Virginia DSS · Assisted Living Facility

Sancerre Atlee Station

📍 9495 Atlee Road, Mechanicsville, VA, 23116

ID 52809Conditional licenseActive
20
Inspections
On record
7
With violations
Visits that cited something
13
Clean visits
Nothing cited
13
Violations cited
Individual findings
9
Standards cited
Distinct rules
13
Complaint visits
Prompted by a complaint

Sancerre Atlee Station was inspected 20 times between July 31, 2023 and April 6, 2026 by the Virginia Department of Social Services. 7 of those visits ended with violations cited and 13 with none. Across that history VDSS cited 13 violations under 9 distinct standards. 13 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. 2 of these 20 are still on the state's site; the other 18 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
Conditional
License expires
09/04/2026
Administrator
Lauren Friedman
Licensing inspector
Yvonne Randolph
Inspector phone
(804) 441-1180
Approved for
Assisted Living · Non-Ambulatory · Special Care Unit

Inspection History

20

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

April 6, 2026Complaint survey0 violations
Inspection dates
04/06/2026
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Technical assistance
22VAC40-73-600. Time interval between meals. The facility shall ensure that time intervals are met for all 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: 4/6/26 9:30 am to 10:22 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 March 19,2026 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, physician orders, medication management plan, policies and procedures 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.
October 14, 2025Inspection0 violations
Inspection dates
10/14/2025, 02/26/2026
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: Initial Dates the licensing inspector was on-site at the facility for each day of the inspection: 10/14/25 and 2/23/26 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: 108 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: building and grounds, resident rooms, common areas Additional Comments/Discussion: Application, registration of fictitious name 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 should the facility be issued a license to operate. 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 a licensed 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 (x804) 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 21, 2025Complaint survey0 violations
Areas reviewed
22VAC40-73 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: 7/21/25, 9:45 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 7/11/25 regarding allegations in the area of: Resident Care And Related Services Number of residents present in the memory care unit at the beginning of the inspection: 21 The licensing inspector completed a tour of the memory care unit. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 1- attempted- resident has serious cognitive impairment Number of interviews conducted with staff: 2 Observations by licensing inspector: file documentation, resident/staff interaction, lunch meal Additional Discussion: documentation of rounds, staffing/supervision of memory care unit An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation of non-compliance with 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.
July 21, 2025Complaint survey1 violation
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 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: 07/21/2025, 9:45 am to 12:10 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 7/14/25 regarding allegations in the areas of: Staffing and Supervision and Resident Care And Related Services Number of residents present on the memory care unit at the beginning of the inspection: 21 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 -resident has serious cognitive impairment Number of interviews conducted with staff: 2 Observations by licensing inspector: resident rooms, lunch meal, staff schedules, fall incident reports An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation supported the allegations of non-compliance with standards or law, and a violation was issued. Any violations not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation 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.randolphe@dss.virginia.gov.
Violations
22VAC40-73-460-A
Based on video photographs, the facility failed to ensure that the facility assume general responsibility for the health, safety, and well-being of a resident.
Evidence
  1. An allegation was received that resident # 1 had a fall on 6/30/25 and remained on the floor in his room for over five hours. Date and time stamped video photographs were received showing resident on the floor from 11:55 pm on 6/30/25 to 5:21 am on 7/1/25. The video photographs do not show staff checking on the resident during the time period, staff does not appear in the video photographs until 5:21 am.
Plan of correction
Not published by VDSS.
July 14, 2025Complaint survey4 violations
Inspection dates
July 14, 2025 and July 21, 2025
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 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: Complaint Dates of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7/14/2025 11am to 1:43 pm and 7/21/2026 9:45 am to 12/10 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 7/10/25 regarding allegations in the area of: Personnel Number of residents present at the facility at the beginning of the inspection: 21 on memory care unit. The licensing inspector completed a tour of the memory care unit. Number of staff records reviewed: 3 Number of interviews conducted with residents: 1 attempted -resident has serious cognitive impairment Number of interviews conducted with staff: 5 Observations by licensing inspector: memory care unit/bedrooms, lunch meal, staff/resident interaction, file documentation, staffing schedules, medication administration records, communication logs Additional Comments/Discussion: discussed documentation of resident rounds and care, supervision of the memory care unit at night, individualized service plan documentation ( inability of residents to use the signaling system), timelines for toileting goals An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation supported the allegations of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited 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) 441-1180 or by email at yvonne.randolph@dss.virginia.gov
Violations
22VAC40-73-1130-C
Based on a review of the staff schedules and interviews, the facility did not ensure that during the night hours, when there are 22 or fewer residents present, there shall be at least two direct staff awake and on duty at all times in each special care unit and shall be responsible for the care and supervision of the residents.
Evidence
  1. An allegation and video was received by VDSS on 7/10/25 of staff 4 and 5 engaging in inappropriate sexual conduct and sleeping in the room of resident 1 from approximately 1:15 am to 5:45 am on the 11 pm to 7 am shift on 7/9/25 while resident 1 was present and sleeping in the room.
  2. Staff 1 stated on 7/14/25 that there were 21 residents in care on the memory care unit.
  3. The staffing schedule for the 11 pm to 7am shift on 7/9/25 document three staff assigned to the memory care unit - staff 4, staff 5, and staff 6.
  4. Staff 1 and 2 confirmed the validity of the allegation and video in an incident report submitted to VDSS on 7/10/25.
Plan of correction
Team members witnessed in inappropriate behavior were terminated. Clinical schedules are posted daily. The staffing ratio is maintained based on the memory care census. Overnight rounds increased to include all department heads rotating between the 11 pm and 7 am shift. This moved the normal nighttime checks from 3 people to a 7 person rotation, Reviewed lead caregiver job description with all med techs assigned lead responsibilities.
22VAC40-73-110-1
Based on documentation review and interviews, the facility did not ensure that staff be considerate and respectful of the rights, dignity and sensitivities of persons who are aged or infirm or who have disabilities,
Evidence
  1. Staff 4 and 5 were observed on surveillance video engaging in inappropriate sexual conduct in the room of resident 1 while resident 1 was present and sleeping.
  2. Resident 1 resides in a secure memory care environment due to a serious cognitive impairment and is unable to recognize danger or protect her own safety and welfare.
  3. Staff 4 and 5 disregarded the rights and dignity of resident 1 by engaging in inappropriate sexual activity and sleeping in full view of resident 1 who was present and sleeping.
  4. Staff 1 and 2 confirmed the validity of the allegation and video in an incident report submitted to VDSS on 7/10/25.
Plan of correction
Assigned Relias training to all employees- Essentials Of Resident Rights and Resident Rights In Assisted Living. Review the violations during All Staff Meeting to ensure that team collectively can hear the impact individual actions are part of the residents' overall experience.
22VAC40-73-190-E
Based on interviews, the facility did not ensure that the staff member in charge is capable of protecting the physical and mental well-being of the residents.
Evidence
  1. Two direct care staff, staff 4 and 5, were videotaped engaged in inappropriate sexual conduct and sleeping in the room of resident 1 in the memory care unit for more than four hours.
  2. Staff 4 was also the medication aide assigned to administer medications on the memory care unit. 3.The physical and mental well-being of the residents in the secure memory care environment was not protected as staff 6, the staff member in charge on the 11 pm to 7 am shift on 7/9/2025, confirmed during a telephone interview on 7/21/25 that: (a) She was not aware that the two staff were asleep and that the 13 residents assigned to the two staff (according to the assignment sheet) were unsupervised from 1:15 am on 7/9/25 until 5:45am on 7/10/25. (b) She did not have a key to access residents? rooms in the event of a health or safety emergency. (c) She was unaware of the whereabouts of staff 4 and staff # 5 from 1:15am on 7/9/25 until 5:45pm on 7/10/25.
  3. Staff 6 during an interview on 7/21/25 could not confirm if care was provided to the 13 residents that staff 4 and staff 5 were responsible for from 1:15am on 7/9/25 until 5:45am on 7/10/25.
Plan of correction
The involved team members were immediately placed on administrative leave, did not return to the community and subsequently terminated. In-services done with night shift reviewing the importance of rounding, frequency and the focus on the role of protecting the physical and mental well-being of the residents the physical and mental well-being of the residents Assigned all care staff the Relias Course: About Caregiver Conduct.
22VAC40-73-930-D
Based on documentation review and interviews, the facility did not ensure that for each resident with an inability to use the signaling device that once the resident has gone to bed each evening until the resident has arisen each morning, that direct care staff shall make rounds no less than every two hours, and the facility shall document the rounds that were made.
Evidence
  1. Staff 4 and 5 were observed on a surveillance video entering the room of resident 1 at 1:15am on 7/9/25 and not leaving the room until 5:45am on 7/10/25.
  2. Staff 4 and 5 were responsible for a total of 13 residents in the safe, secure environment.
  3. There was no documentation of rounds being completed on 7/9/25 for the shift from 11:00pm to 7:00am.
  4. When asked for documentation of the rounds completed on 7/9/25 and 7/10/25. staff 1 and 2 were unable to provide documentation to support that rounds had been completed on the 11 pm to 7 am shift that started on 7/9/25 and ended on 7/10/25.
Plan of correction
Completed a full memory care audit of the plan of care (POC) documentation to ensure that rounding tasks for Memory Care residents reflect the state requirements. Clinical in-services with all staff on the importance of completing and documenting tasks. Temporarily placed a paper rounding log book to support the team and reinforce the importance of rounding, also giving the team time to ensure the POC was updated. During this time the lead was able to quickly review the log and real-time coach as needed to ensure the best practice is established.
July 14, 2025Complaint survey0 violations
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
Type of inspection: Complaint Dates of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7/21/25 9:45 am to 12:10 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 714/25 regarding allegations in the area of: Resident Care And Related Services and Additional Requirements For Facilities That Care For Adults With Serious Cognitive Impairments Number of residents present in the memory care unit at the beginning of the inspection: 21 The licensing inspector completed a tour of the memory care unit. Number of Resident Records Reviewed: 1 Observations by licensing inspector: Memory care unit/bedrooms, staff/resident interaction, file documentation, staffing schedules, staff care logs Additional Comments/Discussion: discussed documentation of resident rounds and care, supervision of the memory care unit during night hours, individualized service plan documentation (inability of residents to use of the signaling system, timelines for toileting goals) 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.
July 7, 2025Inspection1 violation
Inspection dates
July 7, 2025 and July 21, 2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Dates the licensing inspector was on-site at the facility for each day of the inspection: 7/7/25 and 7/21/25 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 7/7/25 of an incident that was self-reported by the facility previously regarding allegations in the area of: Resident Care And Related Services Number of residents present in the secured memory care unit at the beginning of the inspection: 21 The licensing inspector completed a tour of the memory care unit. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 4 Observations by licensing inspector: file documentation, resident rooms, lunch meal, staff/resident interaction, medication administration, activity 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. 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 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
Violations
22VAC40-73-450-H
Based on a documentation review, the facility did not ensure that care and services specified in the individualized service plan are provided to each resident.
Evidence
  1. The individualized service plan for resident # 1 dated 3/2/25 document that resident # 1 is a two person assist with bathing, toileting and transfers. On 5-15-25 the facility self-reported an incident in which the resident received bruising and a cut on the foot as a result of a one person assist with toileting.
Plan of correction
Not published by VDSS.
July 7, 2025Complaint survey0 violations
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
Type of inspection: Complaint Date the licensing inspector was on-site at the facility for each day of the inspection: 7/7/2025 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 7/5/25 regarding allegations in the areas of: Additional Requirements For Facilities That Care For Adults With Serious Cognitive Impairments and Resident Care And Related Services Number of residents present at the facility at the beginning of the inspection: 21 The licensing inspector completed a tour of the secured memory care unit Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 attempted - Resident has serious cognitive impairment Collateral Interview: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: staffing, resident grooming and personal care, staff/resident interactions, toileting 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. 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) 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 7, 2025Complaint survey3 violations
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 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: Complaint Date the licensing inspector was on-site at the facility for each day of the inspection: 7/7/25 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 6/20/2025 regarding allegations in the areas of: Resident Care And Related Services; Staffing And Supervision; Personnel, Additional Requirements For Facilities That Care For Adults With Serious Cognitive Impairments The licensing inspector completed a tour of the secured memory care unit. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 1 attempted - resident has serious cognitive impairment Collateral Interview - 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: toileting protocol, incontinence care, staff/resident interactions, resident transfer/mobility, file documentation, staffing An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; areas of non-compliance with standards or law were: Resident Care And Related Services, Administration and Administrative Services. A violation notice was issued; any violations not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited 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) 441-1180 or by email at yvonne.randolph@dss.virginia.gov
Violations
22VAC40-73-70-C
Based on a documentation review, interviews and photos, the facility failed to ensure that a written report of each incident that has negatively affected or that threatens the life, health, safety or welfare of a resident is submitted to the regional licensing office within seven days from the date of the incident.
Evidence
  1. Photos were received along with a report that resident # 1 was found with bruising on the face and a raised area on the forehead on 5/11/25. The facility was unable to provide documentation of submission of a written report to the regional licensing office when asked by licensing staff.
Plan of correction
Not published by VDSS.
22VAC40-73-450-H
Based on a documentation review, the facility did not ensure that care and services specified in the individualized service plan are provided to each resident.
Evidence
  1. The individualized service plan for resident # 1 dated 2/25/25 (updated 7/18/25) document ed that resident # 1 is a two person assist with toileting and all transfers. Staff # 1 was observed by licensing staff attempting a one person assist with the resident during a sit-to-stand transfer on 7/7/25. An electronic communication log note dated 6/20/25 record one staff assisting resident # 1 during the provision of incontinence care.
Plan of correction
Not published by VDSS.
22VAC40-73-460-A
Based on a documentation review and photographs, the facility did not ensure that the facility assume general responsibility for the health, safety and well-being of a resident.
Evidence
  1. Two photographs of resident # 1 were forwarded to the licensing inspector showing bruising to the face and a discolored raised area on the forehead. A review of facility documentation found that facility staff was unaware of the origin of the injuries. There was no documentation provided of any monitoring or follow-up regarding the unknown injuries.
Plan of correction
Not published by VDSS.
March 6, 2025Complaint survey0 violations
Areas reviewed
22VAC40-73 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: 3/6/25, 12:20 p to 12:30 p The Acknowledgement of Inspection form was signed and emailed to the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 3/5/25 regarding allegations in the area of: Resident Care and Related Services The licensing inspector completed a tour of the dining areas. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: 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 (xxx) 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.
January 13, 2025Inspection1 violation
Inspection dates
Jan. 13, 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
Technical assistance
22VAC40-73-100 - Approval for Placement in Safe, Secure Environment 22VAC40-73-325 - Fall Risk Rating
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: 1/13/24, 12:15 p mto 2:30 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: 100 (22 in the secure environment) 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: lunch meal, required postings, cleanliness/odors, staffing, file documentation, medication storage and administration, staff/resident interaction Additional Comments/Discussion: 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 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 The departments 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
22VAC40-73-720-A
Based on file reviews, the Do Not Resuscitate (DNR) Order for one resident was not included on the individualized service plan for the resident.
Evidence
  1. A Do Not Resuscitate Order dated 8/3/22 was documented in the file for resident # 1.The individualized service plan for resident # 1 dated 2-16-24 did not include the Order.
Plan of correction
The service plan was updated to include the DNR Order at the time of the exit meeting.
January 13, 2025Complaint survey0 violations
Inspection dates
Jan. 13, 2025
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
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: 1/13/24, 12:15pm to 2:00 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 12/31/24 regarding allegations in the areas of: Personnel, staffing and Supervision, Resident Care and Related Services, Resident Accommodations and Related Provisions, Buildings and Ground and Additional Requirements For Facilities That Care For Adults With Serious Cognitive Impairments 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: 3 Number of interviews conducted with residents:0 Number of interviews conducted with staff: 2 Observations by licensing inspector: lunch meal, building and ground, staffing and supervision, menus, resident grooming, staff interaction with residents An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation did not support the (allegation(s)/self-report) 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) x662-745 or by email at yvonne.randolph@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
November 12, 2024Complaint survey0 violations
Inspection dates
Nov. 12, 2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Technical assistance
22VAC40-73-670. Qualifications of staff administering medications in a licensed assisted living facility: When medications are administered to residents, individuals responsible for medication administration shall: a. Be licensed by the Commonwealth of Virginia to administer medications; or b. Be registered with the Virginia Board of Nursing as a medication aide
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: 11/12/24, 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 11/12/24 regarding allegations in the area of: Resident Care and Related Services 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, medication administration records, physician orders 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. 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.
August 20, 2024Complaint survey0 violations
Inspection dates
Aug. 20, 2024
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND
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: 8-20-24, 2:15 p to 2:45 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 8/5/24 regarding allegations in the area(s) of: Building and Grounds, Staffing and Supervision and Resident Care and Related Services The licensing inspector inspected the physical plant. No odors were detected 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: outside sitting area, and dining area, staffing Additional Comments/Discussion: Staff schedules were reviewed for compliance. 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. 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 yonne.randolph@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
March 5, 2024Inspection1 violation
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 and time that the licensing inspector was on-site at the facility for each day of the inspection: 3/5/24 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: Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 5 Observations by licensing inspector: Staffing, resident/staff interaction Additional Comments/Discussion: Interviews held with a family member and staff on duty the day of the incident. An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation supported the non-compliance with standard(s) or law, and a violation was 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 Yvonne Randolph, Licensing Inspector at 804-662-7454 or by email at yvonne.randolph@dss.virginia.gov
Violations
22VAC40-73-460-A
Based on an investigation of a self-reported incident, the facility did not assume general responsibility for the health, safety and welfare of a resident.
Evidence
  1. The facility self-reported a resident to resident altercation on 1/28/24 in the common area of the memory care environment. The self-report documented that resident # 1 was hit by a pillow and fell face first to the floor resulting in injuries to the face. (photo taken of injuries)
  2. Resident # 1 was transported to a local ER and had a CT face scan that documented head injury with facial fracture and a CT head scan that documented fall with sdh/sah (subdural hematoma and subarachnoid hemorrhage).
  3. Interviews with staff on duty at the time of the fall did not support that staff was physically present within an immediate distance of the residents in the common area to prevent the fall or altercation. a. Staff # 3 stated during her interview that she did not observe the incident or fall as she was assisting a resident in the resident’s room. b. Staff # 4 stated during her interview that she did not observe the incident or fall as she was not in the area. c. Staff # 5 stated during her interview that she was walking out of the kitchen area when the incident and fall occurred.
Plan of correction
1 Continue to support the staff in early interventions with resident behaviors. 2. Staff Training: Staff members who currently support Memory Care residents shall receive training on addressing aggressive behavior between residents, to promote early interventions. 3. Oversight Enhancement: The newly hired community’s Memory Care Director, or their designee, shall help manage oversight of resident care. The community’s Memory Care Director, or their designee, shall provide guidance and support to staff in ensuring that residents' needs are met, and potential incidents are addressed promptly.
February 20, 2024Complaint survey0 violations
Inspection dates
Feb. 20, 2024
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 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: Complaint Date of inspection the licensing inspector was on-site at the facility for each day of the inspection: 2/20/24 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: 57 The licensing inspector completed a tour of the memory care environment Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents:0 (residents are cognitively impaired) Number of interviews conducted with staff: 2 Observations by licensing inspector: Memory care environment, resident room, staff/resident interaction, health care documentation Additional Comments/Discussion: Collateral interviews completed. Follow-up on a self reported incident was performed. A complaint was received by VDSS Division of Licensing on 1/25/2026 regarding allegations in the area(s) of: Staffing and Supervision; Resident Care and Related Services; Resident Accommodations and Related Provisions; Building and Grounds; Emergency Preparedness; Additional Requirements for Facilities That Care for Adults with Serious Cognitive Impairments, Follow-up on a self reported incident in regards to Resident Care and Related Services was also performed. A complaint was received subsequently in regards to the incident. An exit meeting was conducted to review the inspection findings. The evidence gathered during the investigation did not support allegations (in the complaint/self-report) 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.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
January 17, 2024Inspection2 violations
Inspection dates
Jan. 17, 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 of inspection the licensing inspector was on-site at the facility for each day of the inspection: 1/17/23 10:30 am to 2:20 pm 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: 57 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 4 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: memory care, environment, medication storage and administration, staff/resident interactions Additional Comments/Discussion: Program documentation and resident and staff files were well-organized. 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 Yvonne Randolph, Licensing Inspector at 804-662-7454 or by email at yvonne.randolph@dss.virginia.gov
Violations
22VAC40-73-440-A
Based on a review of resident files, the facility did not ensure that all residents of and applicants to the assisted living facility shall be assessed face to face using the uniform assessment instrument in accordance with Assessment in Assisted Living Facilities (22VAC30-110) and prior to admission.
Evidence
  1. The file documented that resident #4 was admitted to the facility on 9/12/23. The uniform assessment instrument for Resident # 4 was documented as completed on 9/14/23.
Plan of correction
Ensure that UAI assessments are completed before the admission process for every resident. Implement on 1/17/24 a timeline specifying that the UAI assessments be finalized before admission. It is mandatory for the team to use the UAI as the foundational document for the pre move in assessment. Ongoing compliance will include quality assurance checks as part of the healthcare oversight to ensure compliance with the new process.
22VAC40-73-440-A
Based on a review of resident files, the facility did not ensure that all residents of and applicants to the assisted living facility shall be assessed face to face using the uniform assessment instrument in accordance with Assessment in Assisted Living Facilities (22VAC30-110) and prior to admission.
Evidence
  1. The file documented that resident #4 was admitted to the facility on 9/12/23. The uniform assessment instrument for Resident # 4 was documented as completed on 9/14/23.
Plan of correction
Ensure that UAI assessments are completed before the admission process for every resident. Implement on 1/17/24 a timeline specifying that the UAI assessments be finalized before admission. It is mandatory for the team to use the UAI as the foundational document for the pre move in assessment. Ongoing compliance will include quality assurance checks as part of the healthcare oversight to ensure compliance with the new process.
January 17, 2024Complaint survey0 violations
Inspection dates
Jan. 17, 2024
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
Type of inspection: Complaint Date of inspection the licensing inspector was on-site at the facility for each day of the inspection: 1/17/2023, 10:30 a to 2:30 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: 57 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: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: Resident room and bathroom, memory care environment, Activity and lunch meal A complaint was received by VDSS Division of Licensing on 1/2/24 regarding allegations in the area(s) of: Personnel, Staffing And Supervision, Resident Care And Related Services, Resident Accommodations And Related Services, Building And Grounds, Additional Requirements For Facilities That Care For Adults With Serious Cognitive Impairments. Additional Comments/Discussion: Suggested evaluation for eating and assistive device. 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.
October 30, 2023Inspection0 violations
Inspection dates
Oct. 30, 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: 60 Day, Mandated Monitoring Date of inspection the licensing inspector was on-site at the facility for each day of the inspection: 10:30 a to 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: 46 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: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: Lunch meal, postings, activities, staff/resident interactions, medication storage and administration Additional Comments/Discussion: Services and care observed to be person-centered and individualized. 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@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
July 31, 2023Inspection0 violations
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 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: Initial Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7/31/23 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Building and grounds, resident rooms, memory care enviroment Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. 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 or by email at yvonne.randolph@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.