Inspection Report
Monitoring
Census: 61
Deficiencies: 2
Sep 8, 2025
Visit Reason
The inspection was a monitoring visit triggered by a self-reported incident received by VDSS Division of Licensing on 2025-08-26 regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation supported the self-report of non-compliance related to medication management and administration. Violations were issued for failure to ensure timely filling and refilling of medications and failure to administer medications according to physician orders.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure the medication management plan was implemented including methods to ensure that each resident's medications are filled and refilled in a timely manner to avoid missed dosages. |
| Facility failed to ensure that medication was administered in accordance with the physician or prescriber's orders. |
Report Facts
Number of residents present: 61
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of resident interviews: 1
Number of staff interviews: 2
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 3
Sep 8, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-09-03 regarding allegations in the area of Resident Accommodations and Related Provisions.
Findings
The investigation supported the complaint of non-compliance related to medication management, including failure to ensure timely filling and refilling of medications, improper administration by staff, and failure to administer medications according to physician orders. Violations were issued based on resident record reviews and staff interviews.
Complaint Details
Complaint related: Yes. The complaint was substantiated as violations were issued based on the investigation findings.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure the medication management plan was implemented including methods to ensure that each resident's medications are filled and refilled in a timely manner to avoid missed dosages. |
| Facility failed to ensure that medications were removed, open, and administered to the resident by the same staff person. |
| Facility failed to ensure that medication was administered in accordance with the physician or prescriber's orders. |
Report Facts
Number of residents present: 61
Number of resident records reviewed: 2
Number of staff records reviewed: 1
Number of resident interviews conducted: 1
Number of staff interviews conducted: 2
Inspection Report
Renewal
Census: 60
Deficiencies: 4
Aug 6, 2025
Visit Reason
The inspection was conducted as a renewal inspection to ensure compliance with applicable standards and regulations prior to license expiration.
Findings
The inspection identified multiple violations including failure to maintain resident-specific healthcare oversight records, posting outdated menus, medication administration not following physician orders, and invalid Do Not Resuscitate (DNR) orders in resident records.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure healthcare oversight included specific residents and recommendations were maintained in resident records. |
| Facility failed to ensure menus for meals and snacks for the current week were dated and posted conspicuously to residents. |
| Facility failed to ensure medication was administered according to physician or prescriber orders. |
| Facility failed to ensure that Do Not Resuscitate (DNR) orders were valid and complete. |
Report Facts
Number of residents present: 60
Number of resident records reviewed: 4
Number of staff records reviewed: 3
Number of resident interviews conducted: 2
Number of staff interviews conducted: 3
Medication doses administered against orders: 21
Medication doses administered against orders: 6
Medication doses administered against orders: 1
Medication doses administered against orders: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Velasco | Licensing Inspector | Conducted the inspection and interviews |
| Staff 1 | Interviewed and confirmed deficiencies related to healthcare oversight, menu posting, medication administration, and DNR orders | |
| Staff 2 | Interviewed and confirmed medication administration deficiencies |
Inspection Report
Monitoring
Census: 64
Deficiencies: 3
May 15, 2025
Visit Reason
The inspection was conducted as a monitoring visit following a self-reported incident received by VDSS Division of Licensing on 02/03/2025 regarding allegations in the area of Resident Accommodations and Related Provisions.
Findings
The investigation supported the self-report of non-compliance and violations were issued related to failure to submit a timely incident report, failure to follow the medication management plan, and failure to administer medication according to physician orders. The med-tech involved was placed on administrative leave and later relieved of duty.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure a written incident report was submitted to the regional licensing office within 7 days from the date of the incident. |
| Facility failed to ensure the medication management plan was followed. |
| Facility failed to ensure that medication was administered according to the physician or other prescriber's orders. |
Report Facts
Residents present: 64
Resident records reviewed: 1
Staff records reviewed: 1
Staff interviews conducted: 3
Medication units administered: 22
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Velasco | Licensing Inspector | Conducted the inspection and interviews |
| Staff 1 | Acknowledged failure to submit incident report and confirmed medication plan was not followed | |
| Staff 2 | Notified the Licensing Inspector of the medication error via email | |
| Staff 4 | Interviewed and stated the doctor was not called until around 5:00 PM | |
| Staff 5 | Administered 22 units of insulin contrary to physician's order and provided a written statement | |
| Executive Director | Sent the formal incident report on 5/15/25 and responsible for ensuring timely self-reports | |
| Resident Care Director | Reviewed medication administration plan and responsible for ensuring policy compliance |
Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 2
May 15, 2025
Visit Reason
The inspection was conducted in response to a complaint received by the VDSS Division of Licensing on 2025-05-02 regarding allegations related to Resident Accommodations and Related Provisions.
Findings
The investigation supported the complaint of non-compliance with standards and violations were issued. Specifically, the facility failed to obtain new orders for all medications and treatments when a resident was admitted to the hospital and failed to ensure medications were administered according to physician orders.
Complaint Details
Complaint related: Yes. The complaint was substantiated based on evidence including resident record reviews and staff interviews confirming failures in medication order updates and administration.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure that new orders for all medications and treatments were obtained whenever a resident is admitted to the hospital. |
| Facility failed to ensure that medications were administered in accordance with the physician's or other prescriber's orders. |
Report Facts
Number of residents present: 64
Number of resident records reviewed: 2
Number of staff interviews conducted: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Velasco | Licensing Inspector | Inspector conducting the complaint investigation and interviews |
| Staff 1 | Staff interviewed who confirmed medication order and administration failures |
Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 0
May 15, 2025
Visit Reason
The inspection was conducted in response to a complaint received by the VDSS Division of Licensing on 2025-02-03 regarding allegations in the area of Resident Accommodations and Related Provisions.
Findings
The investigation did not support the allegations of non-compliance with standards or law. Parts of the complaint were investigated as part of a self-reported incident, and call-bell responses were not reviewed due to system downtime at the time of inspection.
Complaint Details
Complaint related to Resident Accommodations and Related Provisions; evidence gathered did not substantiate the allegations.
Report Facts
Number of residents present: 64
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 |
|---|---|---|
| Amanda Velasco | Licensing Inspector | Inspector conducting the complaint investigation |
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 0
Jan 2, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2024-11-04 regarding allegations related to discharge of residents, resident care and related services, resident accommodations and related provisions, and buildings and grounds.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The inspection findings were favorable with no substantiated deficiencies.
Complaint Details
Complaint investigation triggered by allegations received on 2024-11-04. The allegations were not substantiated based on the inspection findings.
Report Facts
Number of residents present: 65
Number of resident records reviewed: 2
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 1
Inspection Report
Monitoring
Census: 66
Deficiencies: 4
Sep 23, 2024
Visit Reason
The inspection was conducted as a monitoring visit following a self-reported incident received by VDSS Division of Licensing on 09/03/2024 regarding allegations in the area of resident care and related services.
Findings
The inspection found multiple violations including failure to ensure proper documentation for private duty personnel, lack of supervision of volunteers when residents are present, insufficient training for staff in managing aggressive residents, and incomplete individualized service plans specifying frequency of daily rounds.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure that files for private duty personnel from licensed home care organizations contained proper documentation. |
| Facility failed to ensure all volunteers were under the supervision of a designated staff person when residents are present. |
| Facility failed to ensure that direct care staff were trained in methods of dealing with aggressive residents including self-protection and de-escalation. |
| Facility failed to ensure that the Individualized Service Plan specified a minimal frequency of daily rounds to be made by direct care staff. |
Report Facts
Number of residents present: 66
Number of resident records reviewed: 2
Number of staff records reviewed: 1
Number of interviews with residents: 3
Number of interviews with staff: 3
Instances of verbally or physically aggressive behavior: 7
Instances of refusal of care: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Velasco | Licensing Inspector | Current inspector conducting the inspection |
| Staff 1 | Provided information regarding private duty aide documentation, training records, and confirmed lack of training on aggressive residents | |
| Staff 2 | Reported on volunteer supervision and incident during Bingo activity | |
| Staff 4 | Volunteer assisting with Bingo, found unsupervised during activity | |
| Resident 1 | Resident involved in multiple findings including private duty aide assignment, aggressive behavior, and incomplete ISP | |
| Resident 3 | Resident who witnessed incident on 09/02/2024 and commented on staff preparedness | |
| Resident 4 | Resident who described staff response during yelling incident |
Inspection Report
Renewal
Census: 64
Deficiencies: 14
Aug 15, 2024
Visit Reason
The inspection was conducted as a renewal inspection of the assisted living facility to assess compliance with applicable regulations and licensing standards.
Findings
The inspection identified multiple areas of non-compliance including failure to conduct annual reviews of infection prevention policies, missing resident disclosure and orientation forms, inadequate health care oversight documentation, unsecured resident records and medications, incomplete oxygen therapy orders, lack of annual fire inspection, and failure to complete semi-annual emergency preparedness reviews. Plans of correction were submitted or noted for all deficiencies.
Deficiencies (14)
| Description |
|---|
| Failed to ensure an annual review of the infection prevention policies and procedures with a licensed health care professional. |
| Resident records did not contain an acknowledgement of the disclosure form for multiple residents. |
| Failed to ensure orientation for new residents and legal representatives was provided and documented. |
| Failed to ensure licensed health care professional certified health care oversight requirements were met, including dates and resident identification. |
| Failed to ensure annual review of resident rights and responsibilities was completed and documented. |
| Resident records were not stored in a locked area; medication closet was unlocked and contained resident information. |
| Failed to ensure oversight of special diets included certification that requirements were met. |
| Medication was not stored in a locked area; medication cart was unattended with medication on top. |
| Oxygen therapy orders did not include oxygen source, delivery device, and flow rate as required. |
| Failed to provide a written response to the resident council prior to the next meeting. |
| Cleaning supplies and hazardous materials were not stored in a locked area. |
| Interior and exterior of buildings were not maintained in good repair; wallpaper missing, drywall cuts, chipped paint. |
| Failed to ensure annual fire inspection was completed; Fire Marshal permit expired and inspection not scheduled timely. |
| Failed to implement semi-annual review on emergency preparedness and response plan for residents, staff, and volunteers. |
Report Facts
Number of residents present: 64
Number of resident records reviewed: 6
Number of staff records reviewed: 3
Number of resident interviews conducted: 3
Number of staff interviews conducted: 3
Date of infection prevention assessment: Jun 27, 2023
Date of special diet oversight: Jul 19, 2024
Date of last fire inspection: Jul 17, 2023
Fire Marshal permit expiration date: Jun 30, 2024
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 5, 2022
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2022-11-21 regarding allegations in the areas of resident care and related services and buildings and grounds.
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 on the facility premises.
Complaint Details
Complaint was related to resident care and related services and buildings and grounds. The evidence gathered did not support the allegation of non-compliance.
Report Facts
Number of interviews conducted: 2
Inspection Report
Renewal
Census: 48
Deficiencies: 1
Aug 10, 2022
Visit Reason
The inspection was conducted as a renewal inspection to assess compliance with applicable standards and laws for the facility's license renewal.
Findings
The inspection found non-compliance related to the absence of fire and emergency evacuation drawings on each floor of the building. The violation was corrected on the day of the inspection with drawings posted on each floor and a plan of correction implemented for ongoing compliance.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure that a fire and emergency evacuation drawing was posted in a conspicuous place on each floor of each building used by residents. |
Report Facts
Residents present: 48
Resident records reviewed: 8
Staff records reviewed: 4
Resident interviews: 1
Staff interviews: 1
Inspection Report
Monitoring
Deficiencies: 0
Sep 1, 2021
Visit Reason
A non-mandated monitoring inspection was initiated to review resident care and related services at the facility.
Findings
The investigation did not yield any violations or deficiencies.
Inspection Report
Renewal
Census: 24
Deficiencies: 1
Aug 3, 2021
Visit Reason
A renewal inspection was initiated to review compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection found non-compliance related to medication administration where medications were not administered or documented according to physician orders and standards.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure medications were administered in accordance with physician's orders and consistent with standards of practice. |
Report Facts
Census: 24
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Velasco | Inspector | Current inspector conducting the inspection |
| Resident Care Director | Resident Care Director | Conducted audit and re-education related to medication administration deficiencies |
| Wellness Nurse | Wellness Nurse | Conducted medication pass observations and audits related to medication administration |
| Executive Director | Executive Director | Responsible for implementation and ongoing compliance with the Plan of Correction |
Inspection Report
Monitoring
Census: 22
Deficiencies: 0
May 19, 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 ensure compliance with applicable standards and laws.
Findings
The inspection reviewed resident and staff records, fire and health inspections, fire drill reports, dietary and healthcare oversight reports, staff schedules, and criminal background checks. No violations were found and no deficiencies were issued.
Report Facts
Inspection dates: 2
Resident census: 22
Inspection Report
Original Licensing
Deficiencies: 0
Feb 18, 2021
Visit Reason
The inspection was conducted due to a change in ownership and was an announced initial inspection performed using an alternate remote protocol due to a state of emergency health pandemic.
Findings
No violations were cited during the inspection. The Fire, Health, and Elevator Inspections have been completed, and the exit interview was held by telephone with the administrator.
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