Inspection Reports for The Barrington at Hioaks
350 Hioaks Rd, Richmond, VA 23225, United States, VA, 23225
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Inspection Report
Renewal
Census: 140
Deficiencies: 2
May 19, 2025
Visit Reason
The inspection was a renewal visit to assess compliance with applicable standards and regulations for the assisted living facility.
Findings
The inspection identified non-compliance with applicable standards related to documentation for approval of placement in a safe, secure environment and individualized service plans addressing inability to use signaling devices. Violations were documented and a plan of correction was requested.
Deficiencies (2)
| Description |
|---|
| Facility did not document that the order of priority was followed for approval of placement in the safe, secure environment. |
| Facility did not ensure that the inability to use the signaling device was included on the individualized service plan for each resident with such inability. |
Report Facts
Number of residents present: 140
Number of resident records reviewed: 8
Number of staff records reviewed: 4
Number of interviews conducted with residents: 3
Number of interviews conducted with staff: 5
Inspection Report
Complaint Investigation
Deficiencies: 1
May 19, 2025
Visit Reason
The inspection was conducted in response to a complaint received by the VDSS Division of Licensing on 2025-05-16 regarding allegations in the areas of Personnel and Resident Care and Related Services.
Findings
The investigation supported one of the allegations related to Resident Care and Related Services. A violation was found because the individualized service plan for a resident was not signed and dated by the resident or their legal representative.
Complaint Details
The complaint was substantiated regarding the individualized service plan not being signed and dated by the legal representative.
Deficiencies (1)
| Description |
|---|
| The facility did not ensure that the individualized service plan was signed and dated by the resident or his legal representative. |
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
Monitoring
Census: 128
Deficiencies: 0
Dec 20, 2024
Visit Reason
The inspection was a Non-Mandated Monitoring (Focus) visit to follow up on the Plan of Correction from the 7/25/24 inspection and to review compliance with personnel, staffing, resident care, and additional requirements for adults with serious cognitive impairments.
Findings
The inspection found no violations with applicable standards and laws. The facility has implemented a restraint-free policy, audited staff files for compliance, and hired new key staff including an Executive Director, Director of Clinical Services, and Director of Human Resources.
Report Facts
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Yvonne Randolph | Licensing Inspector | Current inspector conducting the inspection |
Inspection Report
Monitoring
Census: 128
Deficiencies: 0
Dec 20, 2024
Visit Reason
The inspection was a monitoring non-mandated visit following a self-reported incident received by VDSS Division of Licensing and a subsequent anonymous telephone call regarding allegations in the area of Resident Care and Related Services.
Findings
The evidence gathered during the investigation did not support non-compliance with standards or law. The inspection findings were reviewed in an exit meeting and will be posted publicly.
Report Facts
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 2
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 23, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2024-09-19 regarding allegations in the area of Admission, Retention and Discharge of Residents.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law.
Complaint Details
Complaint related to Admission, Retention and Discharge of Residents; the allegations were not substantiated.
Report Facts
Resident records reviewed: 1
Staff records reviewed: 0
Resident interviews conducted: 0
Staff interviews conducted: 2
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 23, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-09-30 regarding allegations in the areas of Admission, Resident Care and Related Services.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law.
Complaint Details
Complaint related to allegations in Admission, Resident Care and Related Services; investigation found no substantiation of non-compliance.
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
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Yvonne Randolph | Licensing Inspector | Conducted the inspection and investigation |
Inspection Report
Complaint Investigation
Deficiencies: 2
Sep 13, 2024
Visit Reason
The inspection was conducted as a complaint investigation following complaints received by VDSS Division of Licensing on 8/14/24 and 8/21/24 regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation found non-compliance with medication administration standards, including missed dosages of a prescribed medication and failure to document medication errors or omissions in the medication administration record.
Complaint Details
The complaint investigation was substantiated. Complaints received on 8/14/24 and 8/21/24 alleged issues with medication administration. Evidence included medication administration records and interviews confirming missed dosages and undocumented medication errors.
Deficiencies (2)
| Description |
|---|
| The facility did not ensure that medications were administered in accordance with the physician's or prescriber's instructions, evidenced by missed dosages of Dorzolamide for resident #1 in August 2024. |
| The medication administration record did not document medication errors or omissions, including a missed dose of Dorzolamide on 8/10/24 that was not recorded. |
Report Facts
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of collateral interviews: 2
Number of interviews conducted with staff: 1
Missed medication dosages: 7
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 7, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-07-31 regarding allegations in the areas of staffing, resident care and related services, and building and grounds.
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 received on 2024-07-31 regarding staffing, resident care and related services, and building and grounds. The investigation did not substantiate the allegations.
Report Facts
Number of resident records reviewed: 0
Number of staff records reviewed: 0
Number of interviews conducted with residents: 4
Number of interviews conducted with staff: 3
Inspection Report
Complaint Investigation
Deficiencies: 2
Jul 30, 2024
Visit Reason
The inspection was conducted in response to a complaint received by the Virginia Department of Social Services Division of Licensing on July 28, 2024, regarding allegations in the areas of Personnel, Resident Care and Related Services, and Staffing and Supervision.
Findings
The investigation found violations supporting the complaint allegations, including failure of facility staff to provide assistance to residents in need, inadequate staffing coverage on the 4th floor resulting in residents not receiving care or meals, and failure to meet residents' health, safety, and well-being needs. Staff involved were disciplined, including termination of one staff member.
Complaint Details
The complaint was substantiated. Evidence included reports from family members and staff that residents did not receive necessary care and assistance, including a resident found unattended requiring emergency care and residents not fed due to no staff coverage on the 4th floor. Staff #1 was suspended and subsequently terminated for failure to follow procedures.
Deficiencies (2)
| Description |
|---|
| Facility did not ensure general responsibility for the health, safety, and well-being of residents; staff failed to respond to a resident found slumped in a chair requiring emergency care. |
| Facility did not ensure personal assistance and care were provided as necessary, including toileting and feeding; residents on the 4th floor did not receive care or meals due to staffing shortages. |
Report Facts
Inspection dates: 2
Resident records reviewed: 0
Staff records reviewed: 0
Resident interviews: 1
Staff interviews: 1
Time reported without staff coverage: 1.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff #1 | Failed to respond to resident assistance request, suspended and terminated for failure to follow procedures | |
| Yvonne Randolph | Licensing Inspector | Conducted the inspection and exit meeting |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 25, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2024-07-18 regarding allegations in the area of Resident Care and Related Services.
Findings
The inspection found no violations with applicable standards or laws after reviewing resident records, conducting interviews, and observing the facility environment and services.
Complaint Details
Complaint related to Resident Care and Related Services; the complaint was not substantiated as no violations were found.
Report Facts
Resident records reviewed: 1
Staff records reviewed: 0
Resident interviews conducted: 1
Staff interviews conducted: 2
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 24, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-07-18 regarding allegations in the areas of Admission, Retention and Discharge and Resident Care and Related Services.
Findings
The inspection found no violations of applicable standards or laws based on the evidence gathered during the inspection.
Complaint Details
Complaint received on 2024-07-18 regarding Admission, Retention and Discharge and Resident Care and Related Services; no violations were found.
Report Facts
Resident records reviewed: 1
Staff records reviewed: 0
Resident interviews conducted: 1
Staff interviews conducted: 2
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 24, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-07-18 regarding allegations related to staffing and supervision and additional requirements for facilities that care for adults with serious cognitive impairments.
Findings
The inspection found no violations with applicable standards or law after a tour of the physical plant, review of one resident record, and interviews with two staff members. The environment was observed to be safe and secure.
Complaint Details
Complaint received on 2024-07-18 regarding staffing and supervision and additional requirements for facilities caring for adults with serious cognitive impairments. The complaint was not substantiated as no violations were found.
Report Facts
Resident records reviewed: 1
Staff records reviewed: 0
Staff interviews conducted: 2
Inspection Report
Monitoring
Census: 131
Deficiencies: 3
Jul 19, 2024
Visit Reason
The inspection was a monitoring visit to review compliance with resident care and related services standards at the assisted living facility.
Findings
The inspection found non-compliance with applicable standards, including incomplete uniform assessment instruments, unsigned individualized service plans, and failure to update service plans to reflect significant changes in residents' conditions.
Deficiencies (3)
| Description |
|---|
| The facility did not ensure that the uniform assessment instrument is completed as required by 22VAC30-110. |
| The facility did not ensure that the individualized service plan shall be signed and dated by the licensee, administrator, or designee, and by the resident or legal representative. |
| The facility did not ensure that individualized service plans shall be reviewed and updated at least once every 12 months and as needed for significant changes in resident condition. |
Report Facts
Number of residents present: 131
Number of resident records reviewed: 2
Number of interviews conducted with residents: 3
Number of interviews conducted with staff: 2
Weight loss percentage: 9.7
Weight loss percentage: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Yvonne Randolph | Licensing Inspector | Inspector conducting the monitoring visit |
| Director of Clinical Services | Named in plan of correction for review and signing of assessment instruments and service plans |
Inspection Report
Complaint Investigation
Census: 131
Deficiencies: 14
Jul 11, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-07-09 regarding allegations in the areas of Staffing and Supervision and Resident Care and Related Services at The Barrington at Hioaks assisted living facility.
Findings
The investigation supported allegations of non-compliance with multiple standards including insufficient staffing in the special care unit during an emergency, failure to report a major incident timely, inadequate management response to an emergency, lack of posting the on-site person in charge, incomplete individualized service plans, improper use and documentation of physical restraints, failure to provide personal care and assistance as required, and unapproved construction without licensing review.
Complaint Details
The complaint was substantiated as the evidence gathered supported the allegations of non-compliance with standards related to Staffing and Supervision and Resident Care and Related Services.
Deficiencies (14)
| Description |
|---|
| Failed to ensure at least two direct care staff members were awake and on duty at all times in the special care unit except during night hours when 20 or fewer residents are present. |
| Failed to report a major incident (resident death) to the regional licensing office within 24 hours. |
| Staff member in charge was not prepared to carry out duties and respond appropriately in case of emergency. |
| Did not develop and implement procedure for posting the name of the current on-site person in charge conspicuously. |
| Failed to ensure coordinated plan of care including hospice services was documented in individualized service plan (ISP). |
| Failed to review and update individualized service plans at least annually and as needed for significant changes. |
| Failed to provide care and services specified in the individualized service plan, including weekly weighing of resident. |
| Did not assume general responsibility for health, safety, and well-being of residents; resident found deceased with entangled arm in bed rails without proper physician order or documentation. |
| Failed to provide personal assistance and care including bathing as necessary. |
| Failed to ensure meals were served in the designated dining area or documented agreement for alternate arrangements. |
| Staff administered medication after expiration of provisional authorization. |
| Physical restraints used without physician's written order specifying conditions, circumstances, and duration. |
| Failed to meet conditions for use of physical restraints including monitoring and documentation. |
| Did not submit plans for construction, remodeling, or alterations to the department for review prior to beginning work. |
Report Facts
Number of residents present: 131
Number of resident records reviewed: 1
Number of staff interviews conducted: 7
Number of medications administered after certification expiration: 4163
Number of residents affected by medication administration: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff #1 | Placed on suspension and recommended for termination for failure to follow procedures of critical importance; failed to respond to contact attempts. | |
| Staff #3 | Left the special care unit during an emergency to go outside to smoke. | |
| Staff #4 | Staff member in charge during emergency; failed to respond appropriately or communicate about resident death. | |
| Staff #5 | Medication aide | Administered medications after expiration of provisional authorization; found resident entangled in bed rails. |
| Staff #6 | Direct care staff assigned to special care unit during emergency. | |
| Staff #7 | Confirmed number of residents in special care unit by email. | |
| Yvonne Randolph | Licensing Inspector | Conducted the inspection and exit meeting. |
Inspection Report
Complaint Investigation
Deficiencies: 0
May 15, 2024
Visit Reason
The inspection was conducted in response to a complaint and a self-reported incident received by VDSS Division of Licensing regarding allegations in the area of Building and Grounds.
Findings
The licensing inspector completed a tour of the physical plant including the building and grounds and conducted interviews with residents and staff. The evidence gathered did not support the allegations or self-report of non-compliance with standards or law.
Complaint Details
The complaint was related to building and grounds issues, but the investigation found no substantiated non-compliance.
Report Facts
Number of resident interviews: 4
Number of staff interviews: 3
Inspection Report
Complaint Investigation
Deficiencies: 3
Apr 29, 2024
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received on 2024-04-11 regarding allegations in the areas of Staffing and Supervision, and Resident Care and Related Services.
Findings
The investigation supported some but not all allegations; non-compliance was found in Resident Care and Related Services. Violations included failure to update individualized service plans, failure to ensure general responsibility for residents' health and safety, and failure to serve meals in the designated dining area as required.
Complaint Details
Complaint was received on 2024-04-11 regarding Staffing and Supervision and Resident Care and Related Services. The evidence supported some allegations related to Resident Care and Related Services but not all. A violation notice was issued.
Deficiencies (3)
| Description |
|---|
| Facility did not ensure individualized service plans were reviewed and updated at least annually and as needed for significant changes. |
| Facility did not ensure general responsibility for the health, safety, and well-being of residents, evidenced by significant weight loss and hospitalization of a resident. |
| Facility did not ensure all meals were served in the dining area as designated; meals were served in resident's room without proper documentation or agreement. |
Report Facts
Resident records reviewed: 1
Staff records reviewed: 0
Staff interviews conducted: 3
Weight loss: 26.5
Weight loss percentage: 50
Hospital admission date: Apr 3, 2024
Inspection dates: 2
Inspection Report
Complaint Investigation
Census: 89
Deficiencies: 0
Mar 21, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2024-02-27 regarding allegations in the areas of Staffing and Supervision and Building and Grounds.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. An exit meeting was conducted to review the inspection findings.
Complaint Details
Complaint related to allegations in Staffing and Supervision and Building and Grounds; the complaint was not substantiated.
Report Facts
Number of residents present: 89
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 1
Inspection Report
Monitoring
Census: 120
Deficiencies: 0
Jan 29, 2024
Visit Reason
A focus monitoring inspection was completed to follow-up on the September 2023 inspection.
Findings
The evidence gathered during the inspection determined no violations with applicable standards or laws and that the facility is in compliance with the submitted plan of correction.
Report Facts
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
Inspection Report
Monitoring
Census: 120
Deficiencies: 2
Jan 29, 2024
Visit Reason
The inspection was a mandated monitoring visit to assess compliance with applicable regulations and standards at the assisted living facility.
Findings
The inspection found non-compliance with certain standards related to resident service plans, specifically missing Do Not Resuscitate orders and failure to include signaling device usage ability in individualized service plans for some residents.
Deficiencies (2)
| Description |
|---|
| Do Not Resuscitate (DNR) orders were not included on the individualized service plan of two residents. |
| The facility failed to ensure that the inability to use the signaling device was included in the individualized service plan for residents with such inability. |
Report Facts
Number of resident records reviewed: 9
Number of staff records reviewed: 5
Number of interviews conducted with staff: 2
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 29, 2024
Visit Reason
The inspection was conducted in response to a complaint received by the VDSS Division of Licensing regarding allegations in the areas of Staffing and Supervision and Resident Care and Related Services.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. An exit meeting was conducted to review the inspection findings.
Complaint Details
Complaint related to Staffing and Supervision and Resident Care and Related Services; allegations were not substantiated.
Report Facts
Resident records reviewed: 1
Staff records reviewed: 0
Interviews conducted with residents: 0
Interviews conducted with staff: 1
Inspection Report
Complaint Investigation
Deficiencies: 5
Sep 22, 2023
Visit Reason
The inspection was conducted as a complaint-related investigation to review compliance with regulations concerning resident care, administrative services, and other facility requirements.
Findings
Multiple deficiencies were identified including failure to obtain proper written approval for placement in a secured unit, admission of a resident with a prohibited care need, failure to develop and sign an individualized service plan with resident and legal representative input, inadequate supervision to prevent falls, and medication administration without a valid physician order.
Complaint Details
The visit was complaint-related. The individualized service plan deficiency was substantiated based on review and interview. Other deficiencies were identified during the complaint investigation.
Deficiencies (5)
| Description |
|---|
| Facility did not document that the order of priority was followed in obtaining written approval for placement in the safe, secure environment. |
| Resident admitted and retained with a prohibited care need requiring continuous licensed nursing care. |
| Individualized service plan was not developed in conjunction with the resident and/or family/legal representative and was not signed and dated by required parties. |
| Facility failed to provide supervision of the resident schedule, care, and activities, including prevention of falls; resident had three documented falls within five days of admission. |
| Medication was administered without a valid physician order for Seroquel 25 mg on two occasions. |
Report Facts
Fall Risk Assessment score: 75
Fall Risk Rating threshold: 45
Number of documented falls: 3
Medication administration instances without valid order: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Yvonne Randolph | Inspector | Named as current inspector conducting the inspection. |
| Staff #1 | Referenced in relation to unawareness of prohibited condition and inability to provide physician order for medication. |
Inspection Report
Renewal
Census: 139
Deficiencies: 5
May 22, 2023
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 multiple violations including missing criminal background checks for staff, lack of annual tuberculosis screenings, retention of a resident with a prohibited condition, missing signatures on individualized service plans, and failure to address fall risk in service plans.
Deficiencies (5)
| Description |
|---|
| One staff file did not have an original criminal record as required by regulation. |
| Staff were not evaluated annually for tuberculosis; documentation was missing for five staff members. |
| A resident was retained at the facility with a documented prohibited condition or care need. |
| Eight individualized service plans were not signed by residents, families, or legal representatives. |
| Individual service plans did not address identified fall risk needs for five residents. |
Report Facts
Number of residents present: 139
Number of staff records reviewed: 5
Number of resident records reviewed: 10
Number of interviews conducted with residents: 2
Number of interviews conducted with staff: 4
Number of service plans missing signatures: 8
Number of residents with fall risk not addressed in ISP: 5
Inspection Report
Complaint Investigation
Deficiencies: 2
Feb 21, 2023
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received on 2023-02-14 regarding allegations in the areas of Resident Care and Related Services and Staffing and Supervision.
Findings
The investigation did not substantiate the complaint allegations of non-compliance; however, violations not related to the complaint were identified, including failure to report a resident fall incident within 24 hours and inaccurate medication administration documentation.
Complaint Details
Complaint was received by VDSS Division of Licensing on 2023-02-14 regarding allegations in Resident Care and Related Service and Staffing and Supervision. The evidence gathered did not support the allegations of non-compliance with standards or law.
Deficiencies (2)
| Description |
|---|
| Failure to report to the regional licensing office an incident that negatively affected the health, safety or welfare of a resident within 24 hours. |
| Inaccurate documentation of medication administration on the medication administration record (MAR) for a resident. |
Report Facts
Records reviewed: 1
Dates related to resident incident: Dec 12, 2022
Dates related to resident incident: Dec 14, 2022
Medication administration date: Dec 16, 2022
Inspection Report
Complaint Investigation
Deficiencies: 0
May 9, 2022
Visit Reason
A complaint inspection was conducted to investigate allegations in the area of Admission, Retention and Discharge of Residents.
Findings
The evidence gathered during the investigation did not support the allegation of non-compliance with standards or law.
Complaint Details
Investigation of allegations related to Admission, Retention and Discharge of Residents; complaint was not substantiated.
Inspection Report
Monitoring
Census: 138
Deficiencies: 1
May 9, 2022
Visit Reason
A monitoring inspection was conducted to review assisted living and memory care, medication administration, required postings, and resident and staff files for compliance.
Findings
One non-compliance with applicable standards or law was identified related to failure to document that the order of priority was followed for two residents.
Deficiencies (1)
| Description |
|---|
| Failed to document that the order of priority was followed for two residents based on review of five resident files. |
Report Facts
Resident files reviewed: 5
Staff files reviewed: 5
Residents in care: 138
Inspection Report
Renewal
Census: 119
Deficiencies: 4
May 12, 2021
Visit Reason
A renewal inspection was initiated on May 12, 2021, and concluded on May 24, 2021, to determine compliance with applicable standards and laws for The Barrington at Hioaks assisted living facility.
Findings
The inspection identified multiple violations related to individualized service plans not being properly signed or updated, and medication administration records not accurately documenting all medications administered or staff signatures.
Deficiencies (4)
| Description |
|---|
| Individualized service plan for one resident was not signed and dated by the licensee, administrator, or designee. |
| One individualized service plan was not updated to reflect a significant change in the resident's condition. |
| Facility staff failed to document on the medication administration record all medications administered to one resident. |
| One medication administration record did not accurately reflect the name, signature, and/or initials of staff administering medications. |
Report Facts
Residents reviewed: 5
Staff records reviewed: 5
Medications not documented: 9
Medications not documented: 4
Medications not documented: 7
Medications not documented: 1
Medications not documented: 6
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 26, 2021
Visit Reason
A complaint was received by the Department regarding allegations in the areas of meals and resident discharge, prompting a virtual complaint inspection.
Findings
Evidence gathered during the investigation did not support the allegations of non-compliance with applicable standards or laws.
Complaint Details
Complaint related to meals and resident discharge; investigation found no substantiation of non-compliance.
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