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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: February 10, 2026, from 9:45 a.m. until 2:00 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 25 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 staff records reviewed: 4 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 4 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 resident record review and staff interview, the facility failed to obtain a physical examination, including a tuberculosis risk assessment, by an independent physician within 30 days preceding admission. Evidence: 1. The admission date for resident 2 was 01/06/2026. The date of the face-to-face physical examination for resident 2 was 10/29/2025, which was more than 30 days preceding admission. 2. The admission date for resident 2 was 01/06/2026. The risk assessment documenting the absence of tuberculosis for resident 2 was dated 12/02/2025, which was more than 30 days preceding admission. 3. Staff 7 acknowledged that the physical examination report and tuberculosis risk assessment for resident 2 were not completed within 30 days.
Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 6/24/2025 regarding allegations in the area(s) of: Medication Administration, Personnel, Staffing and Supervision. Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7/2/2025 11:30 a.m. ? 12:03 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: 25 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: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: The licensing inspector observed residents and staff during meal service. The licensing inspector reviewed incident reports, staff communication, and staffing. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: 680-D A violation notice was 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 Jessica Gale, Licensing Inspector at (540) 571-0358 or by email at Jessia.gale@dss.virginia.gov
Based on record review and staff interview, the facility failed to administer medication in accordance with physicians or other prescribers instructions. Evidence: 1. A complaint received by the regional licensing office on 6/24/2025 stated that resident 1 received resident 2?s medication including a narcotic. 2. Record review for resident 1 (admitted 2/8/2024) contained a physician?s order for Gabapentin 100 mg written 2/14/2025. Record review for resident 2 (admitted 3/9/2021) contained a physician?s order for Gabapentin 600 mg ordered 3/9/2021. 3. A medication error report was completed by the facility on 5/4/2025 that stated, when the count was done 5/5/2025, it was noted that resident 2 was missing 2 gabapentin and resident 1 was not missing any gabapentin, indicating that staff 2 administered resident 1, resident 2?s 600 mg Gabapentin on 5/4/2025 as opposed to resident 1?s ordered 100 mg Gabapentin. 4. During an interview with staff 1 when asked if the medication error occurred staff 1 stated ?yes?.
Based on record review and staff interview, the facility failed to report to the regional licensing office within 24 hours of any incident that had negatively affected or that threatened the life, health, safety, or welfare of any resident. Evidence: 1. A complaint received by the regional licensing office on 6/24/2025 stated that resident 1 received resident 2?s medication including a narcotic. 2. Record review for resident 1 (admitted 2/8/2024) and resident 2 (admitted 3/9/2021) indicated that resident 1 did receive resident 2?s 600 mg Gabapentin on 5/4/2025 as opposed to resident 1?s ordered 100 mg Gabapentin. 3. The regional licensing office did not receive an incident report for the medication error. 4. During an interview with staff 1, when asked if the medication error was reported to the regional licensing office, staff 1 stated ?I didn?t, that was before I knew I had to report that.?
Type of inspection: Monitoring A self-reported incident was received by VDSS Division of Licensing on 4/21/2025 regarding allegations in the area(s) of: Resident Care and Related Services Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 5/16/2025 from 1:30 p.m. to 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: 26 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 residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: The licensing inspector reviewed the medication administration record, incident reports, and staff communication logs. Additional Comments/Discussion: None An exit meeting will be 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-reported incident 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 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 medications were administered in accordance with physician orders. Evidence: 1. A self-reported incident was received by the regional licensing office from the facility on 4/21/2025 stating that on 4/19/2025 resident 1 (admitted 2/2/2024), who was under hospice services (start of care 3/28/2025) at the time of the incident, had received Lorazepam 0.5 ml at 1:00 a.m., 3:00a.m., and 5:00 a.m. as opposed to the ordered Lorazepam 0.5 ml as needed every four hours by staff 2. 2. Resident 1?s record contained a physician?s order dated 3/28/2025 for Lorazepam concentrate 2 mg/ml, 0.5 ml (1mg) by mouth every four hours as needed for anxiety or agitation. 3. The April 2025 medication administration record for resident 1 indicated that staff 2 administered Lorazepam 2 mg/ml oral concentrate, 0.5 ml, on 4/19/2025 at 1:03 a.m., 3:03 a.m. and 4:58 a.m. to resident 1. 3. During an interview with staff 1 when asked if staff 2 administered the Lorazepam 2 mg/ml oral concentrate, 0.5 ml, on 4/19/2025 at 1:03 a.m., 3:03 a.m. and 4:58 a.m. as opposed to the physician ordered as needed every four hours, staff 1 stated ?yes?.
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 01/31/2025 10:00am-1:40pm 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: 25 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 staff records reviewed: 4 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: The licensing inspector observed residents during meals and during activities. The inspector reviewed healthcare oversight, dietary oversight, pharmacy review, fire drills, and review of emergency preparedness 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 direct observation, the facility failed to store cleaning supplies and other hazardous materials in a locked area. Evidence: 1. During the facility tour on 1/31/2025, a common area bathroom was unlocked and contained a spray bottle of Cleaner with bleach. 2. Photo evidence taken.
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: 8/16/2024, 02:40pm-3:40pm 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 08/14/2024 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: 27 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: 3 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: Observed resident in the apartment at the time of inspection as well as staff interactions with residents. 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 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 Jessica Gale, Licensing Inspector at 540-571-0358 or by email at Jessica.gale@dss.virginia.gov
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 6/4/2024, 9:00am-1:56pm 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: 24 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 staff records reviewed: 3 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 was reviewed at the time of inspection: Menus, activity calendars, fire drills, emergency drills, fire 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 medical procedures or treatments ordered by a physician or other prescriber are provided according to his instructions and documented. Evidence: 1. Resident 1 admitted 5/4/2024, received a physicians order dated 05/21/2024 that states ?d/c candesartan check blood pressure every morning for 1 week? 2. The medication administration record for resident 1 indicates blood pressure checks completed at 10:00 am on 5/21/2024, 5/22/2024, 5/23/2024, and 5/24/2024. There was no evidence present that blood pressure checks were completed for 5/25/2024-5/27/2024 3. An interview with staff 1 stated the physicians order was entered into the MAR
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 1/11/2023 from approximately 6:50 am to 4:15 pm and 1/12/2023 from approximately 7:35 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: 26 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 resident records Number of staff records reviewed: 3 + selected sections of one additional staff record + 2 contract staff + 3 volunteers Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 4 Observations by licensing inspector: Meals, medication and treatment administration observations, activities, resident-staff interactions, emergency food supplies, first aid kit, staff schedules, required postings, buildings and grounds, resident rooms, etc. Additional Comments/Discussion: Thank you for your assistance and cooperation during this inspection. 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. 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. 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 documentation and interviews, the facility failed to ensure one of six residents individualized service plans ( ISP
An unannounced monitoring inspection was conducted on 3/29/2022 from approximately 8:15 am to 5:10 pm and 3/30/2022 from approximately 10:15 am to 4:25 pm. Upon arrival there were four staff on duty and 22 residents in care. 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 and activities calendar were current and accurately reflected this inspector's observations. Medication administration observations were completed with one nurse for five residents. The March 2022 medication administration records, signed physicians' orders and medications were reviewed for all five residents. Five resident, one discharge, three staff and two contract staff records were reviewed. Selected sections of four additional resident and three staff records were also reviewed. The criminal record reports for all current staff hired since the last inspection were reviewed. Individual interviews were conducted with residents and staff. The areas of noncompliance included reporting major incidents, first aid training, posting a list of current staff with first aid and cardiopulmonary resuscitation, posting name of staff in charge, written assurance, individualized service plans and emergency preparedness and response training. 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 four of the six individualized service plans ( ISP
Based upon record reviews and an interview, the facility failed to ensure two of the six residents reviewed received written assurance. Evidence: 1. Resident 2 and 4 had no documentation of written assurance on file. 2. On 3/29/2022, the LI interviewed the administrator who stated she must have forgotten to complete the written assurance for residents 2 and 4 as she checked both records and could not find them.
Based upon observations and an interview, the facility failed to ensure the name of the current on-site person in charge was posted Evidence: 1) On 3/29/2022 at approximately 8:20 am, the LI observed staff 11's name posted on the dry erase board at the nurses' station as the staff in charge. 2) On 3/29/2022, the LI interviewed staff 1 who stated she had forgotten to update the name of the staff in charge on the board. 3) On 3/29/2022, the LI interviewed staff 11 who stated she last worked second shift and left at 11:00 pm on 3/28/2022.
Based upon record reviews and an interview, the facility failed to ensure one of four staff records reviewed had documentation of completion of first aid (FA) within 60 days of hire. Evidence: 1. Staff 2 (hired 9/24/2021) did not have documentation of FA certification. 2. On 3/29/2022, the LI interviewed the administrator who stated staff 2 had not completed the FA training.
Based upon documentation and an interview, the facility failed to ensure the emergency preparedness and response plan (EPRP) was reviewed with all residents at least once every six months. Evidence: 1. The only EPRP review with residents was dated as completed on 12/1/2021 on the training sign in sheets. 2. On 3/29/2022, the LI interviewed the administrator who stated the only training conducted with residents on the EPRP this past year was 12/1/2021.
Based upon documentation and an interview, the facility failed to ensure major incident reports were received within seven days of the incident. Evidence: 1. Incident involving resident 8 occurred on 7/4/2021 and the full report was received on 9/30/2021. 2. Incident involving resident 12 occurred on 8/4/2021 and full report was received on 8/12/2021. 3. Incident involving resident 11 occurred on 8/8/2021 and full report was received on 9/28/2021. 4. Incident involving resident 10 occurred on 8/28/2021 and full report was received on 9/28/2021. 5. Incident involving resident 9 occurred on 8/29/2021 and full report was received on 9/20/2021. 6.Incident involving resident 7 occurred on 1/8/2022 and full report was received on 1/20/2022. 7. Incident involving resident 2 occurred on 3/5/2022 and full report was received on 3/21/2022. 8. Home health nursing notes beginning on 11/17/2021 through 12/17/2021 and 2/23/2022 through 3/23/2022 document wound care to bilateral buttocks. A report was not submitted on either of these two wounds. 9. On 3/30/2022, the LI interviewed the administrator who stated these reports were not submitted as required.
Based upon observations, documentation and an interview, the facility failed to ensure the posted list of staff with current FA and cardiopulmonary resuscitation (CPR) certifications was kept current. Evidence: 1. On 3/29/2022, the LI observed the posted list of staff with current FA and CPR certifications and staff 9 was listed but was no longer employed. 2. staff 10 was not listed; however, she was a current employee who was certified in CPR. 3. The posted list was last updated on 2/2022, according to the date at the bottom of the list. 4. On 3/29/22, the LI interviewed the administrator who stated the list was not current as stated above.
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