Deficiencies per Year
28
21
14
7
0
Unclassified
Census Over Time
Inspection Report
Complaint Investigation
Census: 79
Deficiencies: 1
Oct 2, 2025
Visit Reason
The inspection was conducted in response to a complaint received on 2025-07-27 regarding allegations in the areas of Admission, Retention, and Discharge of Residents; Resident Care and Related Services; and Building and Grounds.
Findings
The investigation supported some, but not all, of the allegations. Non-compliance was found in the area of Building and Grounds, specifically related to hot water temperatures exceeding the required range.
Complaint Details
The complaint was partially substantiated with non-compliance found in Building and Grounds. A violation notice was issued, and the licensee has the opportunity to submit a plan of correction.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure the hot water at taps available to residents was maintained within a range of 105 degrees Fahrenheit to 120 degrees Fahrenheit. |
Report Facts
Number of residents present: 79
Number of resident records reviewed: 3
Number of interviews with residents: 1
Number of interviews with staff: 1
Hot water temperature reading: 121.6
Hot water temperature reading: 123.3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Darunda Flint | Licensing Inspector | Inspector conducting the complaint investigation and named in the report |
Inspection Report
Census: 79
Deficiencies: 0
Oct 2, 2025
Visit Reason
The inspection was conducted as a type 'Other' inspection involving a tour of the physical plant including the building and grounds of the facility.
Findings
The inspection found no violations with applicable standards or laws based on the evidence gathered during the inspection.
Inspection Report
Complaint Investigation
Census: 79
Deficiencies: 0
Oct 2, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-06-24 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 received on 2025-06-24 regarding Resident Care and Related Services; investigation did not substantiate the allegations.
Report Facts
Number of residents present: 79
Number of resident records reviewed: 3
Number of interviews conducted with staff: 1
Number of interviews conducted with residents: 0
Inspection Report
Complaint Investigation
Census: 76
Deficiencies: 0
May 12, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-05-08 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. An exit meeting will be conducted to review the inspection findings.
Complaint Details
Complaint received on 2025-05-08 regarding Resident Care and Related Services; investigation did not substantiate the allegations.
Report Facts
Number of residents present: 76
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 3
Inspection Report
Renewal
Census: 76
Deficiencies: 25
May 12, 2025
Visit Reason
The inspection was a renewal inspection conducted on May 12 and May 13, 2025, to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection identified multiple violations related to resident assessments, documentation, staff training, medication management, emergency preparedness, and regulatory compliance. The facility was found non-compliant in several areas including cognitive assessments, staff certifications, medication administration, fire safety, and record keeping.
Deficiencies (25)
| Description |
|---|
| Facility failed to ensure residents with serious cognitive impairment were assessed by an independent clinical psychologist or physician prior to admission. |
| Facility failed to obtain written approval for placement of residents with serious cognitive impairment in a safe, secure environment. |
| Facility failed to document determination and justification for placement in special care unit by licensee or designee. |
| Facility failed to perform six-month and annual reviews of appropriateness for continued residence in special care unit. |
| Facility failed to retain written acknowledgment of receipt of disclosure by residents or legal representatives. |
| Facility failed to ensure staff orientation and training occurred within first seven working days of employment. |
| Facility failed to ensure tuberculosis risk assessments were completed timely for staff and residents. |
| Facility failed to ensure direct care staff maintained current certification in first aid. |
| Facility failed to ensure physical examinations including TB risk assessments were completed within 30 days preceding admission. |
| Facility failed to ensure fall risk ratings were completed timely and annually for residents meeting assisted living criteria. |
| Facility failed to ascertain and document sex offender status prior to admission for some residents. |
| Facility failed to provide new resident orientation and obtain signed acknowledgment. |
| Facility failed to ensure administrator approval and signature on Uniform Assessment Instruments (UAIs) for private pay residents. |
| Facility failed to develop preliminary plan of care on or within seven days prior to admission. |
| Facility failed to ensure individualized service plans were signed and dated by licensee and resident or legal representative. |
| Facility failed to annually review resident rights and responsibilities with residents and staff. |
| Facility failed to implement medication management plan to prevent use of expired medications. |
| Facility failed to administer medications according to the facility's standard dosing schedule. |
| Facility failed to administer medications in accordance with physician's instructions, including BP medication parameters. |
| Facility failed to ensure valid written Do Not Resuscitate (DNR) orders were documented in individualized service plans. |
| Facility failed to comply with Virginia Statewide Fire Prevention Code by not having annual fire inspection timely. |
| Facility failed to conduct fire and emergency evacuation drills as required by code. |
| Facility failed to ensure first aid kits contained required items and were checked monthly for expired items. |
| Facility failed to maintain a 96-hour supply of emergency drinking water onsite. |
| Facility failed to obtain criminal history record reports on or prior to the 30th day of employment for staff. |
Report Facts
Residents present: 76
Resident records reviewed: 6
Staff records reviewed: 3
Resident interviews: 4
Staff interviews: 3
Inspection dates: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff #4 | Confirmed multiple deficiencies related to resident assessments, documentation, and compliance | |
| Staff #5 | Confirmed deficiencies related to staff orientation, TB assessments, and resident rights reviews | |
| Staff #1 | Mentioned in relation to medication administration and orientation deficiencies | |
| Staff #2 | Mentioned in relation to medication administration deficiencies | |
| Staff #3 | Mentioned in relation to first aid certification and resident rights review deficiencies | |
| Staff #6 | Mentioned in relation to delayed criminal history record report | |
| Staff #7 | Mentioned in relation to delayed criminal history record report |
Inspection Report
Complaint Investigation
Census: 76
Deficiencies: 3
May 12, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-05-08 regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation did not substantiate the complaint allegations of non-compliance; however, violations unrelated to the complaint were identified during the inspection. These violations involved failure to complete annual fall risk ratings, resident UAIs, and individualized service plans as required.
Complaint Details
Complaint was received on 2025-05-08 regarding Resident Care and Related Services. The evidence gathered did not support the allegations of non-compliance with standards or law.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure a fall risk rating is completed at least annually, when the condition of the resident changes, and after a fall. |
| Facility failed to complete a resident's UAI at least annually and whenever there is a significant change in the resident's condition. |
| Facility failed to review and update individualized service plans at least once every 12 months and as needed for a significant change of a resident's condition. |
Report Facts
Number of residents present: 76
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of resident interviews conducted: 1
Number of staff interviews conducted: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff #1 | Confirmed dates of most current fall risk rating, UAI, and ISP for Resident #1 |
Inspection Report
Complaint Investigation
Census: 76
Deficiencies: 4
May 12, 2025
Visit Reason
The inspection was conducted in response to a complaint received by the VDSS Division of Licensing on 2025-05-07 regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation did not substantiate the complaint allegations of non-compliance; however, violations unrelated to the complaint were identified during the inspection. These included failures to complete fall risk ratings, update resident assessments and individualized service plans upon significant condition changes, and ensure consistent two-hour rounding for residents unable to use signaling devices.
Complaint Details
The complaint was related to Resident Care and Related Services. The evidence gathered did not support the allegations of non-compliance with standards or law.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure a fall risk rating is completed when the condition of the resident changes and after a fall. |
| Facility failed to complete a resident's UAI whenever there is a significant change in the resident's condition. |
| Facility failed to review and update individualized service plans as needed for a significant change of a resident's condition. |
| Facility failed to ensure direct care staff make rounds no less often than every two hours for residents with an inability to use the signaling device after going to bed each evening until they arise. |
Report Facts
Number of residents present: 76
Number of resident records reviewed: 4
Number of staff interviews conducted: 3
Number of resident interviews conducted: 1
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 4
Apr 10, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-04-09 regarding allegations in the areas of Personnel, Resident Care and Related Services, and Buildings and Ground.
Findings
The investigation supported some but not all allegations; non-compliance was found in Resident Care and Related Services and Buildings and Ground. A violation notice was issued with opportunities for the licensee to submit a plan of correction.
Complaint Details
The complaint was substantiated in part, with non-compliance found in Resident Care and Related Services and Buildings and Ground. Some violations were not related to the complaint but identified during the investigation.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure the individualized service plan was signed and dated by the resident or their legal representative when reviews and updates were made. |
| Facility failed to ensure care provision and service delivery were resident-centered and included prompt response by staff to resident needs. |
| Facility failed to ensure personal assistance and care were provided to each resident as necessary to meet their needs. |
| Facility failed to ensure medications and dietary supplements prescribed for residents were stored properly in a medicine cabinet, container, or compartment. |
Report Facts
Number of residents present: 86
Number of resident records reviewed: 3
Number of staff records reviewed: 1
Number of resident interviews conducted: 3
Number of staff interviews conducted: 3
Call bell response instances over 15 minutes for Resident #1: 48
Call bell response instances over 15 minutes for Resident #2: 8
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 0
Apr 2, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-03-31 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 to the VDSS website within 5 business days of receipt of the inspection summary.
Complaint Details
Complaint related to allegations in Resident Care and Related Services; investigation did not substantiate the complaint.
Report Facts
Number of residents present: 86
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 3
Inspection Report
Monitoring
Census: 79
Deficiencies: 3
Mar 18, 2025
Visit Reason
The inspection was a monitoring visit conducted on March 18, 2025, following a self-reported incident received on March 17, 2025, regarding allegations in Resident Care and Related Services.
Findings
The investigation supported the self-report of non-compliance with standards and violations were issued related to staff training, resident identification, and medication administration errors.
Deficiencies (3)
| Description |
|---|
| The facility failed to ensure all direct care staff attend at least 18 hours of training annually; Staff #2 lacked documentation of 2024 annual training. |
| The facility failed to ensure a current picture or narrative physical description of Resident #1 was available in the resident record. |
| Staff #2 administered Resident #1 the 4 pm medications prescribed for Resident #2, violating medication administration standards. |
Report Facts
Number of residents present: 79
Number of resident records reviewed: 2
Number of staff records reviewed: 1
Number of resident interviews conducted: 1
Number of staff interviews conducted: 2
Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 6
Feb 27, 2025
Visit Reason
The inspection was conducted in response to a complaint received on 2025-02-24 regarding allegations in staffing and supervision, resident care and related services, and resident accommodations and related provisions.
Findings
The investigation supported the allegations of non-compliance with multiple standards, resulting in violations issued. Deficiencies included failure to notify licensing authorities of administrator changes, inadequate staffing plans, delayed response to resident call bells, medication management errors, and insufficient bed linens.
Complaint Details
The complaint was substantiated with violations issued related to staffing and supervision, resident care, and resident accommodations. Evidence included interviews, record reviews, and observations confirming non-compliance.
Deficiencies (6)
| Description |
|---|
| Facility failed to notify the Virginia Board of Long-Term Care Administrators and licensing office of a change in the facility's administrator. |
| Facility failed to maintain a written staffing plan specifying number and type of direct care staff required to meet residents' needs. |
| Facility failed to ensure resident-centered care with prompt response to resident call bells; multiple instances of response times exceeding 15 minutes were documented. |
| Facility failed to implement medication management plan to verify accurate transcription of medication orders to MARs within 24 hours. |
| Facility failed to ensure medications were administered according to prescriber's instructions. |
| Facility failed to ensure sufficient bed linens; resident was found lying directly on mattress without linens. |
Report Facts
Residents present: 82
Resident records reviewed: 3
Staff interviews conducted: 3
Resident interviews conducted: 3
Call bell response delays for Resident #1: 21
Call bell response delays for Resident #2: 4
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 0
Jan 14, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-01-10 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.
Complaint Details
Complaint related to Resident Care and Related Services; the allegations were not substantiated.
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: 2
Inspection Report
Monitoring
Census: 87
Deficiencies: 0
Dec 10, 2024
Visit Reason
The inspection was a monitoring visit conducted following a self-reported incident received by VDSS Division of Licensing regarding allegations in 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 conducted interviews and record reviews.
Report Facts
Resident records reviewed: 2
Staff records reviewed: 0
Resident interviews conducted: 1
Staff interviews conducted: 2
Inspection Report
Complaint Investigation
Census: 79
Deficiencies: 1
Jul 26, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-07-23 regarding allegations related to Resident Care and Related Services and Additional Requirements for Facilities that Care for Adults with Serious Cognitive Impairments.
Findings
The investigation supported some, but not all, of the allegations; non-compliance was found in Resident Care and Related Services. Specifically, the facility failed to ensure resident-centered care and prompt staff response to resident needs.
Complaint Details
Complaint related: Yes. The complaint was substantiated in part, with non-compliance found in Resident Care and Related Services.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure care provision and service delivery were resident-centered and included prompt response by staff to resident needs as reasonable to the circumstances, evidenced by 87 instances where response time to a resident's call pendant exceeded 30 minutes between March 28, 2024 and June 26, 2024. |
Report Facts
Instances of delayed response: 87
Number of residents present: 79
Number of resident records reviewed: 1
Number of staff interviews conducted: 3
Inspection Report
Renewal
Census: 81
Deficiencies: 4
Jun 4, 2024
Visit Reason
The inspection was a renewal visit 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 certification for direct care staff, incomplete sex offender screening prior to admission, incomplete comprehensive individual service plans reflecting current resident needs, and failure to implement proper medication management including removal of expired medications.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure each direct care staff member maintain current certification in first aid. |
| Facility failed to ascertain and document sex offender screening prior to admission for a resident. |
| Facility failed to ensure comprehensive individual service plan included current identified needs and services. |
| Facility failed to implement written medication management plan including prevention of use of outdated medications and proper disposal. |
Report Facts
Residents present: 81
Resident records reviewed: 9
Staff records reviewed: 4
Resident interviews conducted: 4
Staff interviews conducted: 3
Expired medications observed: 3
Inspection Report
Monitoring
Census: 79
Deficiencies: 0
Mar 7, 2024
Visit Reason
The inspection was a monitoring visit conducted following a self-reported incident received by VDSS Division of Licensing 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. No deficiencies or non-compliance were found.
Report Facts
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of interviews conducted with staff: 4
Number of interviews conducted with residents: 0
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 0
Feb 8, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2024-02-04 regarding allegations in the areas of Resident Care and Related Services and Additional Requirements for Facilities that Care for Adults with Serious Cognitive Impairments.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The inspection summary will be posted to the VDSS website within 5 business days of receipt.
Complaint Details
Complaint related inspection with allegations in Resident Care and Related Services and Additional Requirements for Facilities that Care for Adults with Serious Cognitive Impairments; allegations were not substantiated.
Report Facts
Number of resident records reviewed: 1
Number of interviews conducted with staff: 2
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 0
Oct 19, 2023
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2023-10-10 regarding allegations in the areas of Administration and Administrative Services, Personnel, and Additional Requirements for Facilities that Care for Adults with Serious Cognitive Impairments.
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 investigation related to allegations in Administration and Administrative Services, Personnel, and Additional Requirements for Facilities that Care for Adults with Serious Cognitive Impairments; allegations were not substantiated.
Report Facts
Number of resident records reviewed: 1
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 1
Inspection Report
Monitoring
Census: 81
Deficiencies: 8
Jun 21, 2023
Visit Reason
The inspection was a monitoring visit to review compliance with applicable standards and laws at the assisted living facility.
Findings
The inspection found multiple violations related to staff training, certification, resident assessments, medication management, fire safety, and resident rights. The facility was cited for non-compliance and given opportunities to submit plans of correction.
Deficiencies (8)
| Description |
|---|
| Facility failed to ensure direct care staff attended at least 10 hours of training in cognitive impairment within four months of employment. |
| Facility failed to ensure all direct care staff attended required annual training hours, including infection control and mental impairment topics. |
| Facility failed to ensure direct care staff maintained current certification in first aid. |
| Facility failed to ensure a fall risk rating was completed at least annually for residents. |
| Facility failed to annually review the rights and responsibilities of residents with each resident or their legal representative. |
| Facility failed to implement written plan for medication management, including prevention of outdated medications and proper disposal. |
| Facility failed to post 'No Smoking-Oxygen in Use' signs and enforce smoking prohibition where oxygen is in use. |
| Facility failed to ensure fire and emergency evacuation drill frequency and participation met state code requirements. |
Report Facts
Number of residents present: 81
Number of resident records reviewed: 9
Number of staff records reviewed: 5
Hours of cognitive impairment training: 1.25
Hours of cognitive impairment training: 6.5
Hours of annual training: 2.25
Date of last annual fall risk rating: Sep 17, 2021
Date of last annual fall risk rating: Feb 25, 2020
Expiration date of medication: May 21, 2023
Expiration date of medication: Jun 15, 2023
Date of fire and emergency evacuation drill: May 23, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff #1 | Direct Care Staff | Named in findings for insufficient cognitive impairment training and lack of first aid certification |
| Staff #3 | Direct Care Staff | Named in findings for insufficient cognitive impairment training and lack of first aid certification |
| Staff #5 | RMA/CNA | Named in finding for insufficient annual training hours |
| Staff #6 | Named in finding for fire and emergency evacuation drill documentation |
Inspection Report
Complaint Investigation
Deficiencies: 1
May 2, 2023
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received on 2023-04-17 regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation found non-compliance with standards related to resident record access. Specifically, the facility failed to provide the legal representative of a resident access to the resident's records despite a written request and completed authorization form.
Complaint Details
The complaint was substantiated as the evidence supported the allegation of non-compliance with standards regarding resident record access.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure residents or their legal representatives were allowed access to their own records as required. |
Report Facts
Number of resident records reviewed: 1
Number of staff interviews conducted: 1
Inspection Report
Renewal
Census: 84
Deficiencies: 2
Jul 5, 2022
Visit Reason
The inspection was conducted as a renewal of the facility's license to ensure compliance with applicable standards and laws.
Findings
The inspection found non-compliance with applicable standards, including failure to maintain current first aid certification for direct care staff and inconsistencies in Do Not Resuscitate (DNR) orders in resident records.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure each direct care staff member maintain current certification in first aid. |
| Facility failed to ensure a valid written Do Not Resuscitate (DNR) order has been issued by the resident's attending physician and included in the individualized service plan. |
Report Facts
Number of residents present: 84
Number of resident records reviewed: 7
Number of staff records reviewed: 4
Inspection Report
Renewal
Census: 86
Deficiencies: 2
Jul 6, 2021
Visit Reason
A renewal inspection was initiated on July 1, 2021 and concluded on July 8, 2021 to review compliance with applicable standards and regulations for the assisted living facility.
Findings
The inspection identified non-compliances related to documentation, specifically the failure to ensure the administrator approved and signed the Uniform Assessment Instrument and the individualized service plan for Resident #3.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure the administrator approves and signs the completed Uniform Assessment Instrument for Resident #3. |
| Facility failed to ensure the individualized service plan was signed and dated by the licensee, administrator, or designee, and by the resident or legal representative for Resident #3. |
Report Facts
Census: 86
Audit percentage: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brenda Stevenson | Healthcare Director | Named in plan of correction for signing Resident #3's UAI and ISP |
| Shawn Buckon | Administrator | Named in plan of correction for signing Resident #3's UAI and ISP |
Inspection Report
Complaint Investigation
Deficiencies: 1
Jun 7, 2021
Visit Reason
A complaint inspection was initiated due to allegations regarding staffing, resident care, and maintenance of buildings and grounds at the facility.
Findings
The investigation found no evidence to support the allegations of non-compliance with standards or law related to the complaint. However, unrelated violations were identified, including failure to document descriptions of residents' reactions to known allergies in physical examination reports.
Complaint Details
Complaint related to allegations in staffing, resident care, and maintenance of buildings and grounds. The evidence gathered did not support the allegations of non-compliance.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure that 3 of the 4 physical examination reports reviewed documented descriptions of persons' reactions to known allergies. |
Report Facts
Physical examination reports reviewed: 4
Physical examination reports with deficiencies: 3
Correction deadline: Jul 20, 2021
Inspection dates: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Darunda Flint | Inspector | Current inspector conducting the complaint investigation |
| Staff #5 | Acknowledged that physical examination reports did not include descriptions of residents' reactions to allergies |
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