Inspection Reports for Dunlop House Assisted Living & Memory Care
235 Dunlop Farms Blvd, Colonial Heights, VA 23834, United States, VA
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Inspection Report
Renewal
Census: 119
Deficiencies: 2
Oct 22, 2025
Visit Reason
The inspection was conducted as a renewal inspection to assess compliance with applicable standards and laws for continued licensing of the assisted living facility.
Findings
The inspection found non-compliance with applicable standards related to staff training hours and documentation of annual review of residents' rights and responsibilities. Violations were documented and a plan of correction was requested.
Deficiencies (2)
| Description |
|---|
| The facility did not ensure all direct care staff attended at least 18 hours of training annually. |
| The facility did not ensure there was written acknowledgement of an annual review of the rights and responsibilities of residents in the staff person's record. |
Report Facts
Number of residents present: 119
Number of resident records reviewed: 9
Number of staff records reviewed: 4
Number of interviews conducted with residents: 3
Number of interviews conducted with staff: 2
Training hours on record for Staff member 1: 13.81
Remaining training hours to complete for Staff member 1: 4.19
Inspection Report
Complaint Investigation
Deficiencies: 1
Jul 25, 2025
Visit Reason
The inspection was conducted in response to a complaint received on 2025-06-03 regarding allegations related to Resident Care and Related Services at the facility.
Findings
The investigation supported some, but not all, of the allegations. The facility was found non-compliant with standards related to resident care and related services, specifically failing to review and update the individualized service plan (ISP) for a resident with significant condition changes.
Complaint Details
Complaint related: Yes. The evidence gathered supported some of the allegations regarding resident care and related services. A violation notice was issued. The complaint was substantiated in part.
Deficiencies (1)
| Description |
|---|
| Facility failed to review and update the individualized service plan (ISP) as needed for significant changes in resident's condition, including aggression, refusal of medication, and wandering into other residents' rooms. |
Report Facts
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tyia Venable | Licensing Inspector | Conducted the inspection and reviewed facility documentation and resident records |
Inspection Report
Complaint Investigation
Census: 111
Deficiencies: 0
Jul 10, 2025
Visit Reason
The inspection was conducted in response to a complaint received on 2024-12-18 regarding allegations in the area of staffing and supervision.
Findings
The evidence gathered during the investigation did not support the allegation of non-compliance with standards or law. The inspection findings will be posted publicly.
Complaint Details
Complaint related to staffing and supervision; the allegation was not substantiated.
Report Facts
Number of residents present: 111
Number of resident records reviewed: 0
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 2
Inspection Report
Complaint Investigation
Census: 111
Deficiencies: 0
Jul 10, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-05-22 regarding allegations in the area of resident care and related services.
Findings
The evidence gathered during the investigation did not support the allegation of non-compliance with standards or law. The licensing inspector completed a tour of the physical plant and reviewed one resident record.
Complaint Details
Complaint related to resident care and related services; the allegation was not substantiated.
Report Facts
Number of residents present: 111
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 2
Inspection Report
Complaint Investigation
Census: 111
Deficiencies: 0
Jul 10, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-02-07 regarding allegations in the area of resident care and related services.
Findings
The investigation did not support the allegation of non-compliance with standards or law. The licensing inspector reviewed fall risk assessments and the resident record, and conducted a tour of the facility.
Complaint Details
A complaint was received on 2025-02-07 regarding resident care and related services. The evidence gathered did not support the allegation of non-compliance.
Report Facts
Number of residents present: 111
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 2
Inspection Report
Complaint Investigation
Census: 111
Deficiencies: 0
Jul 10, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-02-27 regarding allegations in the area of resident care and related services.
Findings
The evidence gathered during the investigation did not support the allegation of non-compliance with standards or law. The licensing inspector reviewed incident reports, fall risk assessments, and the resident record.
Complaint Details
Complaint related to resident care and related services; the resident involved was deceased as of 2025-02-26. The investigation did not substantiate the complaint.
Report Facts
Number of residents present: 111
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 2
Inspection Report
Complaint Investigation
Census: 111
Deficiencies: 0
Jul 10, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-02-03 regarding allegations in the area of resident care and related services.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The inspection findings will be posted publicly and a copy is required to be posted on the facility premises.
Complaint Details
Complaint received on 2025-02-03 regarding resident care and related services; investigation did not substantiate the allegations.
Report Facts
Number of residents present: 111
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 2
Inspection Report
Monitoring
Deficiencies: 1
Aug 6, 2024
Visit Reason
The inspection was a monitoring visit conducted to assess compliance with applicable standards and laws at The Dunlop House assisted living facility.
Findings
The inspection found non-compliance related to the failure to ensure that an annual tuberculosis risk assessment was completed for each resident, as required by the Virginia Department of Health standards.
Deficiencies (1)
| Description |
|---|
| Failure to ensure that a risk assessment for tuberculosis was completed annually on each resident as evidenced by the lack of current screening documentation. |
Report Facts
Resident records reviewed: 10
Staff records reviewed: 4
Resident interviews conducted: 4
Staff interviews conducted: 4
Inspection Report
Renewal
Census: 102
Deficiencies: 0
Oct 24, 2023
Visit Reason
The inspection was conducted as a renewal inspection of the assisted living facility to assess compliance with licensing standards.
Findings
The inspection found no violations of applicable standards or laws. The licensing inspector completed a tour of the physical plant and reviewed resident and staff records, as well as conducted interviews.
Report Facts
Resident records reviewed: 10
Staff records reviewed: 5
Resident interviews conducted: 5
Staff interviews conducted: 5
Inspection Report
Renewal
Census: 97
Deficiencies: 6
Oct 18, 2022
Visit Reason
The inspection was conducted as a renewal inspection of The Dunlop House assisted living facility on October 18 and October 20, 2022.
Findings
The inspection found multiple violations related to failure to conduct annual reassessments, incomplete or unsigned individualized service plans (ISPs), failure to update ISPs for significant changes in resident condition, lack of nutritionist oversight documentation, and permitting a resident to keep medication in their room without proper assessment.
Deficiencies (6)
| Description |
|---|
| Failed to ensure annual reassessments and reassessments due to significant change in resident's condition using the UAI were conducted to determine if resident's needs can continue to be met. |
| Failed to ensure the comprehensive individualized service plan was completed within 30 days after admission. |
| Failed to ensure the individualized service plan (ISP) is signed and dated by the licensee, administrator, or designee and by the resident or legal representative. |
| Failed to ensure individualized service plans were updated as needed for significant changes in resident condition. |
| Failed to ensure nutritionist oversight was conducted as required and documented adequately. |
| Failed to ensure a resident not assessed as independent in medication administration was permitted to keep medication in the room. |
Report Facts
Number of residents present: 97
Number of resident records reviewed: 10
Number of staff records reviewed: 5
Number of resident interviews: 2
Number of staff interviews: 4
Inspection Report
Monitoring
Census: 89
Deficiencies: 5
Mar 16, 2022
Visit Reason
An unannounced monitoring inspection was initiated to review compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection found multiple violations related to discharge documentation, individualized service plans (ISP) completion and signatures, ISP updates, and nutritional intervention notifications. The facility failed to provide complete discharge statements, timely and comprehensive ISPs, and documentation of physician notification for significant weight loss.
Deficiencies (5)
| Description |
|---|
| Failure to provide a dated discharge statement signed by the licensee or administrator for discharged residents. |
| Failure to complete a comprehensive individualized service plan within 30 days after admission. |
| Failure to ensure individualized service plans are signed and dated by required parties including resident or legal representative. |
| Failure to review and update individualized service plans at least once every 12 months and as needed with changes in resident condition. |
| Failure to implement nutritional interventions promptly and notify attending physician of significant weight loss in residents not on a physician-approved weight reduction program. |
Report Facts
Residents in care: 89
Discharged residents with incomplete discharge statements: 3
Days late for ISP completion: 2
Date of admission: Aug 14, 2021
Date of admission: May 22, 2019
Date of admission: Aug 10, 2018
Date of admission: Aug 17, 2020
Date of nutrition consultation: Jan 18, 2022
Date of ISP needing update: Mar 24, 2022
Inspection Report
Complaint Investigation
Deficiencies: 5
Mar 10, 2021
Visit Reason
The inspection was conducted in response to allegations made against the facility, initiating a complaint investigation to determine compliance with applicable standards and laws.
Findings
The investigation found multiple violations related to the facility's failure to properly manage and update individualized service plans, coordinate hospice care, and involve the resident's Power of Attorney in care decisions. The facility did not follow its hospice policy or ensure communication and reassessment after significant changes in the resident's condition.
Complaint Details
The complaint investigation was initiated on 2021-03-10 and concluded on 2021-07-19. The complaint was substantiated with violations documented and a violation notice issued to the facility.
Deficiencies (5)
| Description |
|---|
| Administrator failed to be responsible for general administration and management, including compliance and individualized service plan monitoring. |
| Facility failed to ensure reassessments using the Uniform Assessment Instrument (UAI) after significant change in resident's condition. |
| Facility failed to ensure communication and coordinated plan of care between assisted living facility and licensed hospice organization. |
| Facility failed to update individualized service plans as needed for significant change in resident's condition. |
| Administrator failed to ensure care provision was resident-centered and included resident participation in care decisions. |
Report Facts
Resident admission date: Jun 11, 2019
Resident discharge date: Feb 1, 2021
Hospital discharge date: Jan 25, 2021
Hospital admission date: Jan 14, 2021
Individualized Service Plan date: Jun 18, 2020
Uniform Assessment Instrument date: Jun 10, 2020
Hospice agreement date: Jan 23, 2021
Hospice certification fax date: Jan 27, 2021
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