Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 0
Nov 6, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-11-03 regarding allegations in the areas of Resident Care and Related Services and Staffing and Supervision.
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 investigation related to allegations in Resident Care and Related Services and Staffing and Supervision. The complaint was not substantiated.
Report Facts
Number of residents present: 69
Number of interviews conducted with staff: 6
Number of resident records reviewed: 0
Number of staff records reviewed: 0
Inspection Report
Monitoring
Census: 109
Deficiencies: 1
Sep 2, 2025
Visit Reason
The inspection was a monitoring visit conducted on September 2, 2025, to review compliance with staffing, resident care, building and grounds, and additional requirements for adults with serious cognitive impairments.
Findings
The investigation supported self-reports of non-compliance related to malfunctioning exit doors in the secure unit, which led to resident elopements. Violations were issued, and a plan of correction was initiated to address door security and functionality.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure doors leading to unprotected areas were monitored or secured through devices conforming to applicable building and fire codes, resulting in resident elopements. |
Report Facts
Number of residents present: 109
Number of resident records reviewed: 2
Number of staff interviews conducted: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jacquelyn Kabiri | Licensing Inspector | Conducted the inspection and is the contact for questions |
| Director of Facilities | Ordered delayed egress maglocks, inspected exit doors, initiated training, and will conduct monthly door inspections | |
| Skilled Nursing Administrator | Responsible for confirming implementation and ongoing compliance of the plan of correction |
Inspection Report
Monitoring
Census: 69
Deficiencies: 0
Jun 27, 2025
Visit Reason
The inspection was a monitoring visit conducted on June 27, 2025, following a self-reported incident received on June 9, 2025, regarding allegations in Resident Care and Related Services and Personnel.
Findings
The investigation did not support the self-report of non-compliance with standards or law. The licensing inspector completed a tour of the physical plant and conducted interviews and record reviews without identifying deficiencies.
Report Facts
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: 1
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 2
Sep 24, 2024
Visit Reason
The inspection was conducted in response to a complaint received by the VDSS Division of Licensing on 09/24/2024 regarding allegations related to resident accommodations and related provisions, as well as resident care and related services.
Findings
The investigation did not substantiate the complaint allegations; however, violations unrelated to the complaint were identified, including failure to report a major incident within 24 hours and failure to specify a minimal frequency of daily rounds in an Individualized Service Plan (ISP). The facility submitted plans of correction addressing these issues.
Complaint Details
Complaint related to resident accommodations and related provisions, and resident care and related services. The evidence gathered did not support the allegations of non-compliance with standards or law.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure that any major incident negatively affecting or threatening resident health, life, safety, and welfare was reported to the regional licensing office within 24 hours. |
| Facility failed to ensure that the Individualized Service Plan (ISP) specified a minimal frequency of daily rounds by direct care staff to monitor for emergencies or other unanticipated resident needs. |
Report Facts
Number of residents present: 67
Number of resident records reviewed: 1
Number of staff interviews conducted: 4
Audit period for plan of correction monitoring: 3
Inspection Report
Renewal
Census: 70
Deficiencies: 11
May 15, 2024
Visit Reason
The inspection was a renewal inspection conducted on May 15 and May 16, 2024, to assess compliance with applicable standards and laws for the facility's license renewal.
Findings
The inspection identified multiple violations related to documentation, staff orientation, resident notifications, emergency preparedness, and safety measures. The facility was found non-compliant with several standards and was required to submit plans of correction to address these deficiencies.
Deficiencies (11)
| Description |
|---|
| Failed to ensure information on the type and frequency of services by private duty personnel was obtained in writing. |
| Failed to ensure all volunteers attended orientation including duties, resident rights, confidentiality, emergency procedures, infection control, supervisor name, and reporting requirements. |
| Failed to ensure a list of staff with current first aid or CPR certification was posted and readily available. |
| Failed to ensure residents or legal representatives were fully informed about sex offender information upon admission and annually. |
| Failed to ensure the written agreement included descriptions of all accommodations, services, care, related charges, and resident conduct requirements. |
| Failed to ensure acknowledgment of facility orientation was signed and dated by the resident and kept in the resident's record. |
| Failed to ensure a new Uniform Assessment Instrument (UAI) was completed prior to admission, annually, or with significant change in condition. |
| Failed to ensure special diet oversight was certified including date and resident identification. |
| Failed to obtain detailed PRN medication orders including symptoms indicating use when administered by medication aides. |
| Failed to ensure semi-annual review of emergency preparedness and response plan was conducted for all residents. |
| Failed to ensure fire and emergency evacuation drawings were accurate and posted on each floor with correct information. |
Report Facts
Number of residents present: 70
Number of resident records reviewed: 7
Number of staff records reviewed: 6
Number of resident interviews: 3
Number of staff interviews: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Confirmed multiple deficiencies including private duty personnel records, volunteer records, orientation documentation, medication orders, emergency evacuation drawing, and others. | |
| Staff 4 | Confirmed volunteer records were not completed. |
Inspection Report
Monitoring
Deficiencies: 0
Jun 28, 2023
Visit Reason
Unannounced monitoring inspections were conducted on June 28, 2023 and July 7, 2023 in response to a facility reported incident.
Findings
Medication administration and one resident record were observed. An interview was conducted and facility documentation was reviewed. No violations were cited during the inspection.
Inspection Report
Renewal
Census: 68
Deficiencies: 4
Feb 16, 2023
Visit Reason
An unannounced renewal inspection was conducted to assess compliance with applicable standards and laws, including observation of meals, medication administration, activities, building and grounds inspection, and record review.
Findings
The inspection found multiple violations related to medication management, including expired medication on the cart, improper medication storage, administration of medications outside prescribed parameters, and missing PRN medication. Plans of correction were submitted addressing these issues with audits and staff training.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure medication management plan is implemented to prevent use of outdated medication; expired Midodrine found on medication cart. |
| Facility failed to limit medication storage to an out-of-sight place in rooms of residents capable of self-administering medication; unlocked Deep Sea Nasal Spray found in Resident #4's room. |
| Facility failed to ensure medications are administered according to physician's instructions and standards; blood pressure medications given outside parameters for Residents #3 and #11. |
| Facility failed to ensure PRN medications are available and properly stored; Ativan solution for Resident #3 was missing from medication cart. |
Report Facts
Residents on blood pressure medications with parameters audited: 45
Resident records reviewed: 10
Staff records reviewed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marshall Massenberg | Licensing Inspector | Contact person for questions about the VDSS Licensing Programs |
| Jacquelyn Kabiri | Inspector | Current inspector conducting the inspection |
| Resident Care Director | Provided refresher training and responsible for audits and implementation of plan of correction |
Inspection Report
Monitoring
Deficiencies: 0
Jan 18, 2023
Visit Reason
An unannounced monitoring inspection was conducted to follow-up on a facility-reported incident.
Findings
One resident record was observed and interviews were conducted. No violations were cited during the inspection.
Inspection Report
Renewal
Census: 66
Deficiencies: 5
Mar 24, 2022
Visit Reason
An unannounced renewal inspection was conducted to assess compliance with licensing requirements, including review of resident care, medication administration, activities, building and grounds, and records.
Findings
The inspection identified multiple violations related to tuberculosis risk assessments for staff and residents, unsecured resident records and medications, and lack of oxygen therapy safety precautions. Plans of correction were initiated to address these deficiencies.
Deficiencies (5)
| Description |
|---|
| Facility failed to ensure each staff person submits a timely tuberculosis risk assessment prior to first day of work. |
| Facility failed to ensure annual tuberculosis risk assessments were completed on each resident. |
| Facility failed to ensure all resident records are kept in a locked area. |
| Facility failed to ensure medications and dietary supplements are stored in locked cabinets or compartments. |
| Facility failed to ensure safety precautions for oxygen therapy, including posting oxygen signs and having oxygen orders. |
Report Facts
Residents present: 66
Sample size: 10
Sample size: 5
Audit period: 3
Residents with oxygen order: 6
Residents with oxygen tank and door signs: 4
Inspection Report
Deficiencies: 0
Jul 6, 2021
Visit Reason
A non-mandated self-report inspection was initiated due to a self-reported incident regarding allegations in the area of Resident Care and Related Services. The investigation included on-site observation and review of documentation.
Findings
The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law.
Inspection Report
Renewal
Census: 54
Deficiencies: 1
Mar 9, 2021
Visit Reason
The inspection was conducted as a renewal inspection initiated on March 11, 2021, to ensure compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection found non-compliance related to medication administration where Resident #3 did not receive prescribed medication on multiple dates due to pending delivery. A violation notice was issued and a plan of correction was implemented.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure medications were administered according to physician's instructions and standards of practice, specifically Resident #3's Remeron was not administered on several dates due to pending delivery. |
Report Facts
Census: 54
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jacquelyn Kabiri | Inspector | Current inspector conducting the inspection |
Inspection Report
Monitoring
Census: 58
Deficiencies: 2
Jan 7, 2021
Visit Reason
A monitoring inspection was initiated to review compliance with applicable standards and laws using an alternate remote protocol due to a state of emergency health pandemic.
Findings
The inspection found non-compliance with standards related to documentation of residents' physical examinations, specifically missing documentation of allergic reactions for residents #2 and #4.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure that each resident's physical examination contains all of the required information, specifically missing reactions to allergens for Resident #2. |
| Facility failed to document allergic reactions to gluten, lactose, and milk related products for Resident #4 despite documenting reactions to NSAIDs. |
Report Facts
Census: 58
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jacquelyn Kabiri | Inspector | Named as current inspector conducting the inspection |
| RN Resident Care Director | Resident Care Director | Responsible for performing audits and education related to allergen documentation |
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