Deficiencies per Year
4
3
2
1
0
Unclassified
Census Over Time
Inspection Report
Monitoring
Census: 71
Deficiencies: 0
Nov 25, 2024
Visit Reason
The inspection was conducted as a monitoring visit following a self-report received by VDSS Division of Licensing regarding allegations in the area(s) of resident health and medication(s).
Findings
The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law. The licensing inspector completed a tour of the physical plant and reviewed resident and staff records without identifying deficiencies.
Report Facts
Number of resident records reviewed: 1
Number of staff records reviewed: 2
Number of interviews conducted with staff: 2
Number of interviews conducted with residents: 0
Inspection Report
Renewal
Census: 75
Deficiencies: 3
Sep 19, 2024
Visit Reason
The inspection was conducted as a renewal visit to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection identified multiple violations related to healthcare oversight documentation, medication storage, and emergency preparedness review. The facility was found non-compliant with certain standards and was issued a violation notice with an opportunity to submit a plan of correction.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure that the specific residents for whom the health care oversight was provided were identified. |
| Facility failed to ensure that a medicine cabinet, container, or compartment was used for secure storage of medications and dietary supplements. |
| Facility failed to ensure semi-annual review on the emergency preparedness and response plan for all staff and residents was documented by signing and dating. |
Report Facts
Number of resident records reviewed: 4
Number of staff records reviewed: 3
Number of interviews conducted with residents: 2
Number of interviews conducted with staff: 3
Inspection duration hours: 6.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alexandra Roberts | Licensing Inspector | Inspector conducting the inspection |
| Staff 4 | Interviewed staff confirming missing resident identification in healthcare oversight and emergency preparedness documentation | |
| Staff 2 | Staff observed administering medications during medication storage violation | |
| Resident Care Director | Responsible for implementing plan of correction and conducting audits | |
| Executive Director | Responsible for implementation and ongoing compliance with plan of correction | |
| Maintenance Coordinator | Responsible for ensuring signatures on emergency preparedness drill forms |
Inspection Report
Renewal
Census: 67
Deficiencies: 2
Dec 7, 2023
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 found non-compliance with applicable standards or laws, resulting in documented violations. The facility was given the opportunity to submit a plan of correction to address the cited violations and maintain future compliance.
Deficiencies (2)
| Description |
|---|
| The facility failed to ensure that the individualized service plan (ISP) is reviewed and updated at least once every 12 months and as needed for a significant change of a resident's condition. |
| The facility failed to ensure that all information is documented on the Medication Administration Record (MAR). |
Report Facts
Number of residents present: 67
Number of resident records reviewed: 10
Number of interviews with residents: 4
Number of interviews with staff: 2
Inspection Report
Monitoring
Census: 67
Deficiencies: 1
Jun 15, 2023
Visit Reason
An unannounced monitoring inspection was conducted to review meals, medication administration, activities, building and grounds, and records.
Findings
The inspection found non-compliance with medication administration standards, specifically that medications were not administered according to physician instructions and approved standards. A violation was documented related to crushing a medication that should not have been crushed.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure medications were administered in accordance with physician's instructions and standards; specifically, Protonix medication was crushed and administered despite package instructions stating it should not be crushed. |
Report Facts
Residents in care: 67
Resident records reviewed: 10
Staff records reviewed: 5
Plan of correction review period: 3
Inspection Report
Follow-Up
Deficiencies: 2
Feb 27, 2023
Visit Reason
An unannounced focused-monitoring inspection was conducted to follow-up on high-risk violations cited on 12/2/22, specifically reviewing medication administration, resident records, and building and grounds.
Findings
The inspection found non-compliance with applicable standards related to medication orders lacking strength details and improper administration timing of Synthroid medication. Plans of correction were submitted to address these issues.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure that physician or other prescriber orders include the strength of each medication and supplement. |
| Facility failed to ensure medications are administered according to prescriber instructions; Synthroid was not given on an empty stomach as required. |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marshall Massenberg | Licensing Inspector | Contact person for questions regarding the inspection. |
| Alexandra Roberts | Inspector | Current inspector conducting the inspection. |
Inspection Report
Monitoring
Deficiencies: 2
Dec 2, 2022
Visit Reason
The inspection was a monitoring visit to assess compliance with applicable standards and laws at the assisted living facility.
Findings
The inspection found violations including the facility locking doors leading outside in a manner not permitted by fire codes, and failure to administer medications as prescribed according to medication administration records.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure that doors leading to the outside are not locked or secured from the inside in a manner that amounts to a lock, violating fire safety codes. |
| Facility failed to ensure medications were administered according to physician's orders; Resident #1's Eliquis was not administered on multiple dates as documented in the medication administration record. |
Report Facts
Dates medication not administered: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alexandra Roberts | Licensing Inspector | Conducted the inspection |
| Marshall Massenberg | Licensing Inspector | Contact person for questions about the inspection |
| Executive Director | Responsible for addressing door security issues and plan of correction implementation | |
| Resident Care Director | Conducted medication audits and training related to medication administration deficiencies |
Inspection Report
Renewal
Census: 73
Deficiencies: 2
Jun 27, 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 found non-compliance with medication administration standards, including failure to administer medications according to physician orders and failure to ensure PRN medications were available and properly stored.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure that medications are administered in accordance with the physician's or other prescriber's instructions and consistent with standards of practice. |
| Facility failed to ensure that medications ordered for PRN administration are available and properly stored at the facility. |
Report Facts
Number of residents present: 73
Number of resident records reviewed: 10
Number of staff records reviewed: 5
Number of interviews conducted with residents: 3
Inspection Report
Complaint Investigation
Deficiencies: 1
Aug 10, 2021
Visit Reason
A non-mandated complaint inspection was initiated due to allegations regarding Admission, Retention, and Discharge of Residents, Resident Care and Related Services, and Building and Grounds.
Findings
The investigation supported the allegation of non-compliance with standards or law, resulting in violations issued. Specifically, the facility failed to document an analysis of the circumstances of falls and interventions to prevent or reduce risk of subsequent falls for Resident #1.
Complaint Details
The complaint was substantiated as the evidence supported non-compliance with standards or law related to fall documentation and intervention.
Deficiencies (1)
| Description |
|---|
| Facility failed to document an analysis of the circumstances of falls and interventions initiated to prevent or reduce risk of subsequent falls. |
Report Facts
Fall incidents: 6
Plan of Correction monitoring period: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alexandra Roberts | Inspector | Conducted the on-site complaint investigation. |
| Executive Director | Provided education to staff and responsible for Plan of Correction implementation and monitoring. |
Inspection Report
Routine
Census: 72
Deficiencies: 3
Nov 13, 2020
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 11/13/2020 and concluded on 11/19/2020 to review compliance with applicable standards and laws.
Findings
The inspection identified non-compliance with standards related to admission assessments for residents in a safe, secure environment, approval for placement in the Special Care Unit, and completion of sworn statements for employment applicants. Violations were documented and plans of correction were implemented.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure that prior to admission to a safe, secure environment, the resident was assessed by an independent clinical psychologist or physician for serious cognitive impairment as required. |
| Facility failed to obtain written approval from each individual higher on the list of priority for placement in the Special Care Unit or provide explanation for lack of such approval. |
| Facility failed to ensure that sworn statements or affirmations were completed for all applicants for employment; one staff record lacked a sworn statement at time of hire. |
Report Facts
Resident records reviewed: 4
Staff records reviewed: 4
Current census: 72
Staff records missing sworn statement: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alexandra Roberts | Inspector | Named as current inspector conducting the inspection |
| Resident Care Director | Responsible for contacting physician and conducting audits related to assessments and approvals | |
| Executive Director | Administrator | Responsible for reviewing move-in documents and overseeing plan of correction implementation |
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