Inspection Report
Renewal
Census: 7
Deficiencies: 6
Aug 20, 2025
Visit Reason
The inspection was a renewal visit to assess compliance with applicable standards and laws for licensing renewal.
Findings
The inspection identified multiple violations including incomplete individualized service plans, medication administration record deficiencies, unclean HVAC vents, lack of paper towels in common bathrooms, incomplete fire and emergency evacuation plans, and missing emergency telephone numbers.
Deficiencies (6)
| Description |
|---|
| Facility failed to ensure the comprehensive individualized service plan (ISP) includes a written description of services and providers. |
| Medication administration record (MAR) lacked diagnosis, dates medication discontinued or changed, date/time given, and staff initials. |
| Furnishings, fixtures, and equipment including HVAC vents were not kept clean and in good repair. |
| Common face/hand washing sinks lacked paper towels or air dryer and liquid soap. |
| Fire and emergency evacuation drawings did not show secondary escape routes, areas of refuge, assembly areas, telephones, fire alarm boxes, and fire extinguishers as appropriate. |
| Telephone numbers for fire department, rescue squad, ambulance, police, and Poison Control Center were not posted by each telephone on the fire and emergency evacuation plan. |
Report Facts
Number of residents present: 7
Number of resident records reviewed: 2
Number of staff records reviewed: 3
Number of staff interviews conducted: 2
Number of resident interviews conducted: 0
Inspection Report
Complaint Investigation
Census: 6
Deficiencies: 0
Aug 21, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-07-22 regarding allegations related to physical grounds and resident supervision at the facility.
Findings
The investigation found no evidence to support the allegations of non-compliance with standards or law. Residents were observed socializing and participating in therapy services, and the physical plant was toured without noted deficiencies.
Complaint Details
Complaint received on 2024-07-22 concerning physical grounds and resident supervision; investigation did not substantiate the allegations.
Report Facts
Residents present: 6
Resident records reviewed: 3
Staff records reviewed: 3
Resident interviews conducted: 1
Staff interviews conducted: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alexandra Roberts | Licensing Inspector | Inspector conducting the complaint investigation and inspection |
Inspection Report
Renewal
Census: 6
Deficiencies: 15
Aug 21, 2024
Visit Reason
The inspection was a renewal inspection conducted to evaluate compliance with applicable standards and laws for licensing renewal of the assisted living facility.
Findings
The inspection identified multiple violations including failure to complete annual infection prevention policy reviews, lack of annual tuberculosis evaluations for staff, absence of a written hospice agreement, delayed sex offender searches, missing resident acknowledgements for sex offender notifications and resident rights, incomplete emergency preparedness reviews, inadequate fire drill frequency, incomplete and expired first aid kits, and failure to post the most recent license.
Deficiencies (15)
| Description |
|---|
| Facility failed to ensure that the administrator completes an annual review of the infection prevention policies and procedures for any updates. |
| Facility failed to ensure annual tuberculosis evaluations for staff. |
| Facility failed to have a written agreement between the assisted living facility and the hospice program that provides care in the facility. |
| Facility failed to ascertain prior to admission whether a potential resident is a registered sex offender if the stay is longer than three days, and document it in the resident record. |
| Facility failed to ensure residents or their legal representatives are fully informed about sex offender information with written acknowledgement maintained in the resident record. |
| Facility failed to provide orientation to new residents including emergency procedures, mealtimes, and call system use. |
| Facility failed to ensure licensed health care professional identified specific residents for whom health care oversight was provided. |
| Facility failed to post residents' rights and responsibilities with updated contact information for licensing and ombudsman programs. |
| Facility failed to review residents' rights and responsibilities annually with each resident or legal representative. |
| Facility failed to ensure semi-annual review of emergency preparedness and response plan for all staff and residents. |
| Facility failed to document annual emergency preparedness plan review by signing and dating the plan. |
| Facility failed to ensure fire and emergency evacuation drills were conducted for each shift quarterly and not in the same month. |
| Facility failed to ensure a complete first aid kit was on hand with required items and no expired items. |
| Facility failed to ensure monthly checks of first aid kits were completed and documented. |
| Facility failed to post the most recently issued license on premises. |
Report Facts
Number of residents present: 6
Number of resident records reviewed: 3
Number of staff records reviewed: 4
Number of resident interviews: 2
Number of staff interviews: 2
Date of last documented fire drill: May 5, 2024
Expired first aid kit items: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alexandra Roberts | Licensing Inspector | Conducted the inspection and is the contact for more information |
| Staff 1 | Interviewed regarding TB tests, hospice agreement, sex offender notifications, emergency preparedness, fire drills, and first aid kit | |
| Staff 4 | Interviewed and confirmed multiple deficiencies including lack of annual reviews, missing documentation, outdated postings, and incomplete emergency preparedness |
Inspection Report
Renewal
Census: 7
Deficiencies: 5
Sep 19, 2023
Visit Reason
The inspection was a renewal visit to assess compliance with applicable standards and laws for Emilia Assisted Living Of Ashlawn Court.
Findings
The inspection identified multiple violations including failure to obtain criminal history record reports timely, failure to update the activity calendar when activities were substituted, medication aide provisional status exceeding allowed duration, improper documentation on medication administration records, and lack of semi-annual review of the emergency preparedness plan.
Deficiencies (5)
| Description |
|---|
| Failed to ensure the criminal history record report is obtained on or prior to the 30th day of employment for each staff member. |
| Failed to ensure that the activity calendar is updated if one activity is substituted for another. |
| Failed to ensure that an applicant for registration as a medication aide does not act as a medication aide on a provisional basis for longer than 120 days. |
| Failed to ensure that information is documented on the medication administration record (MAR) at the time medication is administered. |
| Failed to ensure that a semi-annual review on the emergency preparedness and response plan was conducted with all staff, residents, and volunteers. |
Report Facts
Number of residents present: 7
Number of resident records reviewed: 2
Number of resident interviews: 3
Number of staff interviews: 2
Provisional medication aide duration: 120
Inspection Report
Monitoring
Census: 6
Deficiencies: 2
May 17, 2023
Visit Reason
An unannounced mandated monitoring inspection was conducted to review compliance with applicable standards and laws, including resident care, staff records, and medication administration.
Findings
The inspection found non-compliance with applicable standards or laws, resulting in documented violations related to individualized service plans and preliminary plans of care for residents.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure that on or within seven days prior to the day of admission a preliminary plan of care was developed to address the basic needs of the resident. |
| Facility failed to ensure that the comprehensive individualized service plan was completed within 30 days after admission and included a description of identified needs. |
Report Facts
Residents in care at time of inspection: 6
Staff providing care at time of inspection: 2
Resident records reviewed: 3
Staff records reviewed: 3
Inspection Report
Renewal
Census: 7
Deficiencies: 0
Sep 13, 2021
Visit Reason
A renewal inspection was initiated on 2021-09-12 and concluded on 2021-09-13 to review compliance and licensing requirements for Emilia Assisted Living Of Ashlawn Court.
Findings
The inspection included review of resident and staff records, staff schedules, health care oversight, fire and emergency drills, and other documentation. No violations were found and no deficiencies were issued.
Inspection Report
Monitoring
Census: 8
Deficiencies: 0
Apr 7, 2021
Visit Reason
A mandated monitoring inspection was initiated due to a state of emergency health pandemic declared by the Governor of Virginia, conducted remotely to ensure compliance with applicable standards and laws.
Findings
The inspection reviewed resident and staff records, medication administration, fire and health inspections, and background checks. No violations or deficiencies were found during the inspection.
Report Facts
Census: 8
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