Deficiencies per Year
8
6
4
2
0
Unclassified
Census Over Time
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 1
Aug 13, 2025
Visit Reason
The inspection was conducted in response to a complaint received on 2025-07-29 regarding allegations in the areas of Administration and Administrative Services and Resident Care and Related Services.
Findings
The investigation found non-compliance with standards related to resident-centered care and prompt response to resident needs. Specifically, a resident's injury noted on 2025-06-28 did not receive timely medical attention until 2025-07-07, confirming a failure in care provision and service delivery.
Complaint Details
Complaint related: Yes. The evidence supported the allegations of non-compliance with standards regarding administration and resident care. The complaint was substantiated with violations issued.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure care provision and service delivery was resident-centered and included prompt response by staff to resident needs. |
Report Facts
Number of residents present: 66
Number of resident records reviewed: 2
Number of staff records reviewed: 0
Number of interviews conducted with staff: 3
Inspection Report
Monitoring
Census: 66
Deficiencies: 4
Aug 13, 2025
Visit Reason
The inspection was a monitoring visit triggered by a self-report incident received on 2025-08-06 regarding allegations in the areas of Resident Care and Related Services, Buildings and Grounds, and Additional Requirements for Facilities That Care for Adults with Serious Cognitive Impairments.
Findings
The investigation supported the self-report of non-compliance with multiple standards, resulting in violations issued related to staffing during night hours, failure to report suspected abuse, failure to ensure resident safety and well-being, and inadequate staff rounds for residents unable to use signaling devices.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure that during night hours, when 22 or fewer residents were present, at least two direct care staff members were awake and on duty at all times in each special care unit. |
| Facility failed to ensure that all mandated staff reported suspected abuse, neglect, or exploitation of residents in accordance with the Code of Virginia. |
| Facility failed to assume general responsibility for the health, safety, and well-being of residents related to an allegation of sexual abuse between two residents. |
| Facility failed to ensure direct care staff made rounds no less often than every two hours for residents unable to use signaling devices. |
Report Facts
Number of residents present: 66
Number of resident records reviewed: 2
Number of staff interviews conducted: 2
Number of staff scheduled on 08/06/2025 evening on second floor: 2
Number of residents on second floor on 08/06/2025 evening: 20
Number of residents on third floor on 08/06/2025 evening: 18
Number of staff scheduled on third floor on 08/06/2025 evening: 1
Number of documented rounds for Resident 1 on 08/06/2025: 4
Number of documented rounds for Resident 2 on 08/06/2025: 2
Inspection Report
Renewal
Census: 49
Deficiencies: 7
Jan 29, 2025
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 multiple violations including failure to assess appropriateness of placement for residents with cognitive impairment, incomplete staff orientation and training, failure to ensure resident-centered care, lack of timely healthcare oversight, inadequate fire and emergency evacuation drills, and insufficient review and practice of emergency procedures with staff.
Deficiencies (7)
| Description |
|---|
| Failed to ensure that prior to admitting a resident with a serious cognitive impairment to a safe, secure environment, an appropriateness of placement assessment was completed. |
| Failed to ensure that orientation and training occurred within the first seven working days of employment for staff. |
| Failed to ensure that care provision and service delivery was resident-centered and personalized to the resident's circumstances and preferences. |
| Failed to ensure that healthcare oversight was completed at least every six months. |
| Failed to ensure fire and emergency evacuation drills were conducted and documented according to Virginia Statewide Fire Prevention Code. |
| Failed to ensure that procedures for resident emergencies were reviewed with all staff at least every six months. |
| Failed to ensure that all staff on duty participated in emergency procedure exercises every six months. |
Report Facts
Number of residents present: 49
Number of resident records reviewed: 8
Number of staff records reviewed: 3
Number of resident interviews: 1
Number of staff interviews: 3
Days rounds not completed every 2 hours: 8
Date of resident admission: Mar 31, 2024
Staff hire date: Dec 11, 2024
Healthcare oversight date: Oct 31, 2024
Fire drill missing months: 8
Emergency preparedness plan review date: Nov 21, 2024
Elopement drill date: Apr 24, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nina Wilson | Licensing Inspector | Current inspector conducting the inspection |
| Staff 3 | Staff member with incomplete orientation and training record | |
| Staff 5 | Staff member interviewed regarding healthcare oversight documentation | |
| Staff 6 | Staff member interviewed regarding fire drills and emergency preparedness |
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 3
Oct 21, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-10-06 regarding allegations in staffing and supervision, admission, retention, and discharge of residents, and resident care and related services.
Findings
The investigation supported some areas of non-compliance related to resident placement and assessment procedures. Violations were found regarding the lack of written approval and justification for placing residents with serious cognitive impairment in a safe, secure environment, and failure to update uniform assessment instruments following significant changes in resident condition.
Complaint Details
Complaint related to staffing and supervision, admission, retention, and discharge of residents, and resident care. Some allegations were substantiated based on record review and staff interview.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure written approval was obtained prior to placing a resident with serious cognitive impairment in a safe, secure environment. |
| Facility failed to ensure written determination and justification for admitting residents with serious cognitive impairment to a safe, secure environment was documented. |
| Facility failed to ensure all residents were assessed face to face using the uniform assessment instrument (UAI) and updated after significant condition changes. |
Report Facts
Number of residents present: 51
Number of resident records reviewed: 3
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nina Wilson | Licensing Inspector | Conducted the inspection and staff interview |
Inspection Report
Renewal
Census: 31
Deficiencies: 1
Jan 25, 2024
Visit Reason
The inspection was a renewal inspection conducted to review compliance with regulatory standards for the assisted living facility.
Findings
The inspection found that four staff records were incomplete, missing required personal and social data. A plan of correction was developed to address these deficiencies, including audits and additional training.
Deficiencies (1)
| Description |
|---|
| Staff records were not complete as required; four of four staff records were missing personal and social data. |
Report Facts
Number of records reviewed: 8
Number of interviews conducted: 9
Number of staff records missing required paperwork: 4
Inspection Report
Monitoring
Census: 28
Deficiencies: 0
Nov 27, 2023
Visit Reason
The inspection was a monitoring visit to review administration, personnel, resident admission, retention, discharge, and resident care services at the assisted living facility.
Findings
The Licensing Inspector reviewed 10 records and conducted 8 interviews, observed residents during activities, snack time, and meals, and reviewed all facility self-reported incidents since the last inspection.
Report Facts
Records reviewed: 10
Interviews conducted: 8
Inspection Report
Original Licensing
Deficiencies: 0
Jul 31, 2023
Visit Reason
The inspection was an announced initial inspection conducted to evaluate the facility for licensing purposes.
Findings
The Licensing Inspector toured the physical plant, verified window and room measurements, policies and procedures, staff and resident records files. Building, Fire and Health Inspections were submitted and reviewed. No violations were found at the time of inspection.
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