Inspection Report
Renewal
Census: 62
Deficiencies: 12
Aug 8, 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 identified multiple violations related to resident placement documentation, staff orientation and training, resident admission documentation, emergency preparedness, facility maintenance, and employee background checks. The facility was found non-compliant with several regulatory standards.
Deficiencies (12)
| Description |
|---|
| Failed to ensure prior to admitting a resident with serious cognitive impairment that placement in the special care unit was appropriate and documented. |
| Failed to perform six-month and annual reviews of appropriateness of continued residence in the special care unit. |
| Failed to ensure staff orientation and initial training occurred within the first seven working days of employment. |
| Failed to provide written assurance to the resident or legal representative that the facility has the appropriate license to meet care needs at admission. |
| Failed to provide a written agreement at or prior to the time of admission. |
| Failed to provide orientation for new residents and legal representatives upon admission with signed acknowledgement. |
| Failed to complete the Uniform Assessment Instrument prior to admission or annually. |
| Failed to annually review the rights and responsibilities of residents with each resident or their legal representative and staff. |
| Failed to maintain the interior and exterior of all buildings in good repair and free of rubbish. |
| Failed to develop a written emergency preparedness and response plan with documentation of contact with local emergency coordinator. |
| Failed to ensure the first aid kit contained all required items as identified in the standard. |
| Failed to ensure no employee worked in direct contact with residents without a completed background check. |
Report Facts
Number of residents present: 62
Number of resident records reviewed: 7
Number of resident interviews: 2
Number of staff interviews: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Darunda Flint | Licensing Inspector | Inspector conducting the inspection |
Inspection Report
Monitoring
Census: 62
Deficiencies: 1
Nov 25, 2024
Visit Reason
The inspection was a monitoring visit conducted on 11/25/2024 following a self-reported incident received on 11/20/2024 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 related to failure to provide supervision of resident schedules, care, and activities, including attention to specialized needs.
Deficiencies (1)
| Description |
|---|
| Facility failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs. |
Report Facts
Number of residents present: 62
Number of resident records reviewed: 1
Number of staff interviews conducted: 3
Inspection Report
Monitoring
Census: 64
Deficiencies: 0
Oct 9, 2024
Visit Reason
The inspection was a monitoring visit conducted as a follow-up on a self-reported incident received by VDSS Division of Licensing regarding allegations in Resident Care and Related Services.
Findings
The investigation found no evidence to support the self-report of non-compliance with standards or law. 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 staff records reviewed: 0
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 1
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 1
Sep 17, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-08-29 regarding allegations related to Resident Care and Related Services at the facility.
Findings
The investigation supported the allegations of non-compliance with regulations concerning timely notification of medical attention when residents suffer serious conditions. Specifically, the facility failed to notify the resident's physician and other required parties within 24 hours of critically low glucose lab results for two residents.
Complaint Details
The complaint was substantiated based on record review and interview, confirming the facility did not secure medical attention notification as required within 24 hours for residents with serious medical conditions.
Deficiencies (1)
| Description |
|---|
| Failure to notify the resident's physician and other required parties within 24 hours of critically low glucose lab results for Resident #1 and Resident #2. |
Report Facts
Number of residents present: 62
Number of resident records reviewed: 2
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: 4
Sep 17, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-09-05 regarding allegations in the areas of Resident Care and Related Services and Buildings and Grounds.
Findings
The investigation supported some of the allegations related to Resident Care and Related Services, resulting in a violation notice. Deficiencies included failure to regularly observe residents for changes in condition, inadequate housekeeping services, violation of resident rights regarding photo and video releases, and failure to implement nutritional interventions for significant weight loss.
Complaint Details
The complaint investigation was substantiated in part, with non-compliance found in Resident Care and Related Services. The complaint involved failure to observe and document resident condition changes, inadequate housekeeping, violation of resident photo release rights, and failure to address significant weight loss.
Deficiencies (4)
| Description |
|---|
| Facility failed to regularly observe each resident for changes in physical, mental, emotional, and social functioning, and failed to document corresponding actions. |
| Facility failed to ensure personal assistance and care, including housekeeping, were provided as necessary to meet resident needs. |
| Facility failed to ensure residents' rights regarding photo and audio/video release were respected, posting images of a resident who had denied permission. |
| Facility failed to implement interventions for significant weight loss, including weighing residents monthly and notifying attending physicians. |
Report Facts
Number of residents present: 62
Number of resident records reviewed: 1
Number of staff interviews conducted: 2
Number of resident interviews conducted: 1
Weight loss percentage: 5
Dates missing housekeeping documentation: 6
Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 0
Aug 27, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2024-08-16 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 and a copy is required to be posted on the facility premises.
Complaint Details
Complaint related to Resident Care and Related Services; allegations were not substantiated.
Report Facts
Number of residents present: 64
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: 2
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 4
Jul 18, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 07/18/2024 regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation supported the allegations of non-compliance with standards and violations were issued. Deficiencies included failure to obtain required staff certification documentation, failure to complete fall risk ratings after falls, delayed medical treatment documentation, and medication administration errors.
Complaint Details
The complaint investigation was substantiated with violations found related to Resident Care and Related Services.
Deficiencies (4)
| Description |
|---|
| Facility failed to obtain a copy of the certificate or documentation indicating staff met required qualifications. |
| Facility failed to ensure a fall risk rating was completed after a resident fall. |
| Facility failed to ensure timely medical attention and documentation after a resident sustained a skin tear. |
| Facility failed to administer medications in accordance with physician's instructions, including failure to notify provider and improper administration of Metoprolol. |
Report Facts
Residents present: 62
Resident records reviewed: 5
Staff records reviewed: 2
Staff interviews conducted: 3
Metoprolol held occasions: 22
Metoprolol improperly administered occasions: 3
Inspection Report
Renewal
Census: 62
Deficiencies: 13
Jul 16, 2024
Visit Reason
The inspection was a renewal visit conducted on July 16 and July 18, 2024, to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection identified multiple violations related to staff training, tuberculosis risk assessments, certification requirements, resident admission documentation, medication management, and building maintenance. The facility was found non-compliant in several areas and issued violation notices with plans of correction.
Deficiencies (13)
| Description |
|---|
| Direct care staff failed to complete at least 10 hours of training in cognitive impairment within four months of employment. |
| Direct care staff did not attend required annual training hours. |
| Staff and household members did not submit timely tuberculosis risk assessments prior to contact with residents. |
| Direct care staff lacked current certification in first aid. |
| Resident physical examinations lacked current tuberculosis risk assessments or follow-up documentation. |
| Facility failed to ascertain and document sex offender status prior to resident admission. |
| Resident admission agreements were not signed and dated at or prior to admission. |
| Expired medications were found in medication carts. |
| Medications, dietary supplements, or treatments were started, changed, or discontinued without valid physician orders. |
| Do Not Resuscitate (DNR) orders were missing or inconsistent with individualized service plans. |
| Interior and exterior building maintenance issues including missing baseboard trim and a missing window. |
| Employment of staff with criminal history record reports showing barrier crimes. |
| Criminal history record reports were not current within 90 days prior to employment. |
Report Facts
Number of residents present: 62
Number of resident records reviewed: 8
Number of staff records reviewed: 4
Number of resident interviews: 4
Number of staff interviews: 3
Expired medications observed: 10
Convictions of misdemeanor barrier crimes: 3
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 2
Jun 13, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-05-28 regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation supported the allegations of non-compliance with standards or law, resulting in violations issued. Specific deficiencies included failure to obtain written approval for placement of a resident with serious cognitive impairment and failure to assume general responsibility for residents' health and safety.
Complaint Details
Complaint related: Yes. The complaint was substantiated based on evidence gathered during the investigation.
Deficiencies (2)
| Description |
|---|
| Facility failed to obtain written approval for placement of Resident #1 with serious cognitive impairment in a safe, secure environment. |
| Facility failed to assume general responsibility for the health, safety, and well-being of residents, evidenced by Resident #1 hitting and punching other residents causing injury. |
Report Facts
Number of residents present: 62
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of resident interviews conducted: 3
Number of staff interviews conducted: 3
Inspection Report
Monitoring
Census: 62
Deficiencies: 4
Jun 13, 2024
Visit Reason
The inspection was a monitoring visit conducted on June 13, 2024, following a self-reported incident received on June 5, 2024, regarding allegations in the area of Resident Care and Related Services.
Findings
The inspection found multiple violations including failure to report suspected abuse, incomplete tuberculosis risk assessments for staff, lack of current first aid certification for direct care staff, and delays in completing physician-ordered medical procedures.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure all staff who are mandated reporters reported suspected abuse, neglect, or exploitation of residents. |
| Facility failed to ensure each staff person submitted a tuberculosis risk assessment prior to contact with residents. |
| Facility failed to ensure each direct care staff member maintained current certification in first aid. |
| Facility failed to ensure medical procedures ordered by a physician were provided according to instructions and documented timely. |
Report Facts
Number of residents present: 62
Number of resident records reviewed: 1
Number of staff records reviewed: 2
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 1
Staff hire date: Sep 27, 2023
Physician ordered labs date: May 17, 2024
Labs completion date: Jun 6, 2024
Labs results available date: Jun 13, 2024
Inspection Report
Monitoring
Census: 62
Deficiencies: 0
Apr 18, 2024
Visit Reason
The inspection was conducted as a monitoring visit following a self-reported incident received by VDSS Division of Licensing on 2024-03-27 regarding allegations in the areas of Personnel and Resident Care and Related Services.
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 and a copy is required to be posted on the facility premises.
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
Monitoring
Census: 61
Deficiencies: 2
Oct 11, 2023
Visit Reason
The inspection was a monitoring visit conducted on October 11, 2023, following two self-reported incidents received by VDSS regarding allegations in admission, resident care, and additional requirements for adults with serious cognitive impairments.
Findings
The investigation found some areas of non-compliance related to resident care and related services, including failure to report major incidents within 24 hours and inadequate supervision of residents, particularly concerning wandering and safety incidents.
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 provide supervision of resident schedules, care, and activities, including attention to specialized needs such as wandering from the premises. |
Report Facts
Residents present: 61
Self-reported incidents: 2
Interviews with residents: 2
Interviews with staff: 1
Plan of correction submission timeframe: 5
Review request timeframe: 15
Posting timeframe: 5
Incident date: Jul 21, 2023
Incident date: Sep 13, 2023
Staff education date: Oct 19, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| M. Tess Pittman | Licensing Inspector | Contact person for questions regarding the inspection |
| Darunda Flint | Current Inspector | Inspector on-site during the inspection |
Inspection Report
Renewal
Census: 56
Deficiencies: 9
Jul 10, 2023
Visit Reason
The inspection was a renewal visit to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection identified multiple violations including failure to maintain current first aid certification for direct care staff, incomplete mental health screenings prior to admission, missing discharge statements, failure to post current activity schedules and menus, expired medications in medication carts, medication administration timing errors, failure to follow physician medication orders, and inadequate documentation of resident rounds.
Deficiencies (9)
| Description |
|---|
| Facility failed to ensure each direct care staff member maintain current certification in first aid. |
| Facility failed to ensure a mental health screening was conducted prior to admission when indicated. |
| Facility failed to ensure a dated discharge statement signed by licensee or administrator was provided at discharge. |
| Facility failed to post the current month's schedule of activities in a conspicuous location. |
| Facility failed to post menus for meals and snacks for the current week in an area conspicuous to residents. |
| Facility failed to implement written plan for medication management including prevention of outdated medications and proper disposal. |
| Facility failed to ensure medications were administered within one hour before or after the standard dosing schedule. |
| Facility failed to ensure medications were administered in accordance with physician's or prescriber's instructions. |
| Facility failed to document rounds for residents with inability to use signaling device including name, date/time, and staff member. |
Report Facts
Number of residents present: 56
Number of resident records reviewed: 8
Number of staff records reviewed: 4
Number of medications not administered on time: 104
Number of expired medications observed: 16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Darunda Flint | Licensing Inspector | Current inspector conducting the inspection. |
| M. Tess Pittman | Licensing Inspector | Contact person for questions regarding the inspection. |
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 3
May 4, 2023
Visit Reason
The inspection was conducted in response to complaints received by the VDSS Division of Licensing on 04/19/2023 and 05/02/2023 regarding allegations in the areas of Administration and Administrative Services, Personnel, and Staffing and Supervision.
Findings
The investigation supported some but not all allegations, identifying non-compliance in Administration and Administrative Services and Personnel. Violations included failure to report major incidents within 24 hours, failure to report suspected abuse to Adult Protective Services, and failure to notify the resident's contact person or legal representative about abuse allegations.
Complaint Details
The complaint investigation was substantiated in part, with evidence supporting violations in Administration and Personnel. Allegations included Staff #4 punching Resident #1 on 4/27/23, failure to report incidents to licensing and Adult Protective Services, and failure to notify the resident's family.
Deficiencies (3)
| Description |
|---|
| Facility failed to report to the regional licensing office within 24 hours of any major incident negatively affecting residents. |
| Facility failed to ensure all mandated reporters reported suspected abuse, neglect, or exploitation of residents. |
| Facility failed to notify the resident's contact person or legal representative when a report was made relating to the resident. |
Report Facts
Number of residents present: 54
Number of resident records reviewed: 4
Number of interviews conducted: 4
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 4
Feb 14, 2023
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2023-02-02 regarding allegations in administration, admission, retention and discharge of residents, and resident care and related services.
Findings
The investigation supported some but not all allegations, identifying non-compliance in administration and resident care. Violations included failure to demonstrate proper administration oversight, confidentiality breaches in use of SafelyYou video for staff training, and medication labeling and administration errors.
Complaint Details
The complaint was substantiated in part, with violations found in administration and resident care areas. A violation notice was issued and the licensee was given opportunity to submit a plan of correction.
Deficiencies (4)
| Description |
|---|
| Administrator failed to demonstrate responsibility for general administration and management, including ensuring staff comply with residents' rights. |
| Facility failed to ensure all records are treated confidentially; SafelyYou video footage was used in general staff training without proper consent. |
| Facility failed to ensure medications include the prescription label or direction label attached. |
| Facility failed to ensure medications were administered according to physician's instructions; resident received incorrect dosage of Sertraline for a period. |
Report Facts
Number of residents present: 42
Number of resident records reviewed: 1
Number of staff interviews conducted: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| M. Tess Pittman | Licensing Inspector | Contact person for questions about the inspection |
| Darunda Flint | Licensing Inspector | Inspector on-site during the inspection |
| Health & Wellness Director | Responsible for corrective actions related to medication labeling and administration, and SafelyYou video confidentiality | |
| Director | Responsible for corrective actions related to resident rights and SafelyYou video use |
Inspection Report
Monitoring
Census: 55
Deficiencies: 0
Jan 5, 2023
Visit Reason
The inspection was conducted as a monitoring visit following a self-reported incident received by VDSS Division of Licensing regarding allegations in resident accommodations, buildings and grounds, and emergency preparedness.
Findings
The licensing inspector toured the facility and conducted interviews with residents and staff. The evidence gathered did not support the self-report of non-compliance with standards or law.
Inspection Report
Renewal
Census: 57
Deficiencies: 7
Jul 12, 2022
Visit Reason
The inspection was a renewal inspection conducted to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection identified multiple violations including failure to maintain current first aid certifications for direct care staff, incomplete uniform assessment instruments for private pay residents, failure to post current schedules and menus conspicuously, medication management deficiencies including missed dosages and incomplete medication orders, and inconsistencies in Do Not Resuscitate (DNR) orders.
Deficiencies (7)
| Description |
|---|
| Facility failed to ensure each direct care staff member maintain current certification in first aid. |
| Facility failed to ensure that the uniform assessment instrument is completed as required for private pay individuals. |
| Facility failed to ensure the current month's schedule was posted in a conspicuous location. |
| Facility failed to post the menus for meals and snacks for the current week in an area conspicuous to residents. |
| Facility failed to implement their written plan for medication management to avoid missed dosages. |
| Facility failed to ensure physician or other prescriber orders included all required information including diagnosis. |
| Facility failed to ensure a valid written Do Not Resuscitate (DNR) order was issued and included in the individualized service plan. |
Report Facts
Number of residents present: 57
Number of resident records reviewed: 8
Number of staff records reviewed: 4
Dates of missed medication administration: 11
Number of residents with incomplete medication diagnosis: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| M. Tess Pittman | Licensing Inspector | Contact person for questions about the VDSS Licensing Programs. |
| Darunda Flint | Licensing Inspector | Inspector who conducted the inspection on 7/12/2022. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Mar 31, 2022
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 03/24/2022 regarding allegations in the areas of administration, staffing and supervision, admission, retention and discharge of residents, and resident care and related services.
Findings
The investigation supported some, but not all, of the allegations. Non-compliance was found in administration and administrative services, admission, retention and discharge of residents, and resident care and related services. A violation notice was issued with opportunities for the licensee to submit a plan of correction.
Complaint Details
The complaint was substantiated in part; evidence supported non-compliance in administration, admission and retention, and resident care. A violation notice was issued and corrective plans were requested.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure any major incident negatively affecting or threatening resident safety was reported to the regional licensing office within 24 hours. |
| Facility failed to ensure that a fall risk rating was completed at least annually and/or after a fall. |
| Facility failed to ensure that personal assistance and care were provided to each resident as necessary to meet their needs, specifically bathing at least twice a week. |
Report Facts
Number of resident records reviewed: 10
Number of staff records reviewed: 3
Inspection Report
Renewal
Census: 47
Deficiencies: 4
Jul 20, 2021
Visit Reason
A renewal inspection was initiated on July 8, 2021 and concluded on July 21, 2021 to review compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection identified multiple violations including failure to ensure Individualized Service Plans (ISP) reflected residents' identified needs, permitting residents to keep medications in their rooms contrary to assessments, improper medication administration not following physician orders, and errors in criminal history record reports for staff.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure the Individualized Service Plan (ISP) included a description of the residents' identified needs. |
| A resident was permitted to keep medications in their room when the Uniform Assessment Instrument indicated the resident was not capable of self-administering medication. |
| Facility failed to ensure medications were administered in accordance with physician's instructions and standards of practice. |
| Operator failed to ensure that each criminal history record report was verified by matching the name to establish accuracy with another form of identification. |
Report Facts
Inspection dates: 4
Resident census: 47
Number of resident records reviewed: 3
Number of staff records reviewed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Darunda Flint | Inspector | Named as current inspector conducting the inspection |
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