Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 2
May 16, 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 Administration and Administrative Services, Resident Care and Related Services, and Resident Accommodations and Related Provisions.
Findings
The investigation supported some, but not all, of the allegations. Areas of non-compliance were found in Resident Care and Related Services and Resident Accommodations and Related Provisions. A violation notice was issued for these findings.
Complaint Details
The complaint was substantiated in part. Evidence included failure to report a resident's hospital transfer on 2025-05-09 within 24 hours and failure of staff to report allegations of abuse (resident punched in the face) to the nurse in charge.
Deficiencies (2)
| Description |
|---|
| The facility failed to report any major incident that negatively affected or threatened the life, health, safety, or welfare of any resident to the regional licensing office within 24 hours. |
| The facility failed to ensure that staff who are mandated reporters reported suspected abuse or neglect of residents. |
Report Facts
Number of residents present: 82
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of resident interviews conducted: 1
Number of staff interviews conducted: 4
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 0
Dec 18, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2024-12-13 regarding allegations in the areas of 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 licensing inspector toured the physical plant and observed resident activities without identifying deficiencies.
Complaint Details
Complaint investigation related to allegations in Resident Care and Related Services, and Resident Accommodations and Related Provisions. The complaint was not substantiated.
Report Facts
Number of residents present: 83
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: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nina Wilson | Licensing Inspector | Conducted the inspection and is the contact person for the report |
Inspection Report
Renewal
Census: 83
Deficiencies: 7
Dec 18, 2024
Visit Reason
The inspection was conducted as a renewal inspection of the assisted living facility to assess compliance with applicable standards and regulations.
Findings
The inspection identified multiple violations including incorrect licensee name on disclosure statements, failure to post the current on-site person in charge, lack of a written agreement with hospice program, absence of a current diet manual, incomplete emergency preparedness plan reviews, and insufficient emergency drinking water supply.
Deficiencies (7)
| Description |
|---|
| Facility failed to ensure that the statement disclosing information about the facility included the current name of the licensee. |
| Facility failed to develop and implement a procedure for posting the name of the current on-site person in charge in a conspicuous place. |
| Facility failed to ensure that a written agreement between the assisted living facility and hospice program was developed. |
| Facility failed to ensure a copy of a diet manual was kept current and readily available to personnel responsible for food preparation. |
| Facility failed to develop and implement an orientation and semi-annual review on the emergency preparedness and response plan for all staff, residents, and volunteers. |
| Facility failed to ensure that the emergency preparedness plan was reviewed annually or more often as needed, documented by signing and dating the plan, and making necessary revisions. |
| Facility failed to ensure the availability of a 96-hour supply of emergency drinking water; only at least 48 hours supply was on site. |
Report Facts
Number of residents present: 83
Number of resident records reviewed: 7
Number of staff records reviewed: 4
Number of resident interviews: 1
Number of staff interviews: 6
Inspection Report
Complaint Investigation
Census: 76
Deficiencies: 5
Oct 7, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-09-26 regarding allegations in the areas of Personnel, Resident Care and Related Services, and Complaint Investigation.
Findings
The investigation supported some, but not all, of the allegations. Violations were found related to orientation and training of private duty personnel, documentation of services provided by private duty personnel, tuberculosis screening, medication administration, and medication order completeness. A violation notice was issued and the licensee was given the opportunity to submit a plan of correction.
Complaint Details
The complaint was substantiated in part, with violations found in Personnel, Resident Care and Related Services, and Complaint Investigation areas.
Deficiencies (5)
| Description |
|---|
| Facility failed to ensure orientation and training were provided to private duty personnel regarding facility policies and procedures. |
| Facility failed to ensure documentation of type and frequency of services delivered by private duty personnel was obtained, reviewed, and communicated. |
| Facility failed to ensure tuberculosis risk assessments were completed within required timeframe for private duty personnel. |
| Facility failed to ensure medications were administered in accordance with physician's or prescriber's instructions, including missed doses of Sertraline HCI. |
| Facility failed to ensure PRN medication orders included symptoms indicating use, exact time frames for administration, and directions if symptoms persist. |
Report Facts
Residents present: 76
Resident records reviewed: 1
Staff records reviewed: 2
Missed medication doses: 9
Plan of correction monitoring timeframe: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nina Wilson | Licensing Inspector | Conducted the inspection and interviews. |
| Staff 1 | Interviewed regarding orientation trainings and private duty personnel records. | |
| Resident Care Director | Responsible for completing orientation, audits, and training related to cited violations. | |
| Executive Director | Responsible for oversight of audits and monitoring plans of correction. |
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 0
Apr 1, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-03-13 regarding allegations of a resident mattress soiled with urine and chuck pads.
Findings
The investigation did not support the allegations of non-compliance with standards or law. The licensing inspector completed a tour of the facility and reviewed investigation statements.
Complaint Details
Complaint received by VDSS Division of Licensing on 2024-03-13 regarding allegations of resident mattress soiled with urine and chuck pads. Evidence gathered did not support the allegations.
Report Facts
Number of residents present: 78
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: 0
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 1, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on January 26, 2024, regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation included a tour of the facility, review of one resident record, and interviews with one resident and three staff members. The evidence gathered did not support the allegation of non-compliance with standards or law.
Complaint Details
Complaint received on 2024-01-26 regarding Resident Care and Related Services; investigation did not substantiate the allegations.
Report Facts
Number of resident records reviewed: 1
Number of resident interviews conducted: 1
Number of staff interviews conducted: 3
Inspection Report
Renewal
Census: 77
Deficiencies: 1
Dec 18, 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 related to medication storage security, specifically that the medication cart was unlocked and unattended. A violation notice was issued and the facility was given the opportunity to submit a plan of correction.
Deficiencies (1)
| Description |
|---|
| The facility failed to ensure that the medication storage area remains locked; the medication cart was observed unlocked and unattended. |
Report Facts
Number of residents present: 77
Number of resident records reviewed: 10
Number of interviews with residents: 3
Number of interviews with staff: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marshall Massenberg | Licensing Inspector | Contact person for questions related to the inspection |
Inspection Report
Renewal
Census: 70
Deficiencies: 4
Dec 6, 2022
Visit Reason
The inspection was a renewal inspection conducted to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection identified multiple violations including failure to complete timely assessments for serious cognitive impairment, expired first aid certification for a staff member, unsigned individualized service plans by residents or their legal representatives, and improper medication storage in resident rooms.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure each resident is assessed by an independent clinical psychologist or physician for serious cognitive impairment before admission to the memory care unit. |
| Facility failed to ensure direct care staff maintain current certification in first aid; one staff member's certification had expired. |
| Individualized service plans were not signed and dated by the administrator or designee and by the resident or their legal representative for several residents. |
| Facility failed to limit medication storage to an out-of-sight place in resident rooms capable of self-administering medication; medication was observed on a shelf in a resident's room. |
Report Facts
Number of residents present: 70
Number of resident records reviewed: 10
Number of staff records reviewed: 5
Number of interviews conducted with residents: 3
Percentage of apartments spot checked for medication storage: 25
Timeframe for first aid certification completion: 60
Duration of audits and QAPI review: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marshall Massenberg | Licensing Inspector | Contact person for questions regarding the inspection |
Inspection Report
Complaint Investigation
Deficiencies: 1
Jul 22, 2022
Visit Reason
Unannounced complaint inspections were conducted on July 22, August 4, August 11, and August 23, 2022, in response to a complaint received on May 26, 2022, regarding Resident Care and Related Services at the facility.
Findings
The investigation found non-compliance with standards related to medication administration and documentation. Specifically, the facility failed to ensure that medical procedures or treatments ordered by a physician were provided and documented as required.
Complaint Details
The complaint investigation was substantiated as the evidence gathered supported the allegation of non-compliance with standards related to resident care and medication administration.
Deficiencies (1)
| Description |
|---|
| Failure to ensure that medical procedures or treatments ordered by a physician or other prescriber were provided according to instructions and documented, including lack of documentation for administration of Calmoseptine ointment and Ketoconazole shampoo to residents. |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marshall Massenberg | Licensing Inspector | Contact person for questions regarding the inspection and findings. |
| Nina Wilson | Inspector | Current inspector conducting the complaint-related inspections. |
Inspection Report
Monitoring
Deficiencies: 1
Jul 11, 2022
Visit Reason
Unannounced monitoring inspections were conducted on multiple dates in July and August 2022 to assess compliance with applicable standards and laws at the assisted living facility.
Findings
The inspection found non-compliance with standards related to resident dignity and respect, specifically involving an incident where a staff member yelled at a resident. The staff member was terminated and corrective actions including retraining and monitoring were implemented.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure that each resident is treated with courtesy, respect, and consideration as a person of worth, sensitivity, and dignity. |
Report Facts
Inspection dates: 4
Plan of correction monitoring period: 90
QAPI meeting duration: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff #1 | Care Manager | Named in the finding for yelling at a resident and subsequently terminated for failure to cooperate with investigation |
| Marshall Massenberg | Licensing Inspector | Contact person for the inspection |
| Nina Wilson | Current Inspector | Inspector listed on the report |
| Executive Director | Responsible for placing Staff #1 on administrative leave, conducting investigation, retraining staff, and overseeing plan of correction | |
| Resident Care Director | Responsible for evaluating residents for signs of abuse as part of the plan of correction |
Inspection Report
Complaint Investigation
Deficiencies: 1
Apr 26, 2022
Visit Reason
An unannounced complaint inspection was conducted due to allegations regarding the facility's response to resident needs.
Findings
The facility failed to ensure a prompt response by staff to resident call bells, with multiple instances where staff took at least 30 minutes or never responded. The allegations were substantiated based on documentation and call bell reports.
Complaint Details
The allegations were determined to be valid, as a preponderance of evidence supported the allegation.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure a prompt response by staff to resident needs as reasonable to the circumstances, with delayed or no response to call bells. |
Report Facts
Call bell uses for Resident #1: 50
Delayed or no response instances for Resident #1: 19
Call bell uses for Resident #2: 119
Delayed or no response instances for Resident #2: 64
Plan of correction audit period: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nina Wilson | Inspector | Current Inspector conducting the complaint inspection |
| Executive Director | Conducted in-services on call bell management as part of plan of correction | |
| Maintenance Coordinator | Responsible for testing call bell batteries and conducting random call bell audits |
Inspection Report
Complaint Investigation
Deficiencies: 2
Feb 23, 2022
Visit Reason
Unannounced inspections were conducted on February 23, 2022 and April 26, 2022 in response to complaints alleging non-compliance with resident care standards.
Findings
The facility was found to have valid violations related to failure to provide services preventing clinically avoidable complications and failure to administer medications according to physician orders. Plans of correction were required to address these deficiencies.
Complaint Details
The allegations were determined to be valid based on a preponderance of evidence. The complaint related to failure in wound care and medication administration was substantiated.
Deficiencies (2)
| Description |
|---|
| Failure to ensure services are provided to prevent clinically avoidable complications, specifically failure to document and provide frequent repositioning for Resident #2 with a stage 2 sacral wound. |
| Failure to ensure medications are administered in accordance with physician's instructions, including missed doses of Iron, Vitamin D, Losartan, and Oxycodone for Residents #1 and #2. |
Report Facts
Inspection dates: 2
Days for plan of correction submission: 10
Audit period: 90
Audit period: 90
Audit period: 3
Audit period: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nina Wilson | Inspector | Named as current inspector conducting the inspection |
| Resident Care Director | Responsible for retraining clinical team, conducting audits, and reporting findings related to wound care and medication administration | |
| Executive Director | Responsible for confirming implementation and ongoing compliance with the plan of correction |
Inspection Report
Renewal
Census: 80
Deficiencies: 4
Dec 2, 2021
Visit Reason
An unannounced renewal inspection was conducted to assess compliance with licensing standards and regulations for the assisted living facility.
Findings
The inspection identified multiple areas of non-compliance including failure to properly assess residents for serious cognitive impairment, medication administration errors, omission of Do Not Resuscitate (DNR) orders in individualized service plans, and unsecured storage of hazardous materials. Plans of correction were developed for each deficiency.
Deficiencies (4)
| Description |
|---|
| Failed to ensure each resident is assessed by an independent clinical psychologist or physician for serious cognitive impairment prior to admission to the safe, secure environment. |
| Failed to ensure medications are administered according to physician's orders and nursing standards. |
| Failed to ensure Do Not Resuscitate (DNR) orders are included in individualized service plans. |
| Failed to store cleaning supplies and hazardous materials in a locked area. |
Report Facts
Residents in care at time of inspection: 80
Sample size of resident records reviewed: 10
Sample size of staff records reviewed: 5
Medication dose discrepancy: 1
Plan of correction audit period: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nina Wilson | Inspector | Named as current inspector conducting the inspection |
| Resident Care Director | RCD | Responsible for implementing plans of correction and conducting audits and trainings |
| Maintenance Coordinator | MC | Responsible for securing hazardous materials and re-educating staff |
Inspection Report
Renewal
Census: 71
Deficiencies: 2
Dec 9, 2020
Visit Reason
A renewal inspection was initiated on 12/9/20 and completed on 12/18/20 to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection identified non-compliance with applicable standards, including failure to ensure annual tuberculosis risk assessments for staff and failure to administer medications according to physician instructions, resulting in documented violations.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure that each staff member annually submits results of a tuberculosis risk assessment documenting freedom from communicable tuberculosis. |
| Facility failed to ensure medications were administered in accordance with physician's instructions, with documented delays in medication delivery and administration. |
Report Facts
Census: 71
Dates of medication delays: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff #3 | Named in tuberculosis risk assessment deficiency; hired 1/5/18. | |
| Resident Care Director | Resident Care Director (RCD) | Conducted audits and training related to medication administration deficiencies. |
| Executive Director | Executive Director (ED) | Responsible for implementation and ongoing compliance with plan of correction. |
| Business Office Coordinator | Business Office Coordinator (BOC) | Responsible for audits and compliance tracking related to tuberculosis screening. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Aug 21, 2020
Visit Reason
A complaint inspection was initiated due to allegations regarding Administration and Administrative Services, Resident Care and Related Services at the facility.
Findings
The investigation found non-compliance with the facility's own COVID-19 Mitigation and Response Plan, specifically missing temperature screenings for multiple staff members during March and April 2020, supporting the complaint allegations.
Complaint Details
The complaint was substantiated as evidence supported non-compliance with standards or law related to COVID-19 screening procedures.
Deficiencies (1)
| Description |
|---|
| Failure to ensure compliance with the facility's own COVID-19 Mitigation and Response Plan, including missing temperature readings for multiple staff members on various dates. |
Report Facts
Missing temperature readings: 9
Documented fever temperature: 100.7
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