Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 0
May 13, 2025
Visit Reason
The inspection was conducted in response to a complaint received by the VDSS Division of Licensing on January 17, 2025, regarding allegations related to resident care, protection of adults, and complaint investigation standards.
Findings
The investigation did not find evidence to support the allegations of non-compliance with the applicable standards or laws. No violation notice was issued.
Complaint Details
Complaint was related to allegations in resident care and protection of adults. The evidence gathered did not support the allegations of non-compliance.
Report Facts
Number of residents present: 62
Number of staff interviews: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shelby Haskins | Licensing Inspector | Inspector who conducted the complaint investigation |
| Executive Director | Interviewed by the inspector regarding the incident |
Inspection Report
Monitoring
Census: 62
Deficiencies: 0
May 13, 2025
Visit Reason
The inspection was a monitoring visit conducted to review compliance with various administrative, personnel, resident care, emergency preparedness, and other regulatory provisions.
Findings
The inspection included a tour of the physical plant, review of resident and staff records, observation of resident activities and medication pass, and review of emergency preparedness and safety reports. No violations of applicable standards or laws were found during the inspection.
Report Facts
Number of resident records reviewed: 6
Number of staff records reviewed: 3
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 3
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 0
Jan 21, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 12/19/2024 regarding allegations related to staffing and supervision, resident care and related services, resident accommodations and related provisions, and complaint investigation.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The inspection included a tour of the facility, review of infection control policy, PPE supplies, and staff schedules.
Complaint Details
Complaint received on 12/19/2024 regarding staffing and supervision, resident care and related services, resident accommodations and related provisions, and complaint investigation. The allegations were not substantiated.
Report Facts
Number of residents present: 59
Number of staff interviews: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shelby Haskins | Licensing Inspector | Inspector conducting the complaint investigation |
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 0
Dec 12, 2024
Visit Reason
The inspection was conducted as a complaint investigation to review allegations of non-compliance with standards or laws at the facility.
Findings
The evidence gathered during the investigation did not support the allegation of non-compliance with standards or law. The inspection findings will be posted publicly within 5 business days.
Complaint Details
The inspection was complaint-related, but the allegations were not substantiated based on the evidence gathered during the investigation.
Report Facts
Number of interviews conducted: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shelby Haskins | Licensing Inspector | Conducted the inspection and interviews |
Inspection Report
Monitoring
Census: 72
Deficiencies: 0
Jun 7, 2024
Visit Reason
The inspection was a monitoring visit conducted to review compliance with applicable standards and laws at the assisted living facility.
Findings
The inspection found no violations of applicable standards or laws. The licensing inspector conducted a tour of the facility, reviewed resident and staff records, observed activities including a medication pass, and monitored emergency preparedness and safety systems.
Report Facts
Number of resident records reviewed: 10
Number of staff records reviewed: 5
Number of interviews conducted with staff: 2
Inspection Report
Complaint Investigation
Census: 110
Deficiencies: 0
Mar 1, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2024-01-03 regarding allegations in the areas of Resident Care and Related Services and Administration and Administrative Services.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The inspector observed adequate PPE supplies, hand sanitizing stations, and reviewed the facility's Infectious Control Plan.
Complaint Details
Complaint related to allegations in Resident Care and Related Services and Administration and Administrative Services; the allegations were not substantiated.
Inspection Report
Renewal
Census: 72
Deficiencies: 0
Jun 21, 2023
Visit Reason
The inspection was a renewal visit conducted to assess compliance with licensing standards for the assisted living facility.
Findings
The inspection found no violations of applicable standards or laws. The licensing inspector completed a tour of the physical plant and reviewed resident and staff records, medication pass, meals, and activities.
Report Facts
Resident records reviewed: 10
Staff records reviewed: 3
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 0
Jan 13, 2023
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on November 27, 2022, regarding allegations in the area of Resident Care and Related Services.
Findings
The evidence gathered during the investigation did not support the allegation of non-compliance with standards or law. The inspection findings will be posted publicly and a copy is required to be posted at the facility.
Complaint Details
Complaint received on November 27, 2022 regarding Resident Care and Related Services. The complaint was not substantiated based on the investigation findings.
Inspection Report
Renewal
Census: 71
Deficiencies: 6
Jun 15, 2022
Visit Reason
The inspection was a renewal inspection conducted to assess compliance with applicable standards and regulations for the assisted living facility.
Findings
The inspection identified multiple violations related to documentation, resident physical examinations, sex offender screening, resident orientation, emergency evacuation drawings, and staff sworn statements. The facility was found non-compliant with several regulatory standards and issued violation notices with plans of correction.
Deficiencies (6)
| Description |
|---|
| Failed to document that the order of priority specified in subsection A was followed in resident Approval for Placement in Special Care Unit forms. |
| Failed to ensure physical examination forms contained description of reactions to known allergies. |
| Failed to ascertain and document whether a potential resident is a registered sex offender prior to admission for stays longer than three days. |
| Failed to ensure orientation was provided upon admission to new residents and their legal representatives. |
| Failed to ensure fire and emergency evacuation drawing showed primary and secondary escape routes, areas of refuge, assembly areas, and fire alarm boxes. |
| Failed to ensure staff persons did not make materially false statements on sworn statements or affirmations. |
Report Facts
Number of residents present: 71
Number of resident records reviewed: 10
Number of staff records reviewed: 3
Number of staff interviews conducted: 2
Date of inspection: Jun 15, 2022
Inspection Report
Complaint Investigation
Deficiencies: 3
Feb 23, 2022
Visit Reason
A complaint investigation was conducted regarding admission, retention and discharge of residents, resident care and related services, and staffing/staff training.
Findings
Violations were found related to failure to report major incidents within 24 hours, failure to update the uniform assessment instrument (UAI) with significant changes in residents' conditions, and failure to ensure individualized service plans (ISP) were signed and dated by residents' legal representatives including reviews and updates.
Complaint Details
The inspection was complaint-related as confirmed by the report. The complaint involved issues with admission, retention, discharge, resident care, and staffing/training. The complaint was substantiated with violations found in multiple areas.
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 any resident. |
| Facility failed to ensure the uniform assessment instrument (UAI) was updated whenever there was a significant change in the resident's condition. |
| Facility failed to ensure the individualized service plan (ISP) was signed and dated by the resident's legal representative including reviews and updates of the plan. |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shelby Haskins | Inspector | Named as the current inspector conducting the inspection. |
| Resident Care Director | Named in relation to counseling/education on reporting requirements and audit of UAI and ISP. | |
| Reminiscence Coordinator | Named in relation to counseling/education on reporting requirements and audit of UAI and ISP. | |
| Executive Director | Responsible for confirming implementation and ongoing compliance with the Plan of Correction. | |
| Director of Nursing | Present onsite for inspection and involved in findings. | |
| Staff #1 | Confirmed failures during interviews related to reporting incidents and ISP signatures. |
Inspection Report
Monitoring
Deficiencies: 1
Aug 23, 2021
Visit Reason
A non-mandated monitoring inspection was initiated due to a self-reported incident regarding allegations in the areas of resident care and related services.
Findings
The investigation found non-compliance with standards or law related to failure to report suspected abuse as mandated by Virginia Code 63.2-1606, resulting in violations being issued.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure all mandated reporters reported suspected abuse, neglect, or exploitation of residents as required by law. |
Report Facts
Inspection dates: 3
Inspection Report
Renewal
Census: 70
Deficiencies: 0
May 6, 2021
Visit Reason
A renewal inspection was initiated due to the facility's license renewal process, conducted remotely due to a state of emergency health pandemic.
Findings
The inspection reviewed multiple areas including resident and staff records, medication administration, and emergency preparedness, and found no violations with applicable standards or law.
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