Cogir of West End, Alexandria
Families consistently rate this highly — reviewers highlight engaging and creative activities program. Schedule a visit to confirm the fit.
based on 97 Google reviews
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What this means for your family
This facility is an excellent choice for families prioritizing social engagement and a warm, community-focused atmosphere. However, because dining experiences are reported inconsistently, you should personally tour the dining area and ask current residents about the current menu variety and food quality.
Google Reviews
Google Reviews
97 reviews on Google“Families considering Cogir of West End can expect a warm, family-like atmosphere characterized by highly praised activity programs and a dedicated staff. While most residents and visitors rave about the engaging events and friendly service, one reviewer raised significant concerns regarding the quality and variety of the food.”
Quality Themes
Tap a score for detailsStrengths
- Engaging and creative activities program
- Warm and attentive staff members
- Clean and beautiful living environment
- Welcoming and professional concierge/sales team
Concerns
- Poor food quality and lack of variety
Rating Trends
Tap a year to see what changed
Distribution · 30 analyzed
How They Respond to Reviews
This facility actively engages with reviewer feedback.
Questions for Your Tour
- 1I noticed how much the team values feedback from the community; how do you typically use resident and family input to improve the dining experience and menu variety?
- 2The activity programs here seem very creative and engaging; could you walk us through a typical weekly schedule for a resident?
- 3Since you are memory care certified, what specific protocols are in place to ensure resident safety and handle medical emergencies during the night?
- 4The facility looks beautiful and very well-maintained; how often is the housekeeping and cleaning schedule performed in the resident living areas?
- 5We are looking for a warm environment for our loved one; how do you support the staff in maintaining that attentive, personalized care that people often mention?
- 6With 127 residents, how do you ensure that each person's specific dietary needs and preferences are met during meal times?
Personalized based on this facility's data
Key Review Excerpts
“I highly recommend Sabrina, the Director of Activities, and her incredible team. Sabrina brings such warmth, creativity, and dedication to everything she does for the residents.”
“Cogir is the best value around the beltway. There is a caring staff, great food, daily exercise programs, weekly field trips, 8 conversational areas that add living space to your apartment for guests and friends.”
“The food here is terrible. No variety, no quality. Do not believe the glowing advertisements on their website.”
State Inspection History
State Inspections
Source: VA State Licensing Agency
Mar 11, 2026Complaint
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: 03/11/2026 Time in: 3:15 PM Time out: 7:14 PM 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 11/17/2025 regarding allegations in the area(s) of: Staffing and Supervision, Resident Care and Related Services and Complaint Investigation. Number of residents present at the facility at the beginning of the inspection: 72 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Licensing inspector (LI) observed residents entering and exiting the facility for community outings and residents interacting with peers and staff in the lobby area. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s); area(s) of non-compliance with standard(s) or law were: Resident Care and Related Services and Complaint Investigation 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. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of these inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov
Based on record review and staff interview, the facility failed to maintain a written plan that specified the number and type of direct care staff required to meet the day-to-day, routine direct care needs and any identified special needs for the residents in care. Evidence: 1. Upon request, 03/11/2026 the facility did not provide the written staffing plan to the licensing representative. 2. During the onsite inspection, 03/11/2026, staff 1 confirmed that the written staffing plan was not provided to the licensing representative upon request.
Based on resident record and staff interview, the facility failed to ensure that financial arrangement for accommodations, services, and care that specified listing of specific charges for accommodations, services, and care to be made to the individual resident signing the agreement, the frequency of payment, and any rules relating to nonpayment. Evidence: 1. Resident 1 admitted to the facility on 06/01/2025. 2. Resident 1?s agreement (signed, 04/30/2025) indicated that the ?Assisted Living ? Care Level monthly charge was $3,220.00;? however, the Schedule of Resident Rates and Fees and Description of Service Levels (Exhibit 2) do not match the $3,220.00, Care Level monthly charge(s). 3. During the onsite inspection, 03/11/2026, staff 3 acknowledged that Exhibit 2 does not match the care level charge of $3,220.00. Staff 3 stated that there was a change of fees that occurred around April 2025 and the most recent and accurate Exhibit 2 may not have been added to resident 1?s agreement. Staff 3 was unable to provide the accurate resident rates and fees for the month of April 2025 to compare to resident 1?s monthly Assisted Living ? Care Level charge.
Based on resident record review and staff interview, the facility failed to ensure that no medication, dietary supplement, diet, medical procedure, or treatment should be started, changed, or discontinued by the facility without a valid order from a physician or other prescriber. Medications include prescription, over-the-counter, and sample medications. Evidence: 1. Upon request, 03/11/2025, the facility did not provide resident 1?s written or discontinued orders from 06/01/2025 through 11/2025. 2. During the onsite inspection, 03/11/2026, staff 1 confirmed that written and discontinued orders were not provided to licensing upon request. Staff 1 also acknowledged that the physician order sheet that was provided to licensing did not include any medications that were discontinued or discontinue order dates.
Based on resident record review and staff interview, the facility failed to ensure that medications were administered in accordance with the physician?s or other prescriber?s instructions and consistent with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing. Evidence: 1. Resident 1 was prescribed Antacid 500 MG (take 1 tablet by mouth three times daily for indigestion for 7 days; start date, 05/20/2025); however, June 2025 medication administration record ( MAR
Mar 11, 2026Complaint
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: 03/11/2026 Time in: 1:20 PM Time out: 3:15 PM 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 02/18/2026 regarding allegations in the area(s) of: Personnel, Staffing and Supervision, Resident Care and Related Services and Complaint Investigation. Number of residents present at the facility at the beginning of the inspection: 72 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 3 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Licensing inspector (LI) observed residents participating in scheduled activities. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegations of non-compliance with standard(s) or law, and violation(s) were 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. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of these inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov
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 ensure that individualized service plans ( ISP
Based on staff record review and staff interview, the facility failed to ensure that the rights and responsibilities of residents in assisted living facilities should be reviewed annually with each staff person. Evidence of this review should be the staff person?s written acknowledgment of having been informed, which should include the date of the review and should be filed in the staff person?s record. Evidence: 1. Staff 5 (hire date, 10/24/2024) records indicated that resident rights training was completed on 02/22/2025. 2. During the onsite inspection, 03/11/2026, staff 1 and staff 2 acknowledged that staff 5 did not complete resident rights training annually.
Based on video recording, the facility failed to ensure that residents were treated with courtesy, respect, and consideration as a person of worth, sensitivity, and dignity. Evidence: 1. Collateral contact 1 provided a video recording on 02/15/2026 of resident 3 receiving ADL
Jan 29, 2026ComplaintCleanReport
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: 01/29/2026 Time in: 5:31 PM Time out: 6:09 PM 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 12/22/2025 regarding allegations in the area(s) of: Resident Care and Related Services and Complaint Investigation Number of residents present at the facility at the beginning of the inspection:77 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed:1 Number of staff records reviewed: 0 Number of interviews conducted with residents:0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Licensing inspector observed residents engaging with peers and staff and participating in scheduled activities. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(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 Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov
Jan 29, 2026Routine13Report
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: 01/29/2026 Time in: 10:32 AM Time out: 5:30 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 77 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: 6 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 4 Observations by licensing inspector: Licensing inspector (LI) observed residents participating in physical therapy, entering and exiting the facility for community outings, interacting with staff, peers, and visitors, and engaging in scheduled activities. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of these inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov
Based on record review and staff interview, the facility failed to ensure that the administrator should ensure at least an annual review of infection prevention and policies and procedures for any necessary updates. A licensed health care professional, practicing within the scope of his profession and with training in infection prevention, should be included in the review to ensure compliance with applicable guidelines and regulations. Documentation of the review should be maintained at the facility. Evidence: 1. Upon request, 01/29/2026, the facility did not provide documentation of the annual review of the infection control program. 2. During the onsite inspection, 01/29/2026, staff 7 stated that a review was completed with staff, but confirmed documentation of the review was not maintained at the facility.
Based on record review and staff interview, the facility failed to ensure that the statement was made on the liability insurance statement form provided by the department. Evidence: 1. Upon request, 01/29/2026, the facility did not provide a liability insurance statement. 2. During the onsite inspection, 01/29/2026, staff 7 confirmed that the liability insurance statement form was not provided to licensing upon request
Based on record review and staff interview, the facility failed to ensure to prepare and provide a statement to the prospective resident and the prospective resident?s legal representative, if any, that discloses information about the facility. The statement should be on a form developed by the department. Evidence: 1. Upon request, 01/29/2026, the facility did not provide a disclosure statement. 2. During the onsite inspection, 01/29/2026, staff 7 confirmed that the disclosure statement was not provided to licensing upon request.
Based on licensing inspector?s observation and staff interview, the facility failed to notify the department?s regional licensing office in writing within 14 days of a change in a facility?s administrator, including the resignation of an administrator, appointment of an acting administrator, and appointment of a new administrator, except that the time period for notification may differ as specified in subdivision 2 of this subsection. Evidence: 1. During the onsite inspection, 01/29/2026, staff 7 confirmed that staff 11?s last day of employment was 11/12/2025. 2. Staff 8 confirmed that collateral contact 2 was notified via email on 11/25/2025; however, the regional licensing office was not included on the email notification.
Based on record review and staff interview, the facility failed to maintain a written work schedule that included the name and job classifications of all staff working each shift, with an indication of whomever was in charge at any given time. The facility should maintain a copy of the schedule for two years. Evidence: 1. Upon request, 01/29/2026, the facility did not provide April 2025 and June 2025?s written work schedule to licensing upon request. 2. During the onsite inspection, 01/29/2026, staff 7 confirmed that April 2025 and June 2025?s written work schedules to include the name and job classifications of all staff working each shift, with an indication of whomever was in charge at any given time was not provided to licensing upon request. Staff 7 confirmed that a copy of April 2025 and June 2025?s written work schedule was not maintained at the facility.
Based on resident record review and staff interview, the facility failed to ensure that a current picture of each resident should be readily available for identification purposes or, if the resident refuses to consent to a picture, there should be a narrative physical description, which is annually updated, maintained in his file. Evidence: 1. Resident 4?s (admit date, 12/22/2025) chart did not include a current picture readily available for identification purposes. 2. During the onsite inspection, 01/29/2026, staff 7 confirmed that resident 4?s chart did not include a current picture or a narrative physical description.
Based on record review and staff interview, the facility failed to ensure to provide a written response to the council prior to the next meeting regarding any recommendations made by the council for resolution of problems or concerns. Evidence: 1. April 2025 through December 2025 resident council documentation did not include a written response to the council prior to the next meeting. 2. During the onsite inspection, 01/29/2026, staff 7 confirmed that a written response was not provided to the council prior to the next meeting regarding any recommendations made by the council for resolution of problems or concerns for the months of April 2025 through December 2025.
Based on record review and staff interview, the facility should develop 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 should be documented by signing and dating. Evidence: 1. Upon request, 01/29/2026, the facility did not provide a semi-annual review on the emergency preparedness and response plan for all staff and residents. 2. During the onsite inspection, 01/29/2026, staff 7 confirmed that the facility did not provide documentation of a semi-annual review with signatures and dates on the emergency preparedness and response plan for all staff and residents to licensing upon request.
Based on record review and staff interview, the facility failed to ensure to review the emergency preparedness plan annually or more often as needed, document the review by signing and dating the plan, and make necessary plan revisions. Evidence: 1. Upon request, 01/29/2026, the facility did not provide documentation of the emergency preparedness plan annual review. 2. During the onsite inspection, 01/29/2026, staff 7 confirmed that documentation of the emergency preparedness plan annual review was not provided to licensing upon request.
Based on record review and staff interview, the facility failed to ensure that fire and emergency evacuation drill frequency and participation should be in accordance with the current edition of the Virginia Statewide Fire Prevention Code. The drills required for each shift in a quarter should not be conducted in the same month. Evidence: 1. Upon request, 01/29/2026, the facility did not provide fire drill documentation for the months of March through June 2025. 2. During the onsite inspection, 01/29/2026, staff 7 and staff 10 confirmed that fire drill documentation was not provided for the months of March through 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 should be kept in the facility for two years. Such record should include the date and time of the drill, the number of residents participating, and weather conditions. Evidence: 1. July 2025 through December 2025?s fire drill records did not include the date and time of the drill, the number of residents participating, and weather conditions. 2. During the onsite inspection, 01/29/2026, staff 7 confirmed that fire drills records did not include the date and time of the drill, the number of residents participating, and weather conditions.
Based on licensing observation and staff interview, the facility failed to ensure the availability of a 96-hour supply of emergency food. At least 48 hours of the supply must be on site at any given time, of which the facility?s rotating stock may be used. Evidence: 1. During the onsite inspection, 01/29/2026, licensing inspector (LI) requested to view the storage area that held emergency food and water. LI observed the storage area with staff 9, who stated that the facility was cycling out emergency food, so it did not spoil. Staff 9 stated that the facility did not have 48 hours supply of emergency food on site. 2. Picture taken.
Based on record review and staff interview, the facility failed to ensure that the procedures in the plan for resident emergencies required in subsection A of this section should be 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, 01/29/2026, the facility did not provide documentation of a review of procedures for resident emergencies. 2. During the onsite inspection, 01/29/2026, staff 7 provided a review of mental health emergencies. Staff 7 confirmed that the review did not cover all of the procedures in the plan for resident emergencies required in subsection A.
Mar 14, 2025Routine
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 03/14/2025 Time in: 9:55 AM Time out: 5:59 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 58 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: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: Licensing inspector (LI) observed the physical plant of the facility. LI observed a medication pass, residents dining for lunch, and participating in scheduled activities. Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. 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 Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov.
Based on staff record review and staff interview, the facility failed to ensure that the administrator attended at least 12 hours of training in cognitive impairment within three months of the starting date of employment. Evidence: 1. Staff 1?s (hire date, 09/24/2024) record did not include cognitive impairment training. 2. On 03/14/2025, LI interviewed staff 1 who confirmed that cognitive impairment training was not included in staff records.
Based on record review and staff interview, the facility failed to provide health care oversight at least every six months. All residents were included at least annually. Evidence: 1. The healthcare oversight was completed 04/28/2025 through 04/28/2025 and reviewed 9 residents. 2. On 03/14/2025, LI interviewed staff 4 who confirmed that the healthcare oversight was completed annually and reviewed 9 residents.
Based on resident record review and staff interview, the facility failed to ensure that no medication was started without a valid order from a physician or other prescriber. Evidence: 1. Resident 1?s (admit date, 02/27/2025) physical examination, recommendations for care included medications, which were used as physician orders. 2. On 03/14/2025, LI interviewed staff 4 who confirmed that physical examinations were used as physician orders. Staff 4 stated that it made the admission process more seamless.
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 and residents. Evidence: 1. Upon request the facility did not provide a semi-annual review of the emergency preparedness and response plan. 2. On 03/14/2025, LI interviewed staff 1 who confirmed that a semi-annual review of the emergency preparedness and response plan was not provided.
Based on record review and staff interview, the facility failed to review the emergency preparedness plan annually and document with signature and date. Evidence: 1. Upon request the facility did not provide the annual review of the emergency preparedness and response plan. 2. On 03/14/2025, LI interviewed staff 1 who confirmed that an annual review of the emergency preparedness and response plan was not provided.
Oct 3, 2024Complaint
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/03/2024 Time In: 12:43 PM Time Out: 4:03 PM 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 09/18/2024 regarding allegations in the area(s) of: Personnel: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 63 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 6 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: LI observed residents interacting with staff, entering and exiting the campus for community activities, and residents at the nursing station. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegations of non-compliance with standard(s) or law, and violation(s) were 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. 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. 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 Nina Wilson Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov.
Based on resident record review and staff interviews, the facility failed to ensure to implement their written medication management plan to include methods to ensure that each resident?s prescription medications and any over-the-counter drugs and supplements ordered for the resident were filled and refilled in a timely manner to avoid missed dosages. Evidence: 1. Resident 1 has an order for Rytary 48.75-195 Capsule ER, give 1 capsule by mouth three times a day for Parkinson, that was not available for administration on 09/05/2024 at 1:00 pm and 6:00 pm or 09/06/2024 at 8:00 am and 1:00 pm, per September 2024 medication administration record ( MAR
Based on resident record review and staff interview, the facility failed to ensure that no medication, dietary supplement, diet, medical procedure, or treatment should be started, changed, or discontinued by the facility without a valid order from a physician or other prescriber. Medications include prescription, over-the-counter, and sample medications. Evidence: The medication cart contained a bubble pack of Vitamin D2 5000U (take 1 capsule by mouth every week ?supplement) for Resident 1 (admit date, 03/01/2023). Resident 1 did not have an order for Vitamin D2 5000U.
Based on resident record review, the facility failed to ensure that medications were administered in accordance with the physician?s or other prescriber?s instructions. Evidence: 1. Resident 1 had an order for Rytary 48.75-195 capsule ER to be administered 1 capsule by mouth three times a day for Parksinsons. 2. Resident 1 September 2024 MAR
Based on resident record review and staff interview, the facility failed to ensure that the Medication Administration Record ( MAR
Feb 29, 2024Complaint
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: 02/29/2024 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 70 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 18 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to Resident Care and Related Services and Staffing and Supervision, 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 Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov
Based on resident record review and resident interview, the facility staff failed to promptly respond to resident?s needs. Evidence: ? According to the Detailed Event Report for the nurse call light response times there were 39 instances between 11/7/2023 and 11/8/2023 in which the nurse call response time was greater than 30 minutes. The following residents rang for assistance using their nurse call pendant, all listed below were answered after 30 minutes: ? Res A on 11/7/2023 at 1:18am, 4:43am, 7:36am, 12:48am, 2:40pm, 4:25pm, 6:13pm, 7:05pm, 9:51pm and on 11/8/2023 at 4:13pm and 9:26pm ? Res B 0n 11/7/20283 at 7:36am ? Res C on 11/7/2023 at 12:44pm ? Res D on 11/7/2023 at 12:53pm and on 11/8/2023 at 1:13am and 8:26am ? Res E on 11/7/2023 at 3:44pm and on 11/8/2023 at 1:46pm ? Res F on 11/7/2023 at 4:16pm, 6:22pm and on 11/8/2023 at 2:44pm ? Res G on 11/7/2023 at 5:38pm and on 11/8/2023 at 9:16am ? Res H on 11/7/2023 at 6:00pm ? Res I on 11/7/2023 at 7:20pm ? Res J on 11/7/2023 at 8:08pm ? Res K on 11/8/2023 at 5:11am and 9:51am ? Res L on 11/8/2023 at 9:14am ? Res M on 11/8/2023 at 9:38am ? Res N on 11/8/2023 at 10:11am ? Res O on 11/8/2023 at 12:40pm ? Res P on 11/8/2023 at 12:45pm ? Res Q on 11/8/2023 at 7:27pm and 9:26pm ? Res R on 11/8/2023 at 7:45pm ? Res S on 11/7/2023 at 8:05pm
Feb 29, 2024Other
Number of residents present at the facility at the beginning of the inspection: 70 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Number of staff records reviewed: 4 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 4 Observations by licensing inspector: LI team toured the physical plant of the facility, and observed residents involved in independent pursuits. This LI team also observed a medication pass. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov
Based on resident records review and staff interview, the facility staff failed to follow the facility?s Weight Tracking and Monitoring policy. The policy states that ?All assisted living residents will be weighed upon move-in and quarterly unless a significant weight change is noted.? Evidence: Resident D?s last weight was obtained on 11/15/2023, Res E?s last recorded weight was on 9/19/2019, Res F?s last recorded weight was on 6/29/2021, and Res H had no recorded weights from January 1- December 31, 2023. Staff interviewed stated there were no other weights documented in Resident D, E, F or H?s medical record.
Based on resident records review and staff interview, the facility staff failed to follow-up on the Dietician?s recommendations to the resident?s physician. Evidence: Dietary Report completed on February 12, 2024, by, Margaret Radzikowski, contained documentation for: ? Resident C recommending change diet to Regular, regular textures, think liquids. ? Resident G recommending discontinue NAS diet. Start No Concentrated Sweets diet. Staff D stated there was no documentation of the communication from the facility to the physician regarding dietary recommendations from the dietician for Resident C or G. Review of resident records and physician orders for Resident C and G did not show evidence of implementation of dietary recommendations from February 12, 2024 Dietician report.
Based on resident records review and staff interview, the facility staff failed to ensure that medications were administered in accordance with the physician?s or other prescriber?s orders. Evidence: Resident A had a prescription dated 11/16/2000 for Atorvastatin 10 mg Tablet, take 1 tablet by mouth at bedtime. The January 2024 and February 2024 Medication Administration Record ( MAR
Based on resident records review and staff interview, the facility staff failed to obtain a physician?s order for a restraint (bedrail) before the restraint was used. Evidence: Resident D, E and F did not have an order from a physician to use a restraint (bedrail) on file.
Based on resident records review and staff interview, the facility staff failed to address the use of bedrails on the resident?s Individualized Service Plan ( ISP
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