Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 22, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-10-07 regarding allegations in the areas of Personnel, Staffing and Supervision.
Findings
The evidence gathered during the investigation did not support the allegation of non-compliance with standards or law. An exit meeting was planned to review the inspection findings.
Complaint Details
Complaint related to allegations in Personnel, Staffing and Supervision. The complaint was not substantiated based on the investigation findings.
Report Facts
Number of interviews conducted: 1
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 22, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-10-14 regarding allegations in the area 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. The licensing inspector completed a tour of the physical plant and reviewed facility records.
Complaint Details
Complaint investigation related to allegations in Resident Care and Related Services; the complaint was not substantiated.
Report Facts
Resident records reviewed: 3
Resident interviews conducted: 2
Staff interviews conducted: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Marie Swink | Licensing Inspector | Conducted the inspection and is the current inspector |
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 22, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-10-03 regarding allegations in the areas of Resident Care and Related Services, and Buildings and Grounds.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The licensing inspector completed a tour of the physical plant including the building and grounds, reviewed two resident records, and conducted interviews with three residents and one staff member.
Complaint Details
Complaint investigation related to allegations in Resident Care and Related Services and Buildings and Grounds. The complaint was not substantiated.
Report Facts
Resident records reviewed: 2
Resident interviews conducted: 3
Staff interviews conducted: 1
Inspection Report
Complaint Investigation
Deficiencies: 1
Oct 22, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-10-07 regarding allegations related to staffing at the facility.
Findings
The investigation found non-compliance with staffing regulations, specifically that the facility failed to maintain a written staffing plan that accurately reflects the number and type of direct care staff required to meet resident needs. Evidence showed that on 2025-10-04, only two direct care staff were working the 8pm to 8am shift, below the written staffing plan of 3-5 staff.
Complaint Details
The complaint was substantiated as the evidence supported the allegation of non-compliance with staffing standards.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure the assisted living facility maintained a written staffing plan specifying the number and type of direct care staff required to meet day-to-day resident needs, and staffing on 10/4/2025 did not meet this plan. |
Report Facts
Direct care staff scheduled: 2
Written staffing plan: 3
Written staffing plan: 5
Audit duration: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Marie Swink | Licensing Inspector | Conducted the inspection and investigation |
Inspection Report
Complaint Investigation
Deficiencies: 3
Oct 22, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 10/20/2025 regarding allegations in the areas of Resident Care and Related Services, and Buildings and Grounds.
Findings
The investigation supported the allegations of non-compliance, resulting in violations issued related to failure to document post-fall interventions, improper signatures on individualized service plans, and maintenance issues with furnishings and fixtures in resident bathrooms.
Complaint Details
The complaint was substantiated as the evidence gathered supported the allegations of non-compliance with standards and laws.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure documentation of analysis and interventions following a resident fall on 10/20/2025. |
| Individualized Service Plan was signed by a previous employee, not the licensee, administrator, or designee. |
| Furnishings and fixtures in resident bathroom were not kept in good repair, including removed toilet paper holder and exposed drywall. |
Report Facts
Number of resident records reviewed: 1
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Marie Swink | Licensing Inspector | Current inspector conducting the complaint investigation |
Inspection Report
Monitoring
Deficiencies: 6
Oct 22, 2025
Visit Reason
The inspection was a monitoring visit conducted following a self-report received by VDSS Division of Licensing regarding allegations in the areas of Administration and Administrative Services, Personnel, Staffing and Supervision, and Resident Care and Related Services.
Findings
The investigation supported the self-report of non-compliance with multiple regulatory standards, resulting in violations issued related to staff records, work schedules, medication management, and administration. Specific deficiencies included failure to maintain accurate staff records, incomplete medication administration documentation, and failure to administer medications according to physician orders.
Deficiencies (6)
| Description |
|---|
| Facility failed to ensure that a record shall be established for each staff person. |
| Facility failed to ensure that personal and social data to be maintained on staff included all required documentation. |
| Facility failed to maintain a written work schedule that includes names, job classifications, and changes for all staff working each shift. |
| Facility failed to follow medication management plan to ensure accurate counts of controlled substances and timely refills to avoid missed dosages. |
| Facility failed to ensure medications were administered in accordance with physician's or prescriber's instructions. |
| Facility failed to ensure that the sworn statement or affirmation was completed for all applicants for employment. |
Report Facts
Number of resident records reviewed: 4
Number of staff records reviewed: 4
Number of interviews conducted with staff: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Marie Swink | Licensing Inspector | Current inspector conducting the monitoring inspection |
| Staff 5 | Interviewed staff who provided information about Staff 6 and staff records | |
| Staff 6 | Staff involved in incident and subject of record and schedule deficiencies | |
| Staff 2 | Staff whose record lacked required documentation and sworn statement |
Inspection Report
Complaint Investigation
Deficiencies: 3
Sep 9, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-09-03 regarding allegations in the areas of Personnel, Staffing and Supervision, and Resident Care and Related Services.
Findings
The investigation supported some, but not all, of the allegations; non-compliance was found in Resident Care and Related Services. Violations included failure to update the Uniform Assessment Instrument and Individualized Service Plans to reflect significant changes in resident condition, and failure to provide prompt response to resident needs.
Complaint Details
The complaint investigation was substantiated in part, with non-compliance found in Resident Care and Related Services. The complaint was related to delayed staff response to resident call bell and failure to update resident assessments and service plans.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure all residents and applicants are assessed face to face using the uniform assessment instrument prior to admission, annually, and with significant changes. |
| Facility failed to ensure Individualized Service Plans are reviewed and updated at least annually and with significant changes. |
| Facility failed to ensure care provision and service delivery were resident-centered and included prompt response by staff to resident needs. |
Report Facts
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of resident interviews conducted: 2
Number of staff interviews conducted: 2
Call bell response time: 69
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Marie Swink | Licensing Inspector | Inspector conducting the complaint investigation |
Inspection Report
Complaint Investigation
Deficiencies: 1
Jul 21, 2025
Visit Reason
The inspection was conducted in response to a complaint received on 2025-07-14 regarding allegations related to Buildings and Grounds, and Resident Accommodations and Related Provisions.
Findings
The investigation found that some allegations were substantiated, specifically non-compliance in the area of Buildings and Grounds. The facility failed to maintain the interior and exterior of all buildings in good repair and kept clean and free of rubbish, as evidenced by waste observed on the dining room floor during multiple tours.
Complaint Details
The complaint was received by VDSS Division of Licensing on 2025-07-14 regarding allegations in Buildings and Grounds and Resident Accommodations. The evidence gathered supported some but not all allegations, specifically non-compliance in Buildings and Grounds. A violation notice was issued.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure that the interior and exterior of all buildings were maintained in good repair and kept clean and free of rubbish, with waste observed on the dining room floor near and underneath multiple tables. |
Report Facts
Number of staff interviews: 3
Correction date: Aug 31, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Marie Swink | Licensing Inspector | Conducted the inspection and authored the report |
Inspection Report
Monitoring
Census: 75
Deficiencies: 1
Jul 10, 2025
Visit Reason
The inspection was a monitoring visit conducted to review compliance with applicable standards and laws related to resident care and building conditions.
Findings
The inspection found non-compliance with standards related to building ventilation, specifically the presence of foul odors including a strong smell of urine in a resident's room and adjacent hallway.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure all buildings shall be well-ventilated and free from foul, stale, and musty odors. |
Report Facts
Number of residents present: 75
Number of resident records reviewed: 1
Number of resident interviews conducted: 1
Number of staff interviews conducted: 3
Inspection Report
Renewal
Census: 75
Deficiencies: 12
Jul 10, 2025
Visit Reason
The inspection was a renewal inspection conducted to evaluate the facility's compliance with applicable standards and laws for license renewal.
Findings
The inspection identified multiple violations related to physical plant safety, infection control, staff training, resident record documentation, medication management, and skilled nursing care requirements. The facility was found non-compliant in several areas and issued violation notices with plans of correction due by August 31, 2025.
Deficiencies (12)
| Description |
|---|
| Facility failed to ensure harmful materials were inaccessible to residents with serious cognitive impairments; laundry room door was unlocked with cleaning supplies accessible. |
| Facility failed to follow Infection Control Program; staff administered medication without gloves despite potential contact with body fluids. |
| Direct care staff did not complete required 18 hours of annual training. |
| Training was not in addition to required first aid, CPR, and continuing education for medication aides. |
| Staff records lacked verification that staff received current job descriptions. |
| Direct care staff did not maintain current certification in first aid. |
| Facility failed to ascertain and document whether residents were registered sex offenders prior to admission. |
| Comprehensive individualized service plans were not completed within 30 days after admission. |
| Skilled nursing treatments were administered by Registered Medication Aides instead of licensed nurses. |
| Medication administration plan was not followed; narcotic shift count records lacked staff initials on multiple dates. |
| Medications and treatments were started without valid physician orders. |
| Medication Administration Record included documentation of medication administered when it was not actually given. |
Report Facts
Residents present: 75
Resident records reviewed: 6
Staff records reviewed: 3
Resident interviews: 3
Staff interviews: 5
Violation correction deadline: Aug 31, 2025
Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 0
Jul 1, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-06-12 regarding allegations in the areas of personnel and 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 to personnel and resident care and related services; the allegations were not substantiated.
Report Facts
Number of resident records reviewed: 1
Number of staff records reviewed: 2
Number of interviews conducted with staff: 2
Inspection Report
Monitoring
Census: 77
Deficiencies: 5
May 29, 2025
Visit Reason
The inspection was a monitoring visit conducted to review compliance with resident care and related services following a self-reported incident received by VDSS Division of Licensing regarding allegations in resident care.
Findings
The investigation supported the self-report of non-compliance with multiple standards related to individualized service plans, uniform assessment instruments, hospice care documentation, and medication administration errors. Violations were issued and plans of correction were required.
Deficiencies (5)
| Description |
|---|
| Failed to ensure written documentation of companion services provided by private duty personnel and reflection on individualized service plan (ISP). |
| Failed to ensure the uniform assessment instrument (UAI) was completed as required for private pay individuals. |
| Failed to ensure the comprehensive individualized service plan (ISP) included detailed descriptions of identified needs, services provided, and responsible providers. |
| Failed to update the individualized service plan (ISP) to include hospice services provided to a resident. |
| Failed to ensure medications were administered in accordance with physician's or prescriber's instructions, resulting in a medication error involving METFORMIN administration to the wrong resident. |
Report Facts
Number of residents present: 77
Number of resident records reviewed: 2
Number of staff records reviewed: 2
Number of interviews conducted with staff: 2
Medication monitoring timeframe: 8
Medication pass monitoring shifts: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Marie Swink | Licensing Inspector | Current inspector conducting the monitoring inspection |
| Holly Copeland | Licensing Inspector | Contact person for questions regarding the inspection |
Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 0
May 12, 2025
Visit Reason
The inspection was conducted in response to a complaint received on 2025-04-30 regarding allegations related to resident care and related services at the facility.
Findings
The investigation found no evidence to support the allegations of non-compliance with standards or law. The inspection findings indicate that the facility was in compliance with the relevant regulations.
Complaint Details
Complaint #62339 was received by VDSS Division of Licensing on 2025-04-30 regarding allegations in resident care and related services. The evidence gathered did not support the allegations of non-compliance.
Report Facts
Number of residents present: 82
Number of resident records reviewed: 1
Number of staff interviews conducted: 2
Inspection Report
Complaint Investigation
Census: 74
Deficiencies: 5
Apr 11, 2025
Visit Reason
The inspection was conducted in response to a complaint received on 2025-03-20 regarding allegations in the area of resident care and related services.
Findings
The investigation found multiple violations including failure to complete the uniform assessment instrument (UAI) accurately and timely, failure to provide care as specified in individualized service plans (ISP), improper medication storage, inadequate ventilation with foul odors, and unclean furnishings posing health hazards.
Complaint Details
The complaint was substantiated as the evidence gathered supported allegations of non-compliance with standards related to resident care and related services.
Deficiencies (5)
| Description |
|---|
| Facility failed to ensure 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 the care and services specified in the individualized service plan (ISP) were provided to the resident. |
| Facility failed to ensure medications remained in the pharmacy issued container with prescription label until administered. |
| Facility failed to ensure all buildings were well-ventilated and free from foul, stale, and musty odors. |
| Facility failed to ensure all furnishings were kept clean and in good repair and condition, presenting a health hazard. |
Report Facts
Number of residents present: 74
Number of resident records reviewed: 1
Number of staff interviews conducted: 3
Date to be corrected: May 31, 2025
Inspection Report
Monitoring
Deficiencies: 1
Mar 5, 2025
Visit Reason
The inspection was a monitoring visit conducted to review compliance with resident care and related services regulations.
Findings
The inspection found non-compliance with medication administration standards, specifically that medications were not administered according to physician orders.
Deficiencies (1)
| Description |
|---|
| The facility failed to ensure that medications were administered in accordance with the physician's or other prescriber's instructions. |
Report Facts
Number of resident records reviewed: 1
Number of staff interviews conducted: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Marie Swink | Licensing Inspector | Current inspector conducting the inspection |
| Staff 1 | Interviewed and confirmed medication was administered at the wrong time | |
| Staff 3 | Administered medication at the wrong time, not following physician orders |
Inspection Report
Monitoring
Deficiencies: 2
Jan 9, 2025
Visit Reason
The inspection was a monitoring visit conducted on January 9, 2025, following a self-reported incident received on November 22, 2024, regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation supported the self-report of non-compliance with standards related to medication administration and documentation. Violations were issued for failure to administer medications according to physician orders and failure to properly document medication administration on the Medication Administration Record (MAR).
Deficiencies (2)
| Description |
|---|
| The facility failed to ensure that medications were administered in accordance with the physician's or other prescriber's instructions. |
| The facility failed to ensure that the Medication Administration Record (MAR) included date and time given and initials of direct care staff administering the medication. |
Report Facts
Number of resident records reviewed: 1
Number of staff interviews conducted: 2
Medication doses prescribed: 3
Inspection Report
Monitoring
Deficiencies: 0
Nov 14, 2024
Visit Reason
The inspection was a monitoring visit to review compliance with additional requirements for facilities that care for adults with serious cognitive impairments.
Findings
The inspection found no violations with applicable standards or laws during the tour of the physical plant and staff interview.
Inspection Report
Monitoring
Census: 75
Deficiencies: 1
Sep 24, 2024
Visit Reason
The inspection was a monitoring visit to review staffing, resident care, and additional requirements for facilities caring for adults with serious cognitive impairments.
Findings
The facility was found non-compliant due to the lack of protective devices on windows in common areas accessible to residents, allowing windows to be opened wide enough for a resident to crawl through.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure protective devices on windows in common areas to prevent residents from opening windows wide enough to crawl through. |
Report Facts
Number of residents present: 75
Number of resident records reviewed: 2
Number of staff interviews conducted: 2
Inspection Report
Monitoring
Census: 78
Deficiencies: 2
Aug 21, 2024
Visit Reason
The inspection was a monitoring visit triggered by a self-reported incident received on 2024-08-17 regarding allegations in Resident Care and Related Services, Personnel, and Buildings and Grounds.
Findings
The investigation supported some but not all of the allegations/self-report, identifying areas of non-compliance in Personnel and Resident Care and Related Services. Violations included inadequate staffing and failure to document medication administration properly.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure staff were adequate in knowledge, skills, and numbers to provide necessary resident care, including abandonment of shift and leaving a resident unattended on a transfer lift. |
| Facility failed to document all medications administered on the medication administration record (MAR), including omission of a physician's order for treatment of a skin tear. |
Report Facts
Number of residents present: 78
Number of resident records reviewed: 2
Number of staff records reviewed: 1
Number of resident interviews conducted: 2
Number of staff interviews conducted: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Marie Swink | Licensing Inspector | Inspector conducting the monitoring visit |
Inspection Report
Monitoring
Census: 75
Deficiencies: 1
Jul 30, 2024
Visit Reason
The inspection was a monitoring visit conducted to review compliance with resident care and related services following a self-reported incident received by VDSS Division of Licensing on 7/25/2024.
Findings
The investigation supported the self-report of non-compliance related to medication administration errors, specifically a resident receiving an extra dose of medications due to a failure in updating the Medication Administrative Record caused by WiFi accessibility issues.
Deficiencies (1)
| Description |
|---|
| Failure to ensure medications were administered in accordance with the physician's or other prescriber's instructions, resulting in a resident receiving a third dose of Coreg 25mg and Metformin 500mg. |
Report Facts
Number of residents present: 75
Number of resident records reviewed: 1
Number of staff interviews conducted: 3
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 0
Jul 15, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-06-30 regarding allegations related to Building and Grounds, and Resident Care and Related Services.
Findings
The investigation did not find evidence to support the allegations of non-compliance with standards or law. The licensing inspector completed a tour of the physical plant and conducted interviews with residents and staff.
Complaint Details
A complaint was received by VDSS Division of Licensing on 2024-06-30 regarding allegations in the areas of Building and Grounds, Resident Care and Related Services. The evidence gathered did not support the allegations.
Report Facts
Number of residents present: 80
Number of resident interviews: 5
Number of staff interviews: 6
Inspection Report
Renewal
Census: 81
Deficiencies: 6
Jul 15, 2024
Visit Reason
The inspection was conducted as a renewal inspection to assess compliance with applicable standards and laws for continued licensing of the assisted living facility.
Findings
The inspection identified multiple violations including failure to ensure protective devices on windows, incomplete hospice service plans, outdated resident records, medication management plan non-compliance, and inconsistent medication administration documentation.
Deficiencies (6)
| Description |
|---|
| Facility failed to ensure protective devices on windows in common areas accessible to residents to prevent windows from being opened wide enough for a resident to crawl through. |
| Facility failed to ensure the services provided by hospice care were included on the individualized service plan (ISP). |
| Facility failed to ensure that resident records are kept current. |
| Facility failed to ensure their Medication Management Plan (MMP) was followed to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes. |
| Facility failed to ensure that no medication, dietary supplement, diet, medical procedure, or treatment was started, changed, or discontinued without a valid order from a physician or other prescriber. |
| Facility failed to ensure the dosage of the medication given was accurately documented on the Medication Administration Record (MAR). |
Report Facts
Number of residents present: 81
Number of resident records reviewed: 7
Number of staff records reviewed: 3
Number of resident interviews conducted: 3
Number of staff interviews conducted: 6
Medication narcotic count missing staff initials: 11
Inspection Report
Complaint Investigation
Census: 79
Deficiencies: 1
Jun 26, 2024
Visit Reason
The inspection was conducted as a complaint investigation to review allegations of non-compliance with standards or law at the assisted living facility.
Findings
The investigation did not substantiate the complaint allegations; however, a violation unrelated to the complaint was identified regarding the failure to review and update the Individualized Service Plan (ISP) at least annually or as needed for significant changes.
Complaint Details
The complaint investigation found no evidence supporting the allegations of non-compliance with standards or law.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure the Individualized Service Plan (ISP) was reviewed and updated at least once every 12 months and as needed for significant changes in a resident's condition. |
Report Facts
Number of residents present: 79
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
Inspection Report
Monitoring
Census: 79
Deficiencies: 0
Jun 26, 2024
Visit Reason
The inspection was a monitoring visit to review staffing and supervision, and admission, retention, and discharge of residents at the assisted living facility.
Findings
The inspection found no violations of applicable standards or laws during the visit. The licensing inspector completed a tour of the physical plant and reviewed one resident record.
Report Facts
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 1
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 1
Apr 4, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-03-22 regarding allegations related to Resident Care and Related Services at the facility.
Findings
The investigation found that the facility failed to provide a current copy of the Comprehensive Individual Service Plan (ISP) to a resident, supporting the complaint allegations and resulting in a violation.
Complaint Details
The complaint was substantiated based on evidence including resident and staff interviews and record review, confirming non-compliance with the requirement to provide the ISP to the resident.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure a current copy of the Comprehensive Individual Service Plan (ISP) was provided to the resident. |
Report Facts
Number of residents present: 88
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of resident interviews conducted: 1
Number of staff interviews conducted: 1
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 1
Mar 20, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2024-03-12 regarding allegations in the area of Admission, Retention, and Discharge of residents.
Findings
The investigation supported the allegation of non-compliance with standards related to failure to provide a disclosure statement to prospective residents and their legal representatives. Violations were issued based on resident record reviews and staff interviews.
Complaint Details
The complaint was substantiated. The facility did not provide a disclosure statement to resident 1 and resident 2 for the current licensee as confirmed by staff interview on 2024-03-28.
Deficiencies (1)
| Description |
|---|
| Facility failed to provide a statement to the prospective resident and his legal representative, if any, that discloses information about the facility. |
Report Facts
Residents present: 88
Resident records reviewed: 2
Staff interviews conducted: 2
Resident interviews conducted: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Marie Swink | Licensing Inspector | Inspector conducting the complaint investigation and interview |
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 2
Mar 20, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-03-18 regarding allegations related to staffing and supervision and resident care and related services at the facility.
Findings
The investigation found non-compliance with standards related to staffing levels and the completion of individualized service plans within 30 days of admission. Violations were issued based on evidence including staff interviews, document reviews, and resident record reviews.
Complaint Details
The complaint was substantiated as the evidence gathered supported the allegations of non-compliance with staffing and supervision and resident care standards.
Deficiencies (2)
| Description |
|---|
| Facility failed to implement their written plan specifying the number and type of direct care staff required to meet day-to-day and special needs of residents. |
| Facility failed to ensure the comprehensive individualized service plan was completed within 30 days after admission. |
Report Facts
Number of residents present: 88
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
Staffing levels per written plan: 4
Staffing levels per written plan: 6
Staffing levels per written plan: 3
Staffing levels per written plan: 5
Non-ambulatory residents: 8
Admission date: Jul 18, 2023
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 1
Jan 9, 2024
Visit Reason
The inspection was conducted in response to a complaint received by the VDSS Division of Licensing on 2024-01-02 regarding allegations related to staffing and resident care and related services.
Findings
The investigation supported some, but not all, of the allegations; non-compliance was found in the area of resident care and related services. A violation notice was issued related to individualized service plans not being signed by residents or their legal representatives.
Complaint Details
The complaint was substantiated in part, specifically regarding resident care and related services. The violation was related to unsigned individualized service plans.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure that individualized service plans (ISP) were signed by the resident or their legal representative. |
Report Facts
Number of residents present: 40
Number of resident records reviewed: 1
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 1
Inspection Report
Renewal
Census: 81
Deficiencies: 10
Jul 20, 2023
Visit Reason
The inspection was a renewal visit to assess the facility's compliance with applicable standards and laws as part of the licensing renewal process.
Findings
The inspection identified multiple areas of non-compliance including infection control failures, staff scope of practice issues, incomplete staff training, missing documentation on resident assessments and plans of care, medication labeling deficiencies, and emergency preparedness shortcomings. Violation notices were issued with opportunities for the licensee to submit plans of correction.
Deficiencies (10)
| Description |
|---|
| Facility failed to follow infection control policy for assisted blood glucose monitoring; glucometers were not labeled. |
| Direct care staff provided services outside their scope of practice by changing Freestyle Libre 2 Sensor without proper training. |
| Staff records lacked evidence of annual tuberculosis screening for some employees. |
| Aggressive behavior training for direct care staff did not include all required components such as demonstration and practical experience. |
| Private pay uniform assessment instrument (UAI) was not signed by the administrator or designee. |
| Individualized service plans (ISPs) for residents receiving hospice care did not include coordinated plan of care or services provided by hospice. |
| ISPs were not updated to reflect discontinued orders and contained inconsistent documentation. |
| Over the counter medications on medication carts were not labeled with resident names. |
| Facility failed to ensure a 6-month review of emergency preparedness policies and procedures was completed with all residents. |
| Emergency water supply on-site was expired and not maintained as required. |
Report Facts
Residents present: 81
Resident records reviewed: 12
Staff records reviewed: 7
Resident interviews conducted: 3
Staff interviews conducted: 4
Plan of correction submission timeframe: 5
Inspection Report
Renewal
Census: 62
Deficiencies: 16
Jun 27, 2022
Visit Reason
The inspection was a renewal inspection conducted to assess compliance with applicable standards and laws for licensing renewal of the assisted living facility.
Findings
The inspection identified multiple areas of non-compliance including deficiencies in staff training, resident record documentation, medication administration, physical plant safety, and fire safety compliance. Violations were documented and a plan of correction was requested to address these issues.
Deficiencies (16)
| Description |
|---|
| Facility failed to ensure direct care staff received the required number of hours of annual training. |
| Facility failed to ensure all direct care staff received at least 2 hours of infection control training annually. |
| Facility failed to ensure staff received tuberculosis screening on or within seven days prior to first day of work. |
| Facility failed to ensure direct care staff received training in methods of dealing with residents with aggressive behavior prior to care involvement. |
| Facility failed to ensure physical examination reports contained all required components. |
| Facility failed to review and update fall risk ratings for residents after falls. |
| Facility failed to obtain all required personal and social information prior to or at admission. |
| Facility failed to ensure private pay uniform assessment instruments were completed as required. |
| Facility failed to update individualized service plans as needed for significant resident condition changes. |
| Facility failed to ensure annual review of resident rights and responsibilities was completed with residents and staff. |
| Facility failed to have a written agreement signed by resident and licensee for residents receiving meals in their rooms. |
| Facility failed to administer medications in accordance with physician orders. |
| Facility failed to ensure all operable windows were effectively screened. |
| Facility failed to ensure cleaning supplies and hazardous materials were stored in a locked area. |
| Facility failed to ensure compliance with Virginia Statewide Fire Prevention Code by not having a recent annual fire inspection. |
| Facility failed to ensure fire drill logs included all required information such as identity of person conducting drill, number of participants, and conditions simulated. |
Report Facts
Residents present: 62
Resident records reviewed: 8
Staff records reviewed: 4
Resident interviews conducted: 3
Staff interviews conducted: 3
Staff training hours required: 18
Infection control training hours required: 2
TB screening timeframe: 7
Medication administration error: 2
Fire Marshall inspection date: Nov 23, 2020
Inspection Report
Monitoring
Deficiencies: 1
Apr 19, 2022
Visit Reason
The inspection was a monitoring visit triggered by a self-reported incident received by the Virginia Department of Social Services Division of Licensing on 04/19/2022 regarding allegations in the area of resident care and related services.
Findings
The investigation supported the self-report of non-compliance with regulations, specifically that the facility failed to ensure immediate medical attention from a licensed healthcare professional when a resident suffered a serious injury. Violations were issued and the licensee was given the opportunity to submit a plan of correction.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure that medical attention from a licensed healthcare professional was secured immediately when a resident suffered a serious accident, injury, illness or medical condition or reason to suspect that such has occurred. |
Report Facts
Number of resident records reviewed: 1
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 2
Incident date and time: 2022-04-17T22:10
Time medical attention was first documented: 2022-04-18T10:22
Hospital discharge date: Apr 22, 2022
Inspection Report
Complaint Investigation
Deficiencies: 1
Apr 13, 2022
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2022-03-04 regarding allegations in the area of resident care and related services.
Findings
The investigation supported the allegation of non-compliance related to medication administration. Specifically, the facility failed to ensure medications remained in the pharmacy-issued container with the prescription label until administered. It was found that staff were placing medication in a weekly medication box for resident self-administration without proper orders.
Complaint Details
The complaint was substantiated based on evidence gathered during the investigation, including resident and staff interviews and record reviews.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure medications remained in the pharmacy issued container with the prescription label until administered to the resident. |
Report Facts
Number of resident records reviewed: 1
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 1
Inspection Report
Renewal
Census: 63
Deficiencies: 5
Jul 15, 2021
Visit Reason
A renewal inspection was initiated on 7/12/2021 and concluded on 7/15/2021 to review compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection identified multiple violations including unlabeled medical equipment, missing PRN medications, incomplete oxygen orders, unclean and damaged carpets, and foul odors due to a resident's cat. Plans of correction were provided for each deficiency.
Deficiencies (5)
| Description |
|---|
| Facility failed to ensure that dedicated medical equipment was appropriately labeled. |
| Facility failed to ensure medications for PRN use were properly stored at the facility. |
| Facility failed to ensure oxygen orders contained all required information. |
| Facility failed to ensure the interior of the building was kept clean and in good repair. |
| Facility failed to ensure that the building was free from foul odors. |
Report Facts
Resident census: 63
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Marie Swink | Inspector | Conducted the inspection |
| Director of Nursing | Participated in exit interview and involved in findings | |
| Director of Health & Wellness | Responsible for medication cart audits and compliance with standards | |
| Executive Director | Responsible for compliance with building maintenance and odor issues | |
| Director of Facility Operations | Responsible for carpet repair and maintenance |
Inspection Report
Monitoring
Census: 59
Deficiencies: 2
May 12, 2021
Visit Reason
A monitoring inspection was initiated and conducted remotely due to a state of emergency health pandemic declared by the Governor of Virginia. The inspection was conducted to review compliance with applicable standards and laws.
Findings
The inspection found non-compliance with standards related to updating private pay uniform assessment instruments (UAI) when there was a significant change in a resident's condition and failure to ensure that all identified needs were addressed on residents' individualized service plans (ISPs). Violations were documented and a plan of correction was issued.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure that private pay uniform assessment instruments (UAI) were updated when there was a significant change in a resident's condition. |
| Facility failed to ensure that all identified needs were addressed on residents individualized service plans (ISPs). |
Report Facts
Resident records reviewed: 4
Staff records reviewed: 4
Inspection Report
Original Licensing
Census: 58
Deficiencies: 2
Dec 16, 2020
Visit Reason
An announced virtual initial 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 found non-compliance with applicable standards, including deficiencies in the infection control policy and lack of established procedures for communication among administrators and staff.
Deficiencies (2)
| Description |
|---|
| The facility infection control policy did not include required information regarding determination of acute infectious disease in prospective or returning residents, use of appropriate measures to prevent disease transmission, and staff training requirements. |
| The facility failed to establish procedures for communication among administrators, designated assistant administrators, managers, and designated staff persons in charge. |
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