Deficiencies (last 3 years)
Deficiencies (over 3 years)
21.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
134% worse than Virginia average
Virginia average: 9.1 deficiencies/yearDeficiencies per year
32
24
16
8
0
Census
Latest occupancy rate
36 residents
Based on a September 2025 inspection.
Occupancy over time
Inspection Report
Renewal
Census: 36
Deficiencies: 14
Date: Sep 15, 2025
Visit Reason
The inspection was a renewal inspection conducted to assess compliance with state regulations and licensing requirements for the assisted living facility.
Findings
The inspection identified multiple violations related to staff training, record keeping, certification, staffing levels, resident care plans, safety procedures, and facility maintenance. The facility was found non-compliant with several standards and issued violation notices with plans of correction required.
Deficiencies (14)
Failed to ensure direct care staff attended six hours of training in working with individuals who have cognitive impairments within four months of employment.
Failed to ensure personal and social data was maintained on staff and included in the staff record.
Failed to ensure direct care staff members maintained current certification in first aid.
Failed to ensure at least one staff person in the building at all times had current CPR certification.
Failed to have sufficient staff numbers to provide services to maintain residents' physical, mental, and psychosocial well-being.
Failed to provide written assurance to residents that the facility had the appropriate license to meet care needs at admission.
Failed to ascertain and document whether a potential resident was a registered sex offender prior to admission.
Failed to provide orientation upon admission for new residents and their legal representatives including emergency procedures, mealtimes, and call system use.
Failed to ensure the preliminary plan of care was developed to address basic resident needs.
Failed to ensure Do Not Resuscitate (DNR) orders were carried out only with valid written physician orders included in individualized service plans.
Failed to store cleaning supplies and hazardous materials in a locked area.
Failed to document rounds for residents unable to use signaling devices.
Failed to ensure a complete first aid kit was on hand containing all required items.
Failed to obtain original criminal history record reports for employees within 30 days of employment.
Report Facts
Number of residents present: 36
Number of resident records reviewed: 4
Number of staff records reviewed: 3
Number of resident interviews conducted: 9
Number of staff interviews conducted: 7
Duration of inspection: 7.3
Number of staff on Sage unit: 0
Number of residents on Sage unit: 18
Number of residents needing two-person assist: 6
Number of residents with wandering/aggressive behaviors: 2
Number of staff hired with late criminal history reports: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela N Via | Licensing Inspector | Conducted the inspection and interviews |
| Staff 5 | Interviewed multiple times regarding deficiencies in training, records, certifications, and procedures | |
| Resident Wellness Director | Named in multiple plans of correction to ensure compliance | |
| Resident Care Director | Named in multiple plans of correction to ensure compliance | |
| Executive Director | Named in multiple plans of correction to provide oversight | |
| Staff 7 | Staff with deficient training and certifications | |
| Staff 9 | Staff with deficient training and certifications | |
| Staff 13 | Provided information about staffing shortages on Sage unit | |
| Staff 3 | Provided information about staffing levels and challenges | |
| Staff 4 | Provided information about staffing levels and challenges | |
| Staff 6 | Interviewed regarding signaling device use and documentation | |
| Maintenance Director | Named in plan of correction for chemical storage compliance | |
| Activities Director | Named in plan of correction for first aid kit maintenance |
Inspection Report
Monitoring
Census: 39
Deficiencies: 1
Date: Jul 11, 2025
Visit Reason
The inspection was a monitoring visit conducted on July 11, 2025, following a self-reported incident received by VDSS Division of Licensing on April 23, 2025, 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 related to medication administration. Violations were issued based on the facility's failure to administer medications according to physician or prescriber instructions, including missed doses of hydrocodone for a resident.
Deficiencies (1)
Facility failed to administer medications in accordance with physician's or prescriber's instructions, including 19 missed doses of hydrocodone for resident 1 between 4/9/2025 and 4/17/2025.
Report Facts
Number of residents present: 39
Number of resident records reviewed: 1
Number of medication doses missed: 19
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 13
Date: Jul 2, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-02-07 regarding allegations in the area of Resident Care and Related Services.
Complaint Details
The complaint investigation was substantiated as the evidence gathered supported the complaint of non-compliance with standards and laws related to resident care and related services.
Findings
The investigation supported the complaint of non-compliance with multiple regulatory standards related to resident care, documentation, admission procedures, mental health screening, medication administration, abuse reporting, and record retention. Violations were issued for failures including late incident reporting, incomplete resident records, lack of mental health screenings, failure to administer medications as ordered, and failure to immediately report suspected abuse.
Deficiencies (13)
Failed to submit a written report of each incident within seven days from the date of the incident.
Failed to maintain a method of written communication between direct care staff on all shifts with documentation retained for at least two years.
Failed to ensure individual's needs could be met prior to admission by reviewing required assessments and conducting documented interviews.
Failed to provide written assurance to the resident that the facility had the appropriate license to meet care needs at admission.
Failed to obtain a physical examination by an independent physician within 30 days preceding admission.
Failed to conduct a mental health screening prior to admission when behaviors caused concern for health, safety, or welfare.
Failed to conduct a mental health screening when a resident displayed behaviors indicative of behavioral disorders causing concern for safety.
Failed to determine appropriateness of admission for an individual with behavioral disorders by obtaining psychosocial and behavioral information from primary sources.
Failed to document notable changes in condition, functioning, or altered behavior and corresponding actions taken when resident had observable unmet needs.
Failed to retain a complete resident record for at least two years following discharge.
Failed to administer medications in accordance with physician's or prescriber's instructions.
Failed to immediately report suspicions of abuse, neglect, or exploitation of an aged or incapacitated adult.
Failed to ensure resident was free of physical or mechanical restraints except as medically necessary and authorized by a physician.
Report Facts
Number of residents present: 39
Number of resident records reviewed: 1
Number of staff interviews conducted: 2
Incident reporting days late: 11
Wanderguard missing/broken/removed counts: 146
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela N Via | Licensing Inspector | Named as the licensing inspector conducting the inspection and interviews. |
| Staff 1 | Interviewed staff member who confirmed multiple deficiencies including failure to provide communication logs, failure to obtain physical exam prior to admission, failure to provide written assurance, failure to report abuse, and lack of physician order for Wanderguard. | |
| Staff 2 | Interviewed staff member who confirmed failure to obtain physical exam prior to admission and failure to administer medication as ordered. | |
| Resident Wellness Director | Named in multiple plans of correction to ensure compliance with reporting, documentation, assessments, and oversight. | |
| Resident Care Director | Named in multiple plans of correction to ensure compliance with documentation, assessments, and oversight. | |
| Executive Director | Named in multiple plans of correction to provide oversight and ensure compliance with standards. |
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 4
Date: Mar 19, 2025
Visit Reason
The inspection was conducted as a complaint investigation to review allegations related to Administration and Administrative Services, Staffing and Supervision, and Resident Care and Related Services at The Warren assisted living facility.
Complaint Details
The complaint investigation found some substantiated violations related to staffing adequacy, individualized service planning, delayed response to call bells, and medication administration timing.
Findings
The investigation supported some but not all allegations, identifying areas of non-compliance in staffing adequacy, individualized service planning, response times to resident call bells, and medication administration timing. A violation notice was issued and plans of correction were required.
Deficiencies (4)
Facility failed to have staff adequate in knowledge, skill and abilities and sufficient in number to provide services to maintain residents' well-being.
Facility failed to develop an Individualized Service Plan that included a written description of services to address identified needs, specifically related to a foley catheter.
Facility failed to respond promptly to resident needs, with multiple instances of staff taking more than 15 minutes to respond to call bells.
Facility failed to administer medications within one hour before or after the standard dosing schedule.
Report Facts
Residents present: 35
Resident records reviewed: 17
Staff interviews conducted: 8
Resident interviews conducted: 1
Medication administration deviations: 15
Call bell delayed responses: 20
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 0
Date: Nov 19, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to resident care and related services at the facility.
Complaint Details
The complaint investigation did not substantiate any non-compliance with standards or law.
Findings
The evidence gathered during the investigation did not support the allegation(s) or self-report of non-compliance with standards or law. The inspection findings will be posted publicly and an exit meeting will be conducted to review the findings.
Report Facts
Number of residents present: 34
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
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 0
Date: Oct 23, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to resident care and related services at The Warren assisted living facility.
Complaint Details
The complaint was investigated and found to be unsubstantiated based on the evidence gathered during the inspection.
Findings
The investigation found no evidence to support the allegation of non-compliance with standards or law. The licensee was informed of the opportunity to submit a plan of correction if any violations were cited.
Report Facts
Number of residents present: 34
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
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 0
Date: Oct 23, 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.
Complaint Details
The inspection was complaint-related, but the allegations were not substantiated based on the evidence gathered during the investigation.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The inspection findings will be posted publicly within 5 business days.
Report Facts
Number of resident records reviewed: 20
Number of staff records reviewed: 0
Number of interviews conducted with residents: 4
Number of interviews conducted with staff: 3
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 0
Date: Oct 23, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to resident care and related services at the facility.
Complaint Details
The inspection was complaint-related. The evidence did not substantiate the allegation of non-compliance.
Findings
The evidence gathered during the investigation did not support the allegation of non-compliance with standards or law. The inspection findings will be posted publicly and an exit meeting will be conducted to review the findings.
Report Facts
Number of residents present: 34
Number of resident interviews: 4
Number of staff interviews: 2
Number of resident records reviewed: 0
Number of staff records reviewed: 0
Inspection Report
Renewal
Census: 35
Deficiencies: 8
Date: Oct 9, 2024
Visit Reason
The inspection was a renewal visit conducted on October 9th and 10th, 2024, to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection found multiple violations including failure to disclose emergency electrical power source information, failure to post staff CPR/first aid certification, incomplete individualized service plans, lack of annual review of resident rights, confidentiality breaches, insufficient dietary oversight, medication administration timing errors, and delayed criminal background checks for staff.
Deficiencies (8)
Facility failed to disclose whether it has an on-site emergency electrical power source.
Facility failed to post a listing of staff with current first aid or CPR certification.
Facility failed to identify resident needs on the Individualized Service Plan (ISP).
Facility failed to annually review the rights and responsibilities with each resident or legal representative.
Facility failed to ensure confidentiality of resident records; binders on medication carts were not supervised.
Facility failed to have oversight at least every six months of special diets by a dietician or nutritionist.
Facility failed to administer medications within one hour before or after the standard dosing schedule.
Facility failed to obtain criminal history record reports on or prior to the 30th day of employment for staff.
Report Facts
Number of residents present: 35
Number of resident records reviewed: 4
Number of staff records reviewed: 3
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Pearson | Licensing Inspector | Contact person for questions about the VDSS Licensing Programs. |
| Angela N Via | Licensing Inspector | Current inspector who conducted the inspection. |
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 6
Date: Sep 18, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-06-26 regarding allegations related to medication, medical issues, and records at the facility.
Complaint Details
The complaint was received by VDSS Division of Licensing on 06/26/2024 regarding allegations in the areas of medication/medical issues and records. The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law.
Findings
The investigation did not substantiate the complaint allegations; however, multiple violations unrelated to the complaint were identified, including issues with resident movement restrictions, unsecured hazardous objects, failure to post the person in charge, incomplete individualized service plans, confidentiality breaches, and improper storage of hazardous materials.
Deficiencies (6)
Facility failed to ensure behavioral observations or evidence supporting movement restrictions were documented before restricting resident movement in the Wanderguard Unit.
Facility failed to ensure potentially harmful objects were inaccessible to residents with serious cognitive impairment; open pumpkin carving kit with serrated knives found in unlocked cabinets.
Facility failed to post the name of the current person in charge in a conspicuous place to residents and the public.
Individualized Service Plans were not reviewed and updated as needed for significant changes in resident condition; DNR order missing from ISP.
Facility failed to ensure all records were treated confidentially; postings of residents with DNR orders and two-person assist needs were displayed with full names in a doorless closet.
Facility failed to ensure cleaning supplies and hazardous materials were stored in a locked area; observed unlocked cabinets with chemicals and staff personal belongings accessible to residents.
Report Facts
Number of residents present: 32
Number of resident records reviewed: 3
Number of staff records reviewed: 2
Number of staff interviews conducted: 6
Number of collateral contacts interviewed: 2
Number of residents with DNR orders posted: 20
Number of residents needing two-person assist posted: 8
Number of bottles of Greasecutter Plus observed: 3
Number of bottles of Lime-A-Way observed: 2
Number of bottles of Febreeze room spray observed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela N Via | Licensing Inspector | Current inspector conducting the inspection |
| Amanda Velasco | Licensing Inspector | Contact person for questions regarding the inspection |
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 2
Date: Feb 1, 2024
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received by VDSS Division of Licensing on 2024-01-16 regarding allegations in the area of personnel.
Complaint Details
Complaint was substantiated as evidence supported allegations of non-compliance in personnel standards.
Findings
The investigation supported the allegations of non-compliance with standards or law related to personnel. Violations were issued including failure to maintain a sworn disclosure statement for one staff member and failure to ensure first aid certification within 60 days of employment for one staff member.
Deficiencies (2)
Facility failed to maintain in the staff record a sworn disclosure statement for one of two staff records.
Facility failed to ensure that each direct care staff member without current certification in first aid received certification within 60 days of employment for one of two staff records.
Report Facts
Number of residents present: 33
Number of staff records reviewed: 2
Number of interviews conducted with staff: 1
Number of interviews conducted with residents: 0
Days to correct first aid certification: 60
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 4
Date: Feb 1, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2024-01-11 regarding allegations in the areas of staffing and supervision and resident care and related services.
Complaint Details
The complaint was substantiated. The evidence gathered during the investigation supported the allegations of non-compliance with standards or law related to staffing and supervision and resident care.
Findings
The investigation supported the allegations of non-compliance with standards or law, resulting in violations issued related to insufficient staffing, failure to complete required resident assessments annually, and incomplete individualized service plans within required timeframes.
Deficiencies (4)
Facility failed to ensure sufficient staff numbers to provide services to maintain residents' physical, mental, and psychosocial well-being during evening and overnight shifts.
Facility failed to ensure all residents were assessed using the Uniform Assessment Instrument (UAI) at least annually for eight out of seventeen residents.
Facility failed to ensure comprehensive individualized service plans were completed within 30 days after admission for two residents.
Facility failed to ensure individualized service plans (ISPs) were updated once every 12 months for nine out of seventeen residents.
Report Facts
Residents present: 33
Resident records reviewed: 17
Staff records reviewed: 0
Resident interviews conducted: 2
Staff interviews conducted: 1
Residents requiring mechanical or physical assistance: 4
Residents without timely UAI assessments: 8
Residents without timely ISP completion: 2
Residents without timely ISP updates: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela N Via | Licensing Inspector | Inspector conducting the complaint-related inspection |
| Sarah Pearson | Licensing Inspector | Contact person for questions regarding the inspection |
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 4
Date: Feb 1, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2024-01-10 regarding allegations in the area of personnel at The Warren assisted living facility.
Complaint Details
The complaint was substantiated as the evidence gathered supported the allegations of non-compliance with standards or law related to personnel and medication management.
Findings
The investigation supported allegations of non-compliance with standards or law, resulting in violations issued related to failure in documentation of coordinated care plans, medication management, timely administration of medications, and adherence to physician's medication instructions.
Deficiencies (4)
Facility failed to have documentation to show the coordinated plan of care on the Individualized Service Plan (ISP) between the facility and the Hospice agency for one of two records.
Facility staff failed to adhere to the medication management plan, including missing signatures on Controlled Drug Count Sheets for multiple days and shifts.
Facility failed to administer physician ordered medications within the required timeframe, with specific instances of late medication administration observed.
Facility failed to ensure medications were administered in accordance with the physician's or other prescriber's instructions, with documented deviations in medication administration times.
Report Facts
Number of residents present: 33
Number of resident records reviewed: 2
Number of staff records reviewed: 0
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 1
Days with missing two person signatures on Controlled Drug Count Sheet: 15
Days with missing two person signatures on Controlled Drug Count Sheet: 8
Days with missing two person signatures on Controlled Drug Count Sheet: 18
Days with missing two person signatures on Controlled Drug Count Sheet: 5
Days with missing two person signatures on Controlled Drug Count Sheet: 5
Days with missing two person signatures on Controlled Drug Count Sheet: 14
Days with missing two person signatures on Controlled Drug Count Sheet for all three shifts: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Pearson | Licensing Inspector | Contact person for questions regarding the inspection |
| Angela N Via | Licensing Inspector | Current inspector conducting the inspection |
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 0
Date: Feb 1, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2024-01-11 regarding allegations in the areas of personnel and resident care and related services.
Complaint Details
Complaint related inspection triggered by allegations concerning personnel and resident care; the allegations were not substantiated.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The inspection findings will be posted publicly within 5 business days of receipt.
Report Facts
Number of residents present: 33
Number of staff records reviewed: 1
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 1
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 20, 2023
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2023-11-24 regarding allegations in the areas of general provisions, administration and administrative services, and personnel.
Complaint Details
Complaint investigation related to allegations in general provisions, administration and administrative services, and personnel. The allegations were not substantiated.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The inspection findings will be posted to the VDSS website within 5 business days of receipt.
Report Facts
Number of resident records reviewed: 7
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 0
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 3
Date: Nov 8, 2023
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received on 2023-10-26 regarding allegations in the areas of general provisions, administration and administrative services, and resident care and related services.
Complaint Details
The complaint was substantiated in part, with findings related to resident care and related services. Some allegations were not supported. A violation notice was issued and the licensee was given the opportunity to submit a plan of correction.
Findings
The investigation supported some, but not all, of the allegations; non-compliance was found in resident care and related services. Violations related to medication management, medication administration according to physician orders, and proper documentation on the Medication Administration Record (MAR) were identified.
Deficiencies (3)
Facility failed to follow medication management policy to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes.
Facility failed to ensure medications were administered in accordance with physician's or prescriber's instructions.
Facility failed to ensure the Medication Administration Record (MAR) included initials of direct care staff administering the medication and had altered documentation.
Report Facts
Number of residents present: 39
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: 1
Inspection Report
Monitoring
Census: 38
Deficiencies: 2
Date: Oct 23, 2023
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(s) of resident care and related services.
Findings
The investigation supported the self-report of non-compliance with standards or law, resulting in violations issued. Violations included failure to maintain confidentiality of records and failure to administer medications according to physician orders.
Deficiencies (2)
The facility failed to ensure that all records were treated confidentially; the Narcotic Logbook was observed lying on top of the medication cart in the hallway.
The facility failed to ensure that medications were administered in accordance with physician or prescriber instructions; residents did not receive medications ordered to be administered at approximately 2:00 pm on 10/18/2023.
Report Facts
Number of residents present: 38
Number of resident records reviewed: 3
Number of staff records reviewed: 1
Inspection Report
Renewal
Census: 37
Deficiencies: 3
Date: Oct 3, 2023
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 non-compliance with several standards including staff first aid certification, missing signatures on Individualized Service Plans (ISPs), and lack of required 'No Smoking-Oxygen in Use' signage in a room with oxygen tanks. Violations were documented and a plan of correction was requested.
Deficiencies (3)
Facility failed to ensure that each direct care staff maintained current certification in first aid for two of the four staff whose records were reviewed.
Facility failed to ensure that Individualized Service Plans (ISPs) were signed and dated by the resident or legal representative for three out of six residents.
Facility failed to ensure the posting of a 'No Smoking-Oxygen in Use' sign in a room where oxygen tanks were present.
Report Facts
Number of residents present: 37
Number of resident records reviewed: 8
Number of staff records reviewed: 4
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 1
Number of residents with unsigned ISPs: 3
Number of staff without current first aid certification: 2
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 28, 2023
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2023-08-24 regarding allegations in the area(s) of resident care and related services.
Complaint Details
Complaint related inspection with allegations concerning resident care and related services; the complaint was not substantiated.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The inspection summary will be posted to the VDSS website within 5 business days of receipt.
Report Facts
Resident records reviewed: 1
Staff records reviewed: 0
Resident interviews conducted: 1
Staff interviews conducted: 2
Inspection Report
Original Licensing
Census: 32
Deficiencies: 0
Date: Apr 13, 2023
Visit Reason
An initial inspection was conducted due to a change in ownership of the facility. The facility had previously undergone a full renewal inspection and earned a three-year license.
Findings
The inspection found no outstanding physical plant issues. The facility was issued a conditional license for six months with requirements for updated agreements, disclosures, background checks, and contracts under the new ownership. Site visits will occur every sixty days until renewal.
Report Facts
License duration: 6
Current census: 32
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