Inspection Reports for The Legacy at North Augusta, Inc.
1410 A N. Augusta Street, VA, 24401
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
6.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
27% better than Virginia average
Virginia average: 9.1 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
96 residents
Based on a September 2025 inspection.
Census over time
Inspection Report
Monitoring
Census: 96
Deficiencies: 1
Sep 23, 2025
Visit Reason
The inspection was a monitoring visit triggered by a self-reported incident received on 2025-09-15 regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation supported the self-report of non-compliance related to medication administration errors. Violations were issued for failure to administer medications according to physician orders, specifically an incident involving incorrect timing of Hydrocodone-acetaminophen doses.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure medications were administered in accordance with the physician's or other prescriber's instructions, including an incident where a resident received two doses together outside the scheduled time frame. |
Report Facts
Residents present: 96
Resident records reviewed: 1
Staff records reviewed: 1
Staff interviews conducted: 2
Resident interviews conducted: 0
Weeks of monitoring: 4
Inspection Report
Renewal
Census: 96
Deficiencies: 5
Sep 23, 2025
Visit Reason
The inspection was a renewal inspection conducted to assess compliance with applicable standards and laws for the facility's license renewal.
Findings
The inspection found multiple violations including failure to document justification for admitting residents with serious cognitive impairments to a secure environment, failure to keep resident records locked, incomplete medication administration documentation, incorrect Do Not Resuscitate (DNR) orders on individualized service plans, and improper storage of cleaning supplies.
Deficiencies (5)
| Description |
|---|
| Failed to ensure prior to admitting a resident with a serious cognitive impairment to a safe, secure environment, the determination and justification was in writing and retained in the resident's file. |
| Failed to ensure all resident records are kept in a locked area. |
| Failed to ensure that at the time medication was administered it was documented on the medication administration record (MAR). |
| Failed to ensure that the Do Not Resuscitate (DNR) Orders were included on the individualized service plan (ISP). |
| Failed to store cleaning supplies in a locked area. |
Report Facts
Number of residents present: 96
Number of resident records reviewed: 6
Number of staff records reviewed: 3
Number of interviews conducted with residents: 3
Number of interviews conducted with staff: 3
Inspection Report
Monitoring
Census: 88
Deficiencies: 2
Jun 17, 2025
Visit Reason
The inspection was a monitoring visit triggered by a self-reported incident received by VDSS Division of Licensing on 2025-06-03 regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation supported the self-report of non-compliance with standards or law, resulting in violations issued related to the individualized service plan and supervision of residents, including a resident wandering from the facility. The licensee was given the opportunity to submit a plan of correction.
Deficiencies (2)
| Description |
|---|
| The facility failed to ensure the comprehensive individualized service plan (ISP) included all identified needs, specifically the resident's aggressive, disruptive, or wandering behaviors were not included. |
| The facility failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs such as wandering from the premises, resulting in a resident wandering from the facility to a neighboring street. |
Report Facts
Number of residents present: 88
Resident progress notes occasions: 15
Resident wandering distance (miles): 0.2
Resident unsupervised time (minutes): 32
Temperature (degrees Fahrenheit): 80
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela N Via | Licensing Inspector | Current inspector conducting the inspection |
| Jessica Gale | Licensing Inspector | Contact person for questions about the inspection findings |
Inspection Report
Monitoring
Census: 87
Deficiencies: 1
Apr 22, 2025
Visit Reason
The inspection was a monitoring visit triggered by a self-reported incident received by VDSS Division of Licensing on 2025-04-08 regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation supported the self-report of non-compliance related to medication administration errors. The facility failed to administer medications according to physicians' or prescribers' instructions, resulting in a medication error involving resident 1 receiving incorrect medications.
Deficiencies (1)
| Description |
|---|
| Facility failed to administer medications in accordance with physicians or other prescriber's instructions. |
Report Facts
Number of residents present: 87
Number of resident records reviewed: 2
Number of staff records reviewed: 1
Number of staff interviews conducted: 2
Date of medication error incident: 2025
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 0
Jan 22, 2025
Visit Reason
The inspection was conducted due to a complaint received by VDSS Division of Licensing on 2025-01-14 regarding allegations in the areas of resident care and related services and building and grounds.
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 related to resident care and related services and building and grounds; allegations were not substantiated.
Report Facts
Number of residents present: 87
Number of resident records reviewed: 2
Number of staff records reviewed: 0
Number of interviews conducted with residents: 2
Number of interviews conducted with staff: 2
Inspection Report
Renewal
Census: 87
Deficiencies: 6
Nov 6, 2024
Visit Reason
The inspection was a renewal inspection conducted on November 6 and 7, 2024, to assess compliance with applicable standards and regulations for the assisted living facility.
Findings
The inspection identified multiple violations including failure to document appropriateness of placement for residents with serious cognitive impairments, incomplete annual tuberculosis risk assessments for staff, failure to update individualized service plans following significant changes in residents' conditions, lack of valid physician orders for oxygen therapy, missing Do Not Resuscitate (DNR) orders on service plans, and unsecured storage of hazardous cleaning supplies.
Deficiencies (6)
| Description |
|---|
| Failure to ensure written appropriateness for placement of residents with serious cognitive impairment in the special care unit was documented. |
| Failure to ensure annual tuberculosis risk assessments were completed and documented for staff. |
| Failure to review or update individualized service plans following significant changes in residents' conditions. |
| Failure to obtain valid physician orders for oxygen therapy for a resident. |
| Failure to include Do Not Resuscitate (DNR) orders on individualized service plans for residents. |
| Failure to ensure cleaning supplies and hazardous materials were stored in locked areas. |
Report Facts
Number of residents present: 87
Number of resident records reviewed: 6
Number of staff records reviewed: 3
Number of resident interviews conducted: 3
Number of staff interviews conducted: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela N Via | Licensing Inspector | Named as the current inspector conducting the inspection |
| Jessica Gale | Licensing Inspector | Contact person for questions about the inspection |
| Staff 1 | Interviewed regarding appropriateness of placement documentation | |
| Staff 2 | Interviewed regarding oxygen therapy orders and DNR orders | |
| Staff 4 | Staff record reviewed for tuberculosis risk assessment | |
| Staff 5 | Interviewed regarding tuberculosis risk assessment completion | |
| Administrator | Directed corrective actions and education following deficiencies | |
| LPN clinical support specialist | Responsible for auditing clinical files and updating service plans | |
| Talent and Culture Director | Audited personal files for tuberculosis risk assessments | |
| Talent and Culture Business Partner | Ensures completion and auditing of tuberculosis risk assessments | |
| Lead maintenance generalist | Replaced locks on housekeeping closets | |
| Facilities Manager | Conducts rounds to ensure hazardous materials are locked | |
| Clinical support specialist | Updated individualized service plans and obtained physician orders |
Inspection Report
Monitoring
Census: 74
Deficiencies: 4
May 28, 2024
Visit Reason
The inspection was a monitoring visit conducted on May 28 and May 29, 2024, to review compliance with applicable standards and regulations for the assisted living facility.
Findings
The inspection identified multiple violations including failure to ensure physical exams within 30 days prior to admission, incomplete oxygen orders, unsecured storage of cleaning supplies and hazardous chemicals, and incomplete fire drills on each shift per Virginia Statewide Fire Prevention Code.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure a physical exam is completed within 30 days prior to admission. |
| Facility failed to ensure oxygen orders contain all required information. |
| Facility failed to ensure cleaning supplies and hazardous chemicals are stored in a locked area. |
| Facility failed to ensure fire drills are completed on each shift in a quarter in accordance with the Virginia Statewide Fire Prevention Code. |
Report Facts
Number of residents present: 74
Number of resident records reviewed: 6
Number of staff records reviewed: 3
Number of resident interviews: 2
Number of staff interviews: 2
Inspection Report
Monitoring
Census: 83
Deficiencies: 1
May 8, 2023
Visit Reason
The inspection was a monitoring visit conducted to review compliance with regulations related to personnel and resident care, specifically focusing on medication administration following several self-reported incidents.
Findings
The facility was found to have failed to ensure medications were administered according to physician orders and nursing standards for all four resident records reviewed, resulting in violations related to medication administration errors.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure medications were administered in accordance with physician orders and nursing standards for four resident records reviewed. |
Report Facts
Residents present: 83
Resident records reviewed: 4
Staff records reviewed: 3
Staff interviews conducted: 2
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 1
May 8, 2023
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2023-04-28 regarding allegations related to buildings and grounds at the facility.
Findings
The investigation found that the facility failed to ensure all areas remained free of foul odors, specifically urine and feces odors in resident rooms. Violations were issued based on observations and interviews confirming these conditions.
Complaint Details
The complaint was substantiated as the evidence gathered supported the allegations of non-compliance with standards related to buildings and grounds, specifically foul odors in resident rooms.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure all areas remained free of foul odors, including urine and feces in resident rooms. |
Report Facts
Number of residents present: 83
Number of resident interviews: 3
Number of staff interviews: 8
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 1
May 8, 2023
Visit Reason
The inspection was conducted in response to a complaint received on 2023-04-28 regarding allegations related to additional requirements for facilities that care for adults with serious cognitive impairments.
Findings
The investigation supported the allegation of non-compliance with staffing requirements on the secured unit, specifically the failure to ensure two staff remained on the secured unit at all times. Violations were issued based on interviews and staff schedules.
Complaint Details
The complaint was substantiated. Evidence included staff interviews and review of the staff schedule for 4/27/2023 showing times when only one staff was present on the secured unit.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure two staff remained on the secured unit at all times. |
Report Facts
Number of residents present: 83
Number of staff interviewed: 6
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 2
Mar 31, 2023
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 3/28/2023 regarding allegations in the areas of Administrative and Administrative Services, Resident Care and Related Services, and Buildings and Grounds.
Findings
The investigation supported some, but not all, of the allegations; non-compliance was found in the area of Resident Care and Related Services. Violations related to incomplete medication administration records and incomplete as-needed medication orders were identified.
Complaint Details
Complaint related: Yes. The complaint was substantiated in part with findings of non-compliance in Resident Care and Related Services.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure all required information was included on three medication administration records (MARs) reviewed. |
| Facility failed to ensure all as-needed (PRN) orders included the specific symptoms for administering medications and instructions for persistent symptoms for three resident records reviewed. |
Report Facts
Residents present: 86
Resident records reviewed: 3
Staff records reviewed: 1
Resident interviews: 3
Staff interviews: 8
Medication administration records reviewed: 3
PRN orders reviewed: 3
Inspection Report
Monitoring
Deficiencies: 0
Jan 10, 2023
Visit Reason
The inspection was a monitoring visit conducted on January 10, 2023, following a self-reported incident received by VDSS regarding allegations in the area of Resident Care.
Findings
The investigation did not support the self-report of non-compliance with standards or law. No deficiencies or non-compliance were found during the inspection.
Report Facts
Resident records reviewed: 1
Staff records reviewed: 0
Resident interviews conducted: 1
Staff interviews conducted: 3
Inspection Report
Monitoring
Deficiencies: 1
Jan 10, 2023
Visit Reason
The inspection was a monitoring visit conducted on January 10, 2023, including a review of staffing, resident care, buildings and grounds, and additional requirements for adults with serious cognitive impairments. The visit was not complaint-related but included investigation of a self-reported incident regarding resident care.
Findings
The investigation did not substantiate the self-reported non-compliance, but violations unrelated to the self-report were identified. Specifically, the facility failed to ensure documentation of rounds by direct care aides as required.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure rounds were documented as required by regulation 22VAC40-73-930-D. |
Report Facts
Number of resident records reviewed: 1
Number of staff records reviewed: 2
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 5
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 0
Nov 4, 2022
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2022-11-03 regarding allegations in the areas of Resident Care and Related Services.
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 related inspection triggered by allegations in Resident Care and Related Services. The complaint was not substantiated.
Report Facts
Number of residents present: 81
Number of resident records reviewed: 0
Number of staff records reviewed: 0
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 3
Inspection Report
Renewal
Census: 89
Deficiencies: 4
Oct 19, 2022
Visit Reason
The inspection was a renewal inspection conducted on October 19 and 20, 2022, to assess compliance with applicable standards and licensing requirements for the assisted living facility.
Findings
The inspection found non-compliance with several standards including incomplete dementia training for staff, outdated first aid and CPR certification postings, unsecured resident records, and unsecured cleaning supplies. Violation notices were issued with plans of correction required.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure four of six staff completed at least 10 hours of dementia training within the first four months of hire. |
| Facility failed to ensure the posting with staff certified in first aid and CPR remained current. |
| Facility failed to ensure resident records were kept in a locked area. |
| Facility failed to ensure all cleaning supplies were kept in a locked storage area. |
Report Facts
Residents present: 89
Residents assisted living: 74
Residents secured unit: 15
Resident records reviewed: 10
Staff records reviewed: 9
Resident interviews: 6
Staff interviews: 6
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 2
May 17, 2022
Visit Reason
The inspection was conducted in response to a complaint received by the VDSS Division of Licensing on 2022-05-16 regarding an allegation in the area of resident care.
Findings
The investigation supported some, but not all, of the allegations. Areas of non-compliance were found in administrative services and resident care. Violations included failure to report major incidents within 24 hours and failure to notify a legal representative within 24 hours of incidents.
Complaint Details
The complaint was related to resident care. The evidence supported some allegations but not all. A violation notice was issued. The licensee was given the opportunity to submit a plan of correction.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure major incidents that threatened the life, health and safety of residents were reported to the licensing office within 24 hours. |
| Facility failed to notify the legal representative for one of two residents within 24 hours of three incidents. |
Report Facts
Number of residents present: 65
Number of residents present: 18
Number of resident records reviewed: 2
Number of interviews conducted with residents: 2
Number of interviews conducted with staff: 12
Inspection Report
Monitoring
Census: 99
Deficiencies: 2
Aug 31, 2021
Visit Reason
A monitoring inspection was initiated on 8/31/2021 and concluded on 9/3/2021 to review compliance with applicable standards and laws at The Legacy at North Augusta, Inc.
Findings
The inspection found non-compliance with medication administration and labeling standards, including failure to implement medication administration plans for two residents and failure to ensure proper labeling of medications for one resident.
Deficiencies (2)
| Description |
|---|
| Facility failed to implement the medication administration plan for two of five resident records reviewed, including missing medications and lack of communication for reordering. |
| Facility failed to ensure one of three residents' medications reviewed were properly labeled. |
Report Facts
Residents reviewed: 5
Staff records reviewed: 5
Additional resident records reviewed: 6
Additional staff records reviewed: 3
Volunteers reviewed: 1
Contract staff reviewed: 1
Medication administration deficiencies: 2
Medication labeling deficiencies: 1
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