Inspection Report
Complaint Investigation
Census: 100
Deficiencies: 2
Oct 9, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-10-03 regarding allegations related to staffing and supervision, and admission, retention, and discharge of residents.
Findings
The investigation supported the complaint of non-compliance with standards and laws, resulting in violations issued. Specifically, the facility failed to keep disclosure form information current and did not maintain a written staffing plan specifying the number and type of staff required to meet resident care needs.
Complaint Details
Complaint related: Yes. The complaint was substantiated as violations were issued based on the investigation of staffing and supervision and admission, retention, and discharge of residents.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure that the information on the disclosure form was kept current. |
| Facility failed to ensure that a written staffing plan specifying the number and type of staff required to meet day-to-day direct care needs was maintained. |
Report Facts
Number of residents present: 100
Number of resident records reviewed: 4
Number of staff interviews conducted: 2
Staffing pattern - 7AM to 3PM: 8
Staffing pattern - 3PM to 11PM: 8
Staffing pattern - 11PM to 7AM: 4
Staffing pattern - 7AM to 3PM: 20
Staffing pattern - 3PM to 11PM: 13
Staffing pattern - 11PM to 7AM: 9
Inspection Report
Monitoring
Census: 100
Deficiencies: 0
Oct 9, 2025
Visit Reason
The inspection was a monitoring visit to review compliance with the Intensive Plan of Correction (IPOC) and ensure ongoing adherence to applicable standards.
Findings
The inspection found no violations of applicable standards or laws. The licensing inspector conducted a tour of the facility and reviewed selective staff, resident, and private duty aide records related to the IPOC.
Report Facts
Number of residents present: 100
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: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Velasco | Licensing Inspector | Conducted the inspection and named in relation to findings |
Inspection Report
Renewal
Census: 100
Deficiencies: 7
Oct 3, 2025
Visit Reason
The inspection was conducted as a renewal inspection of the assisted living facility to assess compliance with applicable standards and regulations.
Findings
The inspection identified multiple violations including failure to ensure physical examination reports specified medication administration capability, failure to review residents' rights annually, incomplete physician orders for medication administration, improper medication administration practices, missing window screens, unsecured hazardous cleaning products, and delayed criminal record checks for staff.
Deficiencies (7)
| Description |
|---|
| Physical examination reports did not indicate whether residents were capable of administering medication. |
| Failure to ensure annual review of residents' rights and responsibilities with residents and staff, with proper documentation. |
| Physician orders lacked route or specific indications for administering medications. |
| Medication was administered by crushing without physician orders permitting this practice. |
| Operable windows lacked effective screening. |
| Cleaning products and hazardous items were stored in accessible, unlocked areas. |
| Criminal records were not obtained prior to the 30th day of employment for a staff member. |
Report Facts
Number of residents present: 100
Number of resident records reviewed: 8
Number of staff records reviewed: 4
Number of resident interviews conducted: 5
Number of staff interviews conducted: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Velasco | Licensing Inspector | Conducted the inspection and interviews |
| Staff 1 | Interviewed regarding physical examination reports, medication orders, and criminal record compliance | |
| Staff 2 | Interviewed regarding physical examination reports and window screening | |
| Staff 4 | Interviewed and accompanied during facility tour for observations of windows and hazardous items | |
| Staff 6 | Administered medication improperly and had delayed criminal record check | |
| Staff 8 | Staff record reviewed for rights and responsibilities acknowledgment | |
| Staff 9 | Interviewed regarding physical examination reports and hazardous items | |
| Staff 10 | Observed administering medication without specific physician order indications | |
| Staff 11 | Confirmed medication administration not per physician orders | |
| Staff 14 | Interviewed regarding physical examination reports and hazardous items | |
| Staff 13 | Interviewed regarding window screening |
Inspection Report
Monitoring
Census: 155
Deficiencies: 2
Jun 12, 2025
Visit Reason
The inspection was conducted as a monitoring visit following a self-reported incident received by VDSS Division of Licensing on 2025-02-18 regarding allegations in the areas of Resident Care and Related Services and Staffing and Supervision.
Findings
The investigation did not support the self-reported non-compliance, but violations unrelated to the self-report were identified, including failure to submit written incident reports within seven days and failure of mandated reporters to report suspected abuse in accordance with Virginia law.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure a written report of each incident was submitted to the regional licensing office within seven (7) days from the date of the incident. |
| Facility failed to ensure that all staff who are mandated reporters reported suspected abuse, neglect, or exploitation in accordance with Virginia Code §63.2-1606. |
Report Facts
Number of residents present: 155
Number of resident records reviewed: 2
Number of staff records reviewed: 4
Number of interviews with residents: 2
Number of interviews with staff: 6
Plan of Correction Completion Date: 2025
Inspection Report
Complaint Investigation
Census: 150
Deficiencies: 7
Dec 3, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-10-29 regarding allegations related to administration, resident care, and resident accommodations at The Virginian assisted living facility.
Findings
The investigation found multiple violations related to the misapplication of assisted living standards to an Independent Living resident residing in a licensed Assisted Living unit, failure to report major incidents within 24 hours, failure to update resident agreements and assessments timely, and inadequate documentation of incidents and care plans. The facility plans to decertify the second floor to separate Independent Living residents from Assisted Living units.
Complaint Details
The complaint was substantiated with violations issued related to administration, resident care, and accommodations. The facility failed to comply with assisted living standards for an Independent Living resident residing in a licensed Assisted Living unit, and multiple documentation and reporting deficiencies were identified.
Deficiencies (7)
| Description |
|---|
| Failure to ensure compliance with all regulations for licensed assisted living facilities and terms of the license, including misclassification of an Independent Living resident in an Assisted Living unit. |
| Failure to report any major incident affecting resident safety to the regional licensing office within 24 hours. |
| Failure to update the original resident agreement when changes occurred, including room changes. |
| Failure to complete the Uniform Assessment Instrument (UAI) annually and upon significant changes in resident condition. |
| Failure to review and update the individualized service plan (ISP) at least every 12 months and as needed. |
| Failure to ensure care provision and service delivery was resident-centered and included prompt response by staff to resident needs. |
| Failure to document circumstances and medical attention related to serious accidents or injuries in the resident's record. |
Report Facts
Number of residents present: 150
Number of resident records reviewed: 1
Number of staff interviews conducted: 7
Call bell response time: 150
Date to be corrected: 2025
Inspection Report
Renewal
Census: 100
Deficiencies: 16
Sep 30, 2024
Visit Reason
The inspection was a renewal inspection conducted on September 30 and October 1, 2024, to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection identified multiple areas of non-compliance including staff training deficiencies, incomplete infection control policy reviews, missing documentation for private duty employees, incomplete volunteer orientation records, failure to inform residents about sex offender information, incomplete resident orientation documentation, unlocked medication storage, unavailable or expired medications, missing Do Not Resuscitate (DNR) orders in service plans, incomplete emergency preparedness documentation, and inadequate fire drill record keeping.
Deficiencies (16)
| Description |
|---|
| Facility failed to ensure direct care staff in the special care unit completed required 6 hours of cognitive impairment training within 4 months of employment. |
| Facility failed to ensure annual review of infection prevention policies and procedures was completed. |
| Facility failed to ensure compliance with its own policies regarding Certificates of Insurance for private duty employees. |
| Facility failed to complete quarterly elopement drills for the memory care community as required. |
| Facility failed to ensure all staff received orientation within the first seven working days of employment. |
| Facility failed to obtain and document written information on type and frequency of services delivered by private duty personnel. |
| Facility failed to ensure all volunteers attended orientation and documentation was signed and dated. |
| Facility failed to ensure residents or legal representatives were annually informed about sex offender information and documentation maintained. |
| Facility failed to ensure new residents and legal representatives received orientation including emergency procedures, mealtimes, and call system use. |
| Facility failed to ensure medication cabinet and medication cart were locked and secure. |
| Facility failed to ensure ordered as needed (PRN) medications were available and not expired. |
| Facility failed to include written Do Not Resuscitate (DNR) orders in residents' individualized service plans. |
| Facility failed to document minimum frequency of daily rounds for residents unable to use signaling devices in individualized service plans. |
| Facility failed to include documentation of initial and annual contact with local emergency coordinator in emergency preparedness plan. |
| Facility failed to ensure semiannual review of emergency preparedness and response plan was implemented for all staff, residents, and volunteers. |
| Facility failed to retain complete records of fire and emergency evacuation drills including number of staff and residents participating and identity of person conducting the drill. |
Report Facts
Number of residents present: 100
Number of resident records reviewed: 8
Number of staff records reviewed: 4
Number of interviews with residents: 2
Number of interviews with staff: 8
Number of private duty employees in binder: 18
Number of private duty employees missing Certificate of Insurance: 1
Number of volunteers with incomplete orientation: 1
Number of residents missing annual sex offender notification: 8
Inspection Report
Monitoring
Census: 100
Deficiencies: 0
Jun 12, 2024
Visit Reason
The inspection was a monitoring visit conducted on June 12, 2024, following a self-reported incident received on May 15, 2024, regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation did not support the self-report of non-compliance with standards or law. The licensing inspector toured the facility and reviewed one resident record and conducted one staff interview. No deficiencies or non-compliance were found.
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
Monitoring
Census: 100
Deficiencies: 10
Jun 12, 2024
Visit Reason
The inspection was a monitoring visit to assess compliance with applicable standards and laws at The Virginian assisted living facility.
Findings
The inspection found multiple violations including failure to post staff certifications and person in charge, lack of resident orientation, delayed staff response to call lights, incomplete special diet oversight, missing oxygen therapy order details, inadequate resident council written responses, unsecured hazardous materials, improper fire drill scheduling, and insufficient emergency food and water supplies.
Deficiencies (10)
| Description |
|---|
| Failed to ensure that a listing of all staff with current certification in first aid or CPR was posted and readily available to all staff. |
| Failed to ensure the posting of the current on-site person in charge in a conspicuous place to residents and the public. |
| Failed to provide an orientation for new residents and their legal representatives including emergency procedures, mealtimes, and call system use upon admission. |
| Failed to ensure prompt response by staff to resident call lights, with documented delays exceeding policy standards. |
| Failed to ensure special diet oversight included a certification that requirements were met. |
| Failed to ensure oxygen therapy orders included the oxygen source such as compressed gas or concentrators. |
| Failed to provide written responses to resident council recommendations prior to the next meeting. |
| Failed to ensure cleaning supplies and hazardous materials were stored in a locked area. |
| Failed to ensure fire and emergency evacuation drills were conducted with required frequency and participation across shifts and months. |
| Failed to ensure at least 48 hours of emergency food and drinking water supply was maintained on site. |
Report Facts
Number of residents present: 100
Number of resident records reviewed: 8
Number of staff records reviewed: 4
Number of resident interviews: 4
Number of staff interviews: 3
Call light response times: 18
Call light response times: 16
Call light response times: 13
Call light response times: 58
Call light response times: 26
Call light response times: 8
Fire drills completed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Velasco | Licensing Inspector | Conducted the inspection and is contact for questions. |
| Staff 1 | Interviewed regarding staff certification posting, person in charge posting, call light response policy and logs. | |
| Staff 2 | Notified and locked cabinet doors for hazardous materials. | |
| Staff 9 | Showed emergency food and water storage to inspector and provided information on water supply. | |
| Staff 10 | Confirmed resident orientation forms not completed and resident council meeting notes handling. | |
| Assisted Living Director | Named in multiple corrective actions including posting certifications, person in charge, resident orientation, call light response, special diet oversight, and oxygen therapy orders. | |
| Memory Care Director | Named in corrective actions related to staff certification posting and hazardous materials storage. | |
| Director of Nursing | Named in corrective actions related to staff certification posting and oxygen therapy orders. | |
| Life Enrichment Director | Named in corrective actions related to resident orientation and resident council written responses. | |
| Administrator | Named in corrective actions related to call light response, special diet oversight, resident council responses, fire drills, emergency supplies, and overall compliance monitoring. | |
| Registered Dietician | Named in corrective action related to special diet oversight. | |
| Food and Beverage Director | Named in corrective action related to emergency food and water supply. |
Inspection Report
Routine
Deficiencies: 0
Nov 1, 2023
Visit Reason
An announced inspection was conducted to observe resident rooms and common areas.
Findings
No violations were cited during the inspection and an exit meeting was held.
Inspection Report
Complaint Investigation
Deficiencies: 1
Aug 18, 2023
Visit Reason
The inspection was conducted in response to a complaint received on 2023-07-21 regarding staffing and supervision, resident care and related services, and building and grounds at the facility.
Findings
The investigation supported some but not all allegations; non-compliance was found in Resident Care and Related Services, specifically regarding delayed staff response to resident call bells.
Complaint Details
The complaint was substantiated in part; the area of non-compliance was Resident Care and Related Services. A violation notice was issued and the licensee was given the opportunity to submit a plan of correction.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure a prompt response by staff to resident needs as reasonable to the circumstances, with multiple occasions where staff took at least 20 minutes to respond to call bells for Residents #1, #2, #3, and #4. |
Report Facts
Call bell delayed responses: 1
Call bell delayed responses: 14
Call bell delayed responses: 8
Call bell delayed responses: 2
Inspection Report
Monitoring
Deficiencies: 1
Jul 18, 2023
Visit Reason
Unannounced focused monitoring inspections were conducted on July 18, 2023 and August 18, 2023 to follow-up on a facility reported incident.
Findings
The inspection determined non-compliance with applicable standards related to medication administration, specifically that medications prescribed for one resident were administered to another without physician orders.
Deficiencies (1)
| Description |
|---|
| Facility failed to administer medications in accordance with the physician's or other prescriber's instructions and consistent with the standards of practice outlined in the current medication aide curriculum approved by the Virginia Board of Nursing. |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Velasco | Inspector | Named as current inspector conducting the inspection. |
| Marshall Massenberg | Licensing Inspector | Contact person for more information regarding the inspection and plan of correction. |
Inspection Report
Renewal
Census: 92
Deficiencies: 2
Jun 14, 2023
Visit Reason
An unannounced renewal inspection was initiated on 6/14/23 and completed on 6/16/23 to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection found non-compliance with standards related to tuberculosis risk assessment documentation for staff and medication management, including missed medication doses due to pharmacy delays.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure that each staff member annually submits the results of a tuberculosis risk assessment. |
| Facility failed to implement the medication management plan to ensure timely filling and refilling of prescription medications, resulting in missed doses for residents. |
Report Facts
Residents in care: 92
Resident records reviewed: 10
Staff records reviewed: 5
Inspection Report
Deficiencies: 0
May 12, 2023
Visit Reason
An announced other inspection was conducted to observe resident rooms and inspect building and grounds.
Findings
No violations were cited during the inspection. An exit meeting was held.
Inspection Report
Monitoring
Deficiencies: 1
Jan 31, 2023
Visit Reason
An unannounced monitoring inspection was initiated on January 31, 2023 in response to a facility reported incident.
Findings
The inspection found non-compliance with applicable standards related to supervision of resident schedules, care, and activities, including attention to specialized needs such as wandering from the premises. A violation notice was issued to the facility.
Deficiencies (1)
| Description |
|---|
| The facility failed to provide supervision of resident schedules, care, and activities including attention to specialized needs, such as wandering from the premises. |
Report Facts
Inspection dates: 2
Distance resident eloped: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marshall Massenberg | Licensing Inspector | Contact person for plan of correction and questions |
Inspection Report
Monitoring
Deficiencies: 0
Oct 14, 2022
Visit Reason
An unannounced focused monitoring inspection was conducted to follow-up on high-risk violations cited on 2022-06-23.
Findings
Building and grounds were inspected and resident rooms were observed. No violations were cited during the inspection.
Inspection Report
Renewal
Census: 137
Deficiencies: 4
Jun 2, 2022
Visit Reason
The inspection was a renewal visit to assess compliance with applicable standards and laws for continued licensure of the assisted living facility.
Findings
The inspection identified multiple violations including incomplete physical examination forms, inadequate supervision leading to resident elopement, unsecured hazardous materials, and lack of documentation for required fire drills. Plans of correction were submitted to address these deficiencies.
Deficiencies (4)
| Description |
|---|
| Failed to ensure the physical examination form, completed within 30 days preceding admission, includes all required information. |
| Failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs such as wandering from the premises. |
| Failed to ensure that hazardous materials are kept in a locked area. |
| Failed to ensure that fire and emergency evacuation drill frequency and participation is in accordance with the Virginia Statewide Fire Prevention Code. |
Report Facts
Number of residents present: 137
Number of resident records reviewed: 10
Number of interviews conducted: 5
Distance resident eloped: 0.3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marshall Massenberg | Licensing Inspector | Contact person for questions about the inspection |
Inspection Report
Deficiencies: 1
Oct 5, 2021
Visit Reason
A non-mandated self-report inspection was initiated following a self-reported incident regarding an allegation 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 a violation issued for failure to supervise resident schedules, care, and activities, including prevention of falls and wandering.
Deficiencies (1)
| Description |
|---|
| Facility failed to supervise resident schedules, care, and activities, including attention to specialized needs such as prevention of falls and wandering from the premises. |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Aug 20, 2021
Visit Reason
Announced focused visits were conducted to inspect the facility's updated secure unit, including resident rooms, building, and grounds, to assess compliance with standards for a safe, secure environment.
Findings
No violations were cited during the inspection. The standards for the safe, secure environment were discussed with the administrator.
Inspection Report
Deficiencies: 1
Mar 29, 2021
Visit Reason
A non-mandated self-report inspection was initiated due to a self-reported incident regarding resident care and related services, specifically an allegation of a resident eloping from the special care unit.
Findings
The investigation supported the self-report of non-compliance with standards, resulting in a violation for failure to ensure supervision of resident schedules, care, and activities, including prevention of falls and wandering. Resident #1 eloped from the special care unit by following a visitor and was found at a friend's house approximately a quarter mile away.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure supervision of resident schedules, care, and activities, including attention to specialized needs such as prevention of falls and wandering from the premises. |
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