Inspection Report
Monitoring
Census: 21
Deficiencies: 8
Apr 29, 2025
Visit Reason
The inspection was a monitoring visit to assess compliance with applicable standards and laws at Magnolia Ridge Assisted Living Facility.
Findings
The inspection identified multiple violations including failure to update individualized service plans timely, inadequate health care oversight, medication management deficiencies, failure to maintain the physical plant, and incomplete fire drill documentation.
Deficiencies (8)
| Description |
|---|
| Facility failed to ensure individualized service plans (ISPs) were reviewed and updated at least once every 12 months and as needed for significant changes. |
| Facility failed to ensure licensed health care professional provided health care oversight at least every three months. |
| Facility failed to implement medication management plan to ensure accurate counts of controlled substances during staff changes. |
| Facility failed to ensure medications remained in pharmacy issued container with proper labeling until administered. |
| Facility failed to ensure medications were administered according to physician instructions. |
| Facility failed to ensure medical procedures ordered by a physician were documented. |
| Facility failed to maintain the interior of the building in good repair; three light fixtures were inoperable. |
| Facility failed to ensure fire and emergency evacuation drills were conducted with required frequency and participation. |
Report Facts
Number of residents present: 21
Number of resident records reviewed: 4
Number of staff records reviewed: 3
Number of resident interviews conducted: 2
Number of staff interviews conducted: 3
Number of inoperable light fixtures: 3
Inspection Report
Complaint Investigation
Census: 21
Deficiencies: 0
Feb 4, 2025
Visit Reason
The inspection was conducted in response to a complaint received by the VDSS Division of Licensing regarding allegations in the areas of administration and administrative services and 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 on the facility premises.
Complaint Details
Complaint related inspection with allegations in administration and resident care; evidence did not support non-compliance.
Report Facts
Number of resident records reviewed: 1
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 2
Inspection Report
Renewal
Census: 24
Deficiencies: 5
May 3, 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 maintain operable security door alarms for residents with serious cognitive impairments, incomplete physical examination documentation for a resident, unlocked medication storage, incomplete medication administration records, and lack of timely medication reviews for residents.
Deficiencies (5)
| Description |
|---|
| Failed to ensure that a system of security monitoring was in place on doors leading to the outside for residents with serious cognitive impairments; alarms on doors next to rooms 12 and 27 were not operable. |
| Failed to ensure that a statement that the individual does not have any prohibited conditions was included in the physical examination for resident 4. |
| Failed to ensure that all medications were stored in a locked area; storage closet next to room 18 was unlocked and contained medication. |
| Failed to ensure that all required information was documented on resident medication administration records (MARs); missing documentation of medication effectiveness for PRN doses. |
| Failed to ensure that a medication review was completed every 6 months for residents assessed as assisted living level of care (residents 2, 3, and 5). |
Report Facts
Number of residents present: 24
Number of resident records reviewed: 5
Number of staff records reviewed: 4
Number of resident interviews conducted: 2
Number of staff interviews conducted: 3
Medication boxes found unlocked: 2
Inspection Report
Renewal
Census: 25
Deficiencies: 7
Apr 19, 2023
Visit Reason
The inspection was a renewal visit to assess compliance with applicable standards and laws for continued licensing of the assisted living facility.
Findings
The inspection identified multiple violations including failure to ensure annual tuberculosis screenings for staff, incomplete annual fall risk ratings for residents, inadequate individualized service plans addressing identified needs, improper medication storage by residents, and physical plant deficiencies such as unsecured light fixtures, unauthorized use of electric space heaters, and malfunctioning signaling devices.
Deficiencies (7)
| Description |
|---|
| Facility failed to ensure all employees completed annual tuberculosis screening. |
| Facility failed to ensure annual fall risk rating was completed for residents assessed as assisted living level of care. |
| Facility failed to ensure identified needs were addressed on individualized service plans. |
| Facility failed to ensure only residents capable of self-administering medications stored medications in their rooms. |
| Facility failed to ensure all furnishings, fixtures, and equipment were kept clean and in good repair and condition. |
| Facility failed to ensure electric space heaters were only used in emergencies with proper approval. |
| Facility failed to ensure signaling devices were accessible, functional, and permitted staff to determine origin of signal. |
Report Facts
Residents present: 25
Resident records reviewed: 6
Staff records reviewed: 3
Resident interviews conducted: 3
Staff interviews conducted: 2
Inspection Report
Monitoring
Census: 25
Deficiencies: 0
Aug 4, 2022
Visit Reason
The inspection was a monitoring visit conducted by the licensing inspector to review administration, resident care, and related services at the assisted living facility.
Findings
The inspection found no violations of applicable standards or laws. The licensing inspector completed a tour of the physical plant and conducted interviews and record reviews without identifying any deficiencies.
Report Facts
Number of resident records reviewed: 2
Number of interviews conducted with residents: 2
Number of interviews conducted with staff: 2
Inspection Report
Monitoring
Census: 24
Deficiencies: 8
May 10, 2022
Visit Reason
The inspection was a monitoring visit conducted to assess compliance with applicable standards and laws at Magnolia Ridge Assisted Living Facility.
Findings
The inspection identified multiple violations related to medication management, health care oversight, dietary compliance, medication storage security, and facility lighting. The facility was found non-compliant in several areas and issued a violation notice with plans of correction required.
Deficiencies (8)
| Description |
|---|
| Failed to ensure blood glucose monitoring practices consistent with CDC recommendations; unlabeled glucometers and multi-use lancets used. |
| Failed to ensure health care oversight was completed at least every 3 months for residents assessed at assisted living level of care. |
| Failed to ensure diets prescribed by physicians were prepared and served according to orders. |
| Failed to follow medication management policy regarding destruction of discontinued and expired medications. |
| Failed to ensure medication cabinets, containers, or compartments were locked. |
| Failed to ensure medications in residents' rooms were stored out of sight and only for residents assessed capable of self-administration. |
| Failed to ensure all medications remained in pharmacy-issued containers with prescription labels until administered. |
| Failed to ensure adequate lighting in the interior of the building for safety and comfort of residents and staff. |
Report Facts
Number of residents present: 24
Number of resident records reviewed: 8
Number of staff records reviewed: 3
Number of resident interviews: 2
Number of staff interviews: 4
Inspection Report
Renewal
Census: 27
Deficiencies: 1
Apr 21, 2021
Visit Reason
A renewal inspection was initiated and completed on April 21, 2021, conducted remotely due to a state of emergency health pandemic declared by the Governor of Virginia.
Findings
The inspection found non-compliance with applicable standards related to the facility's medication management plan, which failed to address all required procedures.
Deficiencies (1)
| Description |
|---|
| The facility medication management plan did not include procedures for standard dosing times, ensuring residents do not receive medications or supplements to which they have known allergies, or identification of the medication aide or licensed person responsible for communicating medication issues to the prescriber. |
Report Facts
Resident records reviewed: 3
Staff records reviewed: 3
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