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Source: VA State Licensing Agency
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: 7/23/2025 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 2/24/2025 regarding allegations in the area of: Administration and Administrative Services, and Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 85 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: NA Number of interviews conducted with residents: NA Number of interviews conducted with staff: 1 Observations by licensing inspector: NA 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: Administration and Administrative Services, and Resident Care and Related Services. 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 Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov
Based on resident record review, the facility failed to implement interventions as soon as nutritional problem is suspected. 1. Weighing residents at least monthly to determine whether the resident has significant weight loss (i.e, 5.0% weight loss in one month, 7.5% in three months, or 10% in six months) and 2. Notifying the attending physician if any resident who is not on a physician-approved weight reduction program and obtaining, documenting, and following physician?s instructions regarding nutritional care. Evidence: 1. According to the Senior Resident Vital Sign Chart document for resident 1, the resident weighed 148 pounds in October 2024 and 121.8 pounds in December 2024, a 17.7% weight loss. 2. Staff 1 was unable to find documentation of resident 1?s physician being notified of the 17.7% weight loss.
Based on resident record review, the facility failed to update the Individualized Service Plan ( ISP
Based on resident record review, facility policy review and staff interview, the facility failed to ensue compliance with the facility?s own policies and procedures. Evidence: 1. According to the facility?s Weights policy, the policy states, 1. The Health & Wellness Director will assign the task of measuring resident weights monthly to Resident Care Associates. 2. The Senior Resident Vital Sign Chart document for resident 1 had weights recorded for August 2024, September 2024, October 2024 and December 2024. There was no weight recorded for resident 1 in November 2024. 3. According to the facility?s Weights policy, the policy states, 5. Significant weight changes will be reported to the resident?s physician, including: a. Five (5) pounds or greater weight change in thirty (30) days, whichever is larger. B. 7.5% or greater in ninety (90) days. c. 10% or greater in six (6) months. 4. According to the Senior Resident Vital Sign Chart document for resident 1, the resident weighed 148 pounds in October 2024 and 121.8 pounds in December 2024, a 17.7% weight loss. 5. Staff 1 was unable to find documentation of resident 1?s physician being notified of the 17.7% weight loss.
Based on resident record review, the facility failed to ensure the Individualized Service Plan ( ISP
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: 7/23/2025 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 6/23/2025 regarding allegations in the areas of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 85 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: NA Number of interviews conducted with residents: NA Number of interviews conducted with staff: 1 Observations by licensing inspector: NA 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 : Resident Care and Related Services 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 Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov
Based on resident record review, staff interview and video footage, the facility did not follow physician orders. Evidence: 1. Resident 1 had an order written on 6/19/2025 that stated: Patient is NPO (nil per os), except liquid meds. 2. Video footage shows staff 2 entering resident 1?s apartment with a small cup and spoon. Staff 2 stirs the contents of the cup, then staff 2 administers the contents from the cup into resident 1?s mouth with a spoon. Staff 2 states he is giving her medicine. 3. Staff 1 stated the staff were educated about not giving residents their medications in applesauce if the resident has an NPO order. 4. Video evidence
Based on resident record review, the facility failed to include hospice services on the Individualized Service Plan. Evidence: 1. Resident 1 had an order for hospice written on 6/19/2025. 2. Resident 1 had an Individualized Service Plan on file dated 5/15/2025 that did not include hospice services.
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: 7/22/2025 & 7/23/2025 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 2/21/2025 regarding allegations in the areas of: Resident Care and Related Services and Building and Grounds Number of residents present at the facility at the beginning of the inspection: 85 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: NA Number of interviews conducted with residents: NA Number of interviews conducted with staff: 2 Observations by licensing inspector: The LI observed residents participating in activity programs and eating lunch. Additional Comments/Discussion: 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-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 Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov
Based on self-reported incident and staff interviews, the facility failed to assume general responsibility for the health, safety, and well-being of the residents. Evidence: 1. Self-reported incident, received on 2/12/2025, stated resident was observed on the floor outside the exit door stairwell of secured unit. 2. Staff 2 stated on 2/12/2025 he was using the stairs to go downstairs, and he found resident 1 laying on the stairwell landing between two floors. Resident 1 resided in the secured unit. 3. Staff 1 and 4 stated the doors are supposed to open once pressed for 15 seconds; staff are notified when the doors open without the use of a staff key fob. 4. The LI was unable to open the door even after pressing on the door exit bar for greater than 15 seconds. 5. Staff 4 was not sure how the door was opened without a key fob.
Based on staff interview, the facility failed to maintain a written work schedule that includes the names and job classifications of all staff working each shift, with an indication of whomever is in charge at any given time. Evidence: The LI asked staff 1 for the written work schedule for 2/12/2025 and staff 1 stated the schedule was no longer available.
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: 7/22/2025 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 4/10/2025 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: 85 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: NA Number of interviews conducted with residents: NA Number of interviews conducted with staff: 1 Observations by licensing inspector: The LI observed residents participating in activity programs and eating meals. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the (allegation(s)/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 Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov
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: 7/22/2025 & 7/23/2025 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 4/30/2025 regarding allegations in the areas of: Administration and Administrative Services, and Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 85 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: NA Number of interviews conducted with residents: NA Number of interviews conducted with staff: 1 Observations by licensing inspector: NA 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: Administration and Administrative Services and Resident Care and Related Services. 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 Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov
Based on a complaint received 4/30/2025, video footage and staff interview, the facility failed to be considerate and respectful of the rights, dignity, and sensitivities of persons who are aged, infirm, or disabled. Evidence: 1. Complainant stated she watched video footage of resident 1 being assisted by staff 1 to walk from her living room to the bathroom while resident 1?s pants were down around her ankles. 2. Video footage was sent to this LI and LI observed a staff member assisting resident 1 to walk from the living room to the bathroom and resident 1?s pants were down around her ankles. 3. Staff 2 verified the staff member in the video was staff 1.
Based on a complaint received 4/30/2025, email correspondence and staff record review, the facility failed to notify the department?s regional licensing office in writing within 14 days of a change in a facility?s administrator. Evidence: 1. Complainant stated the administrator of record (Staff 4) ?quit on Monday? (4/28/2025). 2. Email received by LI on 5/19/2025 stated an interim administrator started 4/29/2025. 3. Employee Update form in staff 4?s had a termination date of 4/29/2025.
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: 7/22/2025 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 3/5/2025 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: 85 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: NA Number of interviews conducted with residents: NA Number of interviews conducted with staff: 1 Observations by licensing inspector: The LI observed residents participating in activity programs and eating lunch. Additional Comments/Discussion: 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 Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@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: 7/22/2025 & 7/23/2025 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 6/20/2025 regarding allegations in the area of: Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 85 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: NA Number of interviews conducted with staff: 1 Observations by licensing inspector: NA 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 Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov
Based on staff record review and staff interview, the facility failed to ensure direct care staff who are licensed health care professionals or certified nurse aides shall attend at least 12 hours of annual training. Evidence: 1. Staff 1 hired 5/5/2023 did not have 12 hours of annual training on file for the year. 2. Staff 2 stated staff 1?s annual training was not available.
Based on staff record review and staff interview, the facility failed to review resident rights annually with each staff person. Evidence: 1. Staff 1 hired 5/5/2023 did not have documentation of resident rights review for the year on file. 2. Staff 2 stated staff 1?s documented resident rights review for the year was not available.
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: 7/22/2025 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 2/6/2025 regarding allegations in the areas of: Personnel and Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 85 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: NA Number of interviews conducted with staff: 1 Observations by licensing inspector: NA Additional Comments/Discussion: 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-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 Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov
Based on self-reported incident on 2/6/2025 and resident record review, the facility failed to ensure that staff who are responsible for administering medications meet the requirement of 22VAC40-73-670. Evidence: 1. Self-reported incident stated staff 1 was not practicing within the parameters of the provisional medication aide letter she received from Virginia Department of Health Professionals. 2. Staff 1 had an Eligibility to test with Provisional Status letter from Virginia Department of Health Professionals on file, dated 10/2/2024. The letter stated: Pursuant to 18 VAC 90-60-91, you are now authorized to practice on a provisional medication aide. 3. Staff 1?s provisionary period to practice as a medication aide ended on 1/30/2025. 4. Staff 1 did not have a Registered Medication Aide license on file and could not be located on the Department of Health Professionals? website (license lookup feature). 5. On the Medication Administration Record for resident 1 for February 2025, staff 1 administered the following medications on 2/2/2025: Carvedilol F/C 12.5 mg tablet (take 1 tablet by mouth twice daily for hypertension) at 5:00pm, Carvedilol F/C 6.25 mg tablet (take 1 tab by mouth twice daily for hypertension) at 5:00pm, Hydroxyzine HCL F/C 25 mg tablet (take 1 tab by mouth twice daily) at 5:00pm, Metformin HCL F/C 1000 mg tablet (take 1 tab by mouth twice daily for diabetes mellitus) at 6:00pm, and Minoxidil 2.5 mg tablet (take 1 tab by mouth daily for BPR greater than 140) at 4:00pm.
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