Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 3
Aug 13, 2025
Visit Reason
An unannounced complaint inspection was conducted on August 13 and August 22, 2025, following a complaint received by VDSS Division of Licensing on August 12, 2025, regarding allegations in resident care and related services and buildings and grounds.
Findings
The investigation supported the allegation of non-compliance with standards or law, resulting in violations issued. Deficiencies included failure to ensure the resident's individualized service plan included all assessed needs, improper storage of cleaning supplies, and failure to maintain a resident's room free from foul odors related to pet care.
Complaint Details
The complaint was substantiated. Allegations involved resident care and related services and buildings and grounds. Violations were issued based on evidence gathered during the investigation.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure the resident's individualized service plan included all assessed needs. |
| Facility failed to ensure cleaning supplies and other hazardous materials were stored in a locked area. |
| Facility failed to ensure a resident's room was free from foul, stale, and musty odors. |
Report Facts
Number of residents present: 58
Number of resident records reviewed: 1
Number of staff interviews conducted: 4
Number of resident interviews conducted: 1
Target Completion Date: Sep 23, 2025
Target Completion Date: Aug 22, 2025
Target Completion Date: Sep 1, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Willie Barnes | Licensing Inspector | Conducted the complaint inspection |
| Executive Director | Named in findings related to cleaning supplies storage and resident room odor issues | |
| Health & Wellness Director | Responsible for auditing and updating individualized service plans | |
| Health and Wellness Coordinator | Responsible for auditing and updating individualized service plans |
Inspection Report
Renewal
Census: 59
Deficiencies: 11
Aug 12, 2025
Visit Reason
An unannounced renewal inspection was conducted on August 12 and 13, 2025 to assess compliance with applicable standards and regulations for the assisted living facility license renewal.
Findings
The inspection identified multiple violations including failure to ensure proper blood glucose monitoring practices, failure to post the current on-site person in charge, incomplete individualized service plans (ISP), missing healthcare oversight reports, incomplete activity calendars, medication management issues, expired emergency supplies, and lack of documentation for resident emergency drills.
Deficiencies (11)
| Description |
|---|
| Facility failed to ensure blood glucose monitoring practice was conducted properly; glucometers were not labeled. |
| Facility failed to ensure the name of the current on-site person in charge was posted. |
| Facility failed to ensure the comprehensive individualized service plan (ISP) included all assessed needs. |
| Facility failed to ensure individualized service plan (ISP) was reviewed and updated to include all assessed needs. |
| Facility failed to ensure a health care oversight (HCO) report was provided to the licensing inspector. |
| Facility failed to ensure the activity calendar included all required information such as length and type of activity. |
| Facility failed to ensure the menu included a listing of snacks provided. |
| Facility failed to ensure it disposed of medication as required; discontinued medication remained on medication cart. |
| Facility failed to ensure medications ordered for PRN administration were available, properly labeled, and stored. |
| Facility failed to ensure the availability of a 96-hour supply of emergency food and drinking water; emergency water was expired. |
| Facility failed to ensure all staff currently on duty on each shift participated in resident emergency practice drills at least once every six months. |
Report Facts
Number of residents present: 59
Number of resident records reviewed: 6
Number of staff records reviewed: 4
Number of resident interviews conducted: 2
Number of staff interviews conducted: 9
Number of boxes of emergency water: 21
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 0
Feb 5, 2025
Visit Reason
An unannounced self-reported complaint inspection was conducted due to a complaint received on 2025-01-31 regarding allegations in the areas of buildings/grounds and infection control.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The licensing inspector completed a tour of the physical plant including buildings and grounds and conducted interviews with staff.
Complaint Details
Complaint received by VDSS Division of Licensing on 2025-01-31 regarding buildings/grounds and infection control. The investigation did not substantiate the allegations.
Report Facts
Number of residents present: 57
Number of staff interviews: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Willie Barnes | Licensing Inspector | Conducted the inspection and is the contact person for questions |
Inspection Report
Monitoring
Census: 57
Deficiencies: 6
Feb 5, 2025
Visit Reason
An unannounced on-site monitoring inspection was conducted on February 5, 2025 and April 9, 2025 following a self-reported complaint received on January 3, 2025 regarding allegations of resident abuse and negative treatment by staff.
Findings
The investigation supported the allegations of non-compliance related to resident abuse and other regulatory violations. Multiple deficiencies were identified including failure to ensure staff treated residents with dignity and respect, failure to have psychotropic treatment plans, incomplete physical examinations, outdated personal and social data, incomplete individualized service plans, and incomplete physician orders for medications.
Complaint Details
The visit was complaint-related based on a self-reported complaint alleging resident abuse and negative treatment by staff. The evidence gathered supported the allegations and violations were issued.
Deficiencies (6)
| Description |
|---|
| Facility failed to ensure staff was considerate and respectful of the rights, dignity, and sensitivities of a person who is aged, infirm, or disabled, including physical abuse by staff. |
| Facility failed to ensure it did not admit or retain individuals with prohibitive conditions per Code of Virginia due to lack of psychotropic treatment plan for prescribed medication. |
| Facility failed to ensure physical examination within 30 days preceding admission contained required information. |
| Facility failed to ensure resident's personal and social data document was kept updated, including allergy and DNR status discrepancies. |
| Facility failed to ensure resident's individualized service plan included all assessed needs, with discrepancies between assessment instruments and ISP. |
| Facility failed to ensure physician or prescriber orders included all required information such as diagnosis or specific indications for medications. |
Report Facts
Number of residents present: 57
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of interviews with residents: 1
Number of interviews with staff: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Willie Barnes | Licensing Inspector | Conducted the inspection and investigation |
| Executive Director | Responsible person who notified agencies and cooperated with investigation; named in plan of correction for abuse incident | |
| Health & Wellness Director | Responsible person for plans of correction related to psychotropic treatment plans, physical exams, personal data, ISP, and medication orders | |
| Health & Wellness Coordinator | Responsible person for plans of correction related to psychotropic treatment plans, physical exams, personal data, ISP, and medication orders |
Inspection Report
Renewal
Deficiencies: 18
Sep 11, 2024
Visit Reason
An on-site Renewal Inspection was conducted on September 11, 13, and 16, 2024, to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection found multiple areas of non-compliance including failure to maintain required staff tuberculosis screening documentation, outdated first aid/CPR certification listings, incomplete resident interviews and individualized service plans, missing psychotropic treatment plans, incomplete fall risk assessments, missing personal and social data in resident records, medication order deficiencies, unavailable PRN medications, and incomplete emergency preparedness documentation.
Deficiencies (18)
| Description |
|---|
| Facility failed to ensure staff submitted tuberculosis risk assessment documentation prior to first day of work. |
| Facility failed to maintain an up-to-date listing of staff certified in first aid or CPR. |
| Facility failed to document interviews between administrator/designee and residents/legal representatives. |
| Facility admitted or retained individuals with prohibitive conditions or care needs without required psychotropic treatment plans. |
| Facility failed to document fall risk assessments for residents, including post-fall assessments. |
| Facility failed to include personal and social data in resident records. |
| Facility failed to obtain and document resident orientation acknowledgements. |
| Facility failed to complete individualized service plans for residents prior to and following admission. |
| Facility failed to ensure individualized service plans included all assessed needs and updates. |
| Facility failed to ensure annual review of residents' rights and responsibilities was documented. |
| Facility failed to ensure residents' prescription medications and supplements were filled and refilled timely to avoid missed dosages. |
| Facility failed to ensure physician orders included all required information such as diagnosis or indication. |
| Facility failed to ensure medication administration records included all required information. |
| Facility failed to ensure PRN medication orders included symptoms, exact dosage, time frames, and directions. |
| Facility failed to ensure PRN medications were available, properly labeled, and stored. |
| Facility failed to document semi-annual review of emergency preparedness and response plan. |
| Facility failed to ensure fire and emergency evacuation drills included all required information such as weather conditions. |
| Facility failed to ensure all staff participated in resident emergency practice exercises every six months. |
Report Facts
Inspection dates: 3
Expired CPR cards: 3
Medication orders missing diagnosis: 6
Fall risk assessments missing: 3
Fire drills missing weather info: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Willie Barnes | Licensing Inspector | Conducted the inspection |
| Staff #1 | Interviewed and acknowledged multiple deficiencies including missing TB documentation, psychotropic treatment plans, fall risk assessments, medication order issues, and emergency preparedness | |
| Staff #2 | Interviewed and acknowledged deficiencies related to resident records, fall risk assessments, medication orders, and emergency preparedness | |
| Staff #4 | Observed medication pass and acknowledged PRN medication order deficiencies | |
| Staff #5 | Acknowledged outdated First Aid/CPR listing | |
| Staff #7 | Acknowledged outdated First Aid/CPR listing and updated it |
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 7
Jul 23, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-07-14 regarding allegations in the area of resident care and related services at the assisted living facility.
Findings
The investigation found multiple violations including failure to document fall analyses and interventions, incomplete individualized service plans not reflecting assessed needs, failure to regularly observe residents for changes in condition, medication administration issues including unavailable medications and incomplete physician orders, and lack of documentation of physician contact after hospitalizations.
Complaint Details
The complaint was substantiated. Evidence included observed bruising on resident's upper chest and neck area, lack of documentation of falls and bruising, and multiple record and policy deficiencies related to resident care and medication management.
Deficiencies (7)
| Description |
|---|
| Facility failed to document analysis of fall circumstances and interventions to prevent subsequent falls. |
| Facility failed to ensure resident's individualized service plan reflected assessed needs. |
| Facility failed to regularly observe each resident for changes in physical, mental, emotional, and social functioning. |
| Facility failed to ensure prescription medications and supplements were filled and refilled timely to avoid missed dosages. |
| Facility failed to ensure physician orders included all required information such as diagnosis, condition, or specific indications. |
| Facility failed to obtain new orders for medications and treatments upon resident's return from hospital. |
| Medication administration records did not include all required information. |
Report Facts
Number of residents present: 54
Number of resident records reviewed: 1
Number of staff interviews conducted: 11
Number of resident interviews conducted: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Willie Barnes | Licensing Inspector | Current inspector conducting the complaint investigation |
| Staff #1 | Interviewed staff involved in documentation and incident reporting | |
| Staff #2 | Interviewed staff involved in resident care and documentation | |
| Staff #6 | Interviewed staff regarding resident behavior and documentation | |
| Staff #11 | Interviewed staff regarding resident falls and observations |
Inspection Report
Renewal
Census: 61
Deficiencies: 19
Sep 25, 2023
Visit Reason
An on-site renewal inspection was conducted to assess compliance with applicable standards and laws, including a tour, medication pass observation, meal observation, staff and resident interviews, and record reviews.
Findings
The inspection found multiple violations of regulatory standards including failure to perform required resident reviews, unsafe materials accessible to residents, infection control lapses during medication administration, failure to report major incidents timely, incomplete staff orientation, inadequate training for private duty personnel, expired certifications, incomplete psychotropic treatment plans, incomplete individualized service plans, medication administration record deficiencies, unavailable PRN medications, improper hot water temperature, malfunctioning signaling devices, outdated fire inspection, expired first aid kit supplies, and insufficient emergency food and water supplies.
Deficiencies (19)
| Description |
|---|
| Failed to ensure six-month and annual review of appropriateness of resident placement in special care unit. |
| Failed to ensure harmful materials were inaccessible to residents except under staff supervision. |
| Failed to implement infection control policy during medication pass observation. |
| Failed to report major incidents to licensing office within 24 hours. |
| Failed to ensure orientation training included all required information. |
| Failed to provide orientation and training to private duty personnel from licensed home care organizations. |
| Failed to ensure direct care staff maintained current first aid certification. |
| Failed to ensure psychotropic treatment plans were completed for medications. |
| Failed to ensure individualized service plans included all assessed needs. |
| Failed to ensure hospice care services were included in individualized service plans. |
| Failed to ensure individualized service plans were reviewed and updated at least annually and as needed. |
| Failed to ensure health care service needs of residents were met. |
| Failed to ensure medication administration record included all required information. |
| Failed to ensure PRN medications were available, properly labeled, and stored. |
| Failed to ensure hot water temperature was maintained within required range. |
| Failed to ensure signaling device permitted staff to determine origin of signal and was audible and visible. |
| Failed to ensure compliance with Virginia Statewide Fire Prevention Code by annual inspection. |
| Failed to ensure first aid kits contained all required items and were not expired. |
| Failed to ensure availability of 96-hour supply of emergency food and drinking water with at least 48 hours on site. |
Report Facts
Facility census: 61
Inspection dates: Inspection conducted on 2023-09-25 and 2023-10-05
Incident report submission dates: Incident reports submitted on 2023-09-30 and 2023-10-02
Fire inspection date: Previous fire inspection dated 2022-05-03
Water temperature: 122
Inspection Report
Complaint Investigation
Deficiencies: 2
Jul 17, 2023
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received on 2023-06-26 regarding allegations related to resident care and medication administration.
Findings
The investigation found some substantiated areas of non-compliance, including failure to report a major incident within 24 hours and failure to administer medications according to physician instructions. A violation notice was issued and plans of correction were required.
Complaint Details
The complaint was substantiated in part; evidence supported some but not all allegations related to medication errors and resident care.
Deficiencies (2)
| Description |
|---|
| Facility failed to report the regional licensing office within 24 hours any major incident that negatively affected or threatened the life, health, or safety of a resident. |
| Facility failed to ensure medications were administered in accordance with physician's instructions and standards of practice. |
Report Facts
Number of resident records reviewed: 1
Incident reporting timeframe: 24
Medication administration error date: Jun 24, 2023
Plan of correction target completion date: Jul 28, 2023
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 2
Jun 20, 2023
Visit Reason
The inspection was conducted in response to a complaint received on 2023-05-18 regarding allegations related to resident care and medication administration at the facility.
Findings
The investigation found non-compliance with regulations including failure to report a major incident within 24 hours and failure to administer medications as prescribed to 41 residents due to medication unavailability. Violations were issued based on these findings.
Complaint Details
The complaint was substantiated. The evidence gathered supported the allegation of non-compliance with standards or law related to medication administration and reporting incidents.
Deficiencies (2)
| Description |
|---|
| Failure to report the regional licensing office within 24 hours any major incident that negatively affected or threatened the life, health, or safety of any resident. |
| Failure to ensure medication was administered in accordance with physician's instructions and standards of practice, resulting in 41 residents not receiving prescribed medications. |
Report Facts
Residents not receiving medications: 41
Residents present at inspection: 61
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 2
Jun 20, 2023
Visit Reason
The inspection was conducted as a complaint investigation following an online complaint received on 2023-05-16 regarding allegations related to resident care, medication, and staff training/knowledge.
Findings
The investigation supported some but not all allegations, identifying areas of non-compliance with standards related to individualized service plans (ISP) not including all assessed needs or being updated to reflect significant changes. A violation notice was issued, and the licensee did not provide a plan of correction by the due date.
Complaint Details
Complaint related: Yes. The complaint was partially substantiated with some areas of non-compliance found. A violation notice was issued. The licensee did not provide a plan of correction by the due date.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure the resident's comprehensive individualized service plan (ISP) included all assessed needs, including walking, wheeling, physical therapy, occupational therapy, psychiatric services, and companion services. |
| Facility failed to ensure the resident's individualized service plan (ISP) was updated to address significant change of a resident, including mechanical device needs, oxygen use, and psychiatric services. |
Report Facts
Number of residents present: 61
Number of resident records reviewed: 2
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 3
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 6
May 15, 2023
Visit Reason
A joint complaint inspection was conducted following a complaint received on 2023-05-09 regarding allegations in resident care and medication administration.
Findings
The investigation supported allegations of non-compliance including failure to complete annual TB risk assessments, incomplete uniform assessment instruments, incomplete individualized service plans, and failure to administer medications as prescribed, resulting in resident hospital admission.
Complaint Details
Complaint related inspection triggered by allegations received on 2023-05-09. The evidence supported the allegations of non-compliance with medication administration and other standards.
Deficiencies (6)
| Description |
|---|
| Facility failed to ensure an annual risk assessment for tuberculosis was completed for a resident. |
| Facility failed to ensure uniform assessment instrument for private pay individual was completed as required. |
| Facility failed to ensure comprehensive individualized service plan included all assessed needs. |
| Facility failed to ensure individualized service plan was signed and dated by required parties. |
| Facility failed to ensure individualized service plan included all updated and/or significant changes. |
| Facility failed to ensure medications were administered in accordance with physician's instructions and standards of practice. |
Report Facts
Residents present: 59
Resident records reviewed: 6
Staff interviews conducted: 4
Medications not administered: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Willie Barnes | Licensing Inspector | Inspector conducting the complaint inspection |
| Staff #1 | Interviewed staff confirming medication administration failures | |
| Staff #2 | Interviewed staff confirming medication administration failures and medication availability issues |
Inspection Report
Monitoring
Census: 61
Deficiencies: 3
May 1, 2023
Visit Reason
An on-site monitoring inspection following IPOC was conducted to review resident records, medication pass, and repeat violations related to individualized service plans and medication administration.
Findings
The inspection found non-compliance with individualized service plans (ISP) not fully reflecting assessed resident needs and medication administration not consistently within the prescribed dosing schedule. Violations were documented and a plan of correction was requested.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure the individualized service plan (ISP) included all assessed needs for two of three resident records. |
| Facility failed to ensure the individualized service plan (ISP) was reviewed and updated at least once every 12 months and as needed for a significant change of a resident's condition for one of three records reviewed. |
| 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. |
Report Facts
Residents present: 61
Inspection dates: 3
Medications scheduled for 9:00 a.m.: 15
Medications scheduled for 8:00 a.m.: 2
Medications scheduled for 9:00 a.m.: 5
Medications scheduled for 9:00 a.m.: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Willie Barnes | Licensing Inspector | Named as current inspector conducting the inspection |
| Health & Wellness Director | Responsible for reviewing medications and monitoring medication variance audits | |
| Health & Wellness Coordinator | Responsible for reviewing medications and monitoring medication variance audits | |
| Exec. Dir. | Executive Director | Responsible for reviewing and approving assessments and service plans |
Inspection Report
Renewal
Census: 60
Deficiencies: 8
Nov 30, 2022
Visit Reason
An unannounced renewal inspection was conducted to assess compliance with applicable standards and laws for the facility license renewal.
Findings
The inspection identified multiple violations including failure to comply with criminal record check policies, incomplete and unsigned individualized service plans, outdated resident social data, improper medication management and disposal, and missing diagnosis information on medication orders and administration records.
Deficiencies (8)
| Description |
|---|
| Facility failed to ensure compliance with policy regarding criminal record checks for new employees. |
| Resident's personal and social information in records was not kept current, including missing allergy information. |
| Individualized service plans (ISP) did not include all assessed needs for multiple residents. |
| ISPs were not signed and dated by required parties including residents or legal representatives. |
| ISPs were not reviewed and updated at least annually or as needed for significant changes in condition. |
| Facility failed to implement medication management plan for proper disposal of medications, including accumulation of discontinued medications. |
| Physician orders and medication administration records lacked required diagnosis or condition information for medications. |
| Medications ordered for PRN administration were not available, properly labeled, or properly stored at the facility. |
Report Facts
Inspection dates: 6
Census: 60
Medication packets/containers counted: 50
Residents with ISP deficiencies: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Willie Barnes | Licensing Inspector | Inspector conducting the renewal inspection |
Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 5
Oct 4, 2022
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received by VDSS Division of Licensing on 2022-09-27 regarding allegations in the area of resident care at Bickford of Virginia Beach.
Findings
The investigation did not substantiate the complaint allegations of non-compliance; however, violations unrelated to the complaint were identified during the inspection. These included failure to ensure annual reassessment using the uniform assessment instrument (UAI), incomplete individualized service plans (ISP), lack of communication and coordination with hospice services, missing no-smoking oxygen signs, and improper use of bed rails without physician orders.
Complaint Details
Complaint investigation was conducted based on a complaint received on 2022-09-27 regarding resident care. The evidence gathered did not support the allegations of non-compliance with standards or law.
Deficiencies (5)
| Description |
|---|
| Failure to ensure an annual reassessment and reassessment due to significant change in resident's condition using the uniform assessment instrument (UAI). |
| Failure to ensure the individualized service plan (ISP) included all assessed needs such as wound care and therapy services. |
| Failure to ensure communication and coordination between the assisted living facility and licensed hospice organization, with hospice services not included in the ISP. |
| Failure to post 'No-Smoking-Oxygen in Use' sign on resident's door where oxygen was in use. |
| Failure to ensure restraints (bed rails) were used only with a physician's written order specifying conditions, circumstances, and duration. |
Report Facts
Number of residents present: 64
Number of resident records reviewed: 1
Number of staff interviews conducted: 6
Number of resident interviews conducted: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Willie Barnes | Licensing Inspector | Named as the current inspector conducting the complaint investigation. |
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 1
Oct 4, 2022
Visit Reason
An unannounced complaint inspection was conducted due to a complaint received on 2022-09-13 regarding allegations in resident care.
Findings
The investigation did not support the allegation of neglect or non-compliance related to the complaint. However, a violation unrelated to the complaint was identified regarding failure to ensure an annual reassessment using the uniform assessment instrument (UAI).
Complaint Details
Complaint was received by VDSS Division of Licensing on 2022-09-13 regarding allegations in resident care. The evidence gathered did not support the allegation of neglect or non-compliance with standards or law.
Deficiencies (1)
| Description |
|---|
| Failure to ensure an annual reassessment and reassessment due to a significant change in the resident's condition using the uniform assessment instrument (UAI). |
Report Facts
Number of residents present: 63
Number of resident records reviewed: 1
Number of staff interviews conducted: 4
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 3
Oct 4, 2022
Visit Reason
An unannounced complaint inspection was conducted due to a complaint received on 2022-09-29 regarding allegations in resident care/abuse at the facility.
Findings
The investigation did not substantiate the complaint of resident care/abuse non-compliance. However, violations unrelated to the complaint were identified during the inspection and cited in the violation notice.
Complaint Details
Complaint was received by VDSS Division of Licensing on 2022-09-29 regarding allegations in resident care/abuse. The evidence gathered did not support the complaint of non-compliance with standards or law.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure an annual review of the appropriateness of each resident's continued residence in the special care unit was conducted. |
| Facility failed to ensure the individualized service plan (ISP) included all assessed needs, including allergies, hearing loss, and assistance needs. |
| Facility failed to ensure health care services needs of a resident were met, specifically lack of documentation of speech therapy evaluation and treatment. |
Report Facts
Number of residents present: 63
Number of resident records reviewed: 2
Number of staff records reviewed: 0
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 4
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 9
Sep 8, 2022
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2022-08-25 regarding allegations in the area of resident care and related services at the assisted living facility.
Findings
The investigation supported allegations of non-compliance with standards and laws, resulting in violations issued. Deficiencies were found in areas including admission and retention of residents, risk assessments, fall risk documentation, notification of rate increases, individualized service plans, catheter care, honoring food preferences, medication administration records, and restraint usage.
Complaint Details
The complaint investigation was substantiated with violations issued. The complaint involved allegations related to resident care and related services, including billing notification, individualized service plans, catheter care, and other care deficiencies.
Deficiencies (9)
| Description |
|---|
| Failed to ensure no admission or retention of individuals with prohibited conditions or care needs; missing psychotropic treatment plan and catheter care not completed. |
| Failed to ensure annual tuberculosis risk assessments were completed for residents. |
| Failed to ensure a fall risk rating was completed after a resident's fall. |
| Failed to provide advanced notice of intent to increase charges to residents or legal representatives. |
| Failed to ensure individualized service plans included all assessed needs for residents. |
| Failed to ensure personal assistance and care needs were met, specifically catheter care and staff training on catheter care. |
| Failed to honor the food preferences of a resident due to menu changes not communicated. |
| Failed to ensure medication administration records included all required information such as diagnosis or indications for medications. |
| Failed to ensure proper documentation and physician orders for use of a restraint (U-bar) on a resident's bed. |
Report Facts
Inspection dates: 5
Residents present: 65
Resident records reviewed: 4
Staff records reviewed: 6
Resident interviews: 4
Staff interviews: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Willie Barnes | Licensing Inspector | Named as the current inspector conducting the complaint investigation |
| Staff #1 | Interviewed staff member acknowledged missing documentation and inability to provide certain records related to medication, billing, and catheter care | |
| Staff #3 | Staff member acknowledged resident food preferences were not honored and participated in meal plan corrections | |
| KM CRD LEC DIR | Persons responsible for meal preference plan of correction | |
| NCC ACC DIR | Persons responsible for multiple plans of correction including medication audits, catheter care training, fall risk assessments, and documentation compliance | |
| DIR ADMIN ASST | Person responsible for billing notification plan of correction |
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 18
Aug 18, 2022
Visit Reason
Complaint-related on-site renewal inspection conducted over multiple days to assess compliance with regulations including personnel, staffing, resident care, emergency preparedness, and criminal history record reports.
Findings
The inspection found multiple violations including unsafe materials left unsupervised on the secure unit, expired facility license posting, incomplete documentation for private duty personnel, missing tuberculosis risk assessments, outdated CPR/first aid certifications, failure to post current on-site person in charge, incomplete annual reassessments and individualized service plans, medication storage and administration issues, missing emergency telephone postings, and lack of criminal history records for private duty staff.
Complaint Details
Inspection was complaint-related as stated in the report. Substantiation status is not explicitly stated.
Deficiencies (18)
| Description |
|---|
| Facility failed to ensure ordinary materials or objects harmful to residents were inaccessible on the safe, secure unit without supervision. |
| Facility failed to post current license; expired license was displayed. |
| Facility failed to obtain and document required information and orientation for private duty personnel. |
| Facility failed to ensure tuberculosis risk assessments were completed for staff prior to work. |
| Facility failed to maintain an up-to-date listing of staff certified in first aid and CPR. |
| Facility failed to post the name of the current on-site person in charge. |
| Facility failed to ensure annual reassessments using the uniformed assessment instrument (UAI) were completed for residents. |
| Facility failed to ensure individualized service plans included all assessed needs for residents. |
| Facility failed to ensure individualized service plans were signed and dated by residents or legal representatives. |
| Facility failed to ensure health care service needs of residents were met, including speech therapy services. |
| Facility failed to ensure annual review of residents' rights and responsibilities was documented. |
| Facility failed to document approximate time needed for meals for residents dependent on feeding assistance. |
| Facility failed to store medications consistent with current standards of practice; medications were unsecured on the safe, secure unit. |
| Facility failed to ensure medications remained in pharmacy-issued containers with prescription labels until administration. |
| Facility failed to ensure medications orders had exact dosages documented. |
| Facility failed to ensure PRN medications were available, properly labeled, and stored. |
| Facility failed to post emergency telephone numbers for poison control near telephones. |
| Facility failed to ensure private duty personnel had original criminal history record reports. |
Report Facts
Inspection days: 4
Facility census: 62
Expired license date: May 11, 2022
CPR/First Aid certification expiration: Jun 9, 2022
CPR/First Aid certification expiration: Jan 1, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Willie Barnes | Licensing Inspector | Named as current inspector conducting the inspection |
| Staff #1 | Acknowledged multiple deficiencies including license posting, private duty personnel documentation, posting of person in charge, and medication issues | |
| Staff #3 | Medication staff involved in medication storage and administration deficiencies | |
| Staff #4 | Acknowledged outdated CPR/First Aid listing and medication storage issues | |
| Maintenance Coordinator | Responsible for putting away carpet drying equipment on safe, secure unit | |
| Director/Admin Assistant | Responsible for license posting and other corrective actions | |
| NCC/ACC/Divisional Nurse | Responsible for nursing and medication corrective actions |
Inspection Report
Renewal
Census: 61
Deficiencies: 16
Apr 7, 2022
Visit Reason
The inspection was a renewal inspection conducted on-site by two inspectors from the Peninsula Licensing Office to assess compliance with applicable standards and laws for license renewal.
Findings
The inspection found multiple areas of non-compliance including failures in resident reassessment documentation, staff training requirements, infection control practices, documentation of resident orientation, uniform assessment instrument (UAI) completion and signing, individualized service plan (ISP) completeness and updates, medication administration records, and health care service documentation.
Deficiencies (16)
| Description |
|---|
| Failure to perform reassessment of appropriateness of continued placement in the unit after resident condition change. |
| Direct care staff did not complete required 10 hours of cognitive impairment training within 4 months of hire. |
| Failure to follow infection control program; unlabeled glucose equipment during medication pass. |
| Failure to ensure required infection control and prevention training hours for staff. |
| Failure to submit tuberculosis risk assessment documentation within required timeframe. |
| Staff written schedules lacked required information including full names, job classifications, and indication of person in charge. |
| Resident personal and social information in records not kept current, including inconsistent code status documentation. |
| Failure to provide orientation for new residents and their legal representatives upon admission. |
| Failure to complete face-to-face assessment using uniform assessment instrument (UAI) prior to admission for some residents. |
| Failure to perform annual reassessment using UAI to determine continued placement appropriateness. |
| Failure to ensure UAI compliance with signature requirements by administrator or designee. |
| Individualized service plans (ISP) did not include all assessed needs for multiple residents. |
| Individualized service plans (ISP) were not reviewed and updated at least every 12 months or as needed for significant changes. |
| Failure to meet health care service needs including lack of documentation of therapy evaluations and services. |
| Individualized service plan did not indicate approximate amount of time needed for meals for residents dependent on feeding. |
| Medication administration record (MAR) did not include required diagnosis, condition, or specific indications for medications. |
Report Facts
Inspection dates: 4
Facility census: 61
Staff training hours: 10
Staff training hours documented: 3
Staff training hours documented: 9.25
Target completion dates: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Willie Barnes | Licensing Inspector | Named as current inspector conducting the inspection |
Inspection Report
Complaint Investigation
Deficiencies: 8
Feb 7, 2022
Visit Reason
An unannounced joint complaint inspection was conducted on 2-7-22 regarding allegations of resident care issues including pressure ulcers, bruising, compression fracture, and severe malnutrition.
Findings
The inspection found multiple deficiencies including failure to report major incidents within 24 hours, failure to admit or retain individuals with prohibited conditions, incomplete individualized service plans, failure to prevent clinically avoidable complications such as malnutrition, failure to keep resident records current, and failure to implement interventions for suspected nutritional problems.
Complaint Details
The complaint was substantiated as valid based on staff interviews and record reviews indicating issues with resident care including pressure ulcers, fractures, and malnutrition.
Deficiencies (8)
| Description |
|---|
| Facility failed to report to the regional licensing office within 24 hours any major incident negatively affecting or threatening resident safety. |
| Facility failed to ensure it did not admit or retain individuals with conditions or care needs prohibited by regulation. |
| Individualized service plan (ISP) did not include all assessed needs. |
| ISP was not updated as needed for significant changes in resident condition. |
| Facility failed to provide services to prevent clinically avoidable complications such as malnutrition. |
| Facility failed to ensure resident records were kept current, including accurate code status documentation. |
| Facility failed to implement interventions as soon as a nutritional problem was suspected. |
| Facility failed to provide medical procedures or treatments ordered by a physician according to instructions and document them. |
Report Facts
Inspection dates: 3
Resident weight loss: 35.7
Resident weight measurements: 83.61
Inspection Report
Monitoring
Deficiencies: 5
Oct 1, 2021
Visit Reason
A non-mandated monitoring inspection was initiated on July 22, 2021 and concluded on November 1, 2021, including a joint on-site observation on October 1, 2021, to assess compliance with assisted living facility regulations.
Findings
The inspection found multiple violations including failure to ensure proper admission and retention of residents with prohibited conditions, incomplete medication administration records, missing diagnoses on medication records, failure to maintain the building interior in good repair and cleanliness, and inadequate response to call bells due to staff pager issues.
Deficiencies (5)
| Description |
|---|
| Facility failed to ensure it did not admit or retain individuals with conditions or care needs prohibited by regulation and Code of Virginia. |
| Facility failed to ensure medications were administered according to prescriber instructions and standards of practice. |
| Medication administration records (MAR) did not include all required information such as diagnosis or indications for medications. |
| Interior of the building was not maintained in good repair and was not kept clean and free of rubbish, including stained carpets. |
| Call bell/signaling device response was inadequate because assigned staff did not have a pager to be alerted to calls. |
Report Facts
Inspection dates: 3
Carpet stain size: 35
Carpet stain size: 18
Call bell response time: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Willie Barnes | Inspector | Named as current inspector conducting the inspection |
| Staff #1 | Acknowledged missing treatment plans, carpet stains, and pager issues | |
| Staff #2 | Acknowledged pager issue and participated in medication record review | |
| Staff #5 | Assigned staff who did not have a pager and could not respond to call bell |
Inspection Report
Renewal
Census: 60
Deficiencies: 4
May 3, 2021
Visit Reason
A renewal inspection was initiated on May 3, 2021 and concluded on May 6, 2021 to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection identified multiple violations including failure to update Individualized Service Plans (ISPs) to reflect residents' current needs, incomplete prescriber orders lacking diagnosis or indications, incorrect medication administration, and incomplete documentation of fire and emergency evacuation drills.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure the Individualized Service Plan (ISP) was reviewed and updated as needed as the condition of the resident changes. |
| Facility failed to ensure prescriber’s orders for administration of all prescription and over-the-counter medications identified the diagnosis or specific indications for administering each drug. |
| Facility did not administer medications in accordance with the physician's instructions. |
| Fire and emergency evacuation drills record did not identify the person conducting the drill nor method used for notification of the drill. |
Report Facts
Inspection dates: 4
Resident records reviewed: 4
Staff records reviewed: 4
Current census: 60
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Willie Barnes | Inspector | Named as current inspector conducting the inspection |
| Prescriber #1 | Nurse Practitioner (NP) | Acknowledged medication administration error for resident #2 |
| Staff #1 | Acknowledged ISP and medication order deficiencies | |
| Staff #2 | Acknowledged ISP and medication order deficiencies |
Inspection Report
Monitoring
Census: 61
Deficiencies: 7
Apr 5, 2021
Visit Reason
A monitoring inspection was initiated due to a state of emergency health pandemic declared by the Governor of Virginia, conducted remotely to assess compliance with applicable standards and laws.
Findings
The inspection identified multiple violations including failure to report major incidents within 24 hours, failure to implement the medication management plan, improper medication orders and administration, failure to conduct required resident safety rounds, and failure to notify guardians of special orders within required timeframes.
Deficiencies (7)
| Description |
|---|
| Facility failed to report to the regional licensing office within 24 hours of any major incident affecting resident safety. |
| Facility failed to implement its medication management plan regarding communication of medication issues. |
| Facility started and discontinued medications without valid physician orders. |
| Medications were administered outside the allowed time window of one hour before or after scheduled time. |
| Medications were not administered in accordance with physician's instructions, including missed doses. |
| Facility failed to make and document rounds every one or two hours as required for residents with signaling device needs. |
| Facility failed to notify guardians or responsible persons in writing within 30 days regarding health and safety violations as required by special order. |
Report Facts
Inspection dates: 5
Resident records reviewed: 4
Current census: 61
Inspection Report
Monitoring
Census: 57
Deficiencies: 4
Jan 13, 2021
Visit Reason
A monitoring inspection was initiated due to a state of emergency health pandemic declared by the Governor of Virginia, conducted remotely to assess compliance with applicable standards and laws.
Findings
The inspection identified multiple non-compliances including failure to update Individualized Service Plans (ISP) as resident conditions changed, incomplete physician orders lacking diagnosis or indications for medications, improper medication administration not following physician instructions, and failure to document treatments as ordered.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure the Individualized Service Plan (ISP) was reviewed and updated as needed when resident conditions changed. |
| Physician orders for prescription and over-the-counter medications did not include diagnosis or specific indications for administration. |
| Medications were not administered in accordance with physician's instructions, including insulin dosing errors and missed doses without physician orders. |
| Treatments ordered by a physician, such as oxygen therapy, were not consistently provided or documented as instructed. |
Report Facts
Inspection dates: 5
Resident records reviewed: 4
Staff records reviewed: 4
Missed insulin doses: 14
Current census: 57
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