VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Showalter Center
1060 Showalter Drive
Blacksburg, VA 24060
(540) 443-3427

Current Inspector: Angela Marie Swink (276) 623-6575

Inspection Date: Dec. 17, 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 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

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: 12/17/2025, 9:49am to 4:12pm 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: 76 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 9 Number of staff records reviewed: 4 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 5 Observations by licensing inspector: 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 Becky Berry, Licensing Inspector at 276-698-8228 or by email at rebecca.berry@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-250-C
Description:	Based on a review of staff records, the facility failed to ensure all required personal and social data is contained in the staff record, including an original criminal record report. EVIDENCE: 1. According to 22VAC40-90-10, "Criminal history record report" means either the criminal record clearance or the criminal history record issued by the Central Criminal Records Exchange, Department of State Police. 2. According to 22VAC40-90-40-B, the criminal history record report shall be obtained within 30 days of employment for each employee. 3. The start date of employment for staff #8 was 10/27/2025. A criminal history record report issued by the State Police was not observed in the record for staff #8 on the date of the inspection (12/17/2025).
Plan of Correction:	A Virginia State Police criminal history background check for Staff #8 was completed on 12/17/2025 immediately upon notification that it was missing from the personnel file. The report was returned the same day and confirmed no criminal history. To prevent recurrence, the HR Director or designee will verify that a Virginia State Police criminal history record report is completed, received, and filed for every newly hired employee within the required 30-day timeframe. A tracking process will be maintained to ensure all background checks are obtained and documented prior to the deadline. [SIC]
Standard #:	22VAC40-73-440-E
Description:	Based on a review of resident records, the facility failed to ensure that for public pay individuals, the Uniform Assessment Instrument (UAI) shall be completed by a case manager or qualified assessor as specified in 22VAC30-110. EVIDENCE: 1. Resident #7 is a recipient of the auxiliary grant according to staff #21 and staff #22. 2. A public pay UAI for resident #7 was completed by a representative with the local department of social services (DSS) on 07/19/2024. 3. According to staff #23, when he contacted the local DSS in 2025 to coordinate with the qualified assessor to ensure that the UAI is completed as required, he was informed the facility would be responsible for completing the UAI. 4. A private pay UAI was completed for resident #7 on 07/17/2025 by staff #22.
Plan of Correction:	The local DSS office was contacted by staff #23 on 12/18/2025, 12/19/2025, and again on 12/22/2025, at which time he was able to speak directly with a representative. He informed them that the facility had received a citation due to their prior instruction that the facility should complete the public pay UAI. In response, a DSS case manager (qualified assessor) visited the facility on 12/23/2025 and completed the required public pay UAI for Resident #7. To prevent recurrence, Showalter staff will immediately request to speak with a DSS supervisor if any DSS representative indicates that the facility is responsible for completing a public pay UAI. Staff will follow regulatory requirements ensuring that all UAIs for public pay residents are completed by a qualified assessor as mandated. [SIC]
Standard #:	22VAC40-73-860-I
Description:	Based on observations made during a tour of the building, the facility failed to store cleaning supplies and other hazardous materials in a locked area. EVIDENCE: 1. At 10:40am and 3:08pm on the day of the inspection, the door to the storage room located by Stair 4N was observed to be unlocked and opened. 2. Cleaning supplies and other hazardous materials were observed in the storage room including insecticide, toilet bowl cleaner, mold control, caulk remover, odor crystals, super glue, wood glue, wood putty, and several tubes of caulk, adhesive and sealants.
Plan of Correction:	Staff received re-education after failing to follow facility policy by leaving the storage room door unlocked, open, and unattended. All staff were instructed that storage rooms containing cleaning supplies or other hazardous materials must remain closed and locked at all times to prevent resident access. To ensure sustained compliance, the Maintenance Supervisor will conduct random checks of all storage rooms for the next 30 days. Any noncompliance will be addressed immediately through corrective coaching or disciplinary action as appropriate. This monitoring process will remain in place to ensure that hazardous materials are consistently secured and inaccessible to residents. [SIC]
Standard #:	22VAC40-73-870-A
Description:	Based on observations made during a tour of the building, the facility failed to ensure the interior and exterior of all buildings shall be maintained in good repair and kept clean and free of rubbish. EVIDENCE: 1. In resident room #414, small stains were observed on the carpet in the living area as well as what appeared to be food crumbs on the carpet near the couch. The waste basket located by the couch was overflowing. 2. In resident room #401, a full trash bag was observed in the kitchen next to the trashcan, and in the bedroom to the left, particles of dirt and debris were observed under and around the bed and a crumpled white cloth or tissue was observed under the lower right corner of the bed. The waste basket by the nightstand in the same bedroom was overflowing. 3. In resident room #310, the waste basket next to the recliner in the living area was overflowing.
Plan of Correction:	Overflowing trash in Rooms #414, #401, and #310 was removed immediately. The carpet stains and food crumbs in Room #414 were cleaned and vacuumed on 12/18/25. Environmental Services staff have been re-educated on the requirement to maintain resident rooms in good repair and free of excessive trash. To prevent recurrence, Environmental Services will conduct scheduled trash checks in all resident rooms twice per week, and residents may request additional trash removal at any time during housekeeping hours. In addition, the Director of Environmental Services will complete random room inspections for the next 30 days to verify that rooms remain clean, free of rubbish, and in compliance with facility standards. Any concerns identified during these checks will be addressed promptly through corrective coaching or additional cleaning. [SIC]
Standard #:	22VAC40-73-870-I
Description:	Based on observations made during the tour of the building, the facility failed to keep elevators in good running condition. EVIDENCE: 1. On the date of the inspection (12/17/2025) the right-side elevator was out of order and not working.
Plan of Correction:	The right-side lobby elevator was out of service on 12/17/2025 due to the age of the equipment and the unavailability of replacement parts. Two elevator service companies previously attempted repairs but were unable to obtain the necessary components. To address this ongoing issue, the facility began obtaining quotes for full modernization in late 2023 and entered into a contract with Southern Elevators in February 2024 to complete a full refurbishment of both lobby elevators. Southern Elevators advised that fabrication of the new elevator cabs would require 16?24 weeks. The facility received confirmation on 12/17/25 that the required parts will be delivered on January 5, and modernization work on both elevators will begin immediately upon delivery. In the interim, the facility continues to maintain two functioning elevators on site - one lobby elevator and one service elevator near the kitchen - to support resident and staff needs. Elevator shutdown procedures during fire emergencies remain in place, and evacuation through stairwells is practiced regularly with staff and residents as part of the facility?s emergency preparedness plan. Stair chairs and lift pads are available to assist residents who cannot ambulate down stairs, and both the first and second floors have ground-level exits to support safe evacuation. [SIC]
Standard #:	22VAC40-73-960-B
Description:	Based on observations made during the tour of the building, the facility failed to ensure the fire and emergency evacuation drawings include all required components. EVIDENCE: 1. The fire and emergency evacuation drawings posted on each floor did not include the areas of refuge and the assembly areas.
Plan of Correction:	The fire and emergency evacuation drawings on all floors were updated to include the required area of refuge and designated assembly areas. Revised drawings have been posted throughout the building. The Administrator will review all evacuation maps quarterly to ensure they remain accurate, complete, and compliant with regulatory requirements. [SIC]