Inspection Report
Renewal
Census: 41
Deficiencies: 0
Mar 10, 2025
Visit Reason
The inspection was conducted as a renewal of the facility's license.
Findings
The inspection found no violations with applicable standards or laws. The inspector conducted a tour of the facility, reviewed resident and staff records, observed medication pass, emergency preparedness drills, and other compliance areas.
Report Facts
Number of resident records reviewed: 4
Number of staff records reviewed: 3
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 2
Inspection Report
Monitoring
Census: 40
Deficiencies: 0
Feb 26, 2024
Visit Reason
The inspection was a monitoring visit conducted following a self-report received by VDSS Division of Licensing regarding allegations in the areas of Resident Care and Related Services and Administration.
Findings
The facility was found compliant with the standards and was administering appropriate medical attention to the resident. The evidence gathered did not support the self-report of non-compliance with standards or law.
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: 0
Inspection Report
Renewal
Census: 40
Deficiencies: 0
Feb 26, 2024
Visit Reason
The inspection was conducted as a renewal of the facility's license to ensure compliance with applicable standards and regulations.
Findings
The inspection found no violations with applicable standards or laws. The facility's physical grounds and building were well maintained, and staff were pleasant and professional. A resident passed away during the inspection, and staff observed respectful procedures.
Report Facts
Resident records reviewed: 8
Staff records reviewed: 5
Resident interviews conducted: 2
Staff interviews conducted: 3
Inspection Report
Monitoring
Census: 36
Deficiencies: 2
Jun 14, 2023
Visit Reason
The inspection was a monitoring visit to review compliance with regulations related to admission, retention, discharge of residents, and care for adults with serious cognitive impairments.
Findings
The inspection found non-compliance with applicable standards, including failure to provide at least 21 hours of scheduled activities per week in the special care unit and failure to document allergy reaction descriptions on residents' physical examinations.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure at least 21 hours of scheduled activities were available to residents in the special care unit. |
| Facility failed to ensure physician included description of reactions to known allergies on residents' physical examinations. |
Report Facts
Scheduled activity hours: 16
Scheduled activity hours: 17
Scheduled activity hours: 16
Scheduled activity hours: 14
Scheduled activity hours: 19
Scheduled activity hours: 18.5
Scheduled activity hours: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shelby Haskins | Inspector | Current inspector conducting the monitoring inspection |
| Alex Poulter | Licensing Inspector | Contact person for questions about the inspection |
| Staff #1 | Confirmed during interview the number of scheduled activity hours was less than 21 per week |
Inspection Report
Monitoring
Deficiencies: 7
May 3, 2022
Visit Reason
The inspection was a monitoring visit conducted to assess compliance with applicable standards and laws for an assisted living facility, focusing on various regulatory areas including administration, resident care, emergency preparedness, and background checks.
Findings
The inspection identified multiple violations including failure to document proper approval for placement in a special care unit, incomplete preliminary and comprehensive individualized service plans (ISPs), unsigned ISPs, hot water temperatures exceeding required ranges, incomplete sworn statements for employees, and missing criminal history record reports.
Deficiencies (7)
| Description |
|---|
| Failed to ensure prior to placing a resident with serious cognitive impairment in a safe, secure environment, the order of priority was followed and documented. |
| Failed to develop a preliminary plan of care within seven days prior to admission that adequately addresses basic resident needs and is identified as preliminary. |
| Failed to ensure the comprehensive individualized service plan included a description of identified needs and date identified based on UAI and other sources. |
| Failed to ensure the individualized service plan was signed by the licensee, administrator, or designee and by the resident or legal representative. |
| Failed to maintain hot water at taps within the required range of 105°F to 120°F; observed temperatures exceeded this range in multiple rooms. |
| Failed to ensure sworn statements or affirmations were completed for all applicants for employment. |
| Failed to obtain a criminal history record report from the Department of State Police for an employee, instead had a national criminal record search. |
Report Facts
Inspection duration: 5.63
Number of residents with ISP deficiencies: 8
Number of rooms with hot water temperature violations: 5
Number of staff with incomplete or missing sworn statements: 3
Inspection Report
Renewal
Census: 40
Deficiencies: 0
Mar 11, 2021
Visit Reason
A renewal inspection was initiated on 3/11/2021 and concluded on 4/26/2021 using an alternate remote protocol due to a state of emergency health pandemic.
Findings
The inspection reviewed resident and staff records, schedules, background checks, medication and health care documentation, and fire safety records. No violations with applicable standards or law were found.
Report Facts
Residents' records reviewed: 3
Staff records reviewed: 3
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