Inspection Report
Census: 83
Deficiencies: 2
Nov 3, 2025
Visit Reason
The inspection was conducted following a self-reported incident received by VDSS Division of Licensing on 09/29/2025 regarding allegations in staffing and supervision, resident care, resident accommodations, and protection of adults and reporting.
Findings
The investigation supported the self-report of non-compliance with standards and violations were issued related to staff conduct and failure to ensure general responsibility for resident health, safety, and wellbeing. Staff involved in the incident were terminated and retraining plans were implemented.
Deficiencies (2)
| Description |
|---|
| Facility did not ensure all staff were considerate and respectful of the rights, dignity, and sensitivities of persons who are aged, infirm, or disabled. |
| Facility failed to ensure that staff assumed general responsibility for health, safety, and wellbeing of the residents. |
Report Facts
Number of residents present: 83
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of staff interviews conducted: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shelby Haskins | Licensing Inspector | Inspector conducting the inspection |
Inspection Report
Monitoring
Census: 75
Deficiencies: 0
May 5, 2025
Visit Reason
The inspection was a monitoring visit conducted to review compliance with various regulatory provisions and to observe facility operations.
Findings
The inspection found no violations of applicable standards or laws. The inspector observed a medication pass, tested water temperature, reviewed fire and health inspections, and toured the building and grounds. Residents were observed participating in a Cinco De Mayo party during the inspection.
Report Facts
Number of resident records reviewed: 6
Number of staff records reviewed: 3
Number of interviews conducted with residents: 2
Number of interviews conducted with staff: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shelby Haskins | Licensing Inspector | Inspector conducting the monitoring inspection |
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 0
Apr 21, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-04-10 regarding allegations in resident care, accommodations, and complaint investigation.
Findings
The investigation did not find evidence to support the allegations of non-compliance with standards or law. No violation notice was issued.
Complaint Details
Complaint received on 2025-04-10 regarding allegations in resident care and accommodations. The evidence gathered did not support the allegations.
Report Facts
Number of residents present: 78
Number of resident records reviewed: 1
Number of interviews with residents: 1
Number of interviews with staff: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shelby Haskins | Licensing Inspector | Inspector conducting the complaint investigation |
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 0
Jan 27, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-01-20 regarding allegations related to resident care, accommodations, and complaint investigation standards.
Findings
The investigation did not find evidence to support the allegations of non-compliance with the applicable standards or laws. The inspection findings will be publicly posted within five business days.
Complaint Details
Complaint investigation was triggered by allegations in the areas of resident care and related services, resident accommodations, and complaint investigation. The evidence gathered did not support the allegations of non-compliance.
Report Facts
Number of residents present: 83
Number of resident records reviewed: 1
Number of staff interviews conducted: 2
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 0
Jul 31, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2024-07-23 regarding allegations in the areas of Staffing and Supervision, Resident Care and Related Services, and Resident Accommodations and Related Provisions.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The facility was found to have completed its due diligence in the areas reviewed.
Complaint Details
Complaint related to allegations in Staffing and Supervision, Resident Care and Related Services, and Resident Accommodations and Related Provisions. The complaint was not substantiated.
Report Facts
Number of residents present: 78
Number of resident records reviewed: 1
Number of interviews conducted with staff: 2
Inspection Report
Monitoring
Census: 81
Deficiencies: 0
Jun 4, 2024
Visit Reason
The inspection was a monitoring visit conducted on June 4, 2024, following a self-report received by VDSS Division of Licensing regarding allegations in resident care, related services, and protection of adults and reporting.
Findings
The licensing inspector completed a tour of the facility and reviewed resident records and staff interviews. The evidence gathered did not support the self-report of non-compliance with standards or law.
Report Facts
Number of resident records reviewed: 1
Number of interviews conducted with staff: 1
Inspection Report
Renewal
Census: 78
Deficiencies: 0
May 8, 2024
Visit Reason
The inspection was conducted as a renewal inspection to evaluate compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection included a tour of the physical plant, review of resident and staff records, observation of resident activities and medication pass, and review of emergency preparedness and safety reports. No violations of applicable standards or laws were found during the inspection.
Report Facts
Number of resident records reviewed: 10
Number of staff records reviewed: 5
Number of interviews conducted with residents: 1
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 0
Jan 9, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2023-11-02 regarding allegations related to Buildings and Grounds and Safe, Secure Environment.
Findings
The investigation found no evidence to support the allegations of non-compliance with standards or law. The inspection included a tour of the physical plant, building, and grounds.
Complaint Details
Complaint received on 2023-11-02 regarding Buildings and Grounds; Safe, Secure Environment. The evidence gathered did not support the allegations of non-compliance.
Inspection Report
Monitoring
Deficiencies: 0
Sep 8, 2023
Visit Reason
The inspection was a monitoring visit following a self-reported incident received on July 7, 2023, 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. The inspection findings will be posted publicly and an exit meeting was conducted to review the findings.
Inspection Report
Renewal
Census: 76
Deficiencies: 5
Jun 20, 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 identified multiple violations related to resident care documentation, including failure to review appropriateness of continued residence in the special care unit, incomplete physical examination forms regarding self-medication capability, lack of coordinated hospice care plans, unidentified residents in healthcare oversight, and missing written specifications for resident sleeping accommodations.
Deficiencies (5)
| Description |
|---|
| Failed to ensure six-month and annual review of appropriateness of continued residence in the special care unit for Resident #5. |
| Physical examination did not specify whether Resident #7 is capable of self-administering medication. |
| Failed to ensure coordinated hospice care plan including hospice services on individualized service plan for Resident #7. |
| Healthcare oversight documents did not identify specific residents reviewed during oversight periods. |
| No written specification obtained for Resident #1's preference to have a recliner instead of a bed. |
Report Facts
Number of resident records reviewed: 11
Number of staff records reviewed: 3
Inspection duration hours: 4
Inspection Report
Complaint Investigation
Census: 76
Deficiencies: 2
Jun 20, 2023
Visit Reason
The inspection was conducted in response to a complaint received on 2023-03-15 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 investigation supported some, but not all, of the allegations, identifying non-compliance with standards related to care for adults with serious cognitive impairments. Violations were found regarding unsafe access to potentially harmful objects and failure to document approval for placement in the special care unit prior to admission.
Complaint Details
The complaint was partially substantiated; evidence supported some allegations related to resident care and additional requirements for adults with serious cognitive impairments.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure that objects potentially harmful to residents with serious cognitive impairments were inaccessible except under staff supervision. |
| Licensee failed to determine and document whether placement in the special care unit was appropriate prior to admission of a resident with serious cognitive impairment. |
Report Facts
Number of residents present: 76
Complaint received date: Mar 15, 2023
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 5
Oct 13, 2022
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2022-09-06 regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation supported the allegation of non-compliance with standards or laws, resulting in violations issued. Deficiencies were found related to annual completion of the UAI, individualized service plan signatures and updates, medication management, and secure storage of medications.
Complaint Details
The complaint investigation was substantiated with violations issued. The complaint was related to Resident Care and Related Services and medication management.
Deficiencies (5)
| Description |
|---|
| Facility failed to ensure the UAI was completed at least annually for Resident #4. |
| Facility failed to ensure the individualized service plan (ISP) was signed and dated by the resident or legal representative for Resident #1. |
| Facility failed to ensure the ISP was reviewed and updated at least once every 12 months and as needed for significant changes for Resident #5. |
| Facility failed to implement a written plan for medication management to ensure timely filling and refilling of prescriptions and supplements for multiple residents. |
| Facility failed to ensure a resident may keep medication in an out-of-sight place in his room if the UAI indicated capability of self-administration; medications were not properly secured for Resident #3. |
Report Facts
Number of residents present: 80
Number of resident records reviewed: 5
Number of resident interviews: 4
Number of staff interviews: 1
Inspection Report
Renewal
Census: 75
Deficiencies: 6
Jun 17, 2022
Visit Reason
The inspection was a renewal inspection conducted on June 17, 2022, to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection identified multiple violations related to documentation, individualized service plans, hospice care coordination, emergency preparedness, and emergency food supply storage. The facility was found non-compliant in several areas and issued violation notices with plans of correction.
Deficiencies (6)
| Description |
|---|
| Failed to document that the order of priority for placing a resident with serious cognitive impairment in a safe, secure environment was followed. |
| Failed to ensure a physical examination by an independent physician within 30 days preceding admission included description of allergy reactions. |
| Failed to ensure the comprehensive individualized service plan included a description of identified needs and date based on the Uniform Assessment Instrument and other sources. |
| Failed to ensure hospice care and licensed hospice organization communicated and established an agreed upon coordinated plan of care included in the individualized service plan. |
| Failed to ensure the fire and emergency evacuation drawing showed primary and secondary escape routes, areas of refuge, assembly areas, and fire alarm boxes. |
| Failed to ensure at least 48 hours of emergency food supply was kept onsite at any given time. |
Report Facts
Number of residents present: 75
Number of resident records reviewed: 10
Number of staff records reviewed: 3
Number of staff interviews conducted: 2
Inspection time duration (hours): 5.62
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alexandra Poulter | Licensing Inspector | Contact person for questions about the VDSS Licensing Programs |
| Shelby Haskins | Current Inspector | Inspector on-site during the inspection |
| Staff #1 | Confirmed deficiencies during interviews related to documentation and hospice care | |
| Staff #2 | Escorted licensing inspector to offsite emergency food storage | |
| Executive Director | Responsible for reviewing and implementing plans of correction | |
| Assisted Living Coordinator | Reviewed and updated individualized service plans and hospice service documentation | |
| Resident Care Director | Reviewed forms and plans of correction related to resident care | |
| Dining Service Coordinator | Relocated emergency food supply onsite and responsible for monthly inspections | |
| Maintenance Coordinator | Inspected emergency evacuation drawings and responsible for annual reviews |
Inspection Report
Deficiencies: 1
Dec 16, 2021
Visit Reason
A remote monitoring was conducted regarding a self-report on December 16, 2021. The Administrator was interviewed via email regarding Administration and Administrative Services.
Findings
The 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 a COVID-19 positive staff member whose positive test was not reported within the required timeframe.
Deficiencies (1)
| Description |
|---|
| Facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or threatens the life, health, safety, or welfare of any resident, specifically delayed reporting of a COVID positive staff member. |
Report Facts
Days late reporting COVID positive staff: 5
Plan of Correction monitoring period: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shelby Haskins | Inspector | Current Inspector conducting the remote monitoring. |
| Executive Director | Responsible for reporting incidents and implementing the Plan of Correction. |
Inspection Report
Renewal
Census: 62
Deficiencies: 0
May 25, 2021
Visit Reason
A renewal inspection was initiated on May 25, 2021, and concluded on May 28, 2021, conducted remotely due to the state of emergency health pandemic declared by the Governor of Virginia.
Findings
The inspection reviewed resident and staff records, schedules, background checks, medication administration, and other facility documentation. No violations or deficiencies were found during the inspection.
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