Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 0
Jun 18, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-05-16 regarding allegations in the area of Resident Care and Related Services.
Findings
The evidence gathered during the investigation did not support the allegations or self-report of non-compliance with standards or law. An exit meeting will be conducted to review the inspection findings.
Complaint Details
Complaint received on 2025-05-16 regarding Resident Care and Related Services; investigation did not substantiate non-compliance.
Report Facts
Number of residents present: 67
Number of resident records reviewed: 2
Number of staff records reviewed: 0
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 2
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 0
Jun 18, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-05-16 regarding allegations in the area of Resident Care and Related Services.
Findings
The evidence gathered during the investigation did not support the allegations or self-report 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 investigation related to allegations in Resident Care and Related Services; the complaint was not substantiated.
Report Facts
Resident records reviewed: 2
Staff records reviewed: 0
Resident interviews conducted: 1
Staff interviews conducted: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lanesha Allen | Licensing Inspector | Inspector conducting the complaint investigation |
Inspection Report
Complaint Investigation
Census: 71
Deficiencies: 1
Mar 3, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-01-15 regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation supported the allegations of non-compliance with standards related to resident care. A violation was issued for failure to regularly observe and document changes in a resident's condition, including an incident where staff failed to respond appropriately to a resident's call bell.
Complaint Details
Complaint related: Yes. The complaint was substantiated as evidence supported the allegations of non-compliance with resident care standards.
Deficiencies (1)
| Description |
|---|
| Facility did not ensure regular observation and documentation of changes in resident's physical, mental, emotional, and social functioning, including failure to respond to a resident's call bell. |
Report Facts
Number of residents present: 71
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of interviews conducted with staff: 1
Number of interviews conducted with residents: 0
Inspection Report
Routine
Deficiencies: 1
Feb 26, 2025
Visit Reason
The inspection was conducted as a routine review of the assisted living facility, covering multiple regulatory areas including administration, personnel, resident care, emergency preparedness, and licensing requirements.
Findings
The inspection found a violation related to the facility's medication management plan, specifically the presence of expired medication in the medication cart. A plan of correction was provided to address the issue.
Deficiencies (1)
| Description |
|---|
| Expired medication (Hyoscyam 0.125mg/ml solution) found in medication cart for resident #8, expired on 01/2025. |
Report Facts
Expired medication date: 202501
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lanesha Allen | Inspector | Named as current inspector conducting the inspection |
| Director of Clinical Services | Named in plan of correction related to medication management |
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 3
Oct 24, 2024
Visit Reason
The inspection was conducted in response to complaints received on 2024-10-21 regarding allegations related to staffing and supervision, resident care and related services, and safe and secure environment at the facility.
Findings
The investigation supported the allegations of non-compliance with standards and laws, resulting in violations issued. Specific deficiencies included failure to ensure skilled nursing treatments were provided by licensed nurses, medications administered beyond physician orders, and lack of proper documentation of medical procedures and treatments.
Complaint Details
Complaints were received by VDSS Division of Licensing on 2024-10-21 regarding staffing and supervision, resident care and related services, and safe and secure environment. The evidence gathered supported the allegations of non-compliance, and violations were issued accordingly.
Deficiencies (3)
| Description |
|---|
| Facility did not ensure a resident's need for skilled nursing treatments was met by a licensed nurse or contractual agreement. |
| Medications were administered beyond the physician's or prescriber's instructions. |
| Medical procedures or treatments ordered by a physician were not provided according to instructions and were not properly documented in the resident's record. |
Report Facts
Number of residents present: 68
Number of resident records reviewed: 2
Number of staff interviews conducted: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lanesha Allen | Licensing Inspector | Conducted the inspection and is the contact for questions |
| Staff #2 | Confirmed medication administration and wound care practices during inspection | |
| Director of Clinical Services | Responsible for implementing preventative measures and monitoring plan of correction | |
| Acting Executive Director | Responsible for monitoring the overall plan of correction |
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 0
Oct 3, 2024
Visit Reason
The inspection was conducted in response to a complaint 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 the allegations of non-compliance with standards or law.
Complaint Details
Complaint related to Resident Care and Related Services; the allegations were not substantiated.
Report Facts
Resident records reviewed: 3
Staff records reviewed: 3
Staff interviews conducted: 2
Inspection duration hours: 2.25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lanesha Allen | Licensing Inspector | Current inspector conducting the complaint investigation |
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 1
Jul 8, 2024
Visit Reason
The inspection was conducted in response to complaints received by VDSS Division of Licensing on 6/17/24, 6/28/24, and 7/1/24 regarding allegations in the areas of Staffing and Supervision, Resident Care and Related Services, and Safe and Secure Environment.
Findings
The investigation did not substantiate the complaint allegations of non-compliance; however, a violation unrelated to the complaints was identified regarding failure to update the Individualized Service Plan (ISP) for a resident following a significant change in condition.
Complaint Details
Complaints were received alleging issues with Staffing and Supervision, Resident Care and Related Services, and Safe and Secure Environment. The evidence gathered did not support the allegations of non-compliance with standards or law.
Deficiencies (1)
| Description |
|---|
| The facility did not ensure the Individualized Service Plan (ISP) was reviewed and updated as needed for a significant change in a resident's condition, specifically failure to update the ISP to reflect a physician-ordered diet change to puree for Resident #4. |
Report Facts
Number of residents present: 69
Number of resident records reviewed: 4
Number of staff records reviewed: 0
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 2
Number of observations by licensing inspector: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lanesha Allen | Licensing Inspector | Conducted the inspection and is the contact for questions |
| Staff #1 | Confirmed that the Individualized Service Plan (ISP) was not updated to include the physician-ordered puree diet |
Inspection Report
Monitoring
Census: 74
Deficiencies: 3
Apr 10, 2024
Visit Reason
An unannounced monitoring inspection was conducted following a self-report received by VDSS Division of Licensing regarding allegations in the areas of Personnel and Resident Care and Related Services.
Findings
The investigation supported the self-report of non-compliance with standards and violations were issued. Violations included failures in staff orientation and training, tuberculosis risk assessments, and medication administration licensing. Corrective actions and staff changes were implemented.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure orientation and training occurred within the first seven working days of employment. |
| Facility failed to ensure each staff person submitted a tuberculosis risk assessment on or within 7 days prior to first day of work. |
| Facility failed to ensure staff administering medication were licensed or registered as required. |
Report Facts
Number of residents present: 74
Number of resident records reviewed: 8
Number of staff records reviewed: 5
Number of staff interviews conducted: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff #1 | Hired as Med Tech without valid license; administered medications without proper licensure; terminated following violation | |
| Staff #2 | Failed to complete orientation and training within seven days; lacked timely tuberculosis risk assessment | |
| Staff #4 | Did not have tuberculosis risk assessment completed on or within 7 days prior to first day of work | |
| Human Resource Manager | Terminated at time of violation; replaced following findings | |
| Executive Director | Re-educated on orientation and training requirements; responsible for reviewing employee files to ensure compliance |
Inspection Report
Complaint Investigation
Census: 74
Deficiencies: 2
Apr 10, 2024
Visit Reason
An unannounced complaint inspection was conducted due to complaints received on 2024-03-25 and 2024-04-01 regarding personnel, resident care and related services, and buildings and grounds.
Findings
The investigation found some substantiated violations related to medication administration errors and failure to document two-hour rounds for residents with inability to use signaling devices. Violations were issued and plans of correction were requested.
Complaint Details
Complaint was substantiated in part; violations related to medication administration and resident care documentation were issued based on evidence gathered during the investigation.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure medications were administered according to physician or prescriber instructions, resulting in multiple medication errors on 03/04/24. |
| Facility failed to ensure documentation of two-hour rounds for residents with inability to use signaling devices during the night shift on 03/04/24. |
Report Facts
Residents present at inspection: 74
Resident records reviewed: 11
Staff records reviewed: 4
Staff interviews conducted: 2
Medication errors documented: 12
Dates medication not administered as prescribed: 1
Dates Eliquis not documented as administered: 22
Hours without documented rounds: 6
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 0
Jan 23, 2024
Visit Reason
An unannounced complaint inspection was conducted following a complaint received by VDSS Division of Licensing on 2024-01-03 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 included review of resident and staff records, medication carts, staffing schedules, and observation of meals and activities.
Complaint Details
Complaint was received on 2024-01-03 regarding Resident Care and Related Services; the investigation did not substantiate the allegations.
Report Facts
Resident records reviewed: 8
Staff records reviewed: 4
Resident interviews conducted: 3
Staff interviews conducted: 4
Inspection Report
Renewal
Census: 66
Deficiencies: 4
Jan 23, 2024
Visit Reason
An unannounced renewal inspection was conducted on January 23 and 24, 2024, to assess compliance with applicable standards and regulations for the assisted living facility.
Findings
The inspection identified multiple violations related to care planning, medication management, and medication administration, including failure to develop a preliminary plan of care within 7 days of admission, expired medication found on the medication cart, missed medication administration, and improperly labeled medications.
Deficiencies (4)
| Description |
|---|
| Failure to ensure a preliminary plan of care was developed on or within 7 days prior to admission for resident #1. |
| Failure to implement a written medication management plan to prevent use of outdated or contaminated medications; expired Clindamycin Phosphate found on medication cart for resident #10. |
| Failure to administer medications according to physician orders; resident #3 did not receive Lumigan Solution eye drops for several days as prescribed. |
| Failure to ensure PRN medications are available, properly labeled, and properly stored; Cran RX medication on cart was not labeled with resident #6's name. |
Report Facts
Number of residents present: 66
Number of resident records reviewed: 8
Number of interviews conducted with residents: 3
Number of staff records reviewed: 4
Number of interviews conducted with staff: 4
Inspection Report
Monitoring
Census: 62
Deficiencies: 0
Sep 12, 2023
Visit Reason
An unannounced monitoring inspection was conducted following a self-report 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 the self-report of non-compliance with standards or law. The inspection included a tour of the physical plant and observations of residents in the safe secure environment.
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: 2
Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 1
Sep 12, 2023
Visit Reason
An unannounced complaint inspection was conducted due to complaints received on 08/30/2023 and 08/31/2023 regarding allegations in the areas of Personnel and Resident Care and Related Services.
Findings
The investigation supported some, but not all, of the allegations. Non-compliance was found in Resident Care and Related Services, specifically related to medication handling where medications were removed from pharmacy containers and placed in unlabeled plastic cups.
Complaint Details
The complaint was substantiated in part; evidence showed medication handling violations involving removal of pills from pharmacy containers into unlabeled plastic cups by staff #3.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure medications remained in the pharmacy issued container with prescription label or direction attached until administered to the resident. |
Report Facts
Residents present: 64
Resident records reviewed: 3
Staff records reviewed: 3
Staff interviews conducted: 4
Resident interviews conducted: 0
Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 0
Jul 31, 2023
Visit Reason
An unannounced complaint inspection was conducted following a complaint received on 07/30/2023 regarding allegations in the area of Building and Grounds.
Findings
The investigation included a tour of the physical plant, cooling temperature measurements in common areas and resident rooms, and a review of the emergency plan. The evidence gathered did not support the allegations of non-compliance with standards or law.
Complaint Details
Complaint received by VDSS Division of Licensing on 07/30/2023 regarding allegations in Building and Grounds. The evidence did not support the allegations.
Report Facts
Number of residents present: 64
Number of resident records reviewed: 0
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 2
Inspection Report
Monitoring
Census: 62
Deficiencies: 0
Jun 22, 2023
Visit Reason
An unannounced monitoring inspection was conducted to review compliance with regulations, including a self-report received regarding allegations in the area of Resident Care and Related Services.
Findings
The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law. The inspection included a tour of the facility, record reviews, interviews, and observations of resident care and activities.
Report Facts
Number of resident records reviewed: 4
Number of staff records reviewed: 3
Number of interviews with residents: 3
Number of interviews with staff: 2
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 2
Jun 22, 2023
Visit Reason
An unannounced complaint inspection was conducted due to multiple complaints received regarding staffing and supervision, resident care and related services, and safe, secure environment.
Findings
The investigation supported some but not all allegations, identifying non-compliance in the area of Safe, Secure Environment. Violations included failure to report major incidents within 24 hours and failure to ensure required staff rounds for residents unable to use signaling devices.
Complaint Details
The complaint was substantiated in part, with findings related to Safe, Secure Environment. Complaints received on 06/05/23, 06/06/23, 06/09/23, 06/13/23, and 06/16/23 regarding staffing and supervision, resident care, and safe environment.
Deficiencies (2)
| Description |
|---|
| Facility failed to report to the regional licensing office within 24 hours any major incident that negatively affected or threatened the life, health, safety, or welfare of any resident. |
| Facility failed to ensure required staff rounds every two hours during nighttime for residents unable to use signaling devices, and failed to document these rounds. |
Report Facts
Residents present: 62
Resident records reviewed: 4
Staff records reviewed: 3
Resident interviews conducted: 3
Staff interviews conducted: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lanesha Allen | Licensing Inspector | Current inspector conducting the inspection |
| Donesia Peoples | Licensing Inspector | Contact person for questions about VDSS Licensing Programs |
| Executive Director | Named in plan of correction related to incident reporting | |
| Director of Clinical Services | Named in plan of correction related to incident reporting and resident rounds | |
| Assistant Director of Clinical Services | Named in plan of correction related to incident reporting and resident rounds |
Inspection Report
Monitoring
Census: 64
Deficiencies: 4
May 25, 2023
Visit Reason
An unannounced monitoring inspection was conducted to review compliance with applicable regulations and standards at the assisted living facility.
Findings
The inspection found multiple violations including failure to implement a written medication management plan, improper medication administration not consistent with physician orders, inadequate documentation of medical treatments, and insufficient documentation of required resident rounds for those unable to use signaling devices.
Deficiencies (4)
| Description |
|---|
| Failed to implement a written plan for medication management to prevent use of outdated medications. |
| Failed to ensure medications were administered according to physician orders and standards of practice. |
| Failed to ensure medical procedures or treatments ordered by a physician were provided and documented as required. |
| Failed to ensure required rounds were made and documented for residents unable to use signaling devices during nighttime hours. |
Report Facts
Number of residents present: 64
Number of resident records reviewed: 8
Number of staff records reviewed: 5
Number of resident interviews: 1
Number of staff interviews: 8
Expired medications observed: 2
Dates medication administered against parameters: 3
Dates with missing wound care documentation: 1
Dates with missing rounds documentation: 11
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 1
Mar 23, 2023
Visit Reason
An unannounced complaint inspection was conducted due to allegations received by VDSS Division of Licensing regarding Resident Care and Related Services.
Findings
The investigation supported the allegation of non-compliance related to resident records not being kept in a locked area. Violations were issued based on onsite observations.
Complaint Details
Complaint related: Yes. The complaint was substantiated as evidence supported non-compliance with standards regarding resident record security.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure all resident records were kept in a locked area; records for residents #1 through #7 were found in an unstaffed, unlocked office area. |
Report Facts
Number of residents present: 69
Number of resident records reviewed: 7
Number of staff interviews conducted: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Acting Director of Clinical Services | Named as responsible person for plan of correction | |
| Assistant Director of Clinical Services | Named as responsible person for plan of correction | |
| Executive Director | Named as responsible person for plan of correction | |
| Certified designee | Named as responsible person for plan of correction |
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 1
Mar 23, 2023
Visit Reason
An unannounced complaint inspection was conducted due to allegations received by VDSS Division of Licensing on 03/20/2023 regarding Resident Care and Related Services.
Findings
The investigation supported the allegation of non-compliance related to medication administration timing. Violations were issued based on the facility's failure to ensure medications were administered within the prescribed time frame according to their policy.
Complaint Details
The complaint was substantiated as the evidence gathered supported the allegation of non-compliance with medication administration timing standards.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure medications were administered not earlier than one hour before and not later than one hour after the facility's standard dosing schedule, except for drugs ordered for specific times. |
Report Facts
Residents present: 69
Resident records reviewed: 3
Staff interviews conducted: 2
Medication administration times outside policy: 16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lanesha Allen | Licensing Inspector | Current inspector conducting the complaint investigation |
| Donesia Peoples | Licensing Inspector | Contact person for questions regarding the inspection |
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 0
Mar 16, 2023
Visit Reason
An unannounced complaint inspection was conducted following a complaint received on 2023-03-14 regarding allegations in staffing and supervision, resident accommodation and related provisions, and safe, secure environment.
Findings
The evidence gathered during the investigation did not support the allegation of non-compliance with standards or law. Observations included a tour of the physical plant, review of linens, and breakfast observation in the safe secure unit.
Complaint Details
Complaint related to staffing and supervision, resident accommodation and related provisions, and safe, secure environment. The complaint was not substantiated based on the investigation findings.
Report Facts
Number of residents present: 69
Number of staff records reviewed: 5
Number of interviews conducted with staff: 2
Number of resident records reviewed: 0
Number of interviews conducted with residents: 0
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 3
Mar 3, 2023
Visit Reason
An unannounced complaint inspection was conducted due to allegations received on 2023-01-18 regarding Staffing and Supervision and Resident Care and Related Services.
Findings
The investigation supported some but not all allegations, with areas of non-compliance found in Resident Care and Related Services. A violation notice was issued and the licensee was given the opportunity to submit a plan of correction.
Complaint Details
The complaint was received by VDSS Division of Licensing on 2023-01-18 regarding allegations in Staffing and Supervision and Resident Care and Related Services. The evidence supported some allegations related to Resident Care and Related Services.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure a preliminary plan of care was developed on or within 7 days prior to admission to address resident's basic needs. |
| Facility failed to ensure medications were administered according to physician's instructions and standards of practice. |
| Facility failed to ensure medical procedures or treatments ordered by a physician were provided and documented as instructed. |
Report Facts
Number of residents present: 68
Number of resident records reviewed: 3
Number of staff interviews conducted: 2
Inspection Report
Renewal
Census: 69
Deficiencies: 12
Jan 24, 2023
Visit Reason
An unannounced renewal inspection was conducted on January 24 and 25, 2023 to assess compliance with applicable standards and regulations for the assisted living facility.
Findings
The inspection identified multiple violations related to staff criminal history record reports, acting administrator licensure, staff certification, posting of manager on duty, fall risk rating updates, resident orientation, annual assessments, individualized service plans, medication administration, and oxygen safety signage. Plans of correction were proposed for each deficiency.
Deficiencies (12)
| Description |
|---|
| Facility failed to ensure the criminal history record report was obtained on or prior to the 30th day of employment for each staff person. |
| Facility failed to ensure a facility licensed for both residential and assisted living care may be operated by an acting administrator for no more than 150 days, or no more than 90 days if the acting administrator has not applied for licensure. |
| Facility failed to ensure each direct care staff member shall maintain certification in first aid. |
| Facility failed to develop and implement a procedure for posting the name of the current on-site person in charge in a conspicuous place. |
| Facility failed to ensure the fall risk rating shall be reviewed and updated after a fall. |
| Facility failed to provide an orientation for new residents and their legal representatives upon admission. |
| Facility failed to ensure the Uniform Assessment Instrument (UAI) shall be completed at least annually. |
| Facility failed to ensure the individualized service plan (ISP) includes a description of identified needs based upon the UAI. |
| Facility failed to ensure the individualized service plan (ISP) shall be signed and dated by the licensee, administrator, or designee, and by the resident or legal guardian. |
| Facility failed to ensure the individualized service plan (ISP) shall be reviewed and updated at least once every 12 months. |
| Facility failed to ensure medications shall be administered in accordance with the physician's order and standards of practice. |
| Facility failed to post 'No Smoking-Oxygen In Use' signs in any room where oxygen is in use. |
Report Facts
Number of residents present: 69
Number of resident records reviewed: 11
Number of resident interviews: 5
Number of staff interviews: 6
Medication administration dates: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lanesha Allen | Licensing Inspector | Current inspector conducting the inspection |
| Donesia Peoples | Licensing Inspector | Contact person for questions about the inspection |
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 2
Jan 24, 2023
Visit Reason
An unannounced complaint inspection was conducted on January 24 and 25, 2023, following a complaint received on January 18, 2023, regarding allegations in the areas of Staffing and Supervision and Resident Care and Related Services.
Findings
The investigation supported some but not all allegations, identifying non-compliance in Resident Care and Related Services. Violations included failure to implement a written medication management plan to prevent use of outdated medications and improper storage of medications.
Complaint Details
Complaint was substantiated in part; evidence supported some allegations related to Resident Care and Related Services but not all. Complaint was related to Staffing and Supervision and Resident Care and Related Services.
Deficiencies (2)
| Description |
|---|
| Facility failed to implement a written plan for medication management to include methods to prevent the use of outdated medications. |
| Facility failed to ensure medications were stored in a medicine cabinet, container, or compartment consistent with current standards of practice. |
Report Facts
Residents present: 69
Resident records reviewed: 11
Resident interviews: 3
Staff interviews: 6
Expired medications observed: 10
Medication packs observed improperly stored: 15
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 1
Jan 24, 2023
Visit Reason
An unannounced complaint inspection was conducted due to allegations received regarding Staffing and Supervision and Resident Care and Related Services.
Findings
The investigation found some substantiated areas of non-compliance related to Resident Care and Related Services, specifically failure to ensure direct care staff made rounds every two hours during nighttime hours as required.
Complaint Details
The complaint was received on 2023-01-13 regarding allegations in Staffing and Supervision and Resident Care and Related Services. The evidence supported some but not all allegations. A violation notice was issued related to Resident Care and Related Services.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure that once the resident has gone to bed each evening until the resident has arisen each morning, direct care staff shall make rounds no less than every two hours. |
Report Facts
Number of residents present: 69
Number of resident records reviewed: 11
Number of resident interviews: 5
Number of staff interviews: 6
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 0
Nov 4, 2022
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received on 2022-10-28 regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation did not support the allegations of non-compliance with standards or law. The inspection included a tour of the facility, review of resident and staff records, interviews, and observation of staffing and activities.
Complaint Details
A complaint was received by VDSS Division of Licensing on 10/28/2022 regarding allegations in the area(s) of Resident Care and Related Services. The evidence gathered during the investigation did not support the allegation(s) of non-compliance.
Report Facts
Number of residents present: 72
Number of resident records reviewed: 3
Number of staff records reviewed: 1
Number of interviews conducted with residents: 2
Number of interviews conducted with staff: 2
Inspection Report
Monitoring
Census: 72
Deficiencies: 2
Oct 13, 2022
Visit Reason
An unannounced monitoring inspection was conducted to review compliance with regulations following a self-reported incident regarding resident care and related services.
Findings
The inspection found violations including failure to ensure the Individualized Service Plan (ISP) was signed and dated by the resident or legal guardian, and failure to provide adequate supervision of a resident during a community outing, resulting in the resident being missing for approximately 30 minutes.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure the ISP was signed and dated by the resident or legal guardian. |
| Facility failed to provide supervision of resident schedules, care, and activities including attention to specialized needs, resulting in a resident going missing during a community outing. |
Report Facts
Number of residents present: 72
Number of resident records reviewed: 1
Number of staff records reviewed: 2
Number of resident interviews conducted: 1
Number of staff interviews conducted: 3
Duration resident was missing: 30
Inspection Report
Complaint Investigation
Census: 71
Deficiencies: 1
Feb 23, 2022
Visit Reason
An unannounced complaint inspection was conducted due to concerns regarding resident care at the facility.
Findings
The inspection found that the facility failed to ensure accurate documentation of medication administration, including falsification of medication administration records, which was substantiated and resulted in employee termination.
Complaint Details
The complaint was substantiated based on record review and interviews, confirming that medication treatments were not administered as documented and that the MAR was falsified.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure that all medications administered to residents, including over-the-counter medications and dietary supplements, were documented on the medication administration record (MAR). |
Report Facts
Facility census: 71
Date of Medication Error Report: Feb 14, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lanesha Allen | Inspector | Named as current inspector conducting the complaint inspection |
Inspection Report
Renewal
Census: 71
Deficiencies: 5
Feb 23, 2022
Visit Reason
An unannounced renewal inspection was conducted to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection identified multiple violations including failure to ascertain sex offender status prior to admission, incomplete Uniform Assessment Instruments (UAI) and Individual Service Plans (ISP), presence of expired medications, and medication administration timing errors.
Deficiencies (5)
| Description |
|---|
| Facility failed to ascertain, prior to admission, whether a potential resident is a registered sex offender. |
| Facility failed to ensure the Uniform Assessment Instrument (UAI) was completed prior to admission, annually, and after significant changes in condition. |
| Facility failed to review and update Individual Service Plans (ISP) at least once every 12 months and as needed for significant changes. |
| Facility failed to prevent use of outdated, damaged, or contaminated medications as observed in medication cart audit. |
| Facility failed to ensure medications were administered within one hour before or after the scheduled dosing time. |
Report Facts
Residents in care: 71
Expired medications observed: 5
Medication administration time deviation: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lanesha Allen | Licensing Inspector | Current inspector conducting the inspection |
| Staff #1 | Acknowledged expired or outdated medications during medication cart audit | |
| Staff #3 | Observed administering medications outside scheduled time | |
| Director of Clinical Services | Responsible for ensuring completion and monitoring of UAI and ISP | |
| Executive Director | Responsible for confirming completion of UAI prior to resident move-in | |
| Business Office Manager | Responsible for confirming sex offender record attainment prior to resident move-in |
Inspection Report
Monitoring
Deficiencies: 0
Jul 30, 2021
Visit Reason
A non-mandated self-report/monitoring inspection was initiated due to a self-reported incident regarding allegations in the areas of Personnel and Resident Care and Related Services.
Findings
The investigation, including an on-site observation, found no evidence to support the self-report of non-compliance with standards or law.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 15, 2021
Visit Reason
A complaint inspection was initiated due to allegations regarding staffing and supervision and resident care and related services at the facility.
Findings
The investigation did not find evidence to support the allegations of non-compliance with standards or law.
Complaint Details
The complaint was related to staffing and supervision and resident care and related services. The evidence gathered did not support the allegation of non-compliance.
Inspection Report
Complaint Investigation
Deficiencies: 3
Jun 7, 2021
Visit Reason
A complaint inspection was initiated due to allegations regarding resident care, related services, and the safe, secure environment following an event occurring in December 2020.
Findings
The investigation supported the allegations of non-compliance with standards or law, including failure to protect a resident from abuse, failure to secure immediate medical attention after a serious injury, and failure to keep resident records in a locked area.
Complaint Details
The complaint was substantiated based on evidence including video footage and staff confirmation showing resident abuse and failure to provide medical attention after the incident.
Deficiencies (3)
| Description |
|---|
| Administrator failed to be responsible for general administration and management of the facility, including ensuring care protects residents' health, safety, and well-being. |
| Facility failed to ensure medical attention was secured immediately when a resident suffered serious injury or medical condition. |
| Facility failed to ensure all resident records were kept in a locked area. |
Report Facts
Inspection dates: 2
Incident date: Dec 23, 2020
Inspection Report
Monitoring
Census: 63
Deficiencies: 1
Feb 16, 2021
Visit Reason
A monitoring inspection was initiated due to a state of emergency health pandemic declared by the Governor of Virginia, conducted remotely to ensure compliance with applicable standards.
Findings
The inspection found non-compliance related to the facility's failure to maintain accurate and complete meal menus, including missing documentation of menu substitutions and breakfast menus for January and February 2021.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure menus for meals for the current week including any menu substitutions or additions were recorded on the posted menu, and breakfast menus were not maintained as required. |
Report Facts
Inspection dates: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lanesha Allen | Inspector | Current Inspector conducting the inspection |
| Staff #1 | Confirmed menu substitutions and breakfast menus were not recorded | |
| Executive Chef | Responsible for ensuring menus include specific notation and maintaining breakfast menus | |
| Executive Director | Reported census and will review menus to ensure compliance |
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