Inspection Reports for
Golden Years Assisted Living Facility, Inc.
40 Hunt Club Boulevard, HAMPTON, VA, 23666
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
21.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
140% worse than Virginia average
Virginia average: 9.1 deficiencies/yearDeficiencies per year
40
30
20
10
0
Census
Latest occupancy rate
74 residents
Based on a February 2025 inspection.
Occupancy over time
Inspection Report
Monitoring
Deficiencies: 5
Date: Oct 7, 2025
Visit Reason
The inspection was a monitoring visit triggered by a self-reported incident received by VDSS Division of Licensing on 2025-10-06 regarding allegations in the areas of Personnel and Resident Care and Related Services.
Findings
The investigation supported the self-report of non-compliance and violations were issued related to staff conduct, fall risk assessment, individualized service plans, and staff training documentation. The licensee was given the opportunity to submit a plan of correction.
Deficiencies (5)
Facility did not ensure all staff were considerate and respectful of the rights, dignity, and sensitivities of persons who are aged, infirm, or disabled, including inappropriate teasing and misgendering of a resident.
Facility failed to ensure that a fall risk assessment was reviewed and updated after a resident experienced a fall on 2025-08-19.
Facility failed to ensure each resident's individualized service plan (ISP) contained a signature and date of the resident or their legal representative.
Resident's individualized service plan (ISP) did not include all assessed needs as documented on the Uniform assessment instrument (UAI).
Facility failed to ensure the rights and responsibilities of residents were reviewed annually with each staff person, including written acknowledgment and date of review filed in the staff person's record.
Report Facts
Number of resident records reviewed: 1
Number of staff records reviewed: 2
Number of interviews conducted with residents: 2
Number of interviews conducted with staff: 2
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Aug 27, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-08-05 regarding allegations in the areas of Personnel and Resident Care and Related Services.
Complaint Details
Complaint related: Yes. The complaint was regarding Personnel and Resident Care and Related Services. The evidence gathered did not support the allegations of non-compliance with standards or law.
Findings
The investigation did not substantiate the complaint allegations of non-compliance; however, violations unrelated to the complaint were identified during the inspection, including failure to have required psychotropic treatment documentation and failure to develop a preliminary plan of care within seven days of admission.
Deficiencies (2)
Facility failed to ensure it did not admit or retain individuals with prohibitive conditions without required documentation, specifically no psychotropic treatment plan for Resident #1 prescribed Sertraline 50 mg.
Facility failed to develop a preliminary plan of care on or within seven days prior to admission for Resident #1, whose initial ISP was dated after admission.
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
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Aug 27, 2025
Visit Reason
The inspection was conducted in response to a complaint received on 2025-08-08 regarding allegations related to resident care and supervision at Golden Years Assisted Living Facility.
Complaint Details
The complaint related to resident care and supervision was not substantiated based on the evidence gathered during the investigation.
Findings
The investigation did not substantiate the complaint allegations of non-compliance; however, violations unrelated to the complaint were identified, including failure to update fall risk assessments after a resident fall, incomplete medication administration records, and poor maintenance of the facility parking lot with multiple potholes.
Deficiencies (3)
Facility failed to ensure that a fall risk assessment was reviewed and updated after a resident experienced a fall on 2025-04-08.
Medication Administration Record (MAR) did not include initials of direct care staff administering medications for Resident #1 in August 2025.
Facility failed to maintain the interior of the building in good repair and kept clean and free of rubbish; parking lot had multiple potholes causing a resident fall.
Report Facts
Resident records reviewed: 2
Staff records reviewed: 0
Interviews conducted with residents: 0
Interviews conducted with staff: 1
Potholes observed: 5
Pothole dimensions: 12
Pothole depth: 2
Inspection Report
Monitoring
Deficiencies: 0
Date: Aug 27, 2025
Visit Reason
The inspection was a monitoring visit conducted on August 27, 2025, following a self-reported incident received on July 31, 2025, regarding allegations in the area of Resident Care and Related Services.
Findings
The inspection found no violations of applicable standards or laws after a tour of the physical plant, review of one resident record, and an interview with one staff member.
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
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Jul 7, 2025
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received on 2025-04-08 regarding allegations related to admission, retention, and discharge of residents.
Complaint Details
The complaint was substantiated. Allegations involved admission, retention, and discharge practices. Evidence supported non-compliance with applicable standards and laws.
Findings
The investigation found multiple violations including failure to have a licensed administrator on record, incomplete resident discharge documentation, failure to provide final statements of account and refunds within 60 days of discharge, and incomplete resident records. Violations were substantiated and cited accordingly.
Deficiencies (4)
Facility failed to have an administrator licensed as an assisted living facility administrator on record.
Facility failed to ensure that a copy of a written discharge statement signed by the administrator was retained in resident records with required details.
Facility failed to ensure that within 60 days of discharge, each resident or legal representative was given a final statement of account and any refunds due.
Facility failed to ensure the complete resident record included copies of all agreements and official acknowledgments signed by all parties.
Report Facts
Resident records reviewed: 2
Staff records reviewed: 1
Staff interviews conducted: 2
Resident interviews conducted: 0
Expired license date: Apr 14, 2025
Discharge notification date: Jul 22, 2024
Refund amount: 4572
Refund return date: Jul 15, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alyshia E Walker | Licensing Inspector | Inspector conducting the complaint investigation |
| Staff #1 | Acting Administrator with expired license and acknowledged missing resident records | |
| Staff #2 | Acknowledged refund of Social Security payments and provided receipt |
Inspection Report
Monitoring
Deficiencies: 2
Date: Jul 7, 2025
Visit Reason
The inspection was a monitoring visit conducted on July 7, 2025, following a self-reported incident received on July 1, 2025, regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation supported the self-report of non-compliance, resulting in violations issued related to medication administration documentation and facility maintenance. Specifically, the facility failed to ensure proper initials on the Medication Administration Record and failed to maintain the interior and exterior of the building in good repair.
Deficiencies (2)
The Medication Administration Record (MAR) did not include staff initials for several medication doses administered in June 2025.
The facility failed to maintain the interior and exterior of the building in good repair, including a torn ceiling exposing pipes and sprinkler system due to a leak.
Report Facts
Number of resident records reviewed: 1
Number of staff records reviewed: 2
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 1
Inspection Report
Annual Inspection
Census: 74
Deficiencies: 10
Date: Feb 10, 2025
Visit Reason
The inspection was a scheduled annual visit to review compliance with applicable standards and laws for Golden Years Assisted Living Facility, Inc. The inspection included a tour of the physical plant, review of resident and staff records, and interviews with residents and staff.
Findings
The inspection found multiple areas of non-compliance including deficiencies in staff tuberculosis risk assessments, resident physical examinations, fall risk assessments, sex offender screenings, individualized service plans, menu postings, medication storage security, linen supply, hot water temperature, and building maintenance. The facility was required to submit plans of correction for these violations.
Deficiencies (10)
Failure to ensure staff submitted tuberculosis risk assessments within seven days prior to first day of work.
Failure to ensure residents had physical examinations including tuberculosis risk assessments within 30 days preceding admission.
Failure to review and update fall risk assessments after every fall.
Failure to ascertain prior to admission whether a potential resident is a registered sex offender.
Failure to ensure individualized service plans contained descriptions of all identified needs and services.
Failure to ensure menus for meals and snacks were dated, posted, and substitutions recorded.
Failure to ensure medication storage areas were locked.
Failure to have sufficient bed and bath linens in good repair so residents always have clean sheets.
Failure to maintain hot water taps within the required temperature range of 105 to 120 degrees Fahrenheit.
Failure to maintain interior and exterior of buildings in good repair and free of rubbish.
Report Facts
Residents present: 74
Resident records reviewed: 6
Staff records reviewed: 4
Resident interviews: 3
Staff interviews: 3
Resident falls: 5
Hot water temperature: 125
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alyshia E Walker | Licensing Inspector | Current inspector conducting the inspection |
| Staff #1 | Acknowledged multiple deficiencies including TB assessment timing, fall risk assessment, sex offender screening, ISP inaccuracies, medication cart unlocked, and bed sheets missing | |
| Staff #4 | Acknowledged medication cart was unlocked | |
| Staff #5 | Staff record contained late TB assessment | |
| Staff #7 | Acknowledged hot water temperature readings | |
| Staff #6 | Acknowledged building maintenance issues |
Inspection Report
Monitoring
Census: 68
Deficiencies: 8
Date: Jan 7, 2025
Visit Reason
The inspection was a monitoring visit conducted to review compliance with personnel, staffing, admission, resident care, and complaint investigation standards following a self-reported incident regarding resident care and related services.
Findings
The investigation did not substantiate the self-reported non-compliance but identified several violations unrelated to the self-report. These included failures in staff training hours, mental health screening prior to admission, physical examinations, sex offender registry checks, resident agreements, orientation for new residents, timely completion of UAI assessments, and updating individualized service plans.
Deficiencies (8)
Facility failed to ensure all direct care staff attended required annual training hours.
Facility failed to conduct mental health screening prior to admission when indicated by recent behaviors.
Facility failed to ensure resident had a physical examination by an independent physician within 30 days preceding admission.
Facility failed to ascertain prior to admission whether a potential resident is a registered sex offender.
Facility failed to have a written agreement signed and dated by the resident or legal representative and licensee or administrator on or prior to admission.
Facility failed to ensure orientation was provided to new residents upon admission.
Facility failed to ensure a resident's UAI was completed within 90 days prior to admission.
Facility failed to ensure individualized service plans were reviewed and updated as needed for significant changes in resident condition.
Report Facts
Number of residents present: 68
Number of resident records reviewed: 1
Number of staff records reviewed: 3
Number of staff interviews conducted: 3
Inspection Report
Census: 75
Deficiencies: 1
Date: Sep 27, 2024
Visit Reason
The inspection was conducted following a self-reported incident received by VDSS Division of Licensing regarding allegations in the areas of incident report and resident care. The visit included a review of documentation, interviews, and a physical plant tour.
Findings
The investigation supported the self-report of non-compliance with regulations, specifically that the facility failed to report major incidents within 24 hours as required. Violations were issued based on these findings.
Deficiencies (1)
Facility failed to ensure that major incidents affecting resident life, health, safety, or welfare were reported to the regional licensing office within 24 hours.
Report Facts
Number of residents present: 75
Number of resident records reviewed: 2
Number of staff records reviewed: 2
Number of resident interviews conducted: 1
Number of staff interviews conducted: 2
Inspection Report
Complaint Investigation
Census: 74
Deficiencies: 5
Date: Sep 27, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-09-20 regarding allegations related to staffing and supervision, and resident care and related services at the assisted living facility.
Complaint Details
The complaint was substantiated. Allegations involved staffing and supervision and resident care and related services. Evidence supported non-compliance with standards and laws, resulting in violations issued.
Findings
The investigation found multiple violations including failure to comply with regulations and facility policies, inadequate staffing levels during a medical emergency resulting in a resident's death, and missing documentation related to resident admission and licensure assurance. Violations were substantiated and corrective plans were required.
Deficiencies (5)
Failure to ensure compliance with all regulations and facility policies, including lack of a written incident report for a medical emergency.
Inadequate staffing during the 11:00 p.m. to 7:00 a.m. shift, resulting in only one staff member on duty during a medical emergency where a resident passed away.
Failure to document an interview between the administrator or designee and the resident or legal representative at admission.
Failure to provide written assurance of licensure to the resident or legal representative prior to admission, and lack of documentation of such assurance in the resident's record.
Failure to ensure a written agreement signed by the resident or legal representative at or prior to admission.
Report Facts
Residents present: 74
Resident records reviewed: 1
Staff records reviewed: 1
Staff interviews conducted: 4
Time of medical emergency: 2.21
Staff on duty during emergency: 1
Resident count during emergency: 71
Inspection Report
Complaint Investigation
Census: 74
Deficiencies: 3
Date: Sep 27, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 10/2/2024 regarding allegations in the areas of Buildings and Grounds and Emergency Preparedness.
Complaint Details
The complaint was substantiated based on evidence gathered during the investigation, supporting non-compliance with standards or law in the areas of Buildings and Grounds and Emergency Preparedness.
Findings
The investigation supported the complaint of non-compliance with standards or law, resulting in violations issued. Deficiencies were found related to building maintenance, pest infestations, and expired emergency food supplies.
Deficiencies (3)
Facility failed to ensure the interior and exterior of all buildings were maintained in good repair and kept clean and free of rubbish, including worn and taped down carpet.
Facility failed to ensure buildings were kept free of infestations of insects and vermin, evidenced by live bed bugs observed on a resident's bedroom wall.
Facility failed to ensure the food supply was current; emergency food stock including peanut butter was expired as of 6/20/2021.
Report Facts
Number of residents present: 74
Number of resident interviews: 2
Number of staff interviews: 3
Expiration date: Jun 20, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alyshia E Walker | Licensing Inspector | Conducted the inspection and investigation |
| Staff #1 | Acknowledged ongoing pest control contract but continued bed bug reports | |
| Staff #3 | Acknowledged worn carpet and expired food |
Inspection Report
Monitoring
Census: 74
Deficiencies: 10
Date: Jul 30, 2024
Visit Reason
The inspection was a monitoring visit conducted to review compliance with various personnel, staffing, resident care, and admission standards at Golden Years Assisted Living Facility.
Findings
The inspection found multiple violations related to employee records, resident records, medication administration, and facility policies. Deficiencies included missing criminal history reports, incomplete orientation and training documentation, missing tuberculosis risk assessments, incomplete medication administration records, and failure to ensure proper admission screenings and documentation.
Deficiencies (10)
Facility failed to ensure criminal history record reports were obtained on or prior to the 30th day of employment for each employee.
Facility staff failed to ensure orientation and required training occurred within the first seven working days of employment.
Facility failed to ensure tuberculosis (TB) risk assessments were submitted on or within seven days prior to first day of work and annually.
Facility failed to ensure direct care staff received first aid certification within 60 days of employment.
Facility failed to ensure physical examination including TB risk assessment was completed within 30 days preceding admission.
Facility failed to ascertain prior to admission whether a potential resident is a registered sex offender.
Facility failed to ensure resident record included signed and dated acknowledgment of receiving orientation.
Facility failed to implement written plan for medication management ensuring accurate counts of controlled substances during staff changes.
Facility failed to have all required items on the Medication Administration Record (MAR), including documentation of medication administration.
Facility failed to ensure sworn statement or affirmation was complete for all applicants for employment.
Report Facts
Number of residents present: 74
Number of resident records reviewed: 7
Number of staff records reviewed: 13
Number of interviews with residents: 2
Number of interviews with staff: 5
Inspection Report
Renewal
Census: 77
Deficiencies: 16
Date: Apr 8, 2024
Visit Reason
The inspection was conducted as a renewal inspection of the Golden Years Assisted Living Facility to assess compliance with applicable standards and laws.
Findings
The inspection found multiple areas of non-compliance including failures in staff orientation and training, documentation of job descriptions, tuberculosis risk assessments for staff and residents, posting of on-site person in charge, resident admission interviews, annual Uniform Assessment Instruments (UAI) reviews, individualized service plans (ISP), healthcare oversight, activity schedules, meal menus, and medication administration records.
Deficiencies (16)
Facility staff failed to ensure orientation and required training occurred within the first seven working days of employment.
Facility failed to verify that each staff person received a copy of his or her current job description.
Facility failed to ensure staff submitted tuberculosis risk assessments on or within seven days prior to first day of work and annually.
Facility failed to post the name of the current on-site person in charge.
Facility failed to ensure documented interview between administrator/designee and resident/legal representative upon admission.
Facility failed to ensure annual tuberculosis risk assessments were completed on each resident.
Facility failed to ensure resident record included signed orientation acknowledgement.
Facility failed to ensure complete Uniform Assessment Instruments (UAI) records were reviewed at least annually.
Facility failed to ensure UAI was signed by administrator or designee.
Facility failed to ensure individualized service plans (ISP) included all assessed needs.
Facility failed to ensure individualized service plans (ISP) were signed and dated by resident or legal representative.
Facility failed to update individualized service plans (ISP) at least once every 12 months.
Facility failed to ensure licensed healthcare professional provided healthcare oversight at least every three months.
Facility failed to post current month's activity schedule in a conspicuous location.
Facility failed to post dated menus for meals and snacks for the current week in a conspicuous area.
Facility failed to have all required items on the Medication Administration Record (MAR); medication administered without MAR or physician orders available.
Report Facts
Number of residents present: 77
Number of resident records reviewed: 10
Number of staff records reviewed: 6
Number of resident interviews conducted: 3
Number of staff interviews conducted: 5
Inspection dates: 3
Inspection Report
Complaint Investigation
Census: 77
Deficiencies: 3
Date: Apr 8, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2024-02-25 regarding allegations in the areas of Resident Care and Related Services and Buildings and Grounds.
Complaint Details
The complaint was substantiated as the evidence gathered supported the allegations of non-compliance with standards related to resident care and building conditions.
Findings
The investigation supported the allegations of non-compliance with standards and violations were issued related to building maintenance, ventilation issues, and infestations of insects and vermin. Specific deficiencies included missing electrical outlet faceplates, ceiling repairs needed, foul odors, and presence of bed bugs and roaches.
Deficiencies (3)
The facility failed to ensure the interior of the building was maintained in good repair and kept clean and free of rubbish, including a missing faceplate to an electrical outlet and ceiling in need of repair.
The facility failed to ensure the building was well-ventilated and free from foul, stale, and musty odors, with a strong smell of urine throughout the facility.
The facility failed to ensure buildings were kept free of infestations of insects and vermin, with observed bed bugs and resident reports of roaches.
Report Facts
Number of residents present: 77
Number of resident interviews: 3
Number of staff interviews: 3
Inspection Report
Complaint Investigation
Census: 77
Deficiencies: 2
Date: Apr 8, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-02-23 regarding allegations in the area of Resident Care and Related Services at Golden Years Assisted Living Facility.
Complaint Details
The complaint was substantiated as the evidence gathered supported the allegation of non-compliance with standards or law.
Findings
The investigation supported the allegation of non-compliance with standards or law, resulting in violations issued. Specific deficiencies included failure to ensure psychotropic medications had treatment plans and failure to keep medications in pharmacy-issued containers until administration.
Deficiencies (2)
Facility failed to ensure it did not admit or retain individuals with psychotropic medications without a treatment plan.
Facility failed to ensure medication remained in the pharmacy issued container with the prescription label or direction label attached until administered to the resident.
Report Facts
Number of residents present: 77
Number of resident records reviewed: 2
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 3
Number of residents with pre-poured medications observed: 2
Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 16
Date: Dec 8, 2023
Visit Reason
The inspection was conducted in response to a complaint received on 2023-11-21 regarding allegations in the area of Resident Care and Related Services at Golden Years Assisted Living Facility.
Complaint Details
The complaint was substantiated as the evidence gathered supported the allegation of non-compliance with standards or law.
Findings
The investigation found multiple violations including failure to obtain criminal history reports timely, improper use of electronic signatures, incomplete staff orientation and training, failure to notify licensing authorities about administrator changes, incomplete resident assessments and service plans, medication management deficiencies, and failure to post required information. Violations were issued and plans of correction were requested.
Deficiencies (16)
Failed to obtain criminal history record report on or prior to the 30th day of employment for two employees.
Failed to ensure use of electronic records or signatures complied with the Uniform Electron Transaction Act.
Failed to ensure orientation and required training occurred within the first seven working days of employment.
Failed to immediately notify the Virginia Board of Long-Term Care Administrators and licensing office about administrator resignation and replacement.
Failed to ensure training for the first year commenced no later than 60 days after employment.
Failed to ensure direct care staff maintained current certification in first aid.
Failed to ensure posting of the name of the current on-site person in charge.
Failed to ensure complete Uniform Assessment Instruments (UAIs) records were reviewed at least annually.
Failed to update Individualized Service Plan (ISP) at least once every 12 months.
Failed to ensure the current month's activity schedule was posted in a conspicuous location.
Failed to ensure menus for meals and snacks for the current week were dated and posted conspicuously.
Failed to implement written plan for medication management ensuring accurate counts of controlled substances during staff changes.
Failed to ensure an applicant for medication aide registration did not act on a provisional basis longer than 120 days.
Failed to ensure medication remained in pharmacy-issued container with label until administered.
Failed to have all required items documented on the Medication Administration Record (MAR).
Failed to ensure medications ordered for PRN administration were available.
Report Facts
Residents present: 75
Resident records reviewed: 16
Staff records reviewed: 3
Resident interviews: 2
Staff interviews: 4
Medication administration missing initials: 80
Medication administration missing dates: 7
Medication pre-poured residents: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alyshia E Walker | Licensing Inspector | Current inspector conducting the complaint investigation |
Inspection Report
Census: 98
Deficiencies: 0
Date: May 10, 2023
Visit Reason
The inspection was conducted as a self-reported incident investigation related to allegations in Resident Care and Related Services, with inspection dates on March 13, 2023 and May 10, 2023.
Complaint Details
The visit was complaint-related based on a self-reported incident received on 2/24/2023 regarding Resident Care and Related Services. The investigation did not substantiate non-compliance.
Findings
The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law. The inspection findings will be posted publicly and an exit meeting was planned to review the findings.
Report Facts
Number of residents present: 98
Number of resident records reviewed: 2
Number of staff records reviewed: 1
Number of interviews conducted with staff: 2
Number of interviews conducted with residents: 0
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 0
Date: May 10, 2023
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2023-05-03 regarding allegations in the areas of Buildings and Grounds and Resident Care and Related Services.
Complaint Details
Complaint related to allegations in Buildings and Grounds and Resident Care and Related Services; the complaint was not substantiated.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The licensing inspector completed a tour of the physical plant and conducted interviews with residents and staff.
Report Facts
Residents present: 98
Resident records reviewed: 2
Resident interviews: 3
Staff interviews: 4
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 0
Date: May 10, 2023
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on May 25, 2023, regarding allegations in the area of Resident Care and Related Services.
Complaint Details
Complaint related to Resident Care and Related Services; the allegations were not substantiated based on the investigation.
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 an exit meeting was planned to review the findings.
Report Facts
Number of residents present: 98
Number of resident records reviewed: 3
Number of staff records reviewed: 0
Number of interviews conducted with residents: 2
Number of interviews conducted with staff: 2
Inspection Report
Renewal
Census: 79
Deficiencies: 13
Date: Mar 13, 2023
Visit Reason
The inspection was conducted as a renewal inspection of the Golden Years Assisted Living Facility, Inc. on March 13, 2023 and May 10, 2023 to assess compliance with applicable standards and laws.
Findings
The inspection found multiple violations including failure to report major incidents timely, inadequate staff training on infection control and mental impairment, incomplete tuberculosis evaluations, missing documentation of resident interviews and treatment plans, medication management issues, hot water temperature violations, malfunctioning call bell system, and incomplete first aid kit supplies.
Deficiencies (13)
Failed to report to the regional licensing office within 24 hours any major incident affecting a resident.
Failed to ensure required infection control and mental impairment training hours for staff.
Failed to ensure subsequent tuberculosis evaluations and reports for staff members.
Failed to document interview between administrator/designee and resident/legal representative.
Failed to admit or retain individuals with psychotropic medications without a treatment plan.
Failed to ensure annual risk assessment for tuberculosis for a resident.
Failed to include signed and dated orientation acknowledgement in resident record.
Failed to comply with requirements for uniformed assessment instrument documentation and signature.
Failed to ensure individualized service plans were signed and dated by resident or legal representative.
Failed to ensure medication remained in pharmacy issued container with label until administered.
Failed to maintain hot water temperature within 105-120 degrees Fahrenheit for residents.
Failed to ensure all furnishings, fixtures, and equipment were in good repair, including call bell system.
Failed to ensure the first aid kit included all required items such as roller gauze and antiseptic wipes.
Report Facts
Number of residents present: 79
Number of resident records reviewed: 8
Number of staff records reviewed: 5
Number of interviews conducted with residents: 4
Number of interviews conducted with staff: 5
Number of repoured medications observed: 17
Water temperature in bathroom for room #21: 150
Water temperature in rooms #37 and #38: 130
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alyshia E Walker | Licensing Inspector | Named as the current inspector conducting the inspection. |
| Staff #1 | Mentioned in relation to missing infection control training and tuberculosis evaluations. | |
| Staff #2 | Acknowledged missing required training hours. | |
| Staff #3 | Acknowledged hot water temperature violations. | |
| Staff #5 | Observed water temperature violations and call bell system issues. | |
| Staff #8 | Mentioned in relation to missing tuberculosis evaluation. | |
| Staff #9 | Mentioned in relation to missing infection control training. | |
| Staff #10 | Observed repoured medications during medication pass. |
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 11
Date: Oct 12, 2022
Visit Reason
The inspection was conducted as a complaint-related investigation following a self-reported incident received on 2022-09-30 regarding allegations in the area of Resident Care at Golden Years Assisted Living Facility.
Complaint Details
The complaint investigation was triggered by a self-report from Staff #1 on 2022-09-20 regarding Resident #3 reporting sexual assault by Resident #2. Interviews and documentation review confirmed Resident #3 reported sexual harassment and feeling unsafe, but the facility lacked documentation that these concerns were addressed.
Findings
The investigation supported the self-report of non-compliance with multiple regulatory standards, resulting in violations issued. Deficiencies included failures in staff tuberculosis risk assessments, first aid certification, sex offender inquiries prior to admission, discharge documentation, uniform assessment instruments completion and review, individualized service plan updates, meeting residents' healthcare needs, resident rights violations, and maintenance issues such as mattress condition and building repairs.
Deficiencies (11)
Facility failed to ensure each staff person submitted tuberculosis risk assessment prior to first day of work.
Facility failed to ensure all staff maintain current certification in first aid.
Facility failed to ascertain prior to admission whether a potential resident is a registered sex offender.
Facility failed to complete a discharge statement with required information at time of discharge.
Facility failed to ensure uniform assessment instruments (UAIs) were completed as required.
Facility failed to ensure uniform assessment instruments were reviewed annually.
Facility failed to ensure individualized service plans were reviewed and updated at least annually and as needed.
Facility failed to ensure health care service needs of a resident were met, including documentation of ordered labs.
Facility failed to ensure a resident had rights and responsibilities as provided by law, including failure to address reported sexual harassment.
Facility failed to supply a comfortable mattress for each resident; mattress in room #9 was sunken.
Facility failed to maintain interior and exterior of building in good repair and keep it clean and free of rubbish, including issues with carpet, lighting, caulking, paint, and planters.
Report Facts
Number of residents present: 83
Number of resident records reviewed: 3
Number of staff records reviewed: 2
Number of interviews with residents: 2
Number of interviews with staff: 2
Inspection Report
Renewal
Census: 86
Deficiencies: 12
Date: Jun 23, 2022
Visit Reason
An unannounced on-site renewal inspection was conducted to assess compliance with applicable standards and laws for license renewal of the assisted living facility.
Findings
The inspection found multiple violations including failure to follow CDC blood glucose monitoring practices, incomplete staff work schedules, lack of annual tuberculosis risk assessments for residents, incomplete individualized service plans, outdated health and fire inspections, missing diet manual, improper water temperature, and failure to obtain timely criminal history reports for new hires.
Deficiencies (12)
Facility failed to ensure blood glucose monitoring practices consistent with CDC recommendations.
Facility failed to ensure the written work schedule included names, job classifications, and indication of person in charge.
Facility failed to ensure annual tuberculosis risk assessments were completed for residents.
Facility failed to ensure annual reassessment using the Uniform Assessment Instrument (UAI) for residents.
Facility failed to ensure individualized service plans included all assessed needs for residents.
Facility failed to ensure individualized service plans were updated as resident conditions changed.
Facility failed to ensure health care service needs of residents were met as recommended by physician.
Facility failed to maintain current health inspection report as required.
Facility failed to keep a current diet manual accessible to food preparation personnel.
Facility failed to maintain hot water temperature within required range of 105 to 120 degrees Fahrenheit.
Facility failed to maintain current fire inspection report as required by Virginia Statewide Fire Prevention Code.
Facility failed to obtain criminal history record reports on or prior to the 30th day of employment for new hires.
Report Facts
Inspection dates: 6
Facility census: 86
Residents with incomplete TB assessments: 4
Residents with incomplete ISPs: 6
Residents with outdated reassessments: 1
Staff missing criminal history reports: 7
Water temperature: 133
Inspection Report
Renewal
Deficiencies: 2
Date: May 24, 2021
Visit Reason
A renewal inspection and IPOC follow-up was initiated and concluded on May 24, 2021, conducted remotely due to a state of emergency health pandemic.
Findings
The inspection found non-compliance with applicable standards, including failure to update the uniform assessment instrument annually and failure to ensure individualized service plans were signed and dated by residents or their legal representatives.
Deficiencies (2)
Facility failed to ensure the uniform assessment instrument was updated annually.
Facility failed to ensure the individualized service plan was signed and dated by the resident or legal representative.
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Sep 22, 2020
Visit Reason
A complaint inspection was initiated due to allegations regarding resident care and administrative services at Golden Years Assisted Living Facility. The investigation was conducted remotely due to a state of emergency health pandemic.
Complaint Details
The complaint investigation was substantiated with evidence supporting allegations of non-compliance in resident care and administrative services, specifically related to medication administration and documentation.
Findings
The investigation found non-compliance with regulations related to medication administration, including failure to obtain physician orders for discontinued medications and failure to administer prescribed medications as ordered. Additional violations included incomplete medication administration records lacking diagnosis or indications for medications.
Deficiencies (3)
Failure to ensure compliance with all regulations for licensed assisted living facilities and terms of the license, including policies and procedures related to medication orders.
Failure to ensure medications were administered according to physician's instructions; 10 out of 21 prescribed medications were not administered between March 10 and March 19, 2020.
Medication administration record did not include diagnosis, condition, or specific indications for administering drugs or supplements for all medications administered during February to July 2020.
Report Facts
Inspection dates: 3
Medications not administered: 10
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 22, 2020
Visit Reason
A complaint inspection was initiated on 09/22/2020 due to allegations regarding administration, resident care, and accommodations at the facility.
Complaint Details
A complaint was received by the department regarding allegations in administration, resident care, and resident accommodations. The investigation found no substantiated non-compliance.
Findings
The evidence gathered during the investigation did not support the allegation of non-compliance with standards or law.
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