14
Inspections
On record
6
With violations
Visits that cited something
8
Clean visits
Nothing cited
24
Violations cited
Individual findings
18
Standards cited
Distinct rules
8
Complaint visits
Prompted by a complaint
Brookdale Midlothian was inspected 14 times between January 21, 2021 and January 14, 2026 by the Virginia Department of Social Services. 6 of those visits ended with violations cited and 8 with none. Across that history VDSS cited 24 violations under 18 distinct standards. 8 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. 13 of these 14 are still on the state's site; the other 1 has since dropped off it and is reproduced from Assisted Living Magazine's archive of the original VDSS reports.
Provider Information
Facility type
Assisted Living Facility
License type
One Year
License expires
01/25/2027
Administrator
Patrick Hines
Licensing inspector
Tamara Watkins
Inspector phone
(804) 840-3710
Approved for
Assisted Living · Special Care Unit · Non-Ambulatory
Inspection History
14Select an inspection to read the areas reviewed, the inspector's comments and any violations cited.
January 14, 2026Complaint survey
Inspection dates
01/14/2026
Areas reviewed
22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
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: 1/14/2026 12:45p – 4:30p
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 11/18/2025 regarding allegations in the area:
22VAC40-73-(10) ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Number of residents present at the facility at the beginning of the inspection: 78
The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility.
Number of interviews conducted with staff: 2
Observations by licensing inspector: Review of staffing schedules for memory care and assisted living environments
Additional Comments/Discussion:
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 Tamara Watkins, Licensing Inspector at (804) 840-3710 or by email at tamara.g.watkins@dss.virginia.gov
Violation Notice Issued: No
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
January 14, 2026Complaint survey
Inspection dates
01/14/2026
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: 1/14/2026 12:45p – 4:30p
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 regarding allegations in:
22VAC40-73-(6) RESIDENT CARE AND RELATED SERVICES
Number of residents present at the facility at the beginning of the inspection: 78
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 interviews conducted with staff: 3
Observations by licensing inspector: Nursing notes, communication logs, hospice notes, hospital discharge summary.
Additional Comments/Discussion:
An exit meeting was 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. 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 Tamara Watkins, Licensing Inspector at (804) 840-3710 or by email at tamara.g.watkins@dss.virginia.gov
Violation Notice Issued: Yes
Violations
22VAC40-73-70-C
Based on interviews and a resident record review the facility failed to submit to the regional licensing office a written report within 7 days of the date of any major incident.
On 9/16/2026 Resident #1 sustained a leg/ankle injury resulting in visit to the emergency room with a subsequent diagnosis of a right ankle fracture. An incident report was not submitted to the regional licensing office.
Plan of correction
When an incident is reported to the Administrator, the Administrator will immediately send out an email from his/her office. The AED will be the follow up and back up in the event the Administrator is not readily available.
January 14, 2026Complaint survey
Inspection dates
01/14/2026
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 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: 12:45p – 4:30p
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 regarding allegations in the area of: Resident Care and Related Services
Number of resident records reviewed: 1
Number of interviews conducted with staff: 3
Observations by licensing inspector: Resident records, staffing and bathing schedules, ISP, UAI, and other facility documentation.
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 Tamara Watkins, Licensing Inspector at (804) 840-3710 or by email at tamara.g.watkins@dss.virginia.gov
Violation Notice Issued: No
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
January 14, 2026Inspection
Inspection dates
01/14/2026
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 REPORT
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: 1/14/2026 12:45p – 4:30p
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: 78
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: 4
Number of interviews conducted with residents: 2
Number of interviews conducted with staff: 3
Observations by licensing inspector: Required postings, staff/resident interaction, physician orders, medication administration records, medications, activity in progress, health and fire inspection reports, health care oversight, pharmacy review and dietary oversight review.
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 Tamara Watkins, Licensing Inspector at (804) 840-3710 or by email at tamara.g.watkins@dss.virginia.gov
Violation Notice Issued: No
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
August 1, 2025Complaint survey
Inspection dates
08/01/2025
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS
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: 8/1/2025 3:00 – 4:00p
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 7/1/2025 regarding allegations in the area of: Admission, Retention and Discharge
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 interviews conducted with staff: 1
Additional Comments/Discussion:
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 Tamara Watkins, Licensing Inspector at (804) 840-3710 or by email at tamara.g.watkins@dss.virginia.gov
Violation Notice Issued: No
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
August 1, 2025Complaint survey
Inspection dates
08/01/2025
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: 8/1/2025 3:00p-4:10p
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 6/23/2025 regarding allegations in the area of : Resident Care and Related Services.
Number of residents present at the facility at the beginning of the inspection:
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: 0
Observations by licensing inspector:
Additional Comments/Discussion:
The evidence gathered during the investigation supported the allegations of non-compliance with standard(s) or law, and violations 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 Tamara Watkins, Licensing Inspector at (804) 840-3710 or by email at tamara.g.watkins@dss.virginia.gov
Violation Notice Issued: Yes
Violations
22VAC40-73-460-D
Based on a review of resident records and facility documentation, the facility failed to provide supervision of resident care and activities.
Evidence
- Resident #1 who resides in the memory care unit sustained skin tears on the hands because of being grabbed roughly by a personal care staff member. The staff member was also observed hitting the same resident in the back. During an investigation of the incident by facility administration the staff member resigned.
Plan of correction
Not published by VDSS.
June 4, 2025Complaint survey
Inspection dates
06/04/2025
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: 6/4/2025 9:45a – 3:15p
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 5/1/2025 regarding allegations in the Resident care and Related services.
Number of residents present at the facility at the beginning of the inspection: 29 in Memory Care.
The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility.
Number of resident records reviewed: 4
Number of staff records reviewed: N/A
Number of interviews conducted with residents: N/A
Number of interviews conducted with staff: 4
Observations by licensing inspector: Memory care unit. Staffing, Residents.
Additional Comments/Discussion:
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 in: Resident care and Related Services.
A violation notice was issued. 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 Tamara Watkins, Licensing Inspector at (804) 840-3710 or by email at tamara.g.watkins@dss.virginia.gov
Violation Notice Issued: Yes
Violations
22VAC40-73-450-F
Based on record reviews, the facility failed to ensure the individualized service plan (ISP) was reviewed and updated to include all assessed needs.
Evidence
- The ISP dated 09/20/2023 for Resident #1 indicated the following need: “Services to be Provided, IADL: Meal Prep: Resident needs assistance with meal preparation. Need identified: 09/20/2023.” The facility did not provide documentation to confirm that the resident was provided with thin liquids or that food was cut for the resident.
- The ISP for Resident #1 dated September 20, 2023, was not updated to address the following needs as detailed in Hospice Care Plans dated March 6, 2024, March 20,2024, and May 1, 2024. Resident #1 had decreased appetite/meal refusal (identified March 6, 2024). unintelligible speech (identified March 20,2024), and contractures to the right hand and lower extremities (identified May 1, 2024).
Plan of correction
Health and Wellness Coordinator corrected file 6/11/2025. Going forward, a second nurse, Health and Wellness Director, or Executive director will review file to make sure UAI, ISP and all orders are matching and correct. Food Service Director and Executive Director will review each resident file to verify diet orders.
22VAC40-73-440-H
Based on inspection and interview conducted, the facility failed to ensure that each Uniform Assessment Instrument (UAI) is completed prior to admission, updated annually, and whenever there is a significant change in a resident’s condition.
1. During an inspection conducted on June 4, 2025, the record for resident #1 did not contain an updated UAI as the result of a significant change in the resident’s condition. The UAI for resident #1 dated September 14, 2023, noted resident #1 did not need assistance with Eating/Feeding.
2. A review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report for resident #1 dated March 6, 2024, noted, “Patient’s appetite is declined and at times she only takes a few bites and other times she does not eat anything. She does refuse at least 1 full meal a day.” Hospice Care Plan dated March 20,2024 notes Resident #1’s “appetite is decreased to only a few bites at a time.” The hospice physician for Resident #1 notes “assistance with eating.”; and “contractures to the right lower extremity and right hand.” The Hospice Plan dated May 1, 2024, notes, “Her appetite is decreased to only a few bites at a time.”
3. Resident #1’s UAI was not updated to reflect a significant change in the resident’s condition.
Plan of correction
Health and Wellness Coordinator corrected file 6/11/2025. Going forward, a second nurse, Health and Wellness Director, or Executive director will review file to make sure UAI, ISP and all orders are matching and correct.
22VAC40-73-930-D
Based on a resident record review and staff interview, the facility failed to ensure that if a resident is unable to use the signaling device or call system, the resident’s individualized service plan (ISP) documents the inability and specifies the minimum frequency of daily rounds to be made by direct care staff to monitor for emergencies or other unanticipated resident needs.
Evidence
- During an inspection conducted on June 4, 2025, review of Resident #1’s record confirms Resident #1 resides in the memory care unit of the facility. The resident’s 9/20/2023 ISP states Resident #1 has a pull cord in her room but due to a cognitive impairment she may not remember to use it. The goal is listed as “Staff are to do frequent rounds throughout the day and 2-hour safety rounds when asleep in bed”. The frequency of rounds made by staff throughout the day is not defined. The facility failed to document when rounds were made, the name of the resident, the date and time of the rounds, and the staff member who made the rounds. This documentation is to be retained for two years. Evidence: The goal for resident #1’s Individual Service Plan (ISP) dated 09/20/2023 reads, “staff are to do frequent rounds throughout the day and 2-hour safety rounds when in bed.” The goal does not specify the date and time of rounds, or the staff member who made the rounds.
Plan of correction
Health and Wellness Coordinator corrected file 6/11/2025. Going forward, a second nurse, Health and Wellness Director, or Executive director will review file to make sure UAI, ISP and all orders are matching and correct. A sheet documenting room checks has been put in place
February 24, 2025Complaint survey
Inspection dates
02/24/2025
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: 2/24/2025 2:00p – 4:15p
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 2/13/2025 regarding allegations in: Resident Care and Related Services
Number of residents present at the facility at the beginning of the inspection: 71
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 interviews conducted with residents:2
Number of interviews conducted with staff: 2
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 Tamara Watkins, Licensing Inspector at (804) 840-3710 or by email at tamara.g.watkins@dss.virginia.gov
Violation Notice Issued: No
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
January 27, 2025Inspection
Inspection dates
01/27/2025
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 and time the licensing inspector was on-site at the facility for each day of the inspection: 1/27/2025 10:40a -3:45p
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: 71
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: 4
Number of interviews conducted with staff: 3
Observations by licensing inspector: Meals. Activity, Medication Observation, Med Cart Review, and Postings.
Additional Comments/Discussion:
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 Tamara Watkins, Licensing Inspector at (804) 662-7422 or by email at tamara.g.watkins@dss.virginia.gov
Violation Notice Issued: Yes
Violations
22VAC40-73-250-D
Based on a review of staff records the facility failed to obtain a tuberculosis risk assessment on or within seven days prior to the first day of work for each staff person.
Evidence
- The tuberculosis risk assessment in the record for staff #2 dated 1/15/2024 is expired.
Plan of correction
Not published by VDSS.
22VAC40-73-1110-B
Based on a review of resident records the facility failed to perform a review of the continued appropriateness of placement in the special care unit.
Evidence
- Resident #3 has been a resident in the special care unit since 12/10/2015. The last review of continued appropriateness of placement in the resident record is 12/8/2023
Plan of correction
Not published by VDSS.
22VAC40-73-320-B
Based on a review of resident records the facility did not complete an annual risk assessment for tuberculosis for each resident.
Evidence
- Resident #3 was admitted to the facility on 12/10/2015. There was no annual TB risk assessment completed for resident #3.
Plan of correction
Not published by VDSS.
22VAC40-73-440-A
Based on a review of resident records the facility failed to complete an annual uniform assessment instrument for all residents.
Evidence
- Resident #3 (DOA 12/10/2015) does not have documentation that an annual uniform assessment was completed.
Plan of correction
Not published by VDSS.
22VAC40-73-550-G
Based on a review of resident records the facility failed to review the rights and responsibilities of residents annually.
Evidence
- Resident #3 (DOA 12/10/2015). There is no resident rights review signed and dated in the resident record.
Plan of correction
Not published by VDSS.
22VAC40-73-250-D
Based on a review of staff records the facility failed to ensure that each staff person submit annually to a tuberculosis risk assessment.
Evidence
- The last recorded tuberculosis risk assessment in the record for staff #3 is dated 5/19/2022.
Plan of correction
Not published by VDSS.
22VAC40-73-450-F
Based on a review of resident records the facility failed to review and update individualized service plans for each resident annually.
Evidence
- Resident #3 (DOA 12/10/2015) does not have an updated annual individualized service plan completed and in their record. Resident #4 (DOA 1/15/22). The last service plan completed in the resident record is dated 5/19/2022.
Plan of correction
Not published by VDSS.
22VAC40-73-260-A
Based on a review of staff records the facility failed to maintain current certification in first aid for each direct care staff.
Evidence
- First Aid certification for staff #3 documented in the staff record expired 10/21/2024.
Plan of correction
Not published by VDSS.
January 10, 2024Inspection
Inspection dates
01/10/2024
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
Technical assistance
Please ensure that individualized service plan is signed and dated by the licensee, administrator, or his/her designee (the person who developed the plan), and by the resident or his legal representative
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: 1/10/2024; 11:00a – 4:30p
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: 70
The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility.
Number of resident records reviewed: 10
Number of staff records reviewed: 5
Number of interviews conducted with residents: 3
Number of interviews conducted with staff: 3
Observations by licensing inspector: Menus, Activities, Medication Pass, Medication Cart
Additional Comments/Discussion:
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 Tamara Watkins, Licensing Inspector at (804) 662-7422 or by email at tamara.g.watkins@dss.virginia.gov
Violations
22VAC40-73-440-A
Based on a review of resident records the facility failed to complete a Uniform Assessment Instrument, at least annually, and whenever there is a significant change in the resident’s condition.
Evidence
- The last UAI completed in the record for resident #3 was completed on 8/23/22. No other UAI was available for review.
Plan of correction
Not published by VDSS.
22VAC40-73-450-F
Based on a review of resident records the facility failed to review or update individualized service plans once every 12 months.
Evidence
- The last ISP completed and available for review in the resident’s record is dated 2/16/22.
Plan of correction
Not published by VDSS.
22VAC40-73-450-A
Based on a review of resident records the facility failed to develop a preliminary plan of care to address the basic needs of the resident within or on seven days prior to the day of admission.
Evidence
- The date of admission for resident #4 was 9/28/23 there was no preliminary or current plan of care in the record or available for review for resident #4.
Plan of correction
Not published by VDSS.
22VAC40-73-1110-B
Based on a review of resident records the facility failed to perform a six-month review of the appropriateness of continued residence in the memory care unit.
Evidence
- The last review of continued appropriateness for placement was completed on 11/17/21 and maintained in the record for resident #2 .
Plan of correction
Not published by VDSS.