Highland House
Limited public data on Highland House. Call, tour, and ask to meet current residents' families — your own impression matters most.
based on 7 Google reviews
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What this means for your family
Families should proceed with extreme caution due to multiple highly critical reports of neglect and management issues. While some families find the medication and meal services beneficial, the severity of the allegations regarding resident safety and cleanliness requires direct, thorough investigation during any facility visit.
Google Reviews
Google Reviews
7 reviews on Google“Highland House presents a starkly polarized experience, with some families praising the facility for providing peace of mind and helpful staff, while others report severe instances of neglect and poor care quality. While some residents find comfort in the meals and medication management, multiple reviewers have raised alarming allegations regarding resident safety and management's lack of accountability.”
Quality Themes
Tap a score for detailsStrengths
- Helpful and communicative staff
- Comprehensive care including meals and medication
- Peace of mind for some family members
Concerns
- Allegations of resident neglect and poor quality of care (mentioned by 2 reviewers)
- Issues with facility cleanliness and management (mentioned by 2 reviewers)
Rating Trends
Tap a year to see what changed
Distribution · 7 analyzed
How They Respond to Reviews
Questions for Your Tour
- 1I noticed some families have mentioned how communicative and helpful the staff can be; how do you ensure that kind of consistent communication continues with families regarding daily updates?
- 2With a smaller, intimate community of 30 residents, what specific steps are taken daily to ensure the facility remains exceptionally clean and well-maintained?
- 3Could you walk us through the protocols for managing medication and how the staff handles medical emergencies during the overnight hours?
- 4What does a typical day look like for residents here, and what kind of social activities are available to keep everyone engaged?
- 5How does the management team work with the staff to ensure that the high standard of care and attention to resident needs is consistently met every single day?
- 6Since meals are a core part of the comprehensive care here, could you tell us a bit more about the dining experience and how much input residents have in their menus?
Personalized based on this facility's data
Key Review Excerpts
“Placing my mom in HH is like being at home but better. Meals, meds, showers, pt and piece of mind.”
“All the employees are great with my mom. They are very helpful, answerers any questions I have. If they can't answer they will tell me how to get the answer.”
“If I ca give to this people-10 stars I wold and o will do this because the experience we had with my mother in law who was patient there. Dirty facility, careless management, only after the benefits, to much to list”
State Inspection History
State Inspections
Source: VA State Licensing Agency
Oct 2, 2025Complaint
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: 10/02/2025 7:40AM to 3:10PM and 11/03/2025 10:47AM to 12:00PM 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 08/25/2025 regarding allegations in the areas of: personnel & resident care and related services Number of residents present at the facility at the beginning of the inspection: 9 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: 4 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: personnel. A violation notice was issued; 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Based on staff record review and staff interview, the facility failed to ensure personal and social data to be maintained on staff and included in the staff record are the date employed, verification that the staff person has received a copy of his current job description, and documentation of orientation. EVIDENCE: 1. On 10/20/2025, staff person 3 provided information via email to the licensing inspector (LI) that the charge aide always provides orientation training to staff regarding the community and will review any special care needs of the residents and review the needs of the building; however, staff person 1?s record does not contain documentation of orientation. 2. The record for staff person 1 does not contain the staff person?s date of employment at the facility and does not contain verification that staff person 1 had received a copy of their current job description. Staff person 2 confirmed this is accurate.
Based on staff 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 shall submit the results of a tuberculosis (TB) risk assessment, documenting the absence of TB. EVIDENCE: Interview with staff person 3 revealed they were unable to locate any verification that staff person 1 had had a TB risk assessment.
Based on staff record review and staff interview, the facility failed to ensure that each direct care staff member who does not have current certification in first aid shall receive certification in first aid within 60 days of employment. EVIDENCE: 1. On 10/10/2025, staff person 3 provided information via email to the licensing inspector (LI) that included dates and times that staff person 1 had worked at the facility during the months of October, November and December 2024 and January 2025 with 10/18/2024 being staff person 1?s first day of work at the facility. 2. During a phone call on 11/03/2025, staff person 6 informed the LI and staff person 2 that staff person 1 had started working at the facility in October 2024. Staff person 6 revealed to the LI and staff person 2 that staff person 1 did not have certification in first aid.
Based on facility documentation review and staff interview, the facility failed to maintain a written work schedule that includes the names and job classifications of all staff working each shift. EVIDENCE: On 10/10/2025, staff person 3 provided information via email to the licensing inspector (LI) that staff person 1 had worked at the facility as a direct care staff person on 10/18/2024, 10/21/2024, 10/22/2024, 10/26/2024, 10/30/2024, 11/14/2024, 11/16/2024, 11/17/2024, 11/19/2024, 12/16/2024, 01/01/2025 and 01/02/2025; however, the facility schedules for October, November, and December 2024 and January 2025 do not contain documentation that staff person 1 worked on these dates. Staff person 3 confirmed this is accurate.
Based on resident record review, the facility failed to ensure medications shall be administered in accordance with the physician?s or other prescriber?s instructions. EVIDENCE: 1. The record for resident 1 contained an electronically prescribed physician?s order, dated 10/17/2024 at 5:02PM, for Cephalexin 500MG capsule take 1 capsule by mouth 3 times daily for 10 days (total of 30 capsules) for cellulitis. The resident?s October 2024 medication administration record ( MAR
Oct 2, 2025Routine
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: 10/02/2025 7:40AM to 2:00PM 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: 9 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: 3 Observations by licensing inspector: medication administration, breakfast and noon-time meal, medication cart audit : 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Based on observation and staff interview, the facility failed to ensure to implement its procedure for posting the name of the current on-site person in charge. EVIDENCE: 1. During on-site inspection on 10/02/2025, at approximately 7:40AM the licensing inspector (LI) observed that staff person 4 was listed as the current on-site staff person in charge posting located in the entrance of the facility. 2. During an interview with staff person 2, staff person 2 informed the LI that they were the current on-site person in charge and that staff person 4 was off and not in the building.
Based on resident record review and staff interview, the facility failed to ensure that for private pay individuals, the assisted living facility shall ensure that the uniform assessment instrument ( UAI
Based on facility medication management plan review, resident record review and staff interview, the facility failed to ensure to implement its medication management plan. EVIDENCE: 1. During on-site inspection on 10/02/2025, staff person 1 provided the licensing inspector (LI) with the facility?s medication management plan (MMP). The MMP states on page 3 of 5 that medications refused or withheld are to be documented with the explanation using the Accuflow system and if the medication is refused, or withheld for three consecutive doses, the facility nurse or administrator will notify the physician and physician response will be documented in the resident?s medication record. 2. The record for resident 2 contains a signed physician?s order, dated 05/07/2025, for Docusate 100MG capsule take 1 capsule by mouth every day for depression. 3. Resident 2?s September and October 2025 medication administration records ( MAR
Based on resident record review and staff interview, the facility failed to ensure medications shall be administered in accordance with the physician?s or other prescriber?s instructions. EVIDENCE: 1. The record for resident 1 contains a signed physician?s order, dated 08/20/2025, for Lorazepam 0.25MG tablet by mouth 3 times daily after meals. The resident?s October 2025 medication administration record ( MAR
Violation cited
Based on facility documentation review and staff interview, the facility failed to implement a semi-annual review on the emergency preparedness and response plan for all staff, residents and volunteers and the review shall be documented by signing and dating. EVIDENCE: Interview with staff person 1 revealed that there is no evidence that there was semi-annual review on the facility?s emergency preparedness and response plan for all staff and residents within 6 months after 09/14/2024 which would have been due in March 2025.
Based on facility documentation and staff interview, the facility failed to ensure the procedures in the facility?s plan for resident emergencies shall be reviewed by the facility at least every six months with all staff and documentation of the review shall be signed and dated by each staff person. EVIDENCE: Interview with staff person 1 revealed that there is no evidence that there was a semi-annual review on the facility?s plan for resident emergencies for all staff within 6 months after 09/14/2024 which would have been due in March 2025.
Apr 23, 2025RoutineCleanReport
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: 04/23/2025 9:42AM to 10:35AM 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: 10 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 An exit meeting will be conducted to review the inspection findings. 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 within five (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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.stokes@dss.virginia.gov
Apr 23, 2025Routine
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: 04/23/2025 9:42AM to 10:35AM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 04/04/2025 regarding allegations in the area of: resident care and related services Number of residents present at the facility at the beginning of the inspection: 10 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 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-report 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.stokes@dss.virginia.gov
Based on resident record review and staff interview, the facility failed to ensure medications shall be administered in accordance with the physician?s or other prescriber?s instructions. EVIDENCE: On 04/04/2025, the licensing inspector (LI) received a self-reported incident via email from staff person 1 that on 04/04/2025 staff person 3 gave the resident their morning medications that were previously given by the night-shift registered medication aide (RMA) 30 minutes prior. Staff person 3 admittedly gave the medications to the resident without referring to the resident?s medication administration record ( MAR
Feb 10, 2025RoutineCleanReport
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: 02/10/2025 10:34AM to 12:15PM 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: 11 Number of resident records reviewed: 0 Number of staff records reviewed: 7 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. 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 within five (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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.stokes@dss.virginia.gov
Feb 10, 2025Routine
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: 02/10/2025 10:34AM to 12:15PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 01/03/2025 regarding allegations in the area of: resident care and related services Number of residents present at the facility at the beginning of the inspection: 11 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 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. However, violation(s) not related to the self-report 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.stokes@dss.virginia.gov
Based on resident record review and staff interview, the facility failed to ensure the fall risk rating shall be reviewed and updated at least annually, when the condition of the resident changes and after a fall. EVIDENCE: 1. The uniform assessment instrument ( UAI
Based on resident record review and staff interview, the facility failed to ensure to notify the next of kin, legal representative, designated contact person, or, if applicable, any responsible social agency of any incident of a resident falling from the premises, whether or not it results in injury, shall occur as soon as possible but no later than 24 hours from the time of initial discovery or knowledge of the incident and the resident?s record shall include documentation of the notification, including date, time, caller, and person or agency notified. EVIDENCE: 1. Resident care notes in the record for resident 1 contain documentation that the resident had a fall on 07/21/2024 at 6:30PM, 07/24/2024 at 1:30AM, and on or around 10/11/2024. Interview with staff person 1 revealed that the facility?s communication log contained information that the resident fell in the bathroom on 11/22/2024. 2. Interview with staff person 1 revealed that the resident?s wife would have been the person that staff would have had to notify if the resident had fallen. The record for resident 1 did not contain documentation that the resident?s wife had been contacted regarding the aforementioned falls. Interview with staff person 1 confirmed this was accurate.
Nov 1, 2024Routine12Report
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: 11/01/2024 7:15AM to 12:30PM 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: 11 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: 2 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 4 Observations by licensing inspector: morning medication administration, medication cart audit, breakfast and noon-time meals Additional Comments/Discussion: To ensure the facility has a thorough understanding of the standards, the licensing inspector (LI) and the licensing administrator (LA) had a discussion with the administrator and the director of maintenance regarding standard 22VAC40-73-880-C.1. & 2. To ensure the facility had a thorough understanding of the standards, the LI had a discussion with the director of maintenance regarding standard 22VAC40-73-860-G. 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Based on staff record review and staff interview, the facility failed to ensure when adults with mental impairments reside in the facility, at least four hours of the required 18 hours of annual training for direct care staff shall focus on topics related to residents? mental impairments. EVIDENCE: 1. Interview with staff person 3 revealed there are residents that reside in the facility that have mental impairments. 2. The record for staff person 1, date of hire 11/18/2022, only contains documentation that the staff person had one hour of training that focused on residents? mental impairments during the training year 11/18/2022 to 11/17/2023. Staff person 3 confirmed this is accurate.
Based on staff record review and staff interview, the facility failed to ensure verification that the staff person has received a copy of his current job description was maintained on staff and included in the staff record. EVIDENCE: 1. Interview with staff person 3 revealed that staff person 2 has been a registered medication aide (RMA) since 10/16/2024 and has administered medications to residents at the facility. 2. The record for staff person 2 does not contain documentation of the staff person?s job description or verification that the staff person received a copy of their current job description since becoming an RMA. Interview with staff person 3 confirmed this is accurate.
Based on resident record and staff interview, the facility failed to ensure the fall risk rating shall be reviewed and updated at least annually, when the condition of the resident changes and after a fall. EVIDENCE: 1. The uniform assessment instrument ( UAI
Based on resident record review and staff interview, the facility failed to ensure the uniform assessment instrument ( UAI
Based on resident record review and staff interview, the facility failed to ensure individualized service plans ( ISP
Based on staff record review and staff interview, the facility failed to ensure the rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each staff person and the staff person?s written acknowledgment of having been so informed, which shall include the date of the review and shall be filed in the staff person?s record. EVIDENCE: Interview with staff person 3 revealed that staff person 1 reviewed the rights and responsibilities of residents in July 2024; however, the staff person did not sign and date that she attended the review and was not filed in the staff person?s record.
Based on resident record review and staff record review, the facility failed to ensure when staff administers medications to residents, each staff person who administers medication shall be authorized by 54.1-3408 of the Virginia Drug Control Act and all staff responsible for medication administration shall be licensed by the Commonwealth of Virginia to administer medications or be registered with the Virginia Board of Nursing as a medication aide. EVIDENCE: 1. The Virginia Department of Health Professions License Lookup website indicates staff person 2?s registered medication aide (RMA) initial license date is 10/16/2024; however, October 2024 medication administration records ( MAR
Based on resident record review and staff interview, the facility failed to ensure medications ordered for PRN
Based on resident record review and staff interview, the facility failed to ensure action taken in response to the recommendations of the medication review shall be documented in the resident?s record. EVIDENCE: 1. The facility?s most recent medication review conducted on 06/06/2024, contains a recommendation for residents 1, 2 and 3. 2. Interview with staff person 3 revealed that the recommendations for residents 1, 2 and 3 had been sent to the residents? physician; however, staff person 3 has not received a response back from the physicians regarding the recommendations for residents 1, 2 and 3.
Based on staff interview, the facility failed to ensure by December 1, 2020 an assisted living facility that is not equipped with an outside emergency generator shall enter into an agreement with a vendor capable of providing the facility with an emergency generator for the provision of electricity during an interruption of the normal electric power supply and enter into at least one agreement with a separate vendor capable of providing an emergency generator in the event that the primary vendor is unable to comply with its agreement with the facility during an emergency. EVIDENCE: 1. Interviews with staff persons 3 and 4 verified that the facility does not have an onsite emergency generator. 2. During on-site inspection, staff person 3 was unable to provide to the licensing inspector (LI) evidence of an agreement with a vendor capable of providing the facility with an emergency generator for the provision of electricity during an interruption of the normal electric power supply. Staff person 3 was also unable to provide to the LI evidence of at least one agreement with a separate vendor capable of providing an emergency generator if the primary vendor is unable to comply with its agreement with the facility during an emergency.
Based on facility documentation review and staff interview, the facility failed to ensure the semi-annual review on the facility?s emergency preparedness and response plan for residents shall be documented by signing and dating. EVIDENCE: Residents reviewed the facility?s emergency preparedness and response plan on 09/14/2024; however, interview with staff person 3 revealed that residents did not sign and date that they had completed the review.
Based on observation during a walkthrough of the facility, the facility failed to ensure the findings of the most recent inspection of the facility was posted on the premises. EVIDENCE: The most recent inspection completed at the facility was on 08/05/2024; however, during the walkthrough of the facility, it was noted by the licensing inspector that the inspection posted was from 10/24/2023.
Aug 5, 2024Routine
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: 08/05/2024 9:28AM until 12:30PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 07/19/2024 and 08/02/2024 regarding allegations in the area of: admission, retention and discharge of residents Number of residents present at the facility at the beginning of the inspection: 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 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-report 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Based on resident record review and staff interview, in accordance with ? 63.2-1805 D, assisted living facilities shall not admit or retain individuals with dermal ulcers III and IV except those stage III ulcers that are determined by an independent physician to be healing. EVIDENCE: 1. Resident 1 was admitted to the facility on 06/21/2024 with an unstageable wound on his right great toe and a stage II sacrum wound. 2. The record for resident 1 contains documentation by Collateral 1, dated 07/10/2024, that the resident has a decubitus butt pressure ulcer that is stage three located on his gluteal cleft. 3. The record for resident 1 contains documentation that the resident was sent from the facility to the hospital on 07/18/2024 and was hospitalized from 07/18/2024 through 07/23/2024. Hospital discharge documentation, dated 07/23/2024, indicates that the resident presented to the emergency room on 07/18/2024 and during admission underwent excisional debridement of necrotic skin, subcutaneous tissue and muscle of the sacrum and that the resident has a stage IV sacrum wound. The hospital discharge documentation also states that the resident is to discharge to a skilled nursing facility. 4. The licensing inspector (LI) received a phone call from staff person 1 on 08/02/2024 that the resident was brought back to the facility on 07/23/2024 by medical transport from the hospital. Staff person 1 stated that the facility was not aware that resident 1 had a stage IV sacrum wound until the facility reviewed the resident?s hospital discharge paperwork after the resident was already readmitted to the facility. 5. The record for resident 1 contains a document, ?wound care assessment and treatment? dated 07/26/2024, by Collateral 1, that indicates the resident has a stage III pressure ulcer on his right great toe and a stage IV sacrum decubitus wound.
Based on resident record review, the facility failed to ensure within the 30 days preceding admission, a person shall have a physical examination by an independent physician that shall be on file at the assisted living facility and shall contain a statement that specifies whether the individual is or is not capable of self-administering medication and if the individual requires continuous licensed nursing care. EVIDENCE: The admission/retention report of physical examination for resident 1, dated 06/18/2024, does not contain documentation on whether the resident is or is not capable of self-administering medication and if the resident requires continuous licensed nursing care.
Based on resident record review, the facility failed to ensure the individualized service plan ( ISP
Based on resident record review and staff interview, the facility failed to ensure medications shall be administered in accordance with the physician?s or other prescriber?s instructions. EVIDENCE: 1. The record for resident 1 contains a signed physician?s order, dated 06/20/2024, for Ure-NA oral packet 15GM give one packet by mouth two times a day for hyponatremia. 2. The June 2024 medication administration record ( MAR
Based on resident record review and staff interview, the facility failed to ensure medical procedures ordered by a physician or other prescriber shall be provided according to his instructions and documented. EVIDENCE: 1. The record for resident 1 contains a physician?s order, dated 07/11/2024, that if the resident?s blood sugar is less than 60 to give the resident orange juice and recheck the resident?s blood sugar after 20 minutes and for the resident?s physician to be contacted. 2. The July 2024 MAR
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