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Source: VA State Licensing Agency
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced renewal took place on 11/18/2025 from 8:55 am to 3:20 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 4 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 7 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: Breakfast was observed. A medication pass observation was completed. The call bell system was monitored. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Based on the record review and staff interview the facility failed to ensure upon admission, the assisted living facility shall provide an orientation for new residents and their legal representatives, including emergency response procedures, mealtimes, and use of the call system. If needed, the orientation shall be modified as appropriate for residents with cognitive impairments. Acknowledgment of having received the orientation shall be signed and dated by the resident and, as appropriate, his legal representative, and such documentation shall be kept in the resident's record. Evidence: 1. The record for resident #1, admission date 10/15/25, did not contain acknowledgment of having received an orientation. 2. The record for resident #2, admission date 09/15/25, did not contain did not contain acknowledgment of having received an orientation. 3. The record for resident #3, admission date 09/15/25, did not contain did not contain did not contain acknowledgment of having received an orientation. 4. Upon request, and during an interview on 11/18/25 with staff #1, staff #1 confirmed the records for residents #1, #2, and #3 did not contain an acknowledgment of having received an orientation.
Based on the record review and staff interview the facility failed to ensure the comprehensive individualized service plan ( ISP
Based on the record review and staff interview the facility failed to ensure the criminal history report shall be obtained within 30 days of employment for each employee. Evidence: 1. The record for staff #4, hire date 09/14/25, does not contain a criminal history report. 2. The record for staff #5, hire date 09/14/25, does not contain a criminal history report. 3. The record for staff #6, hire date 09/14/25, does not contain a criminal history report. 4. Upon request, and during an interview on 11/18/25 with staff #1, staff #1 was not able to provide a criminal history report for staff #4, staff #5, and staff #6.
Based on the record review and staff interview the facility failed to ensure written acknowledgment of the receipt of the disclosure by the resident or the resident?s legal representative shall be retained in the resident's record. Evidence: 1. The record for resident #1, admission date 10/15/25, did not contain written acknowledgment of the receipt of the disclosure by the resident or the resident?s legal representative. 2. The record for resident #2, admission date 09/15/25, did not contain written acknowledgment of the receipt of the disclosure by the resident or the resident?s legal representative 3. The record for resident #3, admission date 09/15/25, did not contain written acknowledgment of the receipt of the disclosure by the resident or the resident?s legal representative 4. Upon request, and during an interview on 11/18/25 with staff #1, staff #1 confirmed the record for residents #1, #2, and #3 did not contain written acknowledgment of the receipt of the disclosure by the resident or the resident?s legal representative.
Based on the record review and staff interview the facility failed to ensure based upon review of the UAI
Based on observation and staff interview the facility failed to ensure over-the-counter medication shall remain in the original container, labeled with the resident's name. Evidence: 1. During observation of the medication storage area the following over the counter medications were not labeled with a resident?s name: ? Tylenol extra strength ? Robitussin ? Coricidin ? Rolaids ? Halls Cough Drops 2. During an interview on 11/18/25 with staff #2, staff #2 confirmed the over the counter medications were not labeled with a resident?s name.
Based on observation and staff interview the facility failed to implement a written plan for medication management to include methods to prevent the use of outdated, damaged, or contaminated medications. Evidence: 1. During observation of the medication storage area the following expired medication was observed: Tylenol extra strength, expired 06/2025. 2. During an interview on 11/18/25 with staff #2, staff #2 confirmed the Tylenol medication had an expiration date of 06/2025.
Based on the record review and staff interview the facility failed to ensure the sworn statement or affirmation shall be completed for all applicants for employment. Evidence: 1. The record for staff #4, hire date 09/14/25, does not contain a sworn statement or affirmation. 2. The record for staff #5, hire date 09/14/25, does not contain a sworn statement or affirmation. 3. The record for staff #6, hire date 09/14/25, does not contain a sworn statement or affirmation. 4. The record for staff #7, hire date 6/10/25 does not contain a sworn statement or affirmation. 5. Upon request, and during an interview on 11/18/25 with staff #1, staff #1 was not able to provide a sworn statement or affirmation for staff #4, staff #5, staff #6, and staff #7.
Based on the record review and staff interview the facility failed to ensure within the 30 days preceding admission, a person shall have a physical examination by an independent physician. The report of such examination shall be on file at the assisted living facility and shall contain the following: ? Address, and telephone number ? results of a risk assessment documenting the absence of tuberculosis (TB) ? A statement that the individual does not have any of the conditions or care needs prohibited by 22VAC40-73-310 H ? A statement that specifies whether the individual is considered to be ambulatory or nonambulatory as defined in this chapter ? A statement that specifies whether the individual is or is not capable of self- administering medication ? The signature of the examining physician or his designee Evidence: 1. Resident #2?s physical examination dated 09/11/25 does not include the following: ? Address, and telephone number; ? results of a risk assessment documenting the absence of tuberculosis (TB) ? A statement that the individual does not have any of the conditions or care needs prohibited by 22VAC40-73-310 H ? A statement that specifies whether the individual is considered to be ambulatory or nonambulatory as defined in this chapter ? A statement that specifies whether the individual is or is not capable of self- administering medication ? The signature of the examining physician or his designee 2. During an interview on 11/18/25 with staff #1, staff #1 confirmed the physical examination for resident #2 did not contain the required items. 3. The record for resident #3, admission date 09/15/25, did not contain a physical examination. 4. Upon request, and during an interview on 11/18/25 with staff #, staff #1 confirmed the record for resident #3 did not contain a physical examination and was not able to provide a physical examination completed for resident #3.
Based on the record review and staff interview the facility failed to ensure each staff person on or within seven days prior to the first day of work at the facility and prior to coming in contact with residents shall submit the results of a risk assessment, documenting the absence of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. The Risk assessment shall be no older than 30 days. Evidence: 1. The record for staff #1, hire date 09/02/25, contains a risk assessment for TB dated as completed on 05/08/25. The staff record did not contain a risk assessment for TB no older than 30 days from the first day of work at the facility. 2. The record for staff #2, hire date 05/14/25, contains a risk assessment for TB dated as completed on 05/14/25. The staff record did not contain a risk assessment for TB no older than 30 days from the first day of work at the facility. 3. Upon request, and during an interview with staff #1, staff #1 was not able to provide a risk assessment for TB for staff # 1 and staff #2 completed no older than 30 days from the first day of work at the facility.
Based on the record review and staff interview the facility failed to ensure the ISP
Based on the record review and staff interview the facility failed to ensure each direct care staff member who does not have current certification in first aid as specified in subdivision 1 of this subsection shall receive certification in first aid within 60 days of employment. Evidence: 1. The record for staff # 3, hire date 08/01/25, does not contain a certification in first aid. 2. Upon request, and during an interview on 11/18/2025 with staff # 1, staff #1 was not able to provide evidence staff #1 has a current certification in first aid.
Based on the record review and staff interview the facility failed to ensure the facility shall ascertain, prior to admission, whether a potential resident is a registered sex offender if the facility anticipates the potential resident will have a length of stay greater than three days or in fact stays longer than three days and shall document in the resident's record that this was ascertained and the date the information was obtained. Evidence: 1. The record for resident #1, admission date 10/15/25, did not contain a sex offender search result. 2. The record for resident #2, admission date 09/15/25, did not contain did not contain a sex offender search result. 3. The record for resident #3, admission date 09/15/25, did not contain did not contain a sex offender search result. 4. Upon request, and during an interview on 11/18/25 with staff #1, staff #1 confirmed a sex offender search has not been completed for residents #1, #2, and #3.
ype of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced monitoring inspection took place on 08/06/2025 from 11:50 am to 12:20 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 0 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. 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: 2 Observations by licensing inspector: Secured windows and exit doors were checked. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Based on email records and staff interviews the facility failed to ensure the facility shall have an administrator of record. Evidence: 1. Staff #1 sent an email to the Licensing Inspector, LI on 08/01/25 stating that staff #1 would no longer be the administrator of record as of 08/01/25. 2. During an onsite visit at the facility and during an interview on 08/06/25 with staff #2, staff #2 stated the facility does not have an administrator on record and is conducting interviews for the administrator position. 3. Staff #2 sent an email to the LI on 08/18/25 stating the facility does not have an administrator on record and is still in the process of conducting interviews for the administrator position.
Type of inspection: Initial Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An announced initial inspection took place on 05/19/2025 at 8:55am to 10:20 am. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 0 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. 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: 2 Observations by licensing inspector: An observation of bedrooms, restrooms, dining area, common areas, medication closet, and the kitchen were observed. The facility?s first aid kit was reviewed. Additional Comments/Discussion: Measurements were completed in bedrooms that will be used for residents. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website should the facility be issued a license to operate. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of a licensed facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
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