St. Mary's Woods — Virginia Inspection Report

Inspections

On record

With violations

Visits that cited something

Clean visits

Nothing cited

Violations cited

Individual findings

Standards cited

Distinct rules

Complaint visits

Prompted by a complaint

St. Mary's Woods was inspected 9 times between October 15, 2020 and June 8, 2026 by the Virginia Department of Social Services. 3 of those visits ended with violations cited and 6 with none. Across that history VDSS cited 10 violations under 9 distinct standards. 3 inspections were prompted by a complaint.

A violation is a licensing standard - a rule in the Virginia Administrative Code - that the inspector found the facility was not meeting. Each is shown with the evidence the inspector recorded and, where VDSS publishes it, the facility's own plan of correction.

VDSS publishes inspections on a rolling window. 7 of these 9 are still on the state's site; the other 2 have since dropped off it and are reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type

Assisted Living Facility

License type

Two Year

License expires

08/01/2026

Administrator

Jotanya Belton

Licensing inspector

Tyia Venable

Inspector phone

(804) 393-2157

Approved for

Assisted Living · Non-Ambulatory

Inspection History

Select an inspection to read the areas reviewed, the inspector's comments and any violations cited.

June 8, 2026Inspection6 violations

Inspection dates

06/08/2026

Areas reviewed

Comments

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: 6/8/2026, 10:45am-2:15pm 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: 116 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: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: Licensing inspector observed required facility posting, medication pass, afternoon activity, and lunch. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of these inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Tyia Venable, Licensing Inspector at 804-393-2157 or by email at tyia.venable2@dss.virginia.gov

Violations

22VAC40-73-390-A

Based on a review of resident records, the facility did not ensure at or prior to the time of admission, there was a written agreement or acknowledgement of notification dated and signed by the resident or applicant for admission or the appropriate legal representative and by the licensee or administrator.

Evidence

Licensing inspector reviewed Resident 3’s record and there was no admission agreement/lease between the resident and the facility.
When asked, Staff 1 stated the admission agreement/lease was not in the record.

Plan of correction

1. Correction: o Resident #3’s admission agreement has been obtained and placed in the record. All charts have been audited 2. Systemic Changes: o Admissions staff have been re-educated on this requirement. 1. Monitoring: o Weekly audit of new admission files for 30 days. 2. Responsible Party: o Admissions Director and or designee

22VAC40-73-320-B

Based on a review of resident records, the facility did not ensure a risk assessment for tuberculosis was completed annually on each resident.

Evidence

Licensing inspector reviewed Resident 1’s record and the risk assessment was last completed on 2/10/2025.
Licensing inspector reviewed Resident 8’s record and the risk assessment was last completed on 2/6/2025.
When asked, Staff 1 stated the risk assessments for tuberculosis had not been completed for Residents 1 and 8.

Plan of correction

1. Correction: o TB risk assessments for Residents #1 and #8 have been completed and documented. All charts have been audited. 1. Systemic Changes: o A tracking log has been implemented to monitor annual TB screening requirements. o Nursing staff have been educated on timely completion. 2. Monitoring: o Monthly audit of health records to verify current TB risk assessments. 1. Responsible Party: o Director of Nursing and or designee

22VAC40-73-720-A

Based on a review of resident records, the facility did not ensure the written do not resuscitate order was included on the resident’s individualized service plan (ISP).

Evidence

Licensing inspector reviewed Resident 5’s record and the ISP did not include the do not resuscitate order given by the physician.
When asked, Staff 1 stated the do not resuscitate order had not been included on Resident 5’s ISP.

Plan of correction

1. Correction: o Resident #5’s ISP has been updated to include the physician’s DNR order. An audit of all files will be completed by 7/31/2026. 2. Systemic Changes: o Nursing staff have been educated on ensuring all DNR orders, including DNR status, are incorporated into the ISP. 3. Monitoring: o DON/designee will conduct weekly ISP audits for 60 days. 4. Responsible Party: o Director of Nursing and or designee

22VAC40-73-410-A

Based on a review of resident records, the facility did not ensure an orientation for new residents and their legal representatives was signed and dated and kept in the resident’s record.

Evidence

Licensing inspector reviewed Resident 7’s record and there was no documentation of orientation provide by the facility for the resident and/or the legal representative.
When asked, Staff 1 stated there was no documentation in Resident 7’s record indicating orientation to the facility.

Plan of correction

1. Correction: o Orientation documentation for Resident #7 has been completed and placed in the record. All charts have been audited. 2. Systemic Changes: o Staff re-educated on requirement. 3. Monitoring: o Weekly admission audits for 30 days. 4. Responsible Party: o Admissions Director / Administrator and or designee

22VAC40-73-350-B

Based on a review of resident records, the facility did not ensure they ascertained, prior to admission, whether a potential resident is a registered sex offender if the facility anticipates the potential resident will have a length of stay greater than three days and shall document in the resident’s record.

Evidence

Licensing inspector reviewed Resident 3’s record and the registered sex offender document did not reflect this resident’s information.
When asked, Staff 1 stated Resident 3 did not have the correct sex offender registry document in the file.

Plan of correction

1. Correction of Deficient Practice: o The record for Resident #3 has been reviewed, and the correct sex offender registry check has been completed and placed in the resident’s file. All resident files have been audited. 2. Systemic Changes: o Admissions staff have been re-educated on this requirement. 3. Monitoring: o The Administrator or designee will audit all new admissions weekly for 30 days, then monthly, to ensure compliance. 1. Responsible Party: o Admissions Director / Administrator and or designee

22VAC40-73-450-F

Based on a review of resident records, the facility did not ensure individualized service plans were reviewed and updated at least once every 12 months and as needed for significant change.

Evidence

Licensing inspector reviewed Resident 8’s record and there was no individualized service plan in the record.
When asked, Staff 1 stated there was not documentation of an updated individualized service plan in the record.

Plan of correction

1. Correction: o Resident #8 now has a current ISP completed and placed in the record. 2. Systemic Changes: o A tracking system has been implemented to alert staff of ISP due dates and changes in condition requiring updates. 1. Monitoring: o Monthly ISP review audit by DON/designee. 2. Responsible Party: o Director of Nursing and or designee

July 9, 2025Complaint survey0 violations

Inspection dates

07/09/2025

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments

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: 7/9/2025; 9:37am-11am 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 11/18/2024 regarding allegations in the area(s) of: resident care and related services. 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: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Licensing inspector reviewed resident record Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation 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 Tyia Venable, Licensing Inspector at (804)393-2192 or by email at Tyia.Venable2@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

May 14, 2025Inspection1 violation

Inspection dates

05/14/2025

Areas reviewed

22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS

Comments

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: 5/14/2025, 9:36am to 1:05pm 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: 128 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: 3 Number of interviews conducted with staff: 2 Observations by licensing inspector: Facility postings and facility documentation were observed. Additional Comments/Discussion: n/a An exit meeting was conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Tyia Venable, Licensing Inspector at (804) 393-2157 or by email at tyia.venable2@dss.virginia.gov

Violations

22VAC40-73-550-G

Based on a review of staff records, the facility failed to ensure the rights and responsibilities of residents in assisted living facilities were reviewed annually with each resident or his legal representative.

Evidence

The record for resident 3 did not contain documentation of an annual review of the resident rights and responsibilities. Staff 1 confirmed the documentation was not available on this date.

Plan of correction

Corrective action –Resident #3 was LOA from the community for a period during the annual resident rights review. The resident rights annual review was completed during the monitoring inspection on 5/14/2025 and placed in the resident’s record. The community failed to provide a resident rights annual review for resident #3 upon their return to the community. Monitoring – The Administrator or designee will audit all resident records to ensure compliance with resident rights annual review. Residents LOA from the community during the resident rights review will receive an annual review upon return to the community. An annual audit of the residents’ rights will take place following the annual review. Audit results will be presented to the Quality Assurance Committee for further action or discontinuation, as appropriate.

June 4, 2024Inspection3 violations

Inspection dates

06/04, 07/2024

Comments

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: On 06/04/2024 approximate time 10:00a.m – 3:42p.m. On 06/07/2024 approximate time 9:50a.m – 3:00p.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: 128 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: 5 Number of interviews conducted with staff: 5 Observations by licensing inspector: An observation of a medication administration pass and the lunch time meal was conducted on 06/07/2024. Additional Comments/Discussion: 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 Angela Rodgers-Reaves, Licensing Inspector at (804) 840-0253 or by email at Angela.r.reaves@dss.virginia.gov Violation Notice Issued: Yes

Violations

22VAC40-73-450-F

Based on the review of facility records and interviews conducted with facility staff the facility failed to ensure that residents Individualized service plans (ISP) were updated at least once every 12 months and as needed for a significant change of a resident’s condition. Resident #5 Documented date of admission 10/26/2020 During staff interviews and the review of facility records while onsite at the facility on 06/04, 07/2024, the facility did not submit for the inspector’s review documented

Evidence

that an updated ISP (Individualized Service Plan) had been developed for resident #5. During interviews facility staff #1 stated that while the resident has been assessed as needing assistance with some activities of daily living (ADLs) the facility does not provide assistance with these services as the resident can do for themselves.

Plan of correction

FACILITY'S RESPONSE: "Corrective action –The Administrator, Director of Nursing and designated certified Universal Assessment Instrument (UAI) assessors will update their VDSS UAI training certification to ensure classification of those Residential Living “Independent Living Status” residents reflects regulation 22VAC40-73-450.B. Based on the updated UAIs, no ISP is required as resident #5 is assessed as capable of maintaining themselves in an independent living status How to identify other residents affected – The DON or designee will review all residential living resident charts to ensure an ISP is in place, if required, based on the UAI. Systemic changes –The DON or designee will review required documents prior to admission to ensure an ISP is in place, as appropriate, based on the UAI. Monitoring - The Administrator of designee will audit 25% of new admission documents for the next quarter. Audit results will be presented to the Quality Assurance Committee for further action or discontinuation, as appropriate."

22VAC40-73-450-A

Based on the review of facility records and interviews conducted with facility staff the facility failed to ensure that on or within seven days prior to the day of admission, a preliminary plan of care is developed to address the basic needs of the resident that adequately protects his health, safety, and welfare.

Evidence

Resident #6 Documented date of admission 04/27/2024 The facility assessed resident # 6 on 05/10/2024 as needing human help and supervision with bathing, toileting and transferring. Resident #8 Documented date of admission 05/08/2024 The facility assessed resident # 6 on 04/30/2024 as needing human help and supervision with bathing, toileting and transferring. During staff interviews and the review of facility records while onsite at the facility on 06/04, 07/2024, the facility did not submit for the inspector’s review documented evidence that a preliminary ISP (Individualized Service Plan) had been developed for resident #s 6 and 8. During interviews facility staff #1 stated that while these residents have been assessed as needing assistance with some of their activities of daily living (ADLs) the facility does not provide assistance with these services as the residents can perform these tasks without assistance.

Plan of correction

FACILITY'S RESPONSE: "Corrective action-The Administrator, Director of Nursing and designated certified Universal Assessment Instrument (UAI) assessors will update their VDSS UAI training certification to ensure classification of those Residential Living “Independent Living Status” residents reflects regulation 22VAC40-73-450.B. The UAIs for residents #s 6 and 8 have been updated to accurately reflect their needs. Based on the updated UAIs, no ISP is required as residents #6 and8 are assessed as capable of maintaining themselves in an independent living status. How to identify other residents affected – The DON or designee will review all residential living resident charts to ensure an ISP is in place, if required, based on the UAI. Systemic changes –The DON or designee will review required documents prior to admission to ensure an ISP is in place, if required, based on the UAI. Monitoring -The Administrator of designee will audit 25% of new admission documents for the next quarter. Audit results will be presented to the Quality Assurance Committee for further action or discontinuation, as appropriate."

22VAC40-73-320-A

Based on the review of facility records and staff interviews the facility failed to ensure that within the 30 days preceding admission, the physical examination report on file at the assisted living facility contained all of the required elements.

Evidence

Resident #4 Date of admission 01/15/2024 The facility documentation reviewed with the facility Administrator and staff #1 and identified by the staff as the results of a risk assessment documenting the absence of tuberculosis in a communicable form for resident #4 is dated 01/22/2024 seven days after the resident’s documented date of admission.

Plan of correction

FACILITY'S RESPONSE: "Corrective action – Chest x-ray dated 1/18/2024 for resident #4 admitted on 1/24/2024 received on 1/22/2024; within 30 days preceding admission missing “free of tuberculosis” finding. How to identify other residents affected – The DON or designee will audit all resident charts to ensure any chest x-rays include a statement that the residents is “free of tuberculosis.” Systemic changes – The DON or designee will review required documents prior to admission to ensure a risk assessment or chest x-ray documenting the absence of tuberculosis in a communicable form. Monitoring – The Administrator of designee will audit 25% of new admission documents for the next quarter. Audit results will be presented to the Quality Assurance Committee for further action or discontinuation, as appropriate."

October 10, 2023Complaint survey0 violations

Inspection dates

10/10/2023

Comments

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: 10/10/2023-approximate time 1:50p.m-2:32p.m The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 08/14/2023 regarding allegations in the area of Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 130 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: N/A Number of staff records reviewed: N/A Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 1 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Angela Rodgers-Reaves, Licensing Inspector at (804) 840-0253 or by email at Angela.r.reaves@dss.virginia.gov Violation Notice Issued: No

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

April 20, 2023Inspection0 violations

Inspection dates

4/20/2023; 04/21/2023

Areas reviewed

22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS

Comments

Type of inspection: Monitoring Date(s) of inspection: 4/20/2023; 04/21/2023 Time the licensing inspector was on-site at the facility for each day of the inspection: (1) 12:11 p.m.- 2:10 p.m. and (2) 2:00 p.m. - 4:00 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: 120 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 05 Number of staff records reviewed: 05 Number of interviews conducted with residents:02 Number of interviews conducted with staff: 03 Observations by licensing inspector: Buildings/grounds, MARs, and training records Additional Comments/Discussion: The department's inspection findings are subject to public disclosure. 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. 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 Vashti Colson , Licensing Inspector at (804) 662-9432 or by email at Vashti.Colson@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

May 16, 2022Inspection0 violations

Inspection dates

05/16/2022

Areas reviewed

Comments

Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/16/2022 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: 126 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 05 Number of staff records reviewed: 05 Number of interviews conducted with residents: Interviews conducted during the building tour with several residents and a personal care giver. Number of interviews conducted with staff: 02 Observations by licensing inspector: Medication pass, meal observation, and activities observation Additional Comments/Discussion: N/A An exit meeting was 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 Vashti Colson, Licensing Inspector at (804) 662-9432 or by email at Vashti. Colson @dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

June 24, 2021Inspection0 violations

Areas reviewed

22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity32.1 Reported by persons other than physicians63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE

Comments

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 06/24/2021 and concluded on 06/25/201. The administrator was contacted by telephone to initiate the inspection. The reported that the current census was one hundred and thirteen (113). The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed four (4) resident records, four (4) staff records, activities calendar, staff schedules, U.A.I.s, I.S.P.s, and resident rights submitted by the facility to ensure documentation was complete. The information gathered during the inspection determined no violations with applicable standards or law. No violations were issued.

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

October 15, 2020Complaint survey0 violations

Inspection dates

Oct. 15, 2020 and Oct. 26, 2020

Areas reviewed

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 STAFFING AND SUPERVISION22VAC40-80 COMPLAINT INVESTIGATION

Comments

This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A complaint inspection was initiated on 10/15/2020 and concluded on 10/26/2020. A complaint was received by the department regarding allegations in the areas of resident care and related services. The administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation did not support the allegation of non-compliance with standards or law.

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.