Deficiencies per Year
16
12
8
4
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Inspection Report
Renewal
Census: 59
Deficiencies: 2
Mar 25, 2025
Visit Reason
The inspection was conducted as a renewal inspection to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection found non-compliance with applicable standards or laws, resulting in documented violations related to physical examination requirements and medication administration.
Deficiencies (2)
| Description |
|---|
| The facility failed to ensure, within the 30 days preceding admission, the physical examination included results of a risk assessment documenting the absence of tuberculosis in a communicable form. |
| The facility failed to ensure medications were administered in accordance with the physician's or other prescriber's instructions, as insulin was administered to Resident #1 on days when blood sugar was below the prescribed threshold. |
Report Facts
Number of residents present: 59
Number of resident records reviewed: 6
Number of staff records reviewed: 3
Number of resident interviews: 5
Number of staff interviews: 3
Inspection Report
Monitoring
Census: 67
Deficiencies: 1
Jan 8, 2025
Visit Reason
The inspection was a monitoring visit conducted on January 8, 2025, following two self-reported incidents received by VDSS Division of Licensing regarding allegations in Resident Care and Related Services.
Findings
The inspection found non-compliance with applicable standards related to medication management, specifically the failure to implement the written plan ensuring accurate counts of controlled substances during staff changes. Violations were documented and a plan of correction was requested.
Deficiencies (1)
| Description |
|---|
| Facility failed to implement their written plan for medication management which includes methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes. |
Report Facts
Residents present: 67
Resident records reviewed: 4
Staff records reviewed: 1
Resident interviews conducted: 2
Staff interviews conducted: 5
Audit frequency: 4
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 1
May 2, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2024-05-01 regarding allegations in the areas of Administration and Administrative Services, Staffing and Supervision, and Resident Care and Related Services.
Findings
The investigation supported some, but not all, of the allegations, specifically identifying non-compliance in Resident Care and Related Services. A violation notice was issued related to failure to ensure personal assistance and care were provided as necessary to meet resident needs.
Complaint Details
Complaint related: Yes. The complaint was substantiated in part, specifically in the area of Resident Care and Related Services.
Deficiencies (1)
| Description |
|---|
| Based on record review, the facility failed to ensure that personal assistance and care are provided to each resident as necessary so that the needs of the resident are met. |
Report Facts
Residents present: 55
Resident records reviewed: 1
Staff records reviewed: 1
Staff interviews conducted: 2
Resident interviews conducted: 0
Inspection Report
Monitoring
Census: 56
Deficiencies: 0
Apr 18, 2024
Visit Reason
The inspection was a monitoring visit following a self-reported incident received by VDSS Division of Licensing regarding allegations in Resident Care and Related Services.
Findings
The investigation did not support the self-report of non-compliance with standards or law. No deficiencies were cited during this monitoring inspection.
Inspection Report
Renewal
Census: 53
Deficiencies: 15
Mar 12, 2024
Visit Reason
The inspection was a renewal inspection conducted to assess compliance with applicable regulations and licensing requirements for the assisted living facility.
Findings
The inspection identified multiple violations related to staff training, medication management, resident orientation, individualized service plans, healthcare oversight, and emergency preparedness. The facility was found non-compliant with several standards and issued violation notices with plans of correction.
Deficiencies (15)
| Description |
|---|
| Facility failed to ensure direct care staff attend six hours of training in working with individuals who have a cognitive impairment within four months of employment. |
| Facility failed to ensure fingerstick devices for blood glucose monitoring are not used for more than one person. |
| Facility failed to ensure staff annual training included at least four hours focused on residents' mental impairments. |
| Facility failed to ensure direct care staff maintain current certification in first aid. |
| Facility failed to provide orientation to new residents and their legal representatives upon admission. |
| Facility failed to ensure administrator or designee approves and signs completed UAIs for private pay individuals. |
| Facility failed to ensure individualized service plans include description of identified needs and time frames for expected outcomes. |
| Facility failed to ensure individualized service plans are signed and dated by residents or their legal representatives. |
| Facility failed to retain a licensed health care professional with required experience to provide on-site health care oversight. |
| Facility failed to implement written medication management plan to prevent use of outdated medications and ensure proper disposal. |
| Facility failed to ensure medications, dietary supplements, diets, medical procedures, or treatments are started, changed, or discontinued only with valid physician orders. |
| Facility failed to ensure medications are administered within one hour before or after scheduled times. |
| Facility failed to ensure medications are administered according to physician's instructions and standards of practice. |
| Facility failed to ensure medication administration records include diagnosis, condition, or specific indications for drugs or supplements. |
| Facility failed to document staff participation in practice exercises for resident emergencies at least every six months. |
Report Facts
Number of residents present: 53
Number of resident records reviewed: 6
Number of staff records reviewed: 3
Number of resident interviews: 3
Number of staff interviews: 3
Number of expired medications observed: 6
Number of active medication orders without valid physician signature: 18
Number of medication administration pass observations: 5
Audit frequency: 4
Audit frequency: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donesia Peoples | Licensing Inspector | Current inspector conducting the inspection |
| M. Tess Pittman | Licensing Inspector | Contact person for questions about the inspection |
Inspection Report
Monitoring
Census: 54
Deficiencies: 2
Sep 28, 2023
Visit Reason
The inspection was a monitoring visit following a self-reported incident received by VDSS Division of Licensing on 09/27/2023 regarding allegations in the area of Personnel.
Findings
The inspection found non-compliance with applicable standards and laws related to personnel records and access. Violations were documented regarding failure to provide timely access to staff records and incomplete staff records.
Deficiencies (2)
| Description |
|---|
| The facility failed to ensure that the department's representative was afforded reasonable opportunity to inspect all facility records and interview staff as required. |
| The facility failed to ensure personal and social data were maintained on staff and included in the staff record, specifically missing verification of receipt of current job description. |
Report Facts
Number of residents present: 54
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 1
Inspection Report
Renewal
Census: 48
Deficiencies: 7
Mar 7, 2023
Visit Reason
The inspection was a renewal inspection conducted to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection found multiple violations including failure to complete timely fall risk ratings, presence of expired and discharged residents' medications in medication carts, failure to have physician-signed verbal orders within 14 days, lack of response to pharmacy medication review recommendations, failure to annually review the emergency preparedness plan, and incomplete sworn disclosure statements for employment applicants.
Deficiencies (7)
| Description |
|---|
| Failed to ensure a written fall risk rating was completed by the time the comprehensive ISP is completed for residents meeting assisted living care criteria. |
| Failed to ensure fall risk ratings were completed at least annually, when resident condition changes, and after a fall. |
| Failed to implement written medication management plan to prevent use of outdated medications and ensure proper disposal. |
| Failed to ensure physician's or prescriber's oral orders were reviewed and signed within 14 days. |
| Failed to act in response to pharmacy medication review recommendations. |
| Failed to review and document annual review of emergency preparedness plan. |
| Failed to ensure sworn statements or affirmations were completed for all applicants for employment. |
Report Facts
Number of residents present: 48
Number of resident records reviewed: 7
Number of staff interviews conducted: 4
Number of sworn disclosure statements incomplete: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donesia Peoples | Licensing Inspector | Named as current inspector conducting the inspection |
| M. Tess Pittman | Licensing Inspector | Contact person for questions regarding the inspection |
Inspection Report
Monitoring
Census: 47
Deficiencies: 1
Dec 22, 2022
Visit Reason
The inspection was a monitoring visit conducted on December 22, 2022, following a self-reported incident received on December 10, 2022, 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 facility's failure to assume general responsibility for the health, safety, and well-being of residents, including an incident where a resident was found outside the facility after wandering.
Deficiencies (1)
| Description |
|---|
| Facility failed to assume general responsibility for the health, safety, and well-being of residents, evidenced by a resident being unable to be located and found outside the facility. |
Report Facts
Number of residents present: 47
Number of resident records reviewed: 1
Number of staff interviews conducted: 2
Inspection Report
Renewal
Census: 47
Deficiencies: 10
Feb 18, 2022
Visit Reason
An unannounced renewal inspection was conducted to assess compliance with applicable standards and laws for licensing renewal.
Findings
The inspection identified multiple areas of non-compliance including failure to post current first aid/CPR certification listings, incomplete annual tuberculosis risk assessments, outdated Uniform Assessment Instruments (UAI) and Individualized Service Plans (ISP), failure to post weekly menus conspicuously, medication administration errors, building maintenance issues, incomplete first aid kits, and missing sworn statements for employment applicants.
Deficiencies (10)
| Description |
|---|
| Facility failed to post a listing of all staff with current first aid or CPR certification. |
| Facility failed to complete annual tuberculosis risk assessments for residents. |
| Facility failed to complete resident Uniform Assessment Instruments (UAI) at least annually. |
| Individualized Service Plans (ISP) did not accurately reflect residents' needs based on UAI. |
| Facility failed to review and update residents' ISPs at least once every 12 months. |
| Facility failed to post weekly menus for meals and snacks in an area conspicuous to residents. |
| Medications were not administered in accordance with physician or prescriber instructions. |
| Facility failed to maintain interior and exterior of buildings in good repair and clean condition. |
| First aid kits in the building and vehicles lacked required items such as blankets, triangular bandages, and instructional manuals. |
| Sworn statements or affirmations were not completed for all employment applicants. |
Report Facts
Residents in care: 47
Resident records reviewed: 4
Staff records reviewed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donesia Peoples | Licensing Inspector | Current inspector conducting the inspection. |
| Staff #1 | Acknowledged multiple deficiencies including missing first aid/CPR posting, incomplete tuberculosis risk assessments, incomplete UAIs and ISPs, medication administration issues, and missing sworn statement for Staff #5. | |
| Staff #2 | Acknowledged medication administration issues. | |
| Staff #5 | Employment applicant missing sworn statement. | |
| Resident Care Director | Responsible for updating first aid/CPR certification postings and monthly checks of first aid kits. | |
| Dining Services Director | Responsible for posting weekly menus. | |
| Maintenance Director | Responsible for repairs and maintenance of facility buildings. | |
| Life Enrichment Director | Responsible for monthly checks of first aid kits. |
Inspection Report
Renewal
Census: 45
Deficiencies: 1
Apr 5, 2021
Visit Reason
A renewal inspection was initiated to assess compliance with applicable standards and regulations for the assisted living facility.
Findings
The inspection found non-compliance related to failure to conduct fire and emergency evacuation drills on the 11pm-7am third shift during the first quarter of 2021.
Deficiencies (1)
| Description |
|---|
| Facility failed to conduct fire and emergency evacuation drills as required during each shift in a quarter, specifically no drill was conducted on the 11pm-7am third shift for the first quarter. |
Report Facts
Resident census: 45
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donesia Peoples | Inspector | Conducted the inspection |
| Staff #4 | Acknowledged no fire and emergency evacuation drill was conducted on the 11pm-7am third shift |
Inspection Report
Complaint Investigation
Deficiencies: 1
Mar 1, 2021
Visit Reason
A complaint inspection was initiated due to allegations that a resident was only given a shower once a week and was not being served food that is liked.
Findings
The investigation supported the allegation of non-compliance with standards or law, resulting in violations being issued. Additionally, violations unrelated to the complaint were identified during the investigation.
Complaint Details
The complaint was substantiated as the evidence gathered supported the allegation of non-compliance with standards or law.
Deficiencies (1)
| Description |
|---|
| The facility failed to complete the Uniform Assessment Instrument (UAI) whenever there is a change in the resident's condition. |
Inspection Report
Monitoring
Census: 51
Deficiencies: 0
Dec 14, 2020
Visit Reason
A 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.
Findings
The inspection found no violations with applicable standards of law; no deficiencies were issued during the inspection.
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