Deficiencies (last 5 years)
Deficiencies (over 5 years)
57.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
529% worse than Virginia average
Virginia average: 9.1 deficiencies/yearDeficiencies per year
24
18
12
6
0
Census
Latest occupancy rate
24 residents
Based on a September 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Monitoring
Census: 24
Deficiencies: 11
Sep 11, 2025
Visit Reason
An unannounced on-site monitoring inspection was conducted to review compliance with applicable standards and laws.
Findings
The inspection found multiple violations including insufficient staff training hours, lack of required infection control training, outdated tuberculosis screenings, expired first aid and CPR certifications, incomplete individualized service plans, failure to maintain hot water temperature within required range, and presence of insect infestation in the facility.
Deficiencies (11)
| Description |
|---|
| Facility failed to ensure all direct care staff attended at least 18 hours of training annually. |
| Facility failed to ensure at least two hours of training focused on infection control and prevention and four hours on mental impairments when applicable. |
| Facility failed to ensure staff submitted current tuberculosis risk assessments annually. |
| Facility failed to ensure direct care staff maintained current certification in adult first aid. |
| Facility failed to ensure staff certification in CPR was current. |
| Facility failed to keep an up-to-date listing of all staff with first aid and CPR certifications. |
| Facility failed to ensure individualized service plan reviews and updates were signed and dated by required parties. |
| Facility failed to ensure individualized service plans included all assessed needs. |
| Facility failed to ensure residents' rights and responsibilities were reviewed annually with staff and documented. |
| Facility failed to maintain hot water temperature at taps within the required range of 105 to 120 degrees Fahrenheit. |
| Facility failed to keep the building free of infestation of insects and vermin. |
Report Facts
Number of residents present: 24
Number of resident records reviewed: 4
Number of staff records reviewed: 3
Number of staff interviews conducted: 3
Staff training hours: 10
Staff training hours: 9.5
Staff mental health training hours: 2
Tuberculosis screening date: Mar 18, 2024
Tuberculosis screening date: Aug 12, 2024
CPR certification expiration: 202508
First aid/CPR certification expiration: 202508
First aid/CPR certification expiration: 202502
First aid/CPR certification expiration: 202507
Resident ISP update date: Mar 6, 2025
Resident UAI assessment date: Mar 5, 2025
Resident rights review date: Aug 12, 2024
Water temperature: 98.6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff #1 | Acknowledged multiple deficiencies including training hours, TB screening, certification, ISP issues, and rights review | |
| Staff #2 | Acknowledged water temperature and insect infestation observations | |
| Staff #4 | Staff record noted with deficient training hours, expired CPR and first aid certifications | |
| Staff #5 | Staff record noted with outdated TB screening and resident rights review | |
| Staff #6 | Staff record noted with deficient training hours and missing infection control training | |
| Staff #7 | Certification expiration noted as expired on first aid/CPR posting | |
| Staff #8 | Certification expiration noted as expired on first aid/CPR posting |
Inspection Report
Monitoring
Census: 25
Deficiencies: 8
Aug 25, 2025
Visit Reason
An unannounced mandated monitoring inspection conducted by two inspectors from the Peninsula Licensing Office to review compliance with applicable standards and laws.
Findings
The inspection found multiple violations including failure to ensure required staff training, incomplete resident assessments and service plans, undocumented menu substitutions, and lack of documentation for emergency preparedness and resident emergency exercises.
Deficiencies (8)
| Description |
|---|
| Facility failed to ensure the administrator supervising medication aides had required annual medication administration training. |
| Facility failed to ensure direct care staff who are licensed health care professionals attended at least 12 hours of annual training. |
| Facility failed to ensure at least two hours of staff training focused on infection control and prevention. |
| Facility failed to ensure an annual reassessment using the uniform assessment instrument (UAI) was completed for a resident. |
| Resident's individualized service plan did not include all assessed information, specifically type of mechanical tool needed for stairclimbing. |
| Facility failed to ensure menu substitutions or additions were recorded on the posted menu. |
| Facility failed to ensure documentation of annual contact with local emergency coordinator regarding emergency preparedness plan. |
| Facility failed to ensure all staff participated in emergency procedure exercises at least every six months. |
Report Facts
Number of residents present: 25
Number of resident records reviewed: 5
Number of staff records reviewed: 2
Annual medication training hours required: 4
Annual training hours required: 12
Date of last medication training: Jun 13, 2024
Date of last public pay UAI: Oct 31, 2023
Date of resident ISP: Nov 1, 2024
Inspection Report
Monitoring
Census: 25
Deficiencies: 2
Jul 25, 2025
Visit Reason
An unannounced monitoring inspection was conducted to review compliance with applicable standards and laws, including personnel, staffing, resident care, emergency preparedness, and background checks.
Findings
The inspection found non-compliance with applicable standards, including deficiencies in individualized service plans and emergency preparedness documentation. Violations were documented and a plan of correction opportunity was provided to the licensee.
Deficiencies (2)
| Description |
|---|
| The facility failed to ensure the reviewed and updated individualized service plan (ISP) included all the required information, such as accurate behavioral assessments and allergy documentation. |
| The facility failed to ensure all staff participated in resident emergency procedure exercises at least once every six months, and documentation was incomplete or unsigned. |
Report Facts
Number of residents present: 25
Number of resident records reviewed: 3
Number of staff records reviewed: 2
Number of staff interviews conducted: 2
Inspection Report
Complaint Investigation
Census: 25
Deficiencies: 0
Jun 12, 2025
Visit Reason
An unannounced complaint inspection was conducted due to a complaint received by VDSS Division of Licensing on 2025-06-06 regarding allegations in the areas of resident care, funding, and building and grounds.
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 to the VDSS website within 5 business days of receipt of the inspection summary.
Complaint Details
Complaint related inspection with allegations in resident care, funding, and building and grounds. The allegations were not substantiated.
Report Facts
Number of residents present: 25
Number of resident records reviewed: 1
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 5
Inspection Report
Monitoring
Census: 25
Deficiencies: 0
Jun 12, 2025
Visit Reason
An unannounced monitoring inspection was conducted to review compliance with applicable standards and laws at the assisted living facility.
Findings
The inspection found no violations with applicable standards or laws. The inspection included a tour of the physical plant, record reviews, interviews, and observations of medication pass, meal service, and first aid kits.
Report Facts
Number of residents present: 25
Number of resident records reviewed: 3
Number of staff records reviewed: 1
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 2
Inspection Report
Monitoring
Census: 25
Deficiencies: 2
May 19, 2025
Visit Reason
An unannounced monitoring inspection was conducted to review compliance with applicable standards and laws, including personnel, staffing, resident care, buildings, and emergency preparedness.
Findings
The inspection found non-compliance with medication administration standards, specifically that a resident was in possession of prescribed medication not administered according to physician instructions, indicating medication management deficiencies.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure medication was administered in accordance with physician's instructions; resident was found in possession of prescribed medication not properly administered. |
| Facility failed to ensure medication was administered in accordance with physician's instructions; staff did not verify resident took medication after administration. |
Report Facts
Number of residents present: 25
Number of resident records reviewed: 5
Number of staff records reviewed: 1
Number of resident interviews conducted: 2
Number of staff interviews conducted: 5
Medication pills counted: 320
Inspection Report
Monitoring
Census: 25
Deficiencies: 4
Apr 21, 2025
Visit Reason
An unannounced non-mandated monitoring inspection was conducted by two Peninsula Licensing Inspectors on April 21, 2025, to review compliance with applicable standards and laws.
Findings
The inspection found multiple violations related to incomplete or inaccurate resident assessments and documentation, including tuberculosis risk assessments, fall risk ratings, discharge statements, and uniform assessment instruments. All issues were corrected on-site or immediately after the inspection.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure the risk assessment for tuberculosis (TB) was completed annually for a resident. |
| Facility failed to ensure the fall risk rating was reviewed and updated at least annually for residents. |
| Facility failed to ensure the discharge statement included all required information. |
| Facility failed to ensure the uniformed assessment instrument (UAI) was accurately completed for a resident. |
Report Facts
Residents present: 25
Resident records reviewed: 3
Staff records reviewed: 0
Resident interviews conducted: 1
Staff interviews conducted: 2
Residents with outdated fall risk rating: 14
Inspection Report
Monitoring
Census: 27
Deficiencies: 1
Mar 19, 2025
Visit Reason
An unannounced monitoring inspection was conducted to review compliance with applicable standards and laws at the facility.
Findings
The inspection found non-compliance with applicable standards or laws, specifically related to the individualized service plan (ISP) not including all required information. A violation notice was issued and the licensee was given the opportunity to submit a plan of correction.
Deficiencies (1)
| Description |
|---|
| The facility failed to ensure the reviewed and updated individualized service plan (ISP) included all the required information. |
Report Facts
Number of residents present: 27
Number of resident records reviewed: 3
Number of staff records reviewed: 1
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Willie Barnes | Licensing Inspector | Contact person for questions about the VDSS Licensing Programs |
Inspection Report
Monitoring
Census: 27
Deficiencies: 1
Feb 27, 2025
Visit Reason
An unannounced monitoring inspection was conducted to review compliance with applicable standards and laws at the facility.
Findings
The inspection found non-compliance with applicable standards related to individualized service plans (ISPs), specifically that the reviewed ISP did not include all required information for assessed resident needs.
Deficiencies (1)
| Description |
|---|
| The facility failed to ensure the reviewed and updated individualized service plan (ISP) included all the required information. |
Report Facts
Number of residents present: 27
Number of resident records reviewed: 3
Number of staff records reviewed: 1
Number of staff interviews conducted: 3
Inspection Report
Monitoring
Census: 27
Deficiencies: 7
Jan 31, 2025
Visit Reason
An on-site non-mandated monitoring inspection was conducted to review compliance with applicable standards and laws at Colonial Manor assisted living facility.
Findings
The inspection found multiple violations related to administration hours, medication management including refrigeration, timely administration, proper documentation, and adherence to physician orders. The facility was cited for non-compliance and given plans of correction with specified completion dates.
Deficiencies (7)
| Description |
|---|
| Facility failed to ensure the administrator served full-time as the on-site agent responsible for day-to-day management. |
| Facility failed to ensure medication for a resident was refrigerated as required. |
| Medications were administered outside the facility's dosing schedule. |
| Resident's medication was not administered in accordance with physician's instructions. |
| Medical procedures or treatments ordered by a physician were not provided or documented as required. |
| Medication administration records (MAR) did not include all required staff initials. |
| Medication aides failed to have detailed medical orders for PRN medications including exact dosage and timing. |
Report Facts
Number of residents present: 27
Administrator hours worked: 29
Administrator hours worked: 34
Administrator hours worked: 14
Medication expiration date: Dec 13, 2023
Medication administration times: 9.28
Medication administration times: 9.18
Medication administration times: 9.19
Medication administration times: 9.38
Medication administration times: 9.45
Medication administration times: 9.55
Medication administration times: 9.42
Medication administration times: 9.34
Medication administration times: 10.59
Medication administration times: 4.04
Medication quantity: 120
Medication supply duration: 60
Medication administration missing initials: 10
Medication administration missing initials: 1
Medication administration missing initials: 2
Medication administration missing initials: 10
Medication administration missing initials: 3
Medication administration missing initials: 5
Medication administration missing initials: 10
Oxygen checks missing initials: 12
Medication administration missing initials: 1
Medication administration missing initials: 10
Medication administration missing initials: 14
Medication administration missing initials: 30
Inspection Report
Complaint Investigation
Census: 27
Deficiencies: 4
Jan 14, 2025
Visit Reason
An unannounced on-site inspection was conducted due to a self-report incident received regarding allegations of resident elopement and related resident care concerns.
Findings
The investigation supported non-compliance with multiple standards related to failure to reassess a resident after significant condition changes, failure to update individualized service plans, failure to ensure resident health and safety, and failure to provide adequate supervision to prevent wandering and elopement.
Complaint Details
The inspection was complaint-related, triggered by a self-report incident on 12-10-24 regarding a resident elopement. The evidence supported the complaint with violations issued.
Deficiencies (4)
| Description |
|---|
| The facility failed to complete a reassessment due to a significant change in the resident's condition using the Uniform Assessment Instrument (UAI). |
| The facility failed to review and update the individualized service plan (ISP) for a significant change in the resident's condition. |
| The facility failed to ensure it provided for the health, safety, and well-being of a resident who eloped from the facility. |
| The facility failed to ensure it provided supervision of a resident's schedule, care, and activities, including prevention of falls and wandering from the premises. |
Report Facts
Number of residents present: 27
Number of resident records reviewed: 1
Number of staff interviews conducted: 6
Resident age: 94
Distance resident eloped: 0.2
Road speed: 45
Temperature low: 43
Temperature high: 65
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Willie Barnes | Licensing Inspector | Contact person for questions about the VDSS Licensing Programs |
Inspection Report
Monitoring
Census: 27
Deficiencies: 9
Dec 27, 2024
Visit Reason
An unannounced monitoring inspection was conducted to review compliance with applicable standards and laws, including administration, personnel, resident care, and building conditions.
Findings
The inspection found multiple violations including improper blood glucose monitoring practices, failure to admit or retain individuals per prohibition conditions, outdated individualized service plans, failure to review resident rights annually, improper diet preparation, medication storage issues, failure to follow medical orders, unsafe storage of hazardous materials, and cleanliness deficiencies.
Deficiencies (9)
| Description |
|---|
| Failed to ensure implementation of blood glucose monitoring practices consistent with CDC recommendations; fingerstick devices used for more than one person. |
| Failed to ensure facility did not admit or retain individuals with prohibition conditions per Code of Virginia 63.2-1805 D. |
| Failed to ensure individualized service plan was reviewed and updated at least once every 12 months and as needed. |
| Failed to ensure resident rights and responsibilities were reviewed annually with residents and staff with written acknowledgment. |
| Failed to prepare and serve diet according to physician's orders; resident served syrup not compliant with low sugar diet. |
| Failed to ensure medication was stored consistent with current standards; medication found in resident's bathroom without orders. |
| Failed to ensure medical procedures and treatments ordered by physician were provided and documented according to instructions. |
| Failed to store cleaning supplies and hazardous materials in a locked area. |
| Failed to ensure all furnishings, fixtures, and equipment were kept clean and in good repair; bathroom and kitchen sink in resident room needed cleaning. |
Report Facts
Number of residents present: 27
Number of resident records reviewed: 5
Number of staff records reviewed: 3
Number of resident interviews conducted: 2
Number of staff interviews conducted: 4
Inspection Report
Complaint Investigation
Census: 29
Deficiencies: 6
Dec 4, 2024
Visit Reason
An unannounced complaint inspection was conducted on December 4 and 6, 2024, following a complaint received on November 27, 2024, regarding allegations in the areas of staff, buildings and grounds, resident care, and related services.
Findings
The investigation supported some but not all allegations, identifying areas of non-compliance with standards or law. Multiple violations were found related to staff training on cleaning agents, dietary menu compliance, pest infestation, equipment repair, and heating system functionality.
Complaint Details
The complaint investigation was substantiated in part, with violations found in areas including staff training, resident care, building maintenance, and equipment functionality.
Deficiencies (6)
| Description |
|---|
| Facility failed to ensure staff was trained on product specific instructions for use of cleaning and disinfecting agents. |
| Facility failed to ensure the daily menu met current USDA food guidance system or dietary allowances. |
| Facility failed to ensure a current diet manual was readily available to personnel responsible for food preparation. |
| Facility failed to ensure the building was kept free of infestation of insects and vermin. |
| Facility failed to ensure all furnishings, fixtures, and equipment were in good repair and condition. |
| Heating system was not working properly; temperature of at least 72 degrees Fahrenheit was not maintained in all resident areas during waking hours. |
Report Facts
Number of residents present: 29
Number of resident interviews: 8
Number of staff interviews: 6
Date of correction: Jan 15, 2025
Date of correction: Dec 8, 2024
Inspection Report
Monitoring
Census: 31
Deficiencies: 14
Nov 22, 2024
Visit Reason
An unannounced monitoring inspection was conducted on-site to review compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection found multiple violations including staff language proficiency, administrator hours, resident care documentation discrepancies, medication administration issues, facility maintenance problems, and resident rights review deficiencies. Plans of correction were submitted for all cited violations.
Deficiencies (14)
| Description |
|---|
| Facility failed to ensure staff was able to speak, read, and understand English as necessary to carry out job responsibilities. |
| Facility failed to ensure the administrator served full-time as the on-site agent responsible for day-to-day management. |
| Resident's physical examination noted needs requiring continuous licensed nursing care, which is prohibited. |
| Individualized service plan (ISP) was not reviewed and updated at least annually or as needed for significant changes. |
| Facility failed to ensure residents' rights and responsibilities were reviewed annually and documented. |
| Medications were started, changed, or discontinued without valid prescriber orders. |
| Prescriber orders did not include diagnosis, condition, or specific indications for medications. |
| Medications were administered outside the facility's standard dosing schedule. |
| Medical procedures or treatments ordered by a physician were not provided or documented as required. |
| Medication administration record (MAR) did not include initials of staff administering medications. |
| Cleaning supplies and hazardous materials were stored unlocked and unattended. |
| Interior of buildings was not maintained in good repair and was not kept clean and free of rubbish. |
| Toilet, bathtub, and showers were not kept clean and in good repair; missing tiles and broken toilet noted. |
| Resident was unable to control the temperature in their bedroom due to locked thermostat. |
Report Facts
Number of residents present: 31
Number of resident records reviewed: 3
Number of staff records reviewed: 1
Number of interviews with residents: 2
Number of interviews with staff: 5
Administrator hours worked: 26
Administrator hours worked: 24
Administrator hours worked: 16
Administrator hours worked: 14
Medication administration days outside schedule: 9
Medications administered outside schedule: 4
Medications administered outside schedule: 10
Inspection Report
Monitoring
Census: 30
Deficiencies: 4
Oct 30, 2024
Visit Reason
An unannounced monitoring inspection was conducted to determine whether the provider had corrected or was in the process of correcting previously cited violations in various regulatory areas.
Findings
The inspection found the provider demonstrated noncompliance with certain standards not identified in the plan of correction, including deficiencies in individualized service plans, window screening, maintenance of furnishings and fixtures, and posting of required notices.
Deficiencies (4)
| Description |
|---|
| The facility failed to ensure the individualized service plan (ISP) included all assessed needs for three residents, with outdated information and missing signatures. |
| The facility failed to ensure any operable window was effectively screened, with windows in multiple rooms lacking screens. |
| The facility failed to ensure all furnishings, fixtures, and equipment were kept clean and in good repair, including toilets that were not functioning properly. |
| The facility failed to ensure compliance with license terms by not posting the Notice of Intent (NOI) in a prominent place at each public entrance, a repeat violation. |
Report Facts
Facility census: 30
Date of correction for ISP deficiencies: Oct 30, 2024
Date of correction for window screening: Dec 1, 2024
Date of correction for furnishings and fixtures: Oct 30, 2024
Date of correction for Notice of Intent posting: Oct 30, 2024
Inspection Report
Monitoring
Census: 32
Deficiencies: 6
Sep 25, 2024
Visit Reason
An on-site mandated monitoring inspection was conducted to assess compliance with applicable standards and laws at Colonial Manor assisted living facility.
Findings
The inspection identified multiple violations including failure to ensure psychotropic medication treatment plans, incomplete individualized service plans, missing diagnosis on medication orders, inadequate PRN medication orders, facility maintenance issues, and failure to post required Notice of Intent. Plans of correction were provided with specified correction dates.
Deficiencies (6)
| Description |
|---|
| Facility failed to ensure it did not admit or retain individuals with psychotropic medical condition without a diagnosis and treatment plan for two of three records reviewed. |
| Facility failed to ensure that the resident's individualized service plan included all assessed needs for one of three records reviewed. |
| Facility failed to ensure physician or prescriber orders included diagnosis, condition, or specific indications for all prescription and OTC medications. |
| Facility failed to ensure medication aides administered PRN medication with detailed medical orders including symptoms, exact dosage, and time frames. |
| Facility failed to ensure the facility was maintained in good repair and kept clean and free of rubbish. |
| Facility failed to ensure compliance with terms of the license by not posting the Notice of Intent/NOI. |
Report Facts
Facility census: 32
Correction date: Oct 16, 2024
Correction date: Oct 3, 2024
Correction date: Nov 10, 2024
Correction date: Oct 25, 2024
Correction date: Oct 1, 2024
Correction date: Sep 25, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Willie Barnes | Licensing Inspector | Contact person for questions regarding the inspection |
Inspection Report
Monitoring
Census: 31
Deficiencies: 10
Aug 23, 2024
Visit Reason
An on-site non-mandated monitoring inspection was conducted to review compliance with applicable standards and laws at the assisted living facility.
Findings
The inspection found multiple areas of non-compliance including failure to verify staff job descriptions, incomplete tuberculosis screening documentation, missing personal and social information in resident records, lack of written resident orientation acknowledgement, improper preparation of prescribed diets, absence of a current diet manual, lack of window coverings for privacy, building maintenance issues, and incomplete staff participation in emergency practice exercises.
Deficiencies (10)
| Description |
|---|
| Facility failed to ensure staff received and acknowledged current job descriptions. |
| Facility failed to ensure tuberculosis risk assessment was properly documented prior to staff contact with residents. |
| Resident record lacked required personal and social information including mental health, behavioral, and substance abuse history. |
| Resident record lacked written acknowledgement of receiving orientation to the facility. |
| Prescribed diet for a resident was not prepared and served as ordered by the physician. |
| Diet manual containing acceptable nutrition practices was not current or readily available to food preparation personnel. |
| Resident's bedroom lacked window coverings for privacy. |
| Interior of the building was not maintained in good repair and was not clean and free of rubbish. |
| Facility failed to ensure furnishings, fixtures, and equipment including bathtub and toilet were clean and in good repair. |
| Staff did not participate in required emergency practice exercises at least once every six months. |
Report Facts
Number of residents present: 31
Number of resident records reviewed: 2
Number of staff records reviewed: 2
Number of staff interviews conducted: 5
Date of resident physical exam: Jul 18, 2024
Date of staff hire: Aug 12, 2024
Date of emergency practice sign-in sheet: May 16, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Willie Barnes | Licensing Inspector | Contact person for questions about VDSS Licensing Programs |
| Darunda Flint | Licensing Inspector | Current inspector conducting the monitoring inspection |
Inspection Report
Monitoring
Census: 30
Deficiencies: 2
Jul 30, 2024
Visit Reason
An on-site unannounced non-mandated monitoring inspection was conducted to assess compliance with applicable standards and laws at the assisted living facility.
Findings
The inspection found non-compliance with standards related to individualized service plans not including all assessed resident needs and issues with cleanliness of furnishings and equipment. Violations were documented and plans of correction were submitted to address these deficiencies.
Deficiencies (2)
| Description |
|---|
| The facility failed to ensure that the resident's individualized service plan (ISP) included all assessed needs for residents, including allergies, mobility aids, and fall risk assessments. |
| The facility failed to ensure all furnishings, fixtures, and equipment, including window coverings and air conditioner vents, were kept clean and in good repair and condition. |
Report Facts
Number of residents present: 30
Number of resident records reviewed: 2
Number of staff records reviewed: 3
Number of interviews conducted with residents: 4
Number of interviews conducted with staff: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Willie Barnes | Licensing Inspector | Contact person for questions about the VDSS Licensing Programs |
Inspection Report
Monitoring
Census: 30
Deficiencies: 6
Jun 28, 2024
Visit Reason
An on-site unannounced mandated monitoring inspection was conducted to assess compliance with applicable standards and laws at Colonial Manor assisted living facility.
Findings
The inspection identified multiple violations including delayed incident reporting, incomplete signatures on individualized service plans (ISPs), ISPs missing assessed needs, incomplete medication administration records, maintenance issues with a kitchen sink, and inadequate fire drill documentation.
Deficiencies (6)
| Description |
|---|
| Failed to submit a written report of each incident to the regional licensing office within seven days, including a death incident. |
| Individualized service plan (ISP) was not signed and dated by the resident's legal representative. |
| Resident's ISP did not include all assessed needs such as medical conditions and allergies. |
| Medication administration record (MAR) missing staff initials on multiple dates for several medications. |
| Kitchen sink in resident room #27 had standing brown water and odor, not in good repair. |
| Fire drills were not conducted for each shift in a quarter and were conducted in the same month, not meeting regulatory requirements. |
Report Facts
Number of residents present: 30
Number of resident records reviewed: 3
Number of staff records reviewed: 2
Number of resident interviews: 3
Number of staff interviews: 5
Incident report submission timeframe: 7
Dates of missing staff initials on MAR: 6
Fire drill dates: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Willie Barnes | Licensing Inspector | Contact person for questions about the VDSS Licensing Programs |
| Darunda Flint | Inspector | Current inspector conducting the monitoring inspection |
Inspection Report
Monitoring
Deficiencies: 5
Jun 5, 2024
Visit Reason
An unannounced monitoring training inspection was conducted to assess compliance with applicable standards and laws at the facility.
Findings
The inspection found multiple violations including failure to ensure timely tuberculosis risk assessments for staff, outdated work schedules, admission or retention of residents with prohibitive conditions without proper documentation, incomplete individualized service plans, and medication administration records missing required staff initials.
Deficiencies (5)
| Description |
|---|
| Facility failed to ensure each staff person submitted tuberculosis risk assessment documentation prior to contact with residents. |
| Facility failed to ensure the written work schedule was current. |
| Facility failed to ensure it did not admit or retain individuals with prohibitive conditions or care needs for two of three records reviewed. |
| Facility failed to ensure the resident's individualized service plan addressed all assessed needs. |
| Facility failed to ensure medication administration records included all requirements, including staff initials. |
Report Facts
Date of staff TB document: May 1, 2024
Date range of outdated work schedule: Mar 4, 2024
Number of resident records reviewed for admission/retention: 3
Medication administration record missing staff initials: 6
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 3
May 9, 2024
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received on April 29, 2024, regarding allegations related to resident supervision at Colonial Manor.
Findings
The investigation found violations including failure to report a major incident involving a resident wandering off the premises within 24 hours, failure to have a psychotropic treatment plan for prescribed medications, and inadequate supervision of a resident with wandering behavior. Violations were issued based on these findings.
Complaint Details
The complaint was substantiated. The investigation supported the allegation of non-compliance related to resident supervision and failure to report incidents. Violations were issued accordingly.
Deficiencies (3)
| Description |
|---|
| Facility failed to report to the licensing office within 24 hours any major incident that negatively affected or threatened the life, health, safety, or welfare of a resident. |
| Facility failed to ensure it did not admit or retain individuals with prohibitive conditions or care needs, evidenced by lack of psychotropic treatment plan documentation. |
| Facility failed to provide adequate supervision to a resident, including prevention of falls and wandering from the premises. |
Report Facts
Number of residents present: 31
Number of resident records reviewed: 1
Number of staff interviews conducted: 5
Incident reporting correction date: May 15, 2024
Psychotropic treatment plan correction date: Jun 15, 2024
Supervision and ISP correction date: May 10, 2024
Inspection Report
Monitoring
Census: 31
Deficiencies: 3
May 9, 2024
Visit Reason
An on-site NOI monitoring inspection was conducted by two licensing inspectors from the Peninsula Licensing Office to assess compliance with applicable standards and laws.
Findings
The inspection found non-compliance with applicable standards or laws, including failure to ensure proper admission and retention criteria, failure to post current menus, and failure to maintain furnishings and equipment in good repair and clean condition.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure it did not admit or retain individuals with prohibitive conditions or care needs for one of six residents due to lack of psychotropic treatment plan documentation. |
| Facility failed to ensure the menu for meals and snacks for the current week was dated and posted in an area conspicuous to residents. |
| Facility failed to ensure all furnishings, fixtures, and equipment, including furniture, window coverings, sinks, toilets, bathtubs, and showers were kept clean and in good repair and condition. |
Report Facts
Residents with prohibitive conditions: 1
Inspection time: 1.75
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff #2 | Acknowledged lack of psychotropic treatment plan and lack of key to open menu display | |
| Staff #3 | Acknowledged bathtub and tile in room #12 needed repair and cleaning |
Inspection Report
Monitoring
Census: 31
Deficiencies: 2
Apr 30, 2024
Visit Reason
An unannounced monitoring inspection was conducted to assess compliance with applicable standards and laws at Colonial Manor.
Findings
The inspection found non-compliance with applicable standards, including failures in tuberculosis risk assessment documentation and incomplete individualized service plans for residents.
Deficiencies (2)
| Description |
|---|
| The facility failed to ensure the results of a risk assessment documenting the absence of tuberculosis in a communicable form were properly completed and dated. |
| The facility failed to ensure that the resident's individualized service plan included all assessed needs for a resident. |
Report Facts
Facility census: 31
Inspection Report
Monitoring
Census: 29
Deficiencies: 6
Mar 21, 2024
Visit Reason
An unannounced on-site monitoring inspection was conducted to assess compliance with applicable standards and laws at Colonial Manor assisted living facility.
Findings
The inspection found multiple violations including failure to ensure residents with prohibited conditions were not admitted or retained, lack of psychotropic treatment plans, outdated fall risk assessments, missing annual reassessments using the uniform assessment instrument, incomplete individualized service plans, and failure to provide appropriate food servings according to dietary guidelines.
Deficiencies (6)
| Description |
|---|
| Facility failed to ensure it did not admit nor retain individuals with prohibited conditions or care needs. |
| Facility failed to have a psychotropic treatment plan for Bupropion prescribed to a resident. |
| Facility failed to ensure the fall risk rating was reviewed and updated at least annually for a resident. |
| Facility failed to ensure an annual reassessment using the uniform assessment instrument (UAI) was utilized to determine resident needs and placement suitability. |
| Facility failed to ensure the resident's individualized service plan included all assessed needs, such as allergy information. |
| Facility failed to ensure posted menu items were served as noted and met USDA food guidance system or dietary allowances. |
Report Facts
Facility census: 29
Fall Risk Scale Assessment score: 35
Medication dosage: 300
Inspection Report
Monitoring
Census: 31
Deficiencies: 3
Feb 22, 2024
Visit Reason
An unannounced monitoring inspection was conducted to assess compliance with applicable standards and laws at the facility.
Findings
The inspection found non-compliance with several standards including failure to update fall risk ratings annually, incomplete individualized service plans, and lack of annual review documentation of residents' rights and responsibilities.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure the fall risk rating was reviewed and updated at least annually for a resident. |
| Facility failed to ensure that the resident's individualized service plan included all assessed needs. |
| Facility failed to ensure that the residents' rights and responsibilities were completed annually. |
Report Facts
Facility census: 31
Inspection Report
Monitoring
Census: 31
Deficiencies: 11
Jan 22, 2024
Visit Reason
An unannounced monitoring inspection was conducted to determine whether the provider had corrected or was in the process of correcting previously cited violations in various regulatory areas.
Findings
The inspection found the provider demonstrated noncompliance with standards not identified in the plan of correction, with multiple violations documented related to staff records, resident care plans, medication management, emergency preparedness, and facility maintenance.
Deficiencies (11)
| Description |
|---|
| Facility failed to ensure staff personal and social data included all required information. |
| Facility failed to ensure the posted listing of staff with first aid or CPR certification was kept up to date. |
| Facility failed to ensure it did not admit or retain individuals with prohibited conditions or care needs. |
| Facility failed to ensure the fall risk rating was reviewed and updated at least annually for residents. |
| Facility failed to ensure a plan of care was developed to address basic needs of residents on or prior to admission. |
| Facility failed to ensure the resident's updated individualized service plan included all assessed needs. |
| Facility failed to ensure residents' rights and responsibilities were completed annually. |
| Facility failed to ensure menu substitutions or additions were recorded on the posted menu. |
| Facility failed to ensure it followed its medication management policy, including removal of expired medications. |
| Facility failed to ensure the interior of the building was maintained in good repair. |
| Facility failed to ensure the availability of the 96-hours supply of emergency food was kept current. |
Report Facts
Facility census: 31
Expired food items: 5
Expired food items: 9
Expired food items: 2
Expired food items: 1
Expired food items: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Willie Barnes | Licensing Inspector | Contact person for questions regarding the inspection. |
| Darunda Flint | Inspector | Current inspector conducting the monitoring inspection. |
| Staff #1 | Acknowledged fall risk rating and menu substitution deficiencies. | |
| Staff #2 | Acknowledged multiple deficiencies including staff records, resident care plans, ceiling stain, food expiration, and resident rights. | |
| Staff #3 | Acknowledged CPR posting, medication expiration, and resident rights deficiencies. | |
| Staff #4 | Staff member with missing job description and CPR certification posting. | |
| Staff #5 | Observed feeding resident with mechanical soft diet. |
Inspection Report
Monitoring
Census: 29
Deficiencies: 8
Dec 11, 2023
Visit Reason
An unannounced monitoring inspection was conducted to assess compliance with applicable standards and laws at Colonial Manor assisted living facility.
Findings
The inspection identified multiple areas of non-compliance including lack of documentation for resident personal funds management, incomplete staff orientation records, insufficient staff training, discrepancies in individualized service plans, menu and food supply issues, medication availability problems, and maintenance deficiencies.
Deficiencies (8)
| Description |
|---|
| Facility failed to ensure documentation that residents requested assistance with management of personal funds. |
| Staff record lacked documentation of orientation to facility's organizational structure within seven working days. |
| Staff training relevant to the population in care was incomplete and not documented. |
| Resident individualized service plans did not reflect assessed needs accurately. |
| Items noted on the posted menu were not served as stated and substitutions were not noted. |
| Medications ordered for PRN administration were not available or properly labeled and stored. |
| Furnishings and fixtures were not kept clean or in good repair, including a pipe sealant issue previously cited. |
| Food supply contained expired and dented items. |
Report Facts
Census: 29
Date to be corrected: Jan 5, 2024
Date to be corrected: Feb 15, 2024
Date to be corrected: Dec 15, 2023
Date to be corrected: Jan 9, 2024
Inspection Report
Monitoring
Census: 30
Deficiencies: 5
Nov 29, 2023
Visit Reason
An on-site monitoring inspection was conducted to assess compliance with applicable standards and laws at Colonial Manor assisted living facility.
Findings
The inspection found multiple violations including failure to report major incidents within 24 hours, incomplete fall risk assessments, discrepancies in individualized service plans, unavailability of PRN medications, and lack of required 'No Smoking-Oxygen in Use' signage.
Deficiencies (5)
| Description |
|---|
| Failed to report to the regional licensing office within 24 hours any major incident that negatively impacted or threatened resident safety. |
| Failed to ensure a written fall risk rating was completed by the time the comprehensive individualized service plan was completed. |
| Failed to ensure the resident's individualized service plan included all assessed needs. |
| Failed to ensure medications ordered for PRN administration were available, properly labeled, and properly stored. |
| Failed to post 'No Smoking-Oxygen in Use' sign and enforce smoking prohibition in rooms where oxygen is in use. |
Report Facts
Facility census: 30
Inspection dates: 2
Inspection Report
Monitoring
Census: 30
Deficiencies: 7
Oct 23, 2023
Visit Reason
A joint on-site monitoring inspection was conducted on October 23, 2023, by two inspectors from the Peninsula licensing office to assess compliance with applicable standards and laws.
Findings
The inspection found multiple violations including failure to report major incidents within 24 hours, incomplete tuberculosis risk assessments for staff, outdated first aid/CPR certification listings, lack of psychotropic treatment plans for residents, incomplete private pay uniform assessment instruments, failure to update individualized service plans annually, and background checks not completed prior to employee contact with residents.
Deficiencies (7)
| Description |
|---|
| Failed to report to the regional licensing office within 24 hours any major incident affecting resident safety. |
| Failed to ensure tuberculosis risk assessments were completed and documented for staff prior to work. |
| First aid/CPR certification listing was not current and not properly maintained. |
| Failed to ensure residents with prohibition conditions were not admitted or retained; missing psychotropic treatment plan for medication. |
| Private pay uniform assessment instrument was not completed as required, missing administrator signature. |
| Individualized service plan was not reviewed and updated at least annually or as needed for significant changes. |
| Employees permitted to work in direct contact with residents before background checks were completed. |
Report Facts
Facility census: 30
Dates of hire for staff with background check issues: Staff #5 hired 10-4-23, first day 10-9-23; background check dated 10-11-23; Staff #7 hired 8-25-23; Staff #8 hired 9-21-23
Expired CPR certificates: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Willie Barnes | Licensing Inspector | Contact person for questions regarding the inspection |
| Darunda Flint | Inspector | Current inspector conducting the monitoring inspection |
| Staff #1 | Acknowledged failure to report psychiatric admission and missing TB assessment date | |
| Staff #2 | Acknowledged missing TB assessment date and discrepancies in UAI and ISP | |
| Staff #4 | Acknowledged outdated first aid/CPR listing and missing psychotropic treatment plan |
Inspection Report
Monitoring
Census: 20
Deficiencies: 11
Sep 21, 2023
Visit Reason
An on-site monitoring inspection was conducted to observe medication pass, meal service, tour the facility, and review resident and staff records to assess compliance with applicable standards and laws.
Findings
The inspection found multiple violations including failure to implement infection control measures, incomplete resident admission documentation, failure to report major incidents timely, incomplete individualized service plans, inadequate fall risk assessments, incomplete resident orientation, and nutritional deficiencies in meal service.
Deficiencies (11)
| Description |
|---|
| Failed to ensure implementation of infection control prevention measures; resident's glucometer was not labeled. |
| Failed to provide disclosure statement to resident/legal representative prior to admission. |
| Failed to report major incident to licensing office within 24 hours. |
| Failed to provide written assurance of appropriate license to resident at admission. |
| Failed to ensure no admission or retention of individuals with prohibition conditions per Code of Virginia. |
| Failed to ensure resident's fall risk rating was reviewed annually and after condition changes or falls. |
| Failed to ensure orientation for new residents included all required information and signatures. |
| Failed to ensure annual reassessment and reassessment after significant change using uniform assessment instrument. |
| Failed to ensure individualized service plan included all assessed needs such as pacemaker and mobility aids. |
| Failed to ensure individualized service plan was reviewed and updated at least annually and as needed. |
| Failed to ensure servings of food met USDA guidelines and dietary allowances; residents not provided all menu items. |
Report Facts
Residents present during inspection: 20
Date to be corrected: Oct 2, 2023
Date to be corrected: Sep 21, 2023
Date to be corrected: Oct 15, 2023
Date to be corrected: Oct 3, 2023
Date to be corrected: Sep 22, 2023
Date to be corrected: Nov 15, 2023
Date to be corrected: Oct 5, 2023
Date to be corrected: Oct 10, 2023
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 1
Aug 29, 2023
Visit Reason
The inspection was conducted in response to a complaint received on 2023-08-22 regarding allegations related to resident care, staffing, supervision, and buildings and grounds at the facility.
Findings
The investigation found some areas of non-compliance with regulations, including inadequate staffing levels and knowledge, diversion of direct care staff to kitchen duties due to cook walk-outs, lack of activity staff, and delays in resident transportation due to meal preparation issues. A violation notice was issued based on these findings.
Complaint Details
Complaint related: Yes. The evidence supported some but not all allegations of non-compliance. A violation notice was issued.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure adequate staff knowledge, skills, abilities, and sufficient numbers to provide services to maintain residents' well-being as determined by assessments and individualized service plans. |
Report Facts
Residents present: 31
Staff available: 2
Residents interviewed: 4
Staff interviewed: 2
Inspection Report
Monitoring
Census: 31
Deficiencies: 14
Aug 29, 2023
Visit Reason
An on-site Monitoring Inspection was conducted on August 29, 2023, to assess compliance with applicable standards and laws at the assisted living facility.
Findings
The inspection found multiple violations including failures in infection control, incident reporting, tuberculosis screening, annual reassessments, individualized service plan updates, medication administration, medication storage security, use of medical restraints, hazardous materials storage, facility maintenance, fire drill documentation, and employee background checks.
Deficiencies (14)
| Description |
|---|
| Failed to ensure implementation of infection control prevention measures. |
| Failed to report major incidents to the regional licensing office within 24 hours. |
| Failed to ensure tuberculosis risk assessment documentation for staff prior to work. |
| Failed to ensure annual reassessment using the uniform assessment instrument (UAI). |
| Failed to ensure individualized service plans were reviewed and updated at least annually. |
| Failed to ensure menus for meals and snacks were dated and posted conspicuously. |
| Failed to ensure medications were started, changed, or discontinued only with valid physician orders. |
| Failed to ensure medication storage areas were locked. |
| Failed to ensure medication was administered according to the facility's dosing schedule. |
| Failed to ensure medical restraints were used only with physician orders and resident consent. |
| Failed to ensure hazardous materials were stored in a locked area. |
| Failed to maintain the building in good repair and keep it clean and free of rubbish. |
| Failed to ensure fire and emergency evacuation drills were conducted and documented as required. |
| Failed to ensure employees had completed required background checks before working unsupervised. |
Report Facts
Medication administration days not according to schedule: 13
Medication administration days not according to schedule: 14
Facility census: 31
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Willie Barnes | Licensing Inspector | Contact person for questions regarding the inspection. |
Inspection Report
Monitoring
Census: 31
Deficiencies: 7
Jul 31, 2023
Visit Reason
An on-site monitoring inspection was conducted to review compliance with applicable standards and laws, including administration, personnel, resident care, and emergency preparedness.
Findings
The inspection found multiple violations including lack of documented direct care staff training, failure to provide scheduled activities, non-operational air conditioning units in several areas, inadequate lighting, and failure to post recent inspection findings. Several violations were repeats from a prior inspection.
Deficiencies (7)
| Description |
|---|
| Facility failed to ensure a written plan for supervision of direct care staff who have not met training requirements. |
| Facility failed to ensure the scheduled activity was provided as noted in the activity schedule. |
| Facility failed to ensure at least one movable thermometer was available for measuring room temperatures. |
| Facility failed to ensure the air conditioning unit was operational throughout the facility. |
| Facility failed to ensure all interior was adequately lighted for safety and comfort of residents and staff. |
| Facility failed to ensure glare was kept to a minimum in rooms used by residents by providing covering on the lights. |
| Facility failed to ensure that the findings of the most recent inspections are posted in the facility. |
Report Facts
Facility census: 31
Inspection dates: Inspection conducted on July 31, 2023 and August 16, 2023
Inspection Report
Monitoring
Census: 32
Deficiencies: 15
Jun 30, 2023
Visit Reason
An on-site monitoring inspection was conducted to review compliance with applicable standards and laws, including personnel, staffing, resident care, emergency preparedness, and background checks.
Findings
The inspection found multiple violations related to staff orientation and training, supervision plans, resident admission documentation, physical examinations, individualized service plans, activity provision, resident identification, facility maintenance, air conditioning operation, and background checks.
Deficiencies (15)
| Description |
|---|
| Failed to ensure orientation and training occurred within the first seven working days of employment. |
| Failed to ensure a written plan for supervision of direct care staff who have not met qualifications. |
| Failed to ensure staff personal records included verification of receipt of current job description. |
| Failed to ensure administrator provided written assurance of appropriate license to residents prior to admission. |
| Failed to ensure resident physical examination and risk assessment were completed prior to admission. |
| Failed to ensure resident records included acknowledgment of orientation to emergency procedures, mealtimes, and call system. |
| Failed to ensure uniform assessment instrument was completed for public pay individuals by qualified assessor. |
| Failed to ensure preliminary plan of care was signed and dated by licensee or legal representative. |
| Failed to ensure individualized service plan was signed, dated, and included assessed needs. |
| Failed to ensure scheduled activity was provided or substituted as noted on activity calendar. |
| Failed to ensure current picture or narrative physical description of resident was available for identification. |
| Failed to ensure furnishings, fixtures, and equipment were kept clean and in good repair. |
| Failed to ensure at least one movable thermometer was available to measure room temperatures. |
| Failed to ensure air conditioning units were operational throughout the facility. |
| Failed to ensure no employee worked in direct contact with residents without a completed background check. |
Report Facts
Inspection dates: 3
Facility census: 32
Staff without orientation documentation: 2
Staff without qualifications documentation: 2
Residents without written assurance documentation: 3
Residents without physical exam or risk assessment prior to admission: 3
Residents without orientation documentation: 3
Residents without completed uniform assessment instrument: 1
Residents without signed preliminary plan of care: 1
Residents without signed individualized service plan: 1
Scheduled activities not provided: 1
Residents without current picture or physical description: 1
Air conditioning units total: 6
Air conditioning units working: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff #3 | Acknowledged kitchen maintenance issues and AC unit problems | |
| Staff #1 | Reported AC unit status and repairs needed | |
| Staff #5 | Lacked documentation of qualifications to provide direct care | |
| Staff #6 | Lacked orientation and training documentation and job description receipt | |
| Staff #7 | Lacked orientation and training documentation, job description receipt, and background check | |
| Staff #8 | Lacked job description receipt | |
| Staff #9 | Lacked documentation of qualifications and direct care training |
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 2
Jun 30, 2023
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received on 2023-06-28 regarding allegations of pest control issues in the building and grounds area.
Findings
The investigation supported the allegation of non-compliance related to pest control, specifically bed bug infestations. Violations were issued for failure to report major incidents within 24 hours and failure to maintain the building free of infestations. Residents were relocated due to bed bugs, and pest control treatments were conducted.
Complaint Details
The complaint was substantiated. The facility was found to have bed bug infestations and failed to report the incident timely. Residents were relocated from affected rooms, and pest control treatments were initiated.
Deficiencies (2)
| Description |
|---|
| Facility failed to report the regional licensing office within 24 hours any major incident that has negatively affected or threatens the life, health, safety or welfare of any resident. |
| Facility failed to ensure the building was kept free of infestations of insects and vermin. |
Report Facts
Number of residents present: 32
Inspection dates: 3
Number of staff interviews: 3
Bed bug treatment dates: 2
Inspection Report
Monitoring
Census: 32
Deficiencies: 15
May 4, 2023
Visit Reason
An unannounced monitoring inspection was conducted to review compliance with applicable standards and laws at Colonial Manor assisted living facility.
Findings
The inspection found multiple violations including failure to provide required disclosures to residents, inadequate staff training and certifications, incomplete resident records, failure to post current activity schedules, improper storage of hazardous materials, and maintenance issues with facility furnishings and equipment.
Deficiencies (15)
| Description |
|---|
| Facility failed to provide a disclosure statement to prospective resident and legal representative with documentation in resident's record. |
| Administrator supervising medication aides lacked documentation of required annual medication administration training. |
| Staff did not complete required 18 hours of annual training including infection control. |
| Staff lacked current certification in first aid. |
| No documented interview and mental health assessment for resident admissions. |
| Facility failed to provide written assurance of appropriate license to resident and legal representative at admission. |
| Resident orientation documents were incomplete or unsigned by resident, legal representative, or facility. |
| Uniform assessment instrument for private pay resident was incomplete and unsigned by assessor and reviewer. |
| Individualized service plans were completed by staff without required ISP training or authorization. |
| Resident health care service needs were not fully met or documented, including missing documentation of PT/OT services. |
| Current month activity schedule was not posted or available to residents and families. |
| Staff records lacked documentation of annual review of resident rights and responsibilities. |
| Food servings did not meet USDA guidelines considering age, sex, and activity of residents. |
| Cleaning supplies and hazardous materials were stored in unlocked areas accessible to residents. |
| Furnishings, fixtures, and equipment were not kept clean or in good repair, including damaged counters, missing toilet parts, and unclean refrigerators. |
Report Facts
Facility census: 32
Resident admission date: Jan 21, 2023
Resident admission date: Jan 5, 2023
Dementia training hours: 12
Serving size: 3.25
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 5
Feb 10, 2023
Visit Reason
An unannounced complaint inspection was conducted on February 10, 2023, following a complaint received by VDSS Division of Licensing on February 3, 2023, regarding allegations in resident care and related services, buildings and grounds, and nutrition.
Findings
The investigation supported some but not all allegations, identifying areas of non-compliance with standards and laws. Violations included inadequate staffing levels and knowledge, failure to conduct required annual reassessments, incomplete individualized service plans, and maintenance issues such as a non-working dryer.
Complaint Details
The complaint was substantiated in part; some allegations were supported by evidence while others were not. A violation notice was issued with opportunity for plan of correction submission.
Deficiencies (5)
| Description |
|---|
| Facility failed to ensure adequate staff knowledge, skills, abilities, and sufficient numbers to provide required services. |
| Facility failed to ensure annual reassessment and reassessment after significant change using the uniform assessment instrument (UAI). |
| Facility failed to ensure individualized service plan (ISP) was completed by trained personnel and was accurate. |
| Facility failed to ensure ISP was reviewed and updated at least annually and as needed for significant resident condition changes. |
| Facility failed to ensure all furnishings, fixtures, and equipment were kept clean and in good repair; specifically, laundry room dryer was not working. |
Report Facts
Number of residents present: 34
Number of resident records reviewed: 2
Number of staff records reviewed: 0
Number of resident interviews: 3
Number of staff interviews: 3
Facility census: 33
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Willie Barnes | Licensing Inspector | Contact person for questions regarding the inspection |
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 6
Dec 16, 2022
Visit Reason
The inspection was an unannounced complaint investigation conducted due to allegations received on 11-29-2022 and 10-11-2022 regarding staffing, resident care, and building conditions at the facility.
Findings
The investigation found multiple violations including the administrator not being present full-time as required, inadequate staffing levels to meet resident needs, lack of documentation indicating who was in charge during absences, failure to post dated menus and document substitutions, and building maintenance issues such as pest control and a non-functioning bathroom.
Complaint Details
The complaint investigation was substantiated with violations found related to staffing, administrator presence, resident care, and building maintenance.
Deficiencies (6)
| Description |
|---|
| Administrator did not serve on a full-time basis as the on-site agent and lacked a schedule documenting presence. |
| Facility failed to ensure adequate staff knowledge, skills, abilities, and sufficient numbers to meet resident needs. |
| Written work schedule did not indicate who was in charge at any given time. |
| Menus and snacks for the current week were not dated or posted in a conspicuous area; substitutions not documented. |
| Facility failed to keep the building free of infestations of insects and vermin; pest control documentation was not provided. |
| Furnishings, fixtures, and equipment including a public bathroom were not kept clean or in good repair; bathroom was out of order for at least a week. |
Report Facts
Facility census: 33
Administrator hours: 21
Administrator hours: 30
Administrator hours: 16.5
Administrator hours: 25
Administrator hours: 35
Administrator hours: 24
Administrator hours: 34.5
Administrator hours: 23
Administrator hours: 23.5
Administrator hours: 31
Administrator hours: 16.5
Administrator hours: 30
Inspection Report
Renewal
Census: 35
Capacity: 85
Deficiencies: 23
Jul 20, 2022
Visit Reason
An on-site unannounced renewal inspection was conducted to assess compliance with applicable standards and regulations for license renewal.
Findings
The inspection found multiple areas of non-compliance including failure to report major incidents timely, incomplete staff orientation and training, missing documentation for medication administration training, incomplete resident treatment plans, outdated tuberculosis risk assessments, incomplete fall risk updates, medication management issues, and facility maintenance deficiencies.
Deficiencies (23)
| Description |
|---|
| Facility failed to report major incidents to licensing office within 24 hours for three of seven records reviewed. |
| Facility failed to ensure orientation and training occurred within first seven working days for staff #13 and #14. |
| Administrator did not have documentation of required annual medication administration training. |
| Direct care staff did not attend at least 18 hours of annual training. |
| Facility failed to maintain complete personnel records for staff #13 and #14. |
| Staff failed to submit tuberculosis risk assessment within seven days prior to first day of work. |
| Written work schedule did not include names, job classifications, or indicate person in charge for shifts. |
| Posting of current on-site person in charge was not updated. |
| Facility admitted or retained individuals with prohibitive conditions without complete treatment plans. |
| Tuberculosis risk assessments for residents were not completed annually as required. |
| Fall risk ratings were not reviewed and updated after each fall. |
| Uniformed Assessment Instrument (UAI) was not completed or signed as required for residents. |
| Individualized service plans (ISP) were not reviewed and updated at least annually or as needed. |
| Rights and responsibilities of residents and staff were not reviewed annually or documented. |
| Facility did not have a current annual health inspection from the Virginia Department of Health. |
| Medication management plan was not implemented to ensure timely filling and refilling of prescriptions. |
| Medication was not kept in pharmacy issued container with prescription label until administered. |
| Written Do Not Resuscitate (DNR) order was not accurately completed as required. |
| Interior of building was not maintained in good repair and clean; bathroom door knob missing and faucet leaking. |
| Fire and emergency evacuation drawings did not include location of telephones. |
| Facility did not maintain a 96-hour supply of emergency food and drinking water with at least 48 hours on site. |
| Findings of the most recent inspection were not posted in the facility. |
| Criminal history record reports were not obtained within 30 days of employment for several staff. |
Report Facts
Inspection dates: 3
Facility census: 35
Facility licensed capacity: 85
Medication unavailability days: 9
Emergency food items: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Willie Barnes | Licensing Inspector | Contact person for questions about the inspection |
| Darunda Flint | Inspector | Current inspector conducting the inspection |
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 7
Jul 20, 2022
Visit Reason
The inspection was an unannounced complaint investigation conducted due to allegations received on 2022-07-11 regarding staffing and resident care issues including food, medication, and wandering/elopement.
Findings
The investigation found multiple violations including failure to report major incidents timely, inadequate staffing and medication administration, incomplete tuberculosis risk assessments, failure to update fall risk ratings, incomplete Uniform Assessment Instruments (UAI), failure to update individualized service plans (ISP), and medication administration errors.
Complaint Details
The complaint was substantiated. Evidence supported allegations of non-compliance with standards related to staffing, resident care, medication administration, and safety incidents including elopement and falls.
Deficiencies (7)
| Description |
|---|
| Facility failed to report to the licensing office within 24 hours any major incident affecting resident safety, including an elopement incident and unreported injuries. |
| Facility failed to ensure adequate staffing with knowledge and numbers to provide required services, resulting in missed medication administration. |
| Facility failed to complete annual tuberculosis risk assessments for residents. |
| Facility failed to update resident fall risk ratings after falls. |
| Facility failed to complete and sign Uniform Assessment Instruments (UAI) as required. |
| Facility failed to update individualized service plans (ISP) at least annually and as needed. |
| Facility failed to administer medications according to the facility's dosing schedule, resulting in missed or late doses. |
Report Facts
Number of residents present: 35
Number of resident records reviewed: 2
Number of staff interviews conducted: 5
Number of resident interviews conducted: 2
Number of Registered Medication Aides in training: 4
Number of Registered Medication Aides hired: 1
Number of medications missed or administered late: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Willie Barnes | Licensing Inspector | Contact person for questions regarding the inspection |
| Darunda Flint | Inspector | Current inspector conducting the complaint inspection |
Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 1
Apr 29, 2022
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on April 29, 2022, regarding allegations related to administration and administrative services, specifically resident personal spending funds.
Findings
The investigation found that the facility failed to maintain a written accounting of money received and disbursed for a resident, and the resident had not received personal funds since December 2021 despite requests. Violations were issued based on these findings.
Complaint Details
The complaint was substantiated. Evidence showed a resident had not received personal funds since December 2021 despite requests, and documentation of disbursements was missing from the resident's record.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure it maintained a written accounting of money received and disbursed by the licensee, administrator, or staff that shows a current balance, made available quarterly and upon request, and placed in the resident's record. |
Report Facts
Resident personal fund amount: 82
Resident personal fund amount: 80
Census: 30
Inspection Report
Monitoring
Census: 40
Deficiencies: 9
Mar 28, 2022
Visit Reason
An unannounced monitoring inspection was conducted on March 28 and 29, 2022, to review compliance with various administrative, personnel, resident care, and medication management standards.
Findings
The inspection identified multiple deficiencies including failure to post the current license, inadequate annual training documentation for certified nurse aides, lack of written work schedules for all staff, incomplete individualized service plans for residents, expired medications on the medication cart, unlocked medication storage areas, pre-pouring medications before administration, and failure to act on pharmacy recommendations.
Deficiencies (9)
| Description |
|---|
| Facility failed to ensure the current license was posted in a conspicuous place. |
| Direct care staff did not attend the required 12 hours of annual training. |
| Facility failed to maintain a written work schedule including names, job classifications, and person in charge. |
| Facility admitted or retained individuals with prohibitive conditions or care needs without proper treatment plans. |
| Individualized service plans did not include all assessed needs for residents. |
| Facility failed to prevent use of outdated, damaged, or contaminated medications. |
| Medication storage area was not locked as required. |
| Medications were not kept in pharmacy-issued containers with labels until administration. |
| Facility failed to take action on pharmacy review recommendations and document in resident records. |
Report Facts
Facility census: 40
Annual training hours documented: 9
Medication expiration date: 2022
Inspection dates: 2
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 4
Mar 28, 2022
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received on 2022-03-20 regarding allegations related to resident food and meal services at the facility.
Findings
The investigation found multiple violations including failure to provide meals as per the posted menu, insufficient food quantities to meet residents' needs, lack of a current diet manual, and inadequate emergency food and water supplies. Violations were substantiated and corrective actions were required.
Complaint Details
The complaint was substantiated based on evidence gathered during the inspection, including observations, staff and resident interviews, and document reviews related to food service and emergency supplies.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure menus and snacks matched posted menus, with undocumented substitutions and additions. |
| Facility failed to ensure daily menu and snacks met USDA food guidance or dietary allowances considering resident age, sex, and activity. |
| Facility failed to maintain a current and readily available diet manual for food preparation personnel. |
| Facility failed to ensure availability of a 96-hour supply of emergency food and drinking water, with less than 48 hours on site. |
Report Facts
Residents present: 40
Emergency food supply cans: 2
Emergency food supply cans: 6
Emergency food supply cans: 4
Emergency food supply cans: 1
Emergency food supply cans: 4
Emergency food supply cans: 3
Emergency food supply cans: 3
Oatmeal containers: 4
Peanut butter containers: 2
Bread loaves: 9
Corn flakes boxes: 2
Inspection Report
Complaint Investigation
Deficiencies: 1
Dec 15, 2021
Visit Reason
An unannounced complaint inspection was conducted in response to a complaint received by the regional licensing office regarding an allegation of resident care.
Findings
The investigation did not support the complaint allegation, determining it to be not valid; however, other violations were cited, including failure to report major incidents affecting resident health or safety within 24 hours to the licensing office.
Complaint Details
Complaint was investigated and determined to be not valid based on the information gathered during the inspection.
Deficiencies (1)
| Description |
|---|
| Facility failed to report to the regional licensing office within 24 hours any major incident that negatively affected or threatened the life, health, safety, or welfare of any resident, specifically regarding sacral wounds of residents #1 and #2. |
Report Facts
Plan of correction due date: Jan 9, 2022
Inspection date: Dec 15, 2021
Inspection Report
Renewal
Census: 41
Deficiencies: 10
Dec 15, 2021
Visit Reason
An unannounced renewal inspection was conducted to assess compliance with assisted living facility regulations, including administration, staffing, resident care, emergency preparedness, and other standards.
Findings
The inspection identified multiple deficiencies including failure to post first aid and CPR certified staff listings, incomplete dietary schedules, lack of posting of the on-site person in charge, incomplete tuberculosis risk assessments, inadequate meal portions and nutritional oversight, failure to act on pharmacy recommendations, poor maintenance and cleanliness of the facility, missing poison control phone numbers, and incomplete first aid kits.
Deficiencies (10)
| Description |
|---|
| Facility failed to ensure the first aid and cardiopulmonary resuscitation (CPR) listing was posted. |
| Facility failed to ensure the written work schedule included names and job classifications of all staff with indication of person in charge. |
| Facility failed to post the name of the current on-site person in charge in a conspicuous place. |
| Facility failed to ensure annual tuberculosis risk assessment was completed for a resident. |
| Facility failed to ensure daily menu met USDA food guidance system or dietary allowances considering resident age, sex, and activity. |
| Facility failed to take action on recommendations noted in nutritional oversight report and document in resident records. |
| Facility failed to take action on pharmacy review recommendations and document in resident records. |
| Facility failed to maintain interior of building in good repair and cleanliness. |
| Facility failed to post telephone number for Poison Control Center by medication room/nursing station phone. |
| Facility failed to ensure first aid kit included all required items. |
Report Facts
Census: 41
Deficiencies cited: 10
Inspection Report
Complaint Investigation
Deficiencies: 1
Dec 15, 2021
Visit Reason
An unannounced complaint inspection was conducted on December 15, 2021, regarding an allegation that residents were not receiving personal fund resources from stimulus income.
Findings
The investigation found non-compliance with regulations related to maintaining accounting of residents' personal funds. The facility failed to provide detailed accounting statements showing money deposited, disbursed, and remaining balances for residents' personal funds.
Complaint Details
The complaint was substantiated as the evidence supported non-compliance with standards regarding residents' personal fund management.
Deficiencies (1)
| Description |
|---|
| Facility failed to maintain accounting of money received and disbursed that shows a current balance, and did not provide residents with required personal fund accounting statements. |
Report Facts
Inspection Dates: 5
Plan of Correction Due Date: 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Darunda Flint | Inspector | Named as the current inspector conducting the complaint investigation. |
| Staff #1 | Named in findings related to management and access of residents' debit cards and personal fund accounts. | |
| Staff #2 | Named as the staff who faxed documents to the office on Feb. 11, 2022. |
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 1
Oct 5, 2021
Visit Reason
A non-mandated complaint investigation was conducted due to concerns about insufficient staffing at the facility.
Findings
The investigation found that the facility failed to ensure adequate staffing in knowledge, skills, and numbers to meet residents' needs, including documented instances of only one staff member on duty during a night shift for 43 residents. Violations were issued based on these findings.
Complaint Details
The complaint investigation was substantiated with evidence supporting non-compliance related to insufficient staffing. The complaint was related to staffing shortages on the night of 9-11-21, including only one staff member present for the 10 p.m. to 6 a.m. shift.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure it had staff adequate in knowledge, skills and abilities and sufficient in numbers to provide services to attain and maintain the physical, mental and psychological well-being of each resident as determined by resident assessments and individualized service plans. |
Report Facts
Residents present: 43
Residents receiving hospice services: 6
Non-ambulatory residents: 3
Residents documented as fall risk: 14
Residents requiring 30-minute checks: 4
Staff on duty: 1
Staff documented on roster: 2
Inspection Report
Renewal
Census: 45
Deficiencies: 3
Jan 31, 2021
Visit Reason
A renewal inspection was initiated on 2021-01-14 and concluded on 2021-01-26 using an alternate remote protocol due to a state of emergency health pandemic declared by the Governor of Virginia.
Findings
The inspection identified non-compliances with applicable standards or law, including deficiencies in resident physical examination documentation and individualized service plans (ISP) not reflecting all assessed needs or hospice care services.
Deficiencies (3)
| Description |
|---|
| The facility failed to ensure the physical examination form included all required information for one of three resident records. |
| The facility failed to ensure the individualized service plan (ISP) included all assessed and documented needs for two of three residents. |
| The facility failed to ensure when hospice care is provided to a resident, the services provided were included on the individualized service plan. |
Report Facts
Census: 45
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Darunda Flint | Inspector | Current inspector conducting the inspection |
| Staff #1 | Acknowledged missing information on physical examination form and ISP documentation |
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