Inspection Reports for The Crossings at Ironbridge
6701 Ironbridge Pkwy, Chester, VA 23831, United States, VA, 23831
Back to Facility ProfileDeficiencies per Year
12
9
6
3
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 0
Jul 10, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on June 23, 2025, regarding allegations related to resident care and staffing at the facility.
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 alleging issues in resident care and staffing. The evidence gathered did not substantiate the allegations.
Report Facts
Resident records reviewed: 1
Staff interviews conducted: 1
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 1
Jul 10, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on June 10, 2025, regarding allegations related to resident care at The Crossings at Ironbridge.
Findings
The investigation did not substantiate the complaint allegations of non-compliance; however, a violation unrelated to the complaint was identified involving the facility's failure to report a major incident to the regional licensing office within 24 hours as required.
Complaint Details
A complaint was received alleging issues with resident care. The evidence gathered did not support the allegations of non-compliance. The violation found was not related to the complaint.
Deficiencies (1)
| Description |
|---|
| The facility failed to ensure reporting to the regional licensing office within 24 hours of a major incident that negatively affected or threatened the life, health, safety, or welfare of a resident. |
Report Facts
Number of residents present: 67
Number of resident records reviewed: 1
Number of staff interviews conducted: 1
Inspection Report
Monitoring
Census: 68
Deficiencies: 2
Jul 3, 2025
Visit Reason
The inspection was a monitoring visit conducted following a self-reported incident received by VDSS Division of Licensing on May 5, 2025, regarding allegations in the areas of personnel and resident care.
Findings
The investigation supported the self-report of non-compliance with standards and violations were issued related to staff conduct and documentation of incidents. Specifically, a staff member was observed pulling a resident's hair, and the facility failed to document the incident and corresponding actions in the resident's record.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure that all staff shall be considerate and respectful of the rights, dignity, and sensitivities of persons who are aged or infirm or who have disabilities, evidenced by a staff member pulling a resident's hair. |
| Facility failed to ensure that any notable change in a resident's condition or functioning and any corresponding action taken shall be documented in the resident's record; the incident of hair pulling was not documented. |
Report Facts
Number of residents present: 68
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 2
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 2
Jul 3, 2025
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received by VDSS Division of Licensing on 2025-05-19 regarding allegations in the area of resident care.
Findings
The investigation supported some, but not all, of the allegations. Violations were found related to failure to update fall risk assessments after a fall and failure to document notable changes in a resident's condition and corresponding actions taken.
Complaint Details
The complaint was partially substantiated; some allegations were supported by evidence while others were not.
Deficiencies (2)
| 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 any notable change in a resident's condition or functioning and any corresponding action taken were documented in the resident's record. |
Report Facts
Number of residents present: 68
Number of resident records reviewed: 1
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 2
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 3
Jul 3, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on June 9, 2025, regarding allegations related to resident care and staffing at the facility.
Findings
The investigation supported some but not all allegations; non-compliance was found in resident care standards. Violations included failure to complete the Uniform Assessment Instrument prior to admission and annually, failure to update Individualized Service Plans to reflect significant changes in resident behavior, and failure to document observations and notifications related to resident condition changes.
Complaint Details
The complaint investigation was substantiated in part; violations related to resident care were confirmed, while some allegations were not supported by evidence.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure that the Uniform Assessment Instrument (UAI) was completed prior to admission, at least annually, and whenever there was a significant change in the resident's condition. |
| Facility failed to ensure that Individualized Service Plans (ISP) were reviewed and updated at least once every 12 months and as needed for significant changes in a resident's condition. |
| Facility failed to regularly observe each resident for changes in physical, mental, emotional, and social functioning, and failed to document corresponding actions and notifications. |
Report Facts
Number of residents present: 68
Number of resident records reviewed: 2
Number of staff interviews conducted: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Davis | Licensing Inspector | Inspector conducting the complaint investigation |
Inspection Report
Renewal
Census: 61
Deficiencies: 10
May 7, 2025
Visit Reason
The inspection was a renewal visit conducted on May 7 and May 23, 2025, to assess compliance with applicable standards and laws for licensing renewal of the assisted living facility.
Findings
The inspection identified multiple violations related to resident record reviews, staff certification, risk assessments, admission procedures, individualized service plans, staff response times, meal menu postings, dietitian oversight, and facility ventilation. Violations were documented and a violation notice was issued to the facility.
Deficiencies (10)
| Description |
|---|
| Failed to ensure six-month and annual review of appropriateness of continued residence in special care unit. |
| Failed to ensure direct care staff maintain current certification in first aid. |
| Failed to ensure tuberculosis risk assessment was conducted by a licensed healthcare provider. |
| Failed to ascertain and document whether potential resident is a registered sex offender prior to admission. |
| Failed to obtain complete personal and social information on residents at or prior to admission. |
| Failed to ensure individualized service plans were signed and dated by resident or legal representative. |
| Failed to provide prompt staff response to resident needs as reasonable to circumstances. |
| Failed to post dated menus for meals and snacks in a conspicuous area to residents. |
| Failed to ensure oversight every six months by dietitian or nutritionist for residents on special diets. |
| Failed to ensure all buildings were well-ventilated and free from foul, stale, and musty odors. |
Report Facts
Number of residents present: 61
Number of resident records reviewed: 6
Number of staff records reviewed: 3
Number of resident interviews conducted: 4
Number of staff interviews conducted: 3
Call bell response time: 11.2833
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 0
Jan 29, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing regarding allegations related to resident care.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law.
Complaint Details
Complaint related to resident care; the allegations were not substantiated.
Report Facts
Number of resident records reviewed: 1
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 1
Inspection Report
Monitoring
Census: 59
Deficiencies: 1
Jan 29, 2025
Visit Reason
The inspection was a monitoring visit conducted to review compliance with additional requirements for facilities that care for adults with serious cognitive impairments, based on a self-reported incident regarding the secure environment.
Findings
The investigation supported the self-report of non-compliance related to the facility's failure to ensure that doors leading to unprotected areas were properly monitored or secured. A resident was able to exit the memory care unit unsupervised and was found at the bottom of a stairwell, resulting in an emergency room visit with no injuries.
Deficiencies (1)
| Description |
|---|
| Failure to ensure that doors leading to unprotected areas were monitored or secured through devices conforming to applicable building and fire codes, including door alarms and staff oversight. |
Report Facts
Number of residents present: 59
Date of self-reported incident: Aug 2, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Davis | Licensing Inspector | Current inspector conducting the monitoring inspection |
| Staff #1 | Staff member who reported that door alarm was not heard at the time of the incident |
Inspection Report
Monitoring
Census: 59
Deficiencies: 3
Jan 29, 2025
Visit Reason
The inspection was a monitoring visit triggered by a self-reported incident regarding resident care and medication administration.
Findings
The investigation confirmed violations related to medication administration, including failure to have signed or dated physician orders, administering medication intended for one resident to another, and failure to document medication administration on the MAR.
Deficiencies (3)
| Description |
|---|
| The facility failed to ensure that the resident's record contained the physician's or other prescriber's signed written order or dated notation of oral order. |
| The facility failed to ensure that medications were administered in accordance with the physician's or other prescriber's instructions, including administering the wrong resident's medication. |
| The facility failed to document on the medication administration record all medications administered to residents, including over-the-counter medications and dietary supplements. |
Report Facts
Number of residents present: 59
Number of resident records reviewed: 2
Number of staff interviews: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Davis | Licensing Inspector | Named as the current inspector conducting the inspection |
| Staff #1 | Interviewed staff member who confirmed medication administration issues |
Inspection Report
Renewal
Census: 66
Deficiencies: 4
May 1, 2024
Visit Reason
The inspection was conducted as a renewal inspection of the assisted living facility to assess compliance with applicable standards and regulations.
Findings
The inspection identified multiple violations related to staff training hours, infection control training, sex offender registry checks prior to admission, and facility ventilation with odor issues. The facility was found non-compliant with certain standards and was issued a violation notice.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure all direct care staff attended at least 18 hours of annual training; Staff #5 (CNA) lacked documentation of 12 hours of training. |
| Facility failed to ensure at least two hours of training focused on infection control and prevention; Staff #5 lacked documentation of 2 hours infection control training. |
| Facility failed to ascertain prior to admission whether potential residents were registered sex offenders; Residents #1 and #10 lacked timely sex offender screening. |
| Facility failed to ensure all buildings were well-ventilated and free from foul odors; strong urine odor observed in first-floor hallway. |
Report Facts
Number of residents present: 66
Number of resident records reviewed: 10
Number of staff records reviewed: 5
Number of resident interviews: 4
Number of staff interviews: 3
Inspection Report
Monitoring
Census: 65
Deficiencies: 0
Mar 26, 2024
Visit Reason
The inspection was a monitoring visit conducted on March 26, 2024, following a self-reported incident received by VDSS Division of Licensing on February 16, 2024, regarding allegations in the area of resident accommodations.
Findings
The investigation did not support the self-report of non-compliance with standards or law. An exit meeting was conducted to review the inspection findings, and the inspection summary will be posted publicly.
Report Facts
Resident records reviewed: 1
Resident interviews conducted: 1
Staff interviews conducted: 1
Inspection Report
Monitoring
Census: 65
Deficiencies: 2
Mar 26, 2024
Visit Reason
The inspection was a monitoring visit triggered by a self-reported incident regarding resident care and related services.
Findings
The inspection found violations related to the facility's medication management plan being outdated and failure to properly store medications, including a missing narcotic medication.
Deficiencies (2)
| Description |
|---|
| The facility's medication management plan was not current as it was dated 12/2014. |
| The facility failed to ensure proper storage of medications; a narcotic medication (Oxycodone 5mg) was missing and not stored properly. |
Report Facts
Number of residents present: 65
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of interviews conducted with staff: 1
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 3
Mar 12, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on February 14, 2024, regarding allegations related to resident care and related services at The Crossings at Ironbridge.
Findings
The investigation found violations related to failure to provide adequate personal assistance with bathing and hygiene, failure to ensure residents are dressed in clean clothing and free of odors, and failure to administer medications according to physician orders. Violations were substantiated and corrective actions were required.
Complaint Details
The complaint was substantiated based on evidence including shower logs, skin integrity monitoring sheets, hospice documentation, and medication administration records indicating non-compliance with care and medication administration standards.
Deficiencies (3)
| Description |
|---|
| Failure to ensure personal assistance and care with bathing at least twice a week and hygiene and grooming including skin care at least twice daily for residents with limited mobility. |
| Failure to ensure each resident is dressed in clean clothing and free of odors related to hygiene. |
| Failure to ensure medications are administered in accordance with physician's instructions, including continued administration of a discontinued medication. |
Report Facts
Residents present: 66
Resident records reviewed: 1
Staff interviews conducted: 1
Shower dates for Resident #1: 6
Medication administration dates for discontinued drug: 8
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 0
Aug 23, 2023
Visit Reason
The inspection was conducted in response to a complaint received on July 24, 2023, regarding allegations related to resident care and personnel at the facility.
Findings
The investigation found no evidence to support the allegations of non-compliance with standards or laws. The inspection included a tour of the facility, record reviews, interviews, and observation of the lunch meal.
Complaint Details
A complaint was received by VDSS Division of Licensing on July 24, 2023 regarding allegations in the areas of resident care and personnel. The evidence gathered did not support the allegations.
Report Facts
Resident records reviewed: 15
Staff records reviewed: 4
Resident interviews conducted: 5
Staff interviews conducted: 1
Inspection Report
Renewal
Census: 65
Deficiencies: 6
Jun 8, 2023
Visit Reason
The inspection was conducted as a renewal inspection to assess compliance with applicable standards and laws for licensing renewal.
Findings
The inspection identified multiple violations related to staff certification, fire safety inspections, emergency preparedness, fire drills, emergency supplies, and background checks. Plans of correction were proposed for each violation to address and maintain compliance.
Deficiencies (6)
| Description |
|---|
| Facility failed to ensure that each direct care staff member who does not have current certification in first aid shall receive certification within 60 days of employment. |
| Facility failed to comply with the Virginia Statewide Fire Prevention Code as determined by at least an annual inspection by the appropriate fire official. |
| Facility failed to ensure the semi-annual review on the emergency preparedness and response plan for all staff, residents, and volunteers was documented. |
| Facility failed to ensure that fire and emergency evacuation drill frequency and participation were in accordance with the Virginia Statewide Fire Prevention Code. |
| Facility failed to ensure the availability of a 96-hour supply of emergency food and drinking water with at least 48 hours on site. |
| Facility failed to ensure that a criminal history record report from the State Police was obtained prior to the 30th day of employment for certain staff. |
Report Facts
Number of residents present: 65
Number of resident records reviewed: 8
Number of staff records reviewed: 4
Number of resident interviews conducted: 3
Number of staff interviews conducted: 4
Date of last fire inspection: Feb 17, 2022
Inspection Report
Census: 62
Deficiencies: 0
Apr 18, 2023
Visit Reason
The licensing inspector conducted an inspection tour of the facility's converted memory care rooms and took measurements. The facility is not requesting a change in their licensed capacity.
Findings
The inspection included a review of buildings and grounds with no complaint related issues. An exit meeting was conducted to review the inspection findings, which are subject to public disclosure.
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 5
Apr 18, 2023
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on March 17, 2023, regarding allegations in the area of resident care.
Findings
The investigation supported some, but not all, of the allegations related to resident care. Several violations were identified, including failure to report major incidents timely, missing discharge statements, unsigned individualized service plans, lack of documentation of notable changes in resident condition, and inadequate documentation of personal care such as bathing.
Complaint Details
The complaint investigation was substantiated in part, with non-compliance found in resident care areas including documentation and reporting failures.
Deficiencies (5)
| Description |
|---|
| Failed to report to the regional licensing office within 24 hours any major incident negatively affecting or threatening resident safety. |
| Failed to retain a copy of the written discharge statement in the resident's record. |
| Individualized service plan (ISP) was not signed or dated by the licensee, administrator, or resident/legal representative. |
| Failed to document notable changes in a resident's condition, including illness, injury, or altered behavior, and corresponding actions taken. |
| Failed to ensure personal assistance and care with bathing at least twice a week, including proper documentation on shower logs. |
Report Facts
Number of residents present: 66
Number of resident records reviewed: 3
Number of resident interviews: 1
Number of staff interviews: 2
Dates missing shower documentation: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Davis | Licensing Inspector | Inspector conducting the complaint investigation |
Inspection Report
Renewal
Census: 75
Deficiencies: 1
Oct 13, 2022
Visit Reason
The inspection was conducted as a renewal of the facility's license to ensure compliance with applicable standards and laws.
Findings
The inspection found non-compliance with the standard requiring annual review of residents' rights and responsibilities, with documentation missing or outdated for several residents. The facility was issued a violation notice and given the opportunity to submit a plan of correction.
Deficiencies (1)
| Description |
|---|
| Failure to ensure that the rights and responsibilities of residents were reviewed annually with each resident or their legal representative, with proper written acknowledgment filed in the resident's record. |
Report Facts
Number of residents present: 75
Number of resident records reviewed: 10
Number of staff records reviewed: 5
Number of interviews conducted with residents: 3
Number of interviews conducted with staff: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Davis | Licensing Inspector | Inspector who conducted the inspection |
Inspection Report
Monitoring
Census: 61
Deficiencies: 0
Feb 8, 2022
Visit Reason
The inspection was a monitoring visit conducted on February 8, 2022, following a self-reported incident received on January 7, 2022 regarding allegations in the area of resident care.
Findings
The inspection found no violations of applicable standards or laws based on the evidence gathered during the visit.
Report Facts
Number of resident records reviewed: 1
Number of interviews conducted with staff: 3
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 2
Feb 8, 2022
Visit Reason
The inspection was conducted in response to a complaint received by the VDSS Division of Licensing regarding allegations in the areas of administration and resident care.
Findings
The investigation supported some, but not all, of the allegations related to administration and resident care. Violations were found including failure to report a major incident within 24 hours and failure to retain a discharge statement in a resident's record.
Complaint Details
The complaint investigation was substantiated in part; the facility failed to report an allegation of physical abuse within the required timeframe. The evidence supported non-compliance in administration and resident care.
Deficiencies (2)
| 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, specifically an allegation of physical abuse by a staff member. |
| Facility failed to ensure that at the time of discharge a copy of the discharge statement was retained in the resident's record. |
Report Facts
Number of residents present: 61
Number of resident records reviewed: 1
Number of staff interviews conducted: 3
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 5, 2021
Visit Reason
A non-mandated complaint inspection was initiated due to a complaint received regarding allegations in the areas of resident food.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law.
Complaint Details
The complaint was related to resident food. The investigation included telephone contact with the nurse supervisor, review of documentation, and an on-site observation. The complaint was not substantiated.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Davis | Licensing Inspector | Conducted the complaint investigation and on-site observation. |
Inspection Report
Renewal
Census: 60
Deficiencies: 0
Jun 11, 2021
Visit Reason
A renewal inspection was conducted using an alternate remote protocol due to a state of emergency health pandemic declared by the Governor of Virginia.
Findings
The inspection reviewed resident and staff records, medication administration, physician orders, and criminal history records. No violations with applicable standards or law were found, and no deficiencies were issued.
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