Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 0
Nov 10, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-10-17 regarding allegations in the areas of Resident Care and Related Services, Buildings and Ground, and Complaint Investigation.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The licensing inspector observed residents interacting with peers and staff during scheduled activities and completed a tour of the physical plant including buildings and grounds.
Complaint Details
Complaint related inspection triggered by allegations in Resident Care and Related Services, Buildings and Ground, and Complaint Investigation. The allegations were not substantiated.
Report Facts
Number of residents present: 48
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 |
|---|---|---|
| Nina Wilson | Licensing Inspector | Conducted the inspection and is the current inspector |
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 1
Oct 6, 2025
Visit Reason
The inspection was conducted in response to a complaint received on 2025-09-19 regarding allegations in the areas of Administration and Administrative Services, Resident Care and Related Services, and Complaint Investigation.
Findings
The investigation supported some, but not all, of the allegations. Areas of non-compliance were found in Administration and Administrative Services and Resident Care and Related Services. A violation notice was issued related to medication administration timing.
Complaint Details
Complaint related: Yes. The complaint was substantiated in part, with non-compliance found in Administration and Administrative Services and Resident Care and Related Services.
Deficiencies (1)
| Description |
|---|
| The facility failed to ensure that 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
Number of residents present: 49
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
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nina Wilson | Licensing Inspector | Current inspector conducting the complaint investigation |
| Staff 1 | Staff member who confirmed medication administration timing discrepancy during inspection |
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 4
Oct 6, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-10-02 regarding allegations in the areas of Administration and Administrative Services, Resident Care and Related Services, and Complaint Investigation.
Findings
The investigation found multiple violations related to failure to report a major incident within 24 hours, failure to implement a written medication management plan, failure to have physician review and sign oral orders within 14 days, and failure to administer medication according to physician instructions.
Complaint Details
The complaint was substantiated as evidence gathered supported the allegations of non-compliance with standards and laws.
Deficiencies (4)
| Description |
|---|
| Facility failed to report to the regional licensing office within 24 hours of any major incident that negatively affected or threatened the life, health, safety, or welfare of any resident. |
| Facility failed to implement a written plan for medication management including accurate transcription of medication orders within 24 hours. |
| Facility failed to ensure that physician's or other prescriber's oral orders were reviewed and signed within 14 days. |
| Facility failed to ensure medication was administered in accordance with physician's instructions. |
Report Facts
Number of residents present: 49
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 |
|---|---|---|
| Nina Wilson | Licensing Inspector | Conducted the inspection and named in findings |
| Staff 1 | Interviewed staff member who confirmed multiple deficiencies related to medication management and incident reporting |
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 1
Jun 18, 2025
Visit Reason
The inspection was conducted in response to a complaint received on 2025-06-04 regarding allegations related to Buildings and Grounds, Emergency Preparedness, and Complaint Investigation.
Findings
The investigation supported some, but not all, of the allegations. The facility was found non-compliant in the area of Buildings and Grounds due to failure to provide air conditioning in all resident-used areas, with temperatures exceeding 80°F in several locations.
Complaint Details
Complaint related: Yes. The complaint was substantiated in part, specifically regarding Buildings and Grounds violations.
Deficiencies (1)
| Description |
|---|
| Facility failed to provide an air conditioning system for all areas used by residents, including bedrooms and common areas, resulting in temperatures exceeding 80°F. |
Report Facts
Temperature readings: 91
Temperature readings: 81.5
Temperature readings: 102
Number of residents present: 51
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nina Wilson | Licensing Inspector | Conducted the inspection and authored the report |
Inspection Report
Monitoring
Deficiencies: 4
May 27, 2025
Visit Reason
The inspection was a monitoring visit conducted to review compliance with applicable standards and laws at the assisted living facility.
Findings
The inspection found multiple violations related to documentation and record-keeping, including failure to provide a required facility disclosure statement, incomplete volunteer orientation records, unsigned resident agreements, and unsigned discharge statements.
Deficiencies (4)
| Description |
|---|
| Facility failed to provide a statement that disclosed information about the facility on a form developed by the department. |
| Facility failed to ensure all volunteers attended orientation and signed a statement acknowledging understanding of duties and policies. |
| Facility failed to ensure resident agreement was dated and signed by the licensee or administrator. |
| Facility did not ensure that at the time of discharge, a dated statement was signed by the licensee or administrator. |
Report Facts
Resident records reviewed: 6
Staff records reviewed: 4
Resident interviews conducted: 1
Staff interviews conducted: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nina Wilson | Licensing Inspector | Inspector who conducted the inspection and interviewed staff |
| Staff 1 | Staff member interviewed who confirmed deficiencies related to documentation and records | |
| Staff 4 | Volunteer staff member whose records were missing |
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 2
Jan 17, 2025
Visit Reason
The inspection was conducted in response to a complaint received on 2024-12-09 regarding allegations related to Admission, Retention and Discharge of Residents, Resident Care and Related Services, and Article 1 - Subjectivity.
Findings
The investigation supported the allegations of non-compliance with applicable standards and laws, resulting in violations issued. Specific deficiencies included failure to perform required six-month reviews for residents in the special care unit and inadequate supervision related to fall prevention and safety checks.
Complaint Details
The complaint was substantiated based on evidence gathered during the investigation, supporting allegations of non-compliance with standards related to resident admission, retention, discharge, and care.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure that six months after placement in the special care unit and annually thereafter, a review of the appropriateness of the resident's continued residence was performed. |
| Facility failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs such as prevention of falls. |
Report Facts
Number of residents present: 51
Number of resident records reviewed: 1
Number of staff interviews conducted: 2
Fall dates for Resident 1: 4
Plan of Correction completion date: Aug 31, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nina Wilson | Licensing Inspector | Conducted the inspection and interviews |
| Staff 2 | Interviewed staff member who confirmed missing 6-month review and lack of 2-hour safety checks |
Inspection Report
Monitoring
Census: 56
Deficiencies: 1
Jan 17, 2025
Visit Reason
The inspection was a monitoring visit conducted to review compliance with regulations following a self-reported incident received by VDSS Division of Licensing regarding allegations in the areas of Admission, Retention and Discharge of Residents, and Resident Care and Related Services.
Findings
The investigation supported some, but not all, of the self-reported allegations and identified areas of non-compliance with standards related to Admission, Retention and Discharge of Residents, and Resident Care and Related Services. A violation notice was issued for failure to ensure all mandated reporters reported suspected abuse, neglect, or exploitation of residents.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure all staff who were mandated reporters reported suspected abuse, neglect, or exploitation of residents. |
Report Facts
Number of residents present: 56
Number of resident records reviewed: 2
Number of staff records reviewed: 2
Number of interviews conducted with staff: 2
Staff hire date: Dec 7, 2023
Inspection Report
Renewal
Census: 60
Deficiencies: 4
Mar 1, 2024
Visit Reason
The inspection was a renewal inspection conducted to review compliance with licensing standards and regulations for the assisted living facility.
Findings
The inspection identified multiple violations including failure to document healthcare oversight every three months, unsecured cleaning supplies, building disrepair including broken windows and fencing, and use of an unapproved portable heating unit.
Deficiencies (4)
| Description |
|---|
| Facility failed to have documentation of a healthcare oversight every three months as required. |
| Facility failed to store cleaning supplies in a locked area; cleaning carts were not locked and supplies were unattended. |
| Interior and exterior of the building was not in good repair, including broken windows, down fencing, and broken cleaning cart doors. |
| Facility staff was using a portable heating unit not approved by state fire authorities. |
Report Facts
Number of records reviewed: 8
Number of interviews conducted: 9
Inspection Report
Renewal
Census: 74
Deficiencies: 1
Mar 30, 2023
Visit Reason
An unannounced renewal inspection was conducted to review resident and staff records, observe resident activities and medication administration, and verify compliance with applicable standards and laws.
Findings
The inspection found non-compliance with staffing requirements, specifically inadequate staff knowledge, skills, and numbers to meet residents' physical, mental, and psychosocial needs, particularly in the memory care environment during meal times.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure that there are staff adequate in knowledge, skills, and abilities and sufficient in numbers to provide services to attain and maintain the physical, mental, and psychosocial well-being of each resident. |
Report Facts
Residents observed during breakfast: 6
Residents observed during lunch: 12
Sample size of records reviewed: 10
Sample size of staff records reviewed: 5
Individual interviews conducted: 3
Days to submit plan of correction: 5
Date for mandatory in-service training: Apr 19, 2023
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 13, 2023
Visit Reason
A complaint was received by VDSS Division of Licensing on 2023-01-10 regarding allegations in the areas of documentation and service plan delivery, prompting an unannounced complaint investigation on 2023-03-13.
Findings
The investigation did not find evidence to support the allegation of non-compliance with standards or law. The inspection findings are subject to public disclosure.
Complaint Details
Complaint related to allegations in documentation and service plan delivery; investigation found no substantiation of non-compliance.
Inspection Report
Complaint Investigation
Deficiencies: 7
Mar 13, 2023
Visit Reason
A complaint was received by VDSS Division of Licensing on 1/10/2023 regarding allegations in the areas of documentation and service plan delivery. An unannounced complaint investigation was conducted on 3/13/2023.
Findings
The investigation did not support the allegation of non-compliance with standards or law. However, multiple deficiencies were identified related to documentation, service plans, fall risk interventions, supervision, and timely medical attention for a resident receiving hospice care.
Complaint Details
Complaint related to documentation and service plan delivery. The evidence gathered did not support the allegation of non-compliance, but multiple documentation and care coordination deficiencies were found.
Deficiencies (7)
| Description |
|---|
| Facility failed to ensure that individuals requiring continuous licensed nursing care were not admitted or retained. |
| Facility failed to document an analysis of the circumstances of falls and interventions to prevent or reduce risk of subsequent falls. |
| Facility failed to complete a comprehensive Individualized Service Plan (ISP) within 30 days after admission. |
| Facility failed to include hospice services on the resident's individualized service plan. |
| Facility failed to provide supervision of resident schedules, care, and activities including prevention of falls and wandering. |
| Facility failed to secure immediate medical attention from a licensed health care professional after a serious fall resulting in injury. |
| Facility failed to document physician's or prescriber's orders, services provided, evaluations of progress, and other pertinent information regarding rehabilitative services in the resident's record. |
Report Facts
Incident dates of resident falls: 8
Date of resident admission: Sep 30, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nina Wilson | Licensing Inspector | Conducted the unannounced complaint investigation. |
| Lynette Storr | Licensing Inspector | Contact person for questions regarding the inspection. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Jan 5, 2023
Visit Reason
The inspection was conducted as an unannounced complaint investigation following a complaint received on 2022-12-16 regarding allegations in the areas of notifications, documentation, and resident injury.
Findings
The investigation supported the allegation of non-compliance with standards or law, resulting in violations related to failure to report incidents to the regional licensing office and Adult Protective Services, and failure to keep resident records current.
Complaint Details
The complaint investigation was substantiated with violations issued for failure to report a resident injury incident to the regional licensing office and Adult Protective Services, and failure to maintain timely and accurate resident documentation.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure that a report was made to the regional licensing office within 24 hours of any major incident affecting a resident. |
| Facility failed to ensure that all mandated reporters reported suspected abuse, neglect, or exploitation of residents as required. |
| Facility failed to ensure that all resident records were kept current. |
Report Facts
Incident date: Nov 20, 2022
Training date: Jan 10, 2023
Inspection Report
Complaint Investigation
Deficiencies: 1
May 6, 2022
Visit Reason
An unannounced complaint inspection was conducted in response to a complaint received regarding Resident Care and Related Services at the facility.
Findings
The allegation was substantiated as the facility failed to administer medication according to the physician's instructions and standards of practice. Specifically, Resident #1 did not receive the last ordered dose of Keflex as documented.
Complaint Details
The complaint was substantiated based on a preponderance of evidence supporting the allegation of medication administration errors.
Deficiencies (1)
| Description |
|---|
| Facility failed to administer medication in accordance with the physician's or other prescriber's instructions and consistent with the standards of practice outlined in the current medication aide curriculum approved by the Virginia Board of Nursing. |
Report Facts
Medication order duration: 10
Medication capsules sent: 20
Medication administration documented: 18
Audit frequency: 3
Audit duration: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nina Wilson | Current Inspector | Named as the inspector conducting the complaint investigation |
| Director of Resident Care | Responsible for re-educating nurses and auditing medication administration |
Inspection Report
Renewal
Census: 79
Deficiencies: 0
Mar 8, 2022
Visit Reason
An unannounced renewal inspection was conducted to assess compliance with licensing standards and regulations.
Findings
The inspection found no violations of applicable standards or laws. Resident care, staff records, medication administration, and facility conditions were reviewed and found compliant.
Report Facts
Resident records reviewed: 9
Staff records reviewed: 5
Individual interviews: 4
Inspection Report
Deficiencies: 1
Oct 18, 2021
Visit Reason
Inspection conducted in response to a self-reported incident regarding issues with the boiler and hot water system at the facility.
Findings
The facility failed to submit a complete written incident report within seven days as required by regulation. A violation notice was issued and risk assigned during the exit interview.
Deficiencies (1)
| Description |
|---|
| Facility failed to submit a written report of each incident within seven days from the date of the incident, including required details and signatures. |
Report Facts
Inspection date: Oct 18, 2021
Inspection Report
Monitoring
Census: 62
Deficiencies: 5
Apr 2, 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 review compliance with licensing standards.
Findings
The inspection identified multiple areas of non-compliance related to admission assessments for residents with serious cognitive impairments, staff record maintenance, sworn statements for employment applicants, and timely criminal history record checks for employees.
Deficiencies (5)
| Description |
|---|
| Facility failed to ensure that prior to admission to a safe, secure environment, the resident was assessed by an independent clinical psychologist or physician for serious cognitive impairment. |
| Facility failed to ensure that prior to admitting a resident with serious cognitive impairment, the licensee or designee determined appropriateness of placement in the special care unit. |
| Facility failed to maintain staff records for at least two years after employment termination. |
| Facility failed to ensure sworn statements or affirmations were completed for all employment applicants. |
| Facility failed to obtain criminal history record reports on or prior to the 30th day of employment for some employees. |
Report Facts
Residents reviewed: 4
Staff records reviewed: 4
Staff records missing sworn statement: 1
Staff records missing timely criminal history record: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nina Wilson | Inspector | Current inspector conducting the inspection |
| Director of Resident Care services | Director of Resident Care services | Responsible for conducting audits and reviewing documentation related to resident assessments and admissions |
| Executive Director | Executive Director | Responsible for performing audits on new move-in files and employee files to verify compliance |
| Business Office Manager | Business Office Manager | Responsible for auditing staff records to ensure sworn statements and criminal history records are obtained and filed |
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 2, 2021
Visit Reason
A complaint inspection was initiated due to allegations received by the department regarding resident care and related services at the facility.
Findings
The investigation did not support the allegations of non-compliance with standards or law. Any violations unrelated to the complaint but identified during the investigation are noted in the violation notice.
Complaint Details
A complaint was received regarding resident care and related services. The investigation was conducted remotely due to a state of emergency health pandemic. The administrator was contacted and documentation was requested. The allegations were not substantiated.
Inspection Report
Complaint Investigation
Deficiencies: 2
Feb 26, 2021
Visit Reason
A complaint inspection was initiated due to allegations regarding Resident Accommodations and Related Provisions, specifically concerning the handling of a resident's personal property.
Findings
The investigation found non-compliance with standards related to the facility's failure to ensure residents could keep reasonable personal property and the lack of written policies for handling missing personal possessions. Violations were issued based on these findings.
Complaint Details
The complaint was substantiated based on evidence gathered during the investigation, supporting allegations of non-compliance with standards or law related to resident personal property handling.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure that each resident shall be permitted to keep reasonable personal property in his possession to maintain individuality and personal dignity. |
| Facility failed to develop and implement a written policy regarding procedures to be followed when a resident's clothing or other personal possessions are reported missing, including investigation and documentation requirements. |
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