Inspection Reports for
Manorhouse Assisted Living & Memory Care
13500 North Gayton Road, RICHMOND, VA, 23233
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
3.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
63% better than Virginia average
Virginia average: 9.1 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
63 residents
Based on a October 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Inspection Report
Monitoring
Deficiencies: 1
Date: Aug 18, 2025
Visit Reason
The inspection was a monitoring visit conducted to review compliance with resident care and related services standards following a self-reported incident involving a resident fall.
Findings
The investigation found non-compliance with standards related to supervision of resident schedules, care, and activities, specifically regarding prevention of falls. A violation was issued based on the facility's failure to ensure wheelchair stability during transport.
Deficiencies (1)
Facility did not ensure supervision of resident schedules, care, and activities, including prevention of falls; specifically, a resident fell out of a wheelchair during transport due to improper securing of the wheelchair.
Report Facts
Number of interviews conducted: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Yvonne Randolph | Licensing Inspector | Conducted the inspection and exit meeting |
| Facilities Director | Involved in plan of correction and corrective actions post-incident |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 30, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-07-24 regarding allegations in the areas of Admission, Discharge, and Retention of residents.
Complaint Details
Complaint was received on 2025-07-24 regarding allegations in admission, discharge, and retention. The complaint was not substantiated based on the evidence gathered.
Findings
The evidence gathered during the inspection did not support the allegations of non-compliance with the standards related to admission, discharge, and retention of residents.
Report Facts
Number of records reviewed: 1
Inspection Report
Renewal
Census: 63
Deficiencies: 2
Date: Oct 15, 2024
Visit Reason
The inspection was a renewal visit to assess compliance with applicable standards and regulations for Manorhouse Assisted Living & Memory Care.
Findings
The inspection identified non-compliance with applicable standards, including missing dated written approval for placement of a resident with serious cognitive impairment and lack of annual tuberculosis screening documentation for three staff members. Violations were documented and a plan of correction was requested.
Deficiencies (2)
Facility did not ensure that prior to placing a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia in a safe, secure environment, the facility obtained the written approval. The approval form for resident #3 was not dated.
Facility did not ensure that each staff person or household member required to be evaluated annually submit the results of a risk assessment documenting freedom from communicable tuberculosis. Annual tuberculosis screening was not documented in three staff files.
Report Facts
Number of residents present: 63
Number of resident records reviewed: 4
Number of medication passes reviewed: 2
Number of staff records reviewed: 4
Number of resident interviews: 2
Number of staff interviews: 3
Inspection Report
Renewal
Census: 81
Deficiencies: 0
Date: Nov 3, 2023
Visit Reason
The inspection was a renewal, unannounced, mandated visit to assess compliance with applicable standards and laws at Manorhouse Assisted Living & Memory Care.
Findings
The inspection found no violations with applicable standards or laws. The licensing inspector completed a tour of the physical plant and reviewed resident and staff records, conducted interviews, and observed facility operations.
Report Facts
Number of resident records reviewed: 10
Number of staff records reviewed: 5
Number of interviews conducted with residents: 4
Number of interviews conducted with staff: 4
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 15, 2023
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2023-08-10 regarding allegations in the areas of Administration and Administrative Services, Staffing and Personnel, Resident Care and Related Services, and Building and Grounds.
Complaint Details
Complaint investigation related to allegations in Administration and Administrative Services, Staffing and Personnel, Resident Care and Related Services, and Building and Grounds. The complaint was not substantiated.
Findings
The evidence gathered during the investigation did not support allegations of non-compliance with standards or law. The inspection findings will be posted to the VDSS website within 5 business days of receipt of the inspection summary.
Report Facts
Resident records reviewed: 2
Staff records reviewed: 0
Staff interviews conducted: 2
Inspection Report
Monitoring
Deficiencies: 1
Date: Jul 31, 2023
Visit Reason
The inspection was a monitoring, non-mandated visit conducted on July 31, 2023 and August 15, 2023, following a self-reported incident and a subsequent complaint regarding building and grounds conditions.
Complaint Details
The visit was complaint-related but only partially substantiated; evidence supported one of the allegations regarding equipment maintenance.
Findings
The investigation supported one, but not all, of the allegations related to equipment not being kept in good repair. Specifically, a resident call cord was found not working due to a dead battery and was installed incorrectly. A violation notice was issued.
Deficiencies (1)
All equipment is not kept in good repair and condition, specifically a resident call cord was not working due to dead battery and was installed upside down.
Report Facts
Inspection dates: 2
Number of interviews: 1
Number of interviews: 1
Days to submit plan of correction: 5
Days to request review: 15
Inspection Report
Monitoring
Deficiencies: 0
Date: Jul 10, 2023
Visit Reason
The inspection was a monitoring, unannounced, non-mandated visit conducted following a self-reported incident received by VDSS Division of Licensing regarding allegations in the area of Resident Care and Related Services.
Findings
The evidence gathered during the investigation did not support any non-compliance with standards or law. No deficiencies were cited.
Inspection Report
Monitoring
Census: 89
Deficiencies: 3
Date: May 26, 2023
Visit Reason
The inspection was a monitoring visit to assess compliance with applicable standards and laws at Manorhouse Assisted Living & Memory Care.
Findings
The inspection found non-compliance with certain standards related to resident placement approvals and individualized service plans, with documented violations issued to the facility.
Deficiencies (3)
The facility did not document the order of priority followed for the approval of placement of two residents in the safe and secure environment.
The individualized service plan (ISP) for one resident did not have a description of an identified need based upon the admission physical examination.
The ISP for one resident contained a goal for a need that was not identified.
Report Facts
Number of residents present: 89
Number of staff records reviewed: 5
Number of resident records reviewed: 10
Number of interviews with residents: 1
Number of interviews with staff: 3
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Jan 9, 2023
Visit Reason
The inspection was conducted as a complaint-related investigation to review compliance with facility policies and resident care standards at Manorhouse Assisted Living & Memory Care.
Complaint Details
The visit was complaint-related, focusing on issues such as wandering resident identification, plan of care adequacy, medication order documentation, and resident rights violations. Specific substantiation status is not stated.
Findings
The facility was found non-compliant with its own policies regarding identification bracelets for wandering residents, preliminary plan of care development, physician order documentation, and resident rights related to consent for physician changes. Multiple violations were documented based on record reviews and staff interviews.
Deficiencies (4)
Failure to ensure compliance with facility policy requiring identification bracelets for confused or wandering residents.
Failure to develop a preliminary plan of care within seven days prior to admission addressing resident's basic needs and safety.
Failure to ensure physician or prescriber orders included diagnosis, condition, or specific indications for administering each drug.
Failure to ensure residents have rights including freedom to select health care services; unauthorized change of physician without Power of Attorney consent.
Report Facts
Dates related to Resident #1 admission and documentation: Jul 25, 2022
Dates of physician orders: Jul 29, 2022
Dates of physician orders: Sep 28, 2022
Inspection Report
Monitoring
Census: 89
Deficiencies: 4
Date: Nov 10, 2022
Visit Reason
The inspection was a monitoring visit conducted on November 10, 2022, following a self-reported incident received on September 29, 2022, regarding allegations in the area of Resident Care and Related Services.
Findings
The inspection found multiple violations related to private duty personnel documentation, individualized service plans (ISP) lacking comprehensive and updated information, unsigned ISPs, and inadequate supervision of residents, including wandering incidents.
Deficiencies (4)
Facility failed to obtain in writing the type and frequency of private duty personnel services and provide orientation and training to private duty personnel.
Facility failed to ensure the comprehensive individualized service plan included a description of identified needs based on psychosocial, behavioral, and emotional functioning.
Facility failed to ensure the individualized service plan was signed and dated by the licensee, administrator, or designee, and by the resident or legal representative.
Facility failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs such as wandering from the premises.
Report Facts
Number of residents present: 89
Inspection Report
Monitoring
Census: 78
Deficiencies: 2
Date: Jun 6, 2022
Visit Reason
The inspection was a monitoring visit conducted to review compliance with applicable standards and laws at Manorhouse Assisted Living & Memory Care.
Findings
The inspection found non-compliance with applicable standards or laws, resulting in documented violations related to staff health information and resident identification records.
Deficiencies (2)
The facility failed to maintain the health information for each staff record; specifically, staff record #1 lacked an initial T.B. assessment within seven days prior to the first day of work.
The facility failed to have a current picture of each resident available for identification purposes; record #1 lacked a current picture or narrative physical description.
Report Facts
Number of residents present: 78
Number of resident records reviewed: 10
Number of staff records reviewed: 5
Number of interviews conducted with staff: 3
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 16, 2020
Visit Reason
A complaint inspection was initiated due to allegations regarding the infection control program under 22VAC40-73-100. The investigation was conducted remotely due to the COVID-19 pandemic.
Complaint Details
A complaint was received concerning infection control program compliance. The investigation concluded with no substantiation of the allegations.
Findings
The evidence gathered during the investigation did not support the allegation of non-compliance with standards or law related to infection control.
Inspection Report
Renewal
Census: 81
Deficiencies: 0
Date: Dec 9, 2020
Visit Reason
A renewal inspection was initiated on December 9, 2020 and concluded on December 15, 2020 to review compliance with applicable standards and laws for Manorhouse Assisted Living & Memory Care.
Findings
The inspection found no violations with applicable standards or law. Documentation reviewed included resident and staff records, infection control guidance, training records, and various inspections, all of which were complete.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 30, 2020
Visit Reason
A complaint inspection was initiated due to allegations received by the department regarding resident care at Manorhouse Assisted Living & Memory Care.
Complaint Details
The complaint was related to resident care. The evidence gathered did not substantiate the allegations of non-compliance.
Findings
The investigation found no evidence to support the allegations of non-compliance with standards or law concerning resident care and related services.
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