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Every family's needs are unique. We encourage you to visit Hills Home for Adults in person, speak with staff and current residents' families, and trust your instincts. The data on this page provides a starting point, but your personal impression matters most.
Families should exercise extreme caution due to serious reports of pest infestations and poor nutritional quality. While some staff members are described as kind and caring, there are significant concerns regarding the lack of fresh food and the cleanliness of the building.
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Key Review Excerpts
“Very caring staff.”
Source: VA State Licensing Agency
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: 08/15/2025 (arrival 9:05 a.m. / departure 4:20 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: 4 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: Lunch was observed. A medication pass observation was completed for 2 residents. The following were reviewed: staff and resident records, call bells, water temperatures, medication carts, and a first aid kit. 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 Darunda Flint, Licensing Inspector at 757-807-9731or by email at Darunda.a.flint@dss.virginia.gov
Based on resident review and review of the Medication Administration Record ( MAR
Based on observation and staff interview, the facility failed to ensure the interior and exterior of all buildings shall be maintained in good repair and kept clean and free of rubbish. Evidence: 1.During a tour of the facility the call system was not working. 2. Staff #3 acknowledged that the call system had not been working for several months.
Based on staff interview, the facility failed to develop a written emergency preparedness and response plan that shall address documentation of initial and annual contact with the local emergency coordinator to determine (i) local disaster risks, (ii) communitywide plans to address different disasters and emergency situations, and (iii) assistance, if any, that the local emergency management office will provide to the facility in an emergency. Evidence: 1. Staff #1 could not provide any documentation of contact with the local emergency official.
Based on document review and staff interview, the facility failed to ensure the findings of the most recent inspection of the facility was posted on the premises. Evidence: 1. During a tour of the facility, the most recent inspection posted in the facility was dated July 5, 2023. 2. Staff #1 acknowledged the most recent inspection was not posted on the premises.
Based on documentation review, the facility failed to provide a written agreement/ acknowledgement of notification dated and signed by the resident or applicant for admission, or the appropriate legal representative, and by the license or administrator. Evidence: 1. Resident # 1 was admitted to the facility on 11/18/2024. The written agreement in resident # 1?s file was not dated.
Based on resident record reviewed and staff interviewed, the facility failed to obtain an acknowledgment from the resident and/or their legal representative upon admission of receiving orientation and related information for new residents. Evidence: 1. Resident #1?s orientation document was not dated by the resident. The resident?s date of admission noted as 11/18/2024. 2. Staff #3 acknowledged the aforementioned was not dated in resident #1?s record.
Based on record review and staff interview, the facility failed to ensure the individualized service plan ( ISP
Based on review, the facility licensed for both residential and assisted living care, the administrator shall serve on a full-time basis as the on-site agent of the licensee and shall be responsible for the day-to- day administration and management of the facility. Evidence: 1. The administrator?s schedule did not reflect the administrator?s presence on a full-time basis as the on-site agent of the licensee. The administrator?s schedule noted the following hours: 08/06/2025 to 08/12/2025 (28 hours (h); and 08/13/2025 to 08/19/2025 (28 h). 2.Staff #3 acknowledged the aforementioned administrator?s schedule was correct.
Based on record review and interview, the facility failed to ensure if the prospective resident is coming from a private residence, information about the individual?s psychosocial and behavioral functioning shall be gathered from primary sources, such as family members, friends, or physician. Although there is no requirement for written information from primary sources, the facility must document the source and content of the information that was obtained. Evidence: 1. Resident #1 was admitted to the assisted living facility on 11/18/2024 from a private residence. 2. During a review of resident # 1?s record and interview with staff #3, the resident?s record did not contain documentation of information about the individual?s psychosocial and behavioral functioning. 3. Staff #3 acknowledged the aforementioned was not in resident #1?s record.
Based on record review, the facility failed to document a required interview between the administrator or a designee responsible for admission and retention decisions, the individual, and his legal representative occurred. Evidence: 1. The record for resident #1 did not contain documentation of the required interview between the administrator or designee and resident or legal representative. 2. Staff #3 acknowledged the record provided to the licensing inspector at the time of the inspection did not contain the required documentation
Based on record review and staff interview, the facility failed to ensure a mental health screening shall be conducted prior to admission if behaviors or patterns of behavior occurred within the previous six months that were indicative of mental illness, intellectual disability, substance abuse, or behavioral disorders and that caused, or continue to cause, concern for the health, safety, or welfare either of that individual or others who could be placed at risk of harm by that individual. Evidence: 1. The UAI
Based on observation, the facility failed to ensure the grounds shall be properly maintained to include mowing of grass and removal of snow and ice. Evidence: 1. The grass was overgrown and needed mowing.
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: 02/02/2024 from 11:10 am to 12:10 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 09/11/2024 regarding allegations in the area(s) of: Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 44 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: 1 Number of interviews conducted with staff: 2 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
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: 07/10/2024 from 9:00 am to 12:12 pm and 07/11/2024 from 8:00 am to 9:05 am. 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: 45 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: 4 Number of interviews conducted with staff: 2 Observations by licensing inspector: Lunch and an activity were observed. A medication pass observation was completed for 3 residents. The following were reviewed: resident and staff records, medication carts, call bells, and water temperatures. 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Based on record review, the facility failed to ensure each staff person on or within seven days prior to the first day of work at the facility and each household member prior to coming in contact with residents submit the results of a risk assessment, documenting the absence of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. The risk assessment shall be no older than 30 days. Evidence: 1. Staff #5 was hired on 03/29/2024; however, Staff #5?s initial TB risk assessment was completed 04/25/2024.
Based on record review, the facility failed to ascertain, prior to admission, whether a potential resident was a registered sex offender and failed to document that this was ascertained and the date the information was obtained. Evidence: 1. Resident #7 (admitted 03/27/2024) did not have a completed sex offender screening in their record.
Based on record review and interview, the facility failed to complete a resident?s UAI
Based on observation, the facility failed to ensure the interior of the building be maintained in good repair and kept clean and free of rubbish. Evidence: 1. Two ceiling tiles outside the Electrical Equipment Room off the dining area were observed with stains.
Based on record review, the facility failed to ensure the medication review include the items identified in the standard. Evidence: 1. The last medication review was completed on 4/30/2024; however, the review indicates a med room/station inspection to include its general appearance and observations, medication cart review, controlled drugs review, emergency kit review, and refrigerator/freezer review. The report did not include a review of the following: all medications that the resident is taking and medications that he could be taking if needed ( PRN
Based on record review, the facility failed to ensure a mental health screening be conducted prior to admission if behaviors or patterns of behavior occurred within the previous six months that were indicative of mental illness, intellectual disability, substance abuse, or behavioral disorders and that caused, or continue to cause, concern for the health, safety, or welfare either of that individual or others who could be placed at risk of harm by that individual. Evidence: 1. Resident #7 admitted to the facility on 03/27/2024 and did not have a mental health screen completed in their resident record. The hospital discharge paperwork indicates Resident #7 had behavior within the previous six months that were indicative of mental illness, intellectual disability, substance abuse, or behavioral disorders and that caused, or continue to cause, concern for the health, safety, or welfare either of that individual or others who could be placed at risk of harm by that individual.
Based on record review, the facility failed to ensure staff?s annual training include at least two of the required hours of training focus on infection control and prevention. Evidence: 1. Staff #2 and Staff #4?s 2023 annual training did not include at least two of the required hours of training focusing on infection control and prevention.
Based on record review, the facility failed to obtain a criminal history record report on or prior to the 30th day of employment for each employee. Evidence: 1. There was not a completed criminal history record report for Staff #5 (hired 03/29/2024) in their record. 2. Staff #6 was hired on 12/30/2023; however, the criminal history record report for Staff #6 was completed on 06/05/2024.
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: 04/09/2024 from 1:15 pm to 1:55 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 04/04/2024 regarding allegations in the area(s) of: Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 46 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: 1 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation(s) 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Based on record review, the facility failed to ensure medications be 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 has an order for Humalog to be administered 3 times daily with the sliding scale as follows ? 150 or less ? 0 units, 151-200 ? 2 units, 201-250 ? 4 units, 251-300 ? 6 units, 301-350 ? 8 units, and 351-400 ? 10 units. 2. Upon review of Resident #1?s April 2024 MAR
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: 02/02/2024 from 10:05 am to 10:40 am. 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 01/31/2024 regarding allegations in the area(s) of: Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 46 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: 1 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. However, violation(s) not related to the complaint(s) but identified during the course of the investigation can 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Based on record review, the facility failed to complete a resident?s UAI
Based on record review, the facility failed to ensure the individualized service plans be reviewed and updated at least once every 12 months. Evidence: 1. The last plan of care for Resident #1 was completed on 12/07/2022.
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: 07/05/2023 from 10:00 am to 2:00 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: 44 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: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Based on record review and interview, the facility failed to ensure first aid kits be checked at least monthly to ensure that all items are present and items with expiration dates are not past their expiration date. Evidence: 1. Staff #1 was unable to provide documentation of monthly checks on the first aid kit. The 2023 documentation available showed the first aid kit was reviewed 7/1/2023 and 4/1/2023.
Based on observation, the facility failed to ensure the availability of a 96-hour supply of emergency drinking water with at least 48 hours of the supply on site. Evidence: 1. Upon review of the facility?s emergency food and water supply with Staff #1, there was no emergency water supply available onsite at the time of inspection.
Based on interview, the facility failed to ensure dietary oversight was conducted every six months for specials diets by a dietitian or nutritionist. Evidence: 1. Staff #1 acknowledged a dietary oversight had not been conducted every six months by a dietitian or nutritionist for residents with a special diet.
Based on record review, the facility failed to ensure on or within seven days prior to the day of admission, a preliminary plan of care be developed to address the basic needs of the resident that adequately protects their health, safety, and welfare. Evidence: 1. Resident #2 admitted to the facility on 06/15/2023; however, there was no preliminary plan of care on or within seven days prior to the day of admission in Resident #2?s record.
Based on record review, the facility failed to ensure a mental health screening be conducted prior to admission if behaviors or patterns of behavior occurred within the previous six months that were indicative of mental illness, intellectual disability, substance abuse, or behavioral disorders and that caused, or continue to cause, concern for the health, safety, or welfare either of that individual or others who could be placed at risk of harm by that individual. Evidence: 1. Resident #1 admitted to the facility on 05/30/2023 and did not have a mental health screen completed in their resident record. The hospital discharge paperwork indicates Resident #1 had behavior within the previous six months that were indicative of mental illness, intellectual disability, substance abuse, or behavioral disorders and that caused, or continue to cause, concern for the health, safety, or welfare either of that individual or others who could be placed at risk of harm by that individual.
Based on record review, the facility failed to obtain a criminal history record report on or prior to the 30th day of employment for each employee. Evidence: 1. There was not a completed criminal history record report for Staff #5 in their record.
Based on observation, the facility failed to ensure menus for meals for the current week are dated and posted in an area conspicuous to residents. Evidence: 1. On 07/05/2023, the posted menu outside the dining room area was for the week of 05/13/2023-05/19/2023.
Based on interview, the facility failed to document staff participation in practice exercises for resident emergencies at least once every six months. Evidence: 1. The facility could not provide documentation that staff had participated in an exercise in which the procedures for resident emergencies were practiced at least every six months.
Based on record review, the facility failed to maintain personal and social data on staff to include verification that the staff person has received a copy of his current job description. Evidence: 1. Staff #2?s record does not include verification that the staff person has received a copy of their current job description.
Based on observation, the facility failed to ensure the interior of the building be maintained in good repair and kept clean and free of rubbish. Evidence: 1. During a tour of the facility, vents and sprinkler heads throughout the facility were observed to have grey colored substance. 2. Two ceiling tiles outside the Electrical Equipment Room off the dining area were observed wet and with stains. 3. One of the men?s tubs was observed to be peeling.
Based on observation, the facility failed to ensure a fire and emergency evacuation drawing be posted in a conspicuous place on each floor of each building used by residents to include the location of the areas of refuge, assembly areas, fire alarm boxes, and telephones. Evidence: 1. There were no fire and emergency evacuation drawings posted in a conspicuous place within the facility.
Based on record review and interview, the facility failed to ensure each staff person on or within seven days prior to the first day of work at the facility and each household member prior to coming in contact with residents submit the results of a risk assessment, documenting the absence of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: 1. Staff #1 was unable to provide the results of a TB risk assessment for Staff #2 (hired 6/24/23).
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: 7/18/22, 7/28/22 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: 44 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: 5 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alyshia E. Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Based on staff interview and observation, the facility failed to have a listing of all staff who have current certification in First Aid and CPR posted in the facility readily available to staff. Evidence: During the 7/18/22 inspection of the facility, there was no posting of staff members who had certification in First Aid and CPR.
Based on review of resident record, the facility failed to ensure that a discharge stated included all of the required information listed in the standards to be provided to the resident and as appropriate, his legal representative and designated contact person at the time of discharge. Evidence: Resident # 6?s discharge statement dated 6/1/22 was blank in the following areas: method of discharge notification to resident, date and method of discharge notification to legal representative, reason for discharge, actions taken by the facility to assist the resident in the discharge, date of the discharge, and destination.
Based on record review and staff interview, the facility failed to ensure it did not admit or retain individuals with psychotropic medications without a treatment plan. Evidence: 1. Resident #3 was admitted to the facility on 4/4/22 with physician orders for psychotropic medications. 2. Staff #2 acknowledged a psychotropic treatment plan for Resident # 3 was not present in the resident?s record for the inspector to review.
Based on documentation review and interview, the facility failed to ensure dietary oversight was conducted every six months for specials diets by a dietitian or nutritionist. Evidence: 1. The last oversight review for special diets was dated 9/19/21. 2. Staff #2 acknowledged dietary oversight had not been conducted every six months by a dietitian or nutritionist for residents with a special diet.
Based on record review the facility failed to ensure the administrator attended at least 20 hours of training related to management or operation of a residential facility for adults or relevant to the population in care annually. Evidence: 1. On 7/18/22, during the review of Staff#1?s training record, the record documented 1 hour of training for 2021. 2. Staff #2 acknowledged the facility did not have documentation of the administrator having the required 20 hours of annual training.
Based on resident record review, the facility failed to prepare and provide to the prospective resident a disclosure which contains all the required components. Evidence: 1. The records reviewed for Resident # 3 and Resident #4 contained Disclosure statements that did not include: general information about the facility, accommodations, services and fees, admission, transfer and discharge criteria, general number, functions and qualification of staff on each shift, and activities provided for residents. 2. Records for Residents #1 and #2 did not include disclosure statements. 3. Staff #2 acknowledged the disclosures for Residents #3 and #4 did not contain all of the required components, and that records for Residents #1 and #2 did not include disclosure statements.
Based on observation, the facility failed to ensure the posting of the name of the current on-site person in charge. Evidence: 1. During the on-site inspection on 7/28/22, the Manager on Duty sign contained information for 7/26/22. 2. Staff #2 acknowledged the sign had not been updated to reflect the current day.
Based on documentation review, the facility failed to document the resident?s orientation to the facility. Evidence: 1. Resident #4 was admitted to the facility on 5/6/22 and the acknowledgement of orientation in the resident?s file was not signed or dated by the resident or his legal representative. 2. Staff #2 acknowledged the acknowledgement of orientation form in the resident?s filed was not signed by the resident or his legal representative.
Based on observations made during the tour of the facility on 7/28/22, the facility failed to have the menu for the current week posted. Evidence: On 7/28/22, the menu posted was for the week of July 16, 2022- July 22, 2022.
Based on observation and interview, the facility failed to maintain the interior and exterior of the building in good repair and keep it clean and free of rubbish. Evidence: 1. During a tour of the facility on 7/18/22, the back bedroom was observed to contain various building supplies and a grocery cart full of maintenance supplies. 2. The men?s tub was observed to be peeling. 3. Staff #2 acknowledged these items were in need of cleaning and repair.
Based on document review, the facility failed to ensure each direct care staff member shall maintain current certification in First Aid. Each direct care staff member who does not have current certification in first aid shall receive certification within 60 days of employment. Evidence: 1. Staff #3 (D.O.H. 3/29/22) is a direct staff member who does not current have current First Aid certification. 2. Staff #2 acknowledged that Staff #3 does not currently have First Aid certification.
Based on staff record review the facility failed to ensure in a facility licensed for both residential and assisted living care, all direct care staff shall attend at least 18 hours of training annually. Evidence: 1. A review of Staff # 4?s record did not contain the required number of annual training hours. 2. Staff #2 acknowledged the staff record for Staff #4 did not contain the required amount of annual training.
Based upon documentation review, the facility failed to ensure at or prior to the time of admission, there shall be a written agreement signed by the resident. Evidence: 1. Resident #4 was admitted to the facility on 5/6/22. The resident agreement was not signed by Resident #4 until 7/18/22. 2. Staff #2 acknowledged the resident agreement for Resident #4 was not signed prior to or at the time of the resident?s admission to the facility.
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7/18/22, 7/28/22 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: 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: 2 Number of interviews conducted with staff: 1 Observations by licensing inspector: Additional Comments/Discussion: Licensing Inspector and staff discussed the requirement of reporting incidents to the regional licensing office/ assigned licensing inspector. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. However, violation(s) not related to the complaint but identified during the course of the investigation can 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 Alyshia E. Walker, Licensing Inspector at (757)670-0504 or by email at Alyshia.walker@dss.virginia.gov
Based on record review and interview, the facility failed to ensure that a report was made to the regional licensing office within 24 hours of any major incident that has negatively affected or that threatens the life, health, safety or welfare of any resident. Evidence: 1. On 5/25/22 Licensing Inspector received a telephone call regarding an Adult Protective Services (APS) alleged incident. 2. On 5/25/22 Licensing Inspector contacted Adult Protective Services Worker who confirmed they were investigating the incident and had been to the facility for the investigation. 3. The regional licensing office did not receive an incident report from the facility regarding the aforementioned incident or APS investigation. 2. Staff#1 acknowledged that the facility had not notified the Licensing Office regarding the APS investigation.
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