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Public Google reviewers rate Spring Arbor of Leesburg highly. Reviewers highlight: compassionate and professional leadership, engaging resident activities and programs. Reviewer identity is not verified, and online reviews may not capture everything. Schedule a visit to assess the fit directly.
Spring Arbor of Leesburg is highly regarded by many families and professionals for its compassionate leadership and engaging community programs. While many reviewers praise the attentive staff and clean environment, there are serious, documented concerns regarding delayed response times to call bells and staffing shortages during night shifts.
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Key Review Excerpts
“The staff of Spring Arbor to be AMAZING! They encouraged and assisted the residents as they connected the LEGO bricks together and cheered every model they created.”
“The care givers do special things for the residents- like a cup of coffee in the morning, wraps for leg edema, walks and talks outdoors, and Susan B. even cut hair when needed during the pandemic.”
“They have terrible staffing issues here, takes a long time for nurses to come after call button has been pushed. My family member had a fall in the middle of the night, they tended to them, and then no one came and checked on them for hours!!”
Source: VA State Licensing Agency
Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 12/29/2025 regarding allegations in the area(s) of: 1. Staffing and Supervision 2. Resident Care and Related Services 3. Resident Accommodations and Related Provisions Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 01/21/2026 12:20 PM to 5:00 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 87 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: 0 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 5 Observations by licensing inspector: Resident rooms Additional Comments/Discussion: Additional staff interviews may be attempted off-site. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the complaint of non-compliance with standard(s) or law, and violation(s) were 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 Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov Should you have any questions, please contact Amanda ?AJ? Velasco, Licensing Inspector at (703) 397 4587 or by email at amanda.velasco@dss.virginia.gov.
Based on facility document review and staff interview, the facility failed to ensure a written plan for medication management was kept current, implemented, and addressed procedures for administering medication including required components. Evidence: 1. The LI requested a copy of the Medication Management Plan (MMP). 2. In an interview with the LI on 01/21/2026, Staff 1 confirmed that the MMP had not changed since the last time it was submitted. The LI pulled up the most recent copy, and Staff 1 confirmed that was the current MMP. 3. Resident 1?s record contains an order, dated 09/24/2025, for CBD 5.91 MG/THC 5.91 MG tablets that states to take one tablet by mouth twice a day. 4. Resident 1?s Medication Administration Record ( MAR
Based on resident record review and staff interview, the facility failed to ensure care provision and service delivery was resident centered and included resident participation in decisions, personalization of care and services, and prompt response to resident needs. Evidence: 1. During a resident interview with the LI on 01/21/2026, the resident stated that they frequently having to wait for care after pushing their call bell pendent. The resident also stated that sometimes during incontinent care, they respond quickly but then will leave the resident on the toilet for long periods of time. 2. In an interview with the LI on 01/21/2026, Staff 6 confirmed an incident where Staff 4 turned off the call bell without notifying another staff member of Resident 1?s need of assistance. Though Staff 5 was unable to provide the date of that incident, Staff 6 stated staff are to respond to call bells within five (5) minutes. 3. In an interview with the LI on 01/21/2026, Staff 1 stated that there was not a policy for expected time to answer resident?s call bells. 4. The call bell records for Resident 1 were reviewed for November and December of 2025. There were 44 instances where Resident 1 had to wait over 15 minutes. Of those instances, the longest wait time was approximately five hours on 12/17/2025.
Based on facility document review and staff interview, the facility failed to ensure a written staffing plan was maintained that specifies the number and type of direct care staff required to meet the day-to-day, routine direct care needs and any identified special needs. Evidence: 1. On 01/21/2026, the LI requested a copy of the facility?s written staffing plan. 2. Staff 1 provided a copy of the disclosure statement and the ?Team Member Staffing Policy? which did not have a specific number and type of staff. 3. In an interview with the LI on 01/21/2026, Staff 1 stated that they did not have a written staffing plan that specifies the number and type of direct care staff required to meet the day-to-day, routine direct care needs and any identified special needs.
Based on staff record review and staff interview, the facility failed to ensure there was 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. Evidence: 1. In an interview with the LI on 01/26/2026, Staff 1 stated that the facility requires four (4) direct care staff on the morning and evening shift, and three (3) direct care staff overnight. Staff 3 stated that this does not include registered medication aides, who will provide care if not passing medication. 2. On 01/21/2026, the LI requested a copy of the direct care staff schedules and daily shift assignments for the assisted living unit at the facility. 3. The direct care staff schedules and daily shift assignments indicate that there was not enough staff on the following dates: a. 11/17/2025, 7:00 AM to 3:00 PM ? three (3) direct care staff on site. b. 12/09/2025, 3:00 PM to 11:00 PM - three (3) direct care staff on site. c. 12/25/2025, 7:00 AM to 3:00 PM - three (3) direct care staff on site. d. 12/26/2025, 3:00 PM to 11:00 PM - three (3) direct care staff on site, 11:00 PM to 7:00 AM - two (2) direct care staff on site. e. 12/31/2025, 3:00 PM to 11:00 PM - three (3) direct care staff on site. 4. In an interview with the LI on 01/26/2025, Resident 3 stated that there are not enough staff which results in frequently having to wait for care. 5. In an interview with the LI on 01/26/2025, Staff 1 stated that despite the facility schedules to adhere to the needs of residents that there are times where the facility identified number of required staff cannot be met due to staff call outs.
Based on resident record review and staff interview, the facility failed to ensure a medication, dietary supplement, diet, medical procedure, or treatment had a valid order from a physician or prescriber to be started, changed, or discontinued by the facility. Evidence: 1. Resident 1?s record contains an order, dated 09/24/2025, for CBD 5.91 MG/THC 5.91 MG tablets that states to take one tablet by mouth twice a day. 2. Resident 1?s Medication Administration Record ( MAR
Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 12/12/2025 regarding allegations in the area(s) of: 1. Admission, Retention, and Discharge of Residents Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/16/2025 8:50 AM to 11:25 AM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 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: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: Resident Rooms/ Cafe Area/ Exercise Activities Additional Comments/Discussion: One resident was sleeping at time of inspection and unable to be interviewed. 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 Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Based on resident record review and staff interview, the facility failed to obtain a detailed medication order including the symptoms that indicate the use of a medication when PRN
Based on resident record review and staff interviews, the facility failed to ensure medication was administered per physician orders. Evidence: 1. Resident 2?s record contains a PRN
Type of inspection: Monitoring A self-reported incident was received by VDSS Division of Licensing on 11/25/2025 regarding allegations in the area(s) of: 1. 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: 12:00 PM to 1:55 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 87 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: 4 Observations by licensing inspector: Elopement Area Additional Comments/Discussion: N/A 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 Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Based on resident record review and staff interview, the facility failed to ensure all required documentation is collected, including the type and frequency of services provided and documentation of these services on the ISP
Based upon record review and staff interview, the facility failed to ensure supervision of specialized needs such as wandering from the premises. Evidence: 1. On 11/25/2025, the facility self-reported an incident in which Resident 1 wandered from the premises on 11/24/2025 while on a daily walk around the building. 2. In an interview with the LI on 12/09/2025, Staff 4 stated that they observed Resident 1 walking away from the building, dressed warm, towards Old Waterford Road. When Resident 1 continued off the premises of the facility, Staff 4 then drove to the pond approximately 0.2 miles away and redirected Resident 1 back to the building. Staff 4 stated that Resident 1 was apologetic. 3. Upon a review of Resident 1?s progress notes, Resident 1 eloped, or attempted to elope, on four dates - 08/25/2025, 11/24/2025, 11/19/2025, and 12/01/2025. 4. In a progress note, dated 08/04/2025, Resident 1 was described as high risk for elopement. Resident 1?s UAI
Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 11/24/2025 regarding allegations in the area(s) of: 1. Resident Care and Related Services 2. Resident Accommodations and Related Provisions Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/09/2025 10:25 AM to 12:00 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 87 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: 4 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: N/A Additional Comments/Discussion: Resident no longer resides at facility, unable to be interviewed. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the complaint of non-compliance with standard(s) or law, and violation(s) were 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 Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@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 of the required hours of training shall focus on topics related to residents' mental impairments. Evidence: 1. In an interview with the LI on 12/09/2025, Staff 1 and Staff 2 stated that the facility served residents with cognitive impairments such as dementia. 2. Staff 6, hired on 08/31/2024, was employed as a licensed medication aide at the facility. Staff 6?s record contained two hours of training on cognitive impairments from August of 2024 to August of 2025. 3. Staff 7, hired on 09/26/2024, was employed as a licensed direct care staff at the facility. Staff 7?s record contained .25 hours of training in cognitive impairments from September of 2024 to September of 2025.
Based on resident record review and staff interview, the facility failed to ensure all required documentation is collected, including a criminal record report, TB screening, and the type and frequency of services provided and documentation of these services on the ISP
Based on resident record review and staff interview, the facility failed to ensure Any resident who does not have a serious cognitive impairment shall be allowed to freely leave the facility. Evidence: 1. Resident 1 was admitted to the facility on 11/05/2025. Resident 1 resided on the assisted living unit and did not have serious cognitive impairment. 2. Resident 1?s progress notes, dated 11/19/2025 through 11/26/2025, state that on 11/23/2025, Resident 1 attempted to leave the facility and was returned by staff. The progress notes state that Resident 1 was placed in the cottage during the day on 11/24/2025, 11/25/2025, and 11/26/2025. 3. In an interview with the LI on 12/09/2025, Staff 1, Staff 2, and Staff 3 stated that Resident 1 was taken over to the safe, secure unit, called the Cottage, from the assisted living unit. Staff 1 and Staff 2 confirmed that Resident 1?s freedom of movement was restricted.
Based on resident record review and staff interview, the facility failed to ensure not admit an individual before a determination has been made that the facility can meet the needs of the individual. Evidence: 1. Resident 1?s record indicated that a mental health screening or evaluation was needed. 2. Resident 1 was admitted on 11/05/2025, without the required mental health screening. 3. In an interview with the LI on 12/09/2025, Staff 1 and Staff 2 confirmed that Resident 1 was admitted to the facility prior to completion of a mental health screening.
Based on staff record review and staff interview, the facility failed to ensure all direct care staff shall attend at least 18 hours of training annually in a facility licensed for both residential and assisted living care. Evidence: 1. Staff 5 were hired on 06/27/2012, as an unlicensed direct care staff. 2. Staff 5?s annual training for 06/27/2024 through 06/27/2025 was reviewed and contained 8 hours. 3. In an interview with the LI on 12/09/2025, Staff 1 and Staff 2 confirmed that Staff 5 did not have the required annual training hours from June of 2024 to June of 2025.
Based on resident record review and staff interview, the facility failed to ensure a mental health screening be conducted prior to admission if behaviors or patterns of behavior occurred within the previous six months that were indicative of mental illness, intellectual disability, substance abuse, or behavioral disorders and that caused, or continue to cause, concern for the health, safety, or welfare either of that individual or others who could be placed at risk of harm by that individual. Evidence: 1. Resident 1 was admitted to the facility on 11/05/2025. 2. Resident 1?s record contained a Physical Examination Report, dated 10/29/2025, that stated a psychiatric evaluation and oversight was needed. 3. Resident 1?s record contained a UAI
Type of inspection: Renewal Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/18/2025 9:15 AM to 3:15 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 87 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 4 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 6 Observations by licensing inspector: Medication Pass (Safe, Secure Unit), Medication Cart Audit (Safe, Secure Unit), Activities on AL and Safe, Secure Units, Meals on AL and Safe, Secure Units, Kitchen. Additional Comments/Discussion: Medication pass was attempted twice but residents were unavailable at time of observation. 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 Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Based on direct observation and staff interview, the facility failed to ensure that cleaning products and other hazardous materials were stored in locked areas. Evidence: 1. During a tour of the facility with Staff 1 on 11/18/2025, the LI observed the following: a. Unlocked buffet cabinet outside of Room 226 containing two spray bottles containing cleaning solution and cleaning wipes b. Unlocked cabinet in the general store area containing cleaning wipes c. Maintenance office containing tools and cleaning supplies was unlocked with the door propped open and nobody inside d. Mechanical Closet in the activities room contained two spray bottles with cleaning solution 2. During the tour, Staff 1 confirmed the items above were not in locked areas. 3. Photo evidence obtained.
Based on resident record review, facility document review, and staff interview, the facility failed to ensure that the medication management plan contained all required components and was implemented. Evidence: 1. Staff 1 provided a copy of the Medication Management Plan. The medication management plan states the following under Ordering and Disposing of Medication, ?The contracted pharmacy will provide guidelines for ordering and disposing of medications?? 2. In an interview with the LI on 11/18/2025, Staff 8 stated all orders are supposed to be stamped, faxed to the pharmacy to be filled, and entered into the electronic medication administration record once the medication is received. 3. Resident 7?s record contained a physician order, signed 10/20/2025, that stated ?Decrease Tylenol to 650 MG PO TID.? Resident 1?s record contained a signed order from 09/29/2025 with the original dose of 1000MG. 4. Resident 7?s Medication Administration Record ( MAR
Based on resident record review and staff interview, the facility failed to ensure the disclosure statement was on the form developed by the department. Evidence: 1. The following resident records contained disclosure statements utilizing the outdated department disclosure statement: a. Resident 3, admitted 02/13/2025 b. Resident 1. admitted 08/28/2025 c. Resident 4, admitted 10/23/2025 d. Resident 6, admitted 10/30/2025 2. In an interview with the LI on 11/18/2025, Staff 1 confirmed the disclosure statement was not on the current department disclosure statement form.
Based on resident record review, direct observation, and staff interview, the facility failed to ensure medication was administered per the physician or prescriber orders. Evidence: 1. During a medication cart audit on 11/18/2025, the LI observed a bubble pack of Tylenol 500 MG caplets (two in each bubble) for Resident 7. 2. Resident 7?s record contained a physician order, signed 10/20/2025, that stated ?Decrease Tylenol to 650 MG PO TID.? Resident 7?s record contained a signed order from 09/29/2025 with the original dose of 1000MG. 3. Resident 7?s Medication Administration Record, MAR
Based on facility document review and staff interview, the facility failed to ensure that a semi-annual review of the emergency preparedness plan was conducted for all staff, residents, and volunteers. Evidence: 1. After a review of the staff semi-annual emergency preparedness plan review conducted for staff, the LI requested a copy of the review done with residents. 2. In an interview with the LI on 11/218/2025 Staff 1 stated that it is reviewed with residents during resident council but confirmed that not all residents attend and sign off of the emergency preparedness plan is not required for residents.
Type of inspection: Monitoring A self-reported incident was received by VDSS Division of Licensing on 08/26/2026 regarding allegations in the area(s) of: 1. Resident Accommodations and Related Services Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/10/2025 12:10 PM to 1:05 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 86 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: N/A Additional Comments/Discussion: Resident not in facility at time of inspection. 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-reported incident 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 Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Based on resident record review and staff interview, the facility failed to ensure that medical procedures or treatment orders were administered in accordance with physician or prescriber?s orders. Evidence: 1. On 08/26/2025, the LI received a self-reported incident regarding Resident 1 being sent out due to altered behavior, including not being able to ambulate at Resident 1?s baseline and a decreased appetite. The incident report states that Resident was diagnosed with a UTI, Anemia, and a pelvic compression fracture. 2. During a review of Resident 1?s record, an order for blood work was dated on 08/13/2025 for diuresis. The results of lab were not in Resident 1?s record. 3. During an interview with the LI on 09/102025, Staff 2 stated that the lab came at an inconvenient time for Resident 1 on two dates (08/17/2025 and 08/21/2025) and did not show up on a third date (08/23/2025). Staff 2 confirmed that the orders were not completed as ordered.
Type of inspection: Monitoring A self-reported incident was received by VDSS Division of Licensing on 08/26/2025 regarding allegations in the area(s) of: 1. Resident Accommodations and Related Services Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/10/2025 10:35 AM to 12:10 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 86 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: N/A Additional Comments/Discussion: Resident not in facility at time of inspection. 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 Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Based on resident record review and staff interview, the facility failed to ensure that the resident was assessed to have a serious cognitive impairment prior to admission to a safe, secure unit. Evidence: 1. Resident 1?s record contains a Review of Appropriateness of Continued Residence in Special Care Unit that lists the Residents date of placement as 03/29/2025. 2. Resident 1?s Assessment of Serious Cognitive Impairment was dated 04/08/2025. 3. In an interview with the LI on 09/102025, Staff 2 confirmed that Resident 1 transferred to the safe, secure unit on 03/29/2025 due to a change in condition prior to being assessed on 04/08/2025.
Based on staff interview, the facility failed to ensure that for each resident with an inability to use the signaling device, rounds were documented including the name of the resident, the date and time of the rounds, and the staff member who made the rounds. Evidence: 1. Resident 1?s Individualized Service Plan, ISP
Based on resident record review and staff interview, the facility failed to ensure that the fall risk rating was reviewed and updated after a fall. Evidence: 1. On 08/26/2025, LI received an incident report documenting an injury of unknown origin for Resident 1 that was possibly related to a fall that occurred on 08/23/2025. 2. Resident 1?s record contains an emergency room after visit summary that stated the resident was seen on 05/07/2025 due to a fall. 3. Resident 1?s record contained a fall risk assessment that was last completed 03/26/2025. 4. In an interview with the LI on 09/10/2025, Staff 2 confirmed that Resident 1?s fall risk was not updated after the 05/07/2025 fall.
Based on resident record review and staff interview, the facility failed to ensure that medical attention was secured immediately when the resident suffers a serious accident, injury, illness, or medical condition, or there is reason to suspect such has occurred. Evidence: 1. On 08/26/2025, the facility submitted an incident report regarding Resident 1?s change in status including wincing, showing pain symptoms, and an inability to walk without assistance on 08/25/2025. The report states that the resident was sent with emergency medical services which revealed R and L pelvic fractures. 2. Resident 1?s progress notes indicate that Resident 1 was found on the floor on 08/23/2025 at 10:41 PM. The next progress note, dated 08/24/2025 at 3:00 PM states that Resident 1 was complaining of pain, walking very slowly, and had a decreased appetite. 3. Resident 1?s record contained a Nurse Practitioner?s note, dated 08/25/2025, that stated Resident 1 was being seen due to an unwitnessed fall that occurred on Saturday, 08/23/2025. The note states further that no visible injuries were seen, however, as the day went on Resident 1 was having increasing pain and was limping. The note states that by Monday, 08/25/2025, morning, Resident 1 was unable to walk. 4. In an interview with the LI on 09/10/2025, Staff 2 confirmed that medical attention was not secured immediately when Resident 1 was suspected of having a serious injury.
Type of inspection: Monitoring A self-reported incident was received by VDSS Division of Licensing on 09/06/2025 regarding allegations in the area(s) of: 1. Resident Accommodations and Related Services Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/10/2025 1:05 PM to 2:20 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 86 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: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: Safe, Secure Unit. Additional Comments/Discussion: Two of three residents were sleeping at time of inspection. 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 Amanda Velasco, Licensing Inspector at (703) 397-4587 or by email at Amanda.Velasco@dss.virginia.gov
Based on resident record review, staff record review, and staff interview, the facility failed to ensure that all staff were considerate and respectful of the rights, dignity, and sensitivities of persons who are aged, inform, or who have disabilities. Evidence: 1. On 09/06/2025, the LI received an incident report documenting a possible abuse allegation between Staff 4 and Resident 1, Resident 2, and Resident 3. The report indicates that Staff 4 was terminated for misconduct. 2. In an interview with the LI on 09/10/2025, Staff 2 shared that on 09/02/2025, Staff 7 reported a verbal altercation that occurred between Staff 4, Staff 5, Staff 6, and Staff 7 on 09/01/2025 in the room of Resident 3 while performing care. Staff 1 stated that while interviewing Staff 4, Staff 5, and Staff 6 about the verbal altercation over the next few days, two additional incidents that occurred on the night shift of 09/03/2025 into 09/04/2025. One incident was that Staff 4 pulled the leg of Resident 1. The second incident was that Staff 4 called Resident 2 an idiot. 3. Written Statements from Staff 4, Staff 5, Staff 6, and Staff 7 were reviewed regarding the incident between Staff 4 and Resident 3. Staff 5, Staff 6, and Staff 7 all maintain that a verbal altercation included name-calling, raised voices, and possible threats toward other staff members occurred while providing care to Resident 3. 4. Written Statements from Staff 4, Staff 5, Staff 6, and Staff 7 were reviewed regarding the incident between Staff 4 and Resident 1. Staff 5?s statement directly alleges rough handling of Resident 1. Staff 7?s statement alleges a general aggressive behavior from Staff 4 to all staff and residents. Staff 4 stated that they were not rough with any residents. 5. Written Statements from Staff 4, Staff 5, Staff 6, and Staff 7 were reviewed regarding the incident between Staff 4 and Resident 2. Staff 6 and Staff 7 both allege that Staff 4 called Resident 2 a name but differ on if that name was ?stupid? or ?idiot.? Staff 4 stated Staff 4 was talking to themselves, and not Resident 2, as Staff 4 had received an upsetting personal call prior to providing care. 6. In an interview with the LI on 09/10/2025, Staff 1, Staff 2, and Staff 3 acknowledged that during the incidents involving Resident 1, Resident 2, and Resident 3, Staff 4 was not considerate and respectful of the rights and sensitivities of residents.
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