Deficiencies (last 7 years)
Deficiencies (over 7 years)
5.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
42% better than Virginia average
Virginia average: 9.1 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
46 residents
Based on a October 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Renewal
Census: 46
Deficiencies: 4
Date: Oct 16, 2025
Visit Reason
The inspection was a renewal visit to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection found multiple violations including failure to ensure annual review of residents' rights with staff, inadequate lighting in interior areas, incomplete sworn statements for employment applicants, and employment of a staff member with a barrier crime conviction.
Deficiencies (4)
Failed to ensure the rights and responsibilities of residents were reviewed annually with each staff person.
Facility failed to have all interior areas adequately lighted for safety and comfort of residents and staff.
Failed to complete the sworn statement or affirmation for all applicants for employment.
Failed to ensure any person required to obtain a criminal history report was ineligible for employment if the report contained convictions of barrier crimes.
Report Facts
Number of residents present: 46
Number of resident records reviewed: 4
Number of interviews with residents: 2
Number of interviews with staff: 3
Staff #4 date of hire: Jul 11, 2017
Last documentation of resident rights review for Staff #4: Jul 16, 2019
Staff #2 hire date: Sep 3, 2024
Sworn statement date for Staff #3: Sep 1, 2025
Inspection Report
Monitoring
Census: 46
Deficiencies: 1
Date: Oct 16, 2025
Visit Reason
The inspection was a monitoring visit triggered by a self-reported incident received on 2025-06-12 regarding allegations in the area of Resident Care and Related Services.
Findings
The facility was found non-compliant for failing to provide adequate supervision of a resident, resulting in the resident exiting a secured memory care gate and wandering into another courtyard. Violations were issued based on document reviews and staff interviews.
Deficiencies (1)
Facility failed to ensure supervision of a resident's schedule, care, and activities, including prevention of falls and wandering from the premises.
Report Facts
Number of residents present: 46
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
Plan of correction audit frequency: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Darunda Flint | Licensing Inspector | Named as the current inspector conducting the inspection and contact for questions |
| Staff #1 | Notified licensing inspector of the incident and confirmed details in interview |
Inspection Report
Renewal
Census: 36
Deficiencies: 5
Date: Aug 20, 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 identified multiple violations including failure to perform required reviews for residents in the special care unit, insufficient scheduled activities, lack of annual review of residents' rights and responsibilities, presence of expired medications, and medication orders without valid physician authorization. Plans of correction were submitted to address these deficiencies.
Deficiencies (5)
Failed to ensure six months after placement and annually thereafter, a review of appropriateness of each resident's continued residence in the special care unit was performed.
Failed to ensure at least 21 hours of scheduled activities available to residents each week for no less than two hours each day.
Failed to annually review the rights and responsibilities of residents with each resident or their legal representative.
Failed to ensure the written plan for medication management includes methods to prevent the use of outdated medications; expired medications were found in medication carts.
Failed to ensure no medication be started, changed, or discontinued without a valid order from a physician or other prescriber.
Report Facts
Residents present: 36
Resident records reviewed: 4
Staff records reviewed: 3
Resident interviews: 3
Staff interviews: 3
Scheduled activity hours: 21
Expired medications observed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Darunda Flint | Licensing Inspector | Current inspector conducting the inspection |
| M. Tess Pittman | Licensing Inspector | Contact person for questions regarding the inspection |
Inspection Report
Monitoring
Census: 36
Deficiencies: 5
Date: Oct 5, 2023
Visit Reason
The inspection was a monitoring visit conducted to review compliance with applicable standards and laws at the assisted living facility.
Findings
The inspection identified multiple violations including failure to maintain current first aid certifications for direct care staff, failure to update individualized service plans for significant resident condition changes, presence of expired medications in medication carts, unlocked medication carts, and medication administration errors.
Deficiencies (5)
Facility failed to ensure each direct care staff member maintain current certification in first aid.
Facility failed to review and update individualized service plans as needed for a significant change of a resident's condition.
Facility failed to ensure their written plan for medication management includes methods to prevent the use of outdated medications.
Facility failed to ensure the medication cart be locked and the individual responsible for medication administration shall keep the keys on their person.
Facility failed to ensure medications be administered in accordance with the physician's or other prescriber's instructions and consistent with standards of practice.
Report Facts
Number of residents present: 36
Number of resident records reviewed: 4
Number of staff records reviewed: 3
Expired medication dates: Expired medications observed with expiration dates 09/27/2023, 09/30/2023, and 08/23/2023
Medication error observation date: Medication error incident date 08/10/2023
Observation times: Medication cart observed unlocked at 11:25 am and 12:55 pm on 10/05/2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #4 | Direct Care Staff | Named in deficiency for lacking current first aid certification and involved in medication error |
| Staff #1 | Provided additional information during onsite inspection and acknowledged medication error | |
| M. Tess Pittman | Licensing Inspector | Contact person for questions about the VDSS Licensing Programs |
Inspection Report
Renewal
Census: 30
Deficiencies: 4
Date: Aug 23, 2022
Visit Reason
The inspection was a renewal visit to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection found multiple violations including failure to ensure assessments for serious cognitive impairment prior to admission, incomplete individualized service plans within required timeframes, presence of expired medications in medication carts, and incomplete first aid kits with expired items and missing supplies.
Deficiencies (4)
Facility failed to ensure prior to admission residents were assessed by an independent clinical psychologist or physician for serious cognitive impairment.
Facility failed to ensure comprehensive individualized service plans were completed within 30 days after admission and included required items.
Facility failed to ensure medication management plan included methods to prevent use of outdated medications; expired medications were found in medication carts.
Facility failed to ensure first aid kit contained all required items; missing scissors and contained expired antiseptic ointment.
Report Facts
Number of residents present: 30
Number of resident records reviewed: 6
Number of staff records reviewed: 4
Expired medication dates: 2015
Expired medication dates: 2020
Expired antiseptic ointment date: 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Darunda Flint | Current Inspector | Named as the licensing inspector conducting the inspection |
| M. Tess Pittman | Licensing Inspector | Contact person for VDSS Licensing Programs |
Inspection Report
Routine
Deficiencies: 2
Date: Feb 3, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with regulatory requirements, including ensuring residents' needs and preferences are accommodated and monitoring antibiotic use.
Findings
The facility failed to keep Resident #2's call bell within reach, posing a risk for falls, and failed to ensure timely administration of antibiotics for Resident #21, resulting in delayed treatment of a urinary tract infection.
Deficiencies (2)
Facility staff failed to ensure Resident #2's call bell remained within reach, despite care plan interventions to minimize fall risk.
Facility staff failed to ensure Resident #21 received timely antibiotic treatment despite documented urinary tract infection and susceptibility to prescribed antibiotic.
Report Facts
Residents in survey sample: 19
Residents affected: 1
Residents affected: 1
Urine specimen colonies: 100000
Antibiotic dosage: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| License Practical Nurse (LPN) #1 | Removed Resident #2's call light from behind bed and attached it to resident's covering | |
| Director of Nursing | Interviewed regarding call bell policy and antibiotic delay; stated call bell should be within reach and antibiotic delay was unjustified | |
| Nurse Practitioner (NP) | Ordered urine culture and antibiotic treatment for Resident #21 |
Inspection Report
Renewal
Census: 28
Deficiencies: 5
Date: Oct 5, 2021
Visit Reason
A renewal inspection was initiated on 10/5/2021 and concluded on 10/20/2021 to review compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection identified multiple violations including inaccuracies in Individualized Service Plans (ISP) compared to Uniform Assessment Instruments (UAI), lack of dietitian oversight for special diets, failure to implement medication management plans leading to missed dosages, absence of physician orders for certain medications found in resident areas, and incomplete fire and emergency evacuation drawings missing areas of refuge and assembly areas.
Deficiencies (5)
Facility failed to ensure the Individualized Service Plan (ISP) included a description of the resident's identified needs based on the Uniform Assessment Instrument (UAI).
Facility failed to ensure oversight at least every six months of special diets by a dietitian or nutritionist for each resident who has such a diet.
Facility failed to implement their written plan for medication management to ensure timely filling and refilling of medications to avoid missed dosages.
Facility failed to ensure the resident's record contained the physician's or other prescriber's signed written order or a dated notation of the physician's or other prescriber's oral order.
Facility failed to ensure a fire and emergency evacuation drawing included areas of refuge and assembly areas.
Report Facts
Resident census: 28
Medication missed dosages: 9
Inspection Report
Deficiencies: 1
Date: Aug 29, 2019
Visit Reason
The inspection was conducted to assess compliance with regulations regarding the use of psychotropic medications, specifically to ensure that residents are free from unnecessary administration of such medications.
Findings
The facility failed to ensure that Resident #16 had a 14-day stop date on the physician-ordered Ativan medication, which was necessary to reassess the need for continued use. The Director of Nursing stated the lack of a stop date was due to the resident being in hospice care.
Deficiencies (1)
Failure to have a 14 day stop date on the use of Ativan ordered for Resident #16.
Report Facts
Residents in survey sample: 15
Medication order date: Jul 29, 2019
Assessment Reference Date: Aug 1, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | DON | Notified by surveyor of findings and provided explanation regarding medication order |
Inspection Report
Complaint Investigation
Deficiencies: 10
Date: Nov 16, 2017
Visit Reason
The inspection was conducted based on complaint-related concerns regarding medication administration, care planning, wound care, infection control, medication storage, food safety, and clinical record accuracy at Lake Prince Woods, Inc.
Complaint Details
The visit was complaint-related, triggered by concerns about medication administration errors, care planning deficiencies, infection control lapses, environmental safety, and clinical record inaccuracies. Substantiation status is not explicitly stated.
Findings
The facility failed to follow physician orders for medication administration, ensure proper care planning for psychoactive medications, implement non-pharmacological interventions prior to analgesic use, maintain infection control during wound care and glucometer use, secure medication carts, store and prepare food safely, maintain a sanitary environment, and keep accurate clinical records.
Deficiencies (10)
Facility staff failed to notify the physician that Phoslo 667 mg capsule was not administered as ordered for Resident #1 due to dialysis absences.
Facility staff failed to include documentation dates in section V of the MDS for Resident #6.
Facility staff failed to develop a psychoactive care plan for Resident #1 receiving Zoloft.
Facility staff failed to ensure non-pharmacological interventions were attempted prior to administration of analgesics for Residents #1, #4, and #8.
Facility staff failed to ensure infection control practices during sacral wound care dressing for Resident #1.
Facility staff failed to secure treatment cart containing medication in the hallway when not in direct sight of the nurse.
Facility staff failed to store and prepare food with professional standards for food service safety.
Facility staff failed to ensure infection control measures of hand hygiene and proper disinfection during glucometer use and wound care for Residents #14 and #1.
Facility staff failed to provide a safe, sanitary, and comfortable environment; observed trash, debris, mold, dead bugs, and non-functioning lights in various facility areas.
Facility staff failed to ensure the Treatment Administration Record (TAR) was accurate for application of ted hose for Resident #1; resident was observed without ted hose despite documentation of application.
Report Facts
Medication non-administration days: 11
Medication non-administration days: 11
Medication non-administration days: 5
Days of Tylenol administration without prior non-pharmacological intervention: 18
Days of Tylenol administration without prior non-pharmacological intervention: 5
Days of Tylenol administration without prior non-pharmacological intervention: 7
Acetaminophen administration times: 6
Oxycodone-acetaminophen administration times: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Observed and interviewed regarding wound care and infection control lapses |
| LPN #3 | Licensed Practical Nurse | Assisted with wound care for Resident #1 |
| LPN #1 | Licensed Practical Nurse | Observed and interviewed regarding glucometer use and infection control |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple findings including medication administration, care planning, infection control, and clinical record accuracy |
| MDS Coordinator | MDS Coordinator | Interviewed regarding care planning deficiencies for psychoactive medications |
| Dietary Manager | Dietary Manager | Interviewed regarding food storage and safety |
| Dietary Aide | Dietary Aide | Interviewed regarding food storage and safety |
| Maintenance Director | Maintenance Director | Interviewed regarding environmental cleanliness and safety |
| NP | Nurse Practitioner | Interviewed regarding medication administration concerns for Resident #1 |
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