Holly Manor AL Il Operations LLC
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State Inspection History
State Inspections
Source: VA State Licensing Agency
Mar 18, 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: 3-18-26 from 10:00 a.m.- 11:30 a.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 2-25-26 regarding allegations in the area(s) of: resident care. Number of residents present at the facility at the beginning of the inspection: 67 Number of resident records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 4 An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Kimberly Davis, Licensing Inspector at (804) 356-3572 or by email at Kimberly.M.Davis@dss.virginia.gov
Oct 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: 10-14-25 from 10:35 a.m.-3:10 p.m. and 10-16-25 from 10:25 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: 71 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, first aid kit, lunch meal/menu, resident activities, medication pass, physician?s orders, medication administration records. 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
Based on a review of resident records the facility failed to ensure that prior to his admission to a safe, secure environment, the resident shall have been assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare. The physician shall be board certified or board eligible in a specialty or subspecialty relevant to the diagnosis and treatment of serious cognitive impairments (e.g., family practice, geriatrics, internal medicine, neurology, neurosurgery, or psychiatry). The assessment shall be in writing and shall include the following areas: 1. Cognitive functions (e.g., orientation, comprehension, problem-solving, attention and concentration, memory, intelligence, abstract reasoning, judgment, and insight); 2. Thought and perception (e.g., process and content); 3. Mood/affect; 4. Behavior/psychomotor; 5. Speech/language; and 6. Appearance. Evidence: The record for Resident # 4 who resides on the facility?s secure unit (admit date: 11-9-21) did not contain an assessment for serious cognitive impairment at all.
Based on a review of resident records the facility failed to ensure that six months after placement of the resident in the safe, secure environment and annually thereafter, the licensee, administrator, or designee shall perform a review of the appropriateness of each resident's continued residence in the special care unit. Evidence: The record for Resident # 4 who resides on the facility?s secure unit (admit date: 11-9-21) did not contain a review of the appropriateness the resident's continued residence in the special care unit at all.
Based on a review of staff records the facility failed to ensure that each direct care staff member shall maintain current certification in first aid. Evidence: The record for Staff # 3 (date of hire:12-19-16) did not contain documentation of first aid certification.
Based on a review of resident records the facility failed to ensure that upon admission, the assisted living facility shall provide an orientation for new residents and their legal representatives, including emergency response procedures, mealtimes, and use of the call system. If needed, the orientation shall be modified as appropriate for residents with cognitive impairments. Acknowledgment of having received the orientation shall be signed and dated by the resident and, as appropriate, his legal representative, and such documentation shall be kept in the resident's record. Evidence: The record for Resident # 2 (admit date: 2-4-25) contained a ?New Resident Orientation? form that was not signed or dated at all.
Based on a review of resident records the facility failed to ensure that at the time of discharge, a copy of the written discharge statement shall be retained in the resident's record. Evidence: The records for discharged Resident # 1 and Resident # 3 did not contain a copy of the written discharge statement.
Based on a review of resident records the facility failed to ensure that the Uniform Assessment Instrument ( UAI
Based on a review of facility documentation the facility failed to ensure that when any portion of an assisted living facility is subject to inspection by the Virginia Department of Health, the facility shall be in compliance with those regulations, as evidenced by an initial and subsequent annual reports from the Virginia Department of Health. The report shall be retained at the facility for a period of at least two years. Evidence: The facility?s health inspection report was last dated 7-17-24.
Based on a review of facility documentation the facility failed to ensure that it shall develop and implement an orientation and semi-annual review on the emergency preparedness and response plan for all staff, residents, and volunteers, with emphasis placed on an individual's respective responsibilities. The review shall be documented by signing and dating. The orientation and review shall cover responsibilities for: 1. Alerting emergency personnel and sounding alarms; 2. Implementing evacuation, shelter in place, and relocation procedures; 3. Using, maintaining, and operating emergency equipment; 4. Accessing emergency medical information, equipment, and medications for residents; 5. Locating and shutting off utilities; and 6. Utilizing community support services. Evidence: The facility was unable to provide documentation of a signed and dated review of the emergency preparedness and response plan for residents.
Based on a review of facility documentation the facility failed to ensure that a record of the required fire and emergency evacuation drills shall be kept in the facility for two years. Such record shall include: 1. Identity of the person conducting the drill; 2. The date and time of the drill; 3. The method used for notification of the drill; 4. The number of staff participating; 5. The number of residents participating; 6. Any special conditions simulated; 7. The time it took to complete the drill; 8. Weather conditions; and 9. Problems encountered, if any. Evidence: The facility?s record of fire and emergency evacuation drills for July, August, and September 2025 did not include all of the required items.
Sep 18, 2025Complaint
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: 9-18-25 from 12:05 p.m.- 2:20 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 9-17-25 regarding allegations in the area(s) of: resident care Number of residents present at the facility at the beginning of the inspection:71 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 interviews conducted with staff: 2 An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s); area(s) of non-compliance with standard(s) or law were: resident care and related services A violation notice was issued; any violation(s) not related to the complaint(s) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Kimberly Davis, Licensing Inspector at (804) 356-3572 or by email at Kimberly.M.Davis@dss.virginia.gov
Based on a review of the identified resident?s record the facility failed to ensure that the individualized service plan ( ISP
Based on a review of the identified resident?s record the facility failed to ensure that it shall regularly observe each resident for changes in physical, mental, emotional, and social functioning. Any notable change in a resident's condition or functioning, including illness, injury, or altered behavior, and any corresponding action taken shall be documented in the resident's record. Evidence: The record for Resident # 1 contained progress notes dated 8-22-25 that documented that ?resident?s toe was bleeding. Resident was assessed for injuries and big toe noted with wound. Area cleansed and dry dressing applied.? However, there was no documentation in the progress notes to indicate that the facility notified the resident?s next of kin or legal representative.
Sep 18, 2025Complaint
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: 9-18-25 from 10:55 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 complaint was received by VDSS Division of Licensing on 8-18-25 regarding allegations in the area(s) of: buildings and grounds and resident care. Number of residents present at the facility at the beginning of the inspection: 71 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of interviews conducted with staff: 1 An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s); area(s) of non-compliance with standard(s) or law were: buildings and grounds A violation notice was issued; any violation(s) not related to the complaint(s) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Kimberly Davis, Licensing Inspector at (804) 356-3572 or by email at Kimberly.M.Davis@dss.virginia.gov
Based on observation as well as an interview with staff the facility failed to ensure that the following sturdy safeguards shall be provided, with installation in compliance with the Virginia Uniform Statewide Building Code: grab bars by toilets. Evidence: During a tour of the facility with Staff # 1 on 9-18-25, Staff # 1 informed the inspector that the facility had removed the toilet grab bars but they had been replaced. However, there were no toilet grab bars in Room # 117 and Room 144. (photographic evidence was taken.)
Jul 23, 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: 7-23-25 from 10:40 a.m.- 12:50 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 regarding allegations in the area(s) of: personnel Number of residents present at the facility at the beginning of the inspection: 65 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
Based on a self-report received from the facility as well as a review of facility documentation, the facility failed to ensure that all staff shall: Be considerate and respectful of the rights, dignity, and sensitivities of persons who are aged or infirm or who have disabilities. Evidence: -According to a self-report received from the facility, on 3-26-25, Resident # 1 stated that a staff member grabbed her arms and squeezed hard, bruising her and Staff # 1 was suspended immediately. -Per progress notes in the record of Resident # 1, the resident was assessed by the DON with the Administrator, with bruising noted to her arms. -Facility documentation indicated that upon a further review it was determined that Staff # 1 was attempting to provide care to the resident who was refusing and exhibiting behaviors. -Per facility documentation Staff # 1 was re-educated on resident rights and safety.
Nov 7, 2024Routine
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: 11-7-24 from 10:05 a.m.- 2:35 p.m. and 11-14-24 from 10:30 a.m.-12:55 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 71 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Additional Comments/Discussion: The following items were also reviewed/observed during the inspection-facility documentation, facility postings, lunch meal/menu, first aid kit, medication pass, physician?s orders, and medication administration records. An exit meeting was conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Kimberly Davis, Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov
Based on a review of resident records the facility failed to ensure that six months after placement of the resident in the safe, secure environment and annually thereafter, the licensee, administrator, or designee shall perform a review of the appropriateness of each resident's continued residence in the special care unit. Evidence: The record for Resident # 2 (admit date: 11-10-22) did not contain a review of appropriateness for continued placement on the memory care unit.
Based on a review of staff records the facility failed to ensure that each staff person on or within seven days prior to the first day of work at the facility and prior to coming in contact with residents shall submit the results of a risk assessment, documenting the absence of Tuberculosis (TB) 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. Each staff person shall annually submit the results of a risk assessment, documenting that the individual is free of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: -The record for Staff # 1 (date of hire: 8-23-24) contained a TB screening dated 2-8-24). -The record for Staff # 2 (date of hire: 1-17-24) contained a TB screening dated 10-22-23. -The record for Staff # 3 (date of hire: 5-13-22) contained a TB screening dated 2-25-23.
Based on a review of staff records the facility failed to ensure that each direct care staff member shall maintain current certification in first aid. Evidence: The record for Staff # 3 (date of hire: 5-13-22) did not contain first aid certification, only CPR certification.
Based on a review of resident records the facility failed to ensure that a copy of the written discharge statement shall be retained in the resident's record. Evidence: -The record for Resident # 3 (discharge date: 8-25-24) did not contain a discharge statement. -The record for Resident # 4 (discharge date: 8-24-24) did not contain a discharge statement.
Based on a review of resident records the facility failed to ensure that for private pay individuals, the UAI
Based on a review of staff records the facility failed to ensure that the rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each resident or his legal representative or responsible individual and each staff person. Evidence of this review shall be the resident's, his legal representative's or responsible individual's, or staff person's written acknowledgment of having been so informed, which shall include the date of the review and shall be filed in the resident's or staff person's record. Evidence: The record for Staff # 3 (date of hire 5-13-22) contained an acknowledgment of the review of the rights and responsibilities of residents in assisted living facilities last dated 5-13-22.
Based on a review of facility documentation the facility failed to ensure that it shall comply with the Virginia Statewide Fire Prevention Code (13VAC5-51) as determined by at least an annual inspection by the appropriate fire official. Evidence: The facility?s last fire inspection was dated 6-13-23.
Based on a review of facility documentation as well as an interview with staff, the facility failed to ensure that it implement a semi-annual review on the emergency preparedness and response plan for all staff, residents, and volunteers, with emphasis placed on an individual's respective responsibilities. The review shall be documented by signing and dating. The orientation and review shall cover responsibilities for: 1. Alerting emergency personnel and sounding alarms; 2. Implementing evacuation, shelter in place, and relocation procedures; 3. Using, maintaining, and operating emergency equipment; 4. Accessing emergency medical information, equipment, and medications for residents; 5. Locating and shutting off utilities; and 6. Utilizing community support services. Evidence: The facility was unable to provide documentation of a semi-annual review on the emergency preparedness and response plan for all staff, residents, and volunteers, with emphasis placed on an individual's respective responsibilities.
Oct 5, 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: 10-5-23 from 10:15 a.m.-3:15 p.m. and 10-11-23 from 10:25 a.m.- 1:25 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: 69 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 5 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 3 Additional Comments/Discussion: The following items were also reviewed/observed during the inspection-facility documentation, facility postings, first aid kit, lunch meal/menu, medication pass, physician?s orders, medication administration records ( MAR
Based on a review of resident records the facility failed to ensure that written acknowledgment of the receipt of the disclosure by the resident or his legal representative shall be retained in the resident's record. Evidence: The record for Resident # 4 (admit date: 1-10-23) did not contain written acknowledgment of the receipt of the disclosure.
Based on a review of staff records the facility failed to ensure that each direct care staff member shall maintain current certification in first aid. Evidence: The record for Staff # 2 (date of hire:12-14-22) did not contain documentation of first aid certification and only contained CPR certification.
Based on a review of resident records the facility failed to ensure that the resident?s physical examination report shall be on file at the assisted living facility. Evidence: The record for Resident # 5 (admit date: 11-17-22) did not contain a physical examination report.
Based on a review of resident records the facility failed to ensure that the required personal and social information required shall be placed in the person's record and kept current. Evidence: The record for Resident # 2 (admit date: 1-27-23) did not contain the resident?s personal and social information.
Based on a review of resident records the facility failed to ensure that upon admission, the assisted living facility shall provide an orientation for new residents and their legal representatives, including emergency response procedures, mealtimes, and use of the call system. If needed, the orientation shall be modified as appropriate for residents with cognitive impairments. Acknowledgment of having received the orientation shall be signed and dated by the resident and, as appropriate, his legal representative, and such documentation shall be kept in the resident's record. Evidence: The record for Resident # 2 (admit date: 1-27-23) did not contain documentation of acknowledgment of having received the orientation.
Based on a review of resident records the facility failed to ensure that a copy of the written discharge statement shall be retained in the resident's record. Evidence: The record for Resident # 3 (discharge date: 3-30-23) did not contain a discharge statement.
Based on a review of resident records the facility failed to ensure that the rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each resident or his legal representative or responsible individual as stipulated in subsection H of this section. Evidence of this review shall be the resident's, his legal representative's or responsible individual's, written acknowledgment of having been so informed, which shall include the date of the review and shall be filed in the resident's or staff person's record. Evidence: The record for Resident # 9 (admit date: 3-21-18) contained a written acknowledgment of a review of resident rights and responsibilities last dated 3-18-22.
Based on a review of facility documentation the facility failed to ensure that the facility shall develop and implement an orientation and semi-annual review on the emergency preparedness and response plan for all staff, residents, and volunteers, with emphasis placed on an individual's respective responsibilities. The review shall be documented by signing and dating. The orientation and review shall cover responsibilities for: 1. Alerting emergency personnel and sounding alarms; 2. Implementing evacuation, shelter in place, and relocation procedures; 3. Using, maintaining, and operating emergency equipment; 4. Accessing emergency medical information, equipment, and medications for residents; 5. Locating and shutting off utilities; and 6. Utilizing community support services. Evidence: The facility did not provide documentation of a 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.
Based on 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. Evidence: The administrator stated that the facility had not conducted a practice exercise for a resident emergency since July 2022.
Oct 26, 2022Routine
Type of inspection: Renewal Date: October 26, 2022, of inspection and 2:09 p.m. to 5:09 p.m. 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: 56 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: (2) Number of interviews conducted with staff: (2) Observations by licensing inspector: building/grounds, medication administration observation and meal observation 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 non-compliance 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, Vashti Colson, Licensing Inspector (804) 662-9432 or by email at Vashti.Colson@dss.virginia.gov
VIOLATION: Based upon the record review, the facility failed to have an oversight at least every six months of special diets by a dietitian or nutritionist. EVIDENCE: The facility failed to have a current / recent healthcare oversight. The administration team provided notice to the licensing inspector that the dietary oversight was conducted but the facility failed to have the current report.
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