Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 2
Sep 18, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-08-13 regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation supported allegations of non-compliance related to individualized service plans not including all assessed needs and inadequate supervision of resident schedules, care, and activities, including prevention of falls and wandering. 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 or law.
Deficiencies (2)
| Description |
|---|
| The facility did not ensure the resident's individualized service plan (ISP) included all assessed needs. |
| The facility did not ensure to provide supervision of resident schedules, care, and activities, including attention to specialized needs such as prevention of falls and wandering from the premises. |
Report Facts
Number of residents present: 62
Number of resident records reviewed: 4
Number of staff records reviewed: 0
Number of resident interviews conducted: 1
Number of staff interviews conducted: 2
Call bell response times: 6
Call bell response times: 8
Inspection Report
Renewal
Deficiencies: 14
Sep 3, 2025
Visit Reason
An unannounced on-site renewal inspection was conducted to assess compliance with applicable standards and laws for facility licensing renewal.
Findings
The inspection identified multiple violations including failure to document approval for placement in the safe, secure environment, insufficient cognitive impairment training for staff, outdated facility license posting, lack of first aid certification for staff, incomplete treatment plans for psychotropic medications, discrepancies between assessed needs and individualized service plans, medication administration errors, missing PRN medications, incomplete first aid kits, failure to post recent inspection findings, and missing criminal history record reports for employees.
Deficiencies (14)
| Description |
|---|
| Facility failed to document approval for placement in the safe, secure environment as required. |
| Direct care staff did not complete required 10 hours of cognitive impairment training within four months of employment. |
| Current facility license was not posted in a conspicuous place to residents and the public. |
| Direct care staff member lacked documentation of adult first aid certification within 60 days of employment. |
| Facility failed to post an updated listing of staff certified in first aid or CPR. |
| Facility did not have treatment plans for residents prescribed psychotropic medications. |
| Private pay uniform assessment instrument (UAI) was not completed as required, including missing signatures. |
| Individualized service plans (ISP) did not include all assessed needs or were not signed and dated as required. |
| Menu for meals and snacks for the current week was not posted in a resident-accessible area. |
| Medications were administered outside the prescribed dosing schedule, constituting medication errors. |
| Medications ordered for PRN administration were not available or properly labeled at the facility. |
| First aid kits lacked required items and were not checked monthly to ensure completeness and expiration dates. |
| Findings of the most recent inspection were not posted as required. |
| Criminal history record reports were not obtained for certain employees within 30 days of employment. |
Report Facts
Number of resident records reviewed: 6
Number of staff records reviewed: 3
Number of interviews conducted with residents: 2
Number of interviews conducted with staff: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Willie Barnes | Licensing Inspector | Contact person for questions about the VDSS Licensing Programs |
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 0
Apr 14, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-04-06 regarding allegations in the area of Resident Care and Related Services.
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 publicly within 5 business days of receipt.
Complaint Details
Complaint received on 2025-04-06 regarding Resident Care and Related Services; allegations were not substantiated.
Report Facts
Number of resident records reviewed: 5
Number of staff records reviewed: 0
Number of interviews conducted with residents: 4
Number of interviews conducted with staff: 3
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 1
Feb 26, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 02/12/2024 regarding allegations related to Admission, Retention and Discharge of Residents, Resident Care and Related Services, and Resident Accommodations and Related Provisions.
Findings
The investigation did not substantiate the complaint allegations of non-compliance; however, a violation unrelated to the complaint was identified regarding failure to notify the designated contact person of a resident's fall incident.
Complaint Details
Complaint was received on 02/12/2024 regarding allegations in admission, retention and discharge of residents, resident care and related services, and resident accommodations. The evidence gathered did not support the allegations of non-compliance.
Deficiencies (1)
| Description |
|---|
| Facility failed to notify the next of kin, legal representative, designated contact person, or responsible social agency of a resident's fall incident on 01/09/2025. |
Report Facts
Number of residents present: 55
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: 55
Deficiencies: 2
Feb 26, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-02-13 regarding allegations in the areas of staffing and supervision at the assisted living facility.
Findings
The investigation found the facility failed to adequately staff with sufficient knowledge, skills, and numbers to meet residents' needs, and failed to maintain a written staffing plan specifying the number and type of direct care staff required. Violations were issued based on these findings.
Complaint Details
The complaint was substantiated. Evidence included a staff schedule showing only one direct care staff from 6:00 am to 10:00 am on 2025-02-08 for approximately 40 residents, and medication administration records indicating several residents did not receive evening medications/treatments on 2025-02-27.
Deficiencies (2)
| Description |
|---|
| Facility failed to adequately staff in knowledge, skills, and abilities and sufficient in numbers to provide services to maintain residents' well-being as determined by assessments and service plans. |
| Facility failed to maintain a written plan specifying the number and type of direct care staff required to meet day-to-day and special needs of residents. |
Report Facts
Residents present: 55
Resident records reviewed: 5
Staff interviews conducted: 5
Direct care staff: 1
Medications for Resident #1: 11
Treatments for Resident #1: 2
Medications for Resident #2: 5
Medications for Resident #3: 4
Treatments for Resident #3: 1
Medications for Resident #4: 4
Medications for Resident #5: 2
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 9
Feb 26, 2025
Visit Reason
The inspection was conducted in response to four complaints received by VDSS Division of Licensing regarding allegations in the areas of Resident Care and Related Services and Buildings and Grounds.
Findings
The investigation supported some, but not all, of the allegations; areas of non-compliance were found in Resident Care and Related Services. Multiple violations were cited related to communication, fall risk assessments, individualized service plans, care provision, notification of incidents, and medication administration.
Complaint Details
Four complaints were received on 02/19/2025, 02/25/2025, 02/27/2025, and 03/07/2025. The evidence supported some allegations related to Resident Care and Related Services. A violation notice was issued and the licensee has the opportunity to submit a plan of correction.
Deficiencies (9)
| Description |
|---|
| Facility failed to ensure a method of written communication to keep direct care staff informed of significant happenings or problems experienced by residents. |
| Facility failed to ensure a fall risk rating is completed at least annually and after a fall. |
| Facility failed to document analysis of fall circumstances and interventions to prevent or reduce risk of subsequent falls for a resident meeting assisted living care criteria. |
| Facility failed to complete a resident's UAI at least annually. |
| Facility failed to review and update individualized service plans at least once every 12 months. |
| Facility failed to ensure care provision and service delivery were resident-centered and included prompt response by staff to resident needs. |
| Facility failed to ensure personal assistance and care were provided to each resident as necessary. |
| Facility failed to secure medical attention immediately and notify appropriate parties within 24 hours of serious accident, injury, or medical condition. |
| Facility failed to ensure medications were administered in accordance with physician's or prescriber's instructions. |
Report Facts
Number of residents present: 55
Number of resident records reviewed: 7
Number of interviews conducted with residents: 4
Number of interviews conducted with staff: 4
Call bell response times (minutes): 37
Call bell response times (minutes): 28
Call bell response times (minutes): 32
Number of medications not administered: 11
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 2
Feb 26, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-02-14 regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation supported the allegations of non-compliance, resulting in violations related to failure to update individualized service plans for significant changes in a resident's condition and failure to ensure medical procedures ordered by a physician were provided and documented.
Complaint Details
Complaint related: Yes. The evidence gathered supported the allegations of non-compliance with standards or laws. Violations were issued based on failure to update service plans and failure to provide and document ordered medical procedures.
Deficiencies (2)
| Description |
|---|
| Facility failed to review and update individualized service plans as needed for a significant change of a resident's condition. |
| Facility failed to ensure medical procedures or treatments ordered by a physician or other prescriber were provided according to their instructions and documented. |
Report Facts
Number of residents present: 55
Number of resident records reviewed: 1
Number of staff interviews conducted: 4
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 5
Feb 3, 2025
Visit Reason
The inspection was conducted in response to a complaint received on 2025-01-15 regarding allegations in the areas of Staffing and Supervision, Resident Care and Related Services, and Buildings and Grounds.
Findings
The investigation supported some but not all allegations; non-compliance was found in Resident Care and Related Services. Multiple violations related to fall risk assessments, individualized service plans, medication administration, medical procedures, and medication administration records were identified.
Complaint Details
The complaint was substantiated in part, with non-compliance found in Resident Care and Related Services. The complaint involved allegations in Staffing and Supervision, Resident Care and Related Services, and Buildings and Grounds.
Deficiencies (5)
| Description |
|---|
| Facility failed to ensure a fall risk rating is completed after a fall. |
| Facility failed to review and update individualized service plans as needed for a significant change of a resident's condition. |
| Facility failed to ensure medications were administered in accordance with the physician's or other prescriber's instructions. |
| Facility failed to ensure medical procedures or treatments ordered by a physician or other prescriber were provided according to their instructions and documented. |
| Facility failed to ensure the Medication Administration Record (MAR) included dosage information consistently. |
Report Facts
Number of residents present: 62
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: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lanesha Allen | Licensing Inspector | Current inspector conducting the inspection |
| M. Tess Pittman | Licensing Inspector | Contact person for questions regarding the inspection |
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 3
Feb 3, 2025
Visit Reason
The inspection was conducted in response to a complaint received on 2025-01-17 regarding allegations in the areas of Resident Care and Related Services and Buildings and Grounds.
Findings
The investigation supported some, but not all, of the allegations; non-compliance was found in Resident Care and Related Services. Violations were issued related to fall risk assessments, general responsibility for resident health and safety, and medication administration.
Complaint Details
The complaint was substantiated in part; violations related to Resident Care and Related Services were found. The complaint involved allegations about resident care and building conditions.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure a fall risk rating is completed after a fall. |
| Facility failed to assume general responsibility for the health, safety, and well-being of the residents. |
| Facility failed to ensure medications were administered in accordance with the physician's or other prescriber's instructions. |
Report Facts
Number of residents present: 62
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 |
|---|---|---|
| M. Tess Pittman | Licensing Inspector | Contact person for questions regarding the inspection |
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 4
Dec 17, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2024-11-21 regarding allegations in the areas of Resident Care and Related Services and Buildings and Grounds.
Findings
The investigation supported some, but not all, of the allegations; non-compliance was found in Resident Care and Related Services. Multiple violations related to personal care, diet orders, medication orders, and medication administration were identified.
Complaint Details
The complaint was substantiated in part; violations related to Resident Care and Related Services were found. The complaint involved allegations about resident care and building conditions.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure that personal assistance and care were provided to each resident as necessary, evidenced by lack of bathing documentation for Resident #1. |
| Facility failed to ensure prescribed diets were prepared and served according to physician orders, with no record of diabetic diet change for Resident #1. |
| Facility failed to ensure no medication was started, changed, or discontinued without a valid order, with missing valid orders for Resident #1's medications. |
| Facility failed to ensure medications were administered according to physician instructions, with multiple missed doses for Resident #1. |
Report Facts
Number of residents present: 62
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: 62
Deficiencies: 1
Dec 17, 2024
Visit Reason
The inspection was conducted in response to two complaints received by VDSS Division of Licensing regarding allegations in the areas of Admission, Retention, and Discharge of Residents, Resident Care and Related Services, Buildings and Grounds, and Additional Requirements for Facilities that Care for Adults with Serious Cognitive Impairments.
Findings
The investigation supported some, but not all, of the allegations; non-compliance was found in Resident Care and Related Services. Specifically, the facility failed to ensure prompt staff response to resident call bells, with documented response times significantly exceeding the facility's policy.
Complaint Details
The complaint investigation was substantiated in part, with violations related to Resident Care and Related Services. Two complaints were received on 12/02/2024 and 12/09/2024. Evidence included documented call bell response times ranging from 45 minutes to over 2 hours, exceeding the facility's policy of 9-12 minutes response time.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure care provision and service delivery were resident-centered and include prompt response by staff to resident needs as reasonable to the circumstances. |
Report Facts
Residents present: 62
Resident records reviewed: 2
Staff interviews conducted: 5
Call bell response time: 62
Call bell response time: 148
Call bell response time: 45
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 5
Dec 17, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2024-11-21 regarding allegations in the areas of Personnel, Staffing and Supervision, Resident Care and Related Services, Buildings and Grounds, and Additional Requirements for Facilities that Care for Adults with Serious Cognitive Impairments.
Findings
The investigation supported some, but not all, of the allegations; areas of non-compliance were found in Personnel, Resident Care and Related Services, and Buildings and Grounds. Multiple violations were cited including failure to maintain required staff certifications, failure to ensure resident safety during transfers, medication administration errors, and inadequate documentation of resident rounds.
Complaint Details
The complaint was substantiated in part; violations related to personnel qualifications, resident care, and building safety were found. Some allegations were not supported.
Deficiencies (5)
| Description |
|---|
| Facility failed to obtain a copy of the certificate or documentation indicating staff met required qualifications. |
| Facility failed to ensure each direct care staff member maintained current certification in first aid. |
| Facility failed to assume general responsibility for the health, safety, and well-being of residents, including unsafe transfer of a resident during CPR. |
| Facility failed to ensure medications were administered according to physician's or prescriber's instructions. |
| Facility failed to ensure direct care staff documented rounds at least every two hours for residents unable to use signaling devices. |
Report Facts
Number of residents present: 62
Number of resident records reviewed: 1
Number of staff records reviewed: 4
Number of staff interviews conducted: 5
Medication doses missed: 4
Inspection dates: 2
Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 4
Nov 4, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2024-10-30 regarding allegations in the areas of Resident Care and Related Services and Buildings and Grounds.
Findings
The investigation supported the allegations of non-compliance with applicable standards and laws, resulting in violations issued. Deficiencies included failure to complete fall risk ratings after falls, delayed staff response to call bells, inadequate supervision and care planning to prevent falls, and failure to document required rounds for residents unable to use signaling devices.
Complaint Details
The complaint investigation was substantiated with violations issued based on evidence including record reviews and interviews. The complaint involved failure to complete fall risk assessments, delayed response to call bells, inadequate supervision to prevent falls, and lack of documentation of required rounds for residents unable to use signaling devices.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure a fall risk rating is completed after a fall. |
| Facility failed to ensure care provision and service delivery were resident-centered with prompt staff response to resident needs. |
| Facility failed to provide supervision of resident schedules, care, and activities including prevention of falls. |
| Facility failed to ensure documentation of rounds at least every two hours for residents unable to use signaling devices. |
Report Facts
Number of residents present: 64
Number of resident records reviewed: 1
Number of staff interviews conducted: 3
Number of resident interviews conducted: 1
Number of falls by Resident #1 in October 2024: 9
Number of fall risk ratings completed for Resident #1 in October 2024: 3
Average staff response time to Resident #1 call bell on 2024-10-21: 42
Staff response time to Resident #1 call bell on 2024-11-14: 29
Number of falls by Resident #1 in September 2024: 3
Inspection Report
Renewal
Census: 63
Deficiencies: 16
Oct 1, 2024
Visit Reason
The inspection was conducted as a renewal of the facility's license, including a tour of the physical plant, review of resident and staff records, and observation of activities and medication administration.
Findings
The inspection found multiple violations related to resident care, staff certifications, medication management, documentation, and safety procedures. The facility failed to comply with several standards including approvals for placement in special care units, fall risk assessments, medication orders, medication cart security, and timely criminal history checks for employees.
Deficiencies (16)
| Description |
|---|
| Failed to obtain written approval for placement of a resident with serious cognitive impairment in a safe, secure environment. |
| Failed to perform six-month and annual reviews of appropriateness for continued residence in the special care unit. |
| Direct care staff members did not maintain current certification in first aid. |
| Failed to ensure fall risk ratings were completed at least annually and after each fall. |
| Failed to complete UAI assessments prior to admission, annually, and after significant changes in condition. |
| Failed to review and update individualized service plans after significant changes in resident condition. |
| Failed to annually review rights and responsibilities of residents or their legal representatives. |
| Failed to prevent use of outdated medications; expired medications were found on medication carts. |
| Medications were started, changed, or discontinued without valid physician orders. |
| Medication cart was found unlocked, open, and unattended. |
| Medications were not administered according to physician or prescriber instructions; multiple medications were unavailable for administration as ordered. |
| Medication Administration Records (MAR) lacked dosage and diagnosis or indication for multiple residents' medications. |
| Failed to act on pharmacy medication review recommendations for a resident. |
| Failed to document rounds at least every two hours for residents unable to use signaling devices. |
| Failed to ensure monthly checks of first aid kits to verify all items present and not expired. |
| Failed to obtain criminal history record report within 30 days of employment for an employee. |
Report Facts
Residents present: 63
Resident records reviewed: 6
Staff records reviewed: 3
Resident interviews: 4
Staff interviews: 3
Expired medications observed: 6
Staff without current first aid certification: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| M. Tess Pittman | Licensing Inspector | Contact person for questions about the inspection |
| Lanesha Allen | Licensing Inspector | Inspector on-site during the inspection |
Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 2
Aug 9, 2024
Visit Reason
The inspection was conducted in response to two complaints received by VDSS Division of Licensing on 07/31/2024 regarding allegations in the areas of Resident Care and Related Services, Buildings and Grounds, and Emergency Preparedness.
Findings
The investigation supported some, but not all, of the allegations related to Resident Care and Related Services. Violations were found including failure to complete fall risk ratings after resident falls and failure to notify designated contacts of resident falls within required timeframes.
Complaint Details
Two complaints were received regarding Resident Care and Related Services, Buildings and Grounds, and Emergency Preparedness. The evidence supported some of the allegations related to Resident Care and Related Services. A violation notice was issued. The complaint related status for the first violation was No, and for the second violation was Yes.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure a fall risk rating is completed after a fall for Resident #1 and Resident #2. |
| Facility failed to notify the next of kin, legal representative, designated contact person, or responsible social agency of a resident fall within 24 hours, as required. |
Report Facts
Number of residents present: 64
Number of resident records reviewed: 2
Number of staff records reviewed: 1
Number of resident interviews conducted: 2
Number of staff interviews conducted: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| M. Tess Pittman | Licensing Inspector | Contact person for questions regarding the inspection |
| Lanesha Allen | Licensing Inspector | Inspector on-site during the inspection |
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 3
Jul 2, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 06/28/2024 regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation supported the allegations of non-compliance with standards related to medication orders and administration. Violations were issued for failure to obtain new medication orders upon hospital discharge, failure to administer medications according to schedule, and failure to follow physician instructions for medication administration.
Complaint Details
The complaint was substantiated as the evidence supported the allegations of non-compliance with medication management standards.
Deficiencies (3)
| Description |
|---|
| Facility failed to obtain new orders for all medications prior to or at the time of the resident's return from hospital discharge. |
| Facility failed to ensure medications were administered not earlier than one hour before and not later than one hour after the facility's standard dosing schedule. |
| Facility failed to ensure medications were administered in accordance with the physician's or other prescriber's instructions. |
Report Facts
Residents present: 67
Resident records reviewed: 1
Staff interviews conducted: 2
Resident interviews conducted: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| M. Tess Pittman | Licensing Inspector | Contact person for questions regarding the inspection findings |
| Lanesha Allen | Licensing Inspector | Current inspector on-site during the inspection |
Inspection Report
Monitoring
Census: 61
Deficiencies: 4
May 22, 2024
Visit Reason
The inspection was a monitoring visit conducted on May 22, 2024, following a self-reported incident received on May 7, 2024, regarding allegations in the area of Resident Care and Related Services.
Findings
The inspection found non-compliance with applicable standards and laws related to the care of residents with serious cognitive impairments, including failures in assessment prior to admission, obtaining required approvals for placement, updating individualized service plans, and providing adequate supervision to prevent wandering and injury.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure residents admitted to a safe, secure environment had been assessed by an independent clinical psychologist or physician for serious cognitive impairment. |
| Facility failed to obtain written approval for placement of a resident with serious cognitive impairment in a safe, secure environment. |
| Facility failed to ensure the comprehensive individualized service plan included a description of current identified needs and services to address those needs. |
| Facility failed to provide supervision of resident schedules, care, and activities, including prevention of falls and wandering. |
Report Facts
Number of residents present: 61
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of resident interviews conducted: 1
Number of staff interviews conducted: 2
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 0
Apr 2, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-03-28 regarding allegations related to staffing and supervision and additional requirements for facilities that care for adults with serious cognitive impairments.
Findings
The investigation did not find evidence to support the allegations of non-compliance with standards or law. The inspection findings were reviewed and no deficiencies were cited.
Complaint Details
Complaint received on 2024-03-28 regarding staffing and supervision and additional requirements for facilities that care for adults with serious cognitive impairments. The complaint was not substantiated based on the evidence gathered during the investigation.
Report Facts
Number of residents present: 63
Number of resident records reviewed: 0
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: 65
Deficiencies: 2
Feb 27, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 02/26/2024 regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation found violations related to medication administration timing and adherence to physician orders for Resident #1. Multiple occasions of medications not being administered within the prescribed timeframes were documented, supporting the complaint allegations.
Complaint Details
The complaint was substantiated based on evidence gathered during the investigation, which supported the allegations of non-compliance with medication administration standards.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure medications were administered not earlier than one hour before and not later than one hour after the facility's standard dosing schedule, except for drugs ordered for specific times. |
| Facility failed to ensure medications were administered in accordance with the physician's or other prescriber's instructions. |
Report Facts
Residents present: 65
Resident records reviewed: 1
Staff records reviewed: 0
Resident interviews conducted: 1
Staff interviews conducted: 2
Medication administration deviations: 39
Medication administration deviations: 3
Medication administration deviations: 6
Medication administration deviations: 9
Medication administration deviations: 3
Medication administration deviations: 3
Medication administration deviations: 1
Medication administration deviations: 19
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| M. Tess Pittman | Licensing Inspector | Contact person for questions regarding the inspection |
| Lanesha Allen | Current Inspector | Licensing inspector on-site during inspection |
Inspection Report
Monitoring
Census: 61
Deficiencies: 5
Jan 9, 2024
Visit Reason
The inspection was a monitoring visit conducted on January 9, 2024, following a self-reported incident received by VDSS Division of Licensing on December 1, 2023, regarding allegations in the area of Resident Care and Related Services.
Findings
The inspection found multiple violations related to resident care, including failure to update fall risk ratings after a fall, failure to ensure individualized service plans were signed, inadequate personal care provision, and medication administration errors.
Deficiencies (5)
| Description |
|---|
| Facility failed to ensure the fall risk rating was reviewed and updated after a fall. |
| Facility failed to ensure the individualized service plan was signed and dated by the resident or their legal representative. |
| Facility failed to ensure personal assistance and care were provided to meet resident needs. |
| Facility failed to ensure medications were administered within the correct time frame according to the dosing schedule. |
| Facility failed to ensure medications were administered in accordance with physician's instructions and medication aide standards. |
Report Facts
Residents present: 61
Resident records reviewed: 1
Staff interviews conducted: 2
Inspection Report
Renewal
Census: 63
Deficiencies: 18
Sep 26, 2023
Visit Reason
The inspection was a renewal inspection conducted on September 26 and 27, 2023, to assess compliance with applicable standards and laws for licensing renewal of the assisted living facility.
Findings
The inspection identified multiple violations including failure to ensure appropriate placement in the special care unit, lack of current first aid certification for staff, failure to post the current on-site person in charge, incomplete physical examinations prior to admission, missing sex offender screenings, incomplete assessments and individualized service plans, expired medications on medication carts, medication administration errors, failure to post required fire safety signage, incomplete emergency preparedness plan reviews, and untimely criminal history record reports for staff.
Deficiencies (18)
| Description |
|---|
| Failed to ensure determination and justification for placement in special care unit for resident with serious cognitive impairment. |
| Direct care staff member lacked current certification in first aid. |
| Failed to post the name of the current on-site person in charge in a conspicuous place. |
| Physical examinations not completed within 30 days preceding admission and did not indicate need for continuous licensed nursing care. |
| Failed to ascertain and document sex offender status prior to admission for several residents. |
| Failed to complete Uniform Assessment Instrument (UAI) prior to admission and for significant changes in condition. |
| Individualized service plans lacked expected outcomes and time frames. |
| Failed to review and update individualized service plans for significant changes in resident condition. |
| Expired medications observed on medication carts for multiple residents. |
| Medications not administered according to physician's instructions; medication given at incorrect time relative to meals. |
| Failed to document all medications administered on medication administration records (MAR), including controlled substances. |
| Medication administration records lacked diagnosis or indication for medications. |
| Failed to post 'No Smoking-Oxygen in Use' signs where oxygen is in use. |
| Failed to document rounds for residents unable to use signaling devices at required frequency. |
| Failed to comply with Virginia Statewide Fire Prevention Code; last fire inspection was over a year prior. |
| Failed to review and update emergency preparedness plan annually or as needed. |
| Failed to post complete fire and emergency evacuation drawings including areas of refuge, assembly areas, fire alarm boxes, and telephones. |
| Failed to obtain criminal history record reports on or prior to the 30th day of employment for multiple staff members. |
Report Facts
Residents present: 63
Resident records reviewed: 6
Staff records reviewed: 3
Expired medications: 12
Controlled substance discrepancy: 1
Staff without timely criminal history report: 7
Inspection Report
Monitoring
Census: 58
Deficiencies: 3
Mar 24, 2023
Visit Reason
The inspection was conducted as a monitoring visit focused on a self-reported incident received by VDSS Division of Licensing regarding allegations in personnel and resident care and related services.
Findings
The investigation supported the self-report of non-compliance with standards related to medication administration errors, documentation failures, and incomplete medication orders. Violations were issued based on these findings.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure medications were administered in accordance with the physician's or other prescriber's instructions, with multiple documented occasions of medications given more frequently than ordered. |
| Facility failed to document action taken in response to medication errors for multiple residents. |
| Facility failed to obtain detailed medication orders from physicians for PRN medications, lacking symptoms, exact dosages, time frames, and directions for persistent symptoms. |
Report Facts
Number of residents present: 58
Medication administration errors: 102
Resident records reviewed: 3
Staff interviews conducted: 1
Inspection Report
Monitoring
Census: 64
Deficiencies: 10
Jan 23, 2023
Visit Reason
The inspection was a monitoring visit focused on a self-reported incident 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 with standards or law, resulting in multiple violations related to private duty personnel documentation, communication methods, fall risk assessments, individualized service plans, notification procedures, and safety signage.
Deficiencies (10)
| Description |
|---|
| Facility failed to ensure private duty personnel qualifications, criminal history, tuberculosis documentation, and orientation/training were obtained and documented. |
| Facility failed to ensure a method of written communication to keep direct care staff informed of significant happenings or problems experienced by residents. |
| Facility failed to ensure a fall risk rating was completed after each fall. |
| Facility failed to complete a resident's Uniform Assessment Instrument (UAI) whenever there was a significant change in condition. |
| Facility failed to ensure the comprehensive Individualized Service Plan (ISP) included current identified needs and written description of services to address those needs. |
| Facility failed to ensure coordinated plan of care between assisted living facility and licensed hospice organization was included in the ISP. |
| Facility failed to ensure the ISP was signed and dated by the licensee, administrator, or designee and by the resident or legal representative. |
| Facility failed to document notification to next of kin, legal representative, or responsible party of resident falls or wandering incidents within 24 hours. |
| Facility failed to secure medical attention immediately and notify appropriate parties when a resident suffered a serious accident or medical condition. |
| Facility failed to post 'No Smoking-Oxygen in Use' signs and enforce smoking prohibition where oxygen is in use. |
Report Facts
Number of residents present: 64
Number of resident records reviewed: 1
Number of interviews conducted: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lanesha Allen | Current Inspector | Named as the licensing inspector conducting the inspection |
| M. Tess Pittman | Licensing Inspector | Contact person for questions regarding the inspection |
| Staff #1 | Staff member interviewed and acknowledged multiple deficiencies related to documentation and care | |
| Nurse Coordinator | Responsible for conducting in-service trainings and follow-ups related to documentation and care procedures | |
| Administrator | Responsible for conducting monthly audits to ensure compliance with assessment and service plan requirements |
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 1
Dec 16, 2022
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2022-12-09 regarding allegations related to staffing and supervision and resident care and related services.
Findings
The investigation supported some but not all allegations; non-compliance was found in the area of resident care and related services, specifically related to medication management failures including missed medication doses due to unavailability.
Complaint Details
The complaint was partially substantiated with non-compliance found in resident care and related services. Some allegations were not supported by the evidence.
Deficiencies (1)
| Description |
|---|
| Failure to implement the written plan for medication management, resulting in missed doses of prescribed medications for residents. |
Report Facts
Number of residents present: 54
Number of resident records reviewed: 3
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 16
Oct 27, 2022
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 10/24/2022 and 10/25/2022 regarding allegations in multiple areas including personnel, staffing and supervision, resident care, building and grounds, emergency preparedness, and additional requirements for facilities caring for adults with serious cognitive impairments.
Findings
The investigation supported some but not all allegations, identifying non-compliance in personnel, staffing and supervision, resident care, and additional requirements for facilities caring for adults with serious cognitive impairments. Multiple violations were cited including failure to ensure proper assessments prior to admission, inadequate staffing in the special care unit, failure to maintain required certifications, incomplete documentation, and failure to ensure proper communication and care plans.
Complaint Details
The complaint investigation was substantiated in part, with evidence supporting non-compliance in personnel, staffing and supervision, resident care, and additional requirements for facilities caring for adults with serious cognitive impairments.
Deficiencies (16)
| Description |
|---|
| Facility failed to ensure prior to admission to a safe, secure environment, residents were assessed by an independent clinical psychologist or physician for serious cognitive impairment. |
| Facility failed to ensure determination and justification of placement in the special care unit by licensee, administrator, or designee prior to admitting a resident with serious cognitive impairment. |
| Facility failed to ensure designated qualified staff person responsible for managing structured activities program is on site in the special care unit at least 20 hours a week. |
| Facility failed to ensure at least two direct care staff members are awake and on duty at all times in each special care unit except during night hours when 20 or fewer residents are present. |
| Facility failed to notify the regional licensing office within 24 hours of any major incident negatively affecting resident safety or welfare. |
| Facility failed to ensure tuberculosis risk assessments were completed and documented for staff prior to first day of work. |
| Facility failed to ensure direct care staff maintained current certification in first aid. |
| Facility failed to ensure written communication methods were used to keep direct care staff informed of significant resident happenings, complaints, incidents, or injuries. |
| Facility failed to ensure a fall risk rating was completed after a resident fall. |
| Facility failed to complete a resident's Uniform Assessment Instrument (UAI) prior to admission. |
| Facility failed to develop a preliminary plan of care addressing basic needs of the resident on or within seven days prior to admission. |
| Facility failed to ensure individualized service plans were reviewed and updated at least annually and as needed for significant changes. |
| Facility failed to ensure personal assistance and care were provided to meet resident needs, including documentation of bathing at least twice a week. |
| Facility failed to post the activity schedule for the current month in a conspicuous location and include all required information. |
| Facility failed to post dated menus for meals for the current week in an area conspicuous to residents. |
| Facility failed to ensure medication administration records (MAR) included diagnosis or specific indications for administering drugs or supplements. |
Report Facts
Residents present: 52
Resident records reviewed: 4
Staff records reviewed: 4
Hours required for qualified staff in special care unit: 20
Staff hire dates missing TB assessment: 3
Staff without current first aid certification: 2
Dates of documented showers for residents: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lanesha Allen | Licensing Inspector | Current inspector conducting the inspection. |
| M. Tess Pittman | Licensing Inspector | Contact person for questions regarding the inspection. |
Inspection Report
Monitoring
Census: 52
Deficiencies: 1
Oct 27, 2022
Visit Reason
The inspection was a monitoring visit conducted to review compliance with applicable standards and laws, including resident accommodations and background checks for assisted living facilities.
Findings
The inspection found non-compliance with the requirement to obtain a criminal history record report on or prior to the 30th day of employment for each employee, resulting in a documented violation.
Deficiencies (1)
| Description |
|---|
| Facility failed to obtain a criminal history record report on or prior to the 30th day of employment for each employee. |
Report Facts
Number of residents present: 52
Number of resident records reviewed: 4
Number of staff records reviewed: 10
Inspection Report
Monitoring
Deficiencies: 1
Oct 27, 2022
Visit Reason
The inspection was a monitoring visit conducted on October 27, 2022, and December 6, 2022, to review compliance with resident care and related services regulations following a self-reported incident received on October 2, 2022.
Findings
The investigation supported the self-report of non-compliance regarding the facility's failure to ensure that doors leading to the outside were not locked or secured from the inside in a manner that amounts to a lock. Violations were issued accordingly.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure doors leading to the outside were not locked from the inside or secured from the inside in any manner that amounts to a lock. |
Inspection Report
Renewal
Census: 45
Deficiencies: 9
Sep 13, 2022
Visit Reason
The inspection was a renewal inspection conducted on September 13 and 14, 2022, to assess compliance with applicable standards and laws for licensing renewal of the assisted living facility.
Findings
The inspection identified multiple violations including incomplete tuberculosis risk assessments for staff, lack of current first aid certification for direct care staff, failure to post a complete activity schedule, presence of expired medication, medication administration not following physician orders, missing diagnoses on medication administration records, lack of valid Do Not Resuscitate orders for several residents, failure to post complete emergency evacuation plans, and incomplete criminal history record reports for multiple staff members.
Deficiencies (9)
| Description |
|---|
| Failed to ensure tuberculosis risk assessments were completed and documented for staff prior to contact with residents. |
| Direct care staff did not maintain current certification in first aid. |
| Activity schedule for the current month was not posted in a conspicuous location and lacked required information. |
| Failed to prevent use of outdated medications; expired medication found in medication room. |
| Medications were administered not in accordance with physician's instructions, including administration despite parameters to hold. |
| Medication administration records did not include diagnosis or specific indications for medications. |
| Failed to ensure valid written Do Not Resuscitate orders were issued by attending physicians and included in individualized service plans. |
| Failed to post fire and emergency evacuation drawings including required details in conspicuous places on each floor. |
| Failed to obtain criminal history record reports on or prior to the 30th day of employment for multiple staff members. |
Report Facts
Number of residents present: 45
Number of resident records reviewed: 8
Number of staff records reviewed: 4
Number of staff without completed criminal history record report: 10
Inspection Report
Monitoring
Census: 39
Deficiencies: 1
Aug 3, 2022
Visit Reason
The inspection was a monitoring visit conducted on August 3, 2022, following a self-reported incident received on July 31, 2022, regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation supported the self-report of non-compliance with standards or law, resulting in violations issued. Specifically, the facility failed to implement established policies, procedures, and services, including failure to perform CPR on a resident found unresponsive despite no Do Not Resuscitate order being in place.
Deficiencies (1)
| Description |
|---|
| Facility failed to implement policies, procedures, and services established by the facility, including failure to perform CPR on a resident found unresponsive without a DNR order. |
Report Facts
Number of residents present: 39
Number of resident records reviewed: 1
Number of staff interviews conducted: 2
Inspection Report
Monitoring
Census: 38
Deficiencies: 4
Jul 22, 2022
Visit Reason
The inspection was a monitoring visit conducted to review compliance with administrative, staffing, resident care, building, emergency preparedness, and additional requirements for facilities caring for adults with serious cognitive impairments.
Findings
The inspection identified multiple violations related to admission procedures, safety measures for residents with cognitive impairments, tuberculosis risk assessments, and preliminary care planning. The facility failed to ensure proper documentation for placement in a special care unit, secure doors in memory care, timely tuberculosis screening, and signed preliminary plans of care.
Deficiencies (4)
| Description |
|---|
| Failed to ensure prior to admitting a resident with serious cognitive impairment that placement in the special care unit is appropriate. |
| Failed to ensure doors leading to unprotected areas were monitored or secured with appropriate devices in the safe, secure environment. |
| Failed to ensure a physical examination including tuberculosis risk assessment was completed within 30 days preceding admission. |
| Failed to ensure a preliminary plan of care was developed and signed by the resident or legal representative on or within seven days prior to admission. |
Report Facts
Number of residents present: 38
Number of resident records reviewed: 1
Number of staff interviews conducted: 4
Date of resident admission: May 17, 2022
Date of tuberculosis risk assessment: May 5, 2022
Date and time of resident missing incident: Jul 9, 2022
Inspection Report
Monitoring
Census: 38
Deficiencies: 9
Jun 27, 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 multiple violations related to resident placement documentation, staff records, tuberculosis risk assessments, staff certifications, resident physical examinations, medication orders, resident rights acknowledgments, DNR orders, and first aid kit contents.
Deficiencies (9)
| Description |
|---|
| Failed to ensure prior to admitting a resident with serious cognitive impairment due to dementia that placement in the special care unit is appropriate. |
| Failed to maintain personal and social data on staff including verification of receipt of current job description. |
| Failed to ensure staff submit tuberculosis risk assessment documentation prior to work. |
| Failed to ensure direct care staff maintain current certification in first aid. |
| Failed to ensure residents have completed physical examinations by an independent physician. |
| Failed to obtain written acknowledgment of receipt and review of resident rights and responsibilities. |
| Failed to ensure medication orders include all required elements including diagnosis or indication. |
| Failed to ensure valid written Do Not Resuscitate (DNR) orders are included in resident records and service plans. |
| Failed to ensure the building first aid kit contained all required items, specifically triangular bandages. |
Report Facts
Number of residents present: 38
Number of resident records reviewed: 7
Number of staff records reviewed: 4
Staff hire date: Apr 13, 2022
Staff hire date: May 19, 2022
Physical exam date: May 12, 2022
Resident ISP date: Jun 18, 2022
Physician admission order date: Apr 26, 2022
Resident emergency code status form date: Apr 19, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lanesha Allen | Licensing Inspector | Current inspector conducting the monitoring inspection. |
| M. Tess Pittman | Licensing Inspector | Contact person for questions regarding the inspection findings. |
| Staff #1 | Acknowledged multiple deficiencies including missing documentation for residents and staff. | |
| Staff #2 | Acknowledged missing triangular bandages in the first aid kit. | |
| Staff #5 | Staff member missing tuberculosis risk assessment documentation. | |
| Staff #6 | Direct care staff missing first aid certification and job description verification. | |
| Nurse Coordinator | Responsible for conducting audits and ensuring compliance with physical exams, medication orders, and DNR status. | |
| Administrator | Responsible for determining appropriate placement of residents with serious cognitive impairment. |
Inspection Report
Original Licensing
Deficiencies: 1
May 6, 2022
Visit Reason
The inspection was an initial licensing inspection conducted to determine compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection found non-compliance related to the first aid kits in the building and vehicle, which lacked required items as identified in the standard.
Deficiencies (1)
| Description |
|---|
| The building first aid kit did not include blankets, plastic bags, small flashlight and extra batteries, triangular bandages, tweezers, or a first aid instructional manual. The vehicle first aid kit did not include plastic bags, small flashlight and extra batteries, or triangular bandages. |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| M. Tess Pittman | Licensing Inspector | Contact person for questions regarding the inspection. |
| Lanesha Allen | Current Inspector | Inspector on-site during the inspection. |
| Divisional Director of Resident Services | Named in plan of correction for updating first aid kits. |
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