Inspection Report
Complaint Investigation
Census: 114
Deficiencies: 1
Nov 20, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on September 29, 2025, regarding allegations related to safe and secure unit staffing at the facility.
Findings
The investigation found that the facility failed to ensure adequate direct care staffing on the memory care unit, specifically not maintaining the required number of awake and on-duty direct care staff members according to the resident census during September 2025.
Complaint Details
The complaint was substantiated as the evidence supported the allegation of non-compliance with staffing standards in the memory care unit.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure that when 20 or fewer residents are present, at least two direct care staff members are awake and on duty at all times in each special care unit, and for every additional 10 residents, at least one more direct care staff member is awake and on duty. |
Report Facts
Number of residents present: 114
Memory care unit census: 40
Memory care unit census: 43
Direct care staff required: 4
Direct care staff required: 5
Number of staff interviews: 2
Inspection Report
Monitoring
Census: 114
Deficiencies: 1
Nov 20, 2025
Visit Reason
The inspection was a monitoring visit triggered by a self-reported incident received by VDSS Division of Licensing on 2025-10-31 regarding allegations in the area of resident care.
Findings
The investigation supported the self-report of non-compliance related to a medication error where a resident was given the wrong dosage of a Fentanyl patch. The resident's family and physician were notified, and no adverse effects were noted. Violations were issued based on these findings.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure medications were administered in accordance with the physician's or other prescriber's instructions, specifically a medication error involving incorrect Fentanyl patch dosage. |
Report Facts
Number of residents present: 114
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of interviews conducted with staff: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Davis | Licensing Inspector | Inspector conducting the monitoring inspection |
Inspection Report
Monitoring
Census: 101
Deficiencies: 2
Jan 17, 2025
Visit Reason
The inspection was a monitoring visit triggered by a self-reported incident regarding allegations in the area of resident care.
Findings
The investigation supported the self-report of non-compliance related to medication administration errors, including failure to administer medications according to physician orders and failure to properly document medication administration on the Medication Administration Record (MAR). Violations were issued and the facility was required to submit a plan of correction.
Deficiencies (2)
| Description |
|---|
| The facility failed to ensure that medications were administered in accordance with the physician's or other prescriber's instructions, resulting in a resident receiving an incorrect dosage of Gabapentin. |
| The facility failed to ensure that the Medication Administration Record (MAR) included the initials of direct care staff administering the medication, leading to undocumented medication administration. |
Report Facts
Number of residents present: 101
Number of resident records reviewed: 1
Number of staff interviews conducted: 2
Inspection Report
Renewal
Census: 108
Deficiencies: 6
Dec 16, 2024
Visit Reason
The inspection was conducted as a renewal of the facility's license, with the licensing inspector on-site on December 16, 2024, and January 17, 2025, to assess compliance with applicable standards and regulations.
Findings
The inspection identified multiple violations related to resident record reviews, individualized service plans, resident rights acknowledgments, first aid kit contents, and staff employment documentation including sworn statements and criminal background checks. The facility was found non-compliant with several regulatory standards and was required to submit plans of correction.
Deficiencies (6)
| Description |
|---|
| Failure to perform six-month and annual reviews of appropriateness of residents' continued placement in the special care unit. |
| Individualized service plans (ISP) were not signed and dated by the resident or legal representative. |
| Failure to ensure annual review and written acknowledgment of residents' rights and responsibilities. |
| First aid kit did not contain adhesive tape, antiseptic ointment, or band aids. |
| Sworn statements or affirmations were missing from multiple staff employment records. |
| Criminal history record reports were not obtained within 30 days of employment for some staff. |
Report Facts
Number of residents present: 108
Number of resident records reviewed: 8
Number of interviews conducted with residents: 3
Number of staff records reviewed: 4
Number of interviews conducted with staff: 2
Number of staff missing sworn statements: 5
Number of staff with late or missing criminal background checks: 3
Inspection Report
Complaint Investigation
Census: 118
Deficiencies: 2
Dec 14, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on November 30, 2023, regarding allegations related to resident care.
Findings
The investigation found some substantiated areas of non-compliance related to resident care and building and grounds. Violations included failure to ensure freedom of movement for residents in memory care and inadequate documentation of required two-hour rounds for a resident.
Complaint Details
The complaint was substantiated in part. The facility was found non-compliant with standards related to resident care and building and grounds based on evidence and staff interviews.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure freedom of movement for residents by locking memory care residents' rooms, contrary to regulations. |
| Facility failed to document two-hour rounds for a resident with inability to use signaling device for multiple days in November 2023. |
Report Facts
Number of residents present: 118
Number of resident records reviewed: 1
Number of staff interviews conducted: 2
Days without documentation: 10
Residents reviewed monthly for rounding compliance: 5
Duration of monitoring: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Davis | Licensing Inspector | Inspector conducting the complaint investigation |
Inspection Report
Complaint Investigation
Census: 113
Deficiencies: 0
Oct 24, 2024
Visit Reason
The inspection was conducted in response to a complaint received by the VDSS Division of Licensing regarding allegations in the area of resident care.
Findings
The investigation found no evidence to support the allegations of non-compliance with standards or law. The inspection findings were reviewed in an exit meeting and will be posted publicly.
Complaint Details
A complaint was received regarding resident care. The evidence gathered did not support the allegations of non-compliance.
Report Facts
Number of resident records reviewed: 1
Number of interviews conducted with staff: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Davis | Licensing Inspector | Current inspector conducting the complaint investigation |
Inspection Report
Monitoring
Census: 113
Deficiencies: 1
Oct 24, 2024
Visit Reason
The inspection was a monitoring visit conducted to review compliance with resident care standards following a self-reported incident regarding resident care.
Findings
The inspection found non-compliance related to a medication error where the facility failed to ensure medications were administered according to the prescriber's instructions. The medication aide administered an incorrect dose of morphine to a resident, though no adverse reactions were observed.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure medications were administered in accordance with the physician's or other prescriber's instructions, based on a medication error self-report. |
Report Facts
Number of residents present: 113
Number of resident records reviewed: 1
Number of staff interviews conducted: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Davis | Licensing Inspector | Named as the current inspector conducting the inspection |
Inspection Report
Monitoring
Census: 113
Deficiencies: 1
Oct 24, 2024
Visit Reason
The inspection was a monitoring visit conducted to review compliance with resident care standards and related services, including care for adults with serious cognitive impairments.
Findings
The inspection found non-compliance with applicable standards based on a self-reported resident elopement incident. Violations were documented and a plan of correction was requested to address the issues and maintain future compliance.
Deficiencies (1)
| Description |
|---|
| Based on a self-report of a resident elopement, the facility failed to ensure supervision of resident schedules, care, and activities, including prevention of wandering from the premises. |
Report Facts
Number of residents present: 113
Number of resident records reviewed: 1
Number of interviews conducted with staff: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Davis | Licensing Inspector | Current inspector conducting the inspection |
Inspection Report
Complaint Investigation
Census: 107
Deficiencies: 0
Aug 23, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on July 5, 2024, regarding allegations related to resident discharges.
Findings
The investigation found no evidence to support the allegations of non-compliance with standards or law. The inspection findings did not substantiate the complaint.
Complaint Details
Complaint related to resident discharges received on July 5, 2024; allegations were not substantiated.
Report Facts
Number of resident records reviewed: 2
Number of interviews conducted with staff: 2
Inspection Report
Complaint Investigation
Census: 107
Deficiencies: 1
Aug 22, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-06-26 regarding allegations related to resident care at the facility.
Findings
The investigation found some substantiated areas of non-compliance related to resident care, specifically failures to ensure personal assistance and care were provided and properly documented for residents.
Complaint Details
The complaint was substantiated in part; evidence showed non-compliance with resident care standards based on review of resident records and documentation.
Deficiencies (1)
| Description |
|---|
| The facility failed to ensure that personal assistance and care were provided to each resident as necessary, including assistance with activities of daily living such as bathing, dressing, toileting, transferring, bowel and bladder control, eating/feeding, hygiene, and grooming. Documentation was incomplete for multiple dates in June 2024. |
Report Facts
Number of residents present: 107
Number of resident records reviewed: 1
Number of staff interviews conducted: 2
Dates missing documentation: 19
Dates with bathing assistance documented: 6
Sample size for weekly compliance review: 5
Compliance review period: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Davis | Licensing Inspector | Inspector conducting the complaint investigation |
| Unnamed Charge Nurse | Charge Nurse | Responsible for ensuring care is provided and documented by 8/29/2024 |
| Unnamed Director of Wellness | Director of Wellness | Responsible for ensuring all residents' care is documented daily by 8/29/2024 |
| Unnamed Executive Director | Executive Director | Responsible for weekly review of 5 residents for compliance for three months |
Inspection Report
Complaint Investigation
Census: 107
Deficiencies: 2
Aug 22, 2024
Visit Reason
The inspection was conducted in response to a complaint received on June 28, 2024, regarding allegations related to personnel and resident care at the assisted living facility.
Findings
The investigation supported some of the allegations, identifying non-compliance in resident care and personnel standards. Violations included failure to properly document private duty personnel qualifications and criminal history, and failure to administer medications according to physician orders.
Complaint Details
The complaint was substantiated in part, with findings supporting non-compliance in personnel and resident care related to private duty personnel documentation and medication administration.
Deficiencies (2)
| Description |
|---|
| Failure to ensure documentation and review of private duty personnel qualifications and criminal history as required by regulations. |
| Failure to administer medications in accordance with physician's orders, as evidenced by discrepancies in medication administration records for Resident #1. |
Report Facts
Number of residents present: 107
Number of resident records reviewed: 1
Number of staff interviews conducted: 2
Inspection Report
Complaint Investigation
Census: 117
Deficiencies: 3
Jul 29, 2024
Visit Reason
The inspection was conducted in response to a complaint received by the VDSS Division of Licensing regarding allegations in the area of resident care.
Findings
The investigation supported some, but not all, of the allegations; areas of non-compliance were found in resident care and buildings and grounds. Violations related to medication orders, physician signatures, and storage of hazardous materials were identified.
Complaint Details
The complaint investigation was partially substantiated; violations related to resident care and buildings and grounds were found. Some allegations were not supported by evidence.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure that no medication, dietary supplement, diet, medical procedure, or treatment shall be started, changed, or discontinued without a valid order from a physician or other prescriber. |
| Facility failed to ensure that the resident's record contained the physician's or other prescriber's signed written order. |
| Facility failed to ensure that cleaning supplies and other hazardous materials were stored in a locked area. |
Report Facts
Number of residents present: 117
Number of resident records reviewed: 1
Number of resident interviews: 1
Number of staff interviews: 3
Inspection Report
Complaint Investigation
Census: 119
Deficiencies: 3
Jun 17, 2024
Visit Reason
The inspection was conducted in response to a complaint received on March 19, 2024, regarding allegations related to personnel and resident care at the facility.
Findings
The investigation supported some but not all allegations; non-compliance was found in the area of resident care. Violations included failure to ensure individualized service plans contained required information and signatures, and failure to have a physician's written order for the use of a restraint (a zippered jumpsuit) for a resident.
Complaint Details
The complaint was substantiated in part, specifically regarding resident care. The facility failed to comply with standards related to individualized service plans and restraint use as per the complaint investigation.
Deficiencies (3)
| Description |
|---|
| The resident's Individualized Service Plan (ISP) did not contain the date of the identified need and a written description of services to address identified needs. |
| The ISP was not signed or dated by the licensee, administrator, or resident/legal representative. |
| The facility used a restraint (zippered jumpsuit) without a physician's written order specifying condition, circumstances, and duration. |
Report Facts
Number of residents present: 119
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of interviews conducted: 1
Days to submit plan of correction: 5
Months for compliance monitoring: 3
Number of ISPs spot checked monthly: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Davis | Licensing Inspector | Current inspector conducting the complaint investigation |
| Staff #1 | Interviewed staff who confirmed lack of physician's order for restraint use | |
| Director of Wellness | Responsible for reviewing and completing ISPs and educated on restraint use | |
| Executive Director | Responsible for spot checking ISPs monthly and re-education on restraint use |
Inspection Report
Complaint Investigation
Census: 119
Deficiencies: 1
Jun 17, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing regarding staffing allegations on the memory care unit.
Findings
The investigation supported the allegations of non-compliance with staffing requirements on the memory care unit, resulting in violations being issued. The facility failed to ensure adequate awake direct care staff were on duty as required by regulation.
Complaint Details
The complaint was substantiated based on evidence including staff schedules showing insufficient awake direct care staff on the memory care unit on multiple dates.
Deficiencies (1)
| Description |
|---|
| The facility failed to ensure that except during night hours, when 20 or fewer residents are present, at least two direct care staff members shall be awake and on duty at all times in each special care unit responsible for resident care and supervision. |
Report Facts
Number of residents present: 119
Staff on memory care unit: 3
Staff on memory care unit: 3
Correction period: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Davis | Licensing Inspector | Conducted the inspection and is the contact for questions |
| Director of Wellness | Responsible for ensuring staffing requirements and documenting replacements for staff call-offs | |
| Executive Director | Will ensure compliance with correction measures for 90 days |
Inspection Report
Complaint Investigation
Census: 119
Deficiencies: 3
Jun 17, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on February 16, 2024, regarding allegations related to resident care at the facility.
Findings
The investigation found violations of regulations related to fall risk assessments, individualized service plan signatures, and notification of next of kin for a resident testing positive for COVID-19. Violations were issued based on these findings.
Complaint Details
The complaint was substantiated as the evidence gathered supported the allegations of non-compliance with standards related to resident care.
Deficiencies (3)
| Description |
|---|
| The facility failed to ensure that the fall risk rating was reviewed and updated at least annually, when the resident's condition changed, and after a fall. |
| The facility failed to ensure that the individualized service plan was signed and dated by the licensee, administrator, or designee, and by the resident or legal representative. |
| The facility failed to ensure that medical attention was secured immediately and that next of kin were notified and documentation made when a resident tested positive for COVID-19. |
Report Facts
Number of residents present: 119
Number of resident records reviewed: 1
Number of interviews conducted with staff: 1
Falls recorded: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Davis | Licensing Inspector | Inspector conducting the complaint investigation |
| Director of Wellness | Responsible for verifying fall risk ratings, reviewing ISPs, reeducating staff, and monitoring notification compliance | |
| Executive Director | Responsible for spot checking compliance with fall risk ratings, ISPs, and notification of changes of condition |
Inspection Report
Complaint Investigation
Census: 115
Deficiencies: 3
Mar 20, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on January 19, 2024, regarding allegations related to resident care and related services at the facility.
Findings
The investigation supported some, but not all, of the allegations; non-compliance was found in the area of resident care. Violations included failure to complete required Uniform Assessment Instruments, incomplete individualized service plans, and inadequate personal assistance and care documentation.
Complaint Details
The complaint investigation was substantiated in part; evidence supported some allegations related to resident care deficiencies. A violation notice was issued, and the licensee was given the opportunity to submit a plan of correction.
Deficiencies (3)
| Description |
|---|
| Failed to ensure all residents and applicants were assessed face to face using the uniform assessment instrument prior to admission, annually, and with significant condition changes. |
| Individualized service plan (ISP) was not signed or dated by the licensee, administrator, or resident/legal representative. |
| Failed to provide personal assistance and care as necessary, including bathing at least twice a week and nail care, with inadequate documentation of care provided. |
Report Facts
Number of residents present: 115
Number of resident records reviewed: 1
Number of staff interviews conducted: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Davis | Licensing Inspector | Current inspector conducting the complaint investigation |
Inspection Report
Complaint Investigation
Census: 115
Deficiencies: 6
Mar 20, 2024
Visit Reason
The inspection was conducted in response to a complaint received on March 7, 2024, regarding allegations related to resident care at the facility.
Findings
The investigation found multiple violations related to resident care, including failure to update fall risk assessments after a fall, failure to provide care as specified in individualized service plans, failure to notify next of kin after incidents, inadequate documentation of care tasks, and failure to document rounds for residents with signaling device needs.
Complaint Details
The complaint was substantiated as the evidence supported allegations of non-compliance with standards related to resident care.
Deficiencies (6)
| Description |
|---|
| Failure to ensure fall risk rating was reviewed and updated after a fall on February 10, 2024. |
| Failure to provide care and services as specified in the individualized service plan, including bathing, toileting, dressing, diet, and housekeeping. |
| Failure to notify next of kin or responsible parties within 24 hours of a resident fall incident. |
| Failure to provide personal assistance and care to meet residents' needs including activities of daily living and instrumental activities. |
| Failure to provide at least three well-balanced meals daily and document meal intake as required. |
| Failure to document rounds for residents with inability to use signaling devices, including date, time, and staff member making rounds. |
Report Facts
Number of residents present: 115
Number of resident records reviewed: 1
Number of staff interviews conducted: 1
Plan of correction monitoring period: 90
Resident charts sampled for review: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Davis | Licensing Inspector | Inspector conducting the complaint investigation |
| Director of Wellness | Responsible for verifying fall risk ratings, monitoring daily charting, and ensuring nurse education | |
| Executive Director | Responsible for spot checks and monitoring compliance with corrective actions | |
| Charge Nurse | Responsible for ensuring care is provided and documented as per individualized service plans |
Inspection Report
Monitoring
Census: 118
Deficiencies: 3
Dec 14, 2023
Visit Reason
The inspection was a monitoring visit conducted on December 14, 2023, following a self-reported incident received on November 27, 2023, regarding allegations related to resident care and building and grounds.
Findings
The investigation supported the self-report of non-compliance with standards related to resident care, including failure to provide assistance as specified in a resident's Individualized Service Plan, delayed staff response to call bells, and failure to provide necessary personal assistance. Violations were issued and plans of correction were required.
Deficiencies (3)
| Description |
|---|
| Failure to ensure that care and services specified in the individualized service plan are provided to each resident. |
| Failure to provide prompt response by staff to residents' needs as evidenced by call bell wait times. |
| Failure to ensure personal assistance and care are provided as necessary, including assistance with activities of daily living such as bowel and bladder control and eating/feeding. |
Report Facts
Number of residents present: 118
Number of resident records reviewed: 1
Number of staff interviews: 2
Call bell wait times: 6
Call bell wait times: 3
Call bell wait times: 4
Call bell wait times: 2
Plan of correction chart reviews: 5
Plan of correction duration: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Davis | Licensing Inspector | Current inspector conducting the inspection |
| Administrator | Mentioned in relation to confirming failure of personal assistant to provide care | |
| Director of Wellness | Mentioned in relation to confirming failure of personal assistant to provide care and monitoring plan of correction |
Inspection Report
Renewal
Census: 122
Deficiencies: 9
Nov 27, 2023
Visit Reason
The inspection was conducted as a renewal inspection of the assisted living facility to assess compliance with applicable regulations and licensing requirements.
Findings
The inspection identified multiple areas of non-compliance including failure to ensure annual tuberculosis screenings for staff, incomplete or unsigned resident service plans, outdated activity schedules and menus, lack of annual resident rights reviews, missing semi-annual emergency preparedness reviews, and failure to document monthly first aid kit inspections. The facility was issued violation notices and given the opportunity to submit plans of correction.
Deficiencies (9)
| Description |
|---|
| Failure to ensure each staff person annually submits tuberculosis screening results. |
| Failure to ensure each resident's Uniform Assessment Instrument (UAI) is completed prior to admission, annually, and with significant changes. |
| Failure to ensure individualized service plans (ISP) are signed and dated by licensee/administrator and resident or legal representative. |
| Failure to ensure individualized service plans are reviewed and updated at least annually and as needed. |
| Failure to ensure current month's activity schedule is posted in a conspicuous location. |
| Failure to ensure annual review of residents' rights and responsibilities with written acknowledgment in records. |
| Failure to ensure menus for meals and snacks are dated and posted conspicuously. |
| Failure to ensure semi-annual review of emergency preparedness and response plan for all staff, residents, and volunteers. |
| Failure to ensure first aid kits are checked monthly for presence and expiration of items. |
Report Facts
Residents present: 122
Resident records reviewed: 10
Staff records reviewed: 5
Resident interviews conducted: 4
Staff interviews conducted: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Davis | Licensing Inspector | Inspector conducting the renewal inspection |
Inspection Report
Monitoring
Census: 125
Deficiencies: 0
Sep 8, 2023
Visit Reason
The inspection was a monitoring visit conducted on September 8 and September 19, 2023, to review compliance with various regulatory provisions for the assisted living facility.
Findings
The inspection included a tour of the physical plant, review of resident and staff records, interviews, and observation of facility operations. No violations of applicable standards or laws were found during the inspection.
Report Facts
Number of resident records reviewed: 10
Number of staff records reviewed: 5
Number of interviews conducted with residents: 4
Number of interviews conducted with staff: 5
Inspection Report
Original Licensing
Deficiencies: 0
Jun 23, 2023
Visit Reason
An initial inspection was conducted by licensing staff due to a change of ownership.
Findings
No violations were cited during the inspection. A conditional license will be recommended.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Davis | Licensing Inspector | Current inspector conducting the initial licensing inspection. |
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