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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: 01/20/2026from 12:15 p.m.- 2:25 p.m. and 02/05/2026 from 3:06 p.m.- 3:55 p.m. 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: 19 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 2 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Additional Comments/Discussion: The following items were also reviewed/observed during the inspection- facility documentation, facility postings, first aid kit, medication pass, physician?s orders, medication administration records. An exit meeting was 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. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). 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 these 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. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. 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 Kimberly Davis, Licensing Inspector at (804) 356-3572 or by email at Kimberly.M.Davis@@dss.virginia.gov
Based on a review of resident records the facility failed to ensure that on or within seven days prior to the day of admission, a preliminary plan of care shall be developed to address the basic needs of the resident that adequately protects his health, safety, and welfare. Evidence: The record for Resident # 2 (admit date: 11-3-25) did not contain an individualized service plan. This was confirmed by staff.
Based on a review of facility documentation the facility failed to ensure that it shall develop and implement an orientation and semi-annual review on the emergency preparedness and response plan for all staff, residents, and volunteers, with emphasis placed on an individual's respective responsibilities. The review shall be documented by signing and dating. The orientation and review shall cover responsibilities for: 1. Alerting emergency personnel and sounding alarms; 2. Implementing evacuation, shelter in place, and relocation procedures; 3. Using, maintaining, and operating emergency equipment; 4. Accessing emergency medical information, equipment, and medications for residents; 5. Locating and shutting off utilities; and 6. Utilizing community support services. Evidence: The facility was unable to provide documentation of a semi-annual review on the emergency preparedness and response plan for all staff and residents. This was confirmed by staff.
Based on observation during a tour of the building the facility failed to ensure that an operable bed lamp or bedside light isaccessible to each resident. Evidence: The residents? room facing the laundry room on the second floor did not contain lamps for the two residents. This was confirmed by staff.
Based on a review of the facility?s first aid kit the facility failed to ensure that first aid kits shall be checked at least monthly to ensure that all items are present and items with expiration dates are not past their expiration date. Evidence: The facility was unable to provide documentation of a monthly review of the first aid kit. This was confirmed by staff.
Based on a review of resident records the facility failed to ensure that a copy of the written discharge statement shall be retained in the resident's record. Evidence: The record of Resident # 1 (discharge date: 11-20-25) did not contain a written discharge statement. This was confirmed by staff.
Based on a review of staff records the facility failed to ensure that personal and social data to be maintained on staff and included in the staff record included an original criminal record report and a sworn disclosure statement. Evidence: The record for Staff # 1 (hire date: 2-16-21) did not contain an original criminal record report and a sworn disclosure statement. This was confirmed by staff.
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 1-20-26 from11:15 a.m.- 12:05 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 1-2-26 regarding allegations in the area(s) of: resident care Number of residents present at the facility at the beginning of the inspection: 19 Number of resident records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. Any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. 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 Kimberly Davis, Licensing Inspector at (804) 356-3572 or by email at Kimberly.M.Davis@dss.virginia.gov
Based on a review of resident records the facility failed to ensure that Individualized service plans ( ISP
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 2-4-25 from 1:00 p.m.-1:40 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on regarding allegations in the area(s) of: buildings and grounds. Number of residents present at the facility at the beginning of the inspection: 19 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation(s) of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint(s) but identified during the course of the investigation can also be found on the violation notice. 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 Kimberly Davis, Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov
Based on interviews with facility staff and the identified resident, the facility failed to ensure that buildings shall be kept free of infestations of insects and vermin. The grounds shall be kept free of their breeding places. Evidence: Staff # 1 informed the inspector that the facility was currently being treated for bed bugs and Resident # 1 indicated that he had some bed bug bites.
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: 2-4-25 from 10:35 a.m.-1:00 p.m. and 3-3-25 from 2:35 p.m.-3:30 p.m. 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: 19 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 2 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Additional Comments/Discussion: The following items were also reviewed/observed during the inspection- facility documentation, facility postings, lunch meal, medication pass, physician?s orders, medication administration records, first aid kit. An exit meeting was 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 Kimberly Davis, Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov
Based on a review of resident records the facility failed to ensure that 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: 1. The person's name, address, and telephone number; 2. The date of the physical examination; 3. Height, weight, and blood pressure; 4. Significant medical history; 5. General physical condition, including a systems review as is medically indicated; 6. Any diagnosis or significant problems; 7. Any known allergies and description of the person's reactions; 8. Any recommendations for care including medication, diet, and therapy; 9. 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; 10. A statement that the individual does not have any of the conditions or care needs prohibited by 22VAC40-73-310 H; 11. A statement that specifies whether the individual is considered to be ambulatory or nonambulatory as defined in this chapter; 12. A statement that specifies whether the individual is or is not capable of self- administering medication; 13. The signature of the examining physician or his designee. Evidence: The record for Resident # 2 (admit date: 3-14-24) did not contain a physical examination and report.
Based on observation during a tour of the facility, the facility failed to ensure that the interior and exterior of all buildings shall be maintained in good repair and kept clean and free of rubbish. Evidence: The following was observed by the Licensing Inspector: -Chipped paint on the handrail of the stairs leading to the second floor. -Dirty, stained carpet in the hallway near the stairwell on the second floor. -Chipped paint on the wall in the second-floor bathroom. -Rust on the baseboard heating vent in the first-floor bathroom. -Chipped paint and wood with areas of dirt on the door frame area at front entrance. (Photographic evidence was taken.)
Based on a review of resident records the facility failed to ensure that the comprehensive individualized service plan ( ISP
Based on a review of facility documentation the facility failed to ensure the semi-annual review on the emergency preparedness and response plan for all staff, residents, and volunteers, with emphasis placed on an individual's respective responsibilities. The review shall be documented by signing and dating. Evidence: The facility was unable to provide documentation of the semi-annual review of the emergency preparedness and response plan for all staff and residents.
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: 3-7-24 from 11:30 a.m.- 2:20 p.m. and 3-13-24 from 11:20 a.m.-12:10 p.m. 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: 18 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Additional Comments/Discussion: The following items were also reviewed/observed during the inspection- facility documentation, facility postings, first aid kit, lunch meal/menu, medication pass, physician?s orders, and medication administration records ( MAR
Based on a review of resident records the facility failed to ensure that 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: 1. The person's name, address, and telephone number; 2. The date of the physical examination; 3. Height, weight, and blood pressure; 4. Significant medical history; 5. General physical condition, including a systems review as is medically indicated; 6. Any diagnosis or significant problems; 7. Any known allergies and description of the person's reactions; 8. Any recommendations for care including medication, diet, and therapy; 9. 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; 10. A statement that the individual does not have any of the conditions or care needs prohibited by 22VAC40-73-310 H; 11.A statement that specifies whether the individual is considered to be ambulatory or nonambulatory as defined in this chapter; 12.A statement that specifies whether the individual is or is not capable of self- administering medication; and 13. The signature of the examining physician or his designee. Evidence: The record for Resident # 6 did not contain a physical examination and report at all.
Based on a review of resident records the facility failed to ensure that at or prior to the time of admission, there shall be a written agreement/acknowledgment of notification dated and signed by the resident or applicant for admission or the appropriate legal representative, and by the licensee or administrator. Evidence: The record for Resident # 6 (admit date: 8-23-23) did not contain a resident agreement with the facility.
Based on a review of staff records the facility failed to ensure that the Uniform Assessment Instrument ( UAI
Based on a review of staff records the facility failed to ensure that each staff person shall annually submit the results of a risk assessment, documenting that the individual is free of tuberculosis (TB) 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. Evidence: -The record for Staff # 1 (date of hire: 11-8-95) and Staff # 2 (date of hire:9-1-13) contained a TB risk assessment last dated 2-17-23. -The record for Staff # 3 (date of hire: 8-8-23) did not contain documentation of a TB risk assessment at all.
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 5-5-23 from 3:26 p.m.-5:40 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing regarding allegations in the area(s) of: resident care. Number of residents present at the facility at the beginning of the inspection: 18 Number of resident records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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 Kimberly Davis, Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 4-6-23 from 9:16 a.m.- 10:30 a.m. 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: 18 Number of resident records reviewed: 5 Number of staff records reviewed: 4 Number of interviews conducted with staff: 1 Additional Comments/Discussion: An unannounced monitoring inspection was conducted by licensing staff to follow up on previously cited high risk violations. An exit meeting was 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 Kimberly Davis, Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov Violation Notice Issued: Yes A copy of this document will be sent to the licensee/provider for signature.
Based on a review of staff records the facility failed to ensure that each staff member?s tuberculosis (TB) risk assessment shall be no older than 30 days. Evidence: The record for Staff # 1 (date of hire: 8-8-22) contained a TB risk assessment that was dated 6-20-22.
Based on a review of resident records the facility failed to ensure that the Uniform Assessment Instrument ( UAI
Based on observation the facility failed to ensure that all furnishings, fixtures, and equipment, including toilets, bathtubs, and showers, shall be kept clean and in good repair and condition, except that furnishings and equipment owned by a resident shall be, at a minimum, in safe condition and not soiled in a manner that presents a health hazard. Evidence: -The ceiling above the shower in Bathroom # 2 was stained. -The administrator stated that he had forgotten to fix the stained area above the shower and would take care of it.
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 4-6-23 from 11:00 a.m.-12:30 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing regarding allegations in the area(s) of: resident care. Number of residents present at the facility at the beginning of the inspection: 18 Number of resident records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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 Kimberly Davis, Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov
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