Inspection Report
Monitoring
Census: 71
Deficiencies: 6
Apr 15, 2025
Visit Reason
The inspection was a monitoring visit conducted on April 15 and April 21, 2025, to review compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection identified multiple violations related to staff certification, resident admission documentation, health care oversight, and annual resident rights review. The facility was found non-compliant with several regulatory standards and was issued violation notices with plans of correction.
Deficiencies (6)
| Description |
|---|
| Facility failed to obtain and maintain a copy of the certificate or documentation for Staff #3 as required. |
| Facility failed to ensure direct care staff member Staff #5 maintained current certification in first aid. |
| Facility failed to provide written assurance to Resident #6 or their legal representative documenting appropriate licensing at admission. |
| Facility failed to ascertain and document whether Resident #6 was a registered sex offender prior to admission. |
| Facility failed to provide health care oversight by a licensed health care professional at least every six months for all residents. |
| Facility failed to annually review and document the rights and responsibilities of Residents #3, #4, and #5. |
Report Facts
Number of residents present: 71
Number of resident records reviewed: 6
Number of staff records reviewed: 3
Number of interviews conducted with residents: 4
Number of interviews conducted with staff: 3
Date of last health care oversight: Oct 2, 2024
Next scheduled health care oversight: May 7, 2025
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 0
Jan 27, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-01-17 regarding allegations in the area of Buildings and Grounds.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law.
Complaint Details
Complaint related to Buildings and Grounds; the allegations were not substantiated.
Inspection Report
Renewal
Census: 73
Deficiencies: 3
May 21, 2024
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 non-compliance with several standards related to resident placement approvals, physical examination documentation, and resident orientation. Violations were documented and a plan of correction was requested.
Deficiencies (3)
| Description |
|---|
| Facility failed to obtain written approval for placement of residents with serious cognitive impairment in a safe, secure environment. |
| Facility failed to ensure physical examinations included a statement that individuals do not have conditions or care needs prohibited by regulation. |
| Facility failed to provide orientation to new residents and their legal representatives, including emergency procedures and use of call system. |
Report Facts
Residents present: 73
Resident records reviewed: 9
Staff records reviewed: 4
Resident interviews: 4
Staff interviews: 3
Medication pass observations: 4
Inspection Report
Deficiencies: 0
Sep 22, 2023
Visit Reason
The inspection was conducted as a license modification request involving a tour of the physical plant including the building and grounds, and inspection of 8 additional apartments.
Findings
The inspection found no violations with applicable standards or law. The inspection summary will be posted publicly within five business days.
Inspection Report
Monitoring
Census: 67
Deficiencies: 2
Sep 22, 2023
Visit Reason
The inspection was a monitoring visit conducted on 09/22/2023 following a self-reported incident received on 08/30/2023 regarding allegations in the area of Resident Care and Related Services.
Findings
The inspection found non-compliance with applicable standards and laws, resulting in documented violations related to medication administration timing and lack of specific indications for administering drugs or supplements on the MAR.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure medications were administered not earlier than one hour before and not later than one hour after the facility's standard dosing schedule. |
| Facility failed to ensure the MAR included specific indications for administering drugs or supplements, such as specifying the left eye for eye medications. |
Report Facts
Number of residents present: 67
Number of resident records reviewed: 1
Inspection Report
Monitoring
Census: 57
Deficiencies: 1
Jun 20, 2023
Visit Reason
The inspection was a monitoring visit conducted following a self-reported incident received by VDSS Division of Licensing on 06/01/2023 regarding allegations in the area of personnel.
Findings
The facility was found to have violated standards related to staff being considerate and respectful of the rights, dignity, and sensitivities of aged persons. Specifically, an incident involving Resident #1 and staff was not documented or reported, and staff failed to maintain appropriate conduct.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure staff were considerate and respectful of the rights, dignity, and sensitivities of aged persons, including failure to document or report an incident involving Resident #1. |
Report Facts
Number of residents present: 57
Number of resident records reviewed: 3
Number of staff records reviewed: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff #3 | Terminated due to failure to be considerate and respectful of resident rights | |
| Staff #4 | Confirmed actions of Staff #3 during incident with Resident #1 | |
| Staff #1 | Acknowledged that Staff #3 and Staff #4 were not considerate and respectful of Resident #1 |
Inspection Report
Renewal
Census: 55
Deficiencies: 10
May 16, 2023
Visit Reason
The inspection was a renewal visit conducted to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection identified multiple violations related to resident admission documentation, staff certification, posting of the person in charge, resident orientation, hospice care coordination, individualized service plan signatures, health care oversight, health inspection compliance, menu posting, and medication administration timing.
Deficiencies (10)
| Description |
|---|
| Failed to document determination and justification for placement of residents with serious cognitive impairment in a safe, secure environment. |
| Direct care staff member lacked current certification in first aid. |
| Failed to post the name of the current on-site person in charge in a conspicuous place. |
| Failed to provide and document orientation for new residents and their legal representatives. |
| Failed to ensure communication and coordinated plan of care between assisted living facility and licensed hospice organization. |
| Individualized service plans were not signed and dated by the licensee, administrator, or resident/legal representative as required. |
| Failed to retain a licensed health care professional with required experience to provide on-site health care oversight. |
| Failed to maintain compliance with Virginia Department of Health inspection requirements and retain reports. |
| Menus for meals were not dated and posted in an area conspicuous to residents. |
| Medications were administered outside the facility's standard dosing schedule. |
Report Facts
Number of residents present: 55
Number of resident records reviewed: 8
Number of staff records reviewed: 4
Medication administration time: 9.32
Medication scheduled time: 6.3
Inspection Report
Monitoring
Deficiencies: 0
Mar 10, 2023
Visit Reason
The inspection was a monitoring visit to review compliance with additional requirements for facilities that care for adults with serious cognitive impairments and emergency preparedness standards.
Findings
The inspection found no violations of applicable standards or laws. The facility's newly renovated safe, secure environment was inspected and met the required standards.
Inspection Report
Renewal
Census: 48
Deficiencies: 8
Apr 19, 2022
Visit Reason
An unannounced renewal inspection was conducted to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection identified multiple violations including failure to maintain current first aid certifications for direct care staff, outdated posting of staff certifications, missing discharge statements for residents, incomplete uniform assessment instruments, deficiencies in individualized service plans, inadequate fire drill frequency, insufficient emergency food and water supplies, and lack of documentation for staff participation in emergency practice exercises.
Deficiencies (8)
| Description |
|---|
| Facility failed to ensure each direct care staff member maintain current certification in first aid from approved organizations. |
| Facility failed to ensure a current listing of all staff with first aid or CPR certification was posted and readily available. |
| Facility failed to ensure a dated discharge statement signed by licensee or administrator was provided and retained in resident records. |
| Facility failed to ensure the uniform assessment instrument (UAI) was completed and signed as required. |
| Facility failed to ensure the Individualized Service Plan (ISP) included descriptions of resident needs based on the UAI and accurate outcome dates. |
| Facility failed to ensure fire and emergency evacuation drills were conducted with required frequency and participation across shifts. |
| Facility failed to ensure availability of a 96-hour supply of emergency food and drinking water with at least 48 hours on site. |
| Facility failed to document that staff participated in practice exercises for resident emergencies at least once every six months. |
Report Facts
Residents in care: 48
Staff records reviewed: 4
Resident records reviewed: 8
Fire drills missing: 3
Expired emergency food items: 3
Timeframe for CPR & First Aid classes: 6
Timeframe for CPR & First Aid course: 5
Discharge statement completion timeframe: 3
Emergency drill training frequency: 6
Inspection Report
Monitoring
Census: 62
Deficiencies: 4
May 10, 2021
Visit Reason
A monitoring inspection was initiated due to a state of emergency health pandemic declared by the Governor of Virginia, conducted remotely to review compliance with administrative, personnel, resident care, emergency preparedness, and other regulatory standards.
Findings
The inspection identified multiple violations related to medication management, including failure to document diagnosis or indications for medications, failure to have physician review and sign oral orders within 14 days, failure to obtain new medication orders upon hospital return, and failure to administer medications according to physician instructions.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure prescriber’s orders identified the diagnosis or specific indications for administering each drug. |
| Facility failed to ensure physician's oral orders are reviewed and signed by a physician within 14 days. |
| Facility failed to ensure new medication orders are obtained prior to or at the time of resident's return from hospital. |
| Facility failed to administer medications in accordance with the physician's instructions. |
Report Facts
Inspection dates: 4
Resident records reviewed: 4
Staff records reviewed: 4
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