VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Cave Creek ALF
8088 Lee Highway
Troutville, VA 24175
(540) 992-4599

Current Inspector: Cynthia Jo Ball (540) 309-2968

Inspection Date: Sept. 10, 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 ARTICLE 1 ? SUBJECTIVITY 32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS 63.2 GENERAL PROVISIONS 63.2 PROTECTION OF ADULTS AND REPORTING 63.2 LICENSURE AND REGISTRATION PROCEDURES 63.2 FACILITIES AND PROGRAMS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 THE LICENSE 22VAC40-80 THE LICENSING PROCESS 22VAC40-80 COMPLAINT INVESTIGATION 22VAC40-80 SANCTIONS

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: 09/10/2025 8:30am until 11:30am 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: 4 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: 2 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 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 Cynthia Ball-Beckner, Licensing Inspector at 540-309-2968 or by email at cynthia.ball@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-210-B
Description:	Based on staff record reviews, the facility failed to ensure that in facilities licensed for both residential and assisted living care, all direct care staff shall attend at least 18 hours of training annually. EVIDENCE: 1. The record for staff person 1 has documentation that the employee only completed 10 hours of annual training from August 2024 through August 2025. 2. The record for staff person 2 has documentation that the employee only completed 12 hours of annual training from June 2024 through June 2025.
Plan of Correction:	Administration will ensure that all training will be taught and documented each month in accordance with the ALF regulations, of 18hrs annual training. I will get the required training completed.
Standard #:	22VAC40-73-210-F
Description:	Based on staff record review, the facility failed to ensure that all staff completed at least 2 hours of training in infection control annually. EVIDENCE: 1. The record for staff persons 1 and 2 do not have documentation of at least 2 hours of training in infection control within the past year.
Plan of Correction:	Administration will ensure to implement the training on infection control to the staff, and will make sure to have at least 2hrs of training annually going forward.
Standard #:	22VAC40-73-520-I
Description:	Based on observations of the facility physical plant, the facility failed to ensure that the current months activity schedule was posted in a conspicuous location in the facility. EVIDENCE: 1. At 8:41 am on the day of on-site inspection the licensing inspector observed that an activity schedule for the current month was not posted in the facility.
Plan of Correction:	Administration will ensure daily activity schedule is updated and posted where it can be seen.
Standard #:	22VAC40-73-550-G
Description:	Based on staff record review, the facility failed to ensure that an annual review of resident rights and responsibilities was completed with all staff. EVIDENCE: 1.The record for staff persons 1 and 2 do not have documentation of an annual review of resident rights and responsibilities within the past year.
Plan of Correction:	Administration will update staff folders with current residents right and responsibilities for the year.
Standard #:	22VAC40-73-610-B
Description:	Based on observations of the facility physical plant, the facility failed to ensure that menus for meals and snacks for the current week were dated and posted in an area conspicuous to residents. EVIDENCE: 1. At 8:41 am on the day of on-site inspection the menu that was posted in the facility was for the week of August 11, 2025, through August 17, 2025.
Plan of Correction:	Administration Will update the current menu and keep a current menu posted.
Standard #:	22VAC40-73-680-E
Description:	Based on resident record review, the facility failed to ensure that the results of medical procedures were documented. EVIDENCE: 1. The September 2025 medication administration record (MAR) for resident 1 has documentation of a physicians order for blood pressure, weight and pulse check each month on the 4th. The September 2025 MAR for resident 1 does not have documentation of the results of resident 1?s blood pressure, weight and pulse check.
Plan of Correction:	Administration will make sure all medical procedures are done and documented on that requested time and date.
Standard #:	22VAC40-73-690-E
Description:	Based on resident record review, the facility failed to ensure that residents physicians were made aware of recommendations included in a medication review. EVIDENCE: 1. The record for resident 1 has documentation that a medication review was completed on 06/05/2025 with recommendations to recheck the residents cholesterol level and to consider removal of Benadryl. The record does not have documentation that resident 1?s physician was made aware of these medication review recommendations. 2. The record for resident 2 has documentation that a medication review was completed on 06/05/2025 with recommendations to recheck the residents cholesterol. The record does not have documentation that resident 2?s physician was made aware of this medication review recommendation.
Plan of Correction:	Administration will ensure that all recommendations for medication sent to the facility for the residents is forwarded to the appropriate Physician for review. We will forward recommendations
Standard #:	22VAC40-73-950-E
Description:	Based on staff record review, the facility failed to ensure that a semi-annual review of the facility emergency preparedness plan was completed with all staff. EVIDENCE: 1. The record for staff persons 1 and 2 have documentation that the last review of the facility emergency preparedness plan was completed on 08/13/2024.
Plan of Correction:	Administration will ensure that the semi-annual review of the facilities emergency preparedness plan gets completed by each staff member and updated in charts
Standard #:	22VAC40-73-990-B
Description:	Based on staff record review, the facility failed to ensure that a six-month review of the facility plan for resident emergencies was completed with all staff. EVIDENCE: 1. The record for staff persons 1 and 2 have documentation that the last review of the facility plan for resident emergencies was completed on 08/12/2024.
Plan of Correction:	Administration will ensure the completion of the six-month review of the facilities plan for the resident emergencies for all staff gets completed and updated in charts.