Deficiencies per Year
8
6
4
2
0
Unclassified
Census Over Time
Inspection Report
Monitoring
Census: 47
Deficiencies: 5
May 28, 2025
Visit Reason
The inspection was a monitoring visit conducted on May 28 and June 3, 2025, to assess compliance with applicable standards and laws at the assisted living facility.
Findings
The inspection found multiple violations including failure to ensure annual tuberculosis risk assessments for staff, expired first aid certification for a direct care staff member, missing signed resident orientation acknowledgments, medication administration errors, and incomplete criminal background checks for terminated staff.
Deficiencies (5)
| Description |
|---|
| Facility did not ensure that each staff member annually submits tuberculosis risk assessment results. |
| Facility did not ensure that each direct care staff member maintains current certification in first aid. |
| Facility did not ensure that each resident record contained a signed acknowledgment of the resident's orientation to the facility. |
| Facility did not ensure that medications were administered in accordance with the physician's instructions. |
| Facility did not ensure that the criminal background check for terminated staff members remains in the facility files for a year after termination. |
Report Facts
Number of residents present: 47
Number of resident records reviewed: 4
Number of resident interviews conducted: 3
Number of staff interviews conducted: 4
Inspection Report
Monitoring
Census: 48
Deficiencies: 0
Apr 17, 2024
Visit Reason
The inspection was a monitoring inspection conducted to review various areas including administration, personnel, resident care, building and grounds, emergency preparedness, and additional requirements for facilities caring for adults with cognitive impairments.
Findings
The inspection found no violations of applicable standards or laws. Observations included residents participating in activities and a medication administration pass. The inspection summary will be posted publicly.
Report Facts
Number of resident records reviewed: 4
Number of staff records reviewed: 4
Number of interviews conducted with residents: 2
Number of interviews conducted with staff: 4
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 5, 2024
Visit Reason
The inspection was conducted as a complaint investigation to review admission, retention and discharge of residents, and resident care and related services.
Findings
The complaint was investigated and determined to be not valid.
Complaint Details
Complaint was determined not valid.
Inspection Report
Monitoring
Census: 50
Deficiencies: 0
Jul 13, 2023
Visit Reason
The inspection was a monitoring visit conducted on July 13, 2023, to review resident care and related services following multiple self-reported incidents received by VDSS Division of Licensing between March and June 2023.
Findings
The investigation did not support the self-reported non-compliance with standards or law. The inspection findings will be posted publicly and an exit meeting will be conducted to review the results.
Report Facts
Resident records reviewed: 6
Staff records reviewed: 0
Resident interviews conducted: 1
Staff interviews conducted: 1
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 0
Dec 7, 2022
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 11/28/2022 and 11/30/2022 regarding allegations in the areas of resident care, staffing quantity, and admission, retention, and discharge of residents.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The licensing inspector completed a tour of the facility, reviewed records, and conducted interviews without identifying deficiencies.
Complaint Details
Complaint related to allegations in resident care, staffing quantity, and admission, retention, and discharge of residents; allegations were not substantiated.
Report Facts
Number of residents present: 41
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of interviews conducted with residents: 4
Number of interviews conducted with staff: 1
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 0
Dec 7, 2022
Visit Reason
The inspection was conducted in response to complaints received by VDSS Division of Licensing on 11/28/2022 and 11/30/2022 regarding allegations in the areas of resident care, staffing quantity, and admission, retention, and discharge of residents.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The licensing inspector completed a tour of the facility and conducted interviews with residents and staff.
Complaint Details
Complaint related to allegations in resident care, staffing quantity, and admission, retention, and discharge of residents; investigation found no substantiated non-compliance.
Report Facts
Number of residents present: 41
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of interviews conducted with residents: 4
Number of interviews conducted with staff: 1
Inspection Report
Renewal
Census: 42
Deficiencies: 0
Nov 17, 2022
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 found no violations with applicable standards or laws. The licensing inspector observed medication administration, resident activities, and meal times without issue.
Report Facts
Resident records reviewed: 10
Staff records reviewed: 4
Resident interviews conducted: 1
Staff interviews conducted: 0
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 8, 2021
Visit Reason
Unannounced complaint investigation regarding resident care conducted from December 8, 2021 to December 14, 2021.
Findings
The complaint regarding resident care was deemed not valid as the preponderance of evidence gathered during the investigation did not support the allegations.
Complaint Details
Complaint related to resident care; investigation concluded complaint was not substantiated.
Inspection Report
Routine
Deficiencies: 0
Dec 8, 2021
Visit Reason
The inspection was an unannounced routine inspection conducted in response to a self-reported incident at the facility.
Findings
The Licensing Inspector reviewed resident records and conducted an interview with administration. No violations were cited during the inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 2, 2021
Visit Reason
Unannounced complaint investigation regarding buildings and grounds, including allegations about resident medication and staff qualifications.
Findings
The complaint regarding resident medication and staff qualifications was deemed not valid as the preponderance of evidence did not support the allegations. The inspection included interviews, physical plant walk-through, and review of repair work orders.
Complaint Details
Complaint related to buildings and grounds, resident medication, and staff qualifications; complaint regarding medication and staff qualifications was not substantiated.
Inspection Report
Monitoring
Deficiencies: 2
Dec 2, 2021
Visit Reason
Unannounced focused monitoring visit conducted to ensure correction of violations cited during the 10/26/2021 renewal study.
Findings
All previous violations were found to have been corrected; however, new violations related to medication orders and physician's verbal orders were cited and reviewed with the administrator.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure that no medication, dietary supplement, diet, medical procedure, or treatment shall be started, changed, or discontinued without a valid order from a physician or other prescriber. |
| Facility failed to ensure that physician's or other prescriber's oral orders are reviewed and signed by a physician or other prescriber within 14 days. |
Inspection Report
Renewal
Census: 48
Deficiencies: 1
Oct 25, 2021
Visit Reason
A renewal inspection was initiated to review compliance with applicable standards and laws for license renewal of the assisted living facility.
Findings
The inspection identified non-compliance with medication administration standards, specifically failure to administer medications according to physician orders, resulting in documented violations.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure medications were administered in accordance with physician's instructions and standards of practice. |
Report Facts
Inspection dates: 2
Medication administration timing deviation: 20
Medication administration timing deviation: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident Care Director | Resident Care Director (RCD) | Conducted refresher training and audits related to medication administration deficiencies |
| Executive Director | Executive Director (ED) | Responsible for implementation and ongoing compliance with Plan of Correction |
Inspection Report
Monitoring
Census: 49
Deficiencies: 1
Aug 31, 2021
Visit Reason
A monitoring inspection was initiated to review compliance with applicable standards and laws, including a remote documentation review and an on-site inspection.
Findings
The inspection found non-compliance with medication administration timing standards, specifically a late administration of medications to a resident, resulting in documented violations.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure medications were administered within one hour before or after the scheduled dosing time, except for drugs ordered for specific times. |
Report Facts
Medication administration delay: 144
Census: 49
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marshall Massenberg | Inspector | Named as current inspector conducting the inspection. |
| Resident Care Director | Responsible for conducting refresher training and monitoring medication administration compliance. | |
| Staff #4 | Interviewed staff who confirmed the late medication administration. |
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
The inspector reviewed policies and procedures, and confirmed that Fire, Health, and Elevator Inspections had been completed. No violations were cited during the inspection.
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