Inspection Reports for The Gardens of Virginia Beach
5620 Wesleyan Dr, Virginia Beach, VA 23455, United States, VA, 23455
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Inspection Report
Complaint Investigation
Census: 109
Deficiencies: 1
Oct 9, 2025
Visit Reason
An unannounced complaint inspection was conducted following a complaint received on 2025-09-11 regarding allegations in the areas of Resident Care and Related Services and Personnel.
Findings
The investigation supported some, but not all, of the allegations related to Resident Care and Related Services. A violation was found where staff fed a resident while the resident was sitting on the floor without offering assistance or asking for the resident's preference, violating resident dignity and rights.
Complaint Details
Complaint was substantiated in part regarding Resident Care and Related Services. The complaint involved failure to respect resident dignity during feeding as evidenced by video footage and staff interview.
Deficiencies (1)
| Description |
|---|
| Facility failed to be considerate and respectful of the rights, dignity, and sensitivities of persons who are aged or infirm or who have disabilities, specifically feeding a resident while sitting on the floor without consent or assistance. |
Report Facts
Number of residents present: 109
Number of resident records reviewed: 4
Number of staff records reviewed: 5
Number of staff interviews conducted: 4
Video footage duration: 10
Corrective action completion deadline: Dec 22, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donesia Peoples | Licensing Inspector | Conducted the inspection and investigation |
| Director of Nursing | Met with staff to review expectations regarding resident dignity and proper assistance techniques; involved in corrective action plan | |
| Executive Director | Met with staff to review expectations regarding resident dignity and proper assistance techniques; involved in corrective action plan | |
| Staff #2 | Caregiver observed feeding resident while resident was sitting on the floor; confirmed incident during interview |
Inspection Report
Complaint Investigation
Census: 109
Deficiencies: 0
Oct 9, 2025
Visit Reason
An unannounced complaint inspection was conducted due to a complaint received on 2025-09-16 regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation did not support the allegations of non-compliance with standards or law. The inspection findings will be posted publicly and a copy is required to be posted at the facility.
Complaint Details
Complaint received by VDSS Division of Licensing on 2025-09-16 regarding allegations in Resident Care and Related Services. The evidence gathered did not support the allegations.
Report Facts
Resident records reviewed: 4
Staff records reviewed: 4
Staff interviews conducted: 6
Resident interviews conducted: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donesia Peoples | Licensing Inspector | Named as the current inspector conducting the complaint investigation |
Inspection Report
Renewal
Census: 101
Deficiencies: 3
Sep 4, 2025
Visit Reason
An unannounced renewal inspection was conducted to evaluate compliance with applicable standards and regulations for license renewal.
Findings
The inspection identified multiple violations related to failure to complete required Uniform Assessment Instruments (UAI) annually, failure to develop preliminary plans of care within required timeframes, and lack of documented health care oversight by a licensed professional. Plans of correction were submitted to address these deficiencies.
Deficiencies (3)
| Description |
|---|
| Failure to ensure the Uniform Assessment Instrument (UAI) was completed prior to admission, at least annually, and whenever there is a significant change in the resident's condition. |
| Failure to ensure a preliminary plan of care was developed on or within 7 days prior to admission to address basic needs of the resident. |
| Failure to ensure licensed health care professional provided health care oversight at least every six months for residents requiring assisted living care. |
Report Facts
Number of residents present: 101
Number of resident records reviewed: 6
Number of staff records reviewed: 3
Number of resident interviews conducted: 2
Number of staff interviews conducted: 3
Plan of correction completion deadline: 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donesia Peoples | Licensing Inspector | Conducted the inspection and is contact for questions |
Inspection Report
Complaint Investigation
Census: 109
Deficiencies: 3
Jul 17, 2025
Visit Reason
An unannounced complaint inspection was conducted following a complaint received on 2025-07-07 regarding allegations in the areas of Staffing and Supervision, Resident Care and Related Services, and Safe Secure Environment.
Findings
The investigation supported some but not all allegations of non-compliance related to Resident Care and Related Services. Violations were found in medication administration documentation, response to medication review recommendations, and failure to document required resident rounds in the safe secure unit.
Complaint Details
Complaint related: Yes. The complaint was substantiated in part, specifically regarding Resident Care and Related Services. Some allegations were not supported.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure medication administration records included date, time, staff initials, and documentation of medication errors or omissions. |
| Facility failed to ensure actions taken in response to recommendations noted in resident medication reviews were documented. |
| Facility failed to ensure individualized service plans specified minimum frequency of daily rounds and failed to document rounds made for residents unable to use signaling devices. |
Report Facts
Residents present: 109
Resident records reviewed: 2
Staff records reviewed: 3
Staff interviews conducted: 5
Medication documentation missing dates: 22
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donesia Peoples | Licensing Inspector | Inspector conducting the complaint investigation and interviews. |
| Staff #4 | Staff interviewed who confirmed missing documentation in medication administration records and rounds documentation. |
Inspection Report
Complaint Investigation
Census: 108
Deficiencies: 0
Jul 17, 2025
Visit Reason
An unannounced complaint inspection was conducted following a complaint received on 2025-07-16 regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation did not support the allegation of non-compliance with standards or law. The inspection included a tour of the facility, review of medication carts and books, and interviews with one resident and one staff member.
Complaint Details
Complaint received by VDSS Division of Licensing on 2025-07-16 regarding Resident Care and Related Services; evidence gathered did not support the allegation of non-compliance.
Report Facts
Number of residents present: 108
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews with residents: 1
Number of interviews with staff: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donesia Peoples | Licensing Inspector | Conducted the inspection and is the contact for questions |
Inspection Report
Monitoring
Census: 104
Deficiencies: 0
Jun 16, 2025
Visit Reason
An unannounced monitoring inspection was conducted following a self-reported incident received on 2025-06-06 regarding allegations in Resident Care and Related Services.
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 reviewed staffing schedules, resident and staff records, and conducted interviews.
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: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donesia Peoples | Licensing Inspector | Inspector conducting the monitoring inspection |
Inspection Report
Monitoring
Census: 104
Deficiencies: 4
Jun 16, 2025
Visit Reason
An unannounced monitoring inspection was conducted following a self-reported incident received by VDSS Division of Licensing regarding allegations in the areas of Personnel and Resident Care and Related Services.
Findings
The inspection found multiple violations including failure to ensure timely orientation and training for staff, failure to assume general responsibility for resident health and safety resulting in bruising due to improper lifting, and failure to obtain criminal history reports within required timeframes. Violations were substantiated and plans of correction were requested.
Deficiencies (4)
| Description |
|---|
| Failed to ensure orientation and training occurred within the first seven working days of employment for staff #1. |
| Failed to assume general responsibility for the health, safety, and well-being of residents, resulting in bruises on resident #1 due to staff lifting practices. |
| Failed to ensure proper storage of medication book and protected health information. |
| Failed to obtain criminal history report on or prior to the 30th day of employment for staff #1. |
Report Facts
Number of residents present: 104
Number of resident records reviewed: 1
Number of staff records reviewed: 3
Number of resident interviews conducted: 1
Number of staff interviews conducted: 1
Inspection Report
Complaint Investigation
Census: 103
Deficiencies: 1
Apr 23, 2025
Visit Reason
An unannounced complaint inspection was conducted following a complaint received on 2025-03-27 regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation supported some of the allegations related to Resident Care and Related Services. A violation was found regarding improper storage of resident medication records, which were left unsecured on a medication cart.
Complaint Details
Complaint was substantiated in part regarding Resident Care and Related Services. A violation notice was issued.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure all resident records were kept current, retained at the facility, and kept in a locked area; medication book and narcotic binder were left unsecured on top of an unstaffed medication cart. |
Report Facts
Number of residents present: 103
Number of resident records reviewed: 1
Number of staff records reviewed: 3
Number of interviews conducted with residents: 4
Number of interviews conducted with staff: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donesia Peoples | Licensing Inspector | Conducted the inspection and investigation |
| Director of Health and Wellness | Named in plan of correction for removing medication book and conducting rounds |
Inspection Report
Monitoring
Census: 105
Deficiencies: 2
Mar 6, 2025
Visit Reason
An announced monitoring inspection was conducted on March 6, 2025, following a self-reported incident received on March 3, 2025, regarding allegations in Resident Care and Related Services and the Safe Secure Environment.
Findings
The inspection found non-compliance with applicable standards, including failure to ensure proper security monitoring of doors leading outside for residents with serious cognitive impairments and failure to ensure the Uniform Assessment Instrument (UAI) was properly completed and signed for private pay individuals.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure doors leading to the outside had a system of security monitoring for residents with serious cognitive impairments, such as door alarms or delayed egress mechanisms. |
| Facility failed to ensure the Uniform Assessment Instrument (UAI) for private pay individuals was completed and signed by a qualified assessor and approved by the administrator or designated representative. |
Report Facts
Number of residents present: 105
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
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donesia Peoples | Licensing Inspector | Inspector conducting the monitoring inspection |
| Staff #2 | Staff interviewed regarding the memory care unit door security failure |
Inspection Report
Complaint Investigation
Census: 100
Deficiencies: 4
Jan 24, 2025
Visit Reason
An unannounced complaint inspection was conducted following a complaint received on 2025-01-10 regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation supported some but not all allegations of non-compliance related to Resident Care and Related Services. Several violations were identified including failure to update fall risk ratings after falls, incomplete annual Uniform Assessment Instruments, unsigned individualized service plans, and failure to ensure general responsibility for resident safety.
Complaint Details
The complaint investigation was substantiated in part, with violations found related to Resident Care and Related Services. The complaint involved safety concerns between two residents, including falls and inadequate supervision.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure fall risk rating was reviewed and updated at least annually, when resident condition changed, and after a fall. |
| Facility failed to ensure the Uniform Assessment Instrument (UAI) was completed at least annually. |
| Facility failed to ensure Individualized Service Plans (ISP) were signed and dated by the licensee, administrator, or designee, and by the resident or legal guardian. |
| Facility failed to ensure general responsibility for the health, safety, and well-being of residents, specifically related to resident interactions and safety concerns. |
Report Facts
Residents present: 100
Resident records reviewed: 2
Staff interviews conducted: 5
Resident interviews conducted: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donesia Peoples | Licensing Inspector | Current inspector conducting the complaint investigation |
Inspection Report
Monitoring
Census: 102
Deficiencies: 1
Dec 5, 2024
Visit Reason
An unannounced monitoring inspection was conducted to review compliance with regulations, including a self-reported incident regarding safe secure environment and buildings and grounds.
Findings
The investigation supported some but not all allegations; non-compliance was found in Resident Care and Related Services. A violation was issued related to staffing in the special care unit.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure except during night hours, when 20 or fewer residents are present, at least two direct care staff members are awake on duty at all times in each special care unit responsible for care and supervision. |
Report Facts
Number of residents present: 102
Number of resident records reviewed: 1
Number of staff interviews conducted: 3
Special care unit census: 18
Inspection Report
Complaint Investigation
Census: 105
Deficiencies: 3
Oct 31, 2024
Visit Reason
An unannounced complaint inspection was conducted following a complaint received on 2024-10-22 regarding allegations in staffing and supervision, resident care and related services, and the safe secure environment.
Findings
The investigation supported some but not all allegations, identifying non-compliance in Resident Care and Related Services. Violations included failure to ensure proper completion and signatures on Uniform Assessment Instruments and Individualized Service Plans, and inadequate documentation of required two-hour rounds for residents with signaling device needs.
Complaint Details
Complaint was substantiated in part; violations related to Resident Care and Related Services were found. Complaint areas included Staffing and Supervision, Resident Care and Related Services, and Safe Secure Environment.
Deficiencies (3)
| Description |
|---|
| Failure to ensure Uniform Assessment Instrument (UAI) was signed by assessor, administrator, or designated representative. |
| Failure to ensure Individualized Service Plan (ISP) was signed and dated by the licensee, administrator or designee, and resident or legal representative. |
| Failure to document two-hour rounds for residents with inability to use signaling devices during specified night hours. |
Report Facts
Residents present: 105
Resident records reviewed: 2
Staff interviews conducted: 3
Dates missing documentation: 3
Dates missing documentation: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donesia Peoples | Licensing Inspector | Inspector conducting the complaint investigation and named in contact information |
Inspection Report
Monitoring
Census: 101
Deficiencies: 0
Jul 10, 2024
Visit Reason
An unannounced monitoring inspection was conducted following a self-reported incident received by VDSS Division of Licensing regarding allegations in the areas of Personnel and Resident Care and Related Services.
Findings
The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law. Observations included resident meals and activities, and interviews were conducted with residents and staff.
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: 2
Inspection Report
Renewal
Census: 101
Deficiencies: 9
Jul 10, 2024
Visit Reason
An unannounced renewal inspection was conducted on July 10 and July 11, 2024, to assess compliance with applicable standards and licensing requirements for the assisted living facility.
Findings
The inspection identified multiple violations related to staff certification, resident assessments, individualized service plans, medication administration, emergency preparedness, and posting of required documents. Plans of correction were proposed to address these deficiencies.
Deficiencies (9)
| Description |
|---|
| Facility failed to ensure each direct care staff member maintained current certification in first aid. |
| Facility failed to ensure Uniform Assessment Instrument (UAI) for private pay individuals was signed by the administrator or designated representative. |
| Facility failed to develop a preliminary plan of care on or within 7 days prior to admission for several residents. |
| Comprehensive individualized service plan (ISP) was not completed within 30 days after admission or did not include identified needs based on UAI. |
| Individualized service plans (ISP) were not signed and dated by the licensee, administrator, or resident/legal representative for multiple residents. |
| Medical procedures or treatments ordered by a physician were not provided according to instructions or documented for a resident. |
| Medication Administration Records (MAR) lacked staff initials, reasons for omissions, exact doses given, and signatures for multiple residents and staff. |
| Facility failed to ensure all staff participated in emergency procedure exercises every six months with documentation maintained. |
| Facility failed to post the most recent license and inspection findings on the premises as required. |
Report Facts
Number of residents present: 101
Number of resident records reviewed: 10
Number of staff records reviewed: 5
Number of resident interviews conducted: 4
Number of staff interviews conducted: 3
Dates of inspection: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donesia Peoples | Licensing Inspector | Current inspector conducting the inspection |
| Staff #5 | Named in deficiency related to expired first aid certification and missing medication administration signatures | |
| Staff #6 | Named in deficiencies related to missing documentation of therapy evaluations, emergency training, and license posting | |
| Staff #7 | Acknowledged missing first aid certification for Staff #5 | |
| Director of Clinical | Responsible party for auditing and corrective actions related to resident assessments, ISPs, medication administration, and staff training | |
| Administrator | Responsible for signing UAIs and ISPs and re-education on documentation requirements |
Inspection Report
Complaint Investigation
Census: 106
Deficiencies: 3
May 14, 2024
Visit Reason
An unannounced complaint inspection was conducted due to multiple complaints received by VDSS Division of Licensing regarding staffing and supervision, resident care and related services, and the safe, secure environment.
Findings
The investigation supported some allegations of non-compliance related to resident care and related services, including failure to promptly respond to resident call bells and medication administration errors. A violation notice was issued and plans of correction were required.
Complaint Details
The complaint investigation was substantiated in part, specifically regarding resident care and related services. Complaints involved staffing and supervision, resident care, and safe environment issues.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure prompt response by staff to resident needs, evidenced by long wait times for resident #3's call bell alerts. |
| Facility failed to ensure medications were administered according to physician's instructions, including missed insulin doses for resident #1. |
| Medication Administration Records (MAR) did not include exact doses given, reasons for omissions, and signatures/initials of staff administering medications for residents #1 and #2. |
Report Facts
Residents present: 106
Resident records reviewed: 6
Staff records reviewed: 1
Resident interviews: 2
Staff interviews: 0
Call bell wait times (minutes): 172
Missed insulin doses: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donesia Peoples | Licensing Inspector | Inspector conducting the complaint investigation |
| Executive Director | Responsible party for addressing call bell response deficiencies | |
| Director of Nursing | Responsible party for medication administration deficiencies and MAR audits |
Inspection Report
Complaint Investigation
Census: 108
Deficiencies: 3
Feb 29, 2024
Visit Reason
An unannounced complaint inspection was conducted due to complaints received regarding Staffing and Supervision, and Resident Care and Related Services.
Findings
The investigation supported some but not all allegations, identifying non-compliance in Resident Care and Related Services, specifically related to medication administration, medical procedures, and documentation.
Complaint Details
The complaint was received by VDSS Division of Licensing on 2024-02-01 and 2024-02-29 regarding allegations in Staffing and Supervision, and Resident Care and Related Services. The evidence supported some allegations related to Resident Care and Related Services.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure medications were administered according to physician or prescriber instructions, with multiple missed medication administrations documented in resident records. |
| Facility failed to ensure medical procedures or treatments ordered by a physician were provided and documented as required. |
| Facility failed to ensure medication administration records (MARs) included the name, signature, and initials of all staff administering medications. |
Report Facts
Residents present: 108
Resident records reviewed: 3
Staff interviews conducted: 5
Resident interviews conducted: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donesia Peoples | Licensing Inspector | Conducted the inspection and is the contact for questions |
Inspection Report
Complaint Investigation
Census: 108
Deficiencies: 2
Jan 30, 2024
Visit Reason
An unannounced complaint inspection was conducted due to allegations received by VDSS Division of Licensing on 2024-01-05 regarding staffing and supervision, resident care and related services, and the safe, secure environment.
Findings
The inspection found non-compliance with applicable standards, including failure to ensure individualized service plans (ISP) were signed and dated by required parties, and failure to document required resident rounds for those unable to use signaling devices. Violations were documented and a plan of correction was requested.
Complaint Details
Complaint was substantiated with findings related to staffing and supervision, resident care and related services, and safe, secure environment. Specific allegations included failure to document rounds for residents unable to use signaling devices and unsigned ISPs.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure the individualized service plan (ISP) was signed and dated by the licensee, administrator, or designee, and by the resident or legal guardian. |
| Facility failed to ensure documentation of rounds made for residents with inability to use signaling devices during specified night shifts. |
Report Facts
Number of residents present: 108
Number of resident records reviewed: 3
Number of staff records reviewed: 0
Number of interviews conducted with residents: 3
Number of interviews conducted with staff: 3
Inspection Report
Monitoring
Census: 108
Deficiencies: 2
Jan 30, 2024
Visit Reason
An announced monitoring inspection was conducted on January 30, 2024, following a self-reported incident received on January 19, 2024, regarding personnel allegations.
Findings
The inspection found non-compliance with applicable standards related to staff conduct and training. Specifically, a staff member used inappropriate language toward a resident and failed to complete required annual training hours.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure all staff were considerate and respectful of the rights, dignity, and sensitiveness of persons who are aged, infirm, or disabled, evidenced by staff using a curse word and the word 'idiot' toward a resident. |
| Facility failed to ensure certified nurse aides attended at least 12 hours of annual training; one staff member documented only 4.9 hours during the required timeframe. |
Report Facts
Number of residents present: 108
Staff annual training hours documented: 4.9
Inspection Report
Monitoring
Census: 105
Deficiencies: 8
Jan 8, 2024
Visit Reason
An announced monitoring inspection was conducted to review compliance with applicable standards and laws, following receipt of a self-reported incident regarding personnel and resident care.
Findings
The inspection found multiple violations related to resident placement approvals, review of appropriateness of placement, staff conduct including verbal abuse and neglect, fall risk assessments, completion of Uniform Assessment Instruments, individualized service plan updates, and timely response to resident needs.
Deficiencies (8)
| Description |
|---|
| Failed to obtain written approval prior to placing a resident with serious cognitive impairment in a safe, secure environment. |
| Failed to perform six month and annual reviews of appropriateness of placement in the special care unit. |
| Staff was not considerate and respectful of the rights, dignity, and sensitiveness of residents, including verbal abuse. |
| Failed to review and update fall risk ratings after each fall. |
| Failed to complete Uniform Assessment Instrument upon significant change in resident condition. |
| Failed to review and update Individualized Service Plans at least annually and after significant changes. |
| Failed to ensure care and services specified in the individualized service plan were provided, including assistance with toileting. |
| Failed to provide prompt response to resident needs as documented by call bell logs showing excessive wait times. |
Report Facts
Number of residents present: 105
Number of resident records reviewed: 2
Number of staff records reviewed: 2
Number of resident interviews: 1
Number of staff interviews: 1
Call bell wait times (minutes): 59
Call bell wait times (minutes): 82
Call bell wait times (minutes): 70
Call bell wait times (minutes): 58
Call bell wait times (minutes): 113
Call bell wait times (minutes): 121
Call bell wait times (minutes): 161
Call bell wait times (minutes): 138
Fall dates: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donesia Peoples | Licensing Inspector | Inspector conducting the monitoring inspection |
Inspection Report
Monitoring
Census: 111
Deficiencies: 1
Aug 22, 2023
Visit Reason
An announced monitoring inspection was conducted following a self-reported incident received by VDSS Division of Licensing regarding allegations in the area of Personnel.
Findings
The inspection found non-compliance with applicable standards related to staff conduct, specifically a violation where a staff member was observed pulling on a resident's arm causing a bruise, resulting in the termination of the staff member.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure all staff are considerate and respectful of the rights, dignity, and sensitiveness of persons who are aged, infirm, or disabled, evidenced by staff pulling on a resident's arm causing a bruise. |
Report Facts
Number of residents present: 111
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of interviews conducted with staff: 2
Number of interviews conducted with residents: 0
Inspection Report
Renewal
Census: 111
Deficiencies: 6
Jul 25, 2023
Visit Reason
An unannounced renewal inspection was conducted to assess compliance with applicable standards and regulations for the facility's license renewal.
Findings
The inspection identified multiple violations related to resident assessments, staff training, individualized service plans, and employment eligibility. The facility was found non-compliant with several regulatory standards and issued a violation notice with opportunities for correction.
Deficiencies (6)
| Description |
|---|
| Facility failed to ensure residents admitted to a safe, secure environment had been assessed by an independent clinical psychologist or physician for serious cognitive impairment. |
| Direct care staff who are certified nurse aides did not attend at least 12 hours of annual training. |
| Training for medication aides did not include required continuing education by the Virginia Board of Nursing. |
| Individualized Service Plan (ISP) did not include a description of identified needs based upon the Uniform Assessment Instrument (UAI). |
| Individualized Service Plans (ISPs) were not signed by the resident or legal guardian. |
| Employee with criminal history containing convictions for barrier crimes was employed, violating eligibility requirements. |
Report Facts
Number of residents present: 111
Number of resident records reviewed: 10
Number of staff records reviewed: 5
Number of resident interviews conducted: 4
Number of staff interviews conducted: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donesia Peoples | Licensing Inspector | Inspector conducting the inspection |
Inspection Report
Monitoring
Census: 108
Deficiencies: 2
Mar 9, 2023
Visit Reason
An announced monitoring inspection was conducted to review compliance with applicable standards and laws, following a self-reported incident received by VDSS regarding personnel allegations.
Findings
The inspection found non-compliance with standards related to staff conduct and training. Specifically, staff used inappropriate language toward a resident and lacked documented training on residents' rights and responsibilities.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure all staff were considerate and respectful of the rights, dignity, and sensitiveness of persons who are aged, infirm, or disabled. |
| Facility failed to ensure all staff were trained in relevant laws, regulations, and facility policies regarding residents' rights and responsibilities. |
Report Facts
Number of residents present: 108
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of resident interviews conducted: 1
Number of staff interviews conducted: 2
Inspection Report
Renewal
Census: 94
Deficiencies: 7
Aug 30, 2022
Visit Reason
An unannounced renewal inspection was conducted on August 30, 2022 and September 1, 2022 to assess compliance with applicable standards and licensing requirements for the assisted living facility.
Findings
The inspection identified multiple violations including failure to ensure direct care staff completed required annual training and first aid certification, outdated posted staff certification lists, failure to post the current on-site person in charge, lack of timely healthcare oversight, absence of dietary oversight for special diets, and failure to implement a medication management plan to prevent use of outdated medications.
Deficiencies (7)
| Description |
|---|
| Facility failed to ensure all direct care staff attended at least 18 hours of training annually. |
| Facility failed to ensure each direct care staff member without current first aid certification received certification within 60 days of employment. |
| Facility failed to keep posted listing of staff certifications in first aid or CPR up to date. |
| Facility failed to develop and implement a procedure for posting the name of the current on-site person in charge. |
| Facility failed to ensure licensed health care professional provided healthcare oversight at least every three months. |
| Facility failed to ensure oversight at least every six months of special diets by a dietitian or nutritionist for residents with such diets. |
| Facility failed to implement a written plan for medication management to prevent use of outdated medications; expired medication was observed on medication cart. |
Report Facts
Number of residents present: 94
Number of resident records reviewed: 10
Number of staff records reviewed: 5
Number of interviews with residents: 5
Number of interviews with staff: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff #1 | Did not have documentation of certification in first aid | |
| Staff #2 | Did not have documentation of 18 hours of annual training | |
| Staff #3 | Did not have documentation of 18 hours of annual training; certifications in first aid and CPR not current | |
| Staff #5 | Certifications in first aid and CPR not current | |
| Staff #6 | Acknowledged lack of current healthcare oversight; acknowledged posting of person in charge was not updated | |
| Staff #7 | Acknowledged lack of documentation for training and first aid certification; acknowledged posted certification list was not current |
Inspection Report
Monitoring
Deficiencies: 4
Feb 25, 2022
Visit Reason
The Licensing Inspector completed an unannounced, non-mandated, monitoring investigation in reference to an initial facility self-reported incident.
Findings
Areas of non-compliance were observed including failure to report a major incident within 24 hours, failure to have individualized service plans signed by residents or legal representatives, and failure to maintain master service plans accessible to direct care staff.
Deficiencies (4)
| Description |
|---|
| Facility failed to report to the regional licensing office within 24 hours any major incident that negatively affected resident health, safety, or welfare. |
| Facility failed to ensure the individualized service plan was signed and dated by the resident or legal representative. |
| Facility failed to ensure the master service plan was maintained in a location accessible at all times to direct care staff. |
| Deficiency noted based on observation (details not specified). |
Report Facts
Incident report delay: 4
Date of incident: Feb 10, 2022
Date of report: Feb 14, 2022
Date of service plan: Sep 5, 2021
Inspection Report
Routine
Deficiencies: 1
Aug 24, 2021
Visit Reason
Two Licensing Inspectors conducted a hybrid inspection to review compliance with regulations related to admission, retention, discharge of residents, and resident care services.
Findings
The inspection identified areas of non-compliance, specifically that medications were not properly secured as required by facility policy.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure medications are locked, with unlocked medications observed in resident #1's apartment. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Jan 14, 2021
Visit Reason
A complaint inspection was initiated on January 7, 2021 regarding allegations related to Resident Care and Related Services, specifically staff performing resident transfers. The investigation was conducted remotely due to a state of emergency health pandemic.
Findings
The evidence gathered did not substantiate the complaint allegations; however, multiple violations of standards were cited related to admission and retention of residents with prohibited conditions, failure to review and update fall risk ratings after falls, lack of physician's written orders for certain care interventions, and improper medication storage documentation.
Complaint Details
A complaint was received regarding allegations related to Resident Care and Related Services as it related to staff performing resident transfers. The complaint was not substantiated based on the evidence gathered.
Deficiencies (4)
| Description |
|---|
| Facility admitted and/or retained individuals with prohibited conditions, including lack of completed psychopharmacologic medication treatment plans and inadequate documentation for pressure ulcers. |
| Facility failed to ensure fall risk ratings were reviewed and updated after each fall. |
| Facility failed to ensure resident records contained physician's signed written orders or dated notations for use of half rails on beds. |
| Facility failed to ensure a resident may be permitted to keep medication in their room only if capable of self-administering as indicated by the Uniform Assessment Instrument (UAI). |
Report Facts
Inspection dates: 4
Falls documented for Resident #2: 2
Falls documented for Resident #3: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donesia Peoples | Inspector | Named as current inspector conducting the complaint investigation |
Inspection Report
Complaint Investigation
Deficiencies: 3
Nov 18, 2020
Visit Reason
A complaint inspection was initiated on November 13, 2020, regarding allegations in the areas of resident care and related services. The inspection was conducted using an alternate remote protocol due to a state of emergency health pandemic.
Findings
The investigation found non-compliance with standards or law related to admission documentation for residents with serious cognitive impairments, failure to complete annual tuberculosis risk assessments, and failure to administer medications according to physician instructions. The complaint itself was determined to be not valid, but violations were issued based on other findings.
Complaint Details
A complaint was received regarding resident care and related services. The complaint was investigated and found to be not valid, but violations unrelated to the complaint were identified and cited.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure prior to admitting residents with serious cognitive impairment that a written determination and justification for placement in the special care unit was completed and retained. |
| Facility failed to ensure a risk assessment for tuberculosis was completed annually on each resident as evidenced by incomplete screening forms. |
| Facility failed to ensure medications were administered in accordance with the physician's or other prescriber's instructions as documented in Medication Administration Records. |
Report Facts
Residents admitted without placement determination: 3
Dates of admission for residents without placement determination: Resident #1 admitted 12-11-19, Resident #2 admitted 09-09-19, Resident #3 admitted 07-03-19.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donesia Peoples | Inspector | Current inspector conducting the complaint investigation. |
| Staff #1 | Confirmed lack of placement determination and justification, tuberculosis screening, and medication administration issues. | |
| Executive Director | Contacted by telephone during investigation and responsible for implementing corrective measures. | |
| Director of Resident Care | Responsible for medication refill management education and monitoring. |
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