Deficiencies per Year
4
3
2
1
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Inspection Report
Renewal
Census: 94
Deficiencies: 1
Oct 7, 2025
Visit Reason
The inspection was conducted as a renewal inspection to assess compliance with applicable standards and regulations prior to license renewal.
Findings
The inspection found non-compliance related to the availability and proper storage of medications ordered for PRN (as needed) administration. 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 medications ordered for PRN (as needed) administration were available and properly stored. |
Report Facts
Number of residents present: 94
Number of resident records reviewed: 3
Number of staff records reviewed: 4
Number of interviews conducted with residents: 2
Number of interviews conducted with staff: 2
Plan of correction audit timeframe: 12
Medication order dates: PRN medication orders dated 02/03/2025 and 02/09/2025 for Resident 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Velasco | Licensing Inspector | Conducted the inspection and is the contact for questions |
| Staff 7 | Interviewed and confirmed PRN medications were not available | |
| Staff 8 | Interviewed and confirmed PRN medications were not available |
Inspection Report
Monitoring
Census: 95
Deficiencies: 0
Jun 10, 2025
Visit Reason
The inspection was conducted as a monitoring visit following a self-reported incident received by VDSS Division of Licensing on 2025-06-06 regarding allegations in Resident Care and Related Services and Staffing and Supervision.
Findings
The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law. No deficiencies were cited during the inspection.
Report Facts
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of interviews conducted with staff: 2
Number of interviews conducted with residents: 0
Inspection Report
Monitoring
Census: 95
Deficiencies: 3
Jun 10, 2025
Visit Reason
The inspection was conducted as a monitoring visit following a self-reported incident received by VDSS Division of Licensing on 05/27/2025 regarding allegations in the areas of Resident Care and Related Services and Staffing and Supervision.
Findings
The investigation supported the self-report of non-compliance with standards and violations were issued related to staffing levels during night hours, failure to follow facility policies regarding abuse reporting, and failure to ensure staff were considerate and respectful of residents' rights and dignity. The facility submitted plans of correction addressing these issues.
Deficiencies (3)
| Description |
|---|
| Failed to ensure that at least three direct care staff members were awake and on duty in each special care unit during night hours when 23 to 32 residents were present. |
| Failed to ensure compliance with the facility's own policies and procedures regarding abuse reporting. |
| Failed to ensure that all staff were considerate and respectful of the rights, dignity, and sensitivities of persons who are aged, infirm, or disabled. |
Report Facts
Number of residents present: 95
Number of resident records reviewed: 1
Number of staff records reviewed: 2
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 5
Residents in Safe, Secure Unit on night of 05/26/2025 into 05/27/2025: 27
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 2
May 16, 2025
Visit Reason
The inspection was conducted in response to a complaint received on 2025-04-04 regarding allegations in the areas of staffing and supervision, resident care and related services, and resident accommodations and related provisions.
Findings
The investigation did not substantiate the complaint allegations of non-compliance. However, violations unrelated to the complaint were identified, including failure to use the department's disclosure form and failure to follow the written staffing plan regarding nurse staffing.
Complaint Details
Complaint was related to staffing and supervision, resident care and related services, and resident accommodations and related provisions. The evidence gathered did not support the allegations of non-compliance with standards or law.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure the disclosure form was on the form developed by the department. |
| Facility failed to ensure the written staffing plan was followed, specifically nurse staffing was not provided as scheduled. |
Report Facts
Number of residents present: 90
Number of resident records reviewed: 5
Number of staff records reviewed: 0
Number of interviews conducted with residents: 3
Number of interviews conducted with staff: 3
Nurse staffing hours target: 8
Days with no nurse on site: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Velasco | Licensing Inspector | Conducted the inspection and investigation |
| Staff 1 | Acknowledged the disclosure form was not on the department form and that the nurse staffing plan was not followed | |
| Staff 2 | Provided the written staffing plan and schedules during the inspection |
Inspection Report
Renewal
Census: 82
Deficiencies: 2
Oct 21, 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 found non-compliance with regulations, including failure to keep all resident records in a locked area and failure to post the most recent inspection summary in a conspicuous place. Violation notices were issued with plans of correction provided by the facility.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure that all resident records are kept in a locked area. |
| Facility failed to ensure the most recent inspection summary and findings was posted in a place conspicuous to the public. |
Report Facts
Number of residents present: 82
Number of resident records reviewed: 6
Number of staff records reviewed: 4
Number of interviews with residents: 2
Number of interviews with staff: 2
Inspection Report
Deficiencies: 0
Sep 20, 2024
Visit Reason
The inspection was conducted as an investigation into a complaint; however, the investigation was suspended because the complainant submitted the wrong facility at the time of filing.
Findings
The evidence gathered during the inspection determined no violations with applicable standards or law.
Complaint Details
The complaint investigation was suspended because the complainant submitted the wrong facility. The resident involved in the complaint has never resided at the facility. The complaint was referred to the appropriate licensing inspector for further review.
Report Facts
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
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 4
Aug 12, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-08-07 regarding allegations in staffing and supervision, resident care and related services, and resident accommodations and related provisions.
Findings
The investigation supported some, but not all, allegations. Areas of non-compliance were found in resident accommodations and related provisions, and staffing and supervision. Multiple violations related to inadequate staffing, failure to provide care as specified in individualized service plans, lack of resident-centered care, and insufficient documentation of rounds were identified.
Complaint Details
The complaint was substantiated in part. Evidence supported non-compliance in staffing and supervision, and resident accommodations and related provisions. A violation notice was issued.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure adequate staffing in knowledge, skills, abilities, and numbers to maintain residents' physical, mental, and psychosocial well-being. |
| Facility failed to ensure care and services specified in individualized service plans were provided to each resident. |
| Facility failed to ensure care provision and service delivery was resident-centered and included resident participation and personalization. |
| Facility failed to specify minimum frequency of daily rounds for residents unable to use signaling devices and failed to document rounds made. |
Report Facts
Number of residents present: 73
Number of resident records reviewed: 7
Number of staff records reviewed: 4
Number of resident interviews conducted: 6
Number of staff interviews conducted: 4
Response time to resident call button: 5.47
Scheduled assistance to bathroom: 7
One-person assist provided: 19
Support provided out of scheduled times: 2
Support provided out of scheduled times: 3
Support provided out of scheduled times: 1
Support provided out of scheduled times: 2
Support provided out of scheduled times: 3
Inspection Report
Renewal
Census: 49
Deficiencies: 2
Oct 6, 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 related to medication storage and administration, resulting in documented violations. The facility was given the opportunity to submit a plan of correction to address these violations.
Deficiencies (2)
| Description |
|---|
| The facility failed to limit medication storage to an out-of-sight place in the rooms of residents whose assessments indicated they are not capable of self-administering their medication. |
| The facility failed to ensure that medications are administered in accordance with the physician's or prescriber's instructions, specifically insulin was administered after meals instead of before as ordered. |
Report Facts
Number of residents present: 49
Number of resident records reviewed: 8
Number of resident interviews: 4
Number of staff interviews: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marshall Massenberg | Licensing Inspector | Contact person for questions related to the inspection |
| Amanda Velasco | Licensing Inspector | Inspector who conducted the inspection |
| Reminiscence Coordinator | Named in plan of correction for medication storage and education | |
| Resident Care Director | Named in plan of correction for medication administration and staff education |
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 0
Oct 6, 2023
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 10/6/23 regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation did not support the allegation of non-compliance with standards or law. An exit meeting was conducted to review the inspection findings.
Complaint Details
A complaint was received regarding Resident Care and Related Services. The evidence gathered did not substantiate the allegation of non-compliance.
Report Facts
Number of resident records reviewed: 1
Inspection Report
Original Licensing
Deficiencies: 0
Apr 19, 2023
Visit Reason
The Licensing Inspector conducted an announced initial inspection of the assisted living facility to verify compliance with regulations, including physical plant review, policy and procedure checks, staff background checks, and testing of the call bell system.
Findings
No violations were cited during the inspection. The Building, Fire, and Health Inspections were submitted and reviewed, and an exit interview was held.
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