VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Benchmark at Alexandria
3440 Berkeley Street
Alexandria, VA 22302
(571) 386-2200

Current Inspector: Nina Wilson (703) 635-6074

Inspection Date: Aug. 20, 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 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Technical Assistance:

Licensing Inspector (LI) reviewed the following standards with the facility: 22VAC40-73-310, 22VAC40-73-325, 22VAC40-73-970, and 22VAC40-73-1110.

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 08/20/2025 Time in: 10:55 AM Time out: 6:44 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: 64 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Number of staff records reviewed: 6 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: Licensing inspector observed residents participating in scheduled activities, entering and exiting the community for outings, dining for breakfast, and interacting with staff and peers. Additional Comments/Discussion: N/A 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 Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-1130-C
Description:	Based on record review and staff interview, the facility failed to ensure that during the night hours, when 22 or fewer residents were present, at least two direct care staff members were awake and on duty at all times in each special care unit and was responsible for the care and supervision of the residents. Evidence: 1. April 2025?s staff schedule for the safe, secure environment was assigned one staff for the care and supervision of ten residents. 2. During the onsite inspection, 08/20/2025, staff 7 acknowledged that April 2025?s staff schedule for the safe, secure environment assigned one staff for the care and supervision of ten residents.
Plan of Correction:	1. Corrective Action for Affected Staff/Residents: All residents in the safe, secure unit were reviewed following the inspection. There were no identified negative outcomes or care concerns resulting from the lack of a second staff member on the dates cited. 2. Identification of Other Potentially Affected Individuals A full audit of the staff scheduling from May 1, 2025 ? June 30, 2025 was conducted. No other deficiencies were identified. 3. Systemic Changes Made to Prevent Recurrence: The scheduler and the Executive Director were educated on regulatory requirements for special care staffing. Effective 6/10/25, the staffing schedule reflects the appropriate staffing levels. 4. Monitoring to Ensure Ongoing Compliance: Beginning June 10, 2025, the Executive Director or designee began auditing staffing schedules weekly for 90 days, then monthly for three additional months to ensure two staff are scheduled and present each shift in the special care unit to ensure ongoing compliance. 5. Completion Date: 09/01/2025
Standard #:	22VAC40-73-220-A
Description:	Based on private duty record review and staff interview, the facility failed to ensure private duty personnel from a licensed home care organization met the requirements of 22VAC40-73-250-D 1 through D 4 regarding tuberculosis and were provided orientation and training regarding the facility?s policies and procedures related to the duties of private duty personnel. Evidence: 1. Upon request, the facility did not provide private duty 5?s tuberculosis risk assessment. 2. Upon request, the facility did not provide documentation of orientation and training for private duty 4, private duty 5, and private duty 6. 3. During the onsite inspection, 08/20/2025, staff 7 confirmed that a risk assessment documenting the absence of tuberculosis in a communicable form was not completed for private duty 5. Additionally, staff 7 confirmed that orientation and training regarding the facility?s policies and procedures was not included in private duty 4, private duty 5, and private duty 6?s records.
Plan of Correction:	1. Corrective Action for Affected Staff/Residents TB risk assessments were immediately requested and obtained for private duty personnel. Orientation and training will be completed and documented by 9/30/2025 2. Identification of Other Potentially Affected Individuals All current and future private duty aides are potentially affected. Records of each were reviewed. 3. Systemic Changes Made to Prevent Recurrence A Private Duty Checklist is now required prior to assignment, verifying TB clearance and completion of orientation. 4. Monitoring to Ensure Ongoing Compliance The Director of Business Administration, or designee will review private duty records monthly to confirm compliance. 5. Completion Date: 09/30/2025
Standard #:	22VAC40-73-490-A-2
Description:	Based on record review and staff interview, the facility failed to ensure for residents who meet the criteria for assisted living care a licensed health care professional, practicing within the scope of the health care profession, provided health care oversight at least every three months, or more often if indicated, based on the health care professional?s professional judgement of the seriousness of a resident?s needs or stability of a resident?s condition. Evidence: 1. The healthcare oversight was completed 04/1/2024 through 10/23/2024 and 03/18/2025 through 03/19/2025. 2. During the onsite inspection, 08/20/2025, staff 7 confirmed the facility does not employ a licensed health care professional who was on site on a fulltime basis with their healthcare oversight for residents who met the criteria for assisted living care being completed by a regional licensed healthcare professional every six month. Staff 7 confirmed over the past year the healthcare oversight was completed on 10/23/2024, 03/18/2025, and 03/19/2025.
Plan of Correction:	1. Corrective Action for Affected Staff/Residents Benchmark at Alexandria is in the process of hiring a licensed health care professional who will be onsite and be responsible for conducting required oversight visits at least every 180 days, or more if clinically indicated, in accordance with the regulation. In the interim, oversight is being covered by a regional nurse specialist to ensure no gaps in compliance. 2. Identification of Other Potentially Affected Individuals All residents receiving assisted living level of care are potentially affected. Each resident?s record will be reviewed to ensure appropriate oversight is scheduled until the onsite licensed health care professional is in place. In addition, Benchmark?s policy and community practice is a weekly tracking meeting. Here, all residents are reviewed over the course of each month. 3. Systemic Changes Made to Prevent Recurrence The onsite licensed health care professional will be responsible for timely completion and documentation of all required oversight. The VDSS Record of Healthcare Oversight model form will be maintained by the onsite licensed health care professional. 4. Monitoring to Ensure Ongoing Compliance Executive Director (ED) or designee will audit oversight documentation quarterly to verify compliance. 5. Completion Date: 10/31/2025 (target date for onsite licensed health care professional hire and oversight schedule).
Standard #:	22VAC40-73-490-A-3
Description:	Based on record review and staff interview, the facility failed to ensure that all residents were included at least annually in healthcare oversight. Evidence: 1. The healthcare oversight completed on 10/23/2024 did not indicate which residents were reviewed during the review period. 2. The healthcare oversight completed on 03/18/2025 and 03/19/2025 indicated that six residents were evaluated for their ability to self-administer medications. The healthcare oversight did not include any other resident reviews. 3. During the onsite inspection, 08/20/2025, staff 7 confirmed that all residents were not included at least annually on the healthcare oversight.
Plan of Correction:	1. Corrective Action for Affected Staff/Residents: The full census will be printed and used during the healthcare oversight process. The census will then be attached to the VDSS Record of Healthcare Oversight model form to ensure all residents are included in the annual review. 2. Identification of Other Potentially Affected Individuals: All residents are potentially affected. Records were reviewed to verify required oversight will be captured for each. 3. Systemic Changes Made to Prevent Recurrence: Oversight reports will now identify each resident by name and date reviewed, and will be stored in a centralized binder. 4. Monitoring to Ensure Ongoing Compliance: The Resident Care Director will cross-check the roster quarterly; ED/Designee will audit semi-annually. 5. Completion Date: 09/30/2025
Standard #:	22VAC40-73-640-A
Description:	Based on observation and staff interview, the facility failed to ensure to implement a written plan for medication that included a plan for proper disposal of medication. Evidence: 1. During the onsite inspection, 08/20/2025, LI observed resident 8?s medication (Morphine Sulfate Oral Solution 100 MG per 5 mL) in plain view, stored in a box under the wellness director?s desk. Staff 7 was present at the time of LI?s observation and acknowledged that the medication was discontinued. 2. The facility?s medication management plan directs staff to ?destroy? expired or discontinued medication ?per BSL Controlled Substance Policy.? 3. Picture taken.
Plan of Correction:	1. Corrective Action for Affected Staff/Residents: The discontinued medication was destroyed immediately following inspection. Staff were re-trained on disposal procedures. 2. Identification of Other Potentially Affected Individuals All residents with discontinued or expired medications are potentially affected. Medication carts and storage were reviewed to ensure compliance. 3. Systemic Changes Made to Prevent Recurrence A retraining of the Controlled Substance Management policy conducted to ensure the plan for proper disposal of medications met state requirements. Medications will be destroyed promptly after discontinuation or returned to the resident/resident responsible party; hospice provider in accordance with the policy. 4. Monitoring to Ensure Ongoing Compliance Weekly spot audits of medication storage and logs will be performed by the Resident Care Director. 5. Completion Date: 09/30/2025
Standard #:	22VAC40-73-950-E
Description:	Based on record review and staff interview, the facility failed to develop and implement a semiannual 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 should be documented by signing and dating. Evidence: 1. Upon request, the facility did not provide documentation of a semi-annual review on the emergency preparedness and response plan for all staff, residents, and volunteers. 2. During the onsite inspection, 08/20/2025, staff 7 confirmed that the semi-annual review on the emergency preparedness and response plan for all staff, residents, and volunteers were not documented as completed by signing and dating.
Plan of Correction:	1. Corrective Action for Affected Staff/Residents A facility-wide emergency preparedness review and training will be conducted October 15, 2025. 2. Identification of Other Potentially Affected Individuals All staff, residents, and volunteers are potentially affected. Attendance will be documented. 3. Systemic Changes Made to Prevent Recurrence Emergency preparedness reviews will be scheduled every six months and tracked on the Safety Committee calendar. 4. Monitoring to Ensure Ongoing Compliance The Safety Committee Chair or designee will maintain training logs and submit them to the Executive Director for verification. 5. Completion Date: 10/15/2025
Standard #:	22VAC40-73-990-B
Description:	Based on record review and staff interview, the facility failed to ensure that procedures in the plan for resident emergencies were reviewed by the facility at least every six months with all staff. Documentation of the review should be signed and dated by each staff person. Evidence: 1. Upon request, the facility did not provide documentation of resident emergency review with all staff. 2. During the onsite inspection, 08/20/2025, staff 7 confirmed that resident emergency reviews with all staff were not documented as completed every six months.
Plan of Correction:	1. Corrective Action for Affected Staff/Residents: All staff will participate in emergency procedure reviews at the October staff meeting, and documentation will be signed and dated. 2. Identification of Other Potentially Affected Individuals: All staff are potentially affected. Each staff member will be scheduled for review. 3. Systemic Changes Made to Prevent Recurrence: Semi-annual reviews will be incorporated into the community?s training calendar. 4. Monitoring to Ensure Ongoing Compliance: The Executive Director will review sign-in sheets after each review to ensure 100% compliance. 5. Completion Date: 10/01/2025