Inspection Reports for Auburn Hill Senior Living
5800 Harbour Ln, Midlothian, VA 23112, United States, VA, 23112
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Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 23, 2025
Visit Reason
An on-site inspection was conducted related to a complaint received by VDSS Division of Licensing regarding allegations in personnel, staffing and supervision, resident accommodations and related provisions, resident care and related services, and buildings and grounds.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. Residents were observed interacting appropriately with staff and each other, and documentation related to meals, maintenance, and laundry services was reviewed without issue.
Complaint Details
Complaint was received on October 24, 2025, concerning personnel, staffing and supervision, resident accommodations and related provisions, resident care and related services, and buildings and grounds. The complaint was not substantiated based on the investigation findings.
Report Facts
Number of interviews conducted: 3
Inspection Report
Renewal
Census: 98
Deficiencies: 1
Jun 2, 2025
Visit Reason
The inspection was a renewal visit conducted to review compliance with applicable standards and regulations for the assisted living facility.
Findings
The facility was found to be generally in good repair with appropriate resident interactions and no obvious safety concerns. However, a violation was documented due to lack of documentation of required annual training for direct care staff.
Deficiencies (1)
| Description |
|---|
| The facility did not have documentation of required annual training for direct care staff. |
Report Facts
Number of residents present: 98
Number of resident records reviewed: 6
Number of staff records reviewed: 4
Number of interviews conducted with residents: 2
Number of interviews conducted with staff: 2
Inspection Report
Complaint Investigation
Deficiencies: 0
May 13, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing regarding allegations in the areas of resident rights and resident accommodations.
Findings
The investigation included a tour of the facility and interviews with residents and staff. The evidence gathered did not support the allegations of non-compliance with standards or law.
Complaint Details
The complaint involved an allegation of physical abuse by a resident, which was determined to be a one-time incident with no charges pressed and no injury to the resident. The door locking mechanism was found to allow resident freedom of movement.
Report Facts
Number of resident interviews: 1
Number of staff interviews: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Coy Stevenson | Licensing Inspector | Conducted the inspection and is the contact person for the report |
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 3, 2025
Visit Reason
The inspection was conducted in response to a complaint received on December 23, 2024, regarding allegations in the area of resident care.
Findings
The investigation found no evidence to support the allegation of non-compliance with standards or law. The inspection summary will be posted publicly.
Complaint Details
Complaint was received on December 23, 2024, related to resident care. The evidence gathered did not support the allegation of non-compliance.
Report Facts
Number of resident records reviewed: 1
Number of interviews conducted with staff: 1
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 3, 2025
Visit Reason
The inspection was conducted in response to a complaint received on December 23, 2024, regarding allegations related to resident care at Auburn Hill Senior Living.
Findings
The investigation found no evidence to support the allegations. Residents were appropriately dressed and groomed, hygiene products were sufficient, and the facility was compliant with licensing standards regarding resident admission and staff training.
Complaint Details
The complaint was not substantiated as the evidence gathered did not support non-compliance with standards or law.
Report Facts
Number of staff interviews: 1
Number of resident interviews: 3
Inspection Report
Renewal
Census: 89
Deficiencies: 1
Jun 12, 2024
Visit Reason
The inspection was conducted as part of the renewal process for the facility's license, with the renewal process beginning on June 7, 2024, and inspection visits occurring on June 7 and June 12, 2024.
Findings
The inspection identified non-compliance with applicable standards related to employee tuberculosis risk assessments. Specifically, one employee's file lacked a complete tuberculosis risk assessment prior to contact with residents. No health or safety issues were noted in other areas of the facility.
Deficiencies (1)
| Description |
|---|
| Facility did not ensure that each new hire provides documentation on, or within seven days prior to the first day of working at the facility, of a tuberculosis risk assessment documenting the absence of tuberculosis in a communicable form. |
Report Facts
Number of residents present: 89
Number of resident records reviewed: 8
Number of staff records reviewed: 5
Number of staff interviews conducted: 2
Number of resident interviews conducted: 0
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 5, 2024
Visit Reason
The inspection was conducted in response to a complaint received on September 30, 2023, regarding allegations related to Safe, Secure Environment and Buildings and Grounds.
Findings
The investigation found no evidence to support the allegations of non-compliance with standards or law.
Complaint Details
A complaint was received by VDSS Division of Licensing on September 30, 2023 regarding allegations in the area(s) of Safe, Secure Environment and Buildings and Grounds. The evidence gathered during the investigation did not support the allegation of non-compliance.
Inspection Report
Monitoring
Census: 76
Deficiencies: 1
Aug 21, 2023
Visit Reason
The inspection was a monitoring visit conducted on August 21, 2023, following self-reported incidents received by VDSS Division of Licensing regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation supported the self-report of non-compliance related to medication administration not following physician or prescriber instructions. Violations were issued based on record review and staff interviews confirming medication errors involving two residents.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure medications were administered in accordance with the physician's or other prescriber's instructions. |
Report Facts
Number of residents present: 76
Number of resident records reviewed: 2
Inspection Report
Renewal
Census: 71
Deficiencies: 4
Aug 21, 2023
Visit Reason
The inspection was a renewal visit conducted to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection found multiple violations related to incomplete or unsigned Uniform Assessment Instruments (UAIs), individualized service plans (ISPs) that did not fully reflect residents' assessed needs or were not updated timely, and incomplete records of fire and emergency evacuation drills.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure UAIs were signed by the administrator or designee after completion by staff. |
| Facility failed to ensure comprehensive individualized service plans included all identified needs based on assessments and other sources. |
| Facility failed to ensure individualized service plans were updated at least once every 12 months and as needed for significant changes. |
| Facility failed to ensure records of fire and emergency evacuation drills included the number of residents participating. |
Report Facts
Number of residents present: 71
Number of resident records reviewed: 10
Number of staff records reviewed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alex Poulter | Licensing Inspector | Contact person for questions about the inspection |
Inspection Report
Monitoring
Census: 71
Deficiencies: 5
Jul 20, 2023
Visit Reason
The inspection was a monitoring visit to investigate self-reported incidents received by VDSS regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation supported the self-report of non-compliance with standards, resulting in multiple violations related to failure to complete annual uniform assessment instruments, failure to ensure individualized service plans were signed and updated, delays in securing medical attention for residents with serious illness, and substantiated abuse and neglect incidents leading to staff termination and re-education.
Deficiencies (5)
| Description |
|---|
| Facility failed to ensure that the uniform assessment instrument (UAI) was completed at least annually. |
| Facility failed to ensure the individualized service plan (ISP) was signed and dated by the resident or legal representative. |
| Facility failed to ensure individualized service plans (ISPs) were reviewed and updated at least once every 12 months. |
| When a resident suffers serious illness or medical condition, medical attention from a licensed health care professional was not secured immediately. |
| Facility failed to ensure any resident has the rights and responsibilities as provided in the Code of Virginia; substantiated abuse and neglect incidents occurred. |
Report Facts
Number of residents present: 71
Resident records reviewed: 4
Dates of self-reported incidents: Incidents received on 4/21/2023 and 5/15/2023
Dates of abuse allegations: Alleged abuse incidents occurred between approximately 4-08-2023 and 4-21-2023
Date of resident #1 death: Resident #1 passed under hospice on 4-29-2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff #5 | Terminated for substantiated abuse and neglect | |
| Staff #1 | Received self-reported incidents and confirmed delay in medical care for Resident #1 | |
| Staff #2 | Involved in substantiated footage related to abuse incident with Resident #4 | |
| Staff #4 | Completed witness statement documenting abuse allegations | |
| Staff #6 | Made allegations regarding Resident #2 and documented concerns | |
| Staff #7 | Alleged to have abused Resident #2 |
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 5
Mar 30, 2023
Visit Reason
The inspection was conducted in response to a complaint received on March 18, 2023, regarding allegations related to Buildings and Grounds, Resident Care and Related Services at Auburn Hill Senior Living.
Findings
The investigation found multiple violations including failure to complete the uniform assessment instrument (UAI) upon significant resident condition changes, failure to ensure individualized service plans (ISPs) were signed, dated, and updated timely, failure to provide written responses to resident council concerns, and failure to maintain elevators in good working condition.
Complaint Details
The complaint was substantiated. Allegations involved Buildings and Grounds, Resident Care and Related Services. Evidence included record reviews and staff interviews confirming violations such as elevator malfunctions on multiple dates and incomplete or unsigned resident service documentation.
Deficiencies (5)
| Description |
|---|
| Facility failed to ensure the uniform assessment instrument (UAI) was completed whenever there was a significant change in the resident's condition. |
| Facility failed to ensure the individualized service plan (ISP) was signed and dated by the licensee, administrator, or designee, and by the resident or legal representative. |
| Facility failed to ensure individualized service plans (ISPs) were reviewed and updated at least once every 12 months and as needed for significant changes. |
| Facility failed to provide a written response to the resident council prior to the next meeting regarding recommendations made by the council. |
| Facility failed to ensure that elevators were kept in good running condition. |
Report Facts
Number of residents present: 83
Number of resident records reviewed: 4
Elevator out of service dates: 3
Resident council concerns on 01-24-2023: 14
Resident council concerns on 02-22-2023: 13
Resident council concerns on 03-29-2023: 6
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 3
Mar 30, 2023
Visit Reason
The inspection was conducted in response to a complaint received on March 9, 2023, regarding allegations related to Admission, Retention, and Discharge of Residents, as well as Resident Care and Related Services.
Findings
The investigation supported some but not all allegations, identifying non-compliance in Admission, Retention, and Discharge of Residents. Multiple violations were found related to incomplete documentation of allergy reactions, failure to update fall risk ratings after falls, and lack of analysis and interventions following falls.
Complaint Details
The complaint was substantiated in part, with evidence supporting non-compliance in Admission, Retention, and Discharge of Residents. The complaint involved failure to update fall risk ratings and lack of documentation of fall analyses and interventions.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure the physical examination for a resident contained a description of the person's reaction to any known allergies. |
| Facility failed to ensure the fall risk rating was reviewed and updated after a fall for multiple residents. |
| Facility failed to show documentation of an analysis of the circumstances of falls and interventions initiated to prevent or reduce risk of subsequent falls for multiple residents. |
Report Facts
Number of residents present: 83
Number of resident records reviewed: 4
Number of falls without updated fall risk ratings: 5
Number of residents discharged related to findings: 3
Inspection Report
Monitoring
Deficiencies: 1
Jul 15, 2022
Visit Reason
The inspection was a monitoring visit conducted on July 15, 2022, following a self-reported incident received on June 8, 2022, regarding allegations in the area of resident care and related services.
Findings
The investigation supported the self-report of non-compliance related to medication administration errors, specifically a medication error where a resident was given another resident's medications. Violations were issued based on these findings.
Complaint Details
The visit was not complaint-related but was triggered by a self-reported incident regarding medication administration errors. The evidence supported the self-report of non-compliance.
Deficiencies (1)
| Description |
|---|
| The facility failed to ensure medications were administered in accordance with the physician's or other prescriber's instructions and consistent with the standards of practice outlined in the current medication aide curriculum approved by the Virginia Board of Nursing. |
Report Facts
Date of incident: Jun 1, 2022
Date of self-report: Jun 8, 2022
Inspection date: Jul 15, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alexandra Poulter | Licensing Inspector | Contact person for questions regarding the inspection |
| Director of Health and Wellness | Educated staff on medication administration and conducted observations; involved in monitoring corrective actions | |
| Staff #1 | Confirmed the medication error incident via email and interview |
Inspection Report
Monitoring
Census: 83
Deficiencies: 3
Jul 15, 2022
Visit Reason
The inspection was a monitoring visit conducted to assess compliance with applicable standards and laws at Auburn Hill Senior Living.
Findings
The inspection identified multiple violations including failure to report major incidents within 24 hours, incomplete physician orders lacking diagnosis or indications for medications, and staff making materially false statements on sworn statements. Plans of correction were submitted indicating no negative outcomes occurred.
Deficiencies (3)
| Description |
|---|
| Facility failed to report to the regional licensing office within 24 hours any major incident that negatively affected or threatened resident safety, including COVID-19 positive cases. |
| Facility failed to ensure physician or other prescriber orders identified the diagnosis, condition, or specific indications for administering each drug. |
| Facility failed to ensure staff did not make materially false statements on the sworn statement or affirmation regarding criminal history. |
Report Facts
Number of residents present: 83
Number of resident records reviewed: 10
Number of staff records reviewed: 3
Number of staff interviews conducted: 2
Number of unreported COVID-19 positive residents: 9
Inspection Report
Monitoring
Deficiencies: 0
Nov 19, 2021
Visit Reason
A non-mandated monitoring inspection was initiated to conduct an investigation through documentation review and on-site observation.
Findings
The evidence gathered during the investigation did not support non-compliance with standards or law.
Inspection Report
Renewal
Census: 72
Deficiencies: 1
Jul 13, 2021
Visit Reason
A renewal inspection was initiated to review compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection found non-compliance related to medication administration where scheduled medications were not administered or documented as given for multiple residents.
Deficiencies (1)
| Description |
|---|
| Facility failed to administer medications in accordance with physician's or other prescriber's instructions and consistent with standards of practice. |
Report Facts
Residents with missed medication documentation: 2
Census: 72
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Contacted to initiate inspection and participated in exit interview. | |
| Director of Nursing | Participated in exit interview where findings were reviewed. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 23, 2021
Visit Reason
A non-mandated complaint inspection was initiated due to a complaint received by the department regarding allegations in the areas of Resident Care and Related Services.
Findings
The investigation concluded that the evidence did not support the allegations of non-compliance with standards or law.
Complaint Details
A complaint was received and investigated; the allegations were not substantiated.
Inspection Report
Monitoring
Census: 63
Deficiencies: 1
May 18, 2021
Visit Reason
A monitoring inspection was initiated due to the state of emergency health pandemic declared by the Governor of Virginia, conducted remotely to ensure compliance with applicable standards and laws.
Findings
The inspection found non-compliance related to failure to obtain criminal record reports from the Virginia State Police for several employees, with violations documented and a plan of correction submitted.
Deficiencies (1)
| Description |
|---|
| Facility failed to obtain criminal record reports from the Virginia State Police for employees, instead using a background screening tool (ADP) not compliant with the Code of Virginia. |
Report Facts
Resident records reviewed: 4
Staff records reviewed: 4
Staff members with deficient background checks: 4
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 31, 2021
Visit Reason
A complaint inspection was initiated due to a complaint received by the department regarding allegations in the areas of Resident Care and Related Services.
Findings
The inspection was conducted remotely due to a state of emergency health pandemic. The administrator was contacted by telephone and requested to provide documentation to complete the investigation.
Complaint Details
The complaint investigation was initiated on 3/31/2021 and concluded on 6/3/2021 regarding allegations in Resident Care and Related Services.
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 8, 2021
Visit Reason
A complaint inspection was initiated due to allegations regarding staffing and supervision at Auburn Hill Senior Living.
Findings
The inspection was conducted remotely due to a state of emergency health pandemic. The investigation involved contacting the administrator and requesting documentation to address the complaint.
Complaint Details
A complaint was received concerning staffing and supervision. The administrator was contacted by telephone and documentation was requested to complete the investigation.
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