Inspection Reports for Discovery Village at the West End

The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-10-28 regarding allegations in the areas of resident care, resident accommodations, buildings and grounds, and complaint investigation.

The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. No violation notice was issued.

Complaint investigation related to allegations in resident care and related services, resident accommodations, buildings and grounds, and complaint investigation. The complaint was not substantiated.

The inspection was conducted as a complaint investigation following a self-reported incident received by VDSS Division of Licensing on 2025-08-12 regarding allegations in staffing and supervision, resident care and related services, protection of adults and reporting, and complaint investigation.

The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law. No violation notice was issued.

The complaint investigation was triggered by a self-reported incident alleging issues in staffing and supervision, resident care, protection of adults, and complaint investigation. The investigation included review of resident and staff records, interviews, and internal investigation documents. The complaint was not substantiated.

The inspection was conducted due to a complaint received by VDSS Division of Licensing on 2025-07-08 regarding self-report in the areas of resident accommodations, buildings and grounds, and complaint investigation.

The licensing inspector toured the facility including the Memory Care Unit and resident rooms, observing flooring, closets, bathrooms, ceilings, air quality, and temperature. The evidence gathered did not support the allegation of non-compliance with standards or law.

Complaint was related to self-report in resident accommodations, buildings and grounds, and complaint investigation. The complaint was not substantiated.

The inspection was conducted following a self-reported incident received by VDSS Division of Licensing regarding allegations in personnel, staffing and supervision, and resident care and related services.

The investigation supported the self-report of non-compliance with standards or law, resulting in violations issued. One staff member was terminated due to poor customer service, and the allegation of abuse was determined to be unsubstantiated.

The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-01-30 regarding allegations related to resident care, accommodations, and complaint investigation.

The investigation found no evidence to support the allegations of non-compliance with standards or law. The inspection findings will be posted publicly and a copy is required to be posted at the facility.

Complaint investigation triggered by allegations in resident care, accommodations, and complaint investigation areas. The evidence did not substantiate the complaint.

The inspection was a monitoring visit conducted to review compliance with various administrative, personnel, resident care, emergency preparedness, and other regulatory provisions for an assisted living facility.

The inspection found no violations of applicable standards or laws. The licensing inspector conducted a thorough tour, observations, and record reviews, concluding that the facility was in compliance.

The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2024-09-23 regarding allegations related to staffing and supervision, resident care and related services, resident accommodations, and complaint investigation.

The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. No deficiencies were cited as a result of this complaint investigation.

Complaint investigation related to allegations in staffing and supervision, resident care and related services, resident accommodations, and complaint investigation. The allegations were not substantiated.

The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 09/23/2024 regarding allegations in the areas of Personnel, Staffing and Supervision, Resident Care and Related Services, Resident Accommodations and Related Provisions, Protection of Adults and Reporting, and Complaint Investigation.

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 related inspection triggered by allegations in Personnel, Staffing and Supervision, Resident Care and Related Services, Resident Accommodations and Related Provisions, Protection of Adults and Reporting, and Complaint Investigation. The allegations were not substantiated.

The inspection was conducted in response to a complaint received on 2024-08-28 regarding allegations related to Personnel, Staffing and Supervision, Resident Care and Related Services, Protection of Adults and Reporting, and Complaint Investigation.

The investigation found no evidence to support the allegations of non-compliance with standards or law. The inspection findings were negative for deficiencies.

Complaint received on 2024-08-28 regarding Personnel, Staffing and Supervision, Resident Care and Related Services, Protection of Adults and Reporting, and Complaint Investigation. The evidence gathered did not support the allegations.

The inspection was conducted in response to a complaint received by the VDSS Division of Licensing on July 30, 2024, regarding allegations in the areas of Resident Care and Related Services, Resident Accommodations and Related Provisions, Buildings and Grounds, and Complaint Investigation.

The licensing inspector toured the facility, including the building and grounds, and conducted interviews with residents and staff. Observations found the nurses' offices and residents' rooms to be clean and orderly. The evidence gathered did not support the allegations of non-compliance with standards or law.

The complaint was investigated but the evidence did not support the allegations of non-compliance.

The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 07/29/2024 regarding allegations related to Resident Care and Related Service, Resident Accommodations and Related Provisions, and Complaint Investigation.

The investigation found no evidence to support the allegations of non-compliance with standards or law. The facility was observed to have PPE supplies available, and COVID-19 cases were managed appropriately with residents and staff isolated as needed.

Complaint related to Resident Care and Related Service, Resident Accommodations and Related Provisions, and Complaint Investigation. The allegations were not substantiated based on the evidence gathered during the inspection.

The inspection was a monitoring visit conducted on July 1, 2024, following a self-reported incident received on June 25, 2024, regarding allegations in staffing and supervision and resident care and related services.

The facility completed an independent investigation of the incident, and the findings were unfounded. The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law.

The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2024-05-17 regarding allegations in the areas of Staffing and Supervision, Resident Care and Related Services, and Complaint Investigation.

The evidence gathered during the investigation did not support the allegation of non-compliance with standards or law. The inspection summary will be posted to the VDSS website within 5 business days of receipt.

Complaint received on 2024-05-17 regarding Staffing and Supervision, Resident Care and Related Services, and Complaint Investigation. The allegations were not substantiated.

The inspection was conducted as a complaint investigation following a complaint received on 2024-01-03 regarding allegations in Resident Care and Related Services and Administration and Administrative Services.

The investigation supported the allegations of non-compliance, resulting in violations issued related to individualized service plans not being signed or updated following significant changes in resident condition. The Executive Director was cooperative and provided requested documentation.

The complaint was substantiated based on evidence gathered during the investigation, supporting non-compliance with standards related to resident care and administrative services.

The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2024-01-25 regarding allegations in the areas of Administration and Administrative Service and Resident Care and Related Services.

The evidence gathered during the investigation did not support the allegation of non-compliance with standards or law. The Executive Director was accommodating and provided all requested documentation.

Complaint investigation related to allegations in Administration and Administrative Service and Resident Care and Related Services; the complaint was not substantiated.

The inspection was a renewal visit conducted to assess compliance with applicable standards and laws for the facility's license renewal.

The inspection found non-compliance with several standards related to staff qualifications, annual training, and inclusion of Do Not Resuscitate (DNR) orders in resident service plans. Violations were documented and a plan of correction was requested.

The inspection was a monitoring visit conducted following a self-reported incident received by VDSS Division of Licensing regarding allegations in the area of Resident Care and Related Services.

The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law. The inspection findings will be posted publicly and an exit meeting was planned to review the findings.

The inspection was conducted in response to a complaint received on 2023-03-13 regarding allegations in the area of Resident Care and Related Services.

The investigation supported the allegation of non-compliance with standards or law, resulting in violations issued. Specific deficiencies included failure to ensure proper assessment prior to admission to the safe, secure environment, retention of individuals presenting imminent physical threat, and failure to have prescriber's verbal orders signed within 14 days.

The complaint was substantiated based on evidence gathered during the investigation, supporting allegations of non-compliance in Resident Care and Related Services.

The inspection was a renewal inspection conducted to assess compliance with applicable standards and laws for the facility's continued licensing.

The inspection found non-compliance with applicable standards or laws, resulting in documented violations. Two specific deficiencies were noted related to resident safety and individualized service plan updates.

The inspection was a monitoring visit conducted on March 21, 2023, following a self-reported incident received on January 23, 2023 regarding allegations in the area of Resident Care and Related Services.

The inspection determined non-compliance with applicable standards related to the comprehensive Individual Service Plan (ISP), specifically the failure to include a description of identified needs based on the uniform assessment instrument (UAI).

The inspection was conducted as a complaint investigation following a complaint received on 2023-01-17 regarding allegations in the areas of Resident Care and Related Services.

The investigation supported the allegation of non-compliance with facility policies and regulatory standards, resulting in violations related to elopement prevention, failure to report major incidents within 24 hours, and failure to ensure attention to specialized resident needs including wandering.

The complaint was substantiated. Evidence included interviews and record reviews confirming a resident left the facility unaccompanied and the incident was not reported to the licensing office within 24 hours.

The inspection was conducted as a complaint investigation following a complaint received on 2022-12-06 regarding allegations in the area of Resident Care and Related Services.

The investigation supported some, but not all, of the allegations, identifying non-compliance in Admission, Retention and Discharge of Residents and Resident Care and Related Services. Violations were found related to incomplete documentation of residents' allergy reactions and failure to update the uniform assessment instrument (UAI) after significant changes in resident condition.

The complaint was received by VDSS Division of Licensing on 2022-12-06 regarding allegations in Resident Care and Related Services. The evidence supported some allegations. A violation notice was issued.

The inspection was conducted in response to a complaint received on 2022-12-06 regarding allegations in the areas of Resident Care and Related Services and Additional Requirements for Facilities That Care for Adults with Serious Cognitive Impairments.

The investigation supported some, but not all, of the allegations. Non-compliance was found in Resident Care and Related Services and additional requirements for facilities caring for adults with serious cognitive impairments. A violation notice was issued.

Complaint related: Yes. The complaint was substantiated in part, with evidence including staff acknowledgment that MARs could be denied to residents due to privacy concerns, and a legal representative reporting repeated denial of access to the MAR despite being the responsible party.

The inspection was conducted in response to a complaint received on July 18, 2022, regarding allegations in the areas of Administration and Administrative Services, Resident Care and Related Services, and Additional Requirements for Facilities that Care for Adults with Serious Cognitive Impairments.

The investigation found some areas of non-compliance with standards or laws related to Administration and Administrative Services and Resident Care and Related Services. Specifically, the facility failed to follow its Fall Management Program policy for multiple residents and did not complete a comprehensive individualized service plan within 30 days after admission for one resident.

Complaint was substantiated in part; evidence supported non-compliance in Administration and Administrative Services and Resident Care and Related Services. A violation notice was issued.

The inspection was a monitoring visit conducted on August 11, 2022, following a self-reported incident received on July 22, 2022, regarding allegations in the area of Resident Care and Related Services.

The investigation supported the self-report of non-compliance with multiple standards related to resident care, including failure to properly document private duty personnel services, update the uniform assessment instrument (UAI) and individualized service plans (ISP) after significant changes in resident condition, and ensure supervision of residents with specialized needs such as wandering. Violations were cited and plans of correction were requested.

The inspection was a monitoring visit conducted on August 11, 2022, to assess compliance with applicable standards and laws at Discovery Village at the West End.

The inspection found no violations of applicable standards or laws. The inspection summary will be posted publicly within five business days.

The inspection was conducted in response to a complaint received by VDSS Division of Licensing on May 7, 2022, regarding allegations in the areas of Resident Care and Related Services, and Buildings and Grounds.

The evidence gathered during the investigation did not support the allegation of non-compliance with standards or law. An exit meeting will be conducted to review the inspection findings.

Complaint received on May 7, 2022 regarding Resident Care and Related Services, and Buildings and Grounds. The investigation did not substantiate the allegations.

An unannounced renewal inspection was conducted at the facility to review compliance with regulations including personnel, resident care, emergency preparedness, and additional requirements for adults with serious cognitive impairments.

The inspection identified multiple deficiencies including failure to provide required dementia training to direct care staff, incomplete tuberculosis risk assessments, inadequate individualized service plans, incomplete fire and emergency evacuation documentation, and delayed criminal history record reports for employees.

An unannounced monitoring inspection was conducted in response to self-reported incidents of resident elopement.

Violations were found related to the facility's failure to ensure the preliminary plan of care addressed the resident's basic needs, failure to provide attention to specialized needs such as wandering, and failure to specify minimal frequency of daily rounds for residents unable to use signaling devices.

An unannounced complaint investigation was conducted regarding call bells not being operational at the facility.

Violations were found related to the failure to keep all equipment in good repair and failure to ensure signaling devices accessible to residents alerted staff when assistance was needed.

The investigation was complaint-related and substantiated by observations and staff interviews confirming malfunctioning call bell pull cords and signaling devices.

A monitoring inspection was conducted in response to a self-reported incident regarding resident care and related services.

The facility failed to comply with its Controlled Substance Accountability policy regarding narcotic supply limits and medication administration qualifications. Additionally, medications were not always kept in pharmacy-issued containers, and a missing narcotic incident was identified.

A non-mandated self-report inspection was initiated due to a self-reported incident regarding allegations in the areas of resident care and related services. The inspection included an on-site observation and investigation of compliance with relevant regulations and facility policies.

The investigation supported the self-report of non-compliance with standards or law, resulting in violations issued related to failure to report an alleged abuse incident, failure to update fall risk rating after a fall, and failure to ensure timely refill of resident prescription medications.

A non-mandated self-report inspection was initiated due to a self-reported incident regarding allegations in the areas of resident care and related services. The inspection was conducted to investigate these allegations and ensure compliance with standards or law.

The investigation found non-compliance with standards related to controlled substances accountability and medication storage. Specifically, the facility failed to ensure accurate counts of controlled substances during staff changes and failed to keep medications in pharmacy-issued containers with proper labeling until administered.

The visit was complaint-related as a self-reported incident was received by the department. The evidence supported the self-report of non-compliance with standards or law.

A focused monitoring inspection was conducted to follow up on the facility's Intensive Plan of Correction (IPOC) regarding medication administration.

The inspection determined no violations with applicable standards or law. No violations were issued.

A complaint inspection was initiated due to allegations regarding resident care, staffing, and buildings and grounds at the facility.

The investigation did not support all allegations of non-compliance, but a violation was found related to resident care for one resident regarding insufficient bathing frequency.

Complaint related: Yes. A complaint was received regarding resident care, staffing, and buildings and grounds. The evidence did not support all allegations, but a violation was issued for resident care.

A renewal inspection as well as a monitoring inspection in follow-up to a previously issued high-risk violation notice was initiated on March 5, 2021 and concluded on March 10, 2021.

The inspection determined no violations with applicable standards or law. No violations were issued.

This monitoring inspection was conducted as a follow-up to a previously issued high-risk violation notice from November 24, 2020, to verify correction of medication administration documentation deficiencies.

The inspection found non-compliance with medication administration documentation standards, specifically missing documentation for administration or omission of medications for Resident #1 on January 5 and January 9, 2021.

This monitoring inspection was conducted as a follow-up to a previously issued high-risk violation notice dated October 14, 2020, and as a monitoring inspection for the facility's Conditional license. The inspection was initiated on November 23, 2020 and concluded on November 24, 2020.

The inspection found non-compliance with medication administration standards, specifically that medications were not administered according to physician's orders as documented in resident records and Medication Administration Records. Violations were documented and a plan of correction was requested.