Inspection Reports for
Ashleigh at Lansdowne Independent & Assisted Living Community
44124 Woodridge Parkway, LEESBURG, VA, 20176
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
7.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
14% better than Virginia average
Virginia average: 9.1 deficiencies/year
Deficiencies per year
24
18
12
6
0
Census
Latest occupancy rate
111 residents
Based on a September 2025 inspection.
Occupancy over time
Inspection Report
Monitoring
Census: 111
Deficiencies: 0
Date: Sep 8, 2025
Visit Reason
The inspection was a monitoring visit triggered by a self-reported incident received by VDSS Division of Licensing on 2025-08-22 regarding allegations in the area of Resident Accommodations and Related Provisions.
Findings
The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law. No deficiencies were cited during the inspection.
Report Facts
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 1
Inspection Report
Complaint Investigation
Census: 113
Deficiencies: 2
Date: Aug 20, 2025
Visit Reason
The inspection was conducted in response to a complaint received on 2025-08-08 regarding allegations related to Resident Accommodations and Related Provisions.
Complaint Details
The complaint was substantiated based on evidence gathered during the investigation, confirming non-compliance with medication management standards.
Findings
The investigation supported the complaint of non-compliance with medication management standards, specifically failures in implementing the medication management plan and administering medications according to physician orders. Violations were issued based on resident record reviews, staff interviews, and document reviews.
Deficiencies (2)
The facility failed to ensure the written medication management plan was implemented, including not ordering medication five days prior to supply running out.
The facility failed to ensure medications were administered in accordance with physician or prescriber instructions, with missed doses documented for Resident 1.
Report Facts
Number of residents present: 113
Number of resident records reviewed: 3
Number of staff interviews conducted: 5
Missed doses of Ativan: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Velasco | Licensing Inspector | Conducted the inspection and interviewed staff |
| Staff 1 | Confirmed medication was not administered according to physician's orders | |
| Staff 2 | Confirmed medication was not ordered five days prior to last dose as per medication management plan |
Inspection Report
Monitoring
Census: 113
Deficiencies: 1
Date: Aug 20, 2025
Visit Reason
The inspection was a monitoring visit to review compliance with applicable standards and laws, including a review of the Intensive Plan of Correction.
Findings
The inspection found non-compliance with applicable standards related to the failure to ensure that original criminal history record reports issued by the Virginia Department of State Police were reviewed prior to initiation of services for private duty personnel not employed by a licensed home care organization.
Deficiencies (1)
Failure to ensure that an original criminal history record report issued by the Virginia Department of State Police was reviewed prior to the initiation of services when private duty personnel who are not employees of a licensed home care organization provide direct care or companion services.
Report Facts
Number of residents present: 113
Number of resident records reviewed: 3
Number of staff records reviewed: 4
Number of interviews conducted with residents: 2
Number of interviews conducted with staff: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Velasco | Licensing Inspector | Current inspector conducting the inspection and interview |
| Staff 1 | Confirmed that collateral contacts did not have required Virginia Department of State Police criminal history record reports reviewed prior to initiation of services |
Inspection Report
Renewal
Census: 113
Deficiencies: 7
Date: Aug 20, 2025
Visit Reason
The inspection was a renewal inspection conducted on August 20 and 21, 2025, to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection identified multiple violations including failure to implement the infection control program, expired or non-compliant first aid certifications among staff, unsecured resident records, improper medication administration and storage, and unsafe storage of cleaning supplies and hazardous materials.
Deficiencies (7)
Facility failed to ensure that the infection control program was implemented, including failure of staff to perform hand hygiene during medication pass.
Facility failed to ensure that each direct care staff member had a current certification in first aid from approved providers.
Facility failed to ensure that resident records were stored in a locked area.
Facility failed to ensure that the UAI indicated a resident is capable of self-administering when a resident keeps their own medication in their room.
Facility failed to ensure medication was administered in accordance with the physician or prescriber's orders, including crushing medication without an order.
Facility failed to ensure that medications ordered for PRN administration were available and properly stored at the facility.
Facility failed to ensure that cleaning supplies and other hazardous materials were stored in a locked area.
Report Facts
Number of residents present: 113
Number of resident records reviewed: 8
Number of staff records reviewed: 4
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 4
Inspection Report
Monitoring
Deficiencies: 0
Date: Jan 10, 2025
Visit Reason
The inspection was conducted as a monitoring visit following a self-reported incident received by VDSS Division of Licensing on 12/05/2024 regarding allegations in the areas of resident care and related services and resident accommodations and related provisions.
Findings
The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law. No deficiencies were cited.
Report Facts
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 4
Inspection Report
Monitoring
Deficiencies: 1
Date: Jan 10, 2025
Visit Reason
The inspection was conducted as a monitoring visit following a self-reported incident received by VDSS Division of Licensing on 2025-01-05 regarding allegations of unexpected death or other serious injury.
Findings
The investigation did not support the self-report of non-compliance with standards or law; however, violations unrelated to the self-reported incident were identified, including failure to ensure the medication management plan was implemented properly.
Deficiencies (1)
The facility failed to ensure that the medication management plan was implemented, including improper documentation and failure to contact the charge nurse, supervisor, or physician when medications were refused or spit out.
Report Facts
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Velasco | Licensing Inspector | Current inspector conducting the inspection |
| Staff 1 | Interviewed staff confirming resident's physician status | |
| Staff 2 | Interviewed staff confirming charge nurse and medication aide roles | |
| Staff 3 | Interviewed staff who pulled Documentation Strike Out for Resident 1's MAR | |
| Staff 4 | Charge Nurse | Interviewed staff responsible for charge nurse duties on 01/03/2025 |
| Staff 5 | Medication Aide | Interviewed staff responsible for medication administration on 01/03/2025 |
Inspection Report
Renewal
Census: 110
Deficiencies: 12
Date: Aug 21, 2024
Visit Reason
The inspection was a renewal inspection conducted on August 21 and 22, 2024, to assess compliance with applicable standards and laws for the assisted living facility license renewal.
Findings
The inspection identified multiple violations including use of an outdated disclosure statement form, incomplete documentation for private duty personnel, missing resident interviews and orientations, unsigned individualized service plans, incomplete meal menus, inadequate oversight of special diets, medication labeling issues, unsecured hazardous materials, lack of annual fire safety inspection compliance, expired first aid kit items, and insufficient emergency water supply.
Deficiencies (12)
Facility failed to ensure the disclosure statement was on the department's current form.
Facility failed to maintain written information on types and frequency of services, orientation, and TB requirements for private duty personnel.
Facility failed to ensure documented interview between facility and resident/legal representative prior to admission.
Facility failed to ensure orientation was provided and signed by residents or legal representatives upon admission.
Individualized service plans were not signed and dated by licensee or resident/legal representative.
Dated menus for meals and snacks for the current week were not posted in an area conspicuous to residents.
Oversight of special diets lacked review of preparation, adequacy, and certification requirements.
Medication was not kept in pharmacy-issued container with prescription label until administered.
Cleaning supplies and hazardous materials were not stored in a locked area.
Facility failed to comply with Virginia Statewide Fire Prevention Code as determined by annual inspection.
First aid kit contained expired items and lacked medical tape.
Facility failed to ensure availability of a 96-hour supply of emergency food and drinking water.
Report Facts
Residents present: 110
Resident records reviewed: 8
Staff records reviewed: 4
Resident interviews conducted: 1
Staff interviews conducted: 4
Emergency water on site (gallons): 125
Additional emergency water ordered (gallons): 90
Inspection Report
Monitoring
Census: 107
Deficiencies: 0
Date: Jul 5, 2024
Visit Reason
The inspection was a monitoring visit conducted on July 5, 2024 and July 29, 2024 to review staffing, admission, retention, discharge of residents, resident care, and general provisions.
Findings
The inspection found no violations of applicable standards or laws. The licensing inspector completed a tour of the physical plant and conducted interviews and record reviews without identifying any deficiencies.
Report Facts
Number of resident records reviewed: 3
Number of staff records reviewed: 0
Number of interviews conducted with residents: 2
Number of interviews conducted with staff: 4
Inspection Report
Complaint Investigation
Census: 107
Deficiencies: 0
Date: Jul 5, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2024-06-20 regarding allegations of exploitation and medical/medication issues.
Complaint Details
Complaint related to allegations of exploitation and medical/medication issues; the complaint was not substantiated.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. No deficiencies were cited.
Report Facts
Number of residents present: 107
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 2
Inspection Report
Monitoring
Census: 107
Deficiencies: 0
Date: Jul 5, 2024
Visit Reason
The inspection was a monitoring visit conducted on July 5, 2024 and July 29, 2024 to review staffing, admission, resident care, and general provisions at the assisted living facility.
Findings
The inspection found no violations of applicable standards or laws. The licensing inspector completed a tour of the physical plant and reviewed resident and staff records, as well as conducted interviews with residents and staff.
Report Facts
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 3
Inspection Report
Monitoring
Census: 107
Deficiencies: 1
Date: Jul 5, 2024
Visit Reason
The inspection was conducted as a monitoring visit following a self-reported incident received by VDSS Division of Licensing on 06/06/2024 regarding allegations in the area of resident care and related provisions.
Findings
The investigation did not support the self-report of non-compliance; however, violations unrelated to the self-reported incident were identified and a violation notice was issued. The facility failed to document rounds made on residents in the special care unit, including the name of the resident, date and time of rounds, and staff member who made the rounds.
Deficiencies (1)
Facility failed to document the rounds that were made, including the name of the resident, the date and time of the rounds, and the staff member who made the rounds.
Report Facts
Number of residents present: 107
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with staff: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Velasco | Licensing Inspector | Current inspector conducting the inspection |
Inspection Report
Monitoring
Census: 103
Deficiencies: 5
Date: May 10, 2024
Visit Reason
The inspection was a monitoring visit conducted on May 10, 2024, following a self-reported incident received on May 5, 2024, regarding allegations in the area of Resident Care and Related Provisions.
Findings
The investigation supported some but not all of the self-report; areas of non-compliance were found in Resident Care and Related Services, Personnel, and Resident Accommodations and Related Provisions. Multiple violations were cited related to staff tuberculosis screenings, sex offender registry checks, individualized service plans, resident rights training, and rounding frequency for residents unable to use signaling devices.
Deficiencies (5)
Facility failed to ensure annual tuberculosis screenings for staff were completed.
Facility failed to ascertain and document sex offender registry checks for residents staying more than three days.
Individualized service plan (ISP) was not signed and dated by the resident or their designee.
Resident rights were not reviewed annually with staff and documented with written acknowledgement.
ISP did not specify minimal frequency of daily rounds for residents unable to use signaling devices.
Report Facts
Residents present: 103
Resident records reviewed: 1
Staff records reviewed: 4
Resident interviews conducted: 1
Staff interviews conducted: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Velasco | Licensing Inspector | Current inspector conducting the monitoring inspection |
| Staff 1 | Confirmed tuberculosis screenings were not completed annually for Staff 2 and 3; confirmed lack of resident or designee signature on ISP; confirmed resident unable to use call bell or pendant and rounding frequency not documented. | |
| Staff 2 | Did not have a completed annual tuberculosis screening. | |
| Staff 3 | Did not have an annual resident rights review completed. | |
| Staff 4 | Provided list of sex offender checks; confirmed sex offender checks for Residents 2 and 3 were not completed; confirmed resident rights had not been completed annually. | |
| Director of Clinical Services | Responsible for reviewing TB screenings, ISPs, and ensuring compliance with corrective actions. | |
| Executive Director | Responsible for conducting quarterly audits and ensuring compliance with corrective actions. | |
| Regional Director of Clinical Services | Responsible for conducting quarterly audits of staff TB screenings and resident ISPs. | |
| Human Resources Manager | Responsible for conducting resident rights training and quarterly audits. |
Inspection Report
Census: 104
Deficiencies: 2
Date: Apr 25, 2024
Visit Reason
The inspection was conducted as a regulatory oversight visit following a self-report received by VDSS Division of Licensing regarding allegations in the areas of Resident Care & Related Services.
Findings
The investigation did not support the self-report of non-compliance; however, violations unrelated to the self-report were identified during the inspection. The facility failed to ensure individualized service plans (ISP) were signed by residents or their legal representatives and failed to update ISPs annually.
Deficiencies (2)
Facility failed to ensure that the individualized service plan (ISP) was signed by the resident or resident's legal representative and the facility.
Facility failed to update the individualized service plan (ISP) annually.
Report Facts
Number of residents present: 104
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Velasco | Licensing Inspector | Current inspector conducting the inspection |
| Staff 1 | Staff interviewed confirming lack of signed ISP and inability to locate updated ISP | |
| Director of Clinical Services | Responsible for reviewing ISPs and ensuring compliance as part of plan of correction | |
| Executive Director | Responsible for conducting quarterly audits of ISPs as part of plan of correction | |
| Regional Director of Clinical Services | Responsible for conducting quarterly audits of ISPs as part of plan of correction |
Inspection Report
Complaint Investigation
Census: 103
Deficiencies: 1
Date: Feb 28, 2024
Visit Reason
The inspection was conducted in response to complaints received by VDSS Division of Licensing on 2024-02-22 regarding allegations in the areas of Administration and Administrative Services and Resident Care and Related Services.
Complaint Details
The complaint investigation was substantiated in part; evidence supported non-compliance in Resident Care and Related Services. A violation notice was issued.
Findings
The investigation supported some, but not all, of the allegations. Non-compliance was found in the area of Resident Care and Related Services, specifically regarding medication orders not being validly authorized by a physician or prescriber.
Deficiencies (1)
The facility failed to ensure that medications or dietary supplements are not started, changed, or discontinued without a valid order from a physician or other prescriber.
Report Facts
Number of residents present: 103
Number of resident records reviewed: 3
Number of resident interviews: 1
Number of staff interviews: 2
Inspection Report
Complaint Investigation
Census: 103
Deficiencies: 0
Date: Jan 31, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2024-01-23 regarding allegations in the area(s) of resident care and related services.
Complaint Details
Complaint received on 2024-01-23 regarding allegations in resident care and related services; investigation did not substantiate the complaint.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The inspection summary will be posted to the VDSS website within 5 business days of receipt.
Report Facts
Number of residents present: 103
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 2
Inspection Report
Routine
Deficiencies: 0
Date: Jan 18, 2024
Visit Reason
Routine inspection of Ashleigh at Lansdowne Independent & Assisted Living Community to review resident care and related services.
Findings
The inspection found no violations with applicable standards or laws. Medication administration was observed during the visit, and the inspection summary will be posted publicly.
Report Facts
Resident records reviewed: 2
Staff records reviewed: 0
Resident interviews conducted: 1
Staff interviews conducted: 0
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 18, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2024-01-03 regarding allegations in the areas of general provisions and resident care and related services.
Complaint Details
Complaint investigation was conducted based on allegations received on 2024-01-03. The allegations were not substantiated by the evidence gathered during the inspection.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The inspection findings will be posted to the VDSS website within 5 business days of receipt.
Report Facts
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 1
Inspection Report
Monitoring
Census: 109
Deficiencies: 1
Date: Dec 14, 2023
Visit Reason
The inspection was a monitoring visit conducted to review compliance with resident care and related services standards.
Findings
The inspection found non-compliance related to medication administration, specifically that medications were not kept in pharmacy-issued containers with proper labeling until administered to residents.
Deficiencies (1)
Facility failed to ensure that medications remained in the pharmacy issued container, with the prescription label or direction label attached until administered to four out of four residents.
Report Facts
Number of residents present: 109
Number of resident records reviewed: 4
Number of staff records reviewed: 0
Number of resident interviews conducted: 3
Number of staff interviews conducted: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Named in medication administration deficiency and interview |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Sep 7, 2023
Visit Reason
The inspection was conducted in response to a complaint received on 2023-08-28 regarding allegations related to resident care and related services at Ashleigh at Lansdowne Independent & Assisted Living Community.
Complaint Details
The complaint investigation substantiated violations related to medication management and administration practices. Evidence included expired medication found in a resident's medication cart, discrepancies in pill counts, illegible medication labels, and failure to administer PRN medication as ordered. Additionally, the facility did not notify the nurse practitioner, cardiology, or family member about a resident's significant weight gain and related symptoms as required.
Findings
The investigation found non-compliance with medication management policies, including expired medications, inaccurate pill counts, illegible labels, and failure to administer medications according to physician orders. Additionally, the facility failed to document and notify appropriate parties regarding significant changes in a resident's condition as ordered by the physician.
Deficiencies (3)
Failure to ensure implementation of medication management plan regarding outdated, contaminated medications, or illegible labels for one of three resident records reviewed.
Failure to ensure medications were administered in accordance with physician's or prescriber's instructions.
Failure to ensure medical procedures or treatments ordered by a physician were provided according to instructions, documented, and maintained in the resident's record.
Report Facts
Resident records reviewed: 3
Staff records reviewed: 0
Staff interviews conducted: 4
Expired medication date: Jun 20, 2023
Pill count discrepancy: 6
Dates with heart rate > 100 without PRN medication given: 8
Weight gain: 9
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Aug 14, 2023
Visit Reason
The inspection was conducted in response to a complaint received on 2023-08-04 regarding allegations in administration and administrative services, staffing and supervision, and resident care and related services at the facility.
Complaint Details
The complaint investigation was substantiated in part, with violations found in administration and administrative services. The complaint involved allegations of improper medication management, failure to report a major incident, and inadequate documentation of resident refusal of medical care.
Findings
The investigation supported some but not all allegations, identifying non-compliance in administration and administrative services. Violations included failure to implement policies on controlled medication inventory, failure to report a major incident within 24 hours, and failure to document a resident's refusal of medical attention after a fall.
Deficiencies (3)
Facility failed to implement policies regarding inventory of controlled medications, including incomplete documentation of administration of Alprazolam on 5/17/2023.
Facility failed to report to the regional licensing office within 24 hours a major incident involving a resident's fall and subsequent death on 5/17/2023.
Facility failed to ensure resident's record contained documentation of refusal of medical attention after a serious fall on 5/17/2023.
Report Facts
Number of resident records reviewed: 2
Number of staff interviews conducted: 5
Medication administration date: May 17, 2023
Medication dosage: 0.25
Timeframe for plan of correction monitoring: 90
Blood pressure reading: 106
Blood pressure reading: 71
Oxygen saturation: 100
Temperature: 97.3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Velasco | Licensing Inspector | Current inspector conducting the complaint investigation |
| Jamie Eddy | Licensing Inspector | Contact person for questions regarding the inspection |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Aug 14, 2023
Visit Reason
The inspection was conducted as a complaint investigation following allegations received on 2023-08-02 regarding resident care and related services at Ashleigh at Lansdowne Independent & Assisted Living Community.
Complaint Details
The complaint was substantiated. Evidence included delayed staff response to a resident's call bell (25 minutes and 48 seconds delay), medication administration errors including timing and dosage not following physician orders, and incomplete medication administration documentation.
Findings
The investigation found multiple violations including failure to ensure prompt staff response to resident needs, improper medication management including administration timing and documentation errors, and failure to administer medications according to physician orders. Violations were substantiated and corrective plans were required.
Deficiencies (5)
Facility failed to ensure prompt response by staff to resident needs as reasonable to the circumstances.
Facility failed to ensure medications remained in pharmacy issued container with prescription label until administered.
Facility failed to ensure medications were administered not earlier than one hour before and not later than one hour after scheduled dosing time for two residents.
Facility failed to ensure medications were administered in accordance with physician's or prescriber's instructions.
Facility failed to ensure Medication Administration Record (MAR) included initials of direct care staff administering medications and documentation of medication errors or omissions.
Report Facts
Resident records reviewed: 7
Staff records reviewed: 0
Resident interviews conducted: 2
Staff interviews conducted: 3
Call bell response time: 25.8
Medication administration observed: 3
Medication administration timing deviation: 2
Medication dosage discrepancy: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Velasco | Licensing Inspector | Current inspector conducting the complaint investigation |
| Jamie Eddy | Licensing Inspector | Contact person for questions about the inspection |
| Lunceford | Licensing Inspector | Observed medication administration and documented findings |
| Staff 1 | Admitted to pre-pouring medications and placing them in medication cart | |
| Staff 2 | Observed administering medications outside scheduled time | |
| Director of Nursing | DON | Responsible for staff in-service and monitoring compliance with medication and response policies |
| Executive Director | ED | Observed medication administration and involved in monitoring corrective actions |
| Nurse Practitioner | Signed progress notes related to Resident 5's condition and medication issues |
Inspection Report
Renewal
Census: 103
Deficiencies: 2
Date: Aug 3, 2023
Visit Reason
The inspection was conducted as a renewal inspection of the assisted living facility to assess compliance with applicable standards and laws prior to license expiration.
Findings
The inspection found non-compliance with applicable standards and laws, specifically related to medication management policies and documentation during medication administration. Violations were documented and a plan of correction was requested.
Deficiencies (2)
Facility failed to ensure compliance with their own medication management policies, including administering medications to multiple residents simultaneously contrary to policy.
Facility failed to document on medication administration records all medications administered to residents at the time of administration.
Report Facts
Number of residents present: 103
Number of resident records reviewed: 10
Number of staff records reviewed: 5
Number of interviews conducted with residents: 3
Number of interviews conducted with staff: 1
Inspection Report
Complaint Investigation
Census: 103
Deficiencies: 0
Date: Aug 3, 2023
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2023-06-22 regarding allegations in the areas of resident care and related services and additional requirements for facilities that care for adults with serious cognitive impairments.
Complaint Details
Complaint related inspection triggered by allegations concerning resident care and additional requirements for adults with serious cognitive impairments; the allegations were not substantiated.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The licensing inspector completed a tour of the physical plant and conducted staff interviews, observing normal facility activities.
Report Facts
Number of residents present: 103
Number of staff interviews: 2
Inspection Report
Monitoring
Census: 126
Deficiencies: 0
Date: Jun 14, 2023
Visit Reason
The inspection was a monitoring visit conducted on June 14, 2023, following multiple self-reported incidents regarding resident care and admission and discharge of residents.
Findings
The investigation found no evidence to support the self-reported non-compliance with standards or law. The inspection findings will be posted publicly within five business days.
Report Facts
Number of resident records reviewed: 6
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 3
Inspection Report
Monitoring
Deficiencies: 0
Date: Sep 26, 2022
Visit Reason
The inspection was a monitoring visit conducted on September 26, 2022, following self-reported incidents received by VDSS regarding allegations in staffing and resident care.
Findings
The investigation found no evidence to support the self-reported non-compliance with standards or law. The inspection findings will be posted publicly and a copy is required to be posted at the facility.
Report Facts
Resident records reviewed: 2
Staff records reviewed: 2
Staff interviews conducted: 1
Resident interviews conducted: 0
Inspection Report
Monitoring
Census: 109
Deficiencies: 1
Date: Jul 19, 2022
Visit Reason
The inspection was a monitoring visit conducted to review compliance with applicable standards and laws at the assisted living facility.
Findings
The inspection found non-compliance with applicable standards or laws related to employee records, specifically the failure to ensure sworn statements or affirmations were completed for all applicants for employment.
Deficiencies (1)
Facility failed to ensure that sworn statement or affirmation was completed for all applicants for employment.
Report Facts
Number of residents present: 109
Number of resident records reviewed: 10
Number of staff records reviewed: 5
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 1
Number of employees without completed sworn statement: 6
Inspection Report
Monitoring
Deficiencies: 0
Date: May 5, 2022
Visit Reason
The inspection was a monitoring visit conducted by the licensing inspector to review resident care and related services, including a tour of the physical plant and review of staff work schedules and emergency drills.
Findings
The investigation did not support the self-report of non-compliance with standards or law. Adequate staffing was observed and emergency drills were reviewed. The inspection findings will be posted publicly.
Report Facts
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Velasco | Licensing Inspector | Current inspector conducting the monitoring visit |
| Jamie Eddy | Licensing Inspector | Contact person for questions regarding the inspection |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 8, 2022
Visit Reason
Unannounced complaint investigation regarding verbal/emotional abuse and concerns about resident medication and staff qualifications.
Complaint Details
Complaint related to verbal/emotional abuse; complaint regarding resident medication and staff qualifications was not substantiated.
Findings
The complaint regarding resident medication and staff qualifications was deemed not valid as evidence did not support the allegations. No violations were cited during the investigation.
Inspection Report
Deficiencies: 0
Date: Sep 27, 2021
Visit Reason
A non-mandated self-report inspection was initiated due to a self-reported incident regarding allegations in the areas of resident care. The investigation was conducted by contacting the administrator and requesting documentation.
Findings
The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law.
Inspection Report
Deficiencies: 0
Date: Sep 27, 2021
Visit Reason
A non-mandated self-report inspection was initiated due to a self-reported incident regarding allegations in the areas of resident care. The investigation was conducted by contacting the administrator and reviewing documentation.
Findings
The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 28, 2021
Visit Reason
A non-mandated complaint inspection was initiated due to a complaint received by the department regarding allegations in the area of resident care.
Complaint Details
A complaint was received regarding resident care. The investigation included contacting the administrator and requesting documentation. The complaint was not substantiated.
Findings
The evidence gathered during the investigation did not support the allegation of non-compliance with standards or law. No violations were cited.
Inspection Report
Renewal
Census: 69
Deficiencies: 0
Date: Jul 21, 2021
Visit Reason
A renewal inspection was initiated to review compliance with applicable standards and laws prior to the expiration of the current license.
Findings
The inspection found no violations with applicable standards or law. Documentation including resident and staff records, background checks, and inspection reports were reviewed and found complete.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 26, 2021
Visit Reason
A non-mandated complaint inspection was initiated due to allegations of physical abuse and neglect at the assisted living facility.
Complaint Details
The complaint was related to allegations of physical abuse and neglect. The evidence gathered did not substantiate the allegations.
Findings
The investigation, including an on-site observation, found no evidence to support the allegations of non-compliance with standards or law.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 11, 2020
Visit Reason
A complaint inspection was initiated due to allegations received by the department regarding resident care at the assisted living facility.
Complaint Details
A complaint was received regarding resident care. The Director of Nursing was contacted and documentation was reviewed. The complaint was found to be unsubstantiated and no violations were identified.
Findings
The investigation did not find any evidence supporting the allegations of non-compliance with standards or law. No violations were cited and the complaint was determined to be not valid.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Velasco | Licensing Inspector | Conducted the complaint investigation and communicated findings. |
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