Inspection Report
Monitoring
Deficiencies: 3
Sep 11, 2025
Visit Reason
The inspection was a monitoring visit conducted to review compliance with regulations related to personnel, resident care and related services, and additional requirements for facilities caring for adults with serious cognitive impairments. The visit was triggered by a self-reported incident regarding allegations in these areas.
Findings
The investigation supported some but not all of the self-reported allegations, identifying areas of non-compliance in Resident Care and Related Services and Mixed Population. Violations were found related to staff training on cognitive impairment, timely updating of resident assessments (UAI), and individualized service plans (ISP) reflecting significant changes in resident conditions.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure direct care staff completed six hours of training in working with individuals who have a cognitive impairment within four months of employment. |
| Facility failed to ensure that all residents and applicants were assessed face to face using the uniform assessment instrument (UAI) prior to admission, annually, and when there was a significant change in condition; UAI was not updated for a resident with significant behavioral changes. |
| Facility failed to ensure individualized service plans (ISP) were reviewed and updated at least annually and as needed for significant changes; a resident's ISP was not updated to reflect significant behavioral changes. |
Report Facts
Number of resident records reviewed: 1
Number of staff records reviewed: 10
Number of interviews conducted with staff: 2
Hours of cognitive impairment training required: 6
Hours of cognitive impairment training completed by Staff 3: 5
Inspection Report
Renewal
Census: 47
Deficiencies: 1
Jan 27, 2025
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 related to medication management, specifically the failure to ensure that medications ordered for PRN administration were available, properly labeled for the specific resident, and properly stored at the facility.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure that medications ordered for PRN administration were available, properly labeled for the specific resident, and properly stored. |
Report Facts
Number of residents present: 47
Number of resident records reviewed: 6
Number of staff records reviewed: 3
Number of interviews conducted with residents: 2
Number of interviews conducted with staff: 4
Inspection Report
Renewal
Census: 47
Deficiencies: 5
Feb 28, 2024
Visit Reason
The inspection was a renewal visit conducted to assess compliance with applicable regulations and licensing standards for the assisted living facility.
Findings
The inspection identified multiple violations related to resident admission procedures, orientation documentation, individualized service plans, physician orders, and emergency preparedness drills. The facility was found non-compliant in these areas and issued violation notices with plans of correction.
Deficiencies (5)
| Description |
|---|
| Failed to ensure prior to admission whether a potential resident is a registered sex offender. |
| Failed to provide an orientation for a new resident with signed and dated acknowledgment. |
| Failed to ensure the services provided by hospice care are included on the individualized service plan (ISP). |
| Failed to ensure the physician's order for oxygen contained the oxygen source and delivery device. |
| Failed to ensure staff participate in an exercise for resident emergencies at least once every six months. |
Report Facts
Number of residents present: 47
Number of resident records reviewed: 12
Number of staff records reviewed: 4
Number of resident interviews conducted: 4
Number of staff interviews conducted: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Marie Swink | Licensing Inspector | Conducted the inspection and interviews |
Inspection Report
Renewal
Census: 47
Deficiencies: 7
Jan 30, 2023
Visit Reason
The inspection was a renewal inspection conducted to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection identified multiple areas of non-compliance including failure to ensure annual medication aide training, incomplete individualized service plans (ISPs), medication management deficiencies, unsigned physician orders, unsecured medication storage, and unsecured cleaning supplies. The facility was issued violation notices and given the opportunity to submit plans of correction.
Deficiencies (7)
| Description |
|---|
| Failed to ensure annual training for medication aides included required continuing education. |
| Failed to ensure identified needs were addressed on individualized service plans (ISPs). |
| Failed to ensure individualized service plans (ISPs) were signed and dated by licensee, administrator, or resident/legal representative. |
| Failed to implement medication management plan to ensure timely filling and refilling of medications. |
| Failed to ensure physician orders were signed within 14 days. |
| Failed to ensure medications prescribed to residents were stored in a locked area. |
| Failed to ensure cleaning supplies were stored in a locked area. |
Report Facts
Residents present: 47
Resident records reviewed: 9
Staff records reviewed: 6
Resident interviews: 3
Staff interviews: 3
Medication missed days: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Marie Swink | Licensing Inspector | Current inspector conducting the inspection |
| Cynthia Ball-Beckner | Licensing Inspector | Contact person for questions about the inspection |
Inspection Report
Monitoring
Deficiencies: 0
May 11, 2022
Visit Reason
Follow up inspection from previous violations to monitor compliance and review medication cart labeling.
Findings
The inspection found no violations with applicable standards or laws. The facility medication carts were observed for proper glucometer labeling.
Report Facts
Number of staff interviews conducted: 3
Inspection Report
Monitoring
Deficiencies: 1
May 11, 2022
Visit Reason
The inspection was a monitoring visit conducted to review compliance with resident care and related services standards.
Findings
The inspection found a violation related to medication administration where a Duragesic patch intended for one resident was mistakenly placed on another. The facility self-reported the incident and violations were issued with an opportunity to submit a plan of correction.
Deficiencies (1)
| Description |
|---|
| Failed to ensure that medications administered to resident 1 were in accordance with physician orders, specifically a Duragesic patch error. |
Report Facts
Date of medication error: May 3, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Marie Swink | Licensing Inspector | Current inspector conducting the monitoring inspection |
| Cynthia Ball-Beckner | Licensing Inspector | Contact person for questions about the VDSS Licensing Programs |
Inspection Report
Complaint Investigation
Deficiencies: 3
May 11, 2022
Visit Reason
The inspection was conducted in response to a complaint received on 2022-04-14 regarding allegations in administration, personnel, staffing, admission, resident care, and building and grounds.
Findings
The investigation supported some but not all allegations, with non-compliance found in resident care and related services. Violations included failure to update individualized service plans, medication administration errors, and malfunctioning signaling devices.
Complaint Details
Complaint related inspection triggered by allegations received on 2022-04-14. Evidence supported some allegations related to resident care and related services. A violation notice was issued with opportunity for plan of correction.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure individualized service plans (ISPs) were updated when a change in a resident occurred. |
| Facility failed to administer medications in accordance with physician instructions. |
| Facility failed to ensure that a signaling device terminating at a central location was continuously staffed and audible/visible to determine the origin of the signal. |
Report Facts
Number of resident records reviewed: 12
Number of resident interviews conducted: 3
Number of staff interviews conducted: 4
Number of times blood pressure was over threshold without medication administered: 7
Inspection time duration (hours): 5.5
Inspection Report
Monitoring
Deficiencies: 1
Apr 7, 2022
Visit Reason
The inspection was an unannounced monitoring investigation conducted on 04/07/2022 following a facility self-reported incident regarding medication administration.
Findings
The investigation found non-compliance with medication administration standards, specifically that a Duragesic patch prescribed for one resident was mistakenly placed on another. Violations related to medication administration according to physician's instructions were cited.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure medications were administered in accordance with physician's instructions, including incorrect placement of a Duragesic patch on a resident. |
Report Facts
Medication patch dosage: 25
Medication patch dosage: 12
Incident date: Mar 31, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Marie Swink | Inspector | Named as current inspector conducting the investigation |
Inspection Report
Renewal
Census: 49
Deficiencies: 9
Mar 14, 2022
Visit Reason
An unannounced renewal study was conducted to assess compliance with licensing standards for the assisted living facility.
Findings
The inspection identified multiple deficiencies related to infection control, documentation accuracy, medication management, labeling of medications, and completion of required assessments and service plans.
Deficiencies (9)
| Description |
|---|
| Failed to ensure infection control policies consistent with CDC recommendations were followed during medication cart audits. |
| Failed to ensure the disclosure statement provided to a prospective resident included all required components. |
| Failed to ensure the uniform assessment instrument (UAI) was completed as required. |
| Failed to ensure the comprehensive individualized service plan (ISP) was completed as required. |
| Failed to implement the medication management plan correctly. |
| Failed to ensure residents with medications in their rooms were capable of self-administering medication as indicated by the UAI. |
| Failed to ensure medications remained in pharmacy issued containers with prescription or direction labels attached until administered. |
| Failed to ensure over-the-counter medication was labeled with the resident's name. |
| Failed to ensure the medication administration record (MAR) contained all required components. |
Report Facts
Residents in care: 49
Medication count audit missing signatures: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Marie Swink | Licensing Inspector | Conducted the inspection and communicated findings. |
| Staff 4 | Observed during medication management deficiencies and interviewed regarding medication cart signatures and medication storage. |
Inspection Report
Monitoring
Deficiencies: 1
Jul 19, 2021
Visit Reason
A non-mandated monitoring inspection was initiated to review compliance with personnel, staffing, supervision, and resident care standards.
Findings
The investigation found non-compliance with documentation requirements on resident treatment administration records (TARs), specifically missing staff initials for medication and treatment administration on multiple dates for two residents.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure that all required information was documented on the MARs and TARs, including missing staff initials for medication and treatment administration. |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Marie Swink | Inspector | Named as the current inspector conducting the investigation. |
Inspection Report
Renewal
Census: 35
Deficiencies: 6
Mar 25, 2021
Visit Reason
A renewal inspection was initiated on 3/24/21 and concluded on 3/26/21 using an alternate remote protocol due to a state of emergency health pandemic declared by the Governor of Virginia.
Findings
The inspection identified multiple non-compliances with applicable standards and laws, including failures in staff scope of practice, certification in first aid, timely history and physical examinations, completion and accuracy of uniform assessment instruments (UAI), individualized service plans (ISP), and inclusion of hospice services in ISPs.
Deficiencies (6)
| Description |
|---|
| Facility failed to ensure direct care staff provided services within their scope of practice and training, specifically registered medication aides providing routine wound care. |
| Facility failed to ensure direct care staff received certification in first aid within 60 days of employment. |
| Facility failed to ensure a history and physical was obtained within 30 days of admission to the assisted living facility. |
| Facility failed to ensure uniform assessment instruments (UAI) were completed as required and accurately reflected resident behaviors. |
| Facility failed to ensure all identified needs were addressed on individualized service plans (ISP), including diet consistency and wound care treatment orders. |
| Facility failed to ensure services provided by both the assisted living facility and licensed hospice organization were included on individualized service plans (ISP). |
Report Facts
Current census: 35
Staff hired dates: 2
Resident readmission date: Jul 2, 2020
Dates of physician orders: Mar 11, 2021
Inspection Report
Monitoring
Deficiencies: 1
Mar 11, 2021
Visit Reason
A monitoring inspection was initiated due to a state of emergency health pandemic and a self-reported incident regarding allegations in resident care and related services.
Findings
The investigation supported the self-report of non-compliance with standards or law, resulting in violations related to resident rights and responsibilities. Staff person 1 was verbally abusive to a resident and was terminated following the incident.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure that the rights and responsibilities were provided as per 63.2-1808 of the Code of Virginia and this chapter. |
Report Facts
Inspection duration: 28
Inspection Report
Monitoring
Deficiencies: 3
Oct 20, 2020
Visit Reason
A monitoring inspection was initiated due to a state of emergency health pandemic and a self-reported incident regarding allegations in resident care and related services.
Findings
The investigation supported the self-reported incident of non-compliance with standards or law, resulting in violations related to failure to notify the licensing office of incidents, failure to complete fall risk ratings after falls, and failure to address identified needs in individualized service plans.
Deficiencies (3)
| Description |
|---|
| Facility failed to notify the regional licensing office within 24 hours of an incident affecting resident 1 involving falls and hospitalization. |
| Facility failed to ensure that a fall risk rating was completed after resident 1's falls on 9/18/2020 and 9/24/2020. |
| Facility failed to ensure that all identified needs were addressed on the individualized service plan for resident 1, including physical and occupational therapy services. |
Report Facts
Incident dates: Falls occurred on 9/18/2020, 9/21/2020, and 9/24/2020; physical therapy from 5/18/2020 to 8/23/2020 and 9/21/2020 to 10/17/2020; occupational therapy from 9/24/2020 to 10/17/2020.
Monthly chart audit sample size: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Marie Swink | Inspector | Current inspector conducting the inspection. |
| Director of Nursing | Responsible for reviewing fall reports and auditing resident records for ISP compliance. | |
| Executive Director | Responsible for reviewing incident reports and conducting monthly audits to ensure compliance. |
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