Woodhaven at Williamsburg Landing
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State Inspection History
State Inspections
Source: VA State Licensing Agency
Mar 3, 2026Routine
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: 03/03/2026 arrival 10:08 a.m. / departure 12:58 p.m.) and 03/27/2026 (arrival 10:26 a.m. / departure 12:39 p.m.) The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 11/26/2026 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: 99 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 2 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: 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. 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 Darunda Flint, Licensing Inspector at (757) 807-9731 or by email at darunda.a.flint@dss.virginia.gov
Based on the record review and staff interview the facility failed to ensure each staff person who administers medication shall be authorized by 54.1-3408 of the Virginia Drug Control Act and shall be licensed by the Commonwealth of Virginia to administer medications or be registered with the Virginia Board of Nursing as a medication aide, except as specified in subdivision 2 of this section. Evidence: 1. A self-reported incident was received by the regional licensing office on November 26, 2025, indicating staff 3# and staff #4 had administered medication without a valid license/registration to administer medication in an assisted living facility. 2. Staff #3 was hired on January 16, 2024, as a Licensed Practical Nurse. Staff #3?s license to practice in Virginia expired on September 30, 2024. 3. During interviews conducted on March 3 and March 27, 2026, Staff #1 and #2 acknowledged, staff #3 was not authorized and/or licensed by the Commonwealth of Virginia to administer medications. Staff #1 and staff #2 acknowledged staff #3 administered prescribed medications to resident #4, resident #5, and resident #6 on 18 days in the month of November 2025. 4. During interviews with staff #1 and staff #2 on March 3 and 27, 2026, staff #1 and #2 acknowledged staff #4 worked five shifts after their medication aide license expired on October 31, 2025. Staff #1 and #2 acknowledged staff #4 administered prescribed medications to resident #1, resident #2, and resident #3 in November 2025.
Mar 3, 2026RoutineCleanReport
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: 03/03/2026 (arrival 10:08 a.m. / departure 12:58 p.m.) and 03/27/2026 (arrival 10:26 a.m. / departure 12:39 p.m.) The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self reported incident was received by VDSS Division of Licensing on 02/25/2026 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: 99 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: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: 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
Feb 18, 2026Other
Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 02/18/2026 (9:35 a.m. arrival / 3:03 p.m.) and 02/19/2026 (9:26 a.m. / 4:01 p.m. departure) 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: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 6 Observations by licensing inspector: Activities were observed. A medication pass observation was completed for three residents. The following were reviewed: emergency preparedness drills, resident fire and resident emergency drills, fire inspection report, health inspection report, a staffing schedule, and water temperatures 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. 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 Darunda Flint Licensing Inspector at (757) 807-9731 or by email at darunda.a.flint@dss.virginia.gov
Based on observation and staff interviewed, the facility failed to ensure menus for meals and snacks for the current week was dated and posted in an area conspicuous to residents. Evidence: 1.The weekly menu was not posted on the safe secure unit. 2. Staff #2 acknowledged that there was no weekly menu posted on the safe secure unit.
Based on the record review it was determined that the facility failed to ensure the procedures in the plan for resident emergencies required in subsection A of this section shall be reviewed by the facility at least every six months with all staff. Documentation of the review shall be signed and dated by each staff person. Evidence: 1. Upon request the facility did not provide documentation that resident emergencies were reviewed at least every six months with all staff. 2. During the onsite inspection on 02/18/2026, staff #2 confirmed that documentation of the resident emergencies review was not completed with all staff every six months.
May 22, 2025Routine
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: May 22, 2025 from 1112-1300. 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 May 16, 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: 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:1 Number of interviews conducted with residents: Number of interviews conducted with staff: 2 Observations by licensing inspector: Video recordings 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. 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 Darunda Flint, Licensing Inspector at (757) 807-9731 or by email at Darunda.a.flint@dss.virginia.gov
Based on document reviewed, staff interviewed, and resident records reviewed, the facility failed to ensure no medication, dietary supplement, diet, medical procedure, or treatment shall be started, changed, or discontinued by the facility without a valid order from a physician or other prescriber. Medications include prescription, over-the-counter, and sample medications. Evidence: 1. On 5-16-25, staff #2 sent an incident report to the licensing department informing of staff #3 administering medications to residents #1 and #2 without a physician?s order. 2.During an inspection conducted on 5-22-25, staff #2 provided an internal facility video of staff #3 preparing medications for administration. The video showed staff #3 pulling a bottle from the medication cart, identified as Haloperidol, along with other medications for resident #1 and #2. Staff #3 is seen in the video pulling the Haloperidol from the medication cart and placing an unknown amount in a medication cup with other medications for administration. 3.According to staff #2, the only resident in the unit prescribed Haloperidol is resident #4. Resident?s record noted resident prescribed Haloperidol PRN
Based on video reviewed and staff interviewed, the facility failed to ensure the storage area was locked. Medications and dietary supplements administered by the facility shall be stored in a medicine cabinet container, or compartment used for storage of medications and dietary supplements prescribed for residents. Medications shall be stored in a manner consistent with current standards of practice. Evidence: 1. During inspection conducted on May 25, 2025, a videorecording titled, ?Video: Med Room_2025_05_04_7PM_1938_8PM? showed staff #3 entering the medication room and exiting the medication room at various intervals from minute marker 06:37 through 39:43 leaving the medication room door open and medication on top of the medication cart. Facility staff #2 identified Haloperidol and two bubble packs on the top of the cart in the unlocked medication room. 2. Staff #4 was observed conducting a controlled medication process with Staff #3 when both staff #3 and #4 exited the medication room without closing/locking the door. Staff #5 was observed entering the unlocked medication room and searching for an item that appeared to be posted on a door in the medication room.
Feb 14, 2025ComplaintCleanReport
Type of inspection: Complaint An unannounced complaint inspection was conducted on 2-14-25 (1:15 p.m./ 13:30 p.m.) The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on (1-27-25) regarding allegations in the Resident Care and Staffing Number of residents present at the facility at the beginning of the inspection: 93 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: Number of interviews conducted with staff: 2 Observations by licensing inspector: 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 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 (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov
Feb 13, 2025Routine
Type of inspection: Renewal An unannounced renewal inspection conducted on 2-13-25 (Ar. 07:05 a.m./Dep 19:00 p.m.) Day two, 2-14-25 (Ar. 9:03/ Dep 14:00). 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: 93 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Yes Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 8 Observations by licensing inspector: Medication pass AL and scu; first aid kit checks, water temperature, activity 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 (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov
Based on record reviewed and staff interviewed, the facility failed to ensure the disclosure document is provided signed prior to the resident agreement being signed. Evidence: 1. On 2-13-25, resident #3?s record noted the disclosure document was signed 11-13-24. The resident agreement was signed and dated 11-8-24. 2. Staff #1 acknowledged the resident?s disclosure was not signed prior to the resident agreement.
Based on record reviewed and staff interviewed, the facility failed to ensure that the individualized service plan ( ISP
Based on document reviewed and observation, the facility failed to ensure the care and services specified on the individualized service plan ( ISP
Based on observation and staff interviewed, the facility failed to ensure it followed the facility?s medication management policy. Evidence: 1. On 2-13-25, medication pass observation with staff #6, the following medications were pulled from the medication cart and taken to the resident?s room and placed on the kitchen counter: (a) Eliquis, (b) Furosemide, (c) Losartan, (d) Preservision Areds and ? Metoprolol Tartate. Staff was asked about leaving medications in the resident?s room without completing the administration process. The inspector was informed that was the process. The February 2025 medication administration record ( MAR
Based on observation, staff interviewed, and document reviewed, the facility failed to ensure it followed its policy for storage of medications. Evidence: 1. On 2-13-25 during the medication pass observation with staff #5, the inspector was informed that resident #2 self-administered some medications, and the resident was allowed to keep medication in room. The following medications were observed on the kitchen counter and a round table near the window. Resident #2 acknowledged keeping medication in room and in the areas mentioned. The medications were not stored in a safe and secure area of the resident?s room/apartment. According to the facility?s storage of medications policy, page 4, ?when a resident self-administers, medications are kept in a safe and secure area of the resident's room/apartment?. 2. Staff #1 acknowledged the resident?s medications were not stored in a safe and secure area.
Based on observation and staff interviewed, the facility failed to ensure when registered medication aide administer medications, the prescriber?s order will be exact. Evidence: 1. On 2-13-25 during the medication pass observation with staff #5, resident #2?s February 2025 medication administration record ( MAR
Based on document reviewed and staff interviewed, the facility failed to ensure that the flow rate for oxygen, when registered medication aide (RMA) administer medication and or treatment, included the exact flow rate. Evidence: 1. On 2-14-25, resident 5?s individualized service plan ( ISP
Jan 16, 2024Routine14Report
Type of inspection: Renewal An on-site renewal inspection conducted by two inspectors from the Peninsula Licensing Office; 01-16-24 (08:35 a.m./Dep 18:20 p.m.; 01-17-24 (09:35 a.m/ dep 17:20 p.m.) The facility census was 90. The Acknowledgement of Inspection form was signed and left at the facility for each date of the 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov
Based on record reviewed and staff interviewed, the facility failed to ensure within the first month of employment, staff, other than the administrator and direct care staff shall complete two hours of training on the nature and needs of residents with cognitive impairments relevant to the population in care. Evidence: 1. On 1-17-24, staff #7?s record documented 1.0 hour of training in cognitive impairment. Staff?s date of hire noted as 8-22-23. 2. Staff #1 and #2 acknowledged the staff did have the required hours of cognitive training.
Based on staff interviewed and document reviewed, the facility failed to ensure it reported the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident. Evidence: 1. On 2-16-24, the inspector was informed and observed that space heaters were used to provide heat to common areas of the assisted living facility. On 2-17-24, during interview with staff #1, the inspectors were informed the facility?s heating system in areas of the assisted living facility was not working. Staff #1 provided a timeline of the heating unit problems which began 11-2-23. The system was repaired but continued to have problems. On 1-12-24, space heaters were put in place in the Charter Room. 2. The facility also experienced a power outage in the facility in August 2023. 3. Staff #1 acknowledged, the power outage and the lack of heat and use of space heaters in common areas were not reported the licensing office.
Based on staff interviewed and record reviewed, the facility failed to ensure the orientation and training required in subsection B and C of the standard (22VAC40-73-120- A and B) occurred within the first seven working days of employment. Evidence: 1. On 1-17-24, staff #5?s record did not include documentation of section B requirements: (a) the purpose of the facility, (b) the facility organizational structure, (c) services provided, (d) facility policies and procedures and (e) required compliance with regulations for assisted living facilities as it relates to staff?s duties and responsibilities. The record also did not include documentation of section C requirements: (a) procedures for handling resident emergencies, (b) use of and location of first aid kit, (c) confidential treatment of personal information and (d) the needs, preferences, and routines of the residents for whom they will provide care. Staff?s date of hire noted as 2-14-23. 2. Staff #6?s record did not include documentation of orientation and training for all requirements for section B and C of the regulations. Staff?s date of hire noted as 5-30-23. 3. Staff #7?s record did not include documentation of orientation and training for all requirements for section B and C of the regulations. Staff?s date of hire noted as 8-22-23. 4. Staff #1 and #2 acknowledged the aforementioned staff records did not include all orientation and training requirements.
Based on staff interviews, the facility failed to ensure a listing of all staff who have current certification in first aid or CPR was posted in the facility so that the information was always readily available to all staff. Evidence: 1. On 1-16-24, during a tour of the facility, staff #5 was inquired about the location of the first aid/cpr posted listing. Staff #3 and #5 searched the nursing station area on the assisted living unit but could not locate the first/cpr listing. Staff #5 also went on the facility?s computer to locate the listing but was not successful. 2. Staff #3 and #5 acknowledged the first aid/cpr listing was not available.
Based on observation and staff interviewed, the facility failed to ensure it posted the name of the current on-site person in charge, in a place in the facility that is conspicuous to the residents and the public. Evidence: 1. On 1-16-24, the name of the current on-site person in charge of was not posted on the assisted living expansion. The inspectors proceed to the nursing station on the assisted living side of the building. The staff in charge posting was not observed. The inspectors inquired of staff #5 where the information was posted and who was in charge. 2. Staff #3 and #5 acknowledged the on-site staff in charge information was not posted for the residents and the public when the inspectors arrived at 08:35 a.m.
Based on records reviewed and staff interviewed, the facility failed to ensure the rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each resident or resident?s legal representative. Evidence of this review shall be written acknowledgement and include the date of the review and filed in the resident?s record. Evidence: 1. On 1-16-24, resident #2 and 3?s record noted the resident?s rights and responsibilities was last reviewed on 1-12-23. Residents? date of admit noted as 1-28-21. 2. Resident #1?s record did not include a current resident?s right review. Resident?s date of admit noted as 6-14-21.
Based on observation, document reviewed, and staff interviewed, the facility failed to ensure that the menu for meals and snacks for the current week was dated and posted. Evidence: 1. On 1-17-24, during a tour of the safe, secure unit, the posted menu did not include the breakfast items served. 2. Staff #4 acknowledged the menu did not include items for all meals served.
Based on observation and staff interviewed, the facility failed to ensure the pharmacy reference book, drug guide, or medication handbook for nurses is no more than two years old. Evidence: 1. On 1-16-24, the reference drug book on the assisted living unit was the year 2021. 2. Staff #3 and #5 acknowledged the nursing drug handbook was more than two years old.
Based on observations and staff interview, the facility failed to ensure medications shall remain in the pharmacy issued container, with the prescription, label or direction label attached, until administered to the resident. Evidence: 1. On 1-16-24, staff was in the process of administering medication to a resident (room #106). Once staff #5 was finished, staff obtained a souffle cup from the medication room with resident #4?s medication and proceeded to administer, the pre-poured medication. The inspector inquired how many medications were in the cup, staff stated there were eight (8) medications. 2. Staff #5 acknowledged, the medications for the aforementioned resident was prepared in advance.
Based on observation, record review and staff interviewed, the facility failed to ensure medication was administered according to the facility?s standard dosing schedule. Evidence: 1. On 1-16-24, during the medication pass observation with staff #5, resident #3?s medication administration record noted Synthroid 100mcg at 07:30 a.m. The medication package label noted 6:00 a.m. The resident was administered the medication at 09:48 a.m. 2. Staff #2 and #5 acknowledged the resident?s medication was not administered according to the facility?s dosing schedule.
Based on observation and staff interviewed, the facility failed to ensure the temperature of at least 72 degrees Fahrenheit (F) was maintained in all areas used by residents during the hours when residents are normally awake. Evidence: 1. On 1-17-24, the temperature in the lobby of the assisted living expansion area was 67 degrees F. 2. The temperature reading near the Charter Room noted 67 degrees F. 3. Staff #3 acknowledged the temperature reading was 67 degrees F.
Based on observation and staff interviewed, the facility failed to ensure the fire and emergency evacuation drawing posted included all required information. Evidence: 1. On 1-16-24, the fire and emergency evacuation postings In the Namaste, safe, secure unit did not include primary and secondary escape routes and areas of refuge. 2. Staff #3 acknowledged, the fire and emergency evacuation posting did not include all required information.
Based on documents reviewed and staff interviewed, the facility failed to ensure the fire and emergency evacuation drills included all required information. Evidence: 1. On 1-16-24, the fire drills dated 12-21-23, 11-24-23 and 10-9-23 did not included the number of residents participating. 2. Staff acknowledged the number of residents participating in the fire drills was not documented.
Based on observations and staff interviews, the facility failed to ensure the first kit included all items and expiration dates must not have dates that have already passed. Evidence: 1. On 1-16-24, the hand sanitizer in the first aid kit on the assisted living hallway was dated 4-2023. The document noted the kit was last checked on 1-1-24. 2. The first aid kit on the Namaste, safe, secure unit did not include a blanket, hand sanitizer, plastic bag, and no extra batteries. 3. Staff #3 acknowledged the first aid kits observed, did not include all required items.
Jan 24, 2023Routine
Type of inspection: Renewal An unannounced renewal inspection was conducted on-site on 1-24-23 (Ar 09:15 a.m./dep 18:00 p.m); 1-26-23 (Ar 08:00 a.m./dep 17:45 p.m) 1-30-23 (ar 09:55 a.m./dep 18:10 p.m.). The census on day 1 was 93. A tour of the main facility was conducted, medication pass observation in the main building on day 1 and day 2 in the safe, secure unit. Resident and staff interviews were conducted, breakfast meal observed in the safe, secure unit, emergency preparedness items check, including 48 hour food and water supplies. A preliminary exit meeting was conducted each day with the administrator and other team members. Additional documents were requested to be sent via email on 1-26-23 and 1-30-23. On 2-3-23 a virtual preliminary meeting was conducted to review a staff record requested on 1-30-23. 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 Willie Barnes, Licensing Inspector at 757-439-6815 or by email at willie.barnes@dss.virginia.gov
Based on record reviewed and staff interviewed, the facility failed to ensure within four months of employment direct care staff, shall complete 10 hours of training on the nature and needs of residents with cognitive impairments relevant to the population in care. Evidence: 1. On 1-30-23, Staff #?7s date of hire was documented as 3-7-22. Staff?s record (Relias) documented cognitive training started 7-20-22, 2. Staff #9?s date of hire was documented as 2-15-22. Training document (Relias) received from staff #11 documented training started on 6-29-22. Training document received from staff #4 following third preliminary exit on 2-3-23 documented 8 hours of cognitive training, certificate dated 4-15-22.
Based on record reviewed, policy reviewed and staff interviewed, the facility failed to ensure it reported the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare for five of ten residents? record reviewed. Evidence: 1. On 1-24-23 and 1-26-23, the sampled residents? clinical notes were requested and provided. Resident #4?s ?Clinical Notes Report (CNR) documented on 1-1-23 resident observed sitting on shower floor; 1-2-23 documented ?resident is S/P fall from two nights ago?. On 1-3-23 ?resident?c/o pain of the lower back and coccyx area since fall.? On 1-4-23, ??still c/o pain of 9 PSR, facial grimacing noted? X-ray of L spine for fall with worsening pain?resident now c/o L. hip pain when ambulating?. On 1-5-23, resident out to local hospital for pain from previous fall. On 1-12-23 resident was seen by medical provider as ?follow up from post fall from last week. Noted swelling and redness of the lower R leg/calf area. Resident c/o numbness of the R foot and coldness noted. New order to send to ER for venous doppler study to R/O DVT and evaluation/treat. Resident returned -no new order or assistive device. 2. Resident #5?s CNR documented on 11-23-22, was sent to a local hospital due to shortness of breath?resident returned and ?has a order for 3Lof continuous oxygen?. 3. Resident #7?s CNR documented on 7-1-22, ?resident assessed by practitioner and was sent out to ER for swelling to BLE?. On 8-19-22, resident reported to practitioner ?having intermittent chest pain on ?left side of chest that is radiating to the right?. Orders to send resident out via 911 following practitioner?s assessment. On 12-21-22, resident c/o lower left abdominal to almost groin pain?resident sent to local hospital. Resident returned, ?CT scan show a hernia?small stones inside kidney?no infection?pain medication ordered?. On 1-9-23, ?sent to ER for groin and left leg pain?returned, ordered Keflex for 7 days for cellulitis, Lasix for 10 days for edema and PRN
Based on observation, staff interviewed and collateral interview, the facility failed to ensue when private duty personnel provide direct care or companion services the identified needs shall be reflected on the resident?s individualized service plan. Evidence: 1. On 1-24-23, a private duty personnel was observed in resident #1 and #2?s apartment. The inspector interviewed the private duty personnel, who stated providing services for both residents. According to staff #4, the private sitter is assigned to resident #2. Resident #2?s ISP
Based on record reviewed and staff interviewed, the facility failed to ensure it did not admit/retrain individuals with a prohibitive condition or care needs in accordance with 63.2-1805 D of the Code of Virginia for three of ten records reviewed. Evidence: 1. On 1-24-23, record review with staff #3 and #4, resident #1?s January 2023 physician order sheet (POS) and medication administration record ( MAR
Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan ( ISP
Based on observation and staff interviewed, the facility did not have a written agreement signed and dated by both the resident and the licensee or administrator and filed in record for residents who routinely have meals in their rooms and have a documented mental health concern. Evidence: 1. On 1-24-23, record reviewed with staff #3 and #4, resident #1?s individualized service plan ( ISP
Based on observation and staff interviewed, the facility failed to ensure the facility first aid kit included all required items. Evidence: 1. On 1-24-23, the first aid kit on the first floor checked with staff #2, the hand sanitizer was dated 8-2022 and there were no extra batteries for the flashlight. 2. On 1-26-23, the first aid kit in the safe, secure unit did not have extra batteries for the flashlight and there was no hand sanitizer in the kit. 3. Staff #2 and #6 acknowledged the first aid kit reviewed did not included all required items.
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