Virginia DSS · Assisted Living Facility

The Estates at Charlottesville

📍 491 Crestwood Drive, Charlottesville, VA, 22903

ID 45763Two Year licenseActive
22
Inspections
On record
10
With violations
Visits that cited something
12
Clean visits
Nothing cited
12
Violations cited
Individual findings
12
Standards cited
Distinct rules
8
Complaint visits
Prompted by a complaint

The Estates at Charlottesville was inspected 22 times between November 7, 2020 and May 19, 2026 by the Virginia Department of Social Services. 10 of those visits ended with violations cited and 12 with none. Across that history VDSS cited 12 violations under 12 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. 20 of these 22 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
06/30/2026
Administrator
David Ter Borg
Licensing inspector
Yvonne Randolph
Inspector phone
(804) 441-1180
Approved for
Assisted Living · Special Care Unit · Non-Ambulatory

Inspection History

22

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

May 19, 2026Inspection1 violation
Inspection dates
05/19/2026
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 IMPAIRMENTS
Comments
Type of inspection: Renewal Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 5/19/2026,10:50 am to 1:30 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 94 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: medication passes, file documentation, activity, lunch meal, required postings, staff/resident interaction, building cleanliness and maintenance An exit meeting was conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standards or law, and a violation was 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 will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard 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 Yvonne Randolph, Licensing Inspector at 804-441-1180 or by email at yvonne.randolph@dss.virginia.gov
Violations
22VAC40-73-260-A
Based on file reviews, the facility did not ensure that each direct care staff member receive, within 60 days of employment, current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department.
Evidence
  1. Staff 1, hired 12 15-25, did not have current certification in first aid.
Plan of correction
Not published by VDSS.
May 19, 2026Inspection0 violations
Inspection dates
05/19/2026
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 5/19/2026, 10:50 am to 1:30 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Self-reported incident were received by VDSS Division of Licensing on 4/22/26 and 3/24/26 regarding allegations in the area of: Resident Care And Related Services Number of residents present at the facility at the beginning of the inspection: 94 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: incident reports, medication administration An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation did not support non-compliance with standards 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 Yvonne Randolph, Licensing Inspector at (804) 441-1180 or by email at yvonne.randolph@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
February 25, 2026Inspection1 violation
Inspection dates
02/25/2026
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 2/25/26,11:15 am The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing regarding allegations in the area of: Resident Care And Related Services The licensing inspector completed a tour of the memory care environment Number of interviews conducted with staff: 1 Observations by licensing inspector: Virginia Health Professions License Lookup, Contract w/Staffing Agency An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation supported non-compliance with standards or law, and a violation was issued. 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 Yvonne Randolph, Licensing Inspector at (804) 441-1180 or by email at yvonne.randolph@dss.virginia.gov
Violations
22VAC40-73-680-A
Based on documentation review and an interview, the facility did not ensure that staff who are licensed, registered, or acting as medication aides on a provisional basis as specified in 22VAC40-73-670 shall administer drugs to those residents who are dependent on medication administration as documented on the UAI.
Evidence
  1. An incident report was received by VDSS regarding an unqualified contract agency employee (staff 1) administering medications at the facility on 9/15/25. A search of the Virginia Health Professions license lookup website found that the registration for staff 1 to practice as a medication aide was revoked on 7/25/25. Staff 2 confirmed during an interview on 2/25/26 and in an email to the licensing inspector on 11/12/25 that medications were administered by staff 1 on 9/15/25. The number of residents affected is unknown as staff 2 reported that medication administration records were not available for review due to a change in pharmacy providers.
Plan of correction
Not published by VDSS.
February 25, 2026Complaint survey0 violations
Inspection dates
02/25/2026
Areas reviewed
22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS
Comments
Type of inspection: Complaint Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 2-25-26, 11:15 am to 12: 15 pm 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 2/9/26 regarding allegations in the area of: Resident Accommodations And Related Provisions The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: resident room, memory care environment An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standardsor 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 Yvonne Randolph, Licensing Inspector at (804) 441-1180 or by email at yvonne.randolph@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
July 1, 2025Inspection0 violations
Inspection dates
07/01/2025
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on May 17. 2025 in the area of: Resident Care And Related Services The licensing inspector completed a tour of the secure environment at the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: file documentation, activity, staff/ interactions An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation did not support non-compliance with standards 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 Yvonne Randolph, Licensing Inspector at (804) 441- 8110 or by email at yvonne.randolph@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 7, 2025Inspection0 violations
Inspection dates
05/07/2025
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Non-Mandated Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 5/7/25, 10:15 am to 11:40 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 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: file documentation A self-reported incident was received by VDSS Division of Licensing on 4/30/25 in the areas of: Resident Care and Related Services and Staffing and Supervision An exit meeting was conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standards 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 Yvonne Randolph, Licensing Inspector at (804) 441-1180 or by email at yvonne.randolph@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 7, 2025Inspection0 violations
Inspection dates
05/07/2025
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 IMPAIRMENTS
Comments
Type of inspection: Mandated Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 5/7/25, 10:15 am to 11:40 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 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: 6 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: Memory care environment, lunch meal (AL and memory care), medication passes, postings, required file documentation, liability insurance coverage, staff/resident interaction An exit meeting was conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standards 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 Yvonne Randolph, Licensing Inspector at (804) 441-1180 or by email at yvonne.randolph@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
November 25, 2024Complaint survey1 violation
Inspection dates
11/25/2024
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS
Comments
Type of inspection: Complaint Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11125/24, 12:25 p to 1:15 p 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 10/17/24 regarding allegations in the area of: Admission, Retention and Discharge of Residents Number of residents present at the facility at the beginning of the inspection: 87 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with staff: 2 An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. However, a violation 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 will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov 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 Yvonne Randolph, Licensing Inspector at (804) 662-7454 or by email at yvonne.randolph@dss.virginia.gov
Violations
22VAC40-73-325-B
Based on a file review, the facility did not ensure that the fall risk rating shall be reviewed and updated after each fall.
Evidence
  1. The file for resident # 1 documented a fall risk rating that was completed on 10/11/24. A review of the fall risk rating was not documented after subsequent falls on 10/14/24. 10/15/25 and 10/16/24.
Plan of correction
The facility will ensure that fall risk ratings are complete after each fall and documentation placed on the individualized service plans. There was an audit completed to review all Morse Fall risk. Director of Health and Wellness will sign off on completion of all incidents after fall risk is completed and review after each with Interim Executive Director. Documents printed in filed in Medical Chart. We will also provide an education session with all team members on completing the fall risk evaluation after each fall. After each incident, the Director of Health and Wellness and Interim Executive director will be responsible for fall risk ratings and updated documentation for ISP implementation of Plan of Correction effective immediately 11/26/2024.
September 3, 2024Inspection0 violations
Inspection dates
09/03/2024
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring, Non-Mandated. Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 9/3/24, 11:30a to 12:15 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 7/16/24 regarding allegations in the area of: Resident Care and Related Services and Staffing and Supervision. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility and secure memory care Number of interviews with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: Memory care An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation did not support non-compliance with standards or laws. 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. Use the following last two statements on every Inspection Summary: For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Yvonne Randolph Licensing Inspector at (804) 662-7454 or by email at yvonne.randolph@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 13, 2024Inspection1 violation
Inspection dates
05/13/2024
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 IMPAIRMENTS
Comments
¿Type of inspection: Renewal Date inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/13/24, 10 am to 1 pm The Acknowledgement of Inspection form was signed and left at the facility for each date 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: 10 Number of staff records reviewed: 5 Number of interviews conducted with residents: 5 Number of interviews conducted with staff: 4 Observations by licensing inspector: Lunch meal, medication administration, staff/resident interactions, required postings, facility maintenance and cleanliness An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard or law, and the violation is 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 will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard 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 Yvonne Randolph, Licensing Inspector at (804)662-7454 or by email at yvonne.randolph@dss.virginia.gov
Violations
22VAC40-73-450-C
Based on file reviews, the facility did not ensure that individualized service plans for two residents include a description of an identified need.
Evidence
  1. The file reviews found written DNR (Do Not Resuscitate) Orders for residents # 2 and # 5. The individualized service plans for residents # 2 ad # 5 did not include the DNR orders. The service plans stated -Full Code Status.
Plan of correction
The facility will ensure that individualized service plans include a description of identified needs. Updated physician orders on DNR status will continue to be placed in medical chart and face sheet for each resident to ensure staff and medical providers have updated and accurate information on providing medical treatment in accordance with resident’s wishes. DNR status will be placed on resident Individualized Service Plans as part of order intake by the Director of Resident Care with sign off by receiving staff, DRC, and Executive Director prior to placing order in Medical Chart. The Executive Director will be responsible for ISP accuracy with implementation of Plan of Correction immediately 5/14/2024.
March 25, 2024Complaint survey0 violations
Inspection dates
03/25/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Complaint Date the licensing inspector was on-site at the facility for each day of the inspection: 3/25/24 The Acknowledgement of Inspection form was completed and left at the facility for each date of the inspection. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 1 Observations by licensing inspector: resident eating dessert, posted menu, staff/resident interactions, Health certificate issued A complaint was received by VDSS Division of Licensing on 2/28/24 regarding allegations in the area(s) of: Resident Care and Related Services An exit meeting was 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 Yvonne Randolph, Licensing Inspector at 804-662-7454 or by email at yvonne.randolph@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
July 21, 2023Complaint survey0 violations
Inspection dates
07/21/2023
Areas reviewed
None22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Complaint Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11:30 a-1:40 p The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. A complaint was received by VDSS Division of Licensing on 7/20/23 regarding an allegation in the area of Resident Care And Related Services. Number of residents present at the facility at the beginning of the inspection: Number of staff records reviewed:1 Number of interviews conducted with staff: 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 Yvonne Randolph, Licensing Inspector at (804-662-7454 or by email at yvonne.randolph@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
July 21, 2023Complaint survey2 violations
Inspection dates
07/21/2023
Areas reviewed
None22VAC40-73(3) PERSONNEL
Comments
Type of inspection: Complaint Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11:30 a-1:40 p The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. A complaint was received by VDSS Division of Licensing on 7/20/23 regarding an allegation in the area of Personnel. Number of staff records reviewed: 17 background checks Number of interviews conducted with staff: 2 The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violations 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. An exit meeting will be conducted to review the inspection findings. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Yvonne Randolph, Licensing Inspector at (804-662-7454 or by email at yvonne.randolph@dss.virginia.gov
Violations
22VAC40-73-110-1
Based on a review of criminal background checks, the facility failed to comply with the requirements specified in the Regulation for Background Checks for Assisted Living Facilities and Adult Day Care Centers (22VAC40-90) which states that an assisted living facility shall not hire an individual with a conviction for an offense in clause (i) of the barrier crime definition in § 19.2-392.02 of the Code of Virginia
Evidence
  1. Staff # 1 was convicted of a barrier crime in February 2021.
Plan of correction
Staff #1 was terminated on 7/21/23. An entire audit of all staff files will be completed to ensure that every staff member has a background check on file and will be in compliance with the standard. In order to prevent this in the future, Prior to any new team member starting work, the ED will date and initial the background check document to ensure it has been completed prior to the first day of work.
22VAC40-73-250-C
Based on a review of criminal background checks for housekeeping and dietary/kitchen staff, one staff did not have an original criminal background check on file.
Evidence
  1. A background check was not available for review for staff # 8.
Plan of correction
After an exhaustive search, the background check results for Staff # 8 was not found. Another background check request was submitted on 7/29/23. He passed with no issues. An entire audit of all staff files will be completed to ensure that every staff member has a background check on file and will comply with the standard. In order to prevent this in the future, Prior to any new team member starting work, the ED will date and initial the background check document to ensure it has been completed prior to the first day of work.
June 15, 2023Complaint survey1 violation
Inspection dates
06/15/2023
Areas reviewed
22VAC40-73 PERSONNEL
Comments
Type of inspection: Complaint Date of inspection: 6/15/23 A complaint was received by VDSS Division of Licensing on 6/15/23 regarding allegations in the area of Personnel. Additional Comments/Discussion: A review of the Virginia Department of Health Professions website was completed on 6-15-23. A qualified licensed administrator shall be immediately employed or a qualified acting administrator shall be appointed. The Virginia Board of Long Term Care shall be notified of the lapse in a qualified administrator. An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation supported the allegations of non-compliance with standard(s) or law, and a violation 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 Yvonne Randolph, Licensing Inspector at 894-662-7454or by e mail at yvonne.randolphdss.virginia.gov
Violations
22VAC40-73-140-E
Based on a review of the Virginia Health Professions website on 6-15-23, the administrator is not currently licensed as an assisted living administrator or nursing home administrator by the Virginia Board of Long Term Care Administrators.
Evidence
  1. A review of the Virginia Health Professions website, license lookup, found that the assisted living administrator license for staff # 1 expired on 3-31-23.
Plan of correction
Administrator immediately renewed license upon learning that it was expired, Receipt of payment and proof of reinstatement was provided to licensing office.
May 2, 2023Inspection1 violation
Inspection dates
05/02/2023
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 IMPAIRMENTS
Comments
Type of inspection: Renewal Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 3-20-23 10:10 a- 12:10 p The Acknowledgement of Inspection form was signed and left at the facility for each date 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: 9 Number of staff records reviewed: 5 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: Lunch meal, medication storage and administration, activity (beauty shop), postings, building maintenance and cleanliness 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. An exit meeting will be conducted to review the inspection findings. 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 Yvonne Randolph, Licensing Inspector at (804)662-7454 by email at yvonne.randolph@dss.virginia.gov
Violations
22VAC40-73-940-A
Based on a file review and an interview, the facility is not in compliance with the Virginia Statewide Fire Code (13 VAC 5-51) as
Evidence
  1. d by an annual fire inspection. Evidence: An annual fire inspection was not available for review by the inspector. The administrator confirmed on 5/5/23 that an inspection was not completed in 2022.
Plan of correction
Albermarle County failed to schedule and complete the annual fire inspection. The fire marshal admits that this is no fault of community.
May 2, 2023Inspection0 violations
Inspection dates
05/02/2023
Areas reviewed
22VAC40-73 BUILDINGS AND GROUND
Comments
Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 5/2/2023 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 5 Observations by licensing inspector: Elevator A self-reported incident was received by VDSS Division of Licensing on 4/19/23 in the area of Building and Grounds An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support 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 Yvonne Randolph, Licensing Inspector at 804-662-7454 or by email at yvonne.randolph@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
March 27, 2023Complaint survey0 violations
Inspection dates
03/27/2023
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND
Comments
Type of inspection: Complaint Unannounced Nonmandated Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 3/27/23 10:15 a- 11: 30 a The Acknowledgement of Inspection form was signed and left at the facility for the date of the inspection. A complaint was received by VDSS Division of Licensing on 3/3/2023 regarding allegations in the area(s): Building and Grounds and Resident Care And Related Services. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: Lunch meal, elevator certifications, activity An exit meeting was conducted to review the inspection findings. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. The evidence gathered during the investigation did not support the allegations of non-compliance with standards 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. Use the following last two statements on every Inspection Summary: For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Yvonne Randolph, Licensing Inspector at (804) 662-7454 or by email at yvonne.randolph@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 16, 2022Inspection2 violations
Inspection dates
05/16/2022
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS
Technical assistance
CDC COVID-19 Community Levels recommendations do not apply in healthcare settings, such as hospitals and nursing homes. Instead, healthcare settings should continue to use community transmission rates and continue to follow CDC’s infection prevention and control recommendations for healthcare settings.
Comments
An unannounced monitoring inspection was completed on 5/16/22 to follow-up on a self-reported incident in the area of Resident Care and Related Services. The resident's room was inspected, the resident's ISP, UAI, staff log notes and nurses notes were reviewed prior to the on-site inspection. The inspector observed the cleanliness of the resident’s room and bathroom and COVID Infection Control Procedures. The administrator was not on site, but communicated with the inspector by telephone. The evidence gathered during the investigation supported the self-report of non-compliance with standards or law, and a violation was issued. Any violations not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violations will be addressed in order to return the facility to compliance and maintain future compliance with applicable standards 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 Yvonne Randolph, Licensing Inspector at 804-662-7454 or by email at yvonne.andolph@dss.virginia.gov
Violations
22VAC40-73-460-A
Based on the follow-up of a self- reported incident, the facility failed to assume general responsibility for the health, safety and well-being of a resident in care.
Evidence
  1. A self reported incident was received on 3/22/22 from the administrator regarding feces being found on the floor of a resident suite on Friday 3/19/22 at approximately 10:30 pm and not being "appropriately cleaned until Saturday after 3 pm".
  2. It was stated in the self-report "One of our resident aides found the spot at approximately 10:30 pm on Friday night, resident assistant reported to the oncoming shift and documented on the 24 hour report that feces needed to be cleaned ".
  3. The administrator reported in an email on "To my understanding, it was completely cleaned on the 3-11 pm shift on Saturday". Based on the administrator report/emails, it has been determined that the facility failed to assume general responsibility for resident care and well-being as the feces on the floor was not appropriately cleaned for three shifts - the 3pm-11pm shift on Friday 3/19/22, the 11pm to 7 am shift on Friday 3/19/22 and the 7am -3 pm shift on Saturday 3/20/22.
Plan of correction
Not published by VDSS.
63.2-100
Based on an onsite inspection on 5/16/22, the facility has failed to implement an infection control program addressing the surveillance, prevention and control of disease and infection that is consistent with the federal Centers for Disease Control and Prevention (CDC) guidelines.
Evidence
  1. CDC Interim Infection Prevention And Control Guidance - February 2, 2022- Establish a process to identify anyone entering the facility, regardless of their vaccination status. who has any of the following three criteria so that they can be properly managed:
  2. a positive viral test for SARS-CoV-2,
  3. symptoms of COVID-19, or
  4. close contact with someone with SARS-CoV-2 infection (for patients and visitors) or a higher-risk exposure (for healthcare personnel (HCP). Options could include (but are not limited to): individual screening on arrival at the facility; or implementing an electronic monitoring system in which individuals can self-report any of the above before entering the facility. On the day of the inspection visit (5/16/22), two licensing inspectors observed that the facility did not have a process in place for visitors entering the facility. Licensing staff and other visitors were allowed to enter and visit in the facility without any type of screening.
Plan of correction
Not published by VDSS.
December 1, 2021Inspection1 violation
Inspection dates
12/01/2021
Areas reviewed
22VAC40-73 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 1Subjectivity
Comments
A monitoring inspection was initiated on 11/9/2021 and concluded on 12/1/2021. the administrator was contacted by telephone to initiate the inspection. The administrator reported the current census as 75 residents. The inspector emailed the administrator a list of items required to complete the documentation review portion of the inspection. The inspector reviewed four resident records, four staff records, background checks for staff hired since 6/1/2021, medication administration records and physician orders, health and fire inspection reports, staff schedules, menus, etc. submitted by the facility to ensure documentation was complete. The on-site inspection was delayed due to COVID. Information gathered during the inspection determined a non-compliance with applicable standards or laws and the violation is and the violation is documented on the violation notice issued to the facility.
Violations
22VAC40-73-150-B-2
Based on an email received on 8/19/2021, the facility failed to immediately notify the Department's regional licensing office that: (1) the licensed administrator had resigned, (2) that a new administrator had been employed, and (3) provide the last date of employment of the previous licensed administrator.
Evidence
  1. On 8/2/2021, the licensing inspector was informed via email from the Central Region licensing administrator that the facility's administrator (staff # 5) had accepted the position of licensed administrator at another licensed assisted living facility.
  2. On 8/19/2021, staff # 1 reported that she accepted the position of administrator at the facility effective 8/15/2021.
  3. The Central Region licensing office was not informed by the facility until 8/19/2021 that:(1) the licensed administrator resigned, (2) that new licensed administrator had been employed, and/or (3) the last date of employment of the previous administrator.
Plan of correction
Administrator became interim Executive Director on 7/29/21. Administrator assumed the role of full time on 8/15/21. Regional Director of Operations did not advisw DSS of the change, Future changes will be communicated ti DSS Licensing Division immediately upon change.
December 1, 2021Complaint survey0 violations
Inspection dates
12/01/2021
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDING AND GROUNDS
Comments
A non-mandated on-site complaint inspection was completed on 12/1/2021. A complaint was received by the department regarding allegations in the areas of resident care and related services, building and grounds and staffing and supervision. The licensing inspector inspected the building for cleanliness and staffing, inspected the food supply and observed the lunch meal. The evidence gathered during the investigation did not support allegations of non-compliance with standards or law.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 3, 2021Inspection1 violation
Areas reviewed
22VAC40-73 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 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity
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. An renewal inspection was initiated with the licensee on 5/3/2021 and concluded on 5/6/2021. The licensee reported a census of 67 residents, The inspector reviewed information submitted for five staff and five residents. medication administration record and physician orders, fire and health inspection documents, Dietician report, health care oversight, staff schedules, etc. for compliance. Information gathered during the inspection determined non-compliance with applicable standards or laws. The non-compliance is noted on the violation notice issued to the facility.
Violations
22VAC40-73-310-H
Based on a review of five resident files on 5/5/2021 during a remote inspection, the facility admitted and retained one individual with a condition prohibited by 22 VAC 40-73-310H.
Evidence
  1. The documented move-in date for resident # 1 is 3/10/2021. The admission physical examination for resident # 1 dated 3/4/2021 documented a prohibited condition - "Psychotropic medications without appropriate diagnosis and treatment plans".
Plan of correction
Error corrected on 5/6/2021.
November 7, 2020Inspection0 violations
Inspection dates
Nov. 7, 2020
Areas reviewed
22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS
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. Licensing staff followed up on a referral received from local social services on 11/7/2020 regarding allegations in the area of a resident discharge. The facility had previously self reported the situation. Licensing staff communicated with the facility's administrator and reviewed the documentation previously submitted regarding the discharge. Evidence gathered during the investigation did not support the allegations.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.