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Covenant Woods

7090 Covenant Woods Drive, Mechanicsville, VA 2311160 bedsLicensed & Active

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State Inspection History

State Inspections

Source: VA State Licensing Agency

8total
16deficiencies
Jan 6, 2026Routine

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: 1-6-26 from 9:47 a.m.- 2:15 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: 50 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 4 Additional Comments/Discussion: The following items were also reviewed/observed- 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

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 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: The record for Staff # 1 (date of hire: 8-20-25) did not contain documentation of first aid certification. This was confirmed by staff.

22VAC40-73-380-B

Based on a review of resident records the facility failed to ensure that the personal and social information required in subsection A of this section shall be placed in the person's record and kept current. Evidence: The record for Resident # 2 (admit date: 11-3-25) did not contain the required personal and social information. This was confirmed by staff.

22VAC40-73-450-E

Based on a review of resident records the facility failed to ensure that the individualized service plan( ISP

Jun 10, 2025Routine

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: 6-10-25 from 10:35 a.m.- 11:15 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/the secure unit. Number of residents present at the facility at the beginning of the inspection: 49 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with 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

22VAC40-73-1040-A

Based on a self-report received from the facility on 4-18-25, the facility failed to ensure monitoring of residents with serious cognitive impairments, such as door alarms, cameras, constant staff oversight, security bracelets that are part of an alarm system, or delayed egress mechanisms. Evidence: Based on an interview with staff, as well as a review of the record for Resident # 1 the resident was able to exit the main front door entrance of the memory care unit on 4-17-25 at 8:56 p.m. and walk to the end of the wheelchair ramp before staff could reach the resident and redirect her back into the facility.

22VAC40-73-460-D

Based on a self-report received from the facility on 4-18-25, the facility failed to ensure that it provided supervision of resident schedules, care, and activities, including attention to specialized needs, such as prevention of wandering from the premises. Evidence: Based on a review of facility documentation and an interview with staff, Resident # 1 was able to wander from the memory care unit and exit the facility on 4-17-25, reaching the end of the wheelchair ramp before staff could redirect her.

Dec 4, 2024Routine
CleanReport

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: 12-4-24 from 9:50 a.m.-2:50 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 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/observed during the inspection- facility documentation, facility postings, lunch meal/menu, first aid kit, medication pass, physician?s orders, and medication administration records ( MAR

Nov 21, 2024Routine

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11-21-24 from 10:15 a.m.-11:20 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 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) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov

22VAC40-73-1040-A

Based on a self-report received from the facility on 9-4-24, the facility failed to ensure monitoring of residents with serious cognitive impairments, such as door alarms, cameras, constant staff oversight, security bracelets that are part of an alarm system, or delayed egress mechanisms. Evidence: Based on an interview with staff, as well as a review of the record for Resident # 1 and Resident # 2, the residents were able to exit the main front door entrance of the memory care unit on 9-3-24 and walk to the end of the ramp before staff could reach the residents and escort them back into the facility. According to staff, it was determined that the wander guard of Resident # 1 was not functioning properly at the time of the incident.

22VAC40-73-460-D

Based on a self-report received from the facility on 9-4-24, the facility failed to ensure that it provided supervision of resident schedules, care, and activities, including attention to specialized needs, such as prevention of wandering from the premises. Evidence: Based on a review of facility documentation and an interview with staff, Resident # 1 and Resident # 2 were able to wander from the memory care unit and exit the facility on 9-3-24, reaching the end of the ramp before staff reached them.

Jul 19, 2024Routine

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: 7-19-24 from 10:42 a.m.- 12:05 p.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 5-16-24 regarding allegations in the area(s) of: the secure environment. Number of residents present at the facility at the beginning of the inspection: 48 Number of resident records reviewed: 1 Number of interviews conducted with staff: 1 Additional Comments/Discussion: A tour of the identified area of the facility was also completed. 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) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov

22VAC40-73-1040-A

Based on a self-report received from the facility on 5-16-24, the facility failed to ensure monitoring of residents with serious cognitive impairments, such as door alarms, cameras, constant staff oversight, security bracelets that are part of an alarm system, or delayed egress mechanisms. Evidence: Based on an interview with Staff # 1, as well as a review of the record for Resident # 1, the resident was able to exit the main front door entrance of the memory care unit on 5-15-24 and walk to the end of the ramp before staff could reach the resident and escort her back into the facility. The resident?s roam bracelet was determined to not be functioning properly.

22VAC40-73-460-D

Based on a self-report received from the facility on 5-16-24, the facility failed to ensure that it provided supervision of resident schedules, care, and activities, including attention to specialized needs, such as prevention of wandering from the premises. Evidence: Based on a review of facility documentation and an interview with Staff # 1, Resident # 1 was able to wander from the memory care unit and exit the facility on 5-15-24, reaching the end of the ramp before staff reached her.

Dec 12, 2023Routine

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: 12-12-23 from 10:23 a.m.-3:00 p.m. and 12-18-23 from 10:02 a.m.-12:30 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 50 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: 3 Number of interviews conducted with staff: 2 Additional Comments/Discussion: The following items were also reviewed/observed during the inspection-facility documentation, facility postings, lunch meal/menu, first aid kit, emergency food and water supplies, medication pass, physician?s orders, and Medication Administration Records ( MAR

22VAC40-73-210-F

Based on a review of staff records the facility failed to ensure that at least two of the required hours of training shall focus on infection control and prevention. Evidence: The training record for Staff # 3 (date of hire: 8-6-2020) did not contain two hours of annual training on infection control and prevention.

22VAC40-73-310-D

Based on a review of resident records the facility failed to ensure that the assisted living facility administrator shall provide written assurance to the resident that the facility has the appropriate license to meet his care needs at the time of admission. Copies of the written assurance shall be given to the legal representative and case manager, if any, and a copy signed by the resident or his legal representative shall be kept in the resident's record. Evidence: The record for Resident # 4 (admit date: 4-17-23) did not contain written assurance.

Mar 7, 2023Routine

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: 3-7-23 from 10:20 a.m.- 3:00 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: 42 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: 3 Number of interviews conducted with staff: 5 Additional Comments/Discussion: The following items were also reviewed/observed during the inspection: facility postings, facility documentation, first aid kit, emergency food and water supplies, medication pass, physician?s orders, and medication administration records ( MAR

22VAC40-73-950-E

Based on a review of facility documentation and an interview with the administrator, the facility failed to ensure the semi-annual review of 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. Evidence: The facility was unable to provide documentation of the semi-annual review of the emergency preparedness and response plan with residents, staff, and volunteers. The administrator stated that the facility would ensure that reviews of the facility?s plan would be conducted and documented semi-annually.

22VAC40-73-990-C

Based on a review of facility documentation and an interview with the administrator the facility failed to ensure that at least once every six months, all staff currently on duty on each shift shall participate in an exercise in which the procedures for resident emergencies are practiced. Documentation of each exercise shall be maintained in the facility for at least two years. Evidence: The facility was unable to provide documentation of an exercise in which a resident emergency was practiced. The administrator stated that the facility had conducted a recent practice exercise for a weather-related emergency, but not a resident emergency practice exercise.

Nov 17, 2021Routine

An unannounced renewal inspection was conducted by the licensing inspector on December 7, 2021 from 10:45 a.m. to 12:50 p.m. A census of 29 residents was reported. A tour of the facility was conducted to include the observation of facility postings, resident rooms, buildings and grounds, lunch meal/menu, activities, medication pass, physician's orders/Medication Administration Records ( MAR

22VAC40-73-250-D

Based on a review of staff records the facility failed to ensure that each staff record contained a current tuberculosis (TB) screening. Evidence: The record for Staff # 2 (date of hire: 2-20-2020) contained a TB screening last dated 3-8-2020.

22VAC40-73-260-C

Based on observation of facility postings, the facility failed to post a listing of all staff who have current certification in first aid or CPR so that the information is readily available to all staff at all times. Evidence: The facility did not have a list posted of staff certified in first aid/CPR.

22VAC40-73-970-E

Based on a review of facility documentation, the facility failed to ensure that it documented the number of residents participating in fire and emergency evacuation drills. Evidence: The facility's Emergency Drill Reporting Forms (November 2020- October 2021) did not document the number of resident's participating in fire/evacuation drills and the facility's accompanying Disaster Drill/Training Attendance sign-in sheets only documented staff who participated.

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