The Estates at West End

22VAC40-73-1090. Assessment. A. Prior to his admission to a safe, secure environment, the resident shall have been assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare. The physician shall be board certified or board eligible in a specialty or subspecialty relevant to the diagnosis and treatment of serious cognitive impairments (e.g., family practice, geriatrics, internal medicine, neurology, neurosurgery, or psychiatry)

Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 4/7/2026, 1:15 pm to 3:08 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: 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: 3 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: facility repair and maintenance, file documentation, resident-staff interaction, required postings 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 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

Type of inspection: Complaint. Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 4/7/26, 1:15 pm to 3:08 pm The Acknowledgement op 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 2/26/26 regarding allegations in the area of: Staffing and Supervision 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: 3 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: file documentation, resident-staff interaction An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation did not support the 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

Type of inspection: Non-Mandated Monitoring Date the licensing inspector was on-site at the facility for each day of the inspection: 6/27/2025 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 5/22/25 regarding allegations in the area of: Resident Care and Related Services Number of resident records reviewed: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: File Documentation An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation supported non-compliance with one standard or law, and a violation was issued. Any violation 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 violation(s) 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)441-1180 or by email at yvonne.randolph@dss.virginia.gov

Type of inspection: Renewal Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 4/1/2025, 12 noon to 3:25 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: 73 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 staff: 2 Observations by licensing inspector: Medication storage/administration/availability, facility maintenance and cleanliness, required postings, file documentation, activity (resident council meeting), secured environment, snack availability An exit meeting was conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standards or laws. 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) 662-7454 or by email at yvonne.randolph@dss.virginia.gov

Type of inspection: Monitoring Mandated Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 4/12/2024, 11a to 2 p The Acknowledgement of Inspection form was left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 76 on site The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 11 Number of staff records reviewed: 7 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 4 Observations by licensing inspector: facility maintenance and repair, medication storage and administration, lunch meal, required posting, file documentation 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 Yvonne Randolph, Licensing Inspector at 804-662-7454 or by email at yvonne.randolph@dss.virginia.gov

Type of inspection: Monitoring Date and time the licensing inspector was on-site at the facility for each day of the inspection: 3/4/2024 11a - 12:30 p The Acknowledgement of Inspection form was emailed 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 memory care environment. Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Staffing, security system for doors entrance/exit doors Additional Comments/Discussion: Inspection completed to follow-up on self -reported resident elopements An exit meeting was 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

Type of inspection: Complaint Date of inspection the licensing inspector was on-site at the facility for each day of the inspection: 10/23/23 1pm to 2 pm 11/6/23 10 am to 11 am The Acknowledgement of Inspection form was emailed 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 residents present at the facility at the beginning of the inspection: Number of resident records reviewed: Number of staff records reviewed: O Number of interviews conducted with residents: O (residents were cognitively impaired) Number of interviews conducted with staff: 11 Observations by licensing inspector: Secure Memory Unit Comments: Licensing staff reviewed ISPs, elopement drill logs, nurses notes, emails A complaint was received by VDSS Division of Licensing on (date) regarding allegations in the area(s) of: Additional Requirements for Facilities That Care For Adults With Serious Cognitive Impairments 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 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

Type of inspection: Complaint , Unannounced Non Mandated Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7/29/23, approximately 11 am and 12 noon 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 8/17/23 regarding an allegation in the areas: Resident Care and Accommodations 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 Yvonne Randolph Licensing Inspector at 894-662-7454 or by email at Yvonne.randolph@dss.virginia.gov

Type of inspection: Complaint, Non-mandated Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7/24/2023 11 am to 12 noon 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 7-19-23 regarding allegations in the areas: Personnel, Admissions, Retention and and Discharge Number of residents present at the facility at the beginning of the inspection: 73 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 attempted Number of interviews conducted with staff: 2 Additional Comments/Discussion: 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 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

Type of inspection: Complaint Date of inspection when the licensing inspector was on-site at the facility : 7/17/23 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 7/11/23 regarding allegations in the areas: Staffing And Supervision, Resident Care And Related Services, Administration And Administrative Services, Personnel, Resident Accommodation And Related Provisions, Building And Grounds, and 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: 73 Number of staff records reviewed: Reviewed staff schedules (housekeeping, direct care) Number of interviews conducted with staff: 2 Observations by licensing inspector: Building and Grounds (outside areas, memory care, 3rd floor staff lounge, staff training room, dining area) Additional Comments/Discussion: The staffing schedules reflects compliance with the standards. An inspection of the 3rd floor and BTR did not find any strong urine odors, residents do smoke and drink unless medically prohibited. 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 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