Deficiencies per Year
8
6
4
2
0
Unclassified
Census Over Time
Inspection Report
Renewal
Census: 64
Deficiencies: 7
Aug 20, 2025
Visit Reason
The inspection was conducted as a renewal inspection to assess compliance with applicable standards and regulations for the assisted living facility.
Findings
The inspection identified multiple violations including insufficient night staffing in the special care unit, lack of tuberculosis risk assessments and orientation for private duty personnel, inadequate healthcare oversight for assisted living residents, improper medication disposal, and failure to document semiannual emergency preparedness and resident emergency procedure reviews.
Deficiencies (7)
| Description |
|---|
| Failed to ensure at least two direct care staff members were awake and on duty during night hours in the special care unit when 22 or fewer residents were present. |
| Failed to ensure private duty personnel met tuberculosis requirements and received orientation and training regarding facility policies. |
| Failed to ensure licensed health care professional provided healthcare oversight at least every three months for residents meeting assisted living criteria. |
| Failed to ensure all residents were included at least annually in healthcare oversight. |
| Failed to implement a written plan for medication that included proper disposal of medication; observed discontinued medication improperly stored. |
| Failed to develop and implement a semiannual review on emergency preparedness and response plan for all staff, residents, and volunteers with documentation by signing and dating. |
| Failed to ensure procedures in the plan for resident emergencies were reviewed by the facility at least every six months with all staff, with documentation signed and dated. |
Report Facts
Number of residents present: 64
Number of resident records reviewed: 7
Number of staff records reviewed: 6
Number of staff interviews conducted: 3
Staff scheduled for care and supervision: 1
Completion date for staffing correction: Sep 1, 2025
Completion date for private duty personnel correction: Sep 30, 2025
Completion date for healthcare oversight correction: Oct 31, 2025
Completion date for healthcare oversight annual inclusion correction: Sep 30, 2025
Completion date for medication disposal correction: Sep 30, 2025
Completion date for emergency preparedness review: Oct 15, 2025
Completion date for resident emergency procedure review: Oct 1, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nina Wilson | Licensing Inspector | Conducted the inspection and is contact for questions |
| Staff 7 | Interviewed staff member who acknowledged multiple deficiencies including staffing, tuberculosis risk assessments, healthcare oversight, medication storage, and emergency preparedness documentation |
Inspection Report
Monitoring
Census: 42
Deficiencies: 3
Jan 17, 2025
Visit Reason
The inspection was a monitoring visit conducted to review compliance with staffing and supervision standards following a self-reported incident received on 2024-11-12 regarding allegations in staffing and supervision.
Findings
The inspection found violations related to staffing levels in the special care unit, malfunctioning fire door egress mechanisms, and failure to provide a dated discharge statement to a resident's legal representative. Violations were supported by record reviews and staff interviews.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure at least two direct care staff members were awake and on duty at all times in each special care unit responsible for resident care and supervision. |
| Facility failed to ensure that doors leading to unprotected areas were monitored or secured with devices conforming to building and fire codes, including door alarms and delayed egress mechanisms. |
| Facility failed to provide a dated discharge statement to the resident, legal representative, and designated contact person at the time of discharge. |
Report Facts
Number of residents present: 42
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of staff interviews conducted: 7
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 2
Jan 17, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 12/2/2024 regarding allegations in the areas of Personnel, Staffing and Supervision, Admission, Retention and Discharge of Residents, Resident Care and Related Services, and Additional Requirements for Facilities that Care for Adults with Serious Cognitive Impairments.
Findings
The investigation supported the allegations of non-compliance with applicable standards and laws, resulting in violations issued related to staffing levels in the special care unit and failure to provide a dated discharge statement to residents and their legal representatives.
Complaint Details
The complaint investigation was substantiated as the evidence gathered supported the allegations of non-compliance in staffing and discharge documentation.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure at least two direct care staff members were awake and on duty at all times in the special care unit responsible for care and supervision of residents. |
| Facility failed to ensure at the time of discharge a dated statement was provided to the resident, legal representative, and designated contact person. |
Report Facts
Number of residents present: 42
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of staff interviews conducted: 7
Number of resident interviews conducted: 0
Residents in special care unit: 6
Inspection Report
Monitoring
Census: 43
Deficiencies: 2
Jan 17, 2025
Visit Reason
The inspection was a monitoring visit conducted on January 17 and January 23, 2025, to review compliance with personnel standards following a self-reported incident received on October 18, 2024 regarding personnel allegations.
Findings
The investigation supported the self-report of non-compliance with personnel standards, resulting in violations related to insufficient direct care staff on duty in the special care unit and incomplete records for private duty personnel, including missing criminal history reports and service documentation.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure at least two direct care staff members were awake and on duty at all times in each special care unit responsible for resident care and supervision. |
| Facility failed to ensure that information on the type and frequency of services delivered to the resident and a review of an original criminal history record report were obtained for private duty personnel. |
Report Facts
Number of residents present: 43
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of staff interviews conducted: 5
Inspection Report
Monitoring
Census: 43
Deficiencies: 1
Jan 17, 2025
Visit Reason
The inspection was a monitoring visit conducted on January 17 and January 23, 2025, following a self-reported incident received on November 29, 2024, regarding allegations related to personnel, care for adults with serious cognitive impairments, and safe, secure environment standards.
Findings
The investigation supported the self-report of non-compliance with applicable standards, resulting in violations issued. Specifically, the facility failed to ensure that direct care staff attended at least 10 hours of cognitive impairment training within four months of employment in the safe, secure environment unit.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure that direct care staff attended at least 10 hours of training in cognitive impairment within four months of the starting date of employment in the safe, secure environment. |
Report Facts
Number of residents present: 43
Number of direct care staff and nurses without required training: 33
Number of direct care staff and nurses hired between one year and four months: 22
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of staff interviews conducted: 4
Inspection Report
Complaint Investigation
Census: 29
Deficiencies: 2
Oct 17, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 10/16/2024 regarding allegations related to personnel and complaint investigation.
Findings
The investigation did not support the allegations of non-compliance with standards or law overall; however, two deficiencies were identified related to staffing levels in the special care unit and failure to provide a dated discharge statement to residents and their legal representatives.
Complaint Details
The complaint was related to personnel and complaint investigation. The evidence gathered did not support the allegations of non-compliance with standards or law overall, but deficiencies were found in staffing and discharge documentation.
Deficiencies (2)
| Description |
|---|
| The facility failed to ensure that at least two direct care staff members were awake and on duty at all times in the special care unit responsible for resident care and supervision. |
| The facility failed to ensure at the time of discharge that a dated statement was provided to the resident, legal representative, and designated contact person. |
Report Facts
Number of residents present: 29
Number of staff records reviewed: 5
Number of staff interviews conducted: 2
Special care unit census: 6
Inspection Report
Renewal
Census: 26
Deficiencies: 3
Sep 16, 2024
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 non-compliance with several standards including incomplete tuberculosis risk assessments for staff, failure to implement a written medication management plan, and incomplete documentation of fire and emergency evacuation drills.
Deficiencies (3)
| Description |
|---|
| Failure to ensure required health information, including tuberculosis risk assessments, was maintained for staff and household members. |
| Failure to implement a written medication management plan ensuring timely availability of prescription and over-the-counter medications. |
| Failure to ensure fire and emergency evacuation drill documentation included number of staff and residents participating and time to complete the drill. |
Report Facts
Number of residents present: 26
Number of resident records reviewed: 2
Number of staff records reviewed: 3
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 3
Dates of missing fire drill documentation: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nina Wilson | Licensing Inspector | Conducted the inspection and is contact for questions |
| Staff 1 | Staff member with incomplete tuberculosis risk assessment documentation | |
| Staff 4 | Staff member interviewed regarding medication management deficiencies | |
| Director of Business Administration | In-serviced on Tuberculin Skin Testing policy and responsible for auditing associate files | |
| Resident 2 | Resident involved in medication management deficiency | |
| Plant Operations Director | In-serviced on Fire Safety policy and responsible for fire drill compliance | |
| Executive Director | Responsible for auditing fire drills monthly |
Inspection Report
Original Licensing
Deficiencies: 0
Mar 25, 2024
Visit Reason
The Licensing Inspector conducted an announced initial inspection of the assisted living facility Benchmark at Alexandria on March 25, 2024.
Findings
The inspector walked the physical plant, verified window and room measurements, reviewed policies, procedures, and records. Building, Fire, and Health Inspections have been submitted and reviewed.
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