Inspection Report
Monitoring
Census: 89
Deficiencies: 2
Sep 30, 2025
Visit Reason
The inspection was a monitoring visit conducted on 09/30/2025 following a self-reported incident received on 09/02/2025 regarding allegations in the area of resident care and related services.
Findings
The investigation did not support the self-report of non-compliance; however, violations unrelated to the self-report were identified. These violations involved failure to update fall risk ratings after a fall and failure to document analysis and interventions following a resident fall.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure the fall risk rating was reviewed and updated after a fall. |
| Facility failed to document analysis of the circumstances of a resident fall and interventions to prevent or reduce risk of subsequent falls. |
Report Facts
Number of residents present: 89
Number of resident records reviewed: 1
Number of staff interviews conducted: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca Berry | Licensing Inspector | Current inspector conducting the monitoring visit |
| Staff #1 | Interviewed staff who confirmed lack of updated fall risk rating and lack of fall analysis documentation |
Inspection Report
Monitoring
Census: 89
Deficiencies: 1
Sep 30, 2025
Visit Reason
The inspection was a monitoring visit conducted on 09/30/2025 to review compliance with resident care and related services as well as buildings and grounds standards. The visit was triggered by a self-reported incident received on 08/04/2025 regarding allegations in resident care.
Findings
The investigation did not support the self-reported non-compliance; however, violations unrelated to the self-report were identified. Specifically, the facility failed to document hourly rounds for a resident unable to use the signaling device as required by their individualized service plan.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure documentation of hourly rounds for resident #1 with inability to use signaling device, including name, date, time, and staff member making rounds. |
Report Facts
Number of residents present: 89
Number of resident records reviewed: 1
Number of staff interviews conducted: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca Berry | Licensing Inspector | Current inspector conducting the monitoring inspection |
| Staff #1 | Confirmed no documentation available of hourly rounds for resident #1 |
Inspection Report
Monitoring
Census: 78
Deficiencies: 0
Jun 25, 2025
Visit Reason
The inspection was a monitoring visit conducted to review compliance with resident care, related services, and building and ground 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.
Report Facts
Number of resident records reviewed: 3
Number of staff interviews conducted: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca Berry | Licensing Inspector | Current inspector conducting the monitoring inspection |
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 1
Jun 25, 2025
Visit Reason
The inspection was conducted in response to a complaint received on 2025-06-16 regarding allegations related to staffing and supervision, resident care and related services, building and grounds, and the safe, secure environment.
Findings
The investigation supported some, but not all, of the allegations. Non-compliance was found in the area of staffing and supervision, specifically related to discrepancies in staff schedules and failure to document absences, substitutions, or changes on the written work schedule.
Complaint Details
The complaint was substantiated in part, specifically regarding staffing and supervision issues. Evidence included discrepancies in daily staffing sheets and employee timecards showing insufficient staffing levels and undocumented schedule changes.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure that any absences, substitutions, or other changes were noted on the written work schedule, resulting in staffing shortages in the safe, secure environment. |
Report Facts
Number of residents present: 78
Number of interviews with residents: 2
Number of interviews with staff: 5
Inspection Report
Monitoring
Census: 77
Deficiencies: 1
May 21, 2025
Visit Reason
The inspection was a monitoring visit conducted to review compliance with resident care and related services standards, following a self-reported incident regarding medication administration.
Findings
The inspection found non-compliance with medication administration standards due to missed doses of prescribed medications for a resident, confirmed by staff and documented in the facility's self-reported incident.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure medications were administered according to physician's orders, resulting in 14 missed doses for a resident due to a clerical error. |
Report Facts
Missed medication doses: 14
Residents present: 77
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca Berry | Licensing Inspector | Conducted the inspection and is the contact for questions |
| Staff #1 | Reported the medication administration incident | |
| Staff #2 | Confirmed the medication administration incident during inspection |
Inspection Report
Renewal
Census: 77
Deficiencies: 7
May 20, 2025
Visit Reason
The inspection was a renewal inspection conducted on May 20 and May 21, 2025, to assess compliance with applicable standards and regulations for the assisted living facility.
Findings
The inspection identified multiple violations including failure to secure potentially harmful materials from residents, incomplete pre-admission sex offender registry checks, incomplete personal/social data on resident records, inaccuracies in uniform assessment instruments (UAI), unsigned individualized service plans (ISP), medication management deficiencies, and maintenance issues such as stains and marks in resident rooms.
Deficiencies (7)
| Description |
|---|
| Failure to ensure harmful materials or objects are inaccessible to residents except under staff supervision. |
| Failure to ascertain prior to admission whether a potential resident is a registered sex offender when stay exceeds three days. |
| Failure to obtain all required personal and social information on a person prior to or at admission. |
| Failure to ensure the uniform assessment instrument (UAI) is completed as required for private pay individuals. |
| Failure to ensure individualized service plans (ISP) are signed and dated by the licensee, administrator, or designee. |
| Failure to implement written medication management plan including accurate counts of controlled substances during staff changes. |
| Failure to maintain interior and exterior of all buildings in good repair and keep clean and free of rubbish. |
Report Facts
Number of residents present: 77
Number of resident records reviewed: 9
Number of staff records reviewed: 5
Number of resident interviews: 1
Number of staff interviews: 6
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 0
Oct 1, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-08-05 regarding allegations related to building and grounds and administrative services.
Findings
The investigation did not find evidence to support the allegations of non-compliance with standards or law. The inspection included a tour of the physical plant and review of policies and procedures.
Complaint Details
Complaint received on 2024-08-05 regarding building and grounds and administrative services; the allegations were not substantiated.
Report Facts
Number of residents present: 72
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
Monitoring
Census: 72
Deficiencies: 0
Oct 1, 2024
Visit Reason
The inspection was a monitoring visit conducted on October 1, 2024, following a self-reported incident received on September 2, 2024, regarding allegations in resident care and related services.
Findings
The inspection found no violations of applicable standards or laws. The licensing inspector completed a tour of the physical plant and reviewed one resident record and conducted one staff interview.
Report Facts
Number of resident records reviewed: 1
Number of staff interviews conducted: 1
Inspection Report
Monitoring
Census: 82
Deficiencies: 0
Jul 2, 2024
Visit Reason
The inspection was a monitoring visit conducted to review facility compliance with personnel and resident care standards.
Findings
The inspection found no violations of applicable standards or laws. Facility training records and audit documentation were reviewed, and an exit meeting was planned to discuss findings.
Inspection Report
Monitoring
Census: 75
Deficiencies: 1
Jun 20, 2024
Visit Reason
The inspection was a monitoring visit conducted on June 20 and June 27, 2024, following a self-reported incident received on June 14, 2024, regarding allegations related to resident care, medication management plan, and reference materials.
Findings
The inspection found non-compliance with applicable standards and laws, specifically a failure to implement a written medication management plan ensuring accurate counts of controlled substances during staff changes. Violations were documented and a violation notice issued to the facility.
Deficiencies (1)
| Description |
|---|
| Facility failed to implement a written plan for medication management including methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes. |
Report Facts
Number of residents present: 75
Number of resident records reviewed: 1
Number of staff interviews conducted: 6
Prefilled morphine syringes received: 60
Prefilled morphine syringes counted: 57
Plan of correction audit duration: 3
Inspection Report
Monitoring
Census: 75
Deficiencies: 0
Jun 20, 2024
Visit Reason
The inspection was a monitoring visit conducted by the licensing inspector to review resident care and related services at the facility.
Findings
The inspection found no violations of applicable standards or laws. The inspector completed a tour of the physical plant and conducted a med cart audit with no deficiencies noted.
Inspection Report
Monitoring
Census: 75
Deficiencies: 0
Jun 20, 2024
Visit Reason
The inspection was a monitoring visit conducted by the licensing inspector to review compliance with personnel standards.
Findings
The inspection found no violations of applicable standards or laws. The inspector completed a tour of the physical plant and reviewed staff training records.
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 0
May 16, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-04-21 regarding allegations in the areas of personnel, 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 within 5 business days of receipt.
Complaint Details
Complaint received on 2024-04-21 regarding personnel, resident care, and related services; investigation did not substantiate the allegations.
Report Facts
Number of residents present: 72
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of staff interviews conducted: 5
Inspection Report
Renewal
Census: 73
Deficiencies: 7
May 9, 2024
Visit Reason
The inspection was a renewal inspection conducted on May 9 and May 10, 2024, to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection identified multiple violations including insufficient staff training hours, incomplete resident personal and social information, failure to update individualized service plans, missing dated menus in the secure care unit, medication management deficiencies, and maintenance and cleanliness issues in resident rooms and bathrooms.
Deficiencies (7)
| Description |
|---|
| Facility failed to ensure all direct care staff attended at least 18 hours of training annually. |
| Facility failed to obtain all required personal and social information on a person prior to or at the time of admission for four of seven resident records reviewed. |
| Facility failed to address all identified needs on the comprehensive individualized service plan for two of seven resident files reviewed. |
| Facility failed to ensure menus for meals and snacks for the current week were dated and posted in an area conspicuous to residents in the safe secure unit. |
| Facility failed to implement a written plan for medication management, including methods to prevent use of outdated, damaged, or contaminated medications. |
| Facility failed to ensure the interior and exterior of all buildings were maintained in good repair and kept clean and free of rubbish. |
| Facility failed to ensure all furnishings, fixtures, and equipment were kept clean and in good repair and condition. |
Report Facts
Number of residents present: 73
Number of resident records reviewed: 7
Number of staff records reviewed: 3
Number of resident interviews: 3
Number of staff interviews: 5
Staff training hours for staff #2: 5
Staff training hours for staff #2: 13.25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca Berry | Licensing Inspector | Current inspector conducting the inspection |
Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 0
Apr 20, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2024-06-04 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 within 5 business days of receipt.
Complaint Details
Complaint related to resident care and related services; allegations were not substantiated.
Report Facts
Number of residents present: 75
Number of resident records reviewed: 1
Number of interviews conducted with residents: 2
Number of interviews conducted with staff: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca Berry | Licensing Inspector | Inspector conducting the complaint investigation |
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 1
Apr 11, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-03-18 regarding allegations related to resident care and health care services at the facility.
Findings
The investigation found non-compliance with standards related to health care services, specifically failure to prevent clinically avoidable complications such as pressure ulcer development or worsening. Violations were issued based on documentation and staff interviews.
Complaint Details
The complaint was substantiated. Evidence showed that staff failed to notify appropriate personnel and hospice about a skin tear observed on Resident #1, resulting in delayed wound care and documentation issues.
Deficiencies (1)
| Description |
|---|
| Failure to ensure health care services were provided to prevent clinically avoidable complications, including pressure ulcer development or worsening of an ulcer. |
Report Facts
Number of residents present: 72
Number of resident records reviewed: 1
Number of staff interviews conducted: 6
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 0
Dec 20, 2023
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2023-12-11 regarding allegations in the areas of personnel, resident care, and related services.
Findings
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 2023-12-11 regarding personnel, resident care, and related services; evidence did not support allegations of non-compliance.
Report Facts
Number of residents present: 80
Number of resident records reviewed: 3
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 4
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 0
Dec 20, 2023
Visit Reason
The inspection was conducted in response to a complaint received on 2023-10-20 regarding allegations in staffing and supervision, and resident care and related services.
Findings
The investigation did not support the allegations of non-compliance with standards or law. No deficiencies were cited during the inspection.
Complaint Details
A complaint was received by VDSS Division of Licensing on 10/20/2023 regarding allegations in staffing and supervision, resident care and related services. The evidence gathered did not support the allegations.
Inspection Report
Monitoring
Census: 87
Deficiencies: 0
Oct 17, 2023
Visit Reason
The inspection was a monitoring visit conducted following a self-reported incident received by VDSS Division of Licensing on 09/26/2023 regarding allegations in the area of resident care and related services.
Findings
The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law. The licensing inspector completed a tour of the physical plant and reviewed resident records and staff interviews.
Report Facts
Number of resident records reviewed: 1
Number of staff interviews conducted: 2
Inspection Report
Complaint Investigation
Census: 91
Deficiencies: 0
Sep 21, 2023
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2023-09-18 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 at the facility.
Complaint Details
Complaint related to allegations in resident care and related services; investigation found no substantiation of non-compliance.
Report Facts
Number of residents present: 91
Number of resident records reviewed: 1
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 3
Inspection Report
Monitoring
Census: 91
Deficiencies: 0
Sep 21, 2023
Visit Reason
The inspection was a monitoring visit conducted to review compliance with resident care, related services, and building and ground standards.
Findings
The inspection found no violations of applicable standards or laws. The licensing inspector completed a tour of the physical plant and reviewed a housekeeping log for one resident room.
Report Facts
Number of resident records reviewed: 1
Number of staff interviews conducted: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca Berry | Licensing Inspector | Inspector conducting the monitoring visit |
Inspection Report
Monitoring
Census: 94
Deficiencies: 0
Aug 15, 2023
Visit Reason
The inspection was a monitoring visit conducted by the licensing inspector to review staff training records and assess compliance with personnel standards.
Findings
The inspection found no violations of applicable standards or laws. The evidence gathered determined the facility was in compliance with regulations.
Inspection Report
Complaint Investigation
Census: 94
Deficiencies: 5
Aug 4, 2023
Visit Reason
The inspection was conducted in response to a complaint received on 2023-07-25 regarding allegations in the areas of personnel, resident care and related services, and building and grounds.
Findings
The investigation supported some but not all allegations, identifying non-compliance in resident care and related services and building and grounds. Violations included failure to ensure health, safety, and well-being of residents, failure to adhere to pet policy, poor ventilation and odors, insect infestations, and inadequate documentation of resident rounds.
Complaint Details
The complaint investigation was substantiated in part, with violations found related to resident care and related services and building and grounds. Some allegations were not supported.
Deficiencies (5)
| Description |
|---|
| Facility failed to assume general responsibility for the health, safety and well-being of residents, including issues with pets and odors. |
| Facility failed to adhere to pet policy allowing only one pet per unit; two cats were found in one resident's room. |
| Facility failed to ensure buildings were well-ventilated and free from foul odors. |
| Facility failed to keep building free of insect infestations; ants were observed on a resident. |
| Facility failed to document hourly rounds for residents unable to use signaling devices as required. |
Report Facts
Number of residents present: 94
Number of resident records reviewed: 12
Number of staff records reviewed: 8
Number of staff interviews conducted: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca Berry | Licensing Inspector | Conducted the inspection and is the contact for questions |
| Staff #1 | Interviewed regarding issues with cats, odors, and insect infestations |
Inspection Report
Monitoring
Census: 94
Deficiencies: 0
Jul 5, 2023
Visit Reason
The inspection was a monitoring visit conducted to review compliance with personnel and resident care standards.
Findings
The inspection found no violations of applicable standards or laws. Staff training records were reviewed and the physical plant was toured.
Inspection Report
Complaint Investigation
Census: 94
Deficiencies: 0
Jun 20, 2023
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2023-05-31 regarding allegations in the areas of resident care and related services, and medication administration.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. An exit meeting was planned to review the inspection findings.
Complaint Details
Complaint related to allegations in resident care and related services, and medication administration. The complaint was not substantiated based on the investigation findings.
Report Facts
Number of residents present: 94
Number of resident records reviewed: 1
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 2
Inspection Report
Renewal
Census: 95
Deficiencies: 6
May 15, 2023
Visit Reason
The inspection was conducted as a renewal inspection to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection found multiple violations related to resident record-keeping, including failure to update fall risk ratings annually, incomplete documentation of orientation and rights acknowledgements, and deficiencies in individualized service plans. Additionally, medication administration practices did not fully comply with standards.
Deficiencies (6)
| Description |
|---|
| Failed to ensure the fall risk rating was updated at least annually for one of nine resident files reviewed. |
| Failed to ascertain, prior to admission, whether a potential resident is a registered sex offender for one of nine resident files reviewed. |
| Failed to document acknowledgement of having received orientation for one of nine resident files reviewed. |
| Failed to address all identified needs on Individualized Service Plans (ISPs) for two of nine resident files reviewed. |
| Failed to maintain written acknowledgement of annual review of rights and responsibilities of residents in assisted living facilities for one resident. |
| Failed to administer medications in accordance with the physician’s or other prescriber’s instructions and consistent with standards of practice. |
Report Facts
Residents present: 95
Resident records reviewed: 9
Staff records reviewed: 4
Resident interviews conducted: 4
Staff interviews conducted: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca Berry | Licensing Inspector | Inspector conducting the renewal inspection |
| Staff #5 | Staff member who completed fall risk rating and sex offender screening during inspection | |
| Administrator | Administrator responsible for corrective actions and plans of correction | |
| Med Tech | Med Tech who completed open date on eye drops during inspection | |
| DON or designee | Director of Nursing or designee | Responsible for auditing medication carts for compliance |
Inspection Report
Monitoring
Census: 95
Deficiencies: 1
May 15, 2023
Visit Reason
The inspection was a monitoring visit conducted on May 15, 2023 and June 20, 2023, following a self-reported incident received on April 28, 2023 regarding allegations related to resident care and resident rights.
Findings
The investigation supported the self-report of non-compliance with standards and violations were issued related to resident rights. Two employees were found to have engaged in inappropriate behavior towards residents, including taunting and posting videos on social media, resulting in their immediate termination and subsequent staff training on resident rights.
Complaint Details
The visit was not complaint-related but was triggered by a self-reported incident. The evidence supported the self-report of non-compliance and violations were issued.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure two residents have the rights and responsibilities as provided in § 63.2-1808 of the Code of Virginia, including staff taunting, threatening, and posting videos of residents on social media. |
Report Facts
Number of residents present: 95
Number of resident records reviewed: 2
Number of staff records reviewed: 2
Number of staff interviews conducted: 1
Inspection Report
Complaint Investigation
Census: 95
Deficiencies: 5
May 15, 2023
Visit Reason
The inspection was conducted in response to a complaint received on 2023-03-08 regarding allegations related to resident care, related services, and administration of medications.
Findings
The investigation supported the allegations of non-compliance with multiple standards including failures in individualized service plans, notification of next of kin for incidents, medication administration errors, and delayed response to resident call systems. Violations were issued based on these findings.
Complaint Details
The complaint was substantiated with violations issued. The complaint involved issues with resident care, medication administration, and timely response to resident needs.
Deficiencies (5)
| Description |
|---|
| Facility failed to ensure the comprehensive Individualized Service Plan includes an accurate description of who will provide certain services and failed to address all identified needs on ISPs. |
| Facility failed to ensure the Individualized Service Plan was signed and dated by the resident or legal representative. |
| Facility failed to notify next of kin of incidents of resident falling or wandering and failed to document notification details. |
| Facility failed to administer medications in accordance with physician's instructions and standards of practice. |
| Facility failed to respond timely to resident call system alerts, with multiple instances exceeding a 30-minute response time. |
Report Facts
Residents present: 95
Resident records reviewed: 2
Staff records reviewed: 3
Staff interviews conducted: 1
Resident call response delays: 12
Resident call response delays: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca Berry | Licensing Inspector | Inspector conducting the complaint investigation |
Inspection Report
Monitoring
Deficiencies: 0
Nov 4, 2022
Visit Reason
The inspection was a monitoring visit conducted on November 4, 2022, to assess compliance with applicable standards and laws at the English Meadows Blacksburg Campus assisted living facility.
Findings
The inspection found no violations of applicable standards or laws during the monitoring visit.
Inspection Report
Monitoring
Deficiencies: 0
Nov 4, 2022
Visit Reason
The inspection was a monitoring visit conducted on November 4, 2022, to assess compliance with applicable standards and laws at the assisted living facility.
Findings
The inspection found no violations of applicable standards or laws during the monitoring visit.
Inspection Report
Monitoring
Deficiencies: 0
Nov 4, 2022
Visit Reason
The inspection was a monitoring visit conducted on November 4, 2022, to assess compliance with applicable standards and laws.
Findings
The inspection found no violations of applicable standards or laws during the monitoring visit.
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 3
Nov 4, 2022
Visit Reason
The inspection was conducted in response to multiple complaints received by VDSS Division of Licensing in October 2022 regarding allegations in the area of resident care.
Findings
The investigation supported some, but not all, allegations of non-compliance. Violations were found related to incomplete medication administration records, unavailable PRN medications, and delayed response to resident call devices.
Complaint Details
A complaint was received on multiple dates in October 2022 regarding resident care. The evidence supported some allegations but not all. A violation notice was issued.
Deficiencies (3)
| Description |
|---|
| The facility failed to ensure the MAR included all medications ordered by a physician, specifically missing Acetaminophen 650 suppository for Resident #1. |
| The facility did not have all PRN medications available for one resident, including Calmoseptine Ointment and Metronidazole 0.75% cream. |
| The facility failed to act in a timely manner to the signaling device used by residents to alert direct care staff, with response times exceeding 30 minutes on multiple occasions. |
Report Facts
Residents present: 58
Resident records reviewed: 3
Staff records reviewed: 3
Resident interviews conducted: 3
Staff interviews conducted: 4
Call pendant alarm durations (minutes): 59.42
Call pendant alarm durations (minutes): 42.6
Call pendant alarm durations (minutes): 38.93
Inspection Report
Complaint Investigation
Deficiencies: 1
Sep 20, 2022
Visit Reason
The inspection was conducted as a complaint investigation to determine compliance with regulations related to resident care and response times to resident call signals.
Findings
The investigation did not substantiate the complaint allegations of non-compliance; however, violations unrelated to the complaint were identified regarding delayed response times to resident call signals, with some responses exceeding 30 minutes.
Complaint Details
Complaint related: Yes. The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law.
Deficiencies (1)
| Description |
|---|
| Facility failed to respond timely when direct care staff was notified that a resident needed assistance, with documented response times exceeding 30 minutes on multiple occasions. |
Report Facts
Response time delays: 6
Response time examples: 125
Inspection Report
Complaint Investigation
Deficiencies: 7
Sep 8, 2022
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received on 2022-07-29 regarding allegations in resident care and related services and resident accommodations.
Findings
The investigation did not substantiate the complaint allegations; however, several violations unrelated to the complaint were identified, including failures in updating fall risk ratings, completing uniform assessments, addressing needs in individualized service plans, including hospice care details in plans, providing necessary personal assistance, managing dietary supplements, and maintaining cleanliness.
Complaint Details
Complaint was received on 2022-07-29 regarding resident care and accommodations. The evidence gathered did not support the allegations of non-compliance with standards or law.
Deficiencies (7)
| Description |
|---|
| Failed to ensure the fall risk rating for a resident was updated at least annually. |
| Failed to ensure that private pay uniform assessments (UAIs) were completed as required. |
| Failed to ensure that all identified needs were addressed on individualized service plans (ISPs). |
| Failed to ensure hospice care services provided by licensed hospice organization were included on the individualized service plan (ISP). |
| Failed to ensure that personal assistance and care were provided to each resident as necessary so that the needs of the resident are met. |
| Failed to ensure dietary supplements kept in resident rooms are only permitted for residents indicated as capable of self-administering their own medications. |
| Failed to maintain and keep clean the interior of the building, including stained carpets and debris under resident's bed. |
Report Facts
Dates of resident documents: Feb 4, 2021
Dates of resident documents: Jul 19, 2022
Date of physician order: Aug 23, 2022
Date of inspection: Sep 8, 2022
Date of plan of correction completion: Sep 9, 2022
Date of plan of correction completion: Sep 15, 2022
Date of carpet replacement scheduled: Sep 16, 2022
Date of staff reeducation: Sep 21, 2022
Inspection Report
Complaint Investigation
Deficiencies: 4
Sep 8, 2022
Visit Reason
The inspection was conducted in response to a complaint received on 2022-07-29 regarding allegations in the areas of resident care and related services and personnel.
Findings
The investigation did not substantiate the complaint allegations; however, violations unrelated to the complaint were identified, including failures in specifying hospice services on individualized service plans, obtaining required signatures on service plans, implementing medication management plans for controlled substances, and obtaining complete oxygen orders for residents.
Complaint Details
Complaint was received on 2022-07-29 regarding resident care and personnel. The evidence gathered did not support the allegations of non-compliance with standards or law.
Deficiencies (4)
| Description |
|---|
| Facility failed to specify what hospice services were being provided on the individualized service plan (ISP). |
| Facility failed to obtain some required signatures on the individualized service plan (ISP). |
| Facility failed to implement their medication management plan regarding methods to ensure accurate counts of controlled substances whenever assigned medication administration staff changes. |
| Facility failed to obtain a complete oxygen order for a resident, lacking information regarding the source of the oxygen (tank or concentrator). |
Report Facts
Dates of narcotic count omissions: 22
Plan of correction audit frequency: 3
Plan of correction audit frequency: 12
Inspection Report
Complaint Investigation
Deficiencies: 2
Sep 8, 2022
Visit Reason
The inspection was conducted in response to a complaint received by the VDSS Division of Licensing on 09/07/2022 regarding allegations in the area of resident care and related services.
Findings
The investigation supported the allegation of non-compliance with standards related to medication management, including failure to implement the medication management plan and incomplete physician orders for medication administration.
Complaint Details
The complaint was substantiated as the evidence gathered supported the allegation of non-compliance with standards related to medication management.
Deficiencies (2)
| Description |
|---|
| The facility failed to ensure implementation of their medication management plan, resulting in delayed administration of medications to a resident. |
| The facility failed to ensure a physician or prescriber’s oral order for administering medication included the route, dosage, and frequency. |
Report Facts
Medication administration delay days: 4
Medication administration staff reeducation deadline: 2022
Medication pass observations date: 2022
Medication cart audit completion date: 2022
Clarification order date: 2022
Inspection Report
Monitoring
Deficiencies: 5
Jul 19, 2022
Visit Reason
The inspection was a monitoring visit conducted on July 19, 2022, following a self-reported incident received on July 15, 2022, regarding allegations in the area of medication administration.
Findings
The investigation supported the self-report of non-compliance with multiple violations related to medication administration, individualized service plan (ISP) updates, hospice care documentation, and medication order details. Violations were issued and corrective actions were required.
Deficiencies (5)
| Description |
|---|
| Facility failed to include hospice care as a provided service on the ISP. |
| Facility failed to update the ISP at least once every 12 months. |
| Facility failed to administer medications in accordance with physician instructions and standards of practice, including a medication error where Resident #1 was given ten times the prescribed dose of Hydromorphone. |
| Facility failed to record pertinent information such as services ordered by a physician and provided by an outside agency and the resulting evaluations of progress. |
| Facility failed to obtain a detailed medication order for PRN medications administered to residents unable to determine when medication is needed. |
Report Facts
Resident records reviewed: 1
Staff records reviewed: 0
Resident interviews conducted: 1
Staff interviews conducted: 3
Medication overdose dose: 5
Start dose of Hydromorphone: 45
Remaining Hydromorphone balance: 40
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 19, 2022
Visit Reason
The inspection was conducted in response to a complaint received on 2022-06-28 regarding allegations in the areas of resident records and resident care.
Findings
The investigation found no evidence to support the allegations of non-compliance with standards or law related to resident records and resident care. The inspection findings will be posted publicly and a copy is required to be posted at the facility.
Complaint Details
Complaint received by VDSS Division of Licensing on 2022-06-28 regarding allegations in resident records and resident care; evidence did not support the allegations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 19, 2022
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 07/12/2022 regarding allegations in the areas of resident records, resident care, and staffing ratios.
Findings
The investigation found no evidence to support the allegations of non-compliance with standards or law related to resident records and resident care. The inspection findings were summarized and will be posted publicly.
Complaint Details
Complaint was received on 07/12/2022 regarding resident records, resident care, and staffing ratios. The evidence gathered did not support the allegations of non-compliance.
Inspection Report
Monitoring
Deficiencies: 0
Jun 15, 2022
Visit Reason
The licensing inspector conducted an on-site monitoring inspection at the facility on June 15, 2022, to review compliance with applicable standards and laws.
Findings
The inspection found no violations with applicable standards or laws during the monitoring visit.
Inspection Report
Monitoring
Deficiencies: 0
Jun 15, 2022
Visit Reason
The licensing inspector conducted an on-site monitoring inspection at the facility to review compliance with applicable standards and regulations.
Findings
The inspection found no violations of applicable standards or laws. The facility was in compliance with all reviewed areas.
Inspection Report
Monitoring
Deficiencies: 7
Jun 15, 2022
Visit Reason
The inspection was a monitoring visit conducted to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection identified multiple violations including inaccurate uniform assessment instruments (UAIs), failure to review resident rights annually, medication administration errors, incomplete oxygen orders, building maintenance issues, and incomplete first aid kit supplies.
Deficiencies (7)
| Description |
|---|
| Failed to ensure that for a private pay individual, the uniform assessment instrument (UAI) is completed as required, with discrepancies between UAI and individualized service plans (ISP). |
| Failed to review the rights and responsibility with one resident on an annual basis. |
| Failed to ensure that no medication shall be started, changed, or discontinued without a valid order from a physician or prescriber, with documented medication administration errors for sliding scale insulin. |
| Failed to ensure oxygen orders contained the oxygen source, delivery device, and flow rate as required. |
| Failed to maintain the interior and exterior of all buildings in good repair and cleanliness, including stained doors, worn paint, and scuffed dining area walls. |
| Failed to keep all furnishings, fixtures, and equipment clean and in good repair, specifically scratches and scrapes on the fish tank cabinet. |
| Failed to include all required items in the first aid kit, missing disposable single-use breathing barriers or shields for rescue breathing or CPR. |
Report Facts
Dates of medication errors: 6
Dates of UAI and ISP reviews: 4
Resident admission date: Jul 7, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca Berry | Inspector | Current inspector conducting the monitoring inspection |
| Holly Copeland | Licensing Inspector | Contact person for questions related to the inspection |
Inspection Report
Complaint Investigation
Deficiencies: 4
Jan 4, 2022
Visit Reason
Two licensing inspectors conducted an unannounced complaint inspection in response to a complaint received on 01/04/2022 regarding a resident not receiving prescribed medications.
Findings
The inspection substantiated the complaint that resident #1 did not receive five prescribed medications from December 7-31, 2021, and found additional violations including failure to complete annual Uniform Assessment Instruments, failure to provide care as specified in Individual Service Plans, failure to obtain physician orders prior to stopping medications, and failure to maintain daily weight records as ordered.
Complaint Details
Complaint was substantiated regarding resident #1 not receiving prescribed medications. The prescribing physician confirmed medications had not been discontinued despite the Medication Administration Record indicating otherwise.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure Uniform Assessment Instruments (UAI) were completed on an annual basis for one resident. |
| Facility failed to ensure the care and services specified in the Individual Service Plans (ISPs) were provided to each resident, including medication administration and assistance with hearing aids. |
| Facility failed to assume general responsibility for the health, safety, and well-being of one resident, including failure to administer prescribed medications. |
| Facility failed to ensure that a physician's order was obtained prior to stopping or changing one resident's medication and treatment. |
Report Facts
Violations cited: 4
Medication doses missed: 5
Timeframe for corrective action plan: 10
Random audits frequency: 5
Hearing aid audits frequency: 2
Daily weight order discontinuation cycles: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca Berry | Licensing Inspector | Conducted the complaint inspection and spoke with resident's prescribing physician. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Dec 29, 2021
Visit Reason
The inspection was conducted in response to a complaint received by the licensing office involving resident care at English Meadows Blacksburg.
Findings
One violation was cited related to the facility's failure to ensure a comprehensive Individual Service Plan (ISP) was completed within 30 days after admission for one resident.
Complaint Details
The inspection was complaint-related, but the cited violation was not complaint related. The complaint was received on 12/29/2021 and the inspection occurred on 01/04/2022.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure a comprehensive ISP was completed within 30 days after admission for one resident. |
Report Facts
Days to complete ISP: 106
Number of violations cited: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca Berry | Inspector | Named as current inspector conducting the inspection |
Inspection Report
Renewal
Census: 74
Deficiencies: 0
May 11, 2021
Visit Reason
A renewal inspection was initiated and conducted on 05/11/2021 using an alternate remote protocol due to a state of emergency health pandemic declared by the Governor of Virginia.
Findings
The inspection reviewed resident and staff records, staff schedules, health care and dietitian oversight, fire and health inspection reports, and emergency drills. No violations with applicable standards or law were found, and no violations were issued.
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