Waltonwood Ashburn, LLC
Families consistently rate this highly — reviewers highlight compassionate and attentive nursing staff. Schedule a visit to confirm the fit.
based on 43 Google reviews
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What this means for your family
This facility is an excellent choice for families seeking high-quality memory care and a beautiful environment for recovery. While the nursing staff is overwhelmingly praised, you should verify the current responsiveness of the administrative team during your tour to ensure your specific communication needs will be met.
Google Reviews
Google Reviews
43 reviews analyzed“Families generally praise Waltonwood Ashburn for its compassionate, high-quality nursing staff and its beautiful, well-maintained campus. While many residents thrive in the memory care and assisted living programs, one former resident reported significant issues with administrative responsiveness and inconsistent care from aides.”
Quality Themes
Tap a score for detailsStrengths
- Compassionate and attentive nursing staff
- Beautiful, clean, and modern facility
- Strong memory care and dementia support
- Engaging life enrichment and activities
Concerns
- Inconsistent care and unresponsive administration
Rating Trends
Tap a year to see what changed
Distribution
How They Respond to Reviews
This facility rarely responds to reviews.
Questions for Your Tour
- 1We've heard wonderful things about the modern and clean atmosphere here; could you show us some of the common areas where residents gather?
- 2Since you offer certified memory care, what specific types of dementia support and specialized programming are available for residents?
- 3We'd love to hear more about the life enrichment programs—what kind of daily activities or social events do residents participate in?
- 4How does the nursing team handle medical emergencies or urgent health changes during the overnight hours?
- 5What steps is the administration taking to ensure consistent communication and responsiveness with families regarding care updates?
- 6With 150 residents in the community, how do you ensure that the nursing staff can provide personalized, attentive care to every individual?
Personalized based on this facility's data
Key Review Excerpts
“My mom is incredibly well taken care of and her being there has afforded me a wonderful peace of mind I hadn’t had in a few years.”
“The level of care she received during her recovery made a world of difference. The staff acted quickly and compassionately after her fall, ensuring she got the medical attention she needed.”
“The staff at all levels have provided superb care and attention in addition to responding timely to any concerns I had about my mom's health.”
State Inspection History
State Inspections
Source: VA State Licensing Agency
Oct 31, 2025Complaint
Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 10/08/2025 regarding allegations in the area(s) of: 1. Admission, Retention and Discharge of Residents 2. Resident Accommodations and Related Provisions Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/31/2025 11:05 AM to 3:20 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: 102 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 4 Observations by licensing inspector: Halloween Activities Additional Comments/Discussion: N/A 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: 1. Admission, Discharge, and Retention of Residents 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 Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Based on resident record review and staff interview, the facility failed to ensure compliance with the facility?s own policies and procedures. Evidence: 1. Resident 1 was admitted to the facility on 11/19/2024 and discharged on 08/27/2025. Resident 1?s agreement, dated 11/12/2024, states the following on page 21: a. ??As it pertains to carpeting, Waltonwood applies a five year useful life for carpeting. Carpeting that is significantly worn, damaged, or stained may necessitate the replacement of the carpeting. A prorated charge for any remaining period in the assumed five-year useful life will be assessed as part of the move out damages for the apartment.? 2. Resident 1?s ROOM READY CHECKLIST, dated 09/04/2025, has two check marks that say good across the Kitchen and Living Room sections that both include Flooring. Resident 1?s MOVE OUT INFO SHEET, dated 09/08/2025, states ?N/A? next to Damages, but lists ?1. Carpet: $760?? for Additional Charges/Credit. 3. Resident 1?s moves out statement, dated 09/23/2025, indicated a $760 charge for ?Carpet Replacement.? 4. In an interview with the LI on 10/31/2025, Staff 4 stated that all residents are charged a carpet depreciation fee regardless of damage. 5. Staff 4 provided the carpet replacement statements. The carpet was replaced on 11/20/2024 prior to Resident 1?s admissionThe carpet was again replaced after Resident 1?s discharge on 09/05/2025. 6. In an interview with the LI on 10/31/2025, Staff 3 stated that Resident 1?s carpet was damaged, despite the forms indicating there was no damage. Staff 3 stated that all carpets are replaced for sanitation purposes between residents (excluding respite stays), regardless of the assumed five-year life stated in the agreement. Staff 3 did not agree with the policy and procedures listed in the agreement were not followed due to interpretation.
Sep 19, 2025Routine
Type of inspection: Monitoring A self-reported incident was received by VDSS Division of Licensing on 09/11/2025 regarding allegations in the area(s) of: 1. Buildings and Grounds Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/19/2025 10:00 AM to 11:12 AM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 104 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: 3 Observations by licensing inspector: Multiple Shower/Sinks, Safe and Secure Unit Additional Comments/Discussion: LI reviewed incident reporting procedures and the inspection process. Facility expressed concerns regarding the issued citation. Review and discussion options reviewed with facility should they wish to proceed. 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 Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Based on resident record review and staff interview, the facility failed to ensure general responsibility for the health, safety, and well-being of the residents. Evidence: 1. On 09/12/2025, Staff 1 submitted an incident report regarding a burn affecting Resident 1. The incident report stated that on 09/11/2025, a caregiver entered the room of Resident 1 to find that the water was ?very hot? and Resident 1?s body was red in various areas. 2. Photo evidence depicting the redness was provided to the LI on 09/19/2025. 3. Patient Discharge instructions, dated 09/12/2025, reviewed on site indicate superficial burns 4. In an interview with the LI on 09/19/2025, Staff 1 and 2 confirmed that the resident received a burn while in the shower at the facility.
Based on resident record review and staff interview, the facility failed to ensure that how water at taps was maintained within a range of 105 to 120 degrees. Evidence: 1. On 09/12/2025, Staff 1 submitted an incident report regarding Resident 1. The incident report stated that on 09/11/2025, a caregiver entered the room of Resident 1 to find that the water was ?very hot? and Resident 1?s body was red in various areas. Photo evidence depicting the redness was provided to the LI on 09/19/2025. Patient Discharge instructions, dated 09/12/2025, reviewed on site indicate superficial burns. 2. In an email to the LI, dated 09/15/2025, Staff 1 stated that the temperature was ?set to max at 122 degrees.? 3. In an interview with the LI on 09/19/2025, both Staff 1 and Staff 3 confirmed the water temperature was not taken at the time of the incident; however, Staff 1 acknowledged that 122 degrees was higher than the required range of 105 to 120.
Sep 4, 2025RoutineCleanReport
Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/04/2025 3:00 PM to 4:06 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: 100 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: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: N/A Additional Comments/Discussion: Selective records were pulled in order to show compliance with submitted Intensive Plan of Correction. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (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 Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Sep 4, 2025Routine
Type of inspection: Renewal Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/04/2025 8:30 AM to 3:00 PM 09/05/2025 9:00 AM to 11:45 AM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 100 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 6 Observations by licensing inspector: Meals, Activities, and Medication Pass (AL & Safe, Secure Unit) Additional Comments/Discussion: Discussed weekly menus at exit meeting. 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 Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Based on direct observation, facility document review, and staff interview, the facility failed to ensure the infection control program was implemented. Evidence: 1. The facility provided the infection control program for review on 09/03/2025. The infection control program includes a policy titled ?Infection Control ? Standard Precautions?, dated 03/2025. On page 1, the policy states that all team members should wash their hands frequently and properly before and after any resident contact. Page 2 states that hand sanitizer may be used for any non-care related resident contact. 2. During a medication pass observation on 09/03/2025, the LI observed Staff 4 administer medication to Resident 9. Staff 4 did not wash hands or use hand sanitizer before or after passing medication, and checking the blood pressure, of Resident 9. Staff 4 confirmed they are supposed to wash their hands between each resident when passing medication. 3. During a medication pass observation on 09/03/2025, the LI observed Staff 5 administer medication to Resident 2. Staff 5 did not wash their hands or use hand sanitizer prior to administering or preparing medication for Resident 2; however, Staff 5 did use hand sanitizer after passing the medication. Staff 5 confirmed they are supposed to wash their hands between each resident when passing medication. 4. In an interview with the LI on 09/03/2025, Staff 1 and 2 confirmed that the infection control program was not followed.
Based on direct observation and staff interview, the facility failed to ensure that the name of the current on-site person in charge was posted in a place that is conspicuous to residents and the public. Evidence: 1. Upon entering the facility on 09/03/2025 at 8:30 AM, the LI observed Staff 2 as the posted ?Manager on Duty.? In an interview with the LI on 09/03/2025, Staff 3 stated that Staff 2 was on vacation, and Staff 1 was the person in charge but would not be in until 9:00 AM. 2. In an interview with the LI, Staff 1 and Staff 2 stated that management staff were always available via phone, and there was a shift lead or designated on site staff. Staff 1 and 2 confirmed the designated on-site person in charge was not posted.
Based on facility document review and staff interview, the facility failed to ensure that a semi-annual review on the emergency preparedness and response plan was conducted for all staff, residents, and volunteers. Evidence: 1. The LI reviewed the facility?s building binder, which included an emergency preparedness semi-annual review dated 07/18/2024. 2. In an interview with the LI on 09/04/2025, Staff 1 confirmed that a semi-annual review had not been completed since 07/18/2024.
Jul 10, 2025Routine
Type of inspection: Monitoring A self-reported incident was received by VDSS Division of Licensing on 06/27/2025 regarding allegations in the area(s) of: 1. 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: 07/10/2025 3:10 PM to 4:42 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: 95 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: 2 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Safe, Secure Unit - Activities Additional Comments/Discussion: Three, signed written staff statements obtained. 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 Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Based on resident record review and staff interview, the facility failed to ensure that all staff who are mandated reporters reported suspected abuse, neglect, or exploitation of residents. Evidence: 1. On 06/27/2025, the department received an incident report of an allegation of physical abuse involving Staff 4 and Resident 1 on 06/25/2025. 2. In an interview with the LI on 07/14/2025, Staff 1 and Staff 2 confirmed a report of suspected abuse was not submitted to adult protective services.
Based on resident record review, staff record review and staff interview, the facility failed to assume general responsibility for the health, safety, and well-being of the residents. Evidence: 1. On 06/27/2025, the department received an incident report via email for Resident 1 that detailed an incident that occurred on 06/25/2025 in which Staff 4 ?brought [Staff 4?s] open hand down on top of [Resident 1?s] legs? while Resident 1 was showing aggressive behavior during incontinence care. 2. During the onsite inspection on 07/10/2025, the LI was provided with three, dated statements from Staff 3, Staff 4, and Collateral Contact 1. Staff 3 and Collateral Contact 1?s witnessed the incident and confirmed Staff 4 hit Resident 1?s legs in their written statement. Staff 4?s statement denies hitting the resident; however, confirms that Staff 4 tried to protect themselves by holding Resident 1?s hands. 3. In an interview with the LI on 07/10/2025, Staff 1 acknowledged that the facility failed to assume general responsibility for the health, safety, and well-being of Resident 1.
Jun 13, 2025Complaint
Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 06/09/2025 regarding allegations in the area(s) of: 1. Resident Care and Related Services 2. Staffing and Supervision Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/13/2025 1:02 PM to 2:24 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: 103 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: 3 Observations by licensing inspector: N/A Additional Comments/Discussion: Resident was not on site at time of inspection for interview. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. However, violation(s) not related to the complaint but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Based on staff record review and staff interview, the facility failed to ensure that direct care staff met one of the qualification requirements within two months of employment including successful completion of an education program that is not covered under subdivision 2 of this subsection that is approved by the department. Evidence: 1. Staff 3 (hired on 05/28/2024) was working as a caregiver in the facility in May of 2025. Staff 3?s record contained personal care aide course completion dated 08/26/2024 by [Collateral Contact 2]. 2. Staff 3's personal care aide course does not indicate it is approved by the Virginia Department of Medial Assistance Services. 3. In an interview with the LI on 06/13/2025, Staff 1 confirmed that Staff 3 did not have the qualifications required as a direct care staff member.
Based on resident record review and staff interview, the facility failed to ensure that direct care or companion services provided by private duty personnel to meet identified needs were reflected on the resident?s Individualized Service Plan ( ISP
Jun 2, 2025RoutineCleanReport
Type of inspection: Monitoring A self-reported incident was received by VDSS Division of Licensing on 03/18/2025 regarding allegations in the area(s) of: 1. Admission, Retention and Discharge of Residents Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/02/2025 10:10 AM to 11:28 AM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 97 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: 1 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A 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 Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Jun 2, 2025Routine
Type of inspection: Monitoring A self-reported incident was received by VDSS Division of Licensing on 05/19/2025 regarding allegations in the area(s) of: 1. Resident Accommodations and Related Provisions Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/02/2025 11:30 AM to 1:30 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: 97 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: 2 Observations by licensing inspector: Medication Cart Audit Additional Comments/Discussion: N/A ? Interview attempted; however, resident unavailable. 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 Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Based on direct observation, resident record review and staff interview, the facility failed to ensure that a written plan for medication management was implemented. Evidence: 1. During a medication cart audit with Staff 3 on 06/02/2025, the LI observed the following medications in blister packs on the cart for Resident 1 with Resident 1?s other medications: a. Famotidine 20 MG b. Ramelteon 8 MG c. Rosuvastatin Calcium 20 MG 2. In an interview with the LI, Staff 3 had stated that Famotidine, Ramelteon, and Rosuvastatin Calcium had been discontinued. Staff 3 stated that discontinued medications are supposed to be pulled on each shift. 3. Resident 1?s record contained a physician order dated 05/08/2025 that stated to discontinue Famotidine and Ramelteon, and decrease Rosuvastatin Calcium to 10 mg. 4. The facility?s written medication management plan continued a policy titled ?Medication Discontinuation and Disposal? dated 09/09/2016. The policy states that non-narcotic medication that has been discontinued should be removed from the resident?s grouping and notification should be given to the pharmacy. 5. In an interview with the LI on 06/02/2025, Staff 1 confirmed the medication management plan was not followed. 6. Photo evidence obtained.
Based on direct observation, resident record review, and staff interviews, the facility failed to ensure that physician or other prescribers? orders contained specific indications for administering each drug. Evidence: 1. On 05/19/2025, the facility submitted an incident report regarding a medication error in which Staff 1 administered a Ciclopirox (intended for administration to Resident 1?s toe) to Resident 1?s eye. 2. On 06/02/2025 during a medication cart audit with Staff 3, the LI observed Resident 1?s topical ointment ?Ciclopirox? in a pharmacy issued contained that stated, ?Apply topically to affected area every day for treatment.? Staff 3 confirmed this was supposed to be administered to Resident 1?s toes. 3. Resident 1?s record contained a Physician Order Summary signed 01/13/2025 that stated the following under Treatments: ?Ciclopirox 8% Solution Apply topically to affected area every day for treatment.? 4. In an interview with the LI on 06/02/2025, Staff 1 acknowledged that the order did not contain specific indications as to the for administering each drug.
Based on resident record review and staff interview, the facility failed to ensure medications were administered in accordance with the physician?s or prescriber?s instructions. Evidence: 1. On 05/19/2025, the facility submitted an incident report regarding a medication error in which Staff 1 administered a Ciclopirox (intended for administration to Resident 1?s toe) to Resident 1?s eye. 2. Resident 1?s record contains physician order summary signed on 01/13/2025. The physician order summary includes an order for Cicloprex dated 11/03/2023 that states ?Apply topically to affected area every day for treatment.? 3. A progress note documented in Resident 1's record by Staff 1 indicates that Staff 1 administered Ciclopirox 8% solution into Resident 1's eye. The note further states the resident experienced pain, redness, and irritation following administration. 4. In an interview with the LI on 06/02/2025, Staff 1 confirmed that medication was not administered according to physician orders.
Based on resident record review and staff interview, the facility failed to ensure that the Medication Administration Record ( MAR
Based on direct observation, resident record review and staff interview, the facility failed to ensure that PRN
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