Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 0
Aug 18, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-08-06 regarding allegations of physical abuse at the facility.
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 physical plant and conducted staff interviews without identifying any substantiated violations.
Complaint Details
Complaint related to allegations of physical abuse received on 2025-08-06; investigation findings did not substantiate the complaint.
Report Facts
Resident records reviewed: 1
Staff records reviewed: 1
Staff interviews conducted: 2
Resident interviews conducted: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alexandra Roberts | Licensing Inspector | Conducted the inspection and investigation |
Inspection Report
Renewal
Census: 72
Deficiencies: 2
Jul 8, 2025
Visit Reason
The inspection was conducted as a renewal inspection to assess compliance with applicable regulations and licensing requirements for the assisted living facility.
Findings
The inspection identified non-compliance with applicable standards, including failure to use the current disclosure statement form and failure to post a listing of staff with current CPR/First Aid certifications. Violation notices were issued and the facility was given the opportunity to submit a plan of correction.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure that the disclosure statement is on the current form developed by the department. |
| Facility failed to ensure that a listing of all staff who have current certification in first aid or CPR is posted and readily available to all staff at all times. |
Report Facts
Number of residents present: 72
Number of resident records reviewed: 3
Number of staff records reviewed: 2
Number of interviews conducted with residents: 2
Number of interviews conducted with staff: 4
Inspection Report
Monitoring
Census: 56
Deficiencies: 2
Mar 25, 2025
Visit Reason
The inspection was a monitoring visit triggered by a self-reported incident received by VDSS Division of Licensing on 2025-03-22 regarding allegations in the area of Resident Supervision.
Findings
The investigation supported the self-report of non-compliance with standards, resulting in violations related to failure to properly document private duty personnel services and failure to provide adequate supervision of a resident who eloped from the facility. The facility submitted a plan of correction addressing these issues.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure written information on the type and frequency of services by private duty personnel was obtained and orientation/training was provided. |
| Facility failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs such as wandering from the premises. |
Report Facts
Number of residents present: 56
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of resident interviews: 1
Number of staff interviews: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alexandra Roberts | Licensing Inspector | Inspector conducting the monitoring visit and named in contact information |
| Staff 1 | Confirmed lack of documentation for private duty personnel and confirmed resident elopement | |
| Executive Director | Responsible for reviewing plan of correction and conducting audits related to signing in/out procedures |
Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 3
Sep 23, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-09-13 regarding allegations of physical abuse in resident care.
Findings
The investigation supported some but not all allegations, identifying non-compliance related to resident documentation and incident reporting. Several violations were cited including failure to report a major incident within 24 hours, failure to ensure individualized service plans were properly signed, and failure to specify frequency of daily rounds for residents unable to use signaling devices.
Complaint Details
The complaint was related to allegations of physical abuse in resident care. The evidence supported some of the allegations involving resident documentation and incident reporting.
Deficiencies (3)
| Description |
|---|
| Facility failed to report to the regional licensing office within 24 hours any major incident that negatively affected or threatened the life, health, safety, or welfare of a resident. |
| Facility failed to ensure that individualized service plans were signed and dated by the licensee, administrator, or designee, and by the resident or legal representative. |
| Facility failed to ensure that individualized service plans for residents unable to use signaling devices included a specified minimal frequency of daily rounds by direct care staff. |
Report Facts
Number of residents present: 75
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alexandra Roberts | Licensing Inspector | Conducted the inspection and is the contact for questions |
| Staff 1 | Interviewed and confirmed failures related to incident reporting and individualized service plans |
Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 0
Sep 23, 2024
Visit Reason
The inspection was conducted in response to a complaint received by the VDSS Division of Licensing on 2024-09-13 regarding allegations in the area of Resident Care.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. No deficiencies were cited.
Complaint Details
Complaint investigation related to allegations in Resident Care; the complaint was not substantiated.
Report Facts
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 2
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 0
Jun 5, 2024
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with applicable standards and laws at the assisted living facility.
Findings
The inspection found no violations with applicable standards or laws based on observations, record reviews, and interviews conducted during the visit.
Complaint Details
The visit was complaint-related; however, the evidence gathered determined no violations and no deficiencies were cited.
Report Facts
Number of resident records reviewed: 5
Number of staff records reviewed: 5
Number of interviews conducted with residents: 2
Number of interviews conducted with staff: 1
Inspection Report
Renewal
Census: 69
Deficiencies: 5
Jun 3, 2024
Visit Reason
The inspection was a renewal inspection conducted from June 3 to June 5, 2024, to assess compliance with applicable standards and laws for licensing renewal of the assisted living facility.
Findings
The inspection identified multiple violations related to failure to review resident rights annually, incomplete emergency preparedness training and documentation, and deficiencies in first aid kit completeness and monthly checks. Plans of correction were submitted to address these issues.
Deficiencies (5)
| Description |
|---|
| Facility failed to ensure that Resident Rights are reviewed annually with each resident or legal representative. |
| Facility failed to implement orientation and semi-annual review on emergency preparedness and response plan for all staff, residents, and volunteers. |
| Facility failed to review the emergency preparedness plan annually or more often as needed, document the review, and make necessary revisions. |
| Facility failed to ensure a complete first aid kit is on hand. |
| Facility failed to ensure first aid kits are checked at least monthly to ensure all items are present. |
Report Facts
Number of residents present: 69
Number of resident records reviewed: 5
Number of staff records reviewed: 5
Number of interviews with residents: 2
Number of interviews with staff: 1
Monthly audit duration: 3
Plan of correction submission timeframe: 5
Review request timeframe: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alexandra Roberts | Licensing Inspector | Conducted the inspection and is contact for questions |
| Resident Care Director | Resident Care Director (RCD) | Audited resident files and first aid kits, re-educated staff on compliance |
| Assisted Living Coordinator / Reminiscence Coordinator | Assisted Living Coordinator (ALC) / Reminiscence Coordinator (RC) | Re-educated on process for annual review of resident rights |
| Maintenance Coordinator | Maintenance Coordinator (MC) | Reviewed and updated Emergency Preparedness binder and procedures |
| Area Facilities Manager | Area Facilities Manager (AFM) | Completed re-education with Maintenance Coordinator on Emergency Preparedness process |
| Staff 1 | Interviewed staff who lacked documentation knowledge for emergency preparedness and first aid kit checks | |
| Staff 5 | Interviewed staff who stated resident rights were not completed for everyone |
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 15, 2023
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2023-11-03 regarding allegations in the area of Administration and Administrative Services.
Findings
The investigation included a tour of the facility and interviews. The evidence gathered did not support the allegation of non-compliance with standards or law.
Complaint Details
Complaint related to Administration and Administrative Services; the complaint was not substantiated as evidence did not support the allegations.
Report Facts
Number of interviews conducted: 3
Inspection Report
Monitoring
Deficiencies: 1
Aug 23, 2023
Visit Reason
An unannounced focused monitoring inspection was conducted on 8/23/23 to follow-up on a high-risk violation that was cited on 6/1/23.
Findings
The inspection found non-compliance with medication administration standards, specifically that medications were not administered according to physician instructions. A violation notice was issued to the facility.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure that medications are administered in accordance with the physician's instructions, specifically regarding parameters for holding Metoprolol. |
Report Facts
Dates medication parameters not met: 9
Plan of Correction timeframe: 3
Business days for plan of correction submission: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alexandra Roberts | Inspector | Current inspector conducting the inspection |
| Marshall Massenberg | Licensing Inspector | Contact person for questions regarding the inspection |
| Resident Care Director | Resident Care Director (RCD) | Named in plan of correction for conducting audits and training |
Inspection Report
Complaint Investigation
Deficiencies: 1
Aug 23, 2023
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2023-07-25 regarding an allegation in the area of Resident Care and Related Services.
Findings
The investigation supported the complaint of non-compliance related to delayed staff response to resident call bells, with documented occasions where staff took at least 20 minutes to respond. Violations were issued based on these findings.
Complaint Details
The complaint was substantiated as the evidence supported non-compliance with standards regarding staff response times to resident call bells.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure a prompt response by staff to resident needs as reasonable to the circumstances, with multiple occasions of delayed call bell responses. |
Report Facts
Call bell delayed responses: 5
Call bell delayed responses: 41
Call bell delayed responses: 7
Resident records reviewed: 5
Resident interviews conducted: 5
Staff interviews conducted: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alexandra Roberts | Licensing Inspector | Current inspector conducting the complaint investigation. |
| Marshall Massenberg | Licensing Inspector | Contact person for questions related to the inspection. |
Inspection Report
Monitoring
Census: 72
Deficiencies: 4
Jun 1, 2023
Visit Reason
An unannounced monitoring inspection was conducted to review compliance with applicable standards and laws, including observation of meals, medication administration, activities, building and grounds inspection, and record review.
Findings
The inspection found multiple violations including failure to ensure annual tuberculosis risk assessments for staff, failure to implement medication management plans to avoid missed dosages, failure to include Do Not Resuscitate (DNR) orders on individualized service plans, and failure to obtain timely criminal history record reports for new employees.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure that each staff member annually submits tuberculosis risk assessment results. |
| Facility failed to implement medication management plan ensuring timely filling and refilling of medications to avoid missed dosages. |
| Facility failed to ensure Do Not Resuscitate (DNR) orders are included on individualized service plans. |
| Facility failed to obtain criminal history record report within 30 days of hiring an employee. |
Report Facts
Residents in care: 72
Sample size: 10
Sample size: 5
Staff hire date: 2016
Staff hire date: 2023
Staff hire date: 2022
Inspection Report
Monitoring
Deficiencies: 0
Oct 14, 2022
Visit Reason
The inspection was a monitoring visit conducted on October 14, 17, and November 4, 2022, following a self-reported incident regarding allegations in Resident Care and Related Services.
Findings
The investigation found no evidence to support the self-report of non-compliance with standards or law. The inspection summary will be posted on the VDSS website.
Inspection Report
Routine
Deficiencies: 2
Sep 16, 2022
Visit Reason
The inspection was a routine licensing visit to assess compliance with resident care, related services, and building safety standards at the assisted living facility.
Findings
The inspection found non-compliance with medication storage and hazardous materials storage requirements. Specifically, medications and dietary supplements were not stored in locked compartments, and cleaning supplies were not kept in locked areas, posing safety risks to residents with serious cognitive impairments.
Deficiencies (2)
| Description |
|---|
| Facility failed to use a locked medicine cabinet, container, or compartment for storage of medications and dietary supplements administered by the facility. |
| Facility failed to keep cleaning supplies and other hazardous materials in a locked area. |
Inspection Report
Monitoring
Deficiencies: 4
Jun 14, 2022
Visit Reason
The inspection was a monitoring visit conducted to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection identified multiple violations including failure to maintain original criminal record reports in staff files, incomplete annual tuberculosis risk assessments for staff, lack of current first aid certification for a direct care staff member, and failure to keep cleaning supplies and hazardous materials locked and secured.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure that an original criminal record report is included in the staff record for Staff #6 and Staff #7. |
| Facility failed to ensure that each staff member annually submits the results of a tuberculosis risk assessment for Staff #2 and Staff #3. |
| Facility failed to ensure that each direct care staff member maintains current certification in first aid; Staff #5 did not have first aid certification at time of inspection. |
| Facility failed to keep cleaning supplies and other hazardous materials in a locked area; Polident, nail polish remover, and Lysol spray cleaner were unlocked and unattended in memory care unit. |
Report Facts
Plan of Correction timeframe: 30
Plan of Correction timeframe: 30
Plan of Correction date: Jun 24, 2022
Audit frequency: 3
Inspection Report
Routine
Census: 58
Deficiencies: 1
Apr 1, 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 inspection was initiated on April 1, 2021 and concluded on April 5, 2021 to review compliance with applicable standards and laws.
Findings
The inspection found non-compliance with the requirement that a physical examination must specify whether a resident is ambulatory or non-ambulatory. Specifically, Resident #3's physical examination incorrectly documented ambulatory status despite use of a hoyer lift for transfer. A plan of correction was implemented including updated physical examination and staff training.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure that a physical examination contains a statement specifying whether the individual is ambulatory or nonambulatory as defined in the chapter. |
Report Facts
Census: 58
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alexandra Roberts | Inspector | Conducted the inspection |
| Resident Care Director | Resident Care Director (RCD) | Contacted resident's primary care physician and involved in plan of correction |
| Executive Director | Executive Director (ED) | Provided training to Resident Care Coordinator and Resident Care Director on ambulatory status verification |
| Resident Care Coordinator | Resident Care Coordinator (RCC) | Conducted audit of resident physical examinations and ambulatory status |
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