Inspection Report
Renewal
Census: 56
Deficiencies: 0
Sep 19, 2025
Visit Reason
The inspection was conducted as a renewal inspection of the assisted living facility to assess compliance with applicable standards and regulations.
Findings
The inspection found no violations of applicable standards or laws. Residents were observed interacting appropriately with staff and engaging in activities, and medication storage was secure.
Report Facts
Number of resident records reviewed: 6
Number of staff records reviewed: 3
Inspection Report
Monitoring
Census: 58
Deficiencies: 2
Sep 3, 2024
Visit Reason
The inspection was a monitoring visit to assess compliance with applicable standards and laws at the assisted living facility.
Findings
The inspection found non-compliance with applicable standards related to staff tuberculosis risk assessments and first aid certification. Violations were documented and a violation notice was issued to the facility.
Deficiencies (2)
| Description |
|---|
| Facility did not ensure that staff required to be evaluated submitted results of a risk assessment documenting they are free of tuberculosis in a communicable form. |
| Each direct care staff member did not maintain current certification in first aid. |
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: 2
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 0
Nov 30, 2023
Visit Reason
The inspection was conducted in response to a complaint received on 2023-11-16 regarding allegations in the areas of staff and resident care and related services.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. No violation notice was issued.
Complaint Details
Complaint investigation triggered by allegations related to staff and resident care; the complaint was not substantiated.
Report Facts
Number of residents present: 33
Number of resident interviews: 6
Number of staff interviews: 4
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 0
Nov 30, 2023
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2023-11-23 regarding allegations in the area of staffing.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. No violation notice was issued.
Complaint Details
Complaint related to staffing allegations; investigation found no substantiation of non-compliance.
Report Facts
Number of residents present: 33
Number of resident interviews: 6
Number of staff interviews: 5
Inspection Report
Renewal
Census: 51
Deficiencies: 2
Oct 10, 2023
Visit Reason
The inspection was conducted as a renewal inspection of the assisted living facility to assess compliance with applicable standards and laws.
Findings
The inspection found non-compliance with applicable standards, including failure to ensure Do Not Resuscitate (DNR) orders were included in individualized service plans and the presence of a foul odor in the common/dining area. Violation notices were issued.
Deficiencies (2)
| Description |
|---|
| Failure to ensure that Do Not Resuscitate (DNR) orders are included in the individualized service plan (ISP). |
| Failure to ensure that the building is free from foul, stale and musty odors. |
Report Facts
Number of residents present: 51
Number of resident records reviewed: 6
Number of staff records reviewed: 3
Number of interviews conducted with residents: 5
Number of interviews conducted with staff: 5
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 0
Jun 23, 2023
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2023-03-07 regarding allegations in staffing and supervision.
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 and a copy is required to be posted on the facility premises.
Complaint Details
Complaint related to staffing and supervision allegations received on 2023-03-07; investigation did not substantiate the complaint.
Inspection Report
Renewal
Deficiencies: 4
Sep 20, 2022
Visit Reason
The inspection was conducted as a renewal inspection of the assisted living facility to assess compliance with applicable standards and laws.
Findings
The inspection found multiple violations including failure to ensure individualized service plans (ISP) were signed and dated by required parties, lack of personalization of care based on resident preferences, failure to implement timely interventions for nutritional problems, and missing documentation of Do Not Resuscitate (DNR) orders in ISPs.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure individualized service plans (ISP) are signed and dated by the licensee, administrator, or designee and by the resident or legal representative. |
| Facility failed to ensure personalization of care and services tailored to the resident's circumstances and preferences. |
| Facility failed to implement interventions as soon as a nutritional problem is suspected. |
| Facility failed to ensure that written Do Not Resuscitate Orders is included in the individualized service plan. |
Report Facts
Number of resident records reviewed: 6
Number of staff records reviewed: 3
Number of interviews conducted with residents: 3
Number of interviews conducted with staff: 3
Weight loss: 6
Weight measurements: 142
Weight measurements: 135
Weight measurements: 134.6
Weight measurements: 133
Inspection Report
Complaint Investigation
Deficiencies: 8
Jun 29, 2022
Visit Reason
The inspection was conducted in response to a complaint received on 2022-05-11 regarding allegations in the areas of admission, retention and discharge of residents and resident care and related services.
Findings
The investigation supported some, but not all, of the allegations and identified areas of non-compliance with standards or law. Multiple deficiencies were found related to resident safety, fall risk assessments, communication, care planning, supervision, and medication administration.
Complaint Details
The complaint was received by VDSS Division of Licensing on 2022-05-11 regarding allegations in admission, retention, discharge, and resident care. The investigation partially substantiated the complaint with some areas of non-compliance found.
Deficiencies (8)
| Description |
|---|
| Facility failed to ensure harmful materials or objects were inaccessible to residents except under staff supervision. |
| Facility failed to ensure a fall risk assessment was conducted after each fall. |
| Facility failed to document analysis of circumstances of falls and interventions to prevent or reduce risk of subsequent falls. |
| Facility failed to ensure written communication kept direct care staff informed of significant resident incidents. |
| Facility failed to ensure a resident's UAI was completed within 90 days prior to admission. |
| Facility failed to ensure a preliminary plan of care was developed within seven days prior to admission. |
| Facility failed to furnish care that fosters resident independence and enables fulfillment of potential. |
| Facility failed to ensure supervision of resident schedules, care, and activities including fall prevention. |
Report Facts
Inspection dates: 2
Resident falls with injuries: 3
Medication dosages not administered: 39
Plan of correction submission timeframe: 5
Plan of correction review timeframe: 15
Inspection Report
Monitoring
Census: 29
Deficiencies: 1
Apr 12, 2022
Visit Reason
An unannounced focused monitoring inspection was conducted to review compliance with applicable standards, including review of resident and staff records, observation of medication administration and meal time, and evaluation of the plan of correction from previously cited violations.
Findings
The inspection determined non-compliance with the requirement that all direct care staff attend at least 12 hours of annual training. Specifically, one staff member had only completed eight hours of training instead of the required twelve.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure that all direct care staff attend at least 12 hours of training annually. |
Report Facts
Annual training hours completed: 8
Residents in care: 29
Inspection Report
Complaint Investigation
Deficiencies: 5
Oct 12, 2021
Visit Reason
A non-mandated complaint investigation was initiated due to allegations regarding resident care, personnel, and medication administration.
Findings
The investigation found multiple violations including failure to implement an infection control program consistent with CDC and OSHA guidelines, failure to document aggressive resident behavior, failure to provide requested facility documentation, failure to obtain criminal record reports for all staff, and failure to provide required discharge statements.
Complaint Details
The complaint investigation was initiated on 10/12/2021 and concluded on 11/19/2021. The evidence gathered supported the allegations of non-compliance with standards or law.
Deficiencies (5)
| Description |
|---|
| Failed to implement an infection control program consistent with CDC and OSHA guidelines. |
| Failed to document observed aggressive behaviors of resident #2 in the Communication Log. |
| Failed to afford reasonable opportunity to inspect all facility records and interview relevant persons; did not provide requested documentation including resident discharge documentation, communication logs, end of shift reports, and medication administration exception report. |
| Failed to obtain an original criminal record report and sworn disclosure statement for all staff, including contracted staff. |
| Failed to provide a dated and signed discharge statement to resident or legal representative at time of discharge. |
Report Facts
Inspection Date: Oct 12, 2021
Inspection Report
Renewal
Census: 49
Deficiencies: 13
Oct 6, 2021
Visit Reason
An unannounced renewal inspection was initiated on 10/06/2021 and concluded on 10/22/2021 to assess compliance with licensing regulations and facility standards.
Findings
The inspection found multiple violations including failure to ensure cognitive impairment training was conducted by qualified personnel, environmental safety hazards, medication management issues, lack of proper facility administration and supervision, incomplete resident assessments and service plans, and improper use of PRN medications.
Deficiencies (13)
| Description |
|---|
| Facility failed to ensure cognitive impairment training was conducted by a licensed health care professional or approved person. |
| Facility failed to ensure special environmental precautions to eliminate hazards to residents, specifically allowing a cognitively impaired resident to access a hot food warmer area. |
| Facility failed to comply with medication management policy, including missed medication administrations due to no supply. |
| Facility failed to provide documentation of Disclosure Statement for inspection. |
| Facility failed to ensure qualified and licensed administration was in place during the inspection period. |
| Facility failed to provide required orientation and training within first seven working days for staff. |
| Facility failed to immediately notify the Virginia Board of Long-Term Care Administrators and licensing office of administrator resignation and replacement. |
| Facility failed to ensure that an administrator licensed by the Virginia Board of Long-Term Care Administrators did not manage multiple facilities exceeding combined licensed capacity and travel time limits. |
| Facility failed to ensure reassessments using the Uniform Assessment Instrument (UAI) were conducted appropriately for significant changes in resident condition. |
| Facility failed to ensure Individualized Service Plans (ISP) were reviewed and updated at least annually and as needed for significant changes. |
| Facility failed to ensure resident records contained signed or dated physician orders organized chronologically. |
| Facility failed to ensure Medication Administration Records (MARs) included documentation of medication errors or omissions. |
| Facility failed to ensure PRN medications were administered only under allowed conditions with proper authorization. |
Report Facts
Current census: 49
Missed medication days: 3
Missed medication days: 6
Combined licensed capacity: 148
Medication errors or omissions: 17
PRN medication administrations: 2
PRN medication administrations: 1
Administrator vacancy days: 37
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Coy Stevenson | Licensing Inspector | Current inspector conducting the inspection |
| Facility staff #1 | Reported not being a licensed health care provider; involved in unauthorized cognitive impairment training | |
| Facility staff #2 | Registered Nurse Coordinator | Failed to provide documentation of required orientation and training |
| Facility staff #3 | Received incomplete dementia training; involved in training documentation issue | |
| Facility staff #4 | Signed UAI for resident reassessment | |
| Facility staff #5 | Administrator | Administrator of record; also administrator of another facility; involved in resident reassessment |
Inspection Report
Renewal
Census: 44
Deficiencies: 5
Apr 6, 2021
Visit Reason
A renewal inspection was initiated on 04/06/2021 and concluded on 05/21/2021 to assess compliance with licensing regulations for the assisted living facility.
Findings
The inspection found multiple violations related to medication management, including failure to implement a written medication plan, improper administration and documentation of PRN medications, and failure to ensure physician orders met regulatory requirements. Registered medication aides were found to be administering medications outside their scope and without proper supervision.
Deficiencies (5)
| Description |
|---|
| Facility failed to implement a written plan for medication management, including timely refills and supervision of medication administration. |
| Physician or prescriber orders lacked required details such as date, route, and diagnosis for medication administration. |
| Medications were administered inconsistently with physician orders and standards, including inappropriate PRN medication administration and documentation. |
| Use of PRN medications was not properly authorized or documented, with registered medication aides administering without detailed physician orders. |
| Facility failed to prohibit use of chemical restraints, with overmedication of resident #2 documented. |
Report Facts
Census: 44
PRN medication administrations: 20
PRN medication administrations: 38
PRN medication administrations: 14
PRN medication administrations: 14
Medication administration errors: 7
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 4, 2021
Visit Reason
A complaint inspection was initiated to investigate allegations of non-compliance with standards or law at the assisted living facility.
Findings
The investigation was conducted remotely due to a state of emergency health pandemic. The evidence gathered did not support the allegations, and the complaint was found to be not valid.
Complaint Details
The complaint was investigated and found to be not valid based on the evidence gathered during the investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 20, 2019
Visit Reason
The inspection was conducted in response to a complaint alleging medical abuse and neglect at the facility.
Findings
The inspection found some inconsistencies in the facility's record keeping protocols but no evidence to substantiate the allegations of medical abuse and neglect. Technical assistance was offered to the facility's administrative staff regarding documentation.
Complaint Details
Complaint related to allegations of medical abuse and neglect; the allegations were not substantiated.
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