Health Services and any areas of concern will be addressed.

June 24, 2021Inspection0 violations

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 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 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 6/24/2021 and concluded on 6/29/2021. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 55. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed 4 resident records, 4 staff records, required facility documentation, medication administration records and physician orders and criminal history records 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. Please contact me by e-mail at T.Lesley@dss.virginia.gov if further assistance is needed.

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.