Inspection Report
Monitoring
Census: 82
Deficiencies: 2
Oct 3, 2025
Visit Reason
The inspection was a monitoring visit to review compliance with applicable standards and laws for an assisted living facility.
Findings
The inspection found non-compliance with applicable standards, including failure to ensure medication staff received required continuing education and failure to post dated weekly menus in a conspicuous area. Violations were documented and a plan of correction was requested.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure medication staff receive continuing education as required by the Virginia Board of Nursing. |
| Facility failed to ensure menus for meals for the current week are dated and posted in an area conspicuous to residents. |
Report Facts
Number of residents present: 82
Number of resident records reviewed: 6
Number of staff records reviewed: 3
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 1
Inspection Report
Renewal
Census: 89
Deficiencies: 2
Jan 29, 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 non-compliance with applicable standards, including failure to post the current on-site person in charge conspicuously and lack of certification statements on dietary oversight records. The facility corrected the posting violation the same day and hired a new dietitian to address dietary oversight certification.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure the current on-site person in charge was posted conspicuously to residents and the public. |
| Facility failed to ensure dietary oversight was certified and met requirements, including certification statements on dietary oversight records. |
Report Facts
Number of residents present: 89
Number of resident records reviewed: 9
Number of staff records reviewed: 4
Number of interviews conducted with residents: 2
Number of interviews conducted with staff: 2
Date of dietary oversight records missing certification: Mar 28, 2024
Date new dietitian hired: Dec 1, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jacquelyn Kabiri | Licensing Inspector | Inspector conducting the inspection |
| Staff 2 | Staff interviewed regarding missing certification statement and posting violation |
Inspection Report
Monitoring
Deficiencies: 0
Jun 12, 2023
Visit Reason
The inspection was a monitoring visit to review compliance with personnel and resident care standards, including verification of correction of a previous B2 violation cited on 3/22/2023.
Findings
The investigation did not support the self-report of non-compliance with standards or law. The licensing inspector reviewed training records and conducted a physical plant tour, finding no substantiated deficiencies.
Report Facts
Resident records reviewed: 3
Staff records reviewed: 0
Interviews with residents: 0
Interviews with staff: 0
Inspection Report
Monitoring
Deficiencies: 3
Mar 22, 2023
Visit Reason
The inspection was a monitoring visit conducted on March 22, 2023, following self-reported incidents received by VDSS Division of Licensing on January 30, 2023, and March 1, 2023, regarding allegations in personnel and resident care and related services.
Findings
The investigation supported the self-report of non-compliance with standards and violations were issued related to abuse reporting, staff licensing, and medication management. The facility failed to ensure mandated reporters reported suspected abuse, maintained current professional licenses for staff, and implemented proper medication management protocols.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure all mandated reporters reported suspected abuse, neglect, or exploitation of residents as required by Virginia Code § 63.2-1606. |
| Facility failed to maintain verification of current professional licenses for staff; nurse aide license for Staff #2 expired on 3/31/2022. |
| Facility failed to implement methods in the medication management plan to ensure accurate counts of all controlled substances during staff changes. |
Report Facts
Number of resident records reviewed: 2
Number of staff records reviewed: 6
Number of interviews conducted with staff: 1
Date of incident: Mar 1, 2023
License expiration date: Mar 31, 2022
Inspection Report
Complaint Investigation
Census: 84
Deficiencies: 0
Feb 3, 2023
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2023-01-27 regarding allegations in the area of resident care.
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.
Complaint Details
Complaint investigation related to resident care allegations received on 2023-01-27; the allegations were not substantiated.
Report Facts
Number of residents present: 84
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
Renewal
Census: 91
Deficiencies: 2
Sep 22, 2022
Visit Reason
The inspection was conducted as a renewal inspection to assess compliance with applicable standards and laws prior to license expiration.
Findings
The inspection identified non-compliance with applicable standards related to staff tuberculosis screening and timely completion of criminal history record reports. Violations were documented and a plan of correction was requested.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure each staff person submitted results of a tuberculosis risk assessment prior to first day of work. |
| Facility failed to ensure criminal history record reports were obtained on or prior to the 30th day of employment for multiple staff members. |
Report Facts
Number of residents present: 91
Number of resident records reviewed: 12
Number of staff records reviewed: 5
Number of interviews conducted with residents: 2
Number of interviews conducted with staff: 2
Number of staff with late criminal history reports: 18
Inspection Report
Monitoring
Census: 69
Deficiencies: 1
May 17, 2022
Visit Reason
The inspection was a monitoring visit conducted on 5/17/2022 following self-reported incidents received by VDSS regarding allegations in staffing, supervision, and resident care.
Findings
The investigation did not support the self-reported non-compliance, but violations unrelated to the self-report were identified. Specifically, the facility failed to ensure fall risk ratings were reviewed and updated after resident falls.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure that the fall risk rating for residents who meet the criteria for assisted living care was reviewed and updated after a fall. |
Report Facts
Number of residents present: 69
Number of resident records reviewed: 8
Number of staff records reviewed: 0
Number of resident interviews conducted: 2
Number of staff interviews conducted: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie Eddy | Licensing Inspector | Contact person for questions regarding the inspection |
Inspection Report
Deficiencies: 0
Oct 27, 2021
Visit Reason
A non-mandated self-report inspection was initiated due to a self-reported incident regarding allegations in the area of resident care. The investigation was conducted by contacting the administrator and reviewing documentation.
Findings
The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law.
Inspection Report
Monitoring
Deficiencies: 0
Oct 13, 2021
Visit Reason
A non-mandated monitoring inspection was conducted to ensure correction of previous B-2 violations cited during the last inspection.
Findings
The evidence gathered during the investigation did not support any non-compliance with any standards or law. No violations were cited.
Report Facts
Previous violations: 2
Inspection Report
Renewal
Census: 85
Deficiencies: 2
Sep 21, 2021
Visit Reason
A renewal inspection was initiated to review compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection identified non-compliances related to medication administration and criminal history record reports for staff, which were documented in a violation notice.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure medications were administered according to physician's instructions, specifically Resident #3 received incorrect dosage of Gabapentin. |
| Facility failed to obtain criminal history record reports on or prior to the 30th day of employment for several staff members. |
Report Facts
Resident census: 85
Date of physician's order: May 21, 2021
Date medication error occurred: Sep 13, 2021
Date of hire for Staff #5: Jul 14, 2021
Date of criminal record report for Staff #5: Sep 22, 2021
Number of staff without criminal history record reports: 6
Inspection Report
Deficiencies: 0
Sep 3, 2021
Visit Reason
A non-mandated self-report inspection was initiated due to a self-reported incident regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation found that the evidence did not support the self-report of non-compliance with standards or law.
Inspection Report
Complaint Investigation
Deficiencies: 1
Jun 29, 2021
Visit Reason
A non-mandated complaint inspection was initiated due to a complaint received regarding allegations in the areas of buildings and grounds, specifically concerning pest infestations.
Findings
The investigation found evidence of mice infestations in multiple areas of the facility as documented by pest control reports from December 2020 through April 2021, resulting in a violation for failure to keep the building free of infestations.
Complaint Details
The complaint was substantiated based on evidence gathered during the investigation, including pest control reports and interviews with administration.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure that buildings were kept free of infestations of insects and vermin, with evidence of mice activity found in various locations. |
Report Facts
Inspection dates: 2
Pest control activity dates: 11
Plan of correction deadline: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jacquelyn Kabiri | Inspector | Named as current inspector conducting the investigation |
Inspection Report
Monitoring
Deficiencies: 3
Nov 5, 2020
Visit Reason
A focused monitoring inspection was initiated due to a self-reported incident regarding allegations in the area of resident care. The investigation was conducted remotely due to a state of emergency health pandemic.
Findings
The investigation supported the self-report of non-compliance with standards or law, resulting in violations related to medication management, including failure to accurately transcribe medication orders within 24 hours, failure to discontinue a medication per physician's order, and failure to administer medications according to physician instructions.
Deficiencies (3)
| Description |
|---|
| Failed to implement a written plan for medication management ensuring medication orders were accurately transcribed to medication administration records within 24 hours. |
| Failed to ensure no medication was started, changed, or discontinued without a valid physician order; Resident continued to receive discontinued medication. |
| Failed to ensure medications were administered according to physician's instructions; prescribed medication was never administered. |
Report Facts
Inspection dates: Inspection conducted from 2020-11-05 to 2020-11-10
Medication order date: Jul 15, 2020
Medication administration period: Discontinued medication administered from 7/16/2020 through 11/3/2020
Medication administration period: Prescribed medication Remeron not administered from 7/15/2020 through 11/4/2020
Plan of correction deadlines: 10
Plan of correction re-education deadline: Nov 30, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jacquelyn Kabiri | Inspector | Current inspector conducting the inspection |
| Wellness Nurse | Counseled and re-educated for failure to transcribe medication orders | |
| Health Services Director | Resumed and continued auditing all resident care orders daily |
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