VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Mission House
516 W. Spotswood Trail
Elkton, VA 22827
(540) 298-8917

Current Inspector: Angela N Via (540) 682-1739

Inspection Date: Aug. 1, 2025

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS ARTICLE 1 ? SUBJECTIVITY 63.2- (1) General Provisions 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation

Technical Assistance:

None

Comments:

Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 8/1/2025 from 8:45 a.m. until 1:30 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 15 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 2 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 5 Observations by licensing inspector: The Licensing Inspector toured the community and observed the residents during activities and meals. The Licensing Inspector reviewed the following at the time of inspection: sample of resident and employee records, medication administration, fire drills, emergency drills, pharmacy review, menus, activity calendars, and dietician report. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. 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 Angela Via, Licensing Inspector at (540) 682-1729 or by email at Angela.Via@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-50-A
Description:	Based on resident record review and staff interviews, the facility failed to provide a statement to the prospective resident and the prospective resident?s legal representative, if any, that disclosed information about the facility. Evidence: 1. Record for resident 3, admitted 7/21/2025, did not contain disclosure statement. 2. Staff 4 acknowledged that resident 3?s paperwork had not been completed.
Plan of Correction:	Administrator will include disclosure statement with admission packet to ensure all paperwork for resident admission is completed upon resident arrival to the facility. Administrator will assume responsibility for future compliance.
Standard #:	22VAC40-73-50-B
Description:	Based on resident record review and staff interviews, the facility failed to ensure written acknowledgment of the receipt of the disclosure by the resident or the resident?s legal representative was retained in the resident's record. Evidence: 1. Record for resident 3, admitted 7/21/2025, did not contain written acknowledgement of receipt of the disclosure statement. 2. Staff 4 acknowledged that resident 3?s paperwork had not been completed.
Plan of Correction:	Administrator will include written acknowledgment of receipt of the disclosure statement with the admission packet to ensure all paperwork for resident?s admission is completed upon arrival to the facility. Administrator will assume responsibility for future compliance.
Standard #:	22VAC40-73-120-A
Description:	Based on staff record review and staff interviews, the facility failed to ensure the required orientation and training occurred within the first seven working days of employment. Evidence: 1. Employee record for staff 6, hired 7/9/25, contained a blank, unsigned orientation form. 2. Staff 5 reviewed the record for staff 6 and confirmed the orientation form was not completed. 3. Staff 4 searched through additional files of paperwork and record for staff 6 and confirmed it was not completed or signed by employee or trainer. 4. Photo evidence taken.
Plan of Correction:	Assistant administrator will review staff hiring packet and ensure the required orientation and training form is included and completed within the first seven working days of employment. Assistant administrator will assume responsibility for future compliance.
Standard #:	22VAC40-73-210-A
Description:	Based on staff record review and staff interviews, the facility failed to ensure all direct care staff attended at least 14 hours of training annually. Evidence: 1. Record for staff 3, hired 2/1/2018, contained a total of 4.5 hours of annual training from 2/1/2024 to 2/1/2025. 2. Staff 4 verbalized being unaware of this standard to licensing inspectors. 3. Staff 5 was aware of the standard but acknowledged that the required number of annual training hours had not been completed for staff 3.
Plan of Correction:	Assistant administrator will review all staff files and annual training forms and develop a training calendar to ensure all direct care staff have attended at least 14 hours of training annually. Assistant administrator assumes responsibility for future compliance.
Standard #:	22VAC40-73-250-D
Description:	Based on staff record review and staff interview, the facility failed to ensure each staff person on or within seven days prior to the first day of work at the facility and annually thereafter submitted the results of a risk assessment, documenting the absence of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: 1. Record for staff 3, hired 2/1/2018, did not contain an annual tuberculosis risk assessment. The last documented risk assessment for staff 3 was dated 8/30/2023. 2. Record for staff 6, hired 7/9/2025, did not contain a tuberculosis risk assessment. 3. Staff 5 acknowledged that annual tuberculosis risk assessments were past due for staff.
Plan of Correction:	Assistant administrator will develop a schedule and/or calendar to ensure all staff have an annual Tuberculosis risk assessment in their file every year. Assistant administrator assumes responsibility for future compliance.
Standard #:	22VAC40-73-310-B
Description:	Based on resident record review and staff interview, the facility failed to ensure a documented interview was completed between the administrator or a designee responsible for admission and retention decisions, the individual, and his legal representative, if any. Evidence: 1. Record for resident 3, admitted 7/21/2025, did not contain a documented interview between the administrator and individual. 2. Staff 5 acknowledged to licensing inspectors that the documented interview for resident 3 had not been completed.
Plan of Correction:	Administrator will ensure that a documented interview will be completed for each new resident upon admission and retained in the resident?s record. Administrator assumes responsibility for future compliance.
Standard #:	22VAC40-73-310-D
Description:	Based on resident record review and staff interview, the facility failed to provide written assurance to the resident that the facility had the appropriate license to meet his care needs at the time of admission with a signed copy of the written assurance retained in the resident?s record. Evidence: 1. Record for resident 3, admit date 7/21/2025, did not contain a written assurance that was signed by the resident or his legal representative. 2. Staff 4 acknowledged that the written assurance for resident 3 had not been completed.
Plan of Correction:	Administrator will ensure the facility provides written assurance to the resident that the facility has the appropriate license to meet his care needs at the time of admission with a signed copy retained in the resident?s record. Administrator assumes responsibility for future compliance.
Standard #:	22VAC40-73-320-B
Description:	Based on resident record review and staff interview, the facility failed to ensure a risk assessment for tuberculosis was completed annually on each resident as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: 1. Record for resident 1, admitted 9/1/2015, did not contain an annual tuberculosis risk assessment. The last documented risk assessment was dated 8/3/2023. 2. Staff 5 acknowledged that annual tuberculosis risk assessments were behind in being completed for residents.
Plan of Correction:	Administrator will develop a schedule and/or calendar to ensure all residents will have an annual Tuberculosis risk assessment in their record every year. Administrator assumes responsibility for future compliance.
Standard #:	22VAC40-73-350-B
Description:	Based on resident record review and staff interview, the facility failed to ascertain, prior to admission, whether a potential resident was a registered sex offender if the facility anticipated the potential resident would have a length of stay greater than three days or in fact stayed longer than three days with documentation in the resident's record that this was ascertained and the date the information was obtained. Evidence: 1. Record for resident 3, admit date 7/21/2025, did not contain evidence of a registered sex offender search. 2. Staff 4 acknowledged to licensing inspectors that the registered sex offender search had not been completed for resident 3 prior to admission.
Plan of Correction:	Assistant administrator will check all potential residents, prior to admission, whether the potential resident was a registered sex offender and provide documentation in the residents record that this was ascertained and the date the information was obtained. Assistant administrator assumes responsibility for future compliance.
Standard #:	22VAC40-73-390-A
Description:	Based on resident record review and staff interview, the facility failed to ensure at or prior to the time of admission, a written resident agreement or acknowledgment of notification was dated and signed by the resident or applicant for admission or the appropriate legal representative and by the licensee or administrator. Evidence: 1. Record for resident 3, admit date 7/21/2025, did not contain an admission resident agreement. 2. Staff 4 acknowledged to licensing inspectors that the admission resident agreement had not been completed.
Plan of Correction:	Administrator will include an admission resident agreement with admission packet to ensure a written agreement was dated and signed by resident or legal representative and the administrator prior to or at the time of admission. Administrator assumes responsibility for future compliance.
Standard #:	22VAC40-73-410-A
Description:	Based on resident record review and staff interview, the facility failed to provide an orientation, upon admission, for new residents and their legal representatives, which included emergency response procedures, mealtimes, and use of the call system. Acknowledgment of having received the orientation should be signed and dated by the resident and, as appropriate, his legal representative, with documentation kept in the resident's record. Evidence: 1. Record for resident 3, admit date 7/21/2025, did not contain a signed acknowledgement of having received orientation. 2. Staff 4 acknowledged to licensing inspectors a signed orientation for resident 3 had not been completed.
Plan of Correction:	Administrator will include an orientation to our facility including meal times, call bell system and emergency response procedures to our admission packet. Acknowledgment of having received orientation will be signed and dated by the resident or legal representative and kept in the resident?s record. Administrator or assumes responsibility for future compliance.
Standard #:	22VAC40-73-450-A
Description:	Based on resident record review and staff interview, the facility failed to ensure a preliminary plan of care was developed, on or within seven days prior to the day of admission, which addressed the basic needs of the resident to ensure his health, safety, and welfare were adequately protected. Evidence: 1. Record for resident 3, admitted 7/21/2025, did not contain a preliminary plan of care. 2. Staff 5 acknowledged to licensing inspectors that preliminary plan of care had not been completed for resident 3 and was not in his record.
Plan of Correction:	Administrator will include in our admission packet the forms to develop a plan of care, on or within seven days prior to the day of admission. Administrator assumes responsibility for future compliance.
Standard #:	22VAC40-73-550-G
Description:	Based on resident record review and staff interview, the facility failed to ensure the rights and responsibilities of residents in assisted living facilities were reviewed annually with each resident or his legal representative or responsible individual and each staff person with written acknowledgement of having been so informed, along with the date of the review, filed in the resident?s or staff?s record. Evidence: 1. Record for resident 3, admitted 7/21/2025, did not contain a signed acknowledgement that the rights and responsibilities of residents had been reviewed. 2. Staff 5 acknowledged to licensing inspectors that the review of rights and responsibilities of residents had not been completed.
Plan of Correction:	Assistant administrator will develop a calendar to ensure the rights and responsibilities of residents are reviewed annually with each resident or his legal representative and each staff person with written acknowledgment of having been so informed, along with the date of review, filed in the resident?s or staff?s record. Assistant administrator assumes responsibility for future compliance.
Standard #:	22VAC40-73-580-A
Description:	Based on facility record review and staff interviews, the facility failed to ensure compliance with annual kitchen inspection by the Virginia Department of Health (VDH) with annual reports retained at the facility for at least two years. Evidence: 1. Last annual report of the kitchen inspection provided by the facility was dated 4/10/2024. 2. Staff 4 was unaware that the facility needed to contact VDH annually if inspection was not completed. 3. Staff 5 stated that VDH was unable to send an inspector due to staffing but did not have written correspondence with VDH of contact to schedule the inspection.
Plan of Correction:	Administrator will ensure we have an annual kitchen inspection by the Virginia Department of Health (VDH) with annual reports retained at the facility for at least 2 years. Administrator assumes all responsibility for future compliance.
Standard #:	22VAC40-73-680-C
Description:	Based on resident record review and staff interview, the facility failed to administer medications not earlier than one hour before and not later than one hour after the facility's standard dosing schedule, except for drugs ordered for specific times, such as before, after, or with meals. Evidence: 1. Staff 3 administered hydralazine 25 mg tablet to resident 1 at noon however the Medication Administration Record (MAR) for hydralazine 25 mg tablet had 2:00 p.m. as the scheduled time for administration. 2. Physician?s order for resident 1?s hydralazine 25 mg listed 2:00 p.m. as the time for administration. 3. Staff 3 stated that the hydralazine 25 mg tablet has always been given to resident 1 at lunch. 4. Staff 5 acknowledged that order for hydralazine 25 mg was written for administration at 2:00 p.m. and should not be given prior to 1:00 p.m.
Plan of Correction:	Administrator will contact prescriber to request a time change so the resident may take medication 1 hour sooner with her meals like she requests. Administrator assumes all responsibility for future compliance.
Standard #:	22VAC40-73-860-I
Description:	Based on observation and staff interview, the facility failed to store cleaning supplies and other hazardous materials in a locked area. Evidence: 1. During a tour of the facility on 8/1/2025, licensing inspectors observed cleaning supplies, including bleach and ammonia, laundry detergent, and bug spray in an unlocked laundry room. 2. Staff 5 acknowledged that door to laundry room was unlocked. 3. Photo evidence taken.
Plan of Correction:	Administrator will instruct all staff to keep all cleaning supplies inside the closet in the laundry room that has a lock on it. Administrator will assume responsibility for future compliance.
Standard #:	22VAC40-73-870-D
Description:	Based on resident record review and staff interviews, the facility failed to ensure buildings were kept free of infestations of insects. Evidence: 1. During a tour of the facility on 8/1/2025, licensing inspections observed fly strips hanging from the ceilings in three rooms. The kitchen contained 3 fly strips. The living room contained 4 fly strips. The laundry room contained 2 fly strips. All strips had visible dead flies attached. 2. Staff 1 stated that fly strips were hung in the kitchen due to ?flies being everywhere?. 3. Staff 4 and 5 acknowledged the presence of the fly strips. 4. Photo evidence taken.
Plan of Correction:	All fly strips are to be removed from facility. In the case of an insect infestation the administrator will contact a pest control company to ensure our building remains free of any pests. Administrator assumes responsibility for future compliance.
Standard #:	22VAC40-73-950-E
Description:	Based on facility record review, resident record review, and staff interviews, the facility failed to implement an orientation and semi-annual review on the emergency preparedness and response plan for all staff, residents, and volunteers, with emphasis placed on an individual's respective responsibilities. The review must be documented by signing and dating. Evidence: 1. Licensing Inspector requested the semi-annual review of the emergency preparedness and response plan for staff, residents and volunteers. 2. Staff 4 and 5 stated that staff and resident emergency preparedness and response plans had not been reviewed since 2023.
Plan of Correction:	Administrator will add this review to the training calendar to be developed for all staff and volunteers. Residents will also receive semi-annual review as part of the resident council meetings. Administrator assumes responsibility for future compliance.
Standard #:	22VAC40-73-980-A
Description:	Based on resident record review and staff interview, the facility failed to ensure a complete first aid kit was on hand at the facility and contained all of the required items as listed in the subsection. Evidence: 1. The first aid kit was missing blankets, disposable single-use breathing barriers or shields for use with rescue breathing or CPR, gauze pads, hand cleaner, plastic bags, small flashlight and extra batteries, triangular bandages, and a first aid manual. 2. Staff 5 stated that items had been used out of kit and not replenished.
Plan of Correction:	Administrator will ensure a complete first aid kit is on hand at all times at the facility and contains all required items. Administrator assumes responsibility for future compliance.
Standard #:	22VAC40-73-980-H
Description:	Based on observation and staff interview, the facility failed to ensure the availability of a 96-hour supply of emergency drinking water with at least 48 hours of the supply on site at any given time. Evidence: 1. During a tour of the facility on 8/1/2025, licensing inspectors did not observe a supply of emergency drinking water. 2. Staff 5 stated that there was not an emergency water supply at the facility.
Plan of Correction:	Administrator assumes responsibility for ensuring a 48 hour supply of emergency water will be on site at any given time. Administrator will assume responsibility for future compliance.