Inspection Report Summary
The most recent inspection on November 12, 2025, found no deficiencies following a complaint investigation related to buildings and grounds. Earlier inspections showed mixed results, including a substantiated complaint in October 2024 where the facility failed to assume general responsibility for a resident’s health and safety, specifically not performing CPR on an unresponsive resident. Prior deficiencies also involved administrative issues such as using an outdated disclosure form and incomplete emergency preparedness planning. Complaint investigations were mostly unsubstantiated except for the October 2024 case, and no fines or enforcement actions were listed in the available reports. The facility’s inspection history shows some areas needing attention but also evidence of corrective actions and no recent deficiencies.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
1.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
86% better than Virginia average
Virginia average: 9.1 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
72 residents
Based on a November 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 0
Date: Nov 12, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-10-30 regarding allegations in the areas of Buildings and Ground and Complaint Investigation.
Complaint Details
Complaint related inspection with allegations in Buildings and Ground and Complaint Investigation; evidence gathered did not support the allegations of non-compliance.
Findings
The licensing inspector toured the physical plant including the building and grounds and observed residents engaged in activities. The investigation did not support the allegations of non-compliance with standards or law.
Report Facts
Number of residents present: 72
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: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nina Wilson | Licensing Inspector | Inspector who conducted the complaint investigation |
Inspection Report
Renewal
Census: 74
Deficiencies: 3
Date: Feb 19, 2025
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 found non-compliance with several standards including failure to update the Assisted Living Facility Disclosure Statement, and failure to develop, implement, and review the emergency preparedness and response plan as required. Violations were documented and a plan of correction was submitted by the facility.
Deficiencies (3)
Facility failed to prepare a statement on a form developed by the Department of Social Services, using an outdated form.
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 review the emergency preparedness plan annually by signing and dating the plan.
Report Facts
Number of residents present: 74
Number of resident records reviewed: 8
Number of staff records reviewed: 3
Number of interviews with residents: 1
Number of interviews with staff: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nina Wilson | Licensing Inspector | Conducted the inspection and interviews |
| Executive Director | Named in plan of correction for updating disclosure statement and emergency preparedness plan | |
| Area Facility's Manager | Named in plan of correction for providing inservice for Maintenance Coordinator |
Inspection Report
Complaint Investigation
Census: 79
Deficiencies: 1
Date: Oct 21, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 08/21/2024 regarding allegations in the areas of Resident Care and Related Services.
Complaint Details
The complaint was substantiated. Evidence showed Resident #1 was found unresponsive with no pulse or blood pressure on 08/19/2024 and was pronounced deceased. Staff acknowledged CPR was not performed.
Findings
The investigation supported the self-report of non-compliance with standards or law, resulting in violations issued. Specifically, the facility failed to assume general responsibility for the health, safety, and well-being of residents, as evidenced by a resident found unresponsive and deceased without CPR being performed.
Deficiencies (1)
Facility failed to assume general responsibility for the health, safety, and well-being of the residents.
Report Facts
Number of residents present: 79
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: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nina Wilson | Licensing Inspector | Conducted the inspection and is the contact for questions |
| Staff #1 | Acknowledged Resident #1 was found unresponsive and CPR was not performed | |
| Community's Executive Director | Executive Director | Conducted investigation and training following the event |
| Resident Care Director | Resident Care Director | Participated in in-service training following the event |
| Assisted Living Coordinator | Assisted Living Coordinator | Participated in in-service training following the event |
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 0
Date: Aug 16, 2024
Visit Reason
The inspection was conducted as a complaint-related investigation to review allegations of non-compliance with standards or law at the assisted living facility.
Complaint Details
The inspection was complaint-related, but the allegations were not substantiated based on the evidence gathered during the investigation.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance. The inspection findings will be posted publicly and a copy is required to be posted at the facility.
Report Facts
Number of residents present: 98
Number of resident records reviewed: 1
Number of staff interviews conducted: 2
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 0
Date: Aug 16, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to resident care and related services at the facility.
Complaint Details
The inspection was complaint-related, but the allegations were not substantiated based on the evidence gathered.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. An exit meeting was planned to review the inspection findings.
Report Facts
Number of resident records reviewed: 1
Number of staff interviews conducted: 1
Inspection Report
Renewal
Census: 74
Deficiencies: 0
Date: Feb 14, 2024
Visit Reason
The inspection was conducted as a renewal inspection to review the facility's compliance with licensing requirements and regulations.
Findings
The Licensing Inspector reviewed multiple areas including administration, staffing, resident care, emergency preparedness, and medication administration. Observations included residents participating in activities and eating lunch, and review of various facility reports such as health inspection and fire marshal reports.
Report Facts
Records reviewed: 5
Interviews conducted: 6
Inspection Report
Monitoring
Census: 71
Deficiencies: 0
Date: Dec 4, 2023
Visit Reason
The inspection was a monitoring visit to review various areas including administration, personnel, resident care, and emergency preparedness at the assisted living facility.
Findings
The Licensing Inspector reviewed six records and conducted four interviews, observed residents during lunch and activities, and reviewed all facility self-reported incidents since the last inspection.
Report Facts
Records reviewed: 6
Interviews conducted: 4
Inspection Report
Original Licensing
Census: 68
Deficiencies: 0
Date: Sep 11, 2023
Visit Reason
The licensing inspector conducted an unannounced initial inspection of the assisted living facility on September 11, 2023.
Findings
The inspector reviewed administration, personnel, resident care, building and grounds, emergency preparedness, and other regulatory areas. Observations included residents eating lunch and engaging in independent activities. Four records and two interviews were reviewed and conducted.
Report Facts
Records reviewed: 4
Interviews conducted: 2
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