Inspection Report
Renewal
Census: 46
Deficiencies: 4
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)
| Description |
|---|
| 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
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)
| Description |
|---|
| 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
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)
| Description |
|---|
| 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
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)
| Description |
|---|
| 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
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)
| Description |
|---|
| 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
Renewal
Census: 28
Deficiencies: 5
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)
| Description |
|---|
| 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
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