20
Inspections
On record
11
With violations
Visits that cited something
9
Clean visits
Nothing cited
26
Violations cited
Individual findings
20
Standards cited
Distinct rules
10
Complaint visits
Prompted by a complaint
Auburn Hill Senior Living was inspected 20 times between February 8, 2021 and October 23, 2025 by the Virginia Department of Social Services. 11 of those visits ended with violations cited and 9 with none. Across that history VDSS cited 26 violations under 20 distinct standards. 10 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. 15 of these 20 are still on the state's site; the other 5 have since dropped off it and are reproduced from Assisted Living Magazine's archive of the original VDSS reports.
Provider Information
Facility type
Assisted Living Facility
License type
Two Year
License expires
08/05/2027
Administrator
Stacey Bowen
Licensing inspector
Coy Stevenson
Inspector phone
(804) 972-4700
Approved for
Non-Ambulatory · Assisted Living · Special Care Unit
Inspection History
20Select an inspection to read the areas reviewed, the inspector's comments and any violations cited.
October 23, 2025Complaint survey
Inspection dates
10/23/2025
Areas reviewed
22VAC40-80 COMPLAINT INVESTIGATION
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: An on-site inspection related to a complaint was conducted on October 23, 2025.
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 October 24, 2025, regarding allegations in the area(s) of: PERSONNEL; STAFFING AND SUPERVISION; RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS; RESIDENT CARE AND RELATED SERVICES; BUILDINGS AND GROUNDS
Number of interviews conducted with staff: 3
Observations by licensing inspector: Residents were observed interacting with each other and staff. These interactions were appropriate. The residents were observed during meal service. The residents were appropriately dressed and groomed for the time of day, weather conditions, and activities they were engaged in.
Additional Comments/Discussion: Menus, scheduled meal times, maintenance inspection reports, and documentation related to monitoring that residents rooms are cleaned and laundry for those residents whose wish to have the facility do their laundry were reviewed.
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 Coy Stevenson, Licensing Inspector at (804) 972-4700 or by email at coy.stevenson@dss.virginia.gov.
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
June 2, 2025Inspection
Inspection dates
06/02/2025
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 IMPAIRMENTS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Technical assistance
Discussed with the provider the importance of maintaining documentation (i.e. emails, phone records, letters, etc…) when corresponding with other oversight agencies (i.e. fire safety, food safety, etc…) to demonstrate due diligence on their part of the required inspections have not been conducted on at least an annual basis.
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: An on-site review of the facility was conducted on June 02, 2025, from approximately 9:00 AM – 1:00 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: 98
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: 2
Observations by licensing inspector: The interior and exterior of the facility were in good repair. No obvious safety concerns were noted. Resident interactions amongst themselves and with staff were appropriate. The residents were appropriately dressed and groomed for the time of day, weather conditions, and activities they were engaged in. Residents were observed during lunch time eating. What was listed as the available menu options were available and served. Registered Medication Aide was observed administering medication.
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 Coy Stevenson, Licensing Inspector at (804) 972-4700 or by email at coy.stevenson@dss.virginia.gov.
Violations
22VAC40-73-210-B
The facility did not have documentation of required annual training for direct care staff.
Evidence
- At the time of the on-site review, a review of the record for Employee #2 did not have documentation showing the employee completed the required number of annual training hours
Plan of correction
Facility Administrator and Business Office Manager were unable to access documentation for the noted employee's training hours. Systematic changes have been made to ensure that documentation is kept up to date and in a central location that is accessible to all managers. BOM and ED will monitor for continued compliance.
May 31, 2025Complaint survey
Inspection dates
05/31/2025
Areas reviewed
22VAC40-80 COMPLAINT INVESTIGATION
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: An on-site inspection was conducted on May 13, 2025, from approximately 10:00 AM – 10:30 AM.
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(s) of: RESIDENT RIGHTS; RESIDENT ACCOMMODATIONS
(free of physical abuse, since the resident physically assaulted her, but it was a on-time incident, no charges pressed, and resident does not recall the incident happening; the resident was not injured
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: The door handle on the resident’s room was able to be locked via a twisting button style mechanism, which locks the door the outside. The door is automatically unlocked when opened from the inside. This type of locking mechanism allows the resident to lock their door if they wish, or asking staff to lock the door, but allowing them freedom of movement, as they are free to exit their room without being forced to ask for assistance to unlock the door.
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 Coy Stevenson, Licensing Inspector at (804) 972-4700 or by email at coy.stevenson@dss.virginia.gov.
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
February 3, 2025Complaint survey
Inspection dates
02/03/2025
Areas reviewed
22VAC40-80 COMPLAINT INVESTIGATION
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: An on-site inspection was conducted on February 03, 2025, from approximately 10:00 AM to 11:30 AM.
A complaint was received by VDSS Division of Licensing on December 23, 2024, regarding allegations in the area(s) of: resident care
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 interviews conducted with staff: 1
Number of interviews conducted with residents: 3
Observations by licensing inspector: The resident’s identified in the complaint were appropriately dressed and groomed for the time of day and activities they were engaged in. There was a sufficient amount and appropriate type of hygiene products readily available for the residents.
Additional Comments/Discussion: No evidence was gather to support the allegation that the facility is admitting residents whom they are not licensed to care, or have the necessary equipment or appropriately trained staff to provide care to residents.
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 Coy Stevenson, Licensing Inspector at (804) 972-4700 or by email at coy.stevenson@dss.virginia.gov.
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
February 3, 2025Complaint survey
Inspection dates
02/03/2025
Areas reviewed
22VAC40-80 COMPLAINT INVESTIGATION
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: An on-site inspection was conducted on February 03, 2025, from approximately 10:00 AM to 11:00 AM.
A complaint was received by VDSS Division of Licensing on December 23, 2024, regarding allegations in the area(s) of: resident care
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: 1
Number of interviews conducted with staff: 1
Observations by licensing inspector:
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 Coy Stevenson, Licensing Inspector at (804) 972-4700 or by email at coy.stevenson@dss.virginia.gov.
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
June 7, 2024Inspection
Inspection dates
06/07/2024; 06/12/2024
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 PREPAREDNESS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE
Technical assistance
Discussed with the provider including required orientation topics into their established training tracking system, or utilize already developed forms on the VDSS website that includes all required topics.
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: The renewal process began on June 07, 2024. The licensing inspector arrived onsite at approximately 11:30 AM. The inspection on this date concluded at approximately 3:00 PM. On June 12, 2024, the licensing inspector arrived onsite at approximately 10:00 AM and concluded at approximately 1:00 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: 89
The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility.
Number of resident records reviewed: 8
Number of staff records reviewed: 5
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 2
Observations by licensing inspector: Common areas of the facility were observed to include dining areas, recreational areas, lounge areas, nurse stations, medication storage areas. Observations of interactions between residents and employees of the facility were also made.
Additional Comments/Discussion: No health or safety issues noted.
An exit meeting will be conducted to review the inspection findings.
The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law.
If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview.
Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected.
Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area.
Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice.
The department's inspection findings are subject to public disclosure.
Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility.
For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov
Should you have any questions, please contact Coy Stevenson, Licensing Inspector at 804-972-4700 or by email coy.stevenson@dss.virginia.gov
Violations
22VAC40-73-250-D
Based on record reviews and interviews, it was determined that the facility did not ensure that each new hire provides documentation on, or within seven days prior to the first day of working at the facility, and prior to coming in contact with residents, the results of a risk assessment documenting the absence of tuberculosis in a communicable form.
Evidence
- A review of Employee #2’s file did not contain a risk assessment documenting the absence of tuberculosis in a communicable form. Employee #2’s file did contain a risk assessment; however, the form was incomplete. The sections of the form used to determine risk were incomplete/blank.
- Employee #6 and Employee #7 confirmed that the risk screening in Employee #2’s file was incomplete.
Plan of correction
Employee #2’s tuberculosis risk assessment was completed on 04/16/2024 by the Director of Memory Care, LPN.
On or within 7 days of hire a tuberculosis risk assessment will be completed by the Director of Health and Wellness/LPN designee The Business Office Manager/designee will ensure a copy of the completed tuberculosis risk assessment is maintained in the employee’s personnel file.
January 5, 2024Complaint survey
Inspection dates
01/05/2024
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: 1-05-2024, 9:50 - 10:25am
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 September 30, 2023 regarding allegations in the area(s) of: Safe, Secure Environment and Buildings and Grounds
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.
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 Alex Poulter, Licensing Inspector at 804-662-9771 or by email at alex.poulter@dss.virginia.gov
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
August 21, 2023Inspection
Inspection dates
08/21/2023
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 EMERGENCY PREPAREDNESS
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: 8-21-2023, 9:11am – 1:00pm
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
Number of resident records reviewed: 10
Number of staff records reviewed: 3
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 Alex Poulter, Licensing Inspector at (804)662-9771 or by email at alex.poulter@dss.virginia.gov
Violations
22VAC40-73-970-E
Based on record review, the facility failed to ensure a record of the required fire and emergency evacuation drills included the number of residents participating.
Evidence
- The 5-29-2023 Fire and Emergency Evacuation Drill at 10:30 p.m. was blank under “Number of residents participating:”.
Plan of correction
Facility will ensure that a record of the required fire and emergency evacuation drills include the number of residents participating. This will be the responsibility of our Director of Environmental Services or the Director of Environmental Services assistant/designee.
22VAC40-73-440-B
Based on record review, the facility failed to ensure an assisted living facility staff person who has completed the uniform assessment instrument (UAI) has it signed by the administrator or the administrator's who approves and then signs the completed UAI.
Evidence
- Resident #9’s UAI dated 10-07-2022 and Resident #10’s UAI dated 9-29-2022 were only signed by former director of memory care, and not by the administrator or designee as having approved the UAIs.
Plan of correction
Facility will ensure that the staff person completing the UAI (uniform assessment instrument) will sign and date it and will make sure that the administrator or administrator’s designee also signs and dates for approval of the completed UAI.
22VAC40-73-450-C
Based on record review and interview with staff, the facility failed to ensure the comprehensive individualized service plan (ISP) included a description of identified needs and date identified based upon the (i) UAI; (ii) admission physical examination; (iii) interview with resident; (iv) fall risk rating, if appropriate; (v) assessment of psychological, behavioral, and emotional functioning, if appropriate; and (vi) other sources.
Evidence
- Resident #2 admitted 6-21-2023. Resident #2’s Uniform Assessment Instrument (UAI) dated 8-08-2023 documented wheeling and stairclimbing assistance as “human help, physical assistance” and that resident is disoriented; however, those needs were not identified on the comprehensive ISP dated 8-08-2023. The resident resided in the special care unit (SCU) which was not on the resident’s ISP. 2.Resident #7 admitted 4-28-2023. Resident #7’s UAI dated 6-22-2023 documented transferring assistance as “mechanical help, human help physical assistance” and that resident is disoriented; however, those needs were not identified on the comprehensive ISP dated 8-03-2023. The resident resided in the SCU, which was also not on the resident’s ISP. 3.Resident #8 admitted 5-16-2023. Resident #8’s UAI dated 6-16-2023 documented behaviors as “wandering”; however, the ISP dated 6-16-2023 did not identify this service need.
Plan of correction
Facility will ensure that the comprehensive individualized service plan (ISP) shall include description of identified needs and date identified based upon the UAI (uniform assessment Instrument), admission physical examination, interview with resident, fall risk rating and if appropriate assessment of psychological, behavioral, and emotional functioning and other sources. This will be the responsibility of our Memory Care Director and/or our Director of Health and Wellness.
Resident # 2- Deceased on 08/21/2023
Resident # 7- Deceased on 9/14/2023
Resident #8- ISP updated on 11/01/2023
An audit of all resident UAIs and ISPs will be conducted to ensure all needs assessed on the UAI are captured on the ISP. Director of Health and Wellness will provide all individuals completing UAIs a copy of the UAI manual. ED will ensure prior to all resident signatures that all assessed needs on the UAI are captured in the ISP.
22VAC40-73-450-F
Based on record review, the facility failed to ensure individualized service plans (ISPs) were updated at least once every 12 months and as needed for a significant change of a resident’s condition.
Evidence
- Resident #10 admitted 2-15-2022. Resident #10’s UAI dated 9-29-2022 documented the resident has wandering behaviors; however, the most recent ISP 9-2022 did not identify wandering behavior. The resident also resided in the Special Care Unit (SCU); however, it was not addressed on the ISP. 2.Resident #9 admitted 2-15-2021. Resident #9’s UAI dated 10-2022 identified the resident as bowel and bladder incontinent, weekly or more; however, the ISP dated 8-22-2023 documented the resident as “continent”. Additionally, the resident’s UAI documented the resident has wandering behaviors and is disoriented, which neither were addressed on the ISP. 3.Resident #6 admitted 2-25-2022. Resident #6’s UAI dated 10-04-2022 documented the resident has bowel incontinence; however, the ISP dated 8-25-2023 documented “continent”. 4.Resident #1 admitted 2-01-2022. Resident #1’s UAI dated 3-29-2023 documented the resident requires “mechanical help, human help physical assistance” with bathing, and “mechanical help, human help supervision” with transferring; however, neither need was addressed on the ISP dated 3-28-2023.
Plan of correction
Facility will ensure that ISP’s (Individual service plan) will be reviewed and updated at least once every 12 months and as needed for a significant change of a resident’s condition. This will be the responsibility of our Memory Care Director and/or our Director of Health and Wellness.
Resident #10- updated on 11/01/2023 for Assessment and care plan to match
Resident # 9- updated on 11/01/2023 for UAI to match ISP
Resident #6- updated on 11/01/2023- for UAI to match ISP
Resident #1- updated on 11/01/2023 for UAI to match ISP
August 21, 2023Inspection
Inspection dates
08/21/2023
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
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: 8-21-2023
1:01 – 1:30 p.m.
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 6/14/2023 and 6/21/2023 regarding allegations in the area of: Resident Care and Related Services.
Number of residents present at the facility at the beginning of the inspection: 76
Number of resident records reviewed: 2
An exit meeting will be conducted to review the inspection findings.
The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-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 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 Alex Poulter, Licensing Inspector at (804)662-9771 or by email at alex.poulter@dss.virginia.gov
Violations
22VAC40-73-680-D
Based on record review and interview with staff, the facility failed to ensure that medications were administered in accordance with the physician's or other prescriber’s instructions.
Evidence
- An incident report received 6-11-2023 documented Resident #1 was administered a medication that was not prescribed to the resident. The final updated report on 6-14-2023 documented the medications were Carvedilol 12.5 mg and Tylenol 650mg and that neither were prescribed to Resident #1.
- Additionally, an incident report received 6-22-2023 documented Resident #2 was administered a medication that was prescribed to the resident with a later effective “start” date. The initial/final report dated 6-21-2023 documented Amoxicillin 500 mg three times per day for seven days, and Chlorhexidine 0.12% rinse twice daily was due to start 8-02-2023.
- The facility’s Medication Administration plan documented, “No medication shall be started without an order by the physician” (dated 07-06-2020).
- The “Five Rights of Medication Administration” provided by the facility documented “the second, and also very obvious, right is to ensure that the medication is being administered to the right patient.” (dated 2016).
- Staff #1 confirmed during interview the aforementioned medications were administered and were not in accordance with physician’s instructions for Resident #1 or Resident #2.
Plan of correction
Resident number one on 06/11/2203 MD and legal representative notified. Resident was monitored with no negative outcome. Internal medication incident was completed.
Resident number two on 06/14/2203 MD and legal representative notified. Resident was monitored with no negative outcome. Internal medication incident was completed.
Reduction to RMA and LPN’s on communities medication management plan(“five rights of medication administration”) to be completed by 11/30/2023.
Director of Health and Wellness, Director of Memory Care, or designee audit medication pass observation weekly x30 days. Reeducation as needed.
July 20, 2023Inspection
Inspection dates
07/20/2023
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
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: 7-20-2023, 9:01 – 10:40 a.m.
Number of residents present at the facility at the beginning of the inspection: 71
Number of resident records reviewed: 4
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 4/21/2023 and 5/15/2023 regarding allegations in the area of: Resident Care and Related Services
The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-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 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 Alex Poulter, Licensing Inspector at (804)662-9771 or by email at alex.poulter@dss.virginia.gov
Violations
22VAC40-73-470-F
Based on record review and interview with staff, when the resident suffers serious illness or medical condition, or there is reason to suspect that such has occurred, medical attention from a licensed health care professional shall be secured immediately.
Evidence
- Resident #1 admitted 1-29-2020 to the facility. Resident #1’s Progress Notes dated 4-17-2023 documented, “Physical therapist states she noticed a decline in the resident from Friday to today (4/17), she reports [Resident #1] not following instructions as well, seems weaker, and her voice was hoarse. She also observed the resident choke on water which she had never observed before. She states her vitals were good and to push fluids in case of dehydration.”
- On 4-22-2023, Progress Notes documented the resident was “lying in bed breathing using accessory muscles, will open eyes briefly when name is called but is unable to say any words. Large area below left ear hardened and slightly warm to touch. Ear lobe swollen as well. Left hand and fingers purple and swollen… also has purplish blotching discoloration to bilateral lower extremities…transported to [hospital] via EMS…”
- Resident #1 was admitted to the hospital on 4-22-2023 with “altered mentation and fever and was admitted with a diagnosis of metabolic encephalopathy, septic shock, renal failure, parotitis, and pneumonia.”
- Resident’s 4-27-2023 facility Progress Note documented, “[Staff] spoke with daughter-in-law about resident’s status, [Resident #1] is in ICU in serious condition…stated she e-mailed Director of Innovations and never received a response.”
- There was no documentation that Resident #1’s physician was contacted following a 4-18-2023 physician’s note regarding Resident #1’s [bilateral extremities] and bruise on chest. Additionally, Staff #1 confirmed during interview that Resident #1 had a delay in medical care from 4-17-2023 to 4-22-2023 as medical attention was not secured immediately. Progress Notes documented Resident #1 passed under hospice on 4-29-2023.
Plan of correction
Resident #1 was seen by a physician on 04/18/23 due to a change in the resident’s medical condition. Resident #1 no longer resides in the community.
All residents who suffer a serious illness or medical condition will be reviewed by the Director of Health and Wellness (DHW)/Director of Memory Care (DMC) in stand-up meeting daily to ensure that medical attention from a licensed health care professional is secured timely.
22VAC40-73-440-A
Based on record review, the facility failed to ensure that the uniform assessment instrument (UAI) was completed at least annually.
Evidence
- Resident #4 admitted 4-23-2021. Resident #4’s latest UAI was dated 3-11-2022. Resident #3 admitted 4-22-2021 and was discharged 5-24-2023. Resident #3’s latest UAI was 4-22-2021.
Plan of correction
Facility will ensure that UAI (uniform assessment instrument) will be completed at least annually and or a change in condition. The UAI’s will be the responsibility of our Memory Care Director and/or our Director of Health and Wellness.
Resident #4’s latest UAI was dated 08/09/23.
Resident #3 no longer resides in the community.
A weekly audit will be completed for the next 30 days by the Director of Health and Wellness and Director of Memory Care to ensure that all UAIs are up to date.
22VAC40-73-450-E
Based on record review, the facility failed to ensure the individualized service plan (ISP) was signed and dated by the resident or his legal representative.
Evidence
- Resident #1 admitted 1-29-2020. Resident #1’s ISP dated 4-13-2022 was not signed by the resident or resident’s legal representative.
Plan of correction
Facility will ensure that the ISP (Individualized service plan) will be signed and dated by the resident or his/her legal representative. It will be the responsibility of our Memory Care Director and/or our Director of Health and Wellness.
Resident #1 no longer resides in the community.
A weekly audit will be completed for the next 30 days by the Director of Health and Wellness and Director of Memory Care to ensure that all individualized service plans (ISPs) are up to date and have been reviewed and signed by resident and/or legal representative.
Weekly audit by ED, HWD , and DIMC conducted for next 30 days.
22VAC40-73-550-C
Based on record review and interview with staff, the facility failed to ensure any resident of an assisted living facility (ALF) has the rights and responsibilities as provided in § 63.2-1808 of the Code of Virginia and this chapter.
Evidence
- Three self-reported incidents were received by Staff #1 on Residents’ #2, #3, and #4 that alleged abuse took place between approximately 4-08-2023 and 4-21-2023.
- A ‘Comment/Concern’ form completed by Staff #6 documented that (on unknown date), “[Staff #7] and [Staff #6] worked 11-7 shift in memory care unit… [Resident #2] is usually agitated... [Staff #7] took the resident blue diaper off resident, the diaper was soaking with which the diaper inflated heavily with urine. [Staff #6] saw [Staff #7] took the diaper and hit resident in the face…”
- A ‘Skin Integrity Monitoring’ form completed by Staff #8 dated 4-21-2023 documented no injuries to Resident #2. Eight staff written statements denied witnessing abuse by Staff #7 at any time or this alleged incident.
- A ‘Witness Statement’ form completed by Staff #4 dated 4-19-2023 documented, “approx. 4/8/23… [Staff #5] asked for assistance with [Resident #3]. [Staff #5] told [Resident #3] several times to “get the f*** up” then she proceeded to closed fist hit [Resident #3] in the groin. On multiple other shifts she was heard yelling at residents in the dining area to leave and “get the hell up”, “get the f*** up”…”
- The aforementioned witness statement by Staff #4 additionally documented, “…On approx. 4/14/23 [Staff #5] was also observed in dining area… trying to get [Resident #4] out of the area… gave [Resident #4] terrible attitude and pushed his walker to him, he got mad and called her an a**hole, she called him one as well and pushed the walker again, she walked off taunting and laughing at him…”
- Skin Integrity Monitoring Forms completed by Staff #8 dated 4-20-2023 documented no injuries to Resident #3 or Resident #4.
- Staff #5 was terminated per Staff #1 due to substantiated footage seen by Staff #1 and Staff #2 involving incident with Resident #4. Staff #1 and Staff #2 stated that Resident #2’s and Resident #3’s incidents could not be substantiated due to lack of witnesses or camera evidence (none seen). Staff #6 who made allegations regarding Resident #2 “quit a couple days ago” and was written up for reporting incidents late to staff.
Plan of correction
A major incident report/investigation for allegation of abuse and neglect for Resident #2 was completed on 04/21/23 by the Executive Director.
A major incident report/investigation for allegation of abuse and neglect for Resident #3 was completed on 04/20/23 by the Executive Director.
A major incident report/investigation for allegation of abuse and neglect for Resident #4 was completed on 04/20/23 by the Executive Director.
Staff member #5 was terminated for abuse and neglect.
All staff were re-educated on abuse and neglect mandated reporter status by the Executive Director.
All staff were re-educated on Residents rights and responsibilities as provided in 63.2-1808 of the Code of Virginia and this chapter on 09/19/2023.
Resident’s rights and responsibilities as provided in 63.2-1808 of the Code of Virginia and this chapter will be reviewed upon hire and annually.
22VAC40-73-450-F
Based on record review, the facility failed to ensure individualized service plans (ISPs) were reviewed and updated at least once every 12 months.
Evidence
- Resident #4 admitted 4-23-2021. Resident #4’s most current ISP was dated 5-13-2022.
Plan of correction
Facility will ensure that ISP’s (Individualized service plan) will be reviewed and updated al least once every 12 months and as needed for a significant change of a resident’s condition.
This will be the responsibility of our Memory Care Director and/or our Director of Health and Wellness.
Resident #4’s latest UAI was dated 08/09/23.
A weekly audit will be completed for the next 30 days by the Director of Health and Wellness and Director of Memory Care to ensure that all individualized service plans (ISPs) are up to date and have been reviewed and updated at least once every 12 months.