Inspection Report
Monitoring
Census: 127
Deficiencies: 5
Oct 29, 2025
Visit Reason
The inspection was a monitoring visit triggered by a self-reported incident received on 2025-10-07 regarding allegations in the area of Resident Accommodations and Related Provisions.
Findings
The investigation supported the self-report of non-compliance and identified multiple violations related to incident reporting, medication management plan implementation, timely physician order signatures, medication administration timing, and adherence to physician orders. The facility failed to report a major incident within 24 hours, did not implement the medication management plan properly, and medication errors occurred including administering the wrong medication to a resident.
Deficiencies (5)
| Description |
|---|
| Failed to report any major incident that negatively affected or threatened residents within 24 hours to the regional licensing office. |
| Failed to ensure that a medication management plan was implemented, including training and documentation for new staff. |
| Failed to ensure physician or prescriber orders were reviewed and signed within 14 days. |
| Failed to ensure medication was administered not earlier than one hour before or one hour after the facility's standard dosing schedule. |
| Failed to ensure medication was administered in accordance with physician or prescriber orders, resulting in a medication error where Resident 1 received Resident 2's medication. |
Report Facts
Number of residents present: 127
Number of resident records reviewed: 2
Number of staff records reviewed: 1
Number of staff interviews conducted: 2
Number of resident interviews conducted: 0
Number of medications administered in error: 17
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Confirmed incident dates, acknowledged failure to report within 24 hours, provided medication management plan, confirmed medication error and lack of signed orders, and participated in interviews. | |
| Staff 2 | Administered wrong medication to Resident 1, did not review medication management plan upon hire, and involved in medication error incident. | |
| Staff 3 | Acknowledged medication was administered late to Resident 2 and participated in interviews. | |
| Executive Director | Responsible for implementing and sustaining plans of correction and reviewing progress at QAPI meetings. | |
| DON | Director of Nursing | Responsible for reviewing incidents, re-educating staff, auditing compliance, and ensuring implementation of plans of correction. |
Inspection Report
Complaint Investigation
Census: 125
Deficiencies: 3
Sep 25, 2025
Visit Reason
The inspection was conducted in response to a complaint received on 2025-09-13 regarding allegations related to Resident Accommodations and Related Provisions.
Findings
The investigation found multiple violations related to personal care, health care service needs, and medication storage. Specifically, the facility failed to provide adequate perineal care, had inconsistent wound care orders, and improperly stored medications in a resident's room.
Complaint Details
The complaint was substantiated based on evidence including resident records, staff interviews, and observations confirming non-compliance with standards related to personal care and medication storage.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure personal care and assistance were provided to meet resident needs, including perineal care issues leading to chronic fungal infections. |
| Facility failed to ensure health care service needs were met either directly or indirectly, with inconsistent wound care orders and improper use of Zinc Oxide products. |
| Facility failed to ensure medication was stored securely and out of sight in resident rooms, and reassessed resident's ability to self-administer medications. |
Report Facts
Number of residents present: 125
Number of resident records reviewed: 1
Number of staff interviews conducted: 3
Audit frequency: 2
Random room checks frequency: 1
Inspection Report
Renewal
Census: 126
Deficiencies: 5
Aug 13, 2025
Visit Reason
The inspection was conducted as a renewal inspection of The Providence Fairfax assisted living facility to assess compliance with applicable standards and regulations.
Findings
The inspection found multiple violations related to staff training requirements, first aid certification, individualized service plan updates, and unsafe storage of cleaning supplies. Plans of correction were proposed to address these deficiencies and prevent recurrence.
Deficiencies (5)
| Description |
|---|
| Facility failed to ensure direct care staff attended at least 10 hours of cognitive impairment training within four months of employment in the safe, secure unit. |
| 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 maintained a current first aid certification from approved organizations. |
| Facility failed to ensure individualized service plan (ISP) was updated as needed for a significant change in resident's condition. |
| Facility failed to ensure cleaning supplies were stored in a locked area. |
Report Facts
Number of residents present: 126
Number of resident records reviewed: 8
Number of staff records reviewed: 4
Number of interviews conducted with staff: 4
Training hours completed by Staff 10: 4.25
Training hours completed by Staff 5: 3
Training hours completed by Staff 11: 0
Training hours completed by Staff 12: 0
Training hours completed by Staff 8: 0
Training hours completed by Staff 11: 3.25
Training hours completed by Staff 5: 5.5
Inspection Report
Complaint Investigation
Census: 124
Deficiencies: 3
Jul 30, 2025
Visit Reason
The inspection was conducted in response to a complaint received on 2025-07-22 regarding staffing and supervision, resident care and related services, and resident accommodations and related provisions.
Findings
The investigation substantiated the complaint of non-compliance with multiple standards, including failure to report incidents within 24 hours, inadequate monitoring of private duty personnel, and failure to ensure supervision of residents with specialized needs such as fall prevention. Violations were issued and plans of correction were required.
Complaint Details
The complaint was substantiated based on evidence including resident records, staff interviews, and documentation showing failures in incident reporting, supervision, and monitoring of private duty aides.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure that each incident negatively affecting residents was reported to the licensing office within 24 hours. |
| Facility failed to monitor delivery of direct care and companion services by private duty personnel from a licensed home care organization. |
| Facility failed to ensure supervision of resident schedules, care, and activities including attention to specialized needs such as falling. |
Report Facts
Number of residents present: 124
Number of resident records reviewed: 1
Number of staff records reviewed: 5
Number of staff interviews conducted: 4
Number of resident interviews conducted: 0
Inspection Report
Complaint Investigation
Census: 124
Deficiencies: 0
Jul 30, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 06/30/2025 regarding allegations related to Admissions, Retention and Discharge of Residents.
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 allegations in Admissions, Retention and Discharge of Residents; investigation found no substantiated non-compliance.
Report Facts
Number of resident records reviewed: 2
Number of staff records reviewed: 0
Number of interviews conducted with staff: 4
Inspection Report
Complaint Investigation
Census: 122
Deficiencies: 3
Jun 16, 2025
Visit Reason
The inspection was conducted in response to a complaint received on 2025-05-07 regarding allegations in the areas of resident care and related services, resident accommodations and related provisions, staffing and supervision, and buildings and grounds.
Findings
The investigation supported the complaint of non-compliance with multiple standards, including failure to update Individualized Service Plans (ISPs) for significant changes in resident condition, failure to provide care and services as specified in ISPs, and failure to ensure operable windows were effectively screened. Violations were issued and plans of correction were required.
Complaint Details
The complaint was substantiated. The investigation found violations related to resident care, accommodations, staffing, and building safety. Evidence included resident records, staff interviews, video footage, and physical inspection.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure that the Individualized Service Plan (ISP) was reviewed and updated as needed for significant change of a resident's condition. |
| Facility failed to ensure that the care and services specified in the Individualized Service Plan (ISP) are provided to each resident. |
| Facility failed to ensure that any operable window was effectively screened. |
Report Facts
Number of residents present: 122
Number of resident records reviewed: 1
Number of staff interviews conducted: 5
Task log grooming assistance failures: 13
Timeframe for window screen correction: 60
Monthly audit sample size: 5
Inspection Report
Monitoring
Census: 120
Deficiencies: 2
Apr 24, 2025
Visit Reason
The inspection was a monitoring visit triggered by a self-reported incident received by VDSS Division of Licensing on April 24, 2025, regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation supported the self-report of non-compliance with standards, resulting in violations related to staff training in cognitive impairment and failure to ensure the general health, safety, and well-being of a resident. Corrective actions including staff suspension, retraining, and policy reviews were implemented.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure that direct care staff attended at least 10 hours of training in cognitive impairment within four months of employment. |
| Facility failed to assume the general health, safety, and well-being of the resident, evidenced by aggressive physical and verbal behavior by staff during care. |
Report Facts
Residents present: 120
Resident records reviewed: 3
Staff records reviewed: 4
Resident interviews conducted: 2
Staff interviews conducted: 2
Inspection Report
Monitoring
Census: 120
Deficiencies: 6
Apr 24, 2025
Visit Reason
The inspection was a monitoring visit to assess compliance with applicable regulations and standards at The Providence Fairfax assisted living facility.
Findings
The inspection identified multiple violations including failure to ensure annual healthcare oversight for all residents, medication management plan non-compliance, improper medication administration timing and storage, lack of semi-annual emergency preparedness plan review, and failure to ensure employee criminal history records were free of barrier crimes. Plans of correction were submitted addressing each deficiency with no direct adverse resident impact reported.
Deficiencies (6)
| Description |
|---|
| Facility failed to ensure all residents were included in healthcare oversight at least annually. |
| Facility failed to ensure the medication management plan was followed. |
| Facility failed to ensure medication was administered according to physician orders. |
| Facility failed to ensure medications were administered not earlier than one hour before and not later than one hour after the standard dosing schedule. |
| Facility failed to ensure a semi-annual review on the emergency preparedness plan was implemented for all staff, residents, and volunteers. |
| Facility failed to ensure that each employee's criminal history record did not contain any barrier crimes. |
Report Facts
Residents present: 120
Resident records reviewed: 8
Staff records reviewed: 4
Resident interviews conducted: 1
Medication administration audit dates: 11
Facility census: 125
Inspection Report
Complaint Investigation
Census: 120
Deficiencies: 0
Apr 23, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-02-11 regarding allegations related to Resident Privacy and Dignity During Health Services.
Findings
The investigation found no evidence to 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 related to Resident Privacy and Dignity During Health Services; the evidence gathered did not support the allegations of non-compliance.
Report Facts
Number of residents present: 120
Number of resident records reviewed: 0
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 4
Inspection Report
Complaint Investigation
Census: 120
Deficiencies: 3
Apr 23, 2025
Visit Reason
The inspection was conducted in response to a complaint received on 2025-01-24 regarding allegations in the areas of Resident Care and Related Services and Resident Accommodations and Related Provisions.
Findings
The investigation found multiple violations including failure to record menu substitutions on the posted menu, medication administration not according to physician orders, and lack of availability of PRN medications for a specific resident. Plans of correction were submitted addressing these issues.
Complaint Details
The complaint was substantiated as the evidence gathered supported non-compliance with standards or law related to menu posting and medication administration.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure that any menu substitutions or additions are recorded on the posted menu. |
| Facility failed to ensure medication was administered according to physician order. |
| Facility failed to ensure that PRN medication was available for the specific resident. |
Report Facts
Number of residents present: 120
Number of resident records reviewed: 3
Number of staff interviews conducted: 3
Medication doses administered incorrectly: 4
Medication doses administered incorrectly: 14
Inspection Report
Complaint Investigation
Census: 120
Deficiencies: 2
Apr 23, 2025
Visit Reason
The inspection was conducted in response to a complaint received by the VDSS Division of Licensing on 2025-03-03 regarding allegations related to staffing and supervision, and resident care and related services.
Findings
The investigation supported some but not all allegations. The facility was found non-compliant in the area of Resident Care and Related Services, including failure to maintain a written staffing plan specifying the number and type of staff needed, and failure to ensure prompt response to resident emergency calls.
Complaint Details
The complaint was substantiated in part. The evidence supported some allegations related to staffing and supervision and resident care. A violation notice was issued for non-compliance in Resident Care and Related Services.
Deficiencies (2)
| Description |
|---|
| Facility failed to maintain a written staffing plan that includes the number and type of staff required to meet day-to-day, routine direct care needs and any specialized needs. |
| Facility failed to ensure prompt response to needs as reasonable to the circumstances, with documented delays in emergency call response times exceeding 20 minutes on multiple occasions. |
Report Facts
Number of residents present: 120
Number of resident records reviewed: 3
Number of staff records reviewed: 4
Number of resident interviews conducted: 2
Number of staff interviews conducted: 2
Instances of delayed emergency call response: 12
Emergency call response times (minutes): 45
Emergency call response times (minutes): 38
Emergency call response times (minutes): 25
Emergency call response times (minutes): 32
Emergency call response times (minutes): 26
Emergency call response times (minutes): 33
Emergency call response times (minutes): 37
Emergency call response times (minutes): 58
Emergency call response times (minutes): 57
Emergency call response times (minutes): 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Velasco | Licensing Inspector | Inspector conducting the complaint investigation |
| Staff 1 | Provided emergency call report and interview regarding response times | |
| Staff 2 | Provided staffing policy documents and interview regarding staffing plan |
Inspection Report
Monitoring
Census: 117
Deficiencies: 0
Jan 15, 2025
Visit Reason
The inspection was conducted as a monitoring visit following a self-reported incident received by VDSS Division of Licensing 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. No deficiencies were cited during this inspection.
Report Facts
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 4
Inspection Report
Monitoring
Census: 117
Deficiencies: 0
Jan 15, 2025
Visit Reason
The inspection was conducted as a monitoring visit following a self-reported incident received by VDSS Division of Licensing 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 were favorable with no deficiencies cited.
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: 4
Inspection Report
Monitoring
Census: 117
Deficiencies: 2
Jan 15, 2025
Visit Reason
The inspection was conducted as a monitoring visit following a self-reported incident received by VDSS Division of Licensing on 10/29/2024 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 staff training in cognitive impairment and documentation of resident care plans and rounds. The facility was found deficient in ensuring required training for direct care staff and proper documentation of individualized service plans and rounding schedules.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure that direct care staff in the special care unit attend at least 10 hours of training in cognitive impairment within 4 months of starting employment. |
| Facility failed to ensure that an inability to use the call bell was documented in the individualized service plan and that written approval of rounds occurring at a frequency other than two hours was documented in the resident's record. |
Report Facts
Number of residents present: 117
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of staff interviews conducted: 4
Inspection Report
Monitoring
Census: 105
Deficiencies: 0
Jun 11, 2024
Visit Reason
The inspection was a monitoring visit conducted following a self-reported incident received by VDSS Division of Licensing regarding allegations in the area of 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. No deficiencies or non-compliance were found during the inspection.
Report Facts
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with staff: 2
Inspection Report
Monitoring
Census: 105
Deficiencies: 5
Jun 11, 2024
Visit Reason
The inspection was a monitoring visit to review compliance with various regulatory standards for an assisted living facility.
Findings
The inspection found multiple violations including failure to conduct annual resident rights reviews, improper storage of resident records, lack of certification for special diet oversight, medication administration issues, and incomplete fire drill documentation. Plans of correction were submitted for each violation.
Deficiencies (5)
| Description |
|---|
| Failed to ensure annual review of residents' rights and responsibilities with each resident or legal representative. |
| Failed to ensure all resident records were kept in a locked area; unsecured census list and electronic tablet with resident information observed. |
| Failed to certify that special diet oversight requirements were met including date of oversight and resident identification. |
| Medications were not kept in pharmacy issued containers with prescription labels until administered; unlabeled pills observed. |
| Failed to ensure fire and emergency evacuation drill frequency and participation met Virginia Statewide Fire Prevention Code; missing fire drill for April 2024. |
Report Facts
Number of residents present: 105
Number of resident records reviewed: 8
Number of staff records reviewed: 6
Number of resident interviews: 2
Number of staff interviews: 3
Date of special diet oversight form: Mar 5, 2024
Fire drill dates: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Velasco | Licensing Inspector | Conducted the inspection |
| Staff 2 | Observed removing census list and provided fire drill logs | |
| Staff 6 | Observed administering medication improperly | |
| Staff 9 | Provided special diet oversight form | |
| Director of Nursing | Director of Nursing | Responsible for medication management training and compliance |
| Executive Director | Executive Director | Responsible for implementing and maintaining compliance with plans of correction |
Inspection Report
Monitoring
Census: 105
Deficiencies: 1
Jun 11, 2024
Visit Reason
The inspection was a monitoring visit conducted to review compliance with regulations following self-reported incidents received by VDSS regarding allegations in Resident Care and Related Services.
Findings
The investigation did not support the self-report of non-compliance; however, violations unrelated to the self-report were identified. One violation was cited for failure to ensure resident records included a current photo or updated narrative physical description.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure that the resident's record included a current photo or a narrative physical description updated annually. |
Report Facts
Number of residents present: 105
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
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Velasco | Licensing Inspector | Current inspector conducting the inspection |
| Executive Director | Named in plan of correction responsibility | |
| Director of Nursing | Named in plan of correction responsibility | |
| Assistant Director of Nursing | Named in plan of correction responsibility |
Inspection Report
Monitoring
Census: 105
Deficiencies: 1
Jun 11, 2024
Visit Reason
The inspection was a monitoring visit conducted following a self-reported incident received by VDSS Division of Licensing on 05/17/2024 regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation did not support the self-report of non-compliance; however, a violation unrelated to the self-report was identified involving failure to report a major incident within 24 hours to the regional licensing office.
Deficiencies (1)
| Description |
|---|
| The facility failed to ensure that an initial report was sent to the regional licensing office for a major incident that negatively affected or threatened the life, health, safety, or welfare of a resident within 24 hours. |
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: 0
Number of interviews conducted with staff: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Velasco | Licensing Inspector | Current inspector conducting the inspection |
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 9
May 14, 2024
Visit Reason
The inspection was conducted in response to a complaint received by the VDSS Division of Licensing regarding allegations in the areas of Staffing & Supervision and Resident Care & Related Services.
Findings
The investigation found some substantiated allegations of non-compliance in Staffing & Supervision, Resident Care & Related Services, and Administration and Administrative Services. Multiple violations were identified related to facility orientation, staffing plans, individualized service plans, call bell response times, and staff record documentation.
Complaint Details
The complaint investigation substantiated some allegations related to Staffing & Supervision and Resident Care & Related Services. Evidence included record reviews, staff interviews, and call bell logs showing delayed responses.
Deficiencies (9)
| Description |
|---|
| Facility failed to utilize the disclosure form developed by the department. |
| Facility failed to ensure all staff were oriented to the facility's purpose, organizational structure, services, routines, policies, duties, and regulatory compliance. |
| Facility failed to obtain written information on the type and frequency of services delivered by private duty personnel and failed to reflect these services on residents' individualized service plans (ISP). |
| Facility failed to maintain a written staffing plan specifying the number and type of direct care staff required to meet routine care needs. |
| Uniform Assessment Instrument (UAI) was not completed annually for residents. |
| Individualized Service Plan (ISP) was not signed and dated by the resident or legal representative. |
| Individualized Service Plan (ISP) was not reviewed and updated at least once every 12 months. |
| Facility failed to ensure care provision was resident-centered with prompt response to resident needs; call bell response times frequently exceeded 20 minutes. |
| Facility failed to ensure substitute staff records contained a letter verifying criminal history record reports were obtained and did not contain barrier crimes. |
Report Facts
Number of residents present: 93
Number of resident records reviewed: 3
Number of staff records reviewed: 3
Number of staff interviews conducted: 2
Call bell response times (minutes): 140.15
Call bell response times (minutes): 138.13
Call bell response times (minutes): 102.4
Call bell response times (minutes): 59.32
Call bell response times (minutes): 44.52
Call bell response times (minutes): 41.98
Call bell response times (minutes): 40.42
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 19, 2023
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 12/12/2022 regarding allegations in the areas of staffing quantity and resident care.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The inspection findings were reviewed in an exit meeting and will be posted publicly.
Complaint Details
Complaint related to staffing quantity and resident care; allegations were not substantiated.
Report Facts
Number of resident records reviewed: 2
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 2
Inspection Report
Monitoring
Deficiencies: 3
Oct 27, 2022
Visit Reason
The inspection was conducted as a monitoring visit following a self-reported incident received by VDSS Division of Licensing on 8/31/2022 regarding allegations in the area(s) of resident care and related services.
Findings
The investigation supported some, but not all, of the self-report; areas of non-compliance were found related to resident care and related services. Violations included failure to perform required six-month reviews of residents' appropriateness of placement in the special care unit, failure to report major incidents within 24 hours, and failure to ensure resident health, safety, and well-being.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure that six months after placement in the special care unit, and annually thereafter, a review of the appropriateness of each resident's continued residence was performed. |
| Facility failed to report to the regional licensing office within 24 hours any major incident that negatively affected or threatened the life, health, safety, or welfare of any resident. |
| Facility failed to ensure the health, safety, and well-being of residents, evidenced by an incident where Resident #1 assaulted Resident #2 causing injury and a fractured hip. |
Report Facts
Number of resident records reviewed: 3
Number of staff records reviewed: 0
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 11
Date of alleged compliance: 2023
Inspection Report
Renewal
Census: 42
Deficiencies: 0
Aug 2, 2022
Visit Reason
The inspection was conducted as a renewal of the facility's license to ensure compliance with applicable standards and laws.
Findings
The inspection found no violations of applicable standards or laws. The licensing inspector observed medication administration and residents during meals, and completed a tour of the physical plant including the building and grounds.
Report Facts
Resident records reviewed: 8
Staff records reviewed: 4
Interviews with residents: 0
Interviews with staff: 0
Inspection Report
Renewal
Census: 15
Deficiencies: 0
Aug 17, 2021
Visit Reason
A renewal inspection was initiated to review compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection included review of resident and staff records, staff schedules, health care oversight, fire and emergency drills, and other documentation. No violations were found and no deficiencies were issued.
Report Facts
Census: 15
Inspection Report
Monitoring
Census: 9
Deficiencies: 0
Jun 7, 2021
Visit Reason
A mandated monitoring inspection was initiated due to a state of emergency health pandemic declared by the Governor of Virginia, conducted remotely to ensure compliance with applicable standards and laws.
Findings
The inspection reviewed resident and staff records, medication administration records, background checks, and other documentation. No violations or deficiencies were found during the inspection.
Report Facts
Census: 9
Inspection Report
Original Licensing
Deficiencies: 0
Feb 9, 2021
Visit Reason
An announced initial inspection was conducted to verify compliance with licensing requirements, including physical plant review, policy and procedure checks, staff background checks, and testing of the call bell system.
Findings
All inspections were completed with no violations cited. Evacuation and Resident Rights postings will be updated. An exit interview was held.
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