Inspection Report
Complaint Investigation
Census: 21
Deficiencies: 1
Jul 21, 2025
Visit Reason
The inspection was conducted in response to a complaint received on 2025-07-14 regarding allegations in the areas of Staffing and Supervision and Resident Care and Related Services.
Findings
The investigation supported the allegations of non-compliance, resulting in a violation related to the facility's failure to ensure general responsibility for the health, safety, and well-being of a resident who fell and remained on the floor for over five hours without staff checking on him.
Complaint Details
Complaint related: Yes. The complaint was substantiated based on video evidence showing a resident on the floor from 11:55 pm on 6/30/25 to 5:21 am on 7/1/25 without staff checking on him.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure general responsibility for the health, safety, and well-being of a resident who fell and remained on the floor for over five hours without staff checking on the resident. |
Report Facts
Number of residents present on memory care unit: 21
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of staff interviews conducted: 2
Number of resident interviews conducted: 0
Inspection Report
Complaint Investigation
Census: 21
Deficiencies: 0
Jul 21, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-07-11 regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation did not support the allegation of non-compliance with standards or law. The licensing inspector conducted a tour, reviewed records, and observed interactions and documentation, concluding no deficiencies were found.
Complaint Details
Complaint related to Resident Care and Related Services; the evidence gathered did not substantiate the allegation of non-compliance.
Report Facts
Number of residents present: 21
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 2
Inspection Report
Complaint Investigation
Census: 21
Deficiencies: 0
Jul 21, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on July 14, 2025, regarding allegations in the areas of Resident Care and Related Services and Additional Requirements for Facilities That Care For Adults With Serious Cognitive Impairments.
Findings
The licensing inspector completed a tour of the memory care unit and reviewed one resident record. Observations included memory care unit conditions, staff/resident interactions, documentation, and staffing schedules. The evidence gathered did not support non-compliance with standards or law.
Complaint Details
Complaint was related to Resident Care and Related Services and Additional Requirements for Facilities That Care For Adults With Serious Cognitive Impairments. The investigation did not substantiate non-compliance.
Report Facts
Number of residents present: 21
Number of Resident Records Reviewed: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Yvonne Randolph | Licensing Inspector | Conducted the inspection and is the contact person for the report |
Inspection Report
Complaint Investigation
Census: 21
Deficiencies: 5
Jul 14, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-07-10 regarding allegations related to personnel conduct at the facility.
Findings
The investigation confirmed violations including staff engaging in inappropriate sexual conduct and sleeping during their shift while residents were present, inadequate staffing and supervision during night hours, failure to complete required resident rounds, and failure to protect residents' rights and well-being. Violations were issued and corrective actions were required.
Complaint Details
The complaint was substantiated based on evidence including video surveillance and staff interviews confirming inappropriate staff conduct and failure to provide adequate supervision and care.
Deficiencies (5)
| Description |
|---|
| Facility did not ensure at least two direct staff awake and on duty during night hours when 22 or fewer residents are present in each special care unit. |
| Staff engaged in inappropriate sexual conduct and sleeping in the room of a resident with serious cognitive impairment. |
| Facility did not ensure staff were considerate and respectful of the rights, dignity, and sensitivities of residents. |
| Staff member in charge was not capable of protecting the physical and mental well-being of residents during the night shift. |
| Facility did not ensure required rounds were made and documented every two hours for residents unable to use signaling devices during night hours. |
Report Facts
Number of residents present: 21
Number of staff records reviewed: 3
Number of staff interviews conducted: 5
Number of resident interviews attempted: 1
Number of residents assigned to staff 4 and 5: 13
Duration of staff inappropriate conduct: 4.5
Inspection Report
Complaint Investigation
Deficiencies: 3
Jul 7, 2025
Visit Reason
The inspection was conducted in response to a complaint received on 2025-06-20 regarding allegations in the areas of Resident Care and Related Services, Staffing and Supervision, Personnel, and Additional Requirements for Facilities That Care For Adults With Serious Cognitive Impairments.
Findings
The investigation supported some, but not all, of the allegations. Areas of non-compliance were found in Resident Care and Related Services and Administration and Administrative Services. Violations included failure to submit timely incident reports, failure to provide care as specified in individualized service plans, and failure to assume general responsibility for resident health and safety.
Complaint Details
The complaint was substantiated in part. Evidence included documentation reviews, photographs of resident injuries, and observations of staff providing care inconsistent with the individualized service plan. Some allegations were not supported.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure that a written report of each incident that negatively affected or threatened the life, health, safety, or welfare of a resident was submitted to the regional licensing office within seven days from the date of the incident. |
| Facility did not ensure that care and services specified in the individualized service plan were provided to each resident. |
| Facility did not ensure that it assumed general responsibility for the health, safety, and well-being of a resident. |
Report Facts
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of interviews conducted with residents: 1
Number of collateral interviews: 1
Number of interviews conducted with staff: 2
Inspection Report
Complaint Investigation
Census: 21
Deficiencies: 0
Jul 7, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-07-05 regarding allegations related to Additional Requirements For Facilities That Care For Adults With Serious Cognitive Impairments and 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 licensing inspector completed a tour of the secured memory care unit and conducted interviews and observations.
Complaint Details
Complaint related to allegations in the areas of Additional Requirements For Facilities That Care For Adults With Serious Cognitive Impairments and Resident Care And Related Services; the allegations were not substantiated.
Report Facts
Number of residents present: 21
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 1
Number of collateral interviews: 1
Number of interviews conducted with staff: 2
Inspection Report
Monitoring
Census: 21
Deficiencies: 1
Jul 7, 2025
Visit Reason
The inspection was a monitoring visit conducted on July 7 and July 21, 2025, following a self-reported incident by the facility related to resident care and related services.
Findings
The investigation found non-compliance with standards or law related to the individualized service plan not being followed, resulting in a violation being issued. The facility self-reported an incident where a resident received bruising and a cut due to improper assistance.
Deficiencies (1)
| Description |
|---|
| Based on a documentation review, the facility did not ensure that care and services specified in the individualized service plan are provided to each resident. |
Report Facts
Number of residents present: 21
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of interviews conducted with staff: 4
Number of interviews conducted with residents: 0
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 6, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-03-05 regarding allegations in the area of Resident Care and Related Services.
Findings
The evidence gathered during the investigation did not support non-compliance with standards or law. No deficiencies were cited.
Complaint Details
Complaint received on 2025-03-05 regarding Resident Care and Related Services; investigation did not substantiate non-compliance.
Report Facts
Number of resident records reviewed: 0
Number of staff records reviewed: 0
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 2
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 13, 2025
Visit Reason
The inspection was conducted in response to a complaint received on 2024-12-31 regarding allegations in personnel, staffing and supervision, resident care and related services, resident accommodations and related provisions, buildings and grounds, and additional requirements for facilities caring for adults with serious cognitive impairments.
Findings
The investigation did not find evidence to support the allegations of non-compliance with standards or law. The inspection included a tour of the facility, review of resident and staff records, and observations of meals, staffing, and resident interactions.
Complaint Details
Complaint received on 2024-12-31 regarding multiple areas including personnel, staffing and supervision, resident care, accommodations, buildings and grounds, and care for adults with serious cognitive impairments. The evidence gathered did not support the allegations of non-compliance.
Report Facts
Resident records reviewed: 1
Staff records reviewed: 3
Staff interviews conducted: 2
Resident interviews conducted: 0
Inspection Report
Renewal
Census: 100
Deficiencies: 1
Jan 13, 2025
Visit Reason
The inspection was conducted as a renewal visit to assess compliance with applicable standards and regulations for the assisted living facility.
Findings
The inspection identified non-compliance with applicable standards, specifically a violation related to the omission of a Do Not Resuscitate (DNR) Order from a resident's individualized service plan. The facility was given the opportunity to submit a plan of correction.
Deficiencies (1)
| Description |
|---|
| Based on file reviews, the Do Not Resuscitate (DNR) Order for one resident was not included on the individualized service plan for the resident. |
Report Facts
Number of residents present: 100
Number of resident records reviewed: 6
Number of staff records reviewed: 3
Number of interviews conducted with residents: 3
Number of interviews conducted with staff: 3
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 12, 2024
Visit Reason
The inspection was conducted in response to a complaint received by the VDSS Division of Licensing on 11/12/24 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 findings were reviewed in an exit meeting and will be posted publicly.
Complaint Details
Complaint related to Resident Care and Related Services; the allegations were not substantiated.
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
Deficiencies: 0
Aug 20, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-08-05 regarding allegations in the areas of Building and Grounds, Staffing and Supervision, and Resident Care and Related Services.
Findings
The licensing inspector found no evidence to support the allegations of non-compliance with standards or law after reviewing the physical plant, staff schedules, and conducting interviews with residents and staff.
Complaint Details
Complaint was received by VDSS Division of Licensing on 8/5/24 regarding allegations in Building and Grounds, Staffing and Supervision, and Resident Care and Related Services. The evidence gathered did not support the allegations of non-compliance.
Report Facts
Number of resident records reviewed: 0
Number of staff records reviewed: 0
Number of interviews conducted with residents: 2
Number of interviews conducted with staff: 1
Inspection Report
Monitoring
Deficiencies: 1
Mar 5, 2024
Visit Reason
The inspection was a monitoring visit to review compliance with staffing, resident care, and additional requirements for facilities caring for adults with serious cognitive impairments.
Findings
The investigation supported non-compliance with standards related to a self-reported resident-to-resident altercation resulting in injury. Staff were not physically present to prevent the incident, and a violation was issued.
Deficiencies (1)
| Description |
|---|
| Based on an investigation of a self-reported incident, the facility did not assume general responsibility for the health, safety and welfare of a resident. |
Report Facts
Resident records reviewed: 1
Staff records reviewed: 0
Resident interviews conducted: 1
Staff interviews conducted: 5
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 0
Feb 20, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2026-01-25 regarding allegations in staffing, resident care, accommodations, building and grounds, emergency preparedness, and additional requirements for adults with serious cognitive impairments. A follow-up on a self-reported incident related to resident care was also performed.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. An exit meeting was conducted to review the inspection findings, and the inspection summary will be posted publicly.
Complaint Details
Complaint received on 2026-01-25 regarding staffing and supervision, resident care and related services, resident accommodations and related provisions, building and grounds, emergency preparedness, and additional requirements for adults with serious cognitive impairments. Follow-up on a self-reported incident related to resident care was also performed. The evidence did not support the allegations.
Report Facts
Number of residents present: 57
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: 57
Deficiencies: 0
Jan 17, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2024-01-02 regarding allegations in the areas of Personnel, Staffing and Supervision, Resident Care and Related Services, Resident Accommodations and Related Services, Building and Grounds, and Additional Requirements for Facilities that Care for Adults with Serious Cognitive Impairments.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. An exit meeting was conducted to review the inspection findings.
Complaint Details
Complaint received on 2024-01-02 regarding allegations in multiple areas including Personnel, Staffing and Supervision, Resident Care and Related Services, Resident Accommodations and Related Services, Building and Grounds, and Additional Requirements for Facilities that Care for Adults with Serious Cognitive Impairments. The allegations were not substantiated.
Report Facts
Number of residents present: 57
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 2
Inspection Report
Renewal
Census: 57
Deficiencies: 1
Jan 17, 2024
Visit Reason
The inspection was a renewal visit to assess compliance with licensing standards for the assisted living facility.
Findings
The inspection found non-compliance with applicable standards related to the timing of uniform assessment instrument (UAI) completion prior to admission. The facility did not ensure that all residents were assessed face to face using the UAI before admission.
Deficiencies (1)
| Description |
|---|
| The facility did not ensure that all residents and applicants were assessed face to face using the uniform assessment instrument prior to admission, as required. |
Report Facts
Number of residents present: 57
Number of resident records reviewed: 8
Number of staff records reviewed: 4
Number of interviews conducted with residents: 3
Number of interviews conducted with staff: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Yvonne Randolph | Licensing Inspector | Named as the inspector conducting the inspection |
Inspection Report
Monitoring
Census: 46
Deficiencies: 0
Oct 30, 2023
Visit Reason
The inspection was a 60 Day, Mandated Monitoring visit to review compliance with applicable standards and regulations.
Findings
The inspection found no violations with applicable standards or laws. Services and care were observed to be person-centered and individualized.
Report Facts
Number of resident records reviewed: 6
Number of staff records reviewed: 3
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 3
Inspection Report
Original Licensing
Deficiencies: 0
Jul 31, 2023
Visit Reason
Initial licensing inspection conducted to evaluate compliance with applicable standards and regulations for an assisted living facility.
Findings
The inspection found no violations of applicable standards or laws. The licensing inspector completed a tour of the physical plant including building, grounds, resident rooms, and memory care environment.
Report Facts
Number of residents present: 0
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 1
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