Inspection Reports for
White Birch Communities
847 Oakwood Drive, ROCKINGHAM, VA, 22801-3924
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
2.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
71% better than Virginia average
Virginia average: 9.1 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
48 residents
Based on a August 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Renewal
Census: 48
Deficiencies: 1
Date: Aug 7, 2025
Visit Reason
The inspection was a renewal visit conducted on August 7, 2025, to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection found non-compliance with medication management standards, specifically failure to implement the written medication management plan, including incomplete documentation of medication administration.
Deficiencies (1)
Facility failed to implement the written plan for medication management, including missing documentation of medication administration on multiple dates for residents.
Report Facts
Number of residents present: 48
Number of resident records reviewed: 5
Number of staff records reviewed: 5
Number of interviews with residents: 2
Number of interviews with staff: 3
Inspection Report
Monitoring
Census: 47
Deficiencies: 1
Date: Dec 27, 2024
Visit Reason
The inspection was a monitoring visit to review compliance with applicable standards and laws at the assisted living facility.
Findings
The inspection found non-compliance with the fire and emergency evacuation plan requirements, specifically the plan did not include the secondary evacuation route or area of refuge. A violation notice was issued to the facility.
Deficiencies (1)
The facility failed to ensure the fire and emergency evacuation plan includes all required information, missing the secondary evacuation route or area of refuge.
Report Facts
Number of residents present: 47
Number of resident records reviewed: 4
Number of staff records reviewed: 3
Number of interviews conducted with residents: 4
Number of interviews conducted with staff: 4
Inspection Report
Renewal
Census: 47
Deficiencies: 0
Date: Aug 23, 2023
Visit Reason
The inspection was a renewal visit to assess compliance with licensing requirements and regulations for the assisted living facility.
Findings
The facility was found to be clean, odor free, and well maintained with secure memory care units. Observations included proper medication administration, accurate records, and staff training exceeding annual requirements. No violations of applicable standards or laws were identified during the inspection.
Report Facts
Number of resident records reviewed: 7
Number of staff records reviewed: 6
Number of interviews conducted with residents: 5
Number of interviews conducted with staff: 3
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 2
Date: Sep 16, 2022
Visit Reason
The inspection was conducted in response to a complaint received on 2022-08-31 regarding allegations in the areas of staffing, resident care and related services, resident accommodations, and buildings and grounds.
Complaint Details
The complaint was substantiated in part, with non-compliance found in resident care and related services. The complaint involved staffing, resident care, resident accommodations, and buildings and grounds.
Findings
The investigation supported some, but not all, of the allegations; non-compliance was found in resident care and related services. Two violations were cited: failure to implement the resident right to select a pharmacy of choice, and failure to document medical treatments and refusals for one resident.
Deficiencies (2)
Facility failed to implement the resident right to select a pharmacy of choice.
Facility failed to ensure medical treatment and refusals for foot soaks were documented for one resident.
Report Facts
Number of residents present: 44
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of resident interviews: 1
Number of staff interviews: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela N Via | Licensing Inspector | Conducted the inspection and interviews |
| Janice Knight | Licensing Inspector | Contact person for questions about VDSS Licensing Programs |
Inspection Report
Monitoring
Census: 44
Deficiencies: 5
Date: Sep 14, 2022
Visit Reason
The inspection was a monitoring visit conducted over three days (September 14-16, 2022) to review compliance with various assisted living facility regulations and standards.
Findings
The inspection identified multiple violations including missing sworn statements for staff, failure to post the snack menu, a medication not administered as ordered, lack of written responses to the resident council, and incomplete documentation of hourly rounds in the secured unit.
Deficiencies (5)
Facility failed to ensure sworn statements were completed and on file for three of 20 staff records reviewed.
Facility failed to ensure the snack menu was posted.
One medication was not administered to one of four residents as ordered.
Facility failed to ensure a written response regarding resolution of problems or concerns was provided to the resident council prior to the next meeting.
Facility failed to ensure hourly rounds were documented in the secured unit.
Report Facts
Number of residents present: 44
Number of staff records reviewed: 20
Number of resident records reviewed: 8
Number of interviews conducted with residents: 5
Number of interviews conducted with staff: 6
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 3, 2022
Visit Reason
The inspection was an unannounced complaint investigation conducted in response to a complaint received on 2022-04-18 alleging neglect, insufficient staffing, poor cleanliness, and failure to provide copies of resident agreements to residents/legal representatives.
Complaint Details
Complaint investigation was substantiated for failure to provide a copy of the resident agreement to one legal representative; other allegations were not supported.
Findings
The investigation did not support allegations of neglect, insufficient staffing, or poor cleanliness, but did substantiate that one legal representative did not receive a copy of the resident agreement.
Deficiencies (1)
Facility failed to ensure one of four legal representatives received a copy of the resident agreement.
Report Facts
Number of legal representatives: 4
Date complaint received: Apr 18, 2022
Date signature pages to be collected by: Jun 30, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela N Via | Licensing Inspector | Conducted the complaint inspection and interviews. |
| Administrator | Interviewed during investigation; could not confirm providing resident agreement copy. |
Inspection Report
Renewal
Census: 43
Deficiencies: 3
Date: Aug 4, 2021
Visit Reason
A renewal inspection was initiated on July 30, 2021 and concluded on August 4, 2021 to review compliance with applicable standards and licensing requirements for the assisted living facility.
Findings
The inspection found non-compliance with standards related to medication self-administration assessments, accurate documentation of treatment refusals, and availability of over-the-counter medications. Violations were documented and plans of correction were developed to address these issues.
Deficiencies (3)
Facility failed to ensure one of four residents was assessed on the uniform assessment instrument (UAI) as capable of self-administering medications when kept in the room.
Facility failed to ensure accurate documentation of treatment refusals on the July and August medication administration records (MARs) for one of four residents.
Facility failed to ensure one over-the-counter medication was available for one of the four residents' records reviewed.
Report Facts
Inspection dates: 4
Residents reviewed: 4
Staff records reviewed: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela N Via | Inspector | Named as current inspector conducting the inspection |
| Administrator | Interviewed regarding inspection findings and plans of correction; also served as nurse on duty during medication audit | |
| Director of Nursing | DON | Responsible for updating UAIs, overseeing audits, and ensuring compliance with medication and treatment documentation |
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