Deficiencies per Year
8
6
4
2
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Inspection Report
Complaint Investigation
Census: 21
Deficiencies: 1
Aug 25, 2025
Visit Reason
An unannounced monitoring inspection was conducted on 08/25/2025 in response to a complaint and a self-report received regarding allegations in the area of Personnel.
Findings
The inspection found non-compliance with applicable standards due to the facility not ensuring that an administrator was in place, resulting in a lapse in administrator coverage.
Complaint Details
The visit was complaint-related. The evidence gathered determined non-compliance with the standard 22VAC40-73-150-B. The complaint was substantiated by onsite confirmation from staff #1 that no administrator was in place.
Deficiencies (1)
| Description |
|---|
| The facility did not ensure that if an administrator becomes unable to perform duties, a new administrator or qualified acting administrator is immediately employed to prevent lapse in coverage. |
Report Facts
Number of residents present: 21
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: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lanesha Allen | Licensing Inspector | Inspector conducting the complaint-related inspection |
Inspection Report
Renewal
Census: 21
Deficiencies: 2
May 15, 2025
Visit Reason
The inspection was conducted as a renewal of the facility's license, including a tour of the physical plant and review of resident and staff records, emergency preparedness, and other compliance areas.
Findings
The inspection found non-compliance with applicable standards and laws, resulting in documented violations related to annual review of resident rights and timely criminal history record reports for employees.
Deficiencies (2)
| Description |
|---|
| The facility did not ensure the rights and responsibilities of residents were reviewed annually with each resident or staff person, as evidenced by missing annual Resident Rights Reviews in records. |
| The facility did not ensure the criminal history record report was obtained on or prior to the 30th day of employment for an employee. |
Report Facts
Number of residents present: 21
Number of resident records reviewed: 5
Number of staff records reviewed: 3
Number of interviews conducted with residents: 2
Number of interviews conducted with staff: 3
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 0
Jan 31, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2024-12-30 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.
Complaint Details
Complaint received on 2024-12-30 regarding Resident Care and Related Services; investigation did not substantiate the allegations.
Report Facts
Number of residents present: 28
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
Inspection duration (minutes): 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lanesha Allen | Licensing Inspector | Conducted the inspection and named in the report |
Inspection Report
Complaint Investigation
Census: 29
Deficiencies: 1
Nov 26, 2024
Visit Reason
The inspection was conducted in response to complaints received by the VDSS Division of Licensing on 11/15/24, 11/18/24, and 11/20/24 regarding allegations related to buildings and grounds, specifically concerning infestations of insects and vermin.
Findings
The investigation confirmed the presence of bed bugs at the facility, supported by staff confirmation and multiple treatment reports from Orkin. Violations were issued for failure to keep the buildings free of infestations.
Complaint Details
The complaint was substantiated based on evidence including staff confirmation and Orkin treatment reports dated 7/1/24 through 11/18/24.
Deficiencies (1)
| Description |
|---|
| Facility did not ensure the buildings were kept free of infestations of insects and vermin; presence of bed bugs confirmed. |
Report Facts
Number of residents present: 29
Orkin treatment dates count: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lanesha Allen | Licensing Inspector | Conducted the inspection and investigation |
| Maintenance Supervisor/Director of Housekeeping | Responsible for following Orkin Pest Control instructions and conducting daily inspections and treatments | |
| Staff #1 | Confirmed presence of bed bugs and provided Orkin reports |
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 0
May 29, 2024
Visit Reason
An unannounced complaint inspection was conducted due to a complaint received on 2024-05-22 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 inspection findings will be posted publicly within 5 business days.
Complaint Details
Complaint received by VDSS Division of Licensing on 2024-05-22 regarding allegations in Resident Care and Related Services; investigation did not substantiate the complaint.
Report Facts
Number of residents present: 31
Number of resident records reviewed: 6
Number of staff records reviewed: 0
Number of resident interviews conducted: 1
Number of staff interviews conducted: 1
Inspection Report
Renewal
Census: 31
Deficiencies: 2
May 29, 2024
Visit Reason
An unannounced renewal inspection was conducted to evaluate compliance with applicable standards and regulations for license renewal.
Findings
The inspection found non-compliance with standards related to staff tuberculosis risk assessments and criminal history record reports, resulting in documented violations.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure each staff person submitted a tuberculosis risk assessment within 7 days prior to first day of work, with the risk assessment no older than 30 days. |
| Facility failed to ensure the criminal history record report was obtained on or prior to the 30th day of employment for each staff person. |
Report Facts
Number of residents present: 31
Number of resident records reviewed: 6
Number of staff records reviewed: 3
Number of interviews conducted with residents: 2
Number of interviews conducted with staff: 2
Inspection Report
Monitoring
Census: 31
Deficiencies: 1
May 29, 2024
Visit Reason
An unannounced monitoring inspection was conducted to review compliance with regulations, including a self-report received regarding allegations in Resident Care and Related Services.
Findings
The investigation supported allegations of non-compliance in Resident Care and Related Services, specifically a failure to administer medications according to physician orders. A violation notice was issued.
Deficiencies (1)
| Description |
|---|
| The facility failed to ensure medications were administered in accordance with the physician's or other prescriber's instructions, as evidenced by a resident not receiving prescribed medications from 03/22/24 through 04/24/24. |
Report Facts
Number of residents present: 31
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
Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 0
Aug 10, 2023
Visit Reason
An unannounced complaint inspection was conducted on 08/10/2023 following a complaint received on 08/07/2023 regarding allegations related to building and grounds.
Findings
The licensing inspector toured the physical plant including building and grounds and found that the evidence gathered did not support the allegations of non-compliance with standards or law.
Complaint Details
Complaint received by VDSS Division of Licensing on 08/07/2023 regarding allegations in the area(s) of Building and Grounds. The evidence gathered did not support the allegation(s) of non-compliance.
Report Facts
Number of residents present: 30
Number of resident records reviewed: 0
Number of staff records reviewed: 0
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 1
Inspection Report
Renewal
Census: 28
Deficiencies: 4
May 31, 2023
Visit Reason
An unannounced renewal inspection was conducted to assess compliance with applicable standards and laws for license renewal.
Findings
The inspection found multiple violations including failure to ensure appropriate diagnosis and treatment plans for psychotropic medications, incomplete personal and social information in resident records, lack of timely health care oversight, and failure to prevent use of expired medications.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure psychotropic medications had appropriate diagnosis and treatment plans for resident #5. |
| Facility failed to ensure personal and social information, including DNR orders and allergies, were current in resident records. |
| Facility failed to provide required health care oversight at least every three months and annually for residents meeting assisted living criteria. |
| Facility failed to implement a written medication management plan to prevent use of outdated medications; expired medication administered to resident #7. |
Report Facts
Number of residents present: 28
Number of resident records reviewed: 6
Number of staff records reviewed: 3
Number of interviews conducted with residents: 2
Number of interviews conducted with staff: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lanesha Allen | Licensing Inspector | Current inspector conducting the inspection |
| Donesia Peoples | Licensing Inspector | Contact person for questions regarding the inspection |
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 3
Mar 20, 2023
Visit Reason
An unannounced complaint inspection was conducted following a complaint received on 2022-11-09 regarding allegations in the areas of Personnel, Resident Care, and Related Services.
Findings
The investigation supported some but not all allegations of non-compliance. Violations were found related to staff providing care outside their scope of practice, failure to assume responsibility for resident health and safety, and failure to follow and document physician orders for medical procedures and treatments.
Complaint Details
Complaint investigation was initiated based on a complaint received on 2022-11-09. The complaint was substantiated in part, with violations issued related to personnel practices, resident care, and documentation.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure direct care staff provided services within the scope of their practice and training, specifically a certified nurse aide removing and placing a condom catheter. |
| Facility did not assume responsibility for the health, safety, and well-being of resident #1, resulting in an unstageable pressure ulcer caused by a tightly applied condom catheter. |
| Facility failed to ensure medical procedures or treatments ordered by a physician were provided according to instructions and documented, including repositioning, skin prep application, and incontinence care. |
Report Facts
Number of residents present: 28
Number of resident records reviewed: 2
Number of staff records reviewed: 3
Number of resident interviews: 2
Number of staff interviews: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lanesha Allen | Licensing Inspector | Current inspector conducting the complaint investigation |
| Donesia Peoples | Licensing Inspector | Contact person for questions regarding the inspection |
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 2
Nov 16, 2022
Visit Reason
An unannounced complaint inspection was conducted due to allegations received on 2022-11-09 regarding Admission, Retention, and Discharge of Residents and Resident Care and Related Services.
Findings
The investigation supported some, but not all, allegations of non-compliance related to Resident Care and Related Services. Violations were found regarding failure to update Fall Risk Ratings and failure to document medical attention and notify responsible parties after a resident's serious condition and refusal of medical care.
Complaint Details
Complaint was substantiated in part regarding Resident Care and Related Services; some allegations were not supported.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure the Fall Risk Rating (FRR) was reviewed and updated annually and when the resident's condition changed. |
| Facility failed to document medical attention received or refused and failed to notify resident's legal representative and designated contact within 24 hours of refusal of medical attention. |
Report Facts
Number of residents present: 33
Number of resident records reviewed: 3
Number of staff records reviewed: 2
Number of resident interviews conducted: 1
Number of staff interviews conducted: 2
Inspection Report
Routine
Deficiencies: 5
May 12, 2022
Visit Reason
The inspection was a routine regulatory visit to review compliance with Virginia assisted living facility regulations, including general provisions, administration, personnel, resident care, emergency preparedness, and building standards.
Findings
The facility was found deficient in several areas including failure to provide health care oversight every six months, failure to document menu substitutions, lack of dietary oversight every six months for special diets, incomplete documentation on the Medication Administration Record (MAR), and failure to ensure an annual fire inspection was conducted.
Deficiencies (5)
| Description |
|---|
| Failed to ensure that health care oversight was provided at least every six months. |
| Failed to have any menu substitutions recorded on the posted menu. |
| Failed to ensure dietary oversight was conducted every six months for special diets by a dietitian or nutritionist. |
| Failed to include all required documentation on the Medication Administration Record (MAR). |
| Failed to ensure that an annual fire inspection was conducted by the appropriate fire official. |
Report Facts
Inspection dates: 2
Dates of last documented health care oversight: Mar 15, 2021
Dates of last dietary oversight: Aug 8, 2021
Dates of last fire inspection: Apr 8, 2021
Inspection Report
Renewal
Census: 26
Deficiencies: 3
May 11, 2021
Visit Reason
A renewal inspection was initiated on May 11, 2021 and concluded on May 12, 2021 to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection identified non-compliances including failure to maintain a written work schedule with staff names and job classifications, incomplete Medication Administration Records missing diagnoses or indications for medications, and employment of a staff member with a disqualifying barrier crime conviction.
Deficiencies (3)
| Description |
|---|
| Facility failed to maintain a written work schedule that included the names and job classifications of all staff working each shift. |
| Facility failed to ensure the Medication Administration Record (MAR) included the diagnosis, condition, or specific indications for administering the drug. |
| Facility failed to ensure any person required to obtain a criminal history record report was ineligible for employment if the report contained convictions of barrier crimes, yet employed a staff member with such a conviction. |
Report Facts
Census: 26
Staff employment dates: Staff #4 employed from 03-16-2021 to 04-21-2021 despite barrier crime conviction
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff #1 | Confirmed issues with staff schedules and MAR documentation | |
| Staff #4 | Housekeeping staff | Employed despite barrier crime conviction making them ineligible |
Inspection Report
Complaint Investigation
Deficiencies: 1
Feb 4, 2021
Visit Reason
A complaint inspection was initiated due to allegations regarding the release of resident information without proper authorization.
Findings
The investigation found that the facility released personal information about a resident without written permission from the resident or legal representative, confirming non-compliance with standards.
Complaint Details
The complaint was substantiated based on evidence including an email sent with resident information without proper authorization.
Deficiencies (1)
| Description |
|---|
| Facility released resident personal information without written permission of the resident or legal representative. |
Report Facts
Inspection dates: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lanesha Allen | Inspector | Conducted the complaint investigation |
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