Inspection Report
Renewal
Census: 18
Deficiencies: 1
May 2, 2025
Visit Reason
The inspection was a renewal inspection conducted on May 2, 2025, to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection found non-compliance with a standard related to oxygen therapy orders. Specifically, the facility did not maintain a valid physician's or prescriber's order for oxygen therapy in a resident's record.
Deficiencies (1)
| Description |
|---|
| The facility did not ensure that when oxygen therapy is provided, a valid physician's or other prescriber's order was maintained in the resident's record. |
Report Facts
Number of residents present: 18
Number of resident records reviewed: 2
Number of staff records reviewed: 2
Number of interviews conducted with staff: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Coy Stevenson | Licensing Inspector | Inspector conducting the inspection and contact person for questions |
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 19, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-10-11 regarding allegations that a resident was inappropriately discharged from the facility.
Findings
The investigation included an interview with the resident care coordinator and a review of the discharge notification. The evidence gathered did not support the allegations of non-compliance with standards or law.
Complaint Details
Complaint was related to an allegation of inappropriate discharge of a resident. The allegation was not substantiated based on the investigation findings.
Inspection Report
Monitoring
Census: 22
Deficiencies: 0
Oct 23, 2024
Visit Reason
The inspection was a monitoring visit following a self-reported incident received by VDSS Division of Licensing on 2023-08-30 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. An exit meeting will be conducted to review the inspection findings.
Inspection Report
Renewal
Deficiencies: 0
Jun 5, 2024
Visit Reason
The inspection was conducted as a renewal inspection of the assisted living facility to assess compliance with applicable regulations and licensing requirements.
Findings
The inspection found no violations with applicable standards or laws. The licensing inspector observed resident interactions, reviewed records, and toured the facility without identifying any deficiencies.
Report Facts
Resident records reviewed: 6
Staff records reviewed: 3
Resident interviews conducted: 1
Staff interviews conducted: 2
Inspection Report
Complaint Investigation
Census: 22
Deficiencies: 0
Oct 23, 2023
Visit Reason
The inspection was conducted in response to a complaint received on September 7, 2023, regarding allegations in the areas of Personnel and Resident Care and Related Services.
Findings
The investigation found no evidence to support the allegation of non-compliance with standards or law. The inspection summary will be posted publicly within five business days.
Complaint Details
A complaint was received by VDSS Division of Licensing on September 7, 2023 regarding allegations in the areas of Personnel and Resident Care and Related Services. The evidence gathered did not support the allegation of non-compliance.
Inspection Report
Renewal
Census: 23
Deficiencies: 2
Jul 13, 2023
Visit Reason
The inspection was a renewal visit to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection found non-compliance with applicable standards, including failure to document allergy reactions in physical examinations and failure to update individualized service plans after a resident's fall.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure the physical examination contained a description of the person’s reaction to known allergies. |
| Facility failed to ensure individualized service plans (ISPs) were reviewed and updated at least once every 12 months and as needed for a significant change of a resident’s condition. |
Report Facts
Number of residents present: 23
Number of resident records reviewed: 7
Number of staff records reviewed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alexandra Poulter | Licensing Inspector | Contact person for questions about the inspection |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 7, 2023
Visit Reason
The inspection was conducted in response to a complaint received on 2023-05-31 regarding allegations in the areas of Admission, Retention, and Discharge of Residents; Resident Care and Related Services.
Findings
The investigation found no evidence to support the allegation 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
A complaint was received by VDSS Division of Licensing on 2023-05-31 regarding allegations in Admission, Retention, and Discharge of Residents; Resident Care and Related Services. The evidence gathered did not support the allegation of non-compliance.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alex Poulter | Licensing Inspector | Contact person for questions regarding the inspection findings. |
Inspection Report
Monitoring
Census: 24
Deficiencies: 1
Jun 7, 2023
Visit Reason
This was a conditional license monitoring inspection during the conditional license period to assess compliance with applicable standards and laws.
Findings
The inspection found non-compliance with applicable standards related to staff tuberculosis (TB) risk assessments, specifically failure to ensure each staff person submitted current TB documentation.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure each staff person submitted the results of a risk assessment documenting that the individual is free of tuberculosis (TB) in a communicable form. |
Report Facts
Number of residents present: 24
Inspection Report
Original Licensing
Census: 22
Deficiencies: 0
Dec 28, 2022
Visit Reason
The inspection was an initial licensing inspection conducted after the facility's quarantine status due to COVID-19 was lifted, with visits on December 20, 2022, and December 28, 2022.
Findings
The inspection included a tour of the physical plant, review of resident and staff records, interviews, and observations. No violations of applicable standards or laws were found during the inspection.
Report Facts
Number of resident records reviewed: 6
Number of staff records reviewed: 5
Number of interviews conducted with residents: 3
Number of interviews conducted with staff: 3
Loading inspection reports...



