Inspection Report
Complaint Investigation
Census: 79
Deficiencies: 0
Jun 18, 2025
Visit Reason
The inspection was conducted as a complaint-related visit to review resident care, accommodations, and complaint investigation standards at the facility.
Findings
The inspection found no violations of applicable standards or laws based on the evidence gathered, including resident record review, hospice documentation, and staff interview.
Complaint Details
The visit was complaint-related; however, no violations were substantiated during the inspection.
Report Facts
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 |
|---|---|---|
| Lanesha Allen | Licensing Inspector | Conducted the inspection and staff interview |
Inspection Report
Monitoring
Census: 79
Deficiencies: 0
Apr 24, 2025
Visit Reason
The inspection was a monitoring visit conducted to review compliance with applicable standards and regulations for the assisted living facility.
Findings
The inspection included a tour of the physical plant, review of resident and staff records, and observation of facility activities. No violations of applicable standards or laws were found during the inspection.
Report Facts
Number of resident records reviewed: 7
Number of staff records reviewed: 3
Number of interviews conducted with residents: 2
Number of interviews conducted with staff: 4
Inspection Report
Renewal
Census: 80
Deficiencies: 4
Mar 27, 2024
Visit Reason
The inspection was a renewal inspection conducted to assess compliance with applicable standards and laws for licensing renewal.
Findings
The inspection identified multiple violations including failure to maintain current first aid certification for direct care staff, unsigned individualized service plans, presence of expired medications in medication carts, and medication administration not consistent with physician orders.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure each direct care staff member maintain current certification in first aid. |
| Facility failed to ensure individualized service plans were signed and dated by the licensee, administrator, or designee and by the resident or legal representative when updated. |
| Facility failed to implement written plan for medication management including prevention of use of outdated medications; expired medications were found in medication carts. |
| Facility failed to ensure medication was administered in accordance with physician's instructions; medication administration records showed discrepancies. |
Report Facts
Residents present: 80
Resident records reviewed: 7
Staff records reviewed: 4
Resident interviews conducted: 4
Staff interviews conducted: 4
Expired medications observed: 4
Medication administration frequency: 3
Inspection Report
Monitoring
Deficiencies: 0
Jun 14, 2023
Visit Reason
The inspection was a monitoring visit conducted on June 14, 2023, following a self-reported incident received on June 12, 2023, regarding allegations in the area of Building and Grounds.
Findings
The inspection found no violations of applicable standards or laws during the visit to the memory care units and apartments. The evidence gathered determined compliance with regulations.
Inspection Report
Renewal
Census: 75
Deficiencies: 10
Mar 28, 2023
Visit Reason
The inspection was a renewal inspection conducted on March 28 and March 30, 2023, to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection identified multiple violations related to staff training documentation, resident risk assessments, medication management, and fire safety compliance. The facility was found non-compliant in several areas and was issued violation notices with plans of correction required.
Deficiencies (10)
| Description |
|---|
| Failed to ensure documentation of type of training, training entity, hours, and dates for staff medication administration refresher courses. |
| Failed to annually complete tuberculosis risk assessments for residents. |
| Failed to complete written fall risk rating for residents meeting assisted living care criteria by the time the comprehensive ISP is completed. |
| Failed to complete fall risk rating at least annually, when resident condition changes, and after a fall. |
| Failed to maintain completed Uniform Assessment Instrument (UAI) in resident records. |
| Failed to implement written medication management plan to prevent use of outdated medications and ensure proper disposal. |
| Failed to ensure medication administration keys were kept on person of responsible individual. |
| Failed to ensure medication administration was documented in accordance with prescriber instructions and standards. |
| Failed to ensure only portable oxygen sources were used by residents outside their rooms; use of long plastic tether lines was observed. |
| Failed to comply with Virginia Statewide Fire Prevention Code; last fire inspection was over a year old. |
Report Facts
Number of residents present: 75
Number of resident records reviewed: 10
Number of staff records reviewed: 5
Inspection dates: Inspection conducted on 03/28/2023 and 03/30/2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lanesha Allen | Licensing Inspector | Current inspector conducting the inspection |
| M. Tess Pittman | Licensing Inspector | Contact person for questions regarding the inspection |
| Director of Resident Services | Named in multiple plans of correction related to oversight of audits and training | |
| Staff #1 | Observed with medication cart containing expired medication | |
| Staff #3 | Referenced in training documentation deficiency | |
| Staff #5 | Referenced in training documentation deficiency | |
| Staff #7 | Acknowledged resident oxygen source deficiency |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 16, 2022
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2022-04-25 regarding allegations in the areas of Resident Care and Related Services and Building and Grounds.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The licensing inspector completed a tour of the physical plant including building and grounds and conducted interviews with staff.
Complaint Details
Complaint received on 2022-04-25 regarding Resident Care and Related Services and Building and Grounds. The complaint was not substantiated based on the investigation findings.
Report Facts
Number of interviews conducted: 2
Inspection Report
Monitoring
Census: 73
Deficiencies: 3
Mar 9, 2022
Visit Reason
An unannounced monitoring inspection was conducted by the Licensing Inspector from the Eastern Regional Office to review compliance with applicable standards and laws.
Findings
The inspection identified multiple violations including failure to post a current list of staff certified in first aid or CPR, failure to document sex offender screening prior to admission for a resident, and failure to maintain the interior and exterior of buildings in good repair and cleanliness.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure a listing of all staff with current certification in first aid or CPR was posted and readily available. |
| Facility failed to ascertain and document sex offender screening prior to admission for a resident. |
| Facility failed to maintain the interior and exterior of all buildings in good repair and kept clean and free of rubbish, including a hole in a shower room wall and a stained ceiling tile in a resident's apartment. |
Report Facts
Residents in care: 73
Staff records reviewed: 3
Resident records reviewed: 4
Inspection Report
Renewal
Census: 71
Deficiencies: 0
Apr 7, 2021
Visit Reason
A renewal inspection was initiated on April 7, 2021 and concluded on April 8, 2021 using an alternate remote protocol due to a state of emergency health pandemic.
Findings
The inspection found no violations with applicable standards or law; no violations were issued.
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