Inspection Report
Renewal
Census: 52
Deficiencies: 2
Jun 6, 2025
Visit Reason
The inspection was conducted as a renewal inspection to assess compliance with applicable standards and laws for licensing renewal.
Findings
The inspection found non-compliance with applicable standards, including failure to conduct fire drills on all shifts as required and failure to obtain criminal history record reports within 30 days of employment for some employees. Violation notices were issued with opportunities for the licensee to submit plans of correction.
Deficiencies (2)
| Description |
|---|
| Failed to ensure that fire and emergency evacuation drill frequency and participation were in accordance with the Virginia Statewide Fire Prevention Code. |
| Failed to ensure that criminal history record reports were obtained on or prior to the 30th day of employment for each employee. |
Report Facts
Number of residents present: 52
Number of resident records reviewed: 6
Number of staff records reviewed: 4
Number of resident interviews conducted: 3
Number of staff interviews conducted: 4
Inspection Report
Renewal
Census: 51
Deficiencies: 1
Jul 2, 2024
Visit Reason
The inspection was conducted as a renewal of the facility's license to ensure compliance with applicable standards and laws.
Findings
The inspection found non-compliance related to the failure to include written Do Not Resuscitate (DNR) orders in the individualized service plans (ISPs) for multiple residents. A violation notice was issued and the licensee was given the opportunity to submit a plan of correction.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure the written Do Not Resuscitate (DNR) order is included in the individualized service plan (ISP) for residents. |
Report Facts
Number of residents present: 51
Number of resident records reviewed: 6
Number of staff records reviewed: 3
Number of resident interviews: 2
Number of staff interviews: 4
Inspection Report
Monitoring
Census: 52
Deficiencies: 0
May 29, 2024
Visit Reason
The inspection was a monitoring inspection conducted to review various areas including administration, personnel, resident care, building and grounds, emergency preparedness, and additional requirements for facilities caring for adults with cognitive impairments.
Findings
The inspection found no violations of applicable standards or laws. Residents were observed participating in activities and eating lunch, and an exit meeting was conducted to review the findings.
Report Facts
Number of resident records reviewed: 3
Number of staff records reviewed: 3
Number of interviews conducted with staff: 3
Inspection Report
Monitoring
Census: 51
Deficiencies: 0
Mar 25, 2024
Visit Reason
The inspection was a monitoring visit conducted to review personnel and resident care and related services at the assisted living facility.
Findings
The inspection findings did not support any allegations or self-reports of non-compliance with standards or laws. Observations included residents participating in activities and preparing for lunch.
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: 2
Inspection Report
Original Licensing
Deficiencies: 0
Nov 27, 2023
Visit Reason
The inspection was an initial licensing inspection conducted to evaluate compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection found no violations with applicable standards or laws. The licensing inspector completed a tour of the physical plant, reviewed policies and procedures, and conducted interviews with staff.
Report Facts
Number of interviews conducted with staff: 50
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