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Source: VA State Licensing Agency
Type of inspection: Mandated Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection:February 11, 2026, from 9:35 a.m. until 1:00 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: 31 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 4 Observations by licensing inspector: The Licensing Inspector toured the community and observed the residents during activities and meals. The Licensing Inspector reviewed the following at the time of inspection: sample of resident and employee records, medication administration, fire drills, emergency drills, pharmacy review, menus, activity calendars, verified appropriate amount of liability insurance, and dietician report. 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. 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 Angie Via, Licensing Inspector at (540) 682-1739 or by email at angela.via@dss.virginia.gov
Based on staff record review and staff interview, the facility failed to ensure documented absence of tuberculosis in a communicable form as evidenced by completion of the current screening form published by the Virginia Department of Health or a form consistent with it, on or within seven days prior to the first day of work at the facility. Evidence: 1. Record for staff 3, hired 05/12/2025, contained a tuberculosis (TB) risk assessment dated 05/25/2025, which is not on or within seven days prior to the first day of work at the facility. 2. Staff 7 acknowledged that the TB risk assessment for staff 3 was not completed on or within seven days prior to the first day of work at the facility.
Based on resident record reviews and staff interview, the facility failed to obtain a physical examination by an independent physician within 30 days preceding admission. Evidence: 1. The admission date for resident 2 was 12/04/2025. The date of the face-to-face physical examination for resident 2 was 11/25/2025, which was not signed by the physician as required. 2. The admission date for resident 4 was 12/05/2025. The date of the face-to-face physical examination for resident 2 was 12/08/2025, which was after admission to the facility. 3. Staff 6 acknowledged that the physical examination reports for residents 2 and 4 were not completed according to the standard.
Type of inspection: Monitoring A self-reported incident was received by VDSS Division of Licensing on 12/5/2025 regarding allegations in the area(s) of: Resident care and related services Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 1/8/2026 from 10:30 a.m. until 11:30 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: 30 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 staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Licensing inspector toured facility and reviewed complete resident record. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-reported incident 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 Angela Via, Licensing Inspector at (540) 682-1739 or by email at Angela.Via@dss.virginia.gov
Based on resident record review and staff interview, the facility failed to ensure the comprehensive individualized service plan ( ISP
Based on resident record review and staff interview, the facility failed to obtain a physical examination, including a tuberculosis risk assessment, by an independent physician within 30 days preceding admission. Evidence: 1. The admission date for resident 1 was 12/1/2025. The date of the face-to-face physical examination for resident 1 was 10/20/2025 which was more than 30 days preceding admission. The physical examination report for resident 1 was not signed by the physician until 12/2/2025 which was after resident 1?s admission date. 2. The admission date for resident 1 was 12/1/2025. The risk assessment documenting the absence of tuberculosis for resident 1 was undated. 3. Staff 1 confirmed that the physical examination report and tuberculosis risk assessment for resident 1 were not completed within 30 days preceding admission.
Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 12/4/2025 regarding allegations in the area(s) of: Resident Care and Related Services Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: January 8, 2026, from 11:30 am to 12:30 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: 30 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 staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Licensing inspector toured the community, reviewed resident record, including MAR
Based on resident record review and staff interview, the facility failed to ensure the comprehensive individualized service plan ( ISP
Based on resident record review and staff interview, the facility failed to administer medications in accordance with the physician's or other prescriber?s instructions. Evidence: 1. A complaint received by the regional licensing office on 12/4/2025 alleged that resident 1 ?had missed several doses of his medications as it was discovered that he was out?. 2. Medication administration record ( MAR
Based on resident record review and staff interviews, the facility failed to follow the facility?s medication management plan to ensure that each resident's prescription medications were refilled in a timely manner to avoid missed dosages. Evidence: 1. A complaint received by the regional licensing office on 12/4/2025 alleged that resident 1 ?had missed several doses of his medications as it was discovered that he was out?. 2. Medication administration record ( MAR
Type of inspection: Monitoring A self-reported incident was received by VDSS Division of Licensing on 9/8/2025 regarding allegations in the area(s) of: Resident Care and Related Services Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 9/18/2025 10:37 a.m. - 11:00 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: 27 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 staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: The licensing inspector reviewed the resident record, staffing, facilities policies, and staff notes. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report 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 Jessica Gale, Licensing Inspector at (540) 571-0358 or by email at Jessica.Gale@dss.virginia.gov
Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 9/10/2025 regarding allegations in the area(s) of: Resident Care and Related Services Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 9/18/2025 10:00 a.m. - 10:37 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: 27 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 staff records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: The licensing inspector reviewed medication administration records and incident reports. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations 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 Jessica Gale, Licensing Inspector at (540) 571-0358 or by email at Jessica.Gale@dss.virginia.gov
Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 8/18/2025 regarding allegations in the area(s) of: Resident Care and Related Services and Building and Grounds Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 8/20/2025 9:30 a.m. - 10:15 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: 30 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 staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: The licensing inspector toured the facility including the resident room and bathrooms and reviewed the facility dining menu and snack availability, meal policies, staffing, the staff schedule and staff communication. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations 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 Jessica Gale, Licensing Inspector at (540) 571-0358 or by email at Jessica.Gale@dss.virginia.gov
Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 6/24/2025 regarding allegations in the area(s) of: Resident Care and Related Services and Building and Grounds. Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7/3/2025 9:45 a.m. ? 11:11 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: 29 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 staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: The licensing inspector checked temperatures throughout the facility including common areas and resident rooms and observed residents and staff in common areas and in their rooms. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. However, violation(s) not related to the complaint but identified during the course of the investigation can 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 Jessica Gale, Licensing Inspector at (540) 571-0358 or by email at Jessica.Gale@dss.virginia.gov
Based on record review and staff interview, the facility failed to have staff adequate in knowledge, skills, and abilities and sufficient in numbers to provide services to attain and maintain the physical, mental, and psychosocial well-being of each resident as determined by resident assessments and individualized service plans. Evidence: 1. On the day of inspection, 7/3/2025, two licensing staff observed three staff on duty at the facility, a housekeeper, a cook and a direct care aide in training. 2. During an interview with staff 2, when asked if there was someone registered or licensed to administer medications on duty, staff 2 stated no that they had left but would be back. 3. During an interview with staff 1, when asked if there was anyone certified to provide care to the residents on duty while staff 3 was out of the facility staff 1 stated ?no?. 4. During an interview with staff 1, when asked if there was anyone on duty at the facility with a current certification in CPR, staff 1 stated ?no?. 5. While staff 1 and staff 3 were out of the facility, there were no staff on duty on the premises who were licensed to administer medications, certified to provide care, or certified in first aid or CPR.
Based on record review and staff interview, the facility failed to develop and implement a written plan for supervision of direct care staff who have not yet met the requirements. Evidence: 1. Staff 2, hired 6/13/2025, did not have the required qualifications for direct care staff. 2. Record review for staff 2 did not contain a written plan for supervision of direct care staff who have not yet met the required qualifications. 3. During an interview with staff 1, when asked if there was a written plan for supervision of staff 2 until staff 2 met the required qualifications, staff 1 stated ?no?.
Based on direct observation, record review, and staff interview the facility failed to ensure the staff member in charge was capable of protecting the physical and mental well-being of the residents. Evidence: 1. Upon entrance to the facility on 7/3/2025, two licensing staff located staff 2 as the person in charge. 2. During an interview with staff 2, when asked who was in charge staff 2 confirmed they were in charge while staff 1 and staff 3 were out of the facility. 3. During another interview with staff 2 when asked how long they had been a direct care aide, staff 2 stated that they had not taken the class yet. 4. Record review for staff 2 did not contain a direct care certification, first aid, or cardiopulmonary resuscitation (CPR) certification. 5. During an interview with staff 1 when asked if staff 2 had a current first aid or CPR certification staff 1 stated ?[staff 2] is not certified in anything.?
Based on direct observation, record review and staff interview, the facility failed to ensure there was at least one staff person in each building at all times who has current certification in CPR. Evidence: 1. On the day of inspection, 7/3/2025, two licensing staff observed three staff on duty at the facility, a housekeeper, a cook and a direct care aide in training. 2. Upon request the facility did not provide a current certification in CPR for the three staff present at the facility upon licensing arrival. 3. During an interview with staff 1, when asked if there was anyone on duty at the facility with a current certification in CPR, staff 1 stated ?no?.
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: 03/20/2025 09:50am-10:32am 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 3/10/2025 regarding allegations in the area(s) of: Building and grounds, dining and nutrition, administration, staffing and supervision. Number of residents present at the facility at the beginning of the inspection: 26 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: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: The Licensing Inspector observed the kitchen, meal preparation, building and grounds, and the administrator schedule. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation(s); area(s) of non-compliance with standard(s) or law were: 150-E A violation notice was 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 Jessica Gale, Licensing Inspector at 540-571-0358 or by email at Jessica.gale@dss.virginia.gov
Based on direct observation, the facility failed to ensure any operable window (i.e., a window that may be opened) was effectively screened. Evidence: 1. During the facility tour completed 3/20/2025 at 9:50am, a window in the kitchen was open with no screen in place, a window in the dining room was open with no screen in place, and the second-floor window above the entrance to the facility was open with a screen in place that was ripped and missing the screen on 75% of the window. 2. Photo evidence taken.
Based on record review and staff interview, the facility failed to ensure for a facility licensed only for residential living care, the administrator was awake and on duty on the premises at least 40 hours per week with no fewer than 24 of those hours being during the day shift on weekdays. Evidence: 1. This facility is licensed for residential care only. 2. During an interview with staff 1, when asked how many days a week the administrator is onsite at the facility, staff 1 stated ?20 hours a week?. When asked how long the 20 hours a week had been in place, staff 1 stated ?since October of last year.? 3. The staff schedule from October 20, the date staff 1 indicated the 20 hours began, through the date of inspection, 3/20/2025, totaling 22 weeks, with 40 hours required on site a week totaling 880 hours. The administrator worked from 7am-3pm on 52 dates totaling 416 hours on site at the facility, leaving the facility without the required administrator supervision a total of 464 hours. 4. During an interview with staff 2, when asked how many days the administrator was present at the facility, staff 2 stated ?3 days a week?.
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