Deficiencies per Year
16
12
8
4
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Inspection Report
Renewal
Census: 113
Deficiencies: 3
Jul 15, 2025
Visit Reason
The inspection was conducted as a renewal inspection to assess compliance with applicable standards and regulations for the assisted living facility.
Findings
The inspection identified non-compliance with several standards including failure to ensure all residents received annual health care oversight, improper medication storage, and omission of Do Not Resuscitate (DNR) orders in individualized service plans. Plans of correction were proposed for each deficiency.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure that all residents were included at least annually in health care oversight. |
| Facility failed to ensure that a medicine compartment was used for storage of medications for residents when administered by the facility; medications were insecurely stored in resident's room. |
| Facility failed to ensure Do Not Resuscitate (DNR) Orders are included in the resident's individualized service plan. |
Report Facts
Residents present: 113
Resident records reviewed: 8
Staff records reviewed: 4
Resident interviews conducted: 1
Staff interviews conducted: 2
Residents reviewed in health care oversight: 12
Medication dosage: 325
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nina Wilson | Licensing Inspector | Inspector conducting the renewal inspection |
| Staff 5 | Confirmed that not all residents were included in annual health care oversight | |
| Staff 6 | Confirmed medication storage violation for resident 4 |
Inspection Report
Complaint Investigation
Census: 143
Deficiencies: 2
Feb 28, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 02/20/2025 regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation supported the allegations of non-compliance, resulting in violations issued related to failure to complete comprehensive individualized service plans within 30 days after admission and failure to ensure medications, diet, and treatments were properly ordered by a physician or prescriber.
Complaint Details
Complaint related: Yes. The complaint was substantiated as violations were issued based on the investigation.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure the comprehensive individualized service plan (ISP) was completed within 30 days after admission. |
| Facility failed to ensure that medications, diet, and treatments were not started, changed, or discontinued without an order from a physician or other prescriber. |
Report Facts
Number of residents present: 143
Number of resident records reviewed: 3
Number of staff records reviewed: 0
Number of staff interviews conducted: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nina Wilson | Licensing Inspector | Inspector conducting the complaint investigation |
Inspection Report
Renewal
Census: 122
Deficiencies: 16
Jul 29, 2024
Visit Reason
The inspection was a renewal inspection conducted to assess compliance with applicable standards and regulations for licensing renewal of the assisted living facility.
Findings
The inspection identified multiple areas of non-compliance including failures in obtaining required written approvals for residents with cognitive impairments, incomplete resident reviews, inadequate staff training on confidentiality, lapses in staff certification, incomplete physical examinations, missing tuberculosis risk assessments, incomplete fall risk assessments, deficiencies in individualized service plans, medication management issues, emergency preparedness plan deficiencies, and incomplete documentation of fire and emergency drills.
Deficiencies (16)
| Description |
|---|
| Failed to obtain written approval prior to placing a resident with serious cognitive impairment in a safe, secure environment. |
| Failed to determine appropriateness of placement in special care unit prior to admission of resident with serious cognitive impairment. |
| Failed to perform six-month and annual reviews of residents' appropriateness for continued residence in special care unit. |
| Failed to ensure all staff were trained to implement confidential treatment of personal information. |
| Failed to ensure direct staff maintained current certification in first aid. |
| Failed to ensure physical examination was completed within 30 days preceding admission by an independent physician. |
| Failed to complete annual tuberculosis risk assessment for residents. |
| Failed to review and update fall risk rating after resident falls. |
| Failed to complete comprehensive individualized service plan within 30 days after admission reflecting identified needs and services. |
| Failed to implement written medication management plan ensuring accurate transcription, timely refills, administration, and proper disposal. |
| Failed to ensure medications or treatments were started, changed, or discontinued only with valid physician or prescriber orders. |
| Failed to ensure physician or prescriber signed oral orders within 14 days. |
| Failed to include emergency generator capacity details in emergency preparedness and response plan. |
| Failed to complete semi-annual review of emergency preparedness and response plan for all staff and residents. |
| Failed to maintain complete records of fire and emergency evacuation drills including required details. |
| Failed to ensure all staff participated in emergency procedure exercises on each shift. |
Report Facts
Residents present: 122
Resident records reviewed: 9
Staff records reviewed: 6
Resident interviews: 2
Staff interviews: 4
Medication administration missed doses: 3
Fire and emergency drills reviewed: 2
Employees on duty during drills: 54
Employees on duty during drills: 62
Employees on duty during drills: 63
Employees on duty during drills: 66
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nina Wilson | Licensing Inspector | Inspector conducting the renewal inspection |
| Staff 11 | Interviewed regarding medication management and documentation issues | |
| Staff 10 | Interviewed regarding medication disposal and administration | |
| Resident Care Director | Nurse | Named in multiple plans of correction related to resident care and compliance |
| Assistant Resident Care Director | Nurse | Named in plans of correction related to resident chart audits and compliance |
| Executive Director | Named in plans of correction related to compliance and emergency preparedness | |
| Human Resources Manager | Educated on CPR and First Aid certification requirements | |
| Maintenance Director | Named in plans of correction related to emergency preparedness and fire drills | |
| Staff 2 | Mentioned in staff certification deficiency | |
| Staff 3 | Mentioned in staff certification deficiency | |
| Staff 4 | Mentioned in staff certification deficiency and interview |
Inspection Report
Monitoring
Deficiencies: 1
Jan 26, 2024
Visit Reason
The inspection was a monitoring visit conducted over three days to review resident care and related services following a self-reported incident regarding an allegation in resident care.
Findings
The inspection found non-compliance with standards related to the improper use of physical restraint on a resident without physician authorization or appropriate safeguards. A violation notice was issued and the facility was required to submit a plan of correction.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure that each resident is free of physical restraint except in authorized situations; staff physically restrained Resident #1 without physician order or proper safeguards. |
Report Facts
Number of resident records reviewed: 1
Number of interviews conducted with residents: 3
Number of interviews conducted with staff: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nina Wilson | Licensing Inspector | Current inspector conducting the inspection |
| Marshall Massenberg | Licensing Inspector | Contact person for questions about the inspection |
| Staff #1 | Assistant Dining Services Director | Named in the physical restraint violation for physically removing Resident #1 from the kitchen area |
Inspection Report
Renewal
Census: 75
Deficiencies: 13
Aug 7, 2023
Visit Reason
The inspection was conducted as a renewal of the facility's license, including a tour of the physical plant, review of resident and staff records, and observations of meals, medication administration, and activities.
Findings
The inspection found multiple violations including failure to properly assess residents for serious cognitive impairment, incomplete tuberculosis risk assessments for staff, lack of current first aid certification for direct care staff, inadequate supervision of residents, improper medication storage and administration, incomplete medication administration records, expired and unavailable medications, failure to conduct emergency preparedness reviews and fire drills as required, and failure to obtain timely criminal history reports for employees.
Deficiencies (13)
| Description |
|---|
| Facility failed to ensure each resident is assessed by an independent clinical psychologist or physician for serious cognitive impairment. |
| Facility failed to ensure each staff member annually submits tuberculosis risk assessment results. |
| Direct care staff members did not maintain current certification in first aid within 60 days of employment. |
| Facility failed to provide supervision of resident schedules, care, and activities including attention to specialized needs such as wandering. |
| Facility failed to ensure that if one activity is substituted for another, the change is noted on the schedule. |
| Facility failed to ensure medication storage areas remain locked and secure. |
| Facility failed to ensure medications are administered according to physician's instructions and standards of practice. |
| Facility failed to ensure all information is documented on the medication administration record (MAR). |
| Facility failed to ensure PRN medications are available and properly stored. |
| Facility failed to implement a semi-annual review of the emergency preparedness and response plan for all staff, residents, and volunteers. |
| Facility failed to ensure fire and emergency evacuation drill frequency complies with state fire prevention code. |
| Facility failed to ensure all staff participate in resident emergency procedure exercises at least every six months. |
| Facility failed to ensure a criminal history record report is obtained on or prior to the 30th day of employment for each employee. |
Report Facts
Residents present: 75
Resident records reviewed: 10
Staff records reviewed: 5
Resident interviews conducted: 7
Inspection Report
Complaint Investigation
Deficiencies: 2
Aug 7, 2023
Visit Reason
An unannounced complaint inspection was conducted in response to complaints received regarding Resident Care and Related Services and Personnel.
Findings
The inspection found non-compliance with applicable standards, including failure to ensure staff annual training requirements and failure to ensure prompt staff response to resident call bells.
Complaint Details
The inspection was complaint-related, triggered by complaints received on 2023-06-28 and 2023-08-10 regarding Resident Care and Related Services and Personnel.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure that each staff member attends 18 hours of annual training, with exceptions for licensed health care professionals or certified nurse aides attending at least 12 hours. |
| Facility failed to ensure a prompt response by staff to resident needs as reasonable to the circumstances, with documented delays in responding to call bells. |
Report Facts
Call bell response delays: 34
Call bell response delays: 19
Call bell response delays: 2
Inspection Report
Complaint Investigation
Deficiencies: 1
May 1, 2023
Visit Reason
Unannounced complaint inspections were conducted on May 1, 2023 and May 18, 2023 in response to a complaint received on April 24, 2023 regarding Resident Care and Related Services.
Findings
The investigation supported the allegation of non-compliance with standards related to personal assistance and care, specifically bathing and dressing. Violations were issued based on record review and documentation showing failure to provide care as required.
Complaint Details
Complaint related: Yes. The complaint was substantiated as the evidence supported non-compliance with standards regarding resident care.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure personal assistance and care were provided as necessary, including bathing at least twice a week and dressing. Resident #1 was only bathed once between 4/22/23 and 4/29/23, and compression stockings were not applied on four mornings without documented reason. |
Report Facts
Inspection dates: 2
Days between bathing documentation: 7
Missed compression stocking applications: 4
Plan of correction timeframe: 5
Audit duration: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marshall Massenberg | Licensing Inspector | Contact person for questions regarding the inspection |
| Nina Wilson | Inspector | Current inspector conducting the complaint investigation |
Inspection Report
Renewal
Census: 39
Deficiencies: 3
Aug 18, 2022
Visit Reason
An unannounced renewal inspection was conducted to assess compliance with applicable standards and laws for the facility's license renewal.
Findings
The inspection found non-compliance with certain standards including failure to post the most recent inspection results, lack of documentation of first aid certification for a staff member, and failure to post the staff person in charge.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure that the most recent inspection results were posted. |
| Facility failed to ensure that each direct care staff member maintains current certification in first aid; Staff #2 hired on 3/28/2022 lacks documentation of First Aid training. |
| Facility failed to ensure staff person in charge is posted. |
Report Facts
Residents in care: 39
Staff member hire date: Mar 28, 2022
Inspection Report
Original Licensing
Deficiencies: 0
Feb 15, 2022
Visit Reason
An announced initial inspection was conducted to verify compliance with licensing requirements, including physical plant, policies, staff records, and call bell system functionality.
Findings
All inspections were completed with no violations cited during the visit. An exit interview was held with the facility.
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