VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Willow Oaks Court
8595 Centreville Road
Manassas, VA 20110-8457
(703) 257-6280

Current Inspector: Margaret Woods-Kane (804) 724-9618

Inspection Date: Aug. 27, 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: Renewal Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: August 27, 2025, from 10:30 a.m. until 6:49 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: 89 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: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 6 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, verified appropriate amount of liability insurance, 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) 682-1739 or by email at Angela.Via@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-40-A
Description:	Based on record review and staff interviews, the facility failed to ensure compliance with the facility's own policies and procedures. Evidence: 1. During the introduction meeting on 8/27/2025, licensing inspector (LI) asked if there were any residents with serious cognitive impairments. Staff 4 stated that there were no residents currently with serious cognitive impairments. During exit meeting, staff 5 confirmed there are no residents with serious cognitive impairments. 2. On page 1 of the Birmingham Green Assisted Living Facility- Willow Oaks Wander Guard System policy, it states ?prior to admission, residents shall have been assessed by an independent physician/Psychologist and or Psychiatrist licensed to practice in the Commonwealth as having a serious cognitive impairment due to primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his or her own safety and welfare?. If the resident is assessed as having a serious cognitive impairment and scores as ?high risk? on risk assessment, wandering risk scale, and case management assessment, Wander Guard bracelet is applied. Based on this policy and the confirmation that no current residents have a serious cognitive impairment; there should be no residents that have a Wander Guard bracelet in place. 3. Staff 5 provided the LI with a list containing 13 residents with roaming alert bracelets. 4. Resident 6, admitted 12/20/2021, had a BHG (Birmingham Green) wandering decision tree assessment on 4/12/2025 and 7/23/2025 with a score of zero, indicating low risk for wandering. 5. Individualized Service Plan (ISP for resident 6 indicated that a ?roam alert bracelet applied R/T impaired cognition and safety issues? was initiated 4/26/2022. 6. The BHG Modified Mini Mental for resident 6 indicated a score of 19, which is a mild cognitive impairment. 7. Resident 7, admitted 11/15/2021, had a BHG Wandering decision tree assessment on 4/3/2025 and 7/17/2025 with a score of zero, indicating low risk for wandering.
Plan of Correction:	The Wander Guard policy is being reviewed and adjusted to ensure that our policy matches the operational procedure.
Standard #:	22VAC40-73-250-D
Description:	Based on record review, the facility failed to ensure each staff person on or within seven days prior to the first day of work at the facility 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. The risk assessment must not be older than 30 days.' Evidence: 1. Record for staff 3, hired 12/17/2024, contained a tuberculosis risk assessment dated 12/18/2024. 2. Record for staff 3, hired 12/17/2024, contained a chest x-ray dated 11/08/2023, which is over 30 days old.
Plan of Correction:	Staff Training Training conducted for staff on the importance of accuracy in documentation, particularly regarding hire dates and compliance protocols. Training conducted, outline the correct procedures for completing, reviewing, and signing new hire documents. Review of Documentation Protocols: A review of current documentation practices conducted to identify areas for improvement in accuracy and compliance. A checklist for staff to verify the accuracy of new hire documentation before submission is created. Regular audits will be conducted on documentation to ensure compliance with established protocols.
Standard #:	22VAC40-73-530-A
Description:	Based on resident record review and staff interviews, the facility failed to allow any resident who does not have a serious cognitive impairment to freely leave the facility. Evidence: 1. During the introduction meeting on 8/27/2025, licensing inspector (LI) asked if there were any residents with serious cognitive impairments. Staff 4 stated that there were no residents currently with serious cognitive impairments. During exit meeting, staff 5 confirmed there are no residents with serious cognitive impairments. 2. Staff 5 provided the LI with a list containing 13 residents with ?roaming alert bracelets?, which would prevent these residents from freely leaving the facility.
Plan of Correction:	Residents with wander guards are being reviewed for need by Geri-Psych and during our ISP reviews to ensure proper diagnosis, along with mini mental and decision tree scores. Residents that do not meet criteria will have wander guards removed.
Standard #:	22VAC40-73-950-E
Description:	Based on facility record review and staff interview, the facility failed to implement a semi-annual review on the emergency preparedness and response plan for all staff, residents, and volunteers included all six elements of this subsection. The review must be documented by signing and dating. Evidence: 1. Licensing Administrator requested the semi-annual review of the emergency preparedness and response plan for staff, residents and volunteers. 2. During document review on 8/27/2025 the LI observed the semiannual review of emergency preparedness with staff and residents did not include the required elements. 3. Staff 8 acknowledged the emergency preparedness and response training were areas that needed improvement.
Plan of Correction:	1. The emergency preparedness policy will be placed on our Healthcare Academy continuing education curriculum and reviewed by all staff once per year. 2. The emergency preparedness policy will be reviewed in person, annually by L&D with all staff.
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 a 48-hour supply on site at any given time. Evidence: 1. During a tour of the facility on 8/27/2025, licensing inspectors did not observe a supply of emergency drinking water. 2. Staff 8 stated that the emergency water supply for this facility was not stored on site but at the sister facility on the same grounds.
Plan of Correction:	Drinking water was on campus. DSS inspectors could not answer definitively if it had to be in the facility without research. We were informed of the decision on 9/23/25. The water was transferred over on 9/23/25 and is now on-site. Please see e-mail for supporting documentation.