Deficiencies per Year
8
6
4
2
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Inspection Report
Monitoring
Census: 48
Deficiencies: 0
Aug 15, 2025
Visit Reason
The inspection was a monitoring visit following a self-reported incident received by VDSS Division of Licensing regarding allegations in the areas of Admission, Retention and Discharge of Residents and 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 licensing inspector observed residents dining and participating in activities, and no deficiencies were noted.
Report Facts
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
Inspection Report
Renewal
Census: 49
Deficiencies: 1
Jul 17, 2025
Visit Reason
The inspection was conducted as a renewal inspection to assess compliance with applicable standards and regulations for the assisted living facility.
Findings
The inspection found non-compliance with the standard requiring semi-annual review of resident emergency plans with all staff. Documentation of these reviews was not provided, indicating a violation.
Deficiencies (1)
| Description |
|---|
| Facility failed to review resident emergencies at least every six months with all staff and did not provide documentation of such reviews. |
Report Facts
Number of residents present: 49
Number of resident records reviewed: 5
Number of staff records reviewed: 3
Number of resident interviews: 1
Number of staff interviews: 1
Time in: 1041
Time out: 1621
Inspection Report
Renewal
Census: 42
Deficiencies: 8
Aug 5, 2024
Visit Reason
The inspection was conducted as a renewal of the facility's license to ensure compliance with applicable standards and laws.
Findings
The inspection identified multiple violations including failure to properly orient volunteers, failure to post weekly menus, unsecured medication carts, improperly labeled over-the-counter medications, lack of written responses to resident council concerns, incomplete emergency preparedness reviews, inadequate documentation of fire and emergency evacuation drills, and insufficient emergency food and water supplies.
Deficiencies (8)
| Description |
|---|
| Volunteers did not complete required orientation or criminal background checks. |
| Menus for meals and snacks were not dated and posted in a conspicuous area. |
| Medication cart was left unlocked during medication pass. |
| Over-the-counter medication was not labeled with the resident's name. |
| Facility failed to provide written responses to resident council recommendations prior to meetings. |
| Emergency preparedness plan was not reviewed and documented by all staff. |
| Fire and emergency evacuation drills were not properly documented for required details. |
| Facility did not maintain a 96-hour supply of non-expired emergency water. |
Report Facts
Number of residents present: 42
Number of resident records reviewed: 6
Number of staff records reviewed: 3
Number of interviews with residents: 1
Number of interviews with staff: 3
Number of staff members on emergency preparedness review list: 46
Number of staff who reviewed emergency preparedness plan: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nina Wilson | Licensing Inspector | Conducted the inspection. |
| Staff 3 | Observed leaving medication cart unlocked during medication pass. | |
| Staff 4 | Dining Service Coordinator | Interviewed regarding menu posting and emergency water supply. |
| Staff 5 | Interviewed regarding volunteer recruitment and orientation. | |
| Staff 6 | Interviewed regarding emergency preparedness plan review. | |
| Executive Director | Responsible for education and corrective actions related to multiple deficiencies. |
Inspection Report
Renewal
Census: 36
Deficiencies: 3
Sep 6, 2023
Visit Reason
The inspection was conducted as a renewal inspection to assess compliance with applicable standards and laws for continued licensure of the assisted living facility.
Findings
The inspection identified non-compliance with several standards including failure to complete a six-month review of continued appropriateness for a resident, improper medication administration inconsistent with physician orders, and unauthorized use of a space heater in a resident's room.
Deficiencies (3)
| Description |
|---|
| Failure to ensure that a review of continued appropriateness is completed six months after a resident is placed in the safe, secure environment. |
| Failure to ensure medications are administered in accordance with physician's instructions and standards of practice. |
| Failure to ensure space heaters are only used to supplement or provide heat in the event of a power failure or similar emergency. |
Report Facts
Number of residents present: 36
Number of resident records reviewed: 6
Number of resident interviews: 4
Number of staff interviews: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nina Wilson | Licensing Inspector | Inspector conducting the renewal inspection |
| Resident Care Director | Provided training and conducted audits related to medication administration and review of resident appropriateness | |
| Executive Director | Responsible for review of continued appropriateness and implementation of plans of correction | |
| Medication Care Manager | Received training on medication administration parameters |
Inspection Report
Monitoring
Deficiencies: 2
Oct 31, 2022
Visit Reason
The inspection was a monitoring visit conducted to review compliance with resident care and medication administration standards at the assisted living facility.
Findings
The facility was found to have two violations: one related to securing the main entrance door in a manner that restricted resident freedom of movement, and another related to medication administration errors including missed doses and lack of proper medication availability.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure that doors leading to the outside were not locked or secured from the inside in a manner amounting to a lock, restricting resident freedom of movement. |
| Facility failed to ensure medications were administered according to physician orders and standards, including missed doses and unavailable medications. |
Report Facts
Missed doses of Famotidine: 22
Missed dose date: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nina Wilson | Inspector | Named as the current inspector conducting the inspection. |
| Marshall Massenberg | Licensing Inspector | Contact person for questions related to the inspection. |
| Resident Care Director | Responsible for implementing the plan of correction related to medication administration. | |
| Executive Director | Responsible for reviewing state code and ensuring compliance with door security and medication administration plans. | |
| Maintenance Coordinator | Involved in reviewing and implementing front door security changes. |
Inspection Report
Renewal
Census: 41
Deficiencies: 3
Aug 17, 2022
Visit Reason
The inspection was conducted as a renewal of the facility's license, including a tour of the physical plant, review of resident and staff records, and interviews with residents.
Findings
The inspection found non-compliance with applicable standards and laws, resulting in documented violations related to staff certification, medication administration, and criminal background checks. The facility was given the opportunity to submit a plan of correction to address these violations.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure direct care staff maintain current certification in first aid within 60 days of employment. |
| Facility failed to ensure medications are administered according to physician's instructions and standards of practice. |
| Facility failed to ensure a criminal history record report is obtained on or prior to the 30th day of employment for each employee. |
Report Facts
Number of residents present: 41
Number of resident records reviewed: 8
Number of staff records reviewed: 4
Number of interviews conducted with residents: 4
Staff #2 hire date: Jun 17, 2022
Staff #5 hire date: Aug 27, 2021
Inspection Report
Renewal
Census: 41
Deficiencies: 0
Aug 4, 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 no violations with applicable standards or law; no violations were issued.
Inspection Report
Monitoring
Census: 37
Deficiencies: 1
May 13, 2021
Visit Reason
A monitoring inspection was initiated to review compliance with applicable standards and laws during a state of emergency health pandemic, conducted remotely due to the pandemic.
Findings
The inspection found non-compliance related to medication administration, specifically that medications were not administered according to physician orders, including missed doses and administration timing errors.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure medications were administered in accordance with physician's orders and standards, including missed Baclofen dose and improper timing of Lasix administration. |
Report Facts
Census: 37
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nina Wilson | Inspector | Current Inspector conducting the inspection |
| Resident Care Director | Conducted eMAR to medication cart audit and responsible for Plan of Correction implementation | |
| Resident Care Coordinator | Conducted refresher training with medication care managers and nurse | |
| Executive Director | Responsible for reviewing Plan of Correction and audit results during QAPI meetings |
Inspection Report
Routine
Census: 36
Deficiencies: 0
Mar 10, 2021
Visit Reason
The inspection was conducted using an alternate remote protocol due to a state of emergency health pandemic declared by the Governor of Virginia. The visit was a routine licensing inspection initiated on March 10, 2021 and concluded on March 12, 2021.
Findings
The inspection found no violations with applicable standards or law. No deficiencies were issued during the inspection.
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