Inspection Reports for Windsormeade Williamsburg, Pinnacle Living
3900 Windsor Hall Drive, VA, 23188
Back to Facility ProfileDeficiencies per Year
8
6
4
2
0
Unclassified
Census Over Time
Inspection Report
Complaint Investigation
Census: 27
Deficiencies: 0
Aug 12, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-05-29 regarding allegations in the area of Resident Care and Related Services.
Findings
The evidence gathered during the investigation did not support the allegation(s) or self-report of non-compliance with standards or law.
Complaint Details
Complaint related to Resident Care and Related Services; the complaint was 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
Complaint Investigation
Census: 31
Deficiencies: 0
Feb 3, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2024-10-03 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.
Complaint Details
Complaint received on 2024-10-03 regarding Resident Care and Related Services; investigation did not substantiate the allegations.
Report Facts
Number of residents present: 31
Number of resident interviews: 2
Number of staff interviews: 4
Number of staff records reviewed: 0
Inspection Report
Monitoring
Census: 31
Deficiencies: 6
Feb 3, 2025
Visit Reason
The inspection was a monitoring visit conducted to review compliance with applicable standards and laws at the assisted living facility.
Findings
The inspection found multiple violations related to staff records, assessment documentation, individualized service plans, and medication orders. The facility was cited for failure to maintain required documentation and ensure proper signatures and certifications.
Deficiencies (6)
| Description |
|---|
| Failed to verify that each staff person has received a copy of his or her current job description. |
| Failed to ensure that each staff person submit the results of a tuberculosis (TB) risk assessment on or within seven days prior to the first day of work and annually. |
| Failed to ensure each direct care staff member who does not have current certification in first aid shall receive certification within 60 days of employment. |
| Failed to ensure the uniform assessment instrument (UAI) was completed and signed by a qualified assessor. |
| Failed to ensure the individualized service plan (ISP) was signed and dated by the resident or legal representative. |
| Failed to ensure no medication, dietary supplement, diet, medical procedure, or treatment be started, changed, or discontinued without a valid order from a physician or other prescriber. |
Report Facts
Number of residents present: 31
Number of resident records reviewed: 4
Number of staff records reviewed: 3
Number of interviews conducted with residents: 3
Number of interviews conducted with staff: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alyshia E Walker | Licensing Inspector | Current inspector conducting the monitoring inspection |
| Staff #7 | Named in multiple findings related to missing job description, TB risk assessment, first aid certification, and employment status | |
| Staff #4 | Acknowledged missing job description, TB risk assessment, and first aid certification in staff records | |
| Staff #2 | Acknowledged missing signatures on uniform assessment instrument and medication order | |
| Staff #3 | Acknowledged missing signatures on individualized service plans and medication order |
Inspection Report
Monitoring
Census: 27
Deficiencies: 0
May 7, 2024
Visit Reason
The inspection was a monitoring visit to review compliance with various regulatory provisions related to administration, personnel, resident care, emergency preparedness, and other facility requirements.
Findings
The inspection found no violations of applicable standards or laws. The licensing inspector observed activities, meal service, call bell responses, emergency supplies, and medication passes, and conducted interviews and record reviews.
Report Facts
Number of resident records reviewed: 10
Number of staff records reviewed: 3
Number of interviews conducted with residents: 3
Number of interviews conducted with staff: 3
Inspection Report
Renewal
Census: 28
Deficiencies: 1
Mar 27, 2023
Visit Reason
The inspection was conducted as a renewal inspection of the assisted living facility to assess compliance with applicable regulations and standards.
Findings
The inspection found non-compliance with the regulation requiring fall risk assessments to be reviewed and updated after every fall. Multiple residents had documented falls without corresponding fall risk assessments completed.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure that a fall risk assessment was reviewed and updated after every fall. |
Report Facts
Number of residents present: 28
Number of resident records reviewed: 7
Number of staff records reviewed: 3
Number of interviews conducted with residents: 3
Number of interviews conducted with staff: 3
Number of documented falls without fall assessments: 5
Plan of correction audit timeframe: 6
Plan of correction audit reporting frequency: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alyshia E Walker | Licensing Inspector | Inspector conducting the inspection |
| Administrator | Responsible for auditing falls process as part of plan of correction | |
| Director of Nursing | Responsible for auditing falls process as part of plan of correction | |
| Clinical Leader | Responsible for auditing falls process as part of plan of correction |
Inspection Report
Monitoring
Deficiencies: 0
Mar 17, 2022
Visit Reason
An unannounced, mandated monitoring inspection was conducted to review resident and staff records, observe the facility physical plant during meal times, and assess emergency supplies and first aid kit compliance.
Findings
The inspection found no violations during the review of records, observations of the facility, and documentation compliance checks.
Report Facts
Resident records reviewed: 5
Staff records reviewed: 3
Inspection Report
Monitoring
Census: 22
Deficiencies: 0
Apr 7, 2021
Visit Reason
A monitoring inspection was initiated due to the state of emergency health pandemic declared by the Governor of Virginia, conducted remotely to ensure compliance with applicable standards.
Findings
The inspection reviewed resident and staff records and other documentation, determining no violations with applicable standards or law; no violations were issued.
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