Inspection Report
Monitoring
Deficiencies: 0
Oct 27, 2025
Visit Reason
The inspection was a monitoring visit conducted to review personnel-related allegations following a self-reported incident received by VDSS Division of Licensing on 2025-10-05.
Findings
The investigation did not support the self-report of non-compliance with standards or law. The licensing inspector completed a tour of the physical plant and reviewed one staff record and conducted one staff interview.
Report Facts
Number of staff records reviewed: 1
Number of interviews conducted with staff: 1
Inspection Report
Complaint Investigation
Deficiencies: 1
Oct 27, 2025
Visit Reason
The inspection was conducted in response to a complaint received on 2025-09-26 regarding allegations related to Resident Care and Related Services.
Findings
The investigation found that the facility failed to follow their medication management plan concerning accurate counts of controlled substances during staff shift changes, resulting in violations being issued.
Complaint Details
The complaint was substantiated based on facility record review and staff interview confirming missing signatures on the Controlled Drug Content Count Signature form for medication Cart 2nd East on 10/15/2025 and 10/16/2025.
Deficiencies (1)
| Description |
|---|
| Failure to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes, as required by the facility's Medication Management Plan. |
Report Facts
Inspection duration: 2.25
Number of staff interviews: 3
Inspection Report
Monitoring
Census: 67
Deficiencies: 0
Sep 23, 2025
Visit Reason
The inspection was a monitoring visit conducted on September 23, 2025, following a self-reported incident received on September 3, 2025, regarding allegations in Resident Care and Related Services and Emergency Preparedness.
Findings
The investigation found no evidence to support the self-report of non-compliance with standards or laws. The inspection findings will be posted publicly and a copy is required to be posted at the facility.
Report Facts
Number of resident records reviewed: 1
Number of interviews conducted with staff: 3
Inspection Report
Monitoring
Census: 67
Deficiencies: 1
Sep 23, 2025
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 standards related to ensuring medical procedures or treatments ordered by a physician were provided and documented properly. Specifically, a blood pressure reading was missing from the medication administration record for a resident.
Deficiencies (1)
| Description |
|---|
| Failure to ensure that medical procedures or treatments ordered by a physician were provided and documented according to instructions, specifically missing blood pressure reading documentation for a resident on 9/17/2025. |
Report Facts
Number of residents present: 67
Number of resident records reviewed: 2
Number of staff interviews conducted: 5
Inspection Report
Monitoring
Deficiencies: 1
Aug 14, 2025
Visit Reason
The inspection was a monitoring visit conducted to investigate self-reported incidents received by VDSS Division of Licensing regarding allegations in Resident Care and Related Services and Personnel.
Findings
The investigation supported the self-report of non-compliance with standards or law, resulting in violations issued related to medication administration errors involving incorrect insulin given to residents without valid physician orders.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure that no medication, dietary supplement, diet, medical procedure, or treatment shall be started, changed, or discontinued without a valid order from a physician or other prescriber, resulting in medication errors involving insulin administration. |
Report Facts
Units of insulin administered incorrectly: 45
Units of insulin prescribed: 45
Units of insulin administered incorrectly: 45
Units of insulin prescribed: 20
Resident records reviewed: 2
Staff records reviewed: 2
Resident interviews conducted: 1
Staff interviews conducted: 2
Inspection Report
Monitoring
Deficiencies: 1
Aug 14, 2025
Visit Reason
The inspection was a monitoring visit conducted following a self-reported incident received on 2025-08-05 regarding allegations in the areas of Personnel and Resident Care and Related Services.
Findings
The investigation supported some, but not all, of the allegations/self-report. Non-compliance was found in Resident Care and Related Services, specifically regarding medication administration without valid physician orders.
Complaint Details
The visit was not complaint-related but was triggered by a self-reported incident. The evidence supported some of the self-reported allegations related to Resident Care and Related Services.
Deficiencies (1)
| Description |
|---|
| The facility failed to ensure that no medication, dietary supplement, diet, medical procedure, or treatment was started, changed, or discontinued without a valid order from a physician or other prescriber. Resident 1 was administered medications not prescribed to them. |
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
Complaint Investigation
Census: 84
Deficiencies: 0
Jun 5, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-04-10 regarding allegations in the area of resident care and related services.
Findings
The evidence gathered during the investigation did not support the allegation of non-compliance with standards or law. The inspection findings will be posted publicly and a copy is required to be posted on the facility premises.
Complaint Details
Complaint received on 2025-04-10 regarding resident care and related services; investigation did not substantiate the allegations.
Report Facts
Number of residents present: 56
Number of residents present: 28
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
Complaint Investigation
Census: 84
Deficiencies: 0
Jun 5, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-05-09 regarding allegations in the area of resident care and related services.
Findings
The evidence gathered during the investigation did not support the allegation of non-compliance with standards or law. The inspection findings will be posted publicly within 5 business days.
Complaint Details
Complaint related to resident care and related services; the complaint was not substantiated based on the investigation findings.
Report Facts
Residents present: 56
Residents present: 28
Resident records reviewed: 2
Staff records reviewed: 0
Resident interviews conducted: 2
Staff interviews conducted: 3
Inspection Report
Monitoring
Census: 84
Deficiencies: 6
Jun 5, 2025
Visit Reason
The inspection was a monitoring visit to assess compliance with applicable regulations and laws for an assisted living facility.
Findings
The inspection found multiple violations including unsecured hazardous materials accessible to residents with serious cognitive impairments, unsigned individualized service plans, improper medication storage and administration, and incomplete medication documentation.
Deficiencies (6)
| Description |
|---|
| Facility failed to ensure hazardous materials were inaccessible to residents with serious cognitive impairments; laundry rooms were unlocked with detergents accessible. |
| Individualized service plan (ISP) was not signed and dated by the resident or legal representative. |
| Resident was permitted to keep medication in an out-of-sight place without proper authorization indicating capability of self-administration. |
| Medications were administered contrary to physician's instructions, including failure to hold medication based on blood pressure readings. |
| Medical procedures and treatments were not documented as ordered by the physician, including missing blood sugar documentation. |
| Medication administration records (MAR) lacked date, time, and staff initials for administered medications. |
Report Facts
Number of residents present: 56
Number of residents present: 28
Number of resident records reviewed: 3
Number of staff records reviewed: 6
Number of resident interviews conducted: 3
Number of staff interviews conducted: 2
Physician order date: Apr 22, 2025
Medication administration record dates: May 2, 2023
Inspection Report
Monitoring
Deficiencies: 3
Mar 19, 2025
Visit Reason
The inspection was a monitoring visit to assess compliance with staffing, resident care, and emergency preparedness regulations.
Findings
The inspection found non-compliance with medication administration and documentation standards, including failure to administer medications according to physician orders, incomplete documentation of medical procedures, and missing dosage information on medication administration records.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure medications were administered in accordance with the physician's or other prescriber's instructions. |
| Facility failed to ensure that medical procedures or treatments ordered by a physician or other prescriber were provided according to instructions and documented in the resident's record. |
| Facility failed to ensure the medication administration record (MAR) includes the dosage. |
Report Facts
Number of resident records reviewed: 2
Number of interviews conducted with residents: 2
Number of interviews conducted with staff: 2
Inspection Report
Monitoring
Census: 57
Deficiencies: 13
Mar 19, 2025
Visit Reason
The inspection was a monitoring visit to assess compliance with applicable standards and laws at Bentley Commons at Lynchburg assisted living facility.
Findings
The inspection identified multiple violations including unsecured hazardous materials accessible to residents with cognitive impairments, failure to follow infection control procedures, incomplete resident records, inaccurate individualized service plans, and issues with staff background checks.
Deficiencies (13)
| Description |
|---|
| Facility failed to ensure hazardous materials were inaccessible to residents with serious cognitive impairments. |
| Facility failed to follow infection control program regarding use of personal protective equipment during medication administration. |
| Facility failed to retain written acknowledgement of receipt of disclosure by resident or legal representative. |
| Facility failed to ensure physical examination by independent physician within 30 days preceding admission. |
| Facility failed to obtain required personal and social information including accurate advance directives documentation. |
| Facility failed to provide orientation documentation for new residents and legal representatives upon admission. |
| Comprehensive individualized service plan was inaccurate and not completed within 30 days after admission. |
| Care and services specified in individualized service plans were not consistently provided, including required safety checks. |
| Facility failed to review and document residents' rights and responsibilities annually with residents or legal representatives. |
| Facility failed to ensure no medication or treatment was started, changed, or discontinued without a valid physician order. |
| Facility failed to ensure residents had valid orders to self-administer medications stored in their rooms. |
| Facility failed to obtain criminal history record reports on or prior to the 30th day of employment for staff. |
| Facility failed to ensure employment was not continued for persons convicted of barrier crimes. |
Report Facts
Number of residents present: 57
Number of resident records reviewed: 10
Number of staff records reviewed: 3
Number of interviews conducted with residents: 5
Inspection Report
Complaint Investigation
Deficiencies: 2
Feb 18, 2025
Visit Reason
The inspection was conducted in response to a complaint received on 2025-02-06 regarding allegations related to Resident Care and Related Services at Bentley Commons at Lynchburg.
Findings
The investigation found non-compliance with medication management standards, including failure to follow the medication management plan for monitoring medication administration and failure to ensure medications were administered according to physician orders. Violations were issued based on these findings.
Complaint Details
The complaint was substantiated as the evidence gathered supported the allegations of non-compliance with standards related to medication management and administration.
Deficiencies (2)
| Description |
|---|
| Facility failed to follow their medication management plan regarding monitoring medication administration and effective use of MARs for documentation. |
| Facility failed to ensure medications were administered in accordance with the physician's or other prescriber's instructions. |
Report Facts
Number of resident records reviewed: 1
Number of staff interviews conducted: 2
Medication doses observed on medication cart: 15
Medication doses expected on medication cart: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Marie Swink | Licensing Inspector | Conducted the inspection and investigation |
| Staff 4 | Interviewed during inspection; confirmed medication observation records and medication administration issues | |
| Staff 5 | Observed medication cart audit confirming medication doses |
Inspection Report
Complaint Investigation
Deficiencies: 2
Jan 8, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2024-11-18 regarding allegations in the areas of Staffing and Supervision, and Resident Care and Related Services.
Findings
The investigation found that the facility failed to implement their written staffing plan, having fewer direct care staff than required during night shifts, and failed to administer medications according to physician orders as documented in resident records.
Complaint Details
The complaint was substantiated as evidence supported allegations of non-compliance with standards related to staffing and supervision, and resident care including medication administration.
Deficiencies (2)
| Description |
|---|
| Facility failed to implement their written plan specifying the number and type of direct care staff required to meet day-to-day and special needs of residents. |
| Facility failed to ensure medications were administered in accordance with physician's instructions, with documented missed doses for a resident. |
Report Facts
Number of resident records reviewed: 2
Number of resident interviews: 1
Number of staff interviews: 2
Direct care staff required on night shift: 3
Direct care staff actually present on night shifts: 2
Missed medication administration dates: 7
Inspection Report
Complaint Investigation
Deficiencies: 3
Jan 8, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 11/25/2024 regarding allegations in the areas of General Procedures, Emergency Preparedness, Resident Care and Related Services, Admission, Retention, and Discharge of Residents.
Findings
The investigation found some substantiated violations including failure to administer medications according to physician orders, failure to follow the written emergency preparedness plan regarding medical information provided to EMS, and failure to post the most recent inspection findings on the premises.
Complaint Details
The complaint investigation was substantiated in part, with violations found related to medication administration, emergency preparedness, and posting of inspection findings.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure medications were administered in accordance with physician's instructions, including missed doses of Baclofen and Tramadol. |
| Facility failed to follow their written emergency preparedness plan by not providing the current Medication Administration Record to EMS during resident emergencies. |
| Facility failed to post the findings of the most recent inspection on the premises as required. |
Report Facts
Number of resident records reviewed: 1
Number of staff interviews conducted: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Marie Swink | Licensing Inspector | Conducted the inspection and investigation |
Inspection Report
Monitoring
Deficiencies: 4
Jan 8, 2025
Visit Reason
The inspection was a monitoring visit conducted on January 8, 2025, following a self-reported incident received on December 10, 2024, regarding allegations in the area of Resident Care and Related Services.
Findings
The facility was found non-compliant with several standards related to medication administration, including failure to ensure residents received prescribed medications timely and accurately, failure to follow medication management plans, and incomplete documentation on Medication Administration Records (MAR). Violations were issued based on resident record reviews, staff interviews, and facility record reviews.
Deficiencies (4)
| Description |
|---|
| Facility failed to assume general responsibility for the health, safety, and well-being of residents, including missed doses of prescribed medication Torsemide and delayed administration of increased dosage. |
| Facility failed to follow medication management plan ensuring prescriptions and supplements are filled and refilled timely to avoid missed dosages. |
| Facility failed to ensure medications were administered according to physician's instructions, resulting in missed doses and inconsistent administration of Torsemide. |
| Medication Administration Record (MAR) did not include date, time given, initials of staff administering medication, or documentation of medication errors or omissions. |
Report Facts
Missed medication doses: 24
Number of resident records reviewed: 1
Number of staff interviews conducted: 2
Inspection Report
Monitoring
Deficiencies: 2
Jan 8, 2025
Visit Reason
The inspection was a monitoring visit conducted on January 8, 2025, to review compliance with resident care and related services following a self-reported incident regarding medication administration.
Findings
The investigation confirmed non-compliance with medication administration standards, specifically that a resident did not receive prescribed cancer medication from December 20 through December 25, 2024, due to medication unavailability. Additional findings included incomplete documentation of medication errors on the Medication Administration Record.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure medications were administered according to physician's instructions, resulting in missed doses of cancer medication from 12/20/2024 through 12/25/2024. |
| Facility failed to ensure the Medication Administration Record included any medication errors or omissions. |
Report Facts
Number of resident records reviewed: 1
Number of staff interviews conducted: 2
Inspection Report
Monitoring
Deficiencies: 0
Oct 22, 2024
Visit Reason
The inspection was a monitoring visit conducted by the licensing inspector to review resident care and related services at the facility.
Findings
The inspection found no violations of applicable standards or laws. The evidence gathered determined compliance with regulations.
Report Facts
Resident records reviewed: 3
Staff interviews conducted: 2
Inspection Report
Monitoring
Census: 63
Deficiencies: 1
Aug 21, 2024
Visit Reason
The inspection was a monitoring visit conducted following a self-reported incident received on 2024-08-13 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 documentation. The facility failed to ensure that the Medication Administration Record included the date, time given, and initials of the direct care staff administering the medication, resulting in a medication not being administered as documented.
Deficiencies (1)
| Description |
|---|
| Failure to ensure that the Medication Administration Record (MAR) included the date and time given and initials of direct care staff administering the medication. |
Report Facts
Number of residents present: 63
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
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Marie Swink | Licensing Inspector | Conducted the inspection and is the contact for questions |
| Staff 2 | Involved in medication administration error and signed off medication not given | |
| Staff 1 | Interviewed and confirmed medication was not administered | |
| Staff 4 | Confirmed medication was found in narcotic drawer and not administered |
Inspection Report
Monitoring
Census: 97
Deficiencies: 2
Aug 5, 2024
Visit Reason
The inspection was a monitoring visit conducted following a self-reported incident received on 2024-07-30 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 that a resident did not receive prescribed medication for 10 days. Violations were issued and corrective actions including staff training and audits were planned.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure medications were administered in accordance with physician's instructions, resulting in a resident not receiving Revlimid 5mg capsule from 7/19/2024 to 7/29/2024. |
| Facility failed to ensure the Medication Administration Record (MAR) included the date, time given, and initials of staff administering medication accurately. |
Report Facts
Residents present: 97
Resident records reviewed: 1
Staff records reviewed: 4
Staff interviews conducted: 3
Days medication not administered: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Marie Swink | Licensing Inspector | Conducted the inspection and interviews |
Inspection Report
Complaint Investigation
Census: 95
Deficiencies: 1
May 15, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-05-07 regarding allegations related to Resident Care and Related Services at the facility.
Findings
The investigation found the facility failed to ensure a resident's need for skilled nursing treatments was met by a licensed nurse or appropriate agency. Violations were issued based on resident record review and staff interviews.
Complaint Details
The complaint was substantiated as the evidence supported the allegation of non-compliance with standards or law related to resident care and related services.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure a resident's need for skilled nursing treatments was met by employing a licensed nurse, contractual agreement with a licensed nurse, home health agency, or private duty licensed nurse. |
Report Facts
Residents present: 95
Resident records reviewed: 1
Staff interviews conducted: 2
Inspection Report
Renewal
Census: 90
Deficiencies: 4
Apr 18, 2024
Visit Reason
The inspection was conducted as a renewal inspection to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection found multiple violations including failure to document required interviews for admission and retention decisions, incomplete medication administration records, unavailable PRN medications, and lack of semi-annual review of emergency preparedness plans for residents.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure a documented interview was completed between the administrator or designee and the individual or legal representative for admission and retention decisions. |
| Facility failed to ensure that the Medication Administration Record (MAR) included the dosage for insulin administration. |
| Facility failed to ensure the medications ordered for PRN administration were available for a resident. |
| Facility failed to ensure a semi-annual review on the emergency preparedness and response plan for all residents was completed. |
Report Facts
Number of residents present: 90
Number of resident records reviewed: 7
Number of staff records reviewed: 3
Number of interviews conducted with residents: 3
Number of interviews conducted with staff: 6
Inspection Report
Monitoring
Census: 90
Deficiencies: 0
Apr 10, 2024
Visit Reason
The inspection was a monitoring visit conducted following a self-reported incident received by VDSS Division of Licensing regarding allegations in the areas of Administration and Administrative Services, and Resident Care and Related Services.
Findings
The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law. The licensing inspector completed a tour of the physical plant and conducted record reviews and interviews without identifying deficiencies.
Report Facts
Resident records reviewed: 1
Staff records reviewed: 1
Resident interviews conducted: 1
Staff interviews conducted: 2
Inspection Report
Monitoring
Census: 97
Deficiencies: 0
Feb 16, 2024
Visit Reason
The inspection was a monitoring visit following a self-reported incident received by VDSS Division of Licensing regarding allegations in the area of Resident Care and Related Services.
Findings
The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law. The licensing inspector completed a tour of the physical plant and conducted limited record and interview reviews.
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: 1
Inspection Report
Renewal
Census: 82
Deficiencies: 10
Apr 25, 2023
Visit Reason
The inspection was a renewal inspection conducted to assess compliance with applicable regulations and licensing requirements for the assisted living facility.
Findings
The inspection identified multiple violations related to staff training, tuberculosis screening, first aid certification, resident physical examinations, individualized service plans, medication storage, and medication administration practices. The facility was found non-compliant with several regulatory standards and issued violation notices.
Deficiencies (10)
| Description |
|---|
| Facility failed to ensure all direct care staff attended at least 18 hours of training annually. |
| Facility failed to ensure staff received tuberculosis screening on or within 7 days prior to first day of work. |
| Facility failed to ensure all direct care staff received first aid certification within 60 days of employment. |
| Facility failed to provide annual refresher training for direct care staff for residents who may be aggressive. |
| Facility failed to ensure resident physical examination within 30 days preceding admission contained all required components. |
| Facility failed to obtain all required resident personal and social information prior to or at admission. |
| Facility failed to ensure individualized service plans were completed as required and accurately reflected resident needs. |
| Facility failed to keep resident records current, including documentation of home health agency wound care visits. |
| Facility failed to ensure medications for residents capable of self-administration were stored out-of-sight and inaccessible to others. |
| Facility failed to ensure medications administered were consistent with standards prohibiting medication aides from administering non-insulin injections. |
Report Facts
Number of residents present: 82
Number of resident records reviewed: 9
Number of staff records reviewed: 7
Number of interviews with residents: 3
Number of interviews with staff: 3
Number of falls for resident 8: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Marie Swink | Licensing Inspector | Current inspector conducting the inspection |
| Cynthia Ball-Beckner | Licensing Inspector | Contact person for questions about VDSS Licensing Programs |
Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 0
Apr 25, 2023
Visit Reason
The inspection was conducted in response to a complaint received on 2023-02-11 regarding allegations related to staffing, resident care and related services, and building and grounds.
Findings
The investigation found no evidence to support the allegations or self-reported non-compliance with standards or law. The inspection included a tour of the physical plant, review of resident records, and interviews with residents and staff.
Complaint Details
Complaint received on 2023-02-11 regarding staffing, resident care and related services, and building and grounds. The evidence gathered did not support the allegations or self-report of non-compliance.
Report Facts
Number of residents present: 82
Number of resident records reviewed: 10
Number of interviews conducted with residents: 3
Number of interviews conducted with staff: 3
Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 0
Jan 12, 2023
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing regarding allegations in the areas of resident care and related services and building and grounds.
Findings
The evidence gathered during the investigation did not support the allegations or self-report of non-compliance with standards or law. The inspection findings will be posted publicly.
Complaint Details
Complaint related inspection with allegations in resident care and related services and building and grounds; evidence did not support non-compliance.
Report Facts
Number of residents present: 75
Number of resident records reviewed: 1
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 2
Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 0
Jan 12, 2023
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing regarding allegations in the areas of resident care and related services and building and grounds.
Findings
The evidence gathered during the investigation did not support the allegations or self-report of non-compliance with standards or law.
Complaint Details
Complaint related inspection with allegations in resident care and related services and building and grounds; findings did not substantiate non-compliance.
Report Facts
Number of residents present: 75
Number of resident interviews: 3
Number of staff interviews: 2
Inspection Report
Renewal
Census: 50
Deficiencies: 6
May 26, 2022
Visit Reason
The inspection was a renewal inspection conducted to assess compliance with applicable standards and laws for continued licensing of the assisted living facility.
Findings
The inspection found multiple violations related to resident records, staff training documentation, tuberculosis screenings, admission interviews, written assurances, and updating of the uniform assessment instrument. The facility was found non-compliant in these areas and was required to submit plans of correction.
Deficiencies (6)
| Description |
|---|
| Facility failed to ensure that the current disclosure state form was used for prospective residents, lacking information on the facility emergency power source. |
| Facility failed to ensure documentation of the number of hours of training for staff. |
| Facility failed to ensure that staff screenings for tuberculosis were completed in entirety on or within 7 days prior to the first day of work. |
| Facility failed to ensure a documented interview occurred between the administrator or designee and the resident and their legal representative prior to or on the date of admission. |
| Facility failed to ensure that written assurance was provided to a resident at the time of their admission. |
| Facility failed to ensure the uniform assessment instrument (UAI) was updated when there was a significant change in the resident's condition. |
Report Facts
Number of resident records reviewed: 10
Number of staff records reviewed: 4
Number of interviews conducted with residents: 3
Number of interviews conducted with staff: 3
Inspection Report
Monitoring
Deficiencies: 5
Apr 14, 2022
Visit Reason
The inspection was a monitoring visit conducted to review compliance with various regulatory provisions, including administration, personnel, resident care, and medication management.
Findings
The facility was found to have multiple violations related to medication administration, confidentiality of resident records, improper storage of medications in resident rooms, failure to follow physician orders for treatments, and improper documentation of medication administration.
Deficiencies (5)
| Description |
|---|
| Facility failed to ensure all records were treated confidentially and that information is made available only when needed for care of the residents. |
| Facility failed to ensure that medications kept in residents' rooms were stored out of sight and only for residents assessed as capable of self-administering medications. |
| Facility failed to ensure that a registered medication aide administered medications consistent with standards of practice, including wearing identification. |
| Facility failed to ensure that medical procedures or treatments ordered by a physician were provided according to instructions and documented. |
| Facility failed to ensure that only medications administered to residents were documented on resident medication administration records. |
Report Facts
Inspection duration hours: 4.75
Plan of correction response timeframe days: 10
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 0
Apr 14, 2022
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2022-03-30 regarding allegations in the area of staffing and supervision.
Findings
The evidence gathered during the investigation did not support the allegation of non-compliance with standards or law. The licensing inspector completed a tour of the physical plant including the building and grounds.
Complaint Details
Complaint related to allegations in staffing and supervision; the complaint was not substantiated.
Report Facts
Number of residents present: 50
Inspection Report
Follow-Up
Deficiencies: 1
Feb 15, 2022
Visit Reason
The inspection was a follow-up visit triggered by a self-reported incident investigation regarding resident supervision and service provision.
Findings
The facility failed to ensure that services specified in a resident's individualized service plan (ISP) were provided, specifically regarding supervision of a resident with mobility needs outside the community. The incident involved a resident found unsupervised outside the facility, leading to corrective actions including increased supervision and staff in-service.
Deficiencies (1)
| Description |
|---|
| Failure to ensure that services specified in a resident's individualized service plan (ISP) were provided, specifically supervision for mobility outside the community. |
Report Facts
Incident date: Feb 11, 2022
Incident report received date: Feb 12, 2022
Follow-up visit date: Apr 14, 2022
Uniform Assessment Instrument date: Jan 13, 2022
Individualized Service Plan date: Jan 13, 2022
Inspection Report
Renewal
Deficiencies: 26
Nov 15, 2021
Visit Reason
An on-site renewal inspection was conducted to review the facility physical plant, medication pass, resident and staff records, and other documentation to assess compliance with regulatory standards.
Findings
The inspection identified multiple violations including inadequate staff training on cognitive impairments and aggressive behavior, failure to maintain proper resident records, infection control lapses during medication administration, medication management deficiencies, physical plant maintenance issues, and incomplete emergency preparedness documentation.
Deficiencies (26)
| Description |
|---|
| Facility failed to ensure direct care staff received six hours of training on cognitive impairment within the first four months of employment. |
| Protective devices were not installed on windows in common areas accessible to residents with cognitive impairments to prevent escape. |
| Facility failed to ensure implementation of infection control policy during medication pass, including improper cleaning of blood pressure cuff and unlabeled glucometers. |
| Facility failed to retain written acknowledgment of disclosure receipt in resident records. |
| Orientation and required training for staff were not completed within the first seven working days. |
| Required health information, including tuberculosis screening dates, was missing or incomplete in staff records. |
| Direct care staff were not trained in methods of dealing with residents with aggressive behavior prior to care involvement. |
| Facility failed to verify whether potential residents were registered sex offenders prior to admission. |
| Facility failed to retain a copy of written discharge statements in resident records. |
| Private pay uniform assessment instruments were not completed as required or contained inaccurate information. |
| Individualized service plans did not address identified resident needs such as wheelchair use and gait belt assistance. |
| Facility failed to conduct annual review of resident rights and responsibilities with residents and staff. |
| Menus posted were not for the current week during inspection. |
| Diets prescribed by physicians were not prepared and served according to orders. |
| Medication management plan was not properly implemented; missing signatures on controlled drug count sheets and unlabeled medication pens. |
| Medications were not stored out of sight in resident rooms and were accessible without physician orders for self-administration. |
| Medications were not kept in pharmacy-issued containers with prescription labels until administration. |
| Medications were administered not in accordance with physician instructions, including improper timing and missed holds. |
| Facility failed to document actions taken in response to recommendations from resident medication reviews. |
| Cleaning supplies were not stored in locked areas, with multiple unlocked storage closets and cabinets. |
| Interior of the building was not maintained in good repair and cleanliness, with stained carpets and marked doors. |
| Facility failed to complete semi-annual review of emergency preparedness and response plan. |
| Fire and emergency evacuation drills were not conducted for each shift in a quarter. |
| Facility failed to ensure semi-annual review of resident emergencies with all staff. |
| Sworn statements or affirmations were not completed or were completed late for multiple staff applicants. |
| Criminal history record reports were not obtained on or prior to the 30th day of employment for several staff. |
Report Facts
Inspection duration: 8.67
Dates of staff hires with training deficiencies: Staff hired on 4/8/21, 8/30/21, 9/22/21, 9/28/21, 8/23/21, 9/13/21, 9/20/21, 7/15/21 with various record deficiencies
Dates of resident admissions with record deficiencies: Residents admitted on 10/25/21, 10/29/21 with missing documentation
Dates of medication orders: Physician orders dated 9/24/21, 10/12/21, 11/6/21, 10/7/21
Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 4
Oct 18, 2021
Visit Reason
A non-mandated complaint inspection was initiated due to allegations regarding resident care and related services, building and grounds, and emergency preparedness.
Findings
The investigation found multiple violations including failure to post the name of the current on-site person in charge, failure to record substitutions on the posted lunch menu, unlocked storage of cleaning supplies, and insufficient 48-hour emergency food supply for all residents.
Complaint Details
The complaint was substantiated with evidence supporting non-compliance in multiple areas including resident care, building and grounds, and emergency preparedness.
Deficiencies (4)
| Description |
|---|
| Failed to implement a procedure for posting the name of the current on-site person in charge in a conspicuous place. |
| Failed to ensure substitutions made to the lunch meal were recorded on the posted menu. |
| Failed to ensure all cleaning supplies were stored in a locked area; storage closet lock was broken and door unlocked. |
| Failed to ensure a 48 hour supply of emergency food was on-site sufficient for all residents. |
Report Facts
Residents in care: 64
Assisted living residents: 44
Inspection Report
Complaint Investigation
Deficiencies: 2
Oct 18, 2021
Visit Reason
A non-mandated complaint inspection was initiated due to allegations in the areas of resident care and related services. The inspection was conducted to investigate these complaints and determine compliance with applicable standards and laws.
Findings
The investigation found non-compliance with reporting requirements related to major incidents and mandated reporting of suspected abuse or neglect. The facility failed to report an incident within 24 hours to the regional licensing office and did not report suspected abuse to the local Adult Protective Agency as required.
Complaint Details
The complaint investigation was substantiated, with evidence supporting allegations of non-compliance in incident reporting and mandated reporting of suspected abuse or neglect.
Deficiencies (2)
| Description |
|---|
| Facility failed to report to the regional licensing office within 24 hours of any major incident that negatively affected or threatened the life, health, safety, or welfare of any resident. |
| Facility failed to ensure mandated reporting occurred as per 63.2-1606 of the Code of Virginia regarding suspected abuse or neglect. |
Report Facts
Days delayed in reporting incident: 17
Date of incident report: Sep 21, 2021
Inspection Report
Monitoring
Deficiencies: 2
Sep 14, 2021
Visit Reason
A non-mandated monitoring inspection was initiated to investigate compliance with personnel training and criminal history record requirements.
Findings
The inspection found violations related to staff training on managing residents with aggressive behavior and failure to obtain criminal history reports for employees within the required timeframe.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure direct care staff were trained in methods of dealing with residents who have a history of aggressive behavior or dangerously agitated states prior to involvement in care. |
| Facility failed to ensure that a criminal history report from the Virginia State Police was obtained on new staff on or prior to their 30th day of employment. |
Inspection Report
Monitoring
Census: 52
Deficiencies: 15
Jun 14, 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 identified multiple violations related to staff training, resident care plans, medication management, documentation, fire drills, and employee records. Several staff records lacked required training and screenings, resident individualized service plans were incomplete or inconsistent, medication administration errors and documentation deficiencies were found, and fire drills were not conducted quarterly as required.
Deficiencies (15)
| Description |
|---|
| Failure to ensure training in working with individuals who have cognitive impairments was completed within four months of employment for all direct care staff. |
| Failure to ensure required orientation and training occurred within the first seven working days of employment. |
| Failure to ensure all staff received tuberculosis screening on or within seven days prior to first day of work. |
| Failure to ensure direct care staff received certification in first aid within 60 days of employment. |
| Failure to ensure direct care staff were trained in methods of dealing with residents with aggressive or agitated behavior prior to involvement in care. |
| Failure to ensure all identified needs were addressed on individualized service plans (ISPs). |
| Failure to ensure annual review of resident rights and responsibilities was conducted with all staff. |
| Failure to ensure all required procedures were addressed in the facility medication management plan. |
| Failure to ensure residents' primary care physicians were notified of new or changed medication orders after hospital discharge. |
| Failure to administer medications in accordance with physician instructions. |
| Failure to ensure all medical procedures were documented as required. |
| Failure to ensure all required documentation was included on resident medication administration records (MARs). |
| Failure to conduct fire drills on each shift quarterly. |
| Failure to ensure sworn statement or affirmation was completed for applicants of employment. |
| Failure to ensure criminal history report was obtained on new staff on or prior to their 30th day of employment. |
Report Facts
Current census: 52
Staff records reviewed: 4
Resident records reviewed: 4
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 28, 2021
Visit Reason
A complaint inspection was initiated due to allegations in the areas of Personnel and resident care and related services.
Findings
The investigation did not find evidence to support the allegations or self-reported non-compliance with standards or law.
Complaint Details
A complaint was received regarding Personnel and resident care and related services; the complaint was not substantiated.
Inspection Report
Complaint Investigation
Deficiencies: 3
Apr 22, 2021
Visit Reason
A complaint inspection was initiated due to allegations regarding resident care and related services, specifically medication administration and compliance with standards.
Findings
The investigation found multiple violations related to medication management, including failure to reorder medications timely, failure to administer medications according to physician orders, and incomplete documentation on medication administration records (MARs).
Complaint Details
The complaint was substantiated with evidence supporting non-compliance in medication administration and documentation.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure medications were reordered in a timely manner to avoid missed doses. |
| Facility failed to ensure medications were administered in accordance with physician's instructions. |
| Facility failed to ensure all required information was documented on resident MARs. |
Report Facts
Inspection duration: 57
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Marie Swink | Inspector | Conducted the complaint investigation |
| Director of Nursing | Addressed medication errors and corrective actions with staff |
Inspection Report
Monitoring
Deficiencies: 4
Apr 1, 2021
Visit Reason
A monitoring inspection was initiated due to a state of emergency health pandemic and a self-reported incident regarding allegations in Resident care and related services and mixed population.
Findings
The facility failed to ensure adequate security monitoring for residents with serious cognitive impairments, failed to report a major incident within 24 hours, failed to provide care and services specified in the individualized service plan, and failed to provide supervision to prevent wandering from the premises. Violations were issued based on these findings.
Deficiencies (4)
| Description |
|---|
| Failed to ensure a system of security monitoring of residents with serious cognitive impairments on all doors leading to the outside. |
| Failed to report to the regional licensing office within 24 hours any major incident that negatively affected or threatened the life, health, safety, or welfare of any resident. |
| Failed to ensure that care and services specified in the individualized service plan were provided. |
| Failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs such as wandering from the premises. |
Report Facts
Incident date: Mar 9, 2021
Incident date: Mar 30, 2021
Resident admission date: Oct 26, 2020
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 4, 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 investigation was conducted remotely due to a state of emergency health pandemic. The evidence gathered did not support the allegation of non-compliance with standards or law.
Complaint Details
A complaint was received regarding allegations in resident care and related services. The investigation found no substantiation of non-compliance.
Inspection Report
Complaint Investigation
Deficiencies: 2
Jan 25, 2021
Visit Reason
A complaint inspection was initiated due to allegations regarding infection control practices at the facility.
Findings
The investigation found non-compliance with infection control standards, including failure to follow Virginia Department of Health recommendations for N95 mask fit testing and incomplete staff training documentation related to emergency temporary standards.
Complaint Details
The complaint was related to infection control. The evidence gathered supported the allegations of non-compliance with standards or law.
Deficiencies (2)
| Description |
|---|
| Facility failed to follow recommendations made by the Virginia Department of Health to prevent or control transmission of an infectious agent in the facility. |
| Licensee failed to ensure compliance with relevant state law, other regulations, and facility policies regarding staff training and certification. |
Report Facts
Employees fit tested for N95 masks: 4
Staff persons reviewed for training documentation: 5
Date of emergency temporary standard effective: Jul 24, 2020
Plan of correction training deadline: May 8, 2021
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