Deficiencies per Year
8
6
4
2
0
Unclassified
Census Over Time
Inspection Report
Renewal
Census: 143
Deficiencies: 6
Jul 18, 2025
Visit Reason
The inspection was a renewal inspection conducted to assess compliance with applicable standards and regulations for the assisted living facility.
Findings
The inspection identified multiple violations including staff certification issues, failure to provide required healthcare oversight, medication administration errors, incomplete PRN medication orders, lack of semi-annual emergency preparedness reviews, and missing criminal history reports for some staff. Plans of correction were submitted addressing each deficiency with systemic measures and monitoring plans.
Deficiencies (6)
| Description |
|---|
| Facility failed to ensure each direct care staff member maintained current certification in first aid from approved organizations. |
| Facility failed to ensure licensed health care professional provided health care oversight at least every six months for residents meeting assisted living care criteria. |
| Facility failed to ensure medications were administered in accordance with physician's or prescriber's instructions. |
| Facility failed to ensure PRN medication orders included directions for persistent symptoms. |
| Facility failed to develop and implement a documented semi-annual review of emergency preparedness and response plan for all staff, residents, and volunteers. |
| Facility failed to ensure criminal history reports were obtained on or prior to the 30th day of employment for certain employees. |
Report Facts
Number of residents present: 143
Number of resident records reviewed: 8
Number of staff records reviewed: 4
Number of resident interviews: 2
Number of staff interviews: 2
Medication audit percentage: 15
Plan of correction monitoring timeframe: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nina Wilson | Licensing Inspector | Conducted the inspection and is contact for questions |
| Staff 1 | Direct care staff member with non-approved first aid certification | |
| Staff 6 | Staff member who confirmed deficiencies during inspection | |
| Resident Care Director | Resident Care Director (RCD) | Responsible for audits and training related to medication administration and PRN medication orders |
| Human Resource Coordinator | Human Resource Coordinator (HRC) | Responsible for audits related to first aid certification and criminal history reports |
| Executive Director | Executive Director | Responsible for implementation and ongoing compliance with plans of correction |
Inspection Report
Complaint Investigation
Census: 149
Deficiencies: 2
Jun 16, 2025
Visit Reason
The inspection was conducted in response to a complaint received by the VDSS Division of Licensing on 06/16/2025 regarding allegations related to Resident Care and Related Services at the facility.
Findings
The investigation supported some, but not all, of the allegations of non-compliance in Resident Care and Related Services. Violations were found related to medication administration timing and adherence to physician instructions.
Complaint Details
The complaint was substantiated in part, with violations found related to medication administration timing and adherence to physician orders.
Deficiencies (2)
| 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 those drugs ordered for specific times. |
| The facility failed to administer medications in accordance with the physician's or other prescriber's instructions. |
Report Facts
Residents present: 149
Resident records reviewed: 1
Staff records reviewed: 3
Staff interviews conducted: 2
Inspection Report
Monitoring
Census: 149
Deficiencies: 2
Jun 16, 2025
Visit Reason
The inspection was a monitoring visit conducted to review compliance following a self-report received on 2025-02-28 regarding allegations related to buildings and grounds.
Findings
The inspection found violations related to the facility's failure to maintain elevators in good running condition and failure to ensure the emergency preparedness plan adequately addressed potential hazards disrupting normal operations.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure that elevators were kept in good running condition; the only elevator in building 2 was offline for approximately 3 weeks. |
| Facility failed to ensure the written emergency preparedness and response plan addressed and analyzed potential hazards disrupting normal operation. |
Report Facts
Duration elevator offline: 3
Number of residents present: 149
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nina Wilson | Licensing Inspector | Current inspector conducting the monitoring inspection. |
| Staff 2 | Provided information regarding resident escorting during elevator outage. |
Inspection Report
Complaint Investigation
Census: 149
Deficiencies: 1
Jun 16, 2025
Visit Reason
The inspection was conducted in response to a complaint received on 2025-06-02 regarding allegations in the areas of Administration and Administrative Services, Staffing and Supervision, and Resident Care and Related Services.
Findings
The investigation supported some, but not all, of the allegations and found non-compliance in Administration and Administrative Services, Staffing and Supervision, and Resident Care and Related Services. A violation notice was issued including a failure to report a major incident within 24 hours.
Complaint Details
The complaint was substantiated in part; evidence supported some allegations of non-compliance in Administration and Administrative Services, Staffing and Supervision, and Resident Care and Related Services.
Deficiencies (1)
| 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, specifically Resident 2's hospitalization and unexpected death. |
Report Facts
Number of residents present: 149
Number of resident records reviewed: 3
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: 145
Deficiencies: 0
Oct 7, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 10/07/2024 regarding allegations in the area of Buildings and Grounds.
Findings
The licensing inspector completed a tour of the physical plant including the building and grounds. The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law.
Complaint Details
Complaint related to Buildings and Grounds; the allegations were not substantiated based on the investigation findings.
Report Facts
Number of residents present: 145
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: 1
Inspection Report
Complaint Investigation
Deficiencies: 2
Aug 21, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-08-12 regarding allegations in the areas of Personnel, Staffing and Supervision, and Resident Care and Related Services.
Findings
The investigation supported some, but not all, of the allegations. Violations were found related to staffing levels not meeting the approved fire and emergency evacuation plan and medication administration timing not adhering to the facility's standard dosing schedule.
Complaint Details
The complaint was substantiated in part; evidence supported some of the allegations related to Personnel, Staffing and Supervision, and Resident Care and Related Services.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure an adequate number of staff persons were on premises at all times to implement the approved fire and emergency evacuation plan. |
| 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
Late medication administrations: 41
Instances of medications administered 14 hours late: 14
Instances of medications administered 12 hours late: 1
Instances of medications administered 4 hours late: 2
Instances of medications administered 3 hours late: 9
Instances of medications administered 2 hours late: 2
Instances of medications administered 1 hour late: 3
Instances of medications administered between 1 and 40 minutes late: 7
Staff scheduled below required levels on multiple dates: 38
Staff scheduled below required levels on specific dates: 3
Staff scheduled below required levels on specific dates: 3
Staff scheduled below required levels on 1st shift: 1
Staff scheduled below required levels on 3rd shift: 2
Staff scheduled below required levels on 2nd shift: 1
Staff scheduled below required levels on 1st shift: 2
Staff scheduled below required levels on 2nd shift: 5
Staff scheduled below required levels on 3rd shift: 15
Staff scheduled below required levels on 1st shift: 1
Number of staff records reviewed: 3
Number of staff interviews conducted: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nina Wilson | Licensing Inspector | Conducted the inspection and interviews |
| Staff 9 | Interviewed regarding staffing plan and medication administration issues |
Inspection Report
Monitoring
Deficiencies: 3
Jun 20, 2024
Visit Reason
The inspection was a monitoring visit conducted to assess compliance with applicable standards and laws at the assisted living facility.
Findings
The inspection identified violations related to elevator inspections, fire marshal inspections, and resident emergency drill procedures. The facility was found non-compliant in maintaining up-to-date elevator inspection certificates, retaining fire marshal inspection reports, and conducting and documenting resident emergency drills every six months.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure elevators were kept in good running condition and inspected at least annually, with the most recent inspection certificate not posted. |
| Facility failed to ensure at least an annual inspection by a fire official was retained at the facility for at least two years. |
| Facility failed to ensure procedures in the plan for resident emergencies were reviewed every six months with all staff, and documentation was signed and dated by each staff person. |
Report Facts
Date of most recent fire official inspection: May 28, 2023
Date of previous fire official inspection: Oct 18, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nina Wilson | Licensing Inspector | Named as the current inspector conducting the monitoring inspection |
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 19, 2023
Visit Reason
The inspection was conducted as a complaint investigation to review staffing, supervision, resident care, and building conditions at the assisted living facility.
Findings
The complaint was investigated and determined to be not valid. No deficiencies or violations were explicitly stated in the report.
Complaint Details
Complaint was determined not valid.
Inspection Report
Renewal
Census: 115
Deficiencies: 1
Aug 30, 2022
Visit Reason
The inspection was a renewal inspection conducted to review compliance with regulatory standards and assess facility operations since the last inspection.
Findings
The inspection found a medication administration violation where prescribed medications were not administered due to unavailability, but no negative effects were reported for the resident involved. The facility implemented corrective actions including audits and staff re-education to prevent recurrence.
Deficiencies (1)
| Description |
|---|
| Facility staff failed to administer medications as prescribed by her physician due to medications not being available. |
Report Facts
Records reviewed and interviews conducted: 8
Inspection Report
Renewal
Census: 106
Deficiencies: 0
Sep 23, 2021
Visit Reason
A renewal inspection was initiated to assess compliance with licensing standards and regulations for the assisted living facility.
Findings
The inspection found no violations with applicable standards or law. Documentation including resident and staff records, criminal background checks, and sworn statements were reviewed and found complete.
Inspection Report
Monitoring
Census: 105
Deficiencies: 3
May 28, 2021
Visit Reason
A monitoring inspection was initiated and conducted using an alternate remote protocol due to a state of emergency health pandemic declared by the Governor of Virginia. The inspection included review of resident and staff records and documentation to ensure compliance.
Findings
The inspection identified non-compliance with applicable standards and laws, including deficiencies in individualized service plans and incomplete sworn statements for staff. Violations were documented and a violation notice was issued requiring a plan of correction.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure that a written description of services provided to address identified needs was included on the comprehensive Individualized Service Plan (ISP). |
| Facility failed to ensure that the sworn statement or affirmation was completed for all applicants for employment. |
| Facility failed to ensure that any person making a materially false statement on the sworn statement or affirmation shall be guilty of a Class 1 misdemeanor. |
Report Facts
Staff records with incomplete sworn statements: 8
Employees with conflicting sworn statements and criminal history records: 4
Resident records reviewed: 5
Staff records reviewed: 5
Inspection Report
Deficiencies: 0
Feb 19, 2021
Visit Reason
The inspection was conducted due to a change of ownership and was initiated with a virtual tour of the facility. Policies and procedures were reviewed as part of the inspection.
Findings
No violations were cited during the inspection. The most recent health and fire inspections were provided with leniency noted due to the state of emergency.
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