The Legacy at North Augusta, INC.
Families consistently rate this highly — reviewers highlight outstanding and caring nursing and support staff. Schedule a visit to confirm the fit.
based on 24 Google reviews
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What this means for your family
This facility is an excellent choice for families prioritizing high-quality dining and a warm, social atmosphere for their loved ones. However, because one recent reviewer reported significant issues with management communication and staff conduct, you should specifically ask during your tour how the facility handles grievances and how they ensure consistent communication between staff and families.
Google Reviews
Google Reviews
24 reviews on Google“The Legacy at North Augusta is highly regarded by many families for its exceptionally kind, professional, and attentive staff and its high-quality dining services. While most reviewers praise the warm, home-like environment and engaging activities, one recent reviewer raised serious concerns regarding staff conduct and a lack of communication from management during a difficult transition.”
Quality Themes
Tap a score for detailsStrengths
- Outstanding and caring nursing and support staff
- High-quality, nutritious dining services
- Engaging resident activities and social events
- Beautiful, clean, and well-maintained facility
- Welcoming and knowledgeable admissions process
Concerns
- Lack of management communication and perceived staff misconduct
Rating Trends
Tap a year to see what changed
Distribution · 24 analyzed
How They Respond to Reviews
This facility rarely responds to reviews.
Questions for Your Tour
- 1We've heard wonderful things about the dining services here; could you tell us more about how the menus are planned to ensure they stay nutritious and varied?
- 2Since the facility is memory care certified, what specific types of engaging social events and daily activities are available to keep residents active and connected?
- 3How does the management team ensure consistent communication with families regarding any changes in a resident's care or facility updates?
- 4In the event of a medical emergency during the night, what is the protocol for getting immediate care and notifying the family?
- 5We noticed the facility is very well-maintained; how often are the common areas and resident rooms deep-cleaned to ensure a comfortable environment?
- 6What steps are in place to ensure that the high standard of care provided by your nursing staff remains consistent across all shifts?
Personalized based on this facility's data
Key Review Excerpts
“The current team at the Legacy is outstanding. Beth, Dan, Chris, Gabby, Neable, Lindsay, Kelly, Mary, Sarah-- the list of excellent people working at the top of their game goes on and on.”
“The apartments are a spacious. Staff is friendly and take care of my aunt wonderfully. Food is amazing!!!”
“Communication with everyone is effortless regarding appointments, short term dietary changes, and her everyday wellbeing.”
State Inspection History
State Inspections
Source: VA State Licensing Agency
Dec 3, 2025Routine
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: 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: 12/3/2025 from 1:09 p.m. until 2:10 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 100 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: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Licensing inspector reviewed resident Medication Administration Record, physician orders, and Registered Medication Aid employee file. 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 administer medications in accordance with the physician's or other prescriber?s instructions. Evidence: 1. The regional licensing office received a self-reported incident on 11/25/2025 indicating that on 11/25/2025 staff 3 had administered medications for resident 2 to resident 1, which included donepezil 10 mg, Allegra 60 mg, venlafaxine 37.5 mg, vitamin D3 50 mg, Azo 95 mg, and fluticasone 50 mg nasal spray. 2. Review of the medication administration record ( MAR
Sep 23, 2025Routine
Type of inspection: Renewal Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 9/23/2025 9:00 a.m. ? 2:30 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: 96 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: The Licensing Inspector observed the residents during activities and meals. The Licensing Inspector reviewed the following at the time of inspection: fire drills, emergency drills, resident council reports, pharmacy review, healthcare oversight, menus, activity calendars 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. 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 ensure prior to admitting a resident with a serious cognitive impairment to a safe, secure environment, the licensee, administrator, or designee determination and justification for the decision was in writing and retained in the resident's file. Evidence: 1. Resident 1 (admitted 8/27/2025), resident 4 (admitted 7/10/2025), and resident 6 (admitted 3/28/2025) resided in the safe, secure, environment. 2. Record reviews for residents 1, 4, and 6, did not contain a written determination or justification for placement in the secure environment by the administrator. 3. Upon request, the facility did not provide a written determination or justification for placement in the secure environment by the administrator for residents 1, 4, or 6. 4. During an interview with staff 1, when asked if there was a written determination or justification for placement in the secure environment by the administrator for residents 1, 4, or 6, staff 1 stated ?I have never done that.?
Based on direct observation and staff interview, the facility failed to ensure all resident records are kept in a locked area. Evidence: 1. During the facility tour on 9/23/2025 with staff 2, the third-floor case base door was left open with no staff present. Inside of the door were 2 separate rooms with both doors unlocked and open with resident records in an unlocked cabinet. 2. During an interview with staff 2 when asked if the door was usually left open staff 2 stated ?no, I?m not sure why it is open?. 3. Photo evidence taken.
Based on record review, the facility failed to ensure that at the time medication was administered it was documented on the medication administration record ( MAR
Based on record review and staff interview, the facility failed to ensure that the Do Not Resuscitate (DNR) Orders for withholding cardiopulmonary resuscitation (CPR) from a resident in the event of cardiac or respiratory arrest were included on the individualized service plan ( ISP
Based on direct observation and staff interview, the facility failed to store cleaning supplies in a locked area. Evidence: 1. During the facility tour on 9/23/2025 with staff 2, the third-floor case base door was left open with no staff present. Inside of the door was a shelf containing a container of Sani-Cloths and a spray bottle of rapid multi surface disinfectant cleaner. 2. During an interview with staff 2 when asked if the door to the care base was usually left open staff 2 stated ?no, I?m not sure why it is open?. 3. Photo evidence taken.
Sep 23, 2025Complaint
Type of inspection: Complaint A complaint was received by VDSS Division of Licensing on 9/19/2025 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: 9/23/2025 3:00 p.m. ? 4:15 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: 96 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: 3 Observations by licensing inspector: The licensing inspector reviewed incident reports, staff communication, the staff schedule, and medication administration records. Additional Comments/Discussion: None 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: 680-D 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 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 provide treatments as ordered by a physician or other prescriber instructions. Evidence: 1.A complaint was received by the regional licensing office alleging that resident 1 did not receive their blood glucose monitoring for nine days. 2.Resident 1 (admitted 2/14/2024) had a physician?s order dated 9/24/2025 for True Metrix Blood Glucose Test In vitro strip, with instructions stating one strip in vitro one time a day every two days for DM and one strip in vitro at bedtime every two days. 3.On 11/21/2024 the test strips were switched from pharmacy order to an outside supplier, and the order was discontinued. 4.On 11/30/2025 the facility realized that when the order for the test strips were discontinued there was no other order in the medication administration record to test the blood glucose level. On 11/30/2025 a new physicians order was written for blood sugar check one time a day every two days for diabetes. 5.There were a total of nine days where the blood glucose level was not checked by the facility. 6. During an interview with staff 2, when asked if the blood sugar was monitored during from 11/21/2025 when the physicians order was discontinued and 11/30/2025 when the physicians order was rewritten, staff 2 stated ?no it wasn?t?.
Sep 23, 2025Routine
Type of inspection: Monitoring A self-reported incident was received by VDSS Division of Licensing on 9/15/2025 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: 9/23/2025 2:30 p.m. ? 3:00 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: 96 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 reviewed medication administration records, staff communication, nurse?s notes, the staff schedule and incident reports. 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 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 ensure medications were administered in accordance with the physician's or other prescriber?s instructions. Evidence: 1. A self reported incident was received by the regional licensing office on 9/15/2025 stating that resident 1 (admitted 7/10/2025) received an incorrect dose of their medication. 2. Record review for resident 1 on 9/23/2025 indicated that resident 1 had a physicians order dated 8/20/2025 for Hydrocodone - acetaminophen tablet, to take one tablet by mouth three times a day at 9:00 a.m., 1:00 p.m., and 8:00 p.m. for pain. 3. On 8/26/2025 staff 3 did not administer the 9:00 a.m. dose of Hydrocodone ? acetaminophen within the scheduled time frame, and administered both the 9:00 a.m. dose and 1:00 p.m. together at 11:00 a.m. 4. During an interview with staff 1, when asked if the medication was administered in accordance with physicians order staff 1 stated ?no?.
Jun 17, 2025Routine
Type of inspection: Monitoring A self-reported incident was received by VDSS Division of Licensing on 6/3/2025 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: 6/17/2025 8:30 a.m. ? 10:19 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: 88 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: 1 Observations by licensing inspector: The licensing inspector reviewed incident notes, staff communication, and staff training. 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 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 ensure the comprehensive individualized service plan ( ISP
Based on record review and staff interview, the facility failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs, such as wandering from the premises. Evidence: 1. On 6/3/2025, the regional licensing office received a self-reported incident from the facility stating resident 1 (admitted 5/5/2025), a resident residing in the special care unit with a diagnosis of a serious cognitive impairment wandered from the facility to a neighboring street. 2. During an interview with staff 1, when asked how resident 1 was able to exit the locked special care unit staff 1 stated that staff 2 assisted the resident out of the special care unit to the front porch and then proceeded to clock out of work for the day an not notify any of the staff resident 1 was on the front porch unattended. 3. Resident 1 was unsupervised on the front porch from 4:11 p.m. until 4:43 p.m. when the facility was alerted by a family member that the resident 1 was on the street and the resident was returned to the facility without incident at 4:54 p.m. 4. The resident walked approximately 0.2 miles according to Google Maps, from the facility to the intersection of the main road of North Augusta Street and Edgewood Road. 5. Weather conditions on 6/3/2025 for Staunton, VA at 4:30 p.m. listed the condition as fair with the temperature at 80 degrees.
Apr 22, 2025Routine
Type of inspection: Monitoring A self-reported incident was received by VDSS Division of Licensing on 4/8/2025 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: 4/22/2025 9:00 am ? 9:50 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: 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: 2 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 (LI), reviewed Medication Administration Records and communication. 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.
Based on record review and staff interview, the facility failed to administer medications in accordance with physicians or other prescriber?s instructions. Evidence: 1. A self-report was received by the Regional Licensing Office on 4/8/2025 alleging that resident 1 had received incorrect medications. 2. Record review for resident 1 indicated that on 3/8/2025 at 9:40am resident 1 was ordered to receive the following medications and did not; Furosemide 40mg, Metoprolol ER 100mg, Potassium ER 10MEq two capsules, and Spironolactone 25mg ? tablet. 3. Record review for resident 1 indicated that resident 1 did receive resident 2?s medications including ASA 81mg, Eliquis 5mg, Iron 325mg, HCTZ 12.5mg, Metformin 500mg, Glimepiride 1mg, Metoprolol ER 50mg, Mirabegron ER 25 mg, Senna 8.6mg two tablets, and Venlafaxine ER 150mg. 4. During an interview with staff 1, when asked if resident 1 received their scheduled medications as ordered on 4/8/2025, staff 1 stated ?no, only the Tylenol?, when asked what medications resident 1 received, staff 1 stated resident 1 received resident 2?s medications.
Jan 22, 2025ComplaintCleanReport
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 1/22/2025 12:00pm-1:20pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 1/14/2025 regarding allegations in the area(s) of: Resident care and related services and building and grounds. 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: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: The licensing inspector toured the kitchen and dining room as well as resident areas. 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 allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jessica Gale, Licensing Inspector at 540-571-0358 or by email at Jessica.gale@dss.virginia.gov
Nov 6, 2024Routine
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: 11/06/2024 9:05am-3:33pm, 11/07/2024 10:00am-12:45pm 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: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: The Licensing Inspector observed the residents during activities, meals and in their apartments. The following were reviewed at the time of inspection: Menus, activity calendars, fire drills, emergency drills, resident council minutes, dietician report, healthcare oversight. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact 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 ensure that prior to admitting a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia to a safe, secure environment, the licensee, administrator, or designee provided in writing that placement in the special care unit is appropriate and retained in the resident file. Evidence: 1. Resident 1, admitted 6/27/2024, resides in the secure environment within the facility. Following record review for resident 1 on 11/6/2024, the written appropriateness for placement was not contained in the resident record. 2. Resident 3, admitted 2/23/2024, resides in the secure environment within the facility. Following record review for resident 3 on 11/6/2024, the written appropriateness for placement was not contained in the resident record. 3. During an interview with staff 1 on 11/6/2024, staff 1 confirmed that the written appropriateness for placement was not completed prior to placement in the secure environment. Staff 1 stated that there was confusion on the initial written appropriateness for placement and the review of appropriateness for placement that is completed after 6 months of placement in a secure environment.
Based on record review and staff interview, the facility failed to ensure each staff person required to be evaluated annually submit the results of a risk assessment, documenting that the individual is free of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: 1. During record review for staff 4 (Hired 9/18/2023) completed 11/6/2024, the staff record contained only a tuberculosis risk assessment dated 9/18/2023. 2. During an interview with staff 5 on 11/6/2024, staff 5 confirmed that the annual risk assessment had not yet been completed.
Based on direct observation, record review, and staff interview the facility failed to ensure that the ISP
Based on direct observation, record review, and staff interview, the facility failed to obtain a valid physicians order for oxygen therapy. Evidence: 1. During a medication pass observation conducted on 11/7/2024, resident 7, admitted 12/14/2021, was observed with oxygen therapy being provided at 1L via nasal canula by concentrator. 2. During a record review for resident 7 on 11/7/2024, there were no physician orders for oxygen therapy. 3. During an interview with staff 2 on 11/7/2024, when asked to provide the physicians order for oxygen therapy, staff 2 stated that there were no physician orders in the resident record for the oxygen therapy, and that the resident returned from the hospital on 9/20/2024 with the oxygen in place.
Based on record review and staff interview, the facility failed to ensure Do Not Resuscitate (DNR) Orders for withholding cardiopulmonary resuscitation from a resident in the event of cardiac or respiratory arrest are included on the individualized service plan ( ISP
Based on direct observation the facility failed to ensure cleaning supplies and other hazardous materials are stored in a locked area. Evidence: 1. During the facility tour on 11/6/2024, the second-floor resident laundry room had an unlocked cabinet containing a container of laundry detergent, a bottle of resolve, a bottle of hydrogen peroxide, and two bottles of Lysol and a bottle of oxy clean on the counter. The third-floor resident laundry room had an unlocked cabinet containing one jug of bleach, a bottle of disinfectant cleaner, and a bottle of hydrogen peroxide. 2. The third-floor common area bathroom contained a container of Sani-cloths and a bottle of Lysol. 3. The laundry room in the memory care unit had an unlocked closet containing an unlocked housekeeping cart with a can of bathroom cleaner, a bottle of glass cleaner, and a can of furniture polish and a bucket of various cleaners. 4. Photo evidence taken.
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EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.
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