Cogir of Old Town, Alexandria

Based on resident record review and staff interview, the facility failed to ensure that not withstanding 63.2-1805 of the Code of Virginia, at the request of the resident, hospice care may be provided in an assisted living facility under the same requirements for hospice programs provided in Article of Chapter 5 of Title 32.1 of the Code of Virginia if the hospice program determines that such program is appropriate for the resident. Acknowledgment that the services provided to each resident should be reflected on the individualized service plan ( ISP

Based on resident record and staff interview, the facility failed to ensure that the original agreement or acknowledgment should be updated whenever there were changes to any of the policies or information referenced or identified in the agreement or acknowledgment and dated and signed by the licensee or administrator and the resident or the resident?s legal representative. Evidence: 1. During the onsite inspection on 02/03/2026, Resident 3?s Resident Agreement (signed, 05/07/2025) was reviewed and indicated that resident 3?s Assisted Living Care Level was Package C. The agreement included a Schedule of Resident Rates and Fees and Description of Service Levels with fees associated with the various package options. Additionally, Resident 3?s Resident Agreement stated, ?sixty (60) days written notice prior to changes in charges or services unless for Enhanced Care which may be time sensitive in order to preserve safe and adequate care of the resident.? 2. On 07/01/2025, the facility implemented a ?simplified Care Package pricing model (effective, 08/01/2025)? which resulted in a change in the fees associated with the various package options. 3. Despite the change in fee in July 2025, Resident 3?s August 2025?s monthly statement stated a change to Package D with the charged fee matching that of Package F on the 07/01/2025 pricing model. 4. In September 2025, the facility implemented another change in their care package pricing model. 5. Resident 3?s September through February 2026?s monthly statement also notes Package D as resident 3?s care package with the charged fee not consistent with the published pricing model established in September 2025. 6. Resident 3?s November 2025 through January 2026?s monthly statement also included an additional ?Ancillary Care Medications AL? fee. 7. Resident 3?s record did not include an updated agreement or acknowledgement by the licensee or administrator or the resident or the resident?s legal representative of such upon changes in charges or services. 8. During the onsite inspection, 02/03/2026, staff 1 confirmed that notification of the care package pricing model change that occurred, September 2025 was not provided to residents and families

Based on resident review and staff interview, the facility failed to provide to each resident or the resident?s legal representative, if one has been appointed, a monthly statement that itemizes any charges made by the facility and any payments received from the resident or on behalf of the resident during the previous calendar month and should show the balance due or any credits for overpayment. The facility should also place a copy of the monthly statement in the resident?s record. Evidence: 1. Upon request 02/03/2026, the facility did not provide monthly statements previous to August 2025. 2. During the onsite inspection, 02/03/2026, licensing inspector (LI) requested monthly statements that reflected resident 3?s assisted living care level change. Staff stated that there was a change in systems and confirmed that monthly statements prior to August 2025 were not made available for inspection by the department?s representative

Based on resident record review and staff interview, the facility failed to ensure that when hospice care was provided to a resident, the assisted living facility and the licensed hospice organization should communicate and establish an agreed upon coordinated plan of care for the resident. The services provided by each should be included on the individualized service plan ( ISP

Based on resident record review and staff interview, the facility failed to ensure that individualized service plans ( ISP

Based on resident record review and staff interview, the facility failed to regularly observe each resident for changes in physical, mental, emotional, and social functioning. Any notable change in a resident?s condition or functioning, including illness, injury, or altered behavior, and any corresponding action taken should be documented in the resident?s record. Evidence: 1. During the onsite inspection on 02/03/2025, August 2025?s monthly statement indicated that resident 3 had a change of condition. 2. Upon request 02/03/2026, the facility did not provide documentation of any notable change in resident 3?s condition or functioning and any corresponding action taken. 3. During the onsite inspection, 02/03/2026, staff 1 stated that the facility transitioned to a different system and confirmed an inability to provide documentation of resident 3?s change in condition through progress notes, and notifications of any changes made to collateral contact 1.

Based on resident record review and staff interview, the facility failed to ensure that residents should be allowed access to their own records. A legal representative of a resident should be provided access to the resident?s record or part of the record as allowed by the scope of his legal authority. Evidence: 1. On 11/25/2025, collateral contact 1 requested? ?copies of all signed authorizations, consent forms, or ISP

Based on resident record review and staff interview, the facility failed to ensure that the fall risk rating should be reviewed and updated after a fall. Evidence: 1. Licensing inspector (LI) received a self report on 09/25/2025 stating that resident 1 had a fall on 09/25/2025. 2. Upon request the facility did not provide a post fall risk rating for resident 1?s fall on 09/25/2025. 3. During the onsite inspection, staff 1 and staff 2 confirmed that a fall risk rating was not reviewed and updated after Resident 1?s fall on 09/25/2025.

Based on resident review and staff interview, the facility failed to ensure that at the time of discharge, the assisted living facility should provide to the resident and, as appropriate, his legal representative and designated contact person a dated statement signed by the licensee or administrator. Evidence: 1. On 10/04/2025, resident 1?s designated contact person emailed a discharge notification to staff 1. 2. Upon request the facility did not provide a written discharge notification that was presented to resident 1?s designated contact person. 3. During the onsite inspection, 11/10/2025, staff 1 confirmed that a written notification of the actual discharge date and place of discharge was not given to resident 1?s contact person.

Based on resident review and staff interview, the facility failed to ensure for each resident with an inability to use the signaling device, in addition to any other services, this inability should be included in the resident?s individualized service plan ( ISP

Based on resident review and staff interview, the facility failed to ensure that prior to admitting a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia to a safe, secure environment, the licensee, administrator, or designee determined whether placement in the special care unit was appropriate. The determination and justification for the decision should be in writing and retained in the resident?s file. Evidence: 1. Upon request, the facility did not provide documentation of the determination and justification on whether placement in the special care unit is appropriate for resident 1 (admit date, 06/20/2025). 2. During the onsite inspection, 08/22/2025, staff 1 confirmed resident 1 did not have documentation of the determination and justification on whether placement in the special care unit is appropriate by the licensee, administrator, or designee in their record.

Based on record review and staff interview, the facility failed to ensure that doors that lead to unprotected areas are monitored or secured through devices that conform to applicable building and fire codes, including door alarms, cameras, constant staff oversight, security bracelets that are part of an alarm system, pressure pads at doorways, delayed egress mechanisms, locking devices, or perimeter fence gates. Residents who reside in safe, secure environments may be prohibited from exiting the facility or the special care unit if applicable building and fire codes were met. Evidence: 1. The initial incident report (dated, 07/22/2025) for an elopement on the safe, secure environment which stated, ?resident 1 had left the third floor through one of the doors with the disabled mag lock.? 2. During the onsite inspection, staff 1 confirmed that the day before the elopement, an outside vendor disabled the mag lock for an unknown reason, permitting resident 1 to exit the special care unit.

Based on record review and staff interview, the facility failed to report to the regional licensing office within 24 hours any major incident that negatively affected or threatened the life, health, safety, or welfare of any resident. Evidence: 1. Licensing inspector received an initial incident report of an elopement from a safe, secure environment on 07/22/2025. The elopement occurred on the evening of 07/18/2025. 2. During the onsite inspection, 08/22/2025, staff 1 acknowledged that the incident report was not sent to the regional licensing office within 24 hours of the elopement.

Based on record review and staff interview, the facility failed to ensure that a method of written communication is utilized as a means of keeping direct care staff on all shifts informed of significant happenings or problems experienced by residents, including complaints and incidents or injuries related to physical or mental conditions. The information was included in the records of the involved residents. Evidence: 1. Upon request, the facility did not provide written communication among direct care staff on all shifts of incidents related to physical conditions to include the elopement of resident 1 on 07/18/2025. 2. During the onsite inspection, 08/22/2025, staff 1 confirmed that the facility did not have a method of written communication that kept direct care staff on all shifts informed of significant happenings experienced by residents. Staff 1 also confirmed written communication of direct care staff was not noted for the elopement of resident 1 on 07/18/2025.

Based on resident record review, the facility failed to ensure that the individualized service plan ( ISP

Based on resident review and staff interview, the facility failed to ensure that the care and services specified in the individualized service plan ( ISP

Based on resident review and staff interview, the facility failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs, such as wandering from the premises. Evidence: 1. The initial incident report received from the facility on 07/22/2025 indicated resident 1 who resides in the safe, secure unit wandered from the premises on 07/18/2025 via an unsecured door around 6pm. Resident 1 walked 0.9 miles from the facility to a family member?s home. Upon arrival, resident 1 removed his shoes and walked an additional 0.8 miles to another family member?s home in 77-degree weather. The report indicated the resident was unaccounted for approximately 2 hours and returned to the facility around 8pm by family. 2. During the onsite inspection on 08/22/2025, staff 1 acknowledged that resident 1 exited the third floors safe, secure environment unsupervised on 07/18/2025. Staff 1 also confirmed that the disabled mag lock and lack of supervision on the first floor resulted in resident 1 wandering from the premises.

Based on resident review and staff interview, the facility failed to ensure each resident with an inability to use the signaling device, in addition to any other services, once the resident has gone to bed each evening until the resident has arisen each morning, at a minimum, direct care staff make rounds no less often than every two hours, except that rounds may be made on a different frequency if requested by the resident and agreed to by the facility. This inability should also be included in the resident?s individualized service plan ( ISP

Based on resident review and staff interview, the facility failed to ensure that prior to admitting a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia to a safe, secure environment, the licensee, administrator, or designee determine whether placement in the special care unit was appropriate. The determination and justification for the decision should be in writing and retained in the resident?s file. Evidence: 1. Upon request, the facility did not provide documentation of the determination and justification on whether placement in the special care unit is appropriate for resident 6 (admit date, 07/01/2025). 2. During the onsite inspection, 08/22/2025, staff 1 confirmed resident 6 did not have documentation of the determination and justification on whether placement in the special care unit is appropriate by the licensee, administrator, or designee in their record.

Based on staff review, the facility failed to ensure that a facility licensed for both residential and assisted living care, all direct care staff attended at least 18 hours of training annually. Evidence: 1. Staff 4 (hire date, 04/16/2021), who works as direct care staff, attended 11.75 hours of training from 04/16/2024 ? 09/18/2024.

Based on staff review and staff interview, the facility failed to ensure that each direct care staff member maintained current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. Evidence: 1. Staff 5?s (hire date, 04/29/2022), who works as direct care staff and their record included a first aid certification was from American Life and Health Foundation. 2. During the onsite inspection, 08/22/2025, staff 6 acknowledged that staff 5?s first aid certification was not from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department.

Based on resident record review, the facility failed to ensure that residents who met the criteria for assisted living care, by the time the comprehensive ISP

Based on resident review and staff interview, the facility failed to ensure that the fall risk rating was reviewed and updated at least annually and after a fall. Evidence: 1. Upon request, the facility did not provide an annual fall risk rating for resident 3 (admit date, 07/21/2024). 2. During the onsite inspection, 08/22/2025, staff 1 confirmed that a fall risk rating was not reviewed and updated at least annually for resident 3. 3. Upon request, the facility did not provide documentation of risk ratings after a fall for resident 3 (progress notes indicate the following fall dates: 07/04/2025, 07/26/2025, 07/28/2025, 07/30/2025, and 08/10/2025). 4. Upon request, the facility did not provide documentation of risk ratings after a fall for resident 6 (fall dates, 07/16/2025, 07/17/2025, and 08/14/2025). 5. During the onsite inspection, 08/22/2025, staff 1 acknowledged that risk ratings were not reviewed and updated after a fall for resident 3 and resident 6.

Based on record review and staff interview, the facility failed to ensure for residents who met the criteria for assisted living care, a licensed health care professional, practicing within the scope of the health care professional?s profession, provided health care oversight at least every six months, or more often if indicated, based on the health care professional?s professional judgement of the seriousness of a resident?s needs or stability of a resident?s condition. Evidence: 1. Upon request, the facility did not provide documentation of a healthcare oversight completed every six months. 2. During the onsite inspection, 08/22/2025, staff 7 was unable to provide documentation of a completed health care oversight.

Based on resident review and staff interview, the facility failed to ensure that medications ordered for PRN

Based on resident review and staff interview, the facility failed to ensure for each resident with an inability to use the signaling device, in addition to any other services, once the resident has gone to bed each evening until the resident has arisen each morning, at a minimum, direct care staff make rounds no less often than every two hours, except that rounds may be made on a different frequency if requested by the resident and agreed to by the facility. This inability should also be included in the resident?s individualized service plan ( ISP

Based on record review and staff interview, the facility failed to develop and implement a semiannual review on the emergency preparedness and response plan for all staff, with emphasis placed on an individual?s respective responsibilities. The review should be documented by signing and dating. Evidence: 1. Upon request, the facility did not provide a semi-annual annual review on the emergency preparedness and response plan for all staff. 2. During the onsite inspection, 08/22/2025, staff 3 confirmed that a semi-annual review on the emergency preparedness and response plan for all staff was not documented as completed.

Based on record review and staff interview, the facility failed to review the emergency preparedness plan annually or more often as needed, documenting the review by signing and dating the plan, and made necessary plan revisions. Evidence: 1. Upon request, the facility did not provide an annual review of the emergency preparedness plan. 2. During the onsite inspection, staff 3 acknowledged that the annual review of the emergency preparedness plan was not documented as reviewed by signing and dating.

Based on record review and staff interview, the facility failed to ensure that the fire and emergency evacuation drill frequency and participation was in accordance with the current edition of the Virginia Statewide Fire Prevention Code. The drills required for each shift in a quarter were not conducted in the same month. Evidence: 1. June 2025 fire and emergency drill was not documented as completed. 2. During the onsite inspection, 08/22/2025, staff 8 confirmed that a fire and emergency drill was not documented as completed in June 2025.

Based on record review and staff interview, the facility failed to ensure that a record of the required fire and emergency evacuation drills included the number of residents participating, the time it took to complete the drill, and weather conditions. Evidence: 1. May 2025, July 2025, and August 2025?s fire and emergency drills documentation were missing the number of residents participating, the time it took to complete the drill, and weather conditions. 2. During the onsite inspection, 08/22/2025, staff 3 acknowledged that May 2025, July 2025, and August 2025?s fire and emergency evacuation drills documentation did not include the number of residents participating, the time it took to complete the drill, and weather conditions.

Based on record review and staff interview, the facility failed to ensure that procedures in the plan for resident emergencies were reviewed by the facility at least every six months with all staff. Documentation of the review should be signed and dated by each staff person. Evidence: 1. Upon request, the facility did not provide a semi-annual review of the procedures in the plan for resident emergencies with all staff. 2. During the onsite inspection, 08/22/2025, staff 3 confirmed that the procedures in the plan for resident emergencies were not documented as reviewed at least every six months with all staff.

Based on record review and staff interview, the facility failed to ensure that at least every six months, all staff currently on duty on each shift participated in an exercise in which the procedures for resident emergencies were practiced. Documentation of each exercise should be maintained in the facility for at least two years. Evidence: 1. The resident emergencies were practiced on 07/25/2024 with staff on each shift. 2. During the onsite inspection, 08/22/2025, staff 3 acknowledged that the procedures for resident emergencies were not practiced every six months, with the drill occurring on 07/25/2024 being the most recent.

Based on resident record and staff interview, the facility failed to ensure compliance with their own policies and procedures. Evidence: 1. The Readmission Policy states, ?the resident is placed on Alert Charting? when returning from a hospitalization. Per progress notes, resident 3 was not placed on alert charting following hospitalization on 05/16/2025. 2. On 06/13/2025, LI interviewed staff 3 who confirmed that resident 3 was not placed on alert charting upon return from the hospital on 05/16/2025.

Based on resident record, the facility failed to ensure that medications were administered not earlier than one hour before and not later than one hour after the facility?s dosing schedule. Evidence: Resident 3 was prescribed Enoxaparin 80 MG/0.8 ML syringe on 05/16/2025, scheduled to be administered at 9:00 am and 9:00 pm for 7 days. Per the resident 3?s progress notes this medication was administered on 05/17/2025 at 6:02 pm, 05/18/2025 at 11:55 am, and 05/21/2025 at 5:50 pm.

Based on resident record, the facility failed to ensure that medications were administered in accordance with the physician?s or other prescriber?s instructions. Evidence: 1. Resident 3 was prescribed Enoxaparin 80 MG/0.8 ML syringe on 05/16/2025, scheduled to be administered at 9:00 am and 9:00 pm for 7 days. 2. Per resident 3?s progress notes the Enoxaparin 80 MG/0.8 ML syringe was administered once daily on 05/17/2025, 05/18/2025, and 05/21/2025. 3. Resident 3?s May 2025 MAR

Based on resident record, the facility failed to ensure that at the time the medication was administered, the facility documented on a medication administration record ( MAR

Based on record review and staff interview, the facility failed to prepare and provide a disclosure statement on a form developed by the department. Evidence: 1. The disclosure statement was prepared on an outdated department form, 10/2019 with a section for the resident and/or legal guardian to initial. 2. On 05/20/2025, LI interviewed staff 9 who confirmed that the disclosure statement was prepared on an outdated department form.

Based on resident record review and staff interview, the facility failed to retain a copy of the written discharge statement in the resident?s records. Evidence: 1. Resident 2 (discharge date, 05/31/2024) and Resident 3 (discharge date, 09/30/2024) records did not include discharge statements. 2. On 05/20/2025, LI interviewed staff 9 who confirmed that the discharge statements were not accessible due to a recent change in management companies.

Based on record review, the facility failed to develop and implement a semi-annual review on the emergency preparedness and response plan for all staff, residents, and volunteers. The review was documented by signing and dating. Evidence: 1. Upon request the facility did not provide a semi-annual review on the emergency preparedness and response plan for all staff, residents, and volunteers.

Based on record review, the facility failed to review the emergency preparedness plan annually and document the review by signing and dating. Evidence: 1. Upon request the facility did not provide an annual review of the emergency preparedness plan.

Based on staff interview, it was determined that the facility failed to prevent residents from leaving the facility unsupervised. Evidence: On 7/31/2023 Resident A and B left the facility unsupervised and were located by a family member. Residents were unharmed and returned to the facility.