Maple Lawn Residential Living
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State Inspection History
State Inspections
Source: VA State Licensing Agency
Feb 5, 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: 02/05/2026 from 10:30 a.m. until 2:45 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: 16 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: 2 Number of interviews conducted with residents: 7 Number of interviews conducted with staff: 3 Observations by licensing inspector: The Licensing Inspector toured the community and observed the residents during activities and meals. The Licensing Inspector reviewed the following at the time of inspection: sample of resident and employee records, medication administration, fire drills, emergency drills, pharmacy review, menus, activity calendars, verified appropriate amount of liability insurance, and dietician report. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of these inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem-solving conference. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Angie Via, Licensing Inspector at (540) 682-1739 or by email at Angela.Via@dss.virginia.gov
Based on staff record reviews and staff interviews, the facility failed to ensure that staff members received training on their duties and responsibilities prior to being placed in charge. Evidence: 1. During staff record review on 2/5/2026, the LI requested the designated direct care staff person in charge written training documentation for staff 2, hired 7/14/2009 and staff 3, hired 9/10/2019. 2. Staff 2 and 3 confirmed there was no documented training on duties and responsibilities prior to being placed in charge.
Based on resident record reviews and staff interviews, the facility failed to ensure that a determination had been made that the facility could meet the needs of the individual based upon a mental health screening in accordance with 22VAC40-73-330 A. Evidence: 1. Resident 1 was admitted on 3/15/2024, without the required mental health screening. 2. Resident 1?s Uniform Assessment Instrument ( UAI
Based on resident record reviews and staff interviews, the facility failed to complete a fall risk rating for residents who meet the criteria for assisted living care by the time the comprehensive Individualized Service Plan ( ISP
Based on resident record reviews and staff interviews, the facility failed to ensure that, upon admission, an orientation for new residents and their legal representatives, including emergency response procedures, mealtimes, and use of the call system was provided to the resident and, as appropriate, his legal representative, and a signed and dated acknowledgment of having received the orientation was maintained in the resident's record. Evidence: 1. The record for resident 1, admitted 3/15/2024, did not contain documentation of orientation to the facility. 2. The record for resident 2, admitted 4/1/2024, did not contain documentation of orientation to the facility. 3. During an interview with the LI on 2/5/2026, staff 3 confirmed a signed and dated acknowledgment of having received the orientation was not completed and maintained in the resident record for residents 2 and 3 at the time of admission.
Feb 18, 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: 2/18/2025 10:00am-1:15pm. 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: 16 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: 2 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: The Licensing Inspector observed the residents during activities, meals and in their apartments. The following were reviewed at the time of inspection: Menus, activity calendars, fire drills, emergency drills, resident council minutes, dietician report, healthcare oversight. Additional Comments/Discussion: None 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 Jessica Gale, Licensing Inspector at 540-571-0358 or by email at Jessica.gale@dss.virginia.gov
Based on record review and staff interview, the facility failed to ensure that within the 30 days preceding admission, a resident had a physical examination by an independent physician completed. Evidence: 1. The record review for resident 2 (admitted 4/1/2024) completed on 2/18/2025, showed a physical examination and report for that was completed on 02/27/2024. 2. During an interview with staff 1 on 2/18/2025, when asked if the physical examination was completed within 30 days prior to admission for resident 2, staff 1 stated ?no?.
Based on record review and staff interview, the facility failed to ensure the comprehensive individualized service plan ( ISP
Dec 27, 2024RoutineCleanReport
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: 12/27/2024 2:19pm-3:00pm 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 12/26/2024 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: 15 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: The licensing inspector reviewed resident records and toured the facility including resident apartments. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report 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 Jessica Gale, Licensing Inspector at 540-571-0358 or by email at Jessica.gale@dss.virginia.gov
Jan 8, 2024RoutineCleanReport
Date of Inspection: January 8, 2024 Type of Inspection: Renewal Inspection If you have any questions or email changes, please do not hesitate to contact me at laura.lunceford@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov. Census 13 All facility self-reported incidents were reviewed at the time of inspection. The Licensing Inspector observed the residents during meals and activities. The Licensing Inspector reviewed the following at the time of inspection: fire drills, emergency drills, resident council reports, dietician report and healthcare oversight.
Apr 4, 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: 4/4/2023 from approximately 6:50 am to 6:00 pm and on 4/5/2023 from approximately 8:45 am to 10:25 am and 1:05 pm to 3:30 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 15 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 + selected sections of 2 additional residents Number of staff records reviewed: 3 + selected sections of 2 contract staff Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 2 Observations by licensing inspector: Medication administration, activities, meals, first aid kits, staffing, postings, medication cart, etc. Additional Comments/Discussion: Once the fire official sends the inspection report, email it to this licensing inspector. 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 Janice Knight, Licensing Inspector at (540) 430-9258 or by email at janice.knight@dss.virginia.gov
Based upon observations and interviews, the facility failed to implement an infection control program regarding hand washing when administering medications. Evidence: 1. On 4/4/2023 at approximately 10:50 am, the licensing inspector (LI) observed staff 2 start to prepare medications for resident 8. As staff 2 prepared to open the medication package, the LI asked staff 2 if she had forgotten anything, she then immediately sanitized her hands. During the preparation, staff 2 did not wear disposable gloves or use hand sanitizer until prompted by the LI. The LI had to prompt staff 2 again when she started to open the medications for resident 9. 2. The facility?s infection control policy states on page 3, ?Staff and volunteers will clean their hands before and after resident care, as needed during the care of an individual, after gloves are removed, after using toilet facilities, immediately when the hands are accidentally contaminated with blood or body substances, and at other times as necessary.?
Based upon documentation and an interview, the facility failed to ensure the administrator completed at least six hours of training on residents with mental impairments. Evidence: 1. The training record for the administrator listed four hours of training addressing residents with mental impairments, 2. On 4/4/2023, the LI interviewed the administrator who stated the hours listed on her training record were the only hours she had completed on residents with mental impairments.
Based upon a record review and interviews, the facility failed to ensure a mental health screening was completed and on file for one of six resident records reviewed. Evidence: 1. Resident 3 was admitted after an extensive hospital stay due to mental health issues. The resident record did not include a mental health screening or progress notes. 2. On 4/4/2023, the LI interviewed the administrator and staff 2 and both stated they did not have a mental health screening completed prior to resident 3?s admission and that a screening and progress notes were not on file. Neither staff could provide documentation as to attempts to obtain the required information or progress notes.
Based upon record reviews and interviews, the facility failed to ensure appointments and communication were maintained between the facility and the mental health services provider for two of six resident records reviewed. Evidence: 1. The facility had a contract (signed 1/18/2023 by the facility administrator and the mental health provider) for all six residents reviewed, which stated, ?Progress report completed after each visit.? 2. The most recent individualized service plan ( ISP
Based upon documentation and an interview, the facility failed to ensure the medication administration records ( MAR
Based upon documentation and an interview, the facility failed to ensure fire drills were conducted on each shift in each quarter. Evidence: 1. Based upon the fire drill log sheets, a fire drill was held during the first shift at 10:00 am on 10/5/2021. The next fire drill on first shift was not held again until 9:30 am on 4/15/2022. 2. On 4/4/2023, the LI interviewed staff 2 who stated, ?I must have gotten mixed up and held a drill on the wrong shift, which got me off track.?
Jan 13, 2022Routine
An unannounced renewal inspection was conducted on 1/13/2022 from approximately 8:20 am to 5:00 pm and on 1/14/2022 from approximately 7:30 am to 11:00 am. Upon arrival there were 16 residents in care and two staff on duty. A tour was immediately conducted of the interior and exterior of the facility. The facility was clean and free from any foul odors. The posted menu included substitutions and thus accurately reflected this inspector's observations. The lunch meal was observed and the one special diet was served according to the physician's order. Medication administration observations were completed with four residents and one registered medication aide. The January 2022 medication administration records, physicians' orders and medications were reviewed for all four residents observed. Individual interviews were conducted with residents; however, there were no family members available to interview. The areas of non-compliance included resident orientation, uniform assessment instruments, dietary oversight, medications, individualized service plans, menus and pet examinations/immunizations. Staff answered all questions and obtained all information requested. Thank you for your assistance and cooperation during this inspection.
Based upon documentation and an interview, the facility failed to ensure three of the four residents' orientations were provided upon admission. Evidence: 1) Resident 1 (admitted 11/30/2021) signed that orientation and written agreement were completed on 11/9/2021; resident 2 (admitted 8/26/2021) signed that orientation and agreement were completed on 7/15/2021; resident 3 (admitted 1/22/2021) signed that orientation and agreement were completed on 1/12/2021. 2. On 1/13/2022, the licensing inspector (LI) interviewed the administrator and staff 2 and both stated the residents received the orientation when the agreements were signed and that the dates of orientation completion were correct. Both stated no additional orientations were completed upon the residents' admission.
Based upon documentation and an interview, the facility failed to ensure two of five residents' uniform assessment instruments ( UAI
Based upon documentation and an interview, the facility failed to ensure one of five residents' ISP
Based upon observations, documentation and an interview, the facility failed to ensure snacks for the current week were included on the posted menu. Evidence: 1. On 1/13/2021 at approximately 8:30 am, the LI observed the current posted menu on the bulletin board at the entrance of the facility. The menu did not include snacks but had a statement at the top that, "Snacks are available at all times." 2. On 1/13/2022, the LI interviewed the administrator who stated she changed the menu format and thought since snacks had to be available at all times she only needed to state that information on the menu and no longer needed to list the specific snacks to be available each week.
Based upon documentation, the facility failed to ensure the dietary oversight was completed at least once every six months for one of five residents' records reviewed. Evidence: 1. The last dietary oversight was signed as completed on 2/24/2021. 2. On 1/13/2022, the LI interviewed the administrator and staff 2 and both stated 2/24/2021 was the last time the dietician conducted an oversight. Both also stated they had not contacted the dietician to conduct an oversight for August 2021.
Based upon observations and an interview, the facility failed to ensure two of the approximately 25 over the counter (OTC) medications reviewed were labeled with a pharmacy label or the residents' names. Evidence: 1. On 1/13/2022, the LI conducted an audit of the medication cart and observed a bottle of Melatonin and Sleep-Aid that did not have pharmacy labels or the residents' names written on the bottles. 2. On 1/13/2021, the LI interviewed staff 2, the registered medication aide on duty, and she stated the bottles were not labeled with pharmacy labels or the residents' names.
Based upon documentation and interviews, the facility failed to ensure two of the eight pets that live on the premises had all the required immunizations and annual physicals. Evidence: 1. The last pet immunization and physical examination information on file for resident 2's pet was dated as completed 6/22/2020. The rabies vaccination expired 6/22/2021. 2. The last pet physical examination information on file for resident 9's pet was dated as completed 5/20/2020. 3. On 1/14/2022, the LI interviewed staff 2 and the resident and both stated the pet's annual examination had not been completed. Staff 2 also stated the immunizations were not current for resident 9's pet.
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