Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 24, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-09-22 regarding allegations in the area of buildings and grounds.
Findings
The evidence gathered during the investigation did not 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
Complaint related to buildings and grounds; the allegation was not substantiated.
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 29, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-08-19 regarding allegations in the areas of resident care and related services and buildings and grounds.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. An exit meeting will be conducted to review the inspection findings.
Complaint Details
Complaint related inspection with allegations concerning resident care and related services and buildings and grounds; allegations were not substantiated.
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
Monitoring
Deficiencies: 1
Aug 29, 2025
Visit Reason
The inspection was a monitoring visit triggered by a self-reported incident received on 2025-08-02 regarding allegations in the area of resident care and related services.
Findings
The investigation supported the self-report of non-compliance related to a resident's rights violation involving economic abuse or exploitation. A staff member was suspended pending an Adult Protective Services investigation and subsequently terminated.
Deficiencies (1)
| Description |
|---|
| The facility failed to ensure that a resident had the rights and responsibilities as provided in 63.2-1808 of the Code of Virginia, specifically related to economic abuse or exploitation involving a questionable $750 check. |
Report Facts
Amount involved in economic abuse: 750
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of staff interviews conducted: 2
Compliance correction timeframe (days): 18
Inspection Report
Monitoring
Census: 98
Deficiencies: 1
Jul 30, 2025
Visit Reason
The inspection was a monitoring visit triggered by a self-reported incident received on 2025-07-21 regarding allegations related to additional requirements for facilities that care for adults with serious cognitive impairments.
Findings
The investigation did not substantiate the self-reported non-compliance, but violations unrelated to the self-report were identified. Specifically, the facility failed to ensure medications were administered according to physician or prescriber instructions, as evidenced by a resident incident involving failure to administer a prescribed PRN medication.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure medications were administered in accordance with the physician's or prescriber's instructions. |
Report Facts
Number of residents present: 98
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of staff interviews conducted: 5
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 0
Jul 8, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-05-29 regarding allegations in the area of resident care and related services.
Findings
The evidence gathered during the investigation did not 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
Complaint received on 2025-05-29 regarding resident care and related services; investigation did not substantiate the allegations.
Report Facts
Number of resident records reviewed: 1
Number of interviews conducted with staff: 3
Inspection Report
Renewal
Census: 98
Deficiencies: 7
Jul 8, 2025
Visit Reason
The inspection was conducted as a renewal inspection to assess compliance with applicable standards and laws for licensing renewal.
Findings
The inspection identified multiple violations including failure to maintain confidentiality of resident records, medication management deficiencies, improper medication storage, hot water temperature issues, poor building maintenance and cleanliness, excessive temperatures in resident areas, and incomplete documentation of emergency preparedness reviews.
Deficiencies (7)
| Description |
|---|
| Facility failed to ensure all records are treated confidentially; unattended medication cart with controlled drug records exposed. |
| Facility failed to implement medication management plan ensuring accurate counts of controlled substances during shift changes. |
| Medications ordered for PRN administration were not available, properly labeled, or properly stored. |
| Hot water taps were not maintained within the required temperature range of 105 to 120 degrees Fahrenheit. |
| Interior of buildings not maintained in good repair and cleanliness; presence of insects and trash in resident rooms. |
| Temperatures in resident areas exceeded the maximum allowed 80 degrees Fahrenheit. |
| Semi-annual review of emergency preparedness plan was not documented by resident signatures. |
Report Facts
Number of residents present: 98
Number of resident records reviewed: 7
Number of staff records reviewed: 3
Number of resident interviews: 2
Number of staff interviews: 5
Hot water temperature: 138
Hot water temperature: 139
Hot water temperature: 134
Hot water temperature: 94.5
Temperature in resident areas: 84
Temperature in resident areas: 84.2
Temperature in resident areas: 81.7
Temperature in resident areas: 81.9
Number of new heat pumps ordered: 20
Lead time for heat pumps: 20
Inspection Report
Monitoring
Deficiencies: 2
May 28, 2025
Visit Reason
The inspection was a monitoring visit conducted on May 28 and May 29, 2025, following two self-reported incidents regarding resident care and related services.
Findings
The investigation supported some of the self-reported incidents, identifying non-compliance related to medication administration. Violations were found regarding failure to administer medications according to physician orders and failure to properly document medication errors or omissions.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure medications were administered in accordance with the physician's or other prescriber's instructions. |
| Facility failed to ensure the medication administration record (MAR) included any medication errors or omissions. |
Report Facts
Number of resident records reviewed: 1
Number of staff interviews conducted: 4
Date of physician's medication order: May 15, 2025
Inspection Report
Complaint Investigation
Census: 99
Deficiencies: 0
May 23, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-05-12 regarding allegations in the areas of personnel and building & grounds.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law.
Complaint Details
Complaint related to personnel and building & grounds; allegations were not substantiated.
Report Facts
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: 4
Inspection Report
Monitoring
Census: 99
Deficiencies: 0
May 23, 2025
Visit Reason
The inspection was conducted as a monitoring visit following a complaint received by VDSS Division of Licensing on 2025-05-21 regarding allegations related to resident care and additional requirements for adults with serious cognitive impairments.
Findings
The investigation did not find evidence to support the allegations of non-compliance with standards or law. Observations included activity in the memory care unit, and an exit meeting was planned to review findings.
Complaint Details
A complaint was received on 2025-05-21 concerning resident care and additional requirements for adults with serious cognitive impairments. The evidence gathered did not substantiate the allegations.
Report Facts
Number of residents present: 99
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: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Stokes | Licensing Inspector | Named as current inspector and contact for the inspection |
Inspection Report
Complaint Investigation
Census: 106
Deficiencies: 1
May 8, 2025
Visit Reason
The inspection was conducted in response to a complaint received on 2025-03-16 regarding allegations related to resident care and related services at the facility.
Findings
The investigation did not substantiate the complaint allegations of non-compliance; however, a violation unrelated to the complaint was identified concerning the failure to provide personal assistance with bathing as required.
Complaint Details
Complaint related to resident care and related services; the evidence did not support the allegation of non-compliance with standards or law.
Deficiencies (1)
| Description |
|---|
| The facility failed to ensure that personal assistance and care are provided to each resident as necessary, including assistance with bathing at least twice a week or more often if needed or desired. |
Report Facts
Number of residents present: 106
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: 3
Showers received: 1
Inspection Report
Complaint Investigation
Census: 106
Deficiencies: 0
May 8, 2025
Visit Reason
The inspection was conducted in response to a complaint received on 2025-04-07 regarding allegations related to resident care and related services.
Findings
The investigation found no evidence to support the allegations of non-compliance with standards or law.
Complaint Details
A complaint was received by VDSS Division of Licensing on 2025-04-07 regarding allegations in the area of resident care and related services. The evidence gathered during the investigation did not support the allegations of non-compliance.
Report Facts
Number of residents present: 106
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: 3
Inspection Report
Monitoring
Census: 106
Deficiencies: 0
May 8, 2025
Visit Reason
The inspection was a monitoring visit conducted by the licensing inspector to review the physical plant including the building and grounds of the assisted living facility.
Findings
The inspection found no violations of applicable standards or laws. The evidence gathered determined compliance with all relevant regulations.
Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 0
Jan 23, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 12/31/2024 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
A complaint was received on 12/31/2024 regarding resident care and related services; the investigation did not substantiate the allegations.
Report Facts
Residents present: 82
Resident records reviewed: 1
Staff records reviewed: 0
Resident interviews conducted: 1
Staff interviews conducted: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Stokes | Licensing Inspector | Current Inspector conducting the complaint investigation |
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 1
Jan 23, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-01-10 regarding allegations related to buildings and grounds at the facility.
Findings
The investigation found that the facility failed to ensure space heaters were used only in accordance with state or local building or fire authority approvals. Space heaters were observed in multiple resident rooms without proper approval, constituting a violation.
Complaint Details
The complaint was substantiated based on observations during a walkthrough and staff interviews confirming unapproved use of space heaters in resident rooms.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure space heaters may be used only to provide or supplement heat in the event of a power failure or similar emergency with approval by state or local building or fire authorities. |
Report Facts
Number of residents present: 80
Number of resident interviews: 3
Number of staff interviews: 2
Number of rooms with unapproved space heaters: 5
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 1
Jan 23, 2025
Visit Reason
The inspection was conducted in response to a complaint received on 2025-01-15 regarding allegations related to buildings and grounds at the facility.
Findings
The investigation confirmed non-compliance with regulations as the facility failed to maintain a temperature of at least 72 degrees Fahrenheit in all resident-used areas during waking hours. Multiple areas measured temperatures significantly below the required minimum.
Complaint Details
The complaint was substantiated based on temperature measurements taken during a walkthrough and staff interviews, confirming heating system issues in multiple areas of the facility.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure a temperature of at least 72 degrees Fahrenheit in all areas used by residents during hours when residents are normally awake. |
Report Facts
Number of residents present: 80
Temperature measurements (degrees Fahrenheit): 64
Temperature measurements (degrees Fahrenheit): 62
Temperature measurements (degrees Fahrenheit): 68
Temperature measurements (degrees Fahrenheit): 56
Temperature measurements (degrees Fahrenheit): 54
Temperature measurements (degrees Fahrenheit): 64
Temperature measurements (degrees Fahrenheit): 63
Temperature measurements (degrees Fahrenheit): 66
Inspection Report
Monitoring
Deficiencies: 0
Sep 4, 2024
Visit Reason
The inspection was a monitoring visit conducted on September 4, 2024, following a self-reported incident received on July 11, 2024, regarding allegations in personnel and resident care and related services.
Findings
The investigation found no evidence to support the self-report of non-compliance with standards or law. The inspection findings will be posted publicly.
Report Facts
Number of staff records reviewed: 1
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 2
Inspection Report
Monitoring
Deficiencies: 0
Sep 4, 2024
Visit Reason
The inspection was a monitoring visit to review compliance with standards 22VAC40-73-880-B and 22VAC40-73-880-C, including a tour of the physical plant and discussion with facility leadership.
Findings
The inspection found no violations of applicable standards or laws. The inspection summary will be posted publicly and a copy of the findings is required to be posted on the facility premises.
Inspection Report
Monitoring
Deficiencies: 0
Aug 22, 2024
Visit Reason
The inspection was conducted as a monitoring visit following a self-reported incident received by VDSS Division of Licensing on 08/01/2024 regarding allegations in the areas of personnel and resident care & related services.
Findings
The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law. The inspection findings will be posted to the VDSS website within 5 business days of receipt of the inspection summary.
Report Facts
Resident records reviewed: 1
Staff records reviewed: 1
Resident interviews conducted: 1
Staff interviews conducted: 2
Inspection Report
Renewal
Census: 85
Deficiencies: 5
Jul 22, 2024
Visit Reason
The inspection was conducted as a renewal inspection to assess compliance with applicable standards and laws for continued licensing of the assisted living facility.
Findings
The inspection found multiple violations including inadequate staffing for fire and emergency evacuation, medication administration errors, poor maintenance and cleanliness of building interiors and exteriors, failure to maintain resident area temperatures below 80 degrees Fahrenheit, and incomplete documentation of semi-annual emergency preparedness reviews.
Deficiencies (5)
| Description |
|---|
| Facility failed to ensure an adequate number of staff persons on premises at all times to implement the approved fire and emergency evacuation plan. |
| Facility failed to ensure medications were administered in accordance with physician's instructions, resulting in a resident receiving fewer pills than prescribed. |
| Facility failed to maintain interior and exterior of buildings in good repair and cleanliness, including stained carpets and chipping paint. |
| Facility failed to ensure temperatures in all resident areas did not exceed 80 degrees Fahrenheit. |
| Facility failed to document semi-annual review of emergency preparedness and response plan by staff, residents, and volunteers with signatures and dates. |
Report Facts
Number of residents present: 85
Number of resident records reviewed: 6
Number of staff records reviewed: 3
Number of resident interviews conducted: 4
Number of staff interviews conducted: 5
Temperature in common area: 81.5
Temperature in hallway: 83
Inspection Report
Complaint Investigation
Deficiencies: 3
Jun 13, 2024
Visit Reason
The inspection was conducted in response to a complaint received by the VDSS Division of Licensing on June 13, 2024, regarding allegations in the areas of administration and administrative services and resident care and related services.
Findings
The investigation supported some, but not all, of the allegations; non-compliance was found in the area of 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 investigation was substantiated in part, with non-compliance found in resident care and related services. The complaint involved allegations related to administration and resident care.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure a method of written communication was utilized to keep direct care staff on all shifts informed of significant happenings or problems experienced by residents. |
| Facility failed to ensure the comprehensive individualized service plan (ISP) was completed within 30 days after admission and included all required information, including court-appointed guardianship. |
| Facility failed to ensure immediate medical attention was secured when a resident suffered a serious medical condition, and proper documentation and notifications were not completed. |
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: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Stokes | Licensing Inspector | Inspector conducting the complaint investigation |
| Staff person 1 | Interviewed staff related to communication log deficiency | |
| Staff person 2 | Interviewed staff and provided communication log documentation | |
| Staff person 3 | Documented resident medical incident related to failure to secure immediate medical attention |
Inspection Report
Monitoring
Deficiencies: 1
Jun 11, 2024
Visit Reason
The inspection was a monitoring visit conducted on June 11, 2024, following a self-reported incident received on June 10, 2024, regarding allegations in the area of resident care and related services.
Findings
The investigation supported the self-report of non-compliance related to medication administration, specifically that a resident did not receive prescribed nighttime medications on June 9, 2024. Violations were issued based on resident record review and staff and resident interviews.
Deficiencies (1)
| Description |
|---|
| The facility failed to ensure that medications were administered in accordance with the physician's or other prescriber's instructions, resulting in a resident not receiving nighttime medications on 06/09/2024. |
Report Facts
Date of missed medication: Jun 9, 2024
Number of medications missed: 5
Inspection Report
Complaint Investigation
Deficiencies: 0
May 29, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2024-05-24 regarding allegations in the area of buildings and grounds.
Findings
The evidence gathered during the investigation did not support the allegation of non-compliance with standards or law.
Complaint Details
Complaint related to buildings and grounds; the allegation was not substantiated.
Inspection Report
Complaint Investigation
Deficiencies: 2
May 29, 2024
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received by VDSS Division of Licensing on 05/15/2024 regarding allegations in the area of resident care and related services.
Findings
The investigation did not substantiate the complaint allegations of non-compliance; however, violations unrelated to the complaint were identified related to medication administration and use of PRN medications.
Complaint Details
Complaint was received on 05/15/2024 regarding resident care and related services. The evidence gathered did not support the allegations of non-compliance with standards or law.
Deficiencies (2)
| Description |
|---|
| The facility failed to ensure that medications were administered in accordance with the physician's or other prescriber's instructions, including administering PRN quetiapine 50MG doses less than six hours apart. |
| The facility failed to ensure the use of PRN medications is prohibited unless the resident is capable of determining when the medication is needed, licensed health care professionals administer the PRN medications, or medication aides administer PRN medications with detailed physician orders including symptoms, dosage, time frames, and directions. |
Report Facts
Medication administrations: 19
Medication administrations: 11
Medication administrations: 22
Medication administrations: 2
Medication administrations: 4
Medication administrations: 16
Inspection Report
Complaint Investigation
Deficiencies: 0
May 29, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-04-30 regarding allegations in the area of resident care and related services.
Findings
The investigation found no evidence to support the allegations of non-compliance with standards or law. The inspection summary will be posted publicly within 5 business days of receipt.
Complaint Details
A complaint was received by VDSS Division of Licensing on 04/30/2024 regarding allegations in resident care and related services. The evidence gathered did not support the allegations.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Stokes | Licensing Inspector | Named as the current inspector conducting the complaint investigation. |
Inspection Report
Monitoring
Deficiencies: 0
May 17, 2024
Visit Reason
The inspection was conducted as a monitoring visit following a self-reported incident received by VDSS Division of Licensing regarding allegations in the areas of personnel and 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 findings will be posted publicly and a copy is required to be posted on the facility premises.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Stokes | Licensing Inspector | Named as the current inspector conducting the monitoring inspection. |
Inspection Report
Monitoring
Deficiencies: 0
Apr 23, 2024
Visit Reason
The inspection was a monitoring visit conducted on April 23, 2024, following a self-reported incident received on April 9, 2024, regarding allegations in personnel and resident care and related services.
Findings
The investigation did not support the 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.
Inspection Report
Monitoring
Deficiencies: 0
Apr 23, 2024
Visit Reason
The inspection was a monitoring visit conducted on April 23, 2024, following a self-reported incident received on April 18, 2024, regarding allegations in personnel and resident care and related services.
Findings
The investigation did not support the self-report of non-compliance with standards or law. The inspection findings will be posted publicly and a copy is required to be posted on the facility premises.
Inspection Report
Monitoring
Deficiencies: 0
Apr 23, 2024
Visit Reason
The inspection was a monitoring visit conducted on April 23, 2024, following a self-reported incident received by VDSS Division of Licensing on April 22, 2024, regarding allegations in personnel and resident care and related services.
Findings
The investigation did not support the 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.
Inspection Report
Monitoring
Deficiencies: 0
Nov 21, 2023
Visit Reason
The inspection was a monitoring visit conducted on November 21, 2023, to review resident care and related services following a self-reported incident received by VDSS on November 26, 2023.
Findings
The inspection found no violations of applicable standards or laws. The inspection summary will be posted publicly within five business days of receipt.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 25, 2023
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2023-10-13 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.
Complaint Details
Complaint received on 2023-10-13 regarding resident care and related services; investigation did not substantiate the allegations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 5, 2023
Visit Reason
The inspection was conducted in response to a complaint received on 2023-09-30 regarding allegations related to staffing and supervision and resident care and related services.
Findings
The investigation found no evidence to support the allegations of non-compliance with standards or law. The inspection findings will be posted publicly and a copy is required to be posted on the facility premises.
Complaint Details
A complaint was received by VDSS Division of Licensing on 09/30/2023 regarding allegations in the areas of staffing and supervision and resident care and related services. The evidence gathered during the investigation did not support the allegations of non-compliance.
Inspection Report
Monitoring
Deficiencies: 1
Sep 29, 2023
Visit Reason
The inspection was a monitoring visit triggered by a self-reported incident received on 2023-09-20 regarding allegations in the area of resident care and related services.
Findings
The investigation supported the self-report of non-compliance with regulations related to medication administration. A violation was issued for administering medication without a physician's order.
Deficiencies (1)
| Description |
|---|
| The facility failed to ensure that medications were administered in accordance with the physician's or other prescriber's instructions, specifically administering Aricept 10MG to a resident without a valid order. |
Report Facts
Date of medication administration error: Sep 19, 2023
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 16, 2023
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 07/14/2023 regarding allegations in the areas of personnel 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.
Complaint Details
Complaint related inspection with allegations concerning personnel and resident care; the complaint was not substantiated.
Inspection Report
Renewal
Census: 88
Deficiencies: 10
Aug 16, 2023
Visit Reason
The inspection was a renewal inspection conducted to assess compliance with applicable standards and laws for licensing renewal.
Findings
The inspection identified multiple violations including failure to secure windows for residents with serious cognitive impairments, failure to report major incidents within 24 hours, failure to update individualized service plans for significant resident condition changes, medication management deficiencies including incomplete controlled substance counts and unsecured medication storage, improper storage of medications and hazardous materials, and maintenance issues such as interior building repairs and temperature control exceeding 80 degrees Fahrenheit in resident areas.
Deficiencies (10)
| Description |
|---|
| Facility failed to ensure protective devices on bedroom windows and common area windows to prevent residents with serious cognitive impairments from crawling through. |
| Facility failed to report major incidents affecting resident safety to the regional licensing office within 24 hours. |
| Facility failed to ensure individualized service plans were reviewed and updated as needed for significant changes in resident condition. |
| Facility failed to implement medication management plan ensuring accurate counts of controlled substances during staff shift changes. |
| Facility failed to ensure medication storage areas were locked. |
| Facility failed to ensure medications in resident rooms were stored out of sight and only for residents assessed as capable of self-administration. |
| Facility failed to ensure cleaning supplies and hazardous materials were stored in locked areas. |
| Facility failed to ensure residents who keep their own cleaning supplies or hazardous materials stored them out of sight and inaccessible to others. |
| Facility failed to maintain the interior of the building in good repair and kept clean, with observed stains and damage to ceilings and cabinets. |
| Facility failed to ensure temperature in resident areas did not exceed 80 degrees Fahrenheit. |
Report Facts
Residents present: 88
Resident records reviewed: 10
Staff records reviewed: 5
Resident interviews: 5
Staff interviews: 5
Inspection start time: 850
Inspection end time: 945
Temperature readings exceeding 80F: 6
Inspection Report
Complaint Investigation
Deficiencies: 1
Jul 11, 2023
Visit Reason
The inspection was conducted in response to a complaint received on 2023-07-06 regarding allegations in the areas of resident care and related services and buildings and grounds.
Findings
The investigation supported some, but not all, of the allegations; non-compliance was found in the buildings and grounds area. Specifically, the facility failed to ensure that the temperature in all areas used by residents did not exceed 80 degrees Fahrenheit.
Complaint Details
The complaint was partially substantiated with non-compliance found in buildings and grounds. A violation notice was issued related to the complaint.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure that the temperature in all areas used by residents did not exceed 80 degrees Fahrenheit. |
Report Facts
Temperature readings: 81
Temperature readings: 82
Temperature readings: 82.5
Temperature readings: 83
Temperature readings: 87.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Stokes | Licensing Inspector | Conducted the inspection and is the contact for questions |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 28, 2023
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2023-06-01 regarding allegations in the areas of personnel 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. An exit meeting will be conducted to review the inspection findings.
Complaint Details
Complaint related to allegations in personnel and resident care and related services; the complaint was not substantiated.
Inspection Report
Monitoring
Deficiencies: 8
May 31, 2023
Visit Reason
The inspection was a monitoring visit to assess compliance with applicable standards and laws at the assisted living facility.
Findings
The inspection identified multiple violations including failure to complete timely tuberculosis screenings, improper posting of person in charge, incomplete individualized service plans, medication administration errors, missing oxygen use signage, unsecured hazardous materials, building maintenance issues, and delayed criminal history background checks.
Deficiencies (8)
| Description |
|---|
| Facility failed to ensure tuberculosis risk assessments were completed prior to staff contact with residents. |
| Facility failed to follow person in charge posting procedures. |
| Facility failed to ensure individualized service plans (ISPs) were completed as required. |
| Facility failed to ensure medications were administered according to physician instructions and standards. |
| Facility failed to post 'No Smoking-Oxygen in Use' signs in rooms where oxygen is in use. |
| Facility failed to ensure cleaning supplies and hazardous materials were stored in a locked area. |
| Facility failed to maintain the exterior and interior of the building in good repair. |
| Facility failed to ensure criminal history record reports were obtained on or prior to the 30th day of employment for each employee. |
Report Facts
Staff persons with late TB assessments: 4
Resident with incomplete ISP: 1
Medication administration errors: 4
Staff with delayed criminal background checks: 6
Inspection Report
Complaint Investigation
Deficiencies: 0
May 31, 2023
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 05/24/2023 regarding allegations in the areas of personnel and 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.
Complaint Details
Complaint related to personnel and resident care and related services; the complaint was not substantiated.
Inspection Report
Original Licensing
Deficiencies: 3
Dec 22, 2022
Visit Reason
The inspection was an initial licensing inspection conducted to determine compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection found multiple violations related to the facility's failure to maintain and keep clean the interior and exterior of the building, lack of documentation of initial contact with the local emergency coordinator, and the facility's fire and emergency evacuation plan not yet being approved by the appropriate fire official.
Deficiencies (3)
| Description |
|---|
| Facility failed to maintain and keep clean the interior and exterior of the building, including damaged front entrance doors, unclean windows, chipped stucco, chipping paint, stained carpets, scuffed walls, and stained exterior walls. |
| Facility failed to ensure documentation of initial contact with the local emergency coordinator to determine emergency requirements. |
| Facility's written plan for fire and emergency evacuation has been submitted but not yet approved by the appropriate fire official. |
Report Facts
Inspection duration: 45
Plan of correction deadlines: 5
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