Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 0
Aug 12, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-04-24 regarding allegations in the area of Resident Care and Related Services.
Findings
The evidence gathered during the investigation did not support the allegation 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 2025-04-24 regarding Resident Care and Related Services; investigation did not substantiate the allegations.
Report Facts
Number of residents present: 59
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
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Pearson | Licensing Inspector | Current inspector conducting the complaint investigation |
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 0
Aug 12, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-05-13 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 2025-05-13 regarding Resident Care and Related Services; investigation did not substantiate the allegations.
Report Facts
Resident records reviewed: 1
Staff records reviewed: 0
Resident interviews conducted: 0
Staff interviews conducted: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Pearson | Licensing Inspector | Conducted the inspection and is the contact for questions |
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 0
Aug 12, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-07-17 regarding allegations in the area of Administration and Administrative Services.
Findings
The evidence gathered during the investigation did not support the allegation 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 related to Administration and Administrative Services; the allegation was not substantiated based on the investigation.
Report Facts
Number of residents present: 59
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of staff interviews conducted: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Pearson | Licensing Inspector | Inspector conducting the complaint investigation |
Inspection Report
Monitoring
Census: 59
Deficiencies: 1
Aug 12, 2025
Visit Reason
The inspection was a monitoring visit conducted on August 12, 2025, following a self-reported incident received on April 1, 2025, regarding allegations in the areas of Resident Care and Related Services.
Findings
The investigation supported the self-report of non-compliance related to medication administration. Violations were issued for failure to administer medications in accordance with physician instructions, based on resident record review and self-reported incident.
Deficiencies (1)
| Description |
|---|
| Facility failed to administer medications in accordance with the physician's or other prescriber's instructions as evidenced by medication discrepancies for Resident 1. |
Report Facts
Number of residents present: 59
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: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Pearson | Licensing Inspector | Current inspector conducting the monitoring inspection |
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 3
Feb 26, 2025
Visit Reason
The inspection was conducted in response to complaints received by VDSS Division of Licensing on 2/19/2025 and 2/28/2025 regarding allegations in the areas of Staffing and Supervision and Resident Care and Related Services.
Findings
The investigation supported some, but not all, of the allegations. Areas of non-compliance were found in Administration and Administrative Services, Staffing and Supervision, and Resident Care and Related Services. A violation notice was issued with opportunities for the licensee to submit a plan of correction.
Complaint Details
The complaint investigation was substantiated in part. Complaints included allegations of understaffing, failure to provide required training to direct care staff, failure to provide snacks as specified in the Individualized Service Plan, and failure to report incidents to the licensing office within required timeframes.
Deficiencies (3)
| Description |
|---|
| Facility failed to report to the regional licensing office any incident that negatively affected the life, health, safety or welfare of any resident. |
| Facility failed to ensure that employees working as direct care staff successfully completed a department approved 40-hour direct care staff training program within the first two months of employment. |
| Facility failed to ensure that the care and services specified in the Individualized Service Plan are provided to each resident, including provision of snacks as required. |
Report Facts
Number of residents present: 59
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of staff interviews conducted: 5
Number of resident interviews conducted: 0
Inspection Report
Monitoring
Census: 57
Deficiencies: 0
Feb 20, 2025
Visit Reason
The inspection was a monitoring visit conducted by the licensing inspector to review personnel and the physical plant of the facility.
Findings
The inspection found no violations of applicable standards or laws. Residents were observed participating in activities and eating lunch, and the inspection summary will be posted publicly.
Report Facts
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 0
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 8
Feb 20, 2025
Visit Reason
The inspection was conducted as a complaint investigation with visits on February 20, 24, and 26, 2025, to review allegations of non-compliance with standards or laws at the Legacy Ridge Memory Care Community.
Findings
The investigation found multiple violations including inadequate staffing levels and skills, failure to complete required resident assessments and service plans, failure to ensure skilled nursing treatments were administered by licensed nurses, and failure to maintain current resident records. The evidence supported the allegations of non-compliance and violations were issued.
Complaint Details
The inspection was complaint-related. The evidence gathered supported the allegations of non-compliance with standards or laws, and violations were issued. The licensee was given the opportunity to submit a plan of correction.
Deficiencies (8)
| Description |
|---|
| Facility failed to ensure adequate staff in knowledge, skills and abilities and sufficient in numbers to provide services to maintain residents' well-being. |
| Facility failed to complete the Uniform Assessment Instrument (UAI) at least annually and with significant resident condition changes. |
| Facility failed to develop an Individualized Service Plan (ISP) including written description of services provided and responsible parties. |
| Facility failed to have the resident's legal representative sign and date the ISP. |
| Facility failed to review and update the ISP at least every 12 months and as needed for significant resident condition changes. |
| Facility failed to assume general responsibility for residents' health, safety, and well-being, including monitoring and treatment of wounds. |
| Facility failed to ensure residents' need for skilled nursing treatments were met by licensed nurses or contractual agreements. |
| Facility failed to ensure all resident records were kept current and retained at the facility. |
Report Facts
Number of residents present: 55
Number of resident records reviewed: 1
Number of staff interviews conducted: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Pearson | Licensing Inspector | Named as the current inspector conducting the inspection. |
| Staff 1 | Interviewed staff member referenced in findings related to resident assessments and documentation. | |
| Staff 2 | Registered Medication Aide / Certified Nursing Assistant | Provided ordered treatments to resident as noted in medication administration records. |
| Staff 3 | Medication Technician | Provided ordered treatments to resident as noted in medication administration records. |
Inspection Report
Monitoring
Census: 57
Deficiencies: 0
Feb 20, 2025
Visit Reason
The inspection was a monitoring visit conducted by the licensing inspector to review personnel and the physical plant of the facility.
Findings
The inspection found no violations with applicable standards or laws. Residents were observed participating in activities and eating lunch, and the inspection summary will be posted publicly.
Report Facts
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 1
Inspection Report
Monitoring
Census: 57
Deficiencies: 0
Feb 20, 2025
Visit Reason
The inspection was a monitoring visit conducted by the licensing inspector to review personnel and the physical plant of the facility.
Findings
The inspection found no violations of applicable standards or laws. Residents were observed participating in activities and eating lunch, and the inspection summary will be posted publicly.
Report Facts
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 1
Inspection Report
Renewal
Census: 55
Deficiencies: 8
Feb 19, 2025
Visit Reason
The inspection was conducted as a renewal visit to assess compliance with licensing requirements and applicable regulations for the assisted living facility.
Findings
The inspection identified multiple violations including medication labeling errors, failure to provide written assurance of licensing to residents, incomplete individualized service plans, improper administration of skilled nursing treatments, insufficient emergency water supply, failure to post recent inspection findings, and delays in obtaining criminal history record reports for staff.
Deficiencies (8)
| Description |
|---|
| Failed to ensure compliance with all regulations for licensed assisted living facilities and terms of the license; medication label altered without proper documentation. |
| Failed to provide written assurance to residents that the facility has the appropriate license at time of admission. |
| Failed to develop Individualized Service Plans that accurately describe identified needs and services provided. |
| Failed to ensure resident's need for skilled nursing treatments met by licensed nurse or contractual agreement. |
| Failed to administer medications in accordance with physician's or prescriber's instructions. |
| Failed to ensure availability of a 48-hour on-site supply of emergency drinking water. |
| Failed to post findings of the most recent inspection on the premises of the licensed facility. |
| Failed to obtain criminal history record report prior to the 30th day of employment for each employee. |
Report Facts
Residents present: 55
Resident records reviewed: 6
Staff records reviewed: 3
Staff interviews conducted: 5
Gallons of emergency water available: 36
Inspection Report
Routine
Deficiencies: 0
Jan 22, 2024
Visit Reason
Routine inspection of Legacy Ridge Memory Care Community covering administration, personnel, staffing, resident care, building and grounds, emergency preparedness, and background checks.
Findings
The report lists the areas reviewed during the inspection but does not provide specific findings or deficiencies.
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 20, 2023
Visit Reason
The inspection was conducted as a complaint investigation related to staffing and supervision at Legacy Ridge Memory Care Community.
Findings
The complaint was investigated and determined to be not valid.
Complaint Details
Complaint was determined not valid.
Inspection Report
Monitoring
Census: 56
Deficiencies: 1
Jul 19, 2023
Visit Reason
The inspection was a monitoring visit to review personnel, staffing and supervision, resident care, building and grounds, emergency preparedness, and background checks for the assisted living facility.
Findings
The facility was found to have failed to prevent residents from leaving the facility unsupervised on 7/13/2023. Residents were unharmed and returned safely. A plan of correction was implemented to secure the door and ensure staff monitoring.
Deficiencies (1)
| Description |
|---|
| Facility failed to prevent residents from leaving the facility unsupervised. |
Report Facts
Records reviewed and interviews conducted: 3
Deficiencies cited: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Pearson | Licensing Inspector | Inspector conducting the monitoring inspection |
Inspection Report
Monitoring
Census: 43
Deficiencies: 0
Feb 15, 2023
Visit Reason
The inspection was a monitoring visit to review various areas including administration, personnel, resident care, and emergency preparedness at Legacy Ridge Memory Care Community.
Findings
The inspection included review of 8 records and 7 interviews, as well as all facility self-reported incidents since the last inspection. No complaint was related to this visit.
Report Facts
Records reviewed: 8
Interviews conducted: 7
Inspection Report
Renewal
Census: 34
Deficiencies: 1
Jan 26, 2022
Visit Reason
The inspection was conducted as a renewal inspection to review compliance with regulatory standards and assess facility operations.
Findings
The inspection found that the facility failed to update the Individual Service Plan (ISP) to reflect changes in residents' conditions, specifically noting missing documentation for a resident's head laceration care and open coccyx wound.
Deficiencies (1)
| Description |
|---|
| Facility failed to update the Individual Service Plan (ISP) to reflect a change in condition for residents in care, including lack of documentation for head laceration care and open coccyx wound. |
Report Facts
Number of records reviewed: 9
Number of interviews conducted: 7
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 19, 2021
Visit Reason
A complaint inspection was initiated due to allegations received by the department regarding resident care at the facility.
Findings
The investigation supported the allegations of non-compliance with standards or law; however, no violations were issued as the facility had already taken corrective action.
Complaint Details
The complaint was related to resident care. The evidence gathered supported the allegations, but no violations were issued because corrective actions had already been taken.
Inspection Report
Renewal
Census: 7
Deficiencies: 0
Feb 19, 2021
Visit Reason
A renewal inspection was initiated on 02/19/2021 and concluded on 02/24/2021 to review compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection reviewed resident and staff records, staff schedules, and training documentation. No violations or deficiencies were found during the inspection.
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