17
Inspections
On record
3
With violations
Visits that cited something
14
Clean visits
Nothing cited
9
Violations cited
Individual findings
9
Standards cited
Distinct rules
10
Complaint visits
Prompted by a complaint

Ginter Hall South was inspected 17 times between January 19, 2021 and November 3, 2025 by the Virginia Department of Social Services. 3 of those visits ended with violations cited and 14 with none. Across that history VDSS cited 9 violations under 9 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 and no longer serves any of these on its site. All 17 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
02/28/2026
Administrator
Mrs. Linda Bishop
Licensing inspector
Shelby Haskins
Inspector phone
(804) 305-4876
Approved for
Special Care Unit · Residential and Assisted Living Care · Non-Ambulatory

Inspection History

17

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

November 3, 2025Complaint survey0 violations
Inspection dates
Nov. 3, 2025
Areas reviewed
22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-80 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: 11/03/2025 arrival time 2:45pm departure time 3:45pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 10/20/2025 regarding allegations in the area(s) of: 22VAC40-73-(7) RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73-(8) BUILDINGS AND GROUND 22VAC40-80-(G7) COMPLAINT INVESTIGATION Number of residents present at the facility at the beginning of the inspection: 47 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of interviews conducted with staff: 2 Observations by licensing inspector: Inspector interviewed administrator along with Maintenance Director, observed facility kitchen and resident space as well as reviewed the Maintenance plan and the pest control contract/invoice from 10/23/2025. The facility is now on an updated contract and schedule for pest control to come and treat the facility on a weekly basis as opposed to bi weekly as of 10/23/2025 Additional Comments/Discussion: An exit meeting will be 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 Shelby Haskins, Licensing Inspector at (804) 305-4876 or by email at shelby.haskins@dss.virginia.gov. Violation Notice Issued: No
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
September 18, 2025Inspection0 violations
Inspection dates
Sept. 18, 2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS63.2 PROTECTION OF ADULTS AND REPORTING
Comments
Type of inspection: Other Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/18/2025 arrival time: 1:45pm departure time: 2:45pm. 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 09/14/2025 regarding allegations in the area(s) of: 22VAC40-73-(6) RESIDENT CARE AND RELATED SERVICES, 22VAC40-73-(10) ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS and 63.2-(16) PROTECTION OF ADULTS AND REPORTING Number of residents present at the facility at the beginning of the inspection: 47 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: Inspector reviewed facility’s incident report, police report from Chesterfield County Police Department? s police report, reviewed resident’s record (which included the nurses log for 9/13/2025 prior to being signed out by POA and elopement), interviewed the Administrator and reviewed the facility’s policy on resident sign in and sign out of the facility and resident discharge notification. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the 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 Shelby Haskins, Licensing Inspector at (804) 305-4876 or by email at shelby.haskins@dss.virginia.gov.
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
August 8, 2025Complaint survey1 violation
Inspection dates
Aug. 8, 2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING
Comments
Type of inspection: Other Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 08/08/2025 10:10 am to 11:45am 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 07/21/2025 regarding allegations in the area(s) of: 22VAC40-73-(6) RESIDENT CARE AND RELATED SERVICES 22VAC40-73-(7) RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS Number of residents present at the facility at the beginning of the inspection: 47 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of interviews conducted with staff: 3 Number of interviews conducted with residents: 1 Observations by licensing inspector: Inspector reviewed resident file, reviewed Doctors Order for Project Lifesaver (monitoring/location device), reviewed contract with Chesterfield Police Department for Project Lifesaver, facility incident investigation and Nurses Notes on incident. Additional Comments/Discussion: 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 (complaint(s)/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 Shelby Haskins, Licensing Inspector at (804) 305-4876 or by email at shelby.haskins@dss.virginia.gov.
Violations
22VAC40-73-460-D
Staff #2 confirmed the alarm sounded the Memory Care Unit when resident #1 exited, it could only be heard in the unit’s hallway and not throughout the unit. Due to this, staff were not aware of the elopement until they stepped into the hallway as they were rendering care in other resident rooms.
Plan of correction
Not published by VDSS.
June 10, 2025Complaint survey0 violations
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-80 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: 06/10/2025 arrival time 11:58am departure time 1:10pm 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 05/13/2025 regarding allegations in the area(s) of: 22VAC40-73-(4) STAFFING AND SUPERVISION, 22VAC40-73-(6) RESIDENT CARE AND RELATED SERVICES 22VAC40-73-(7) RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS and 22VAC40-80-(G7) COMPLAINT INVESTIGATION An exit meeting will be 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 Shelby Haskins, Licensing Inspector at (804) 305-4876 or by email at shelby.haskins@dss.virginia.gov. Violation Notice Issued: No A copy of this document will be sent to the licensee/provider for signature. Inspector Name: Shelby Haskins Date Inspection Summary Issued: 7/1/2025
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
June 10, 2025Complaint survey0 violations
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-80 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: 06/10/2025 11:58am to 1:30pm 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 06/04/2025 regarding allegations in the area(s) of: 22VAC40-73-(6) RESIDENT CARE AND RELATED SERVICES, 22VAC40-73-(7) RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS, 22VAC40-73-(8) BUILDINGS AND GROUND and 22VAC40-80-(G7) COMPLAINT INVESTIGATION Number of residents present at the facility at the beginning of the inspection: 49 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of staff records reviewed: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: Inspector observed both elevators in the facility and both were operational. Inspector interviewed Administrator in reference to disciplinary actions and training for direct care staff that have been implemented. Inspector also reviewed employee counseling reviews for those employees involved. Additional Comments/Discussion: An exit meeting will be 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 Shelby Haskins, Licensing Inspector at (804) 305-4876 or by email at shelby.haskins@dss.virginia.gov. Violation Notice Issued: No A copy of this document will be sent to the licensee/provider for signature. Inspector Name: Shelby Haskins Date Inspection Summary Issued: 6/24/2025
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
February 10, 2025Inspection0 violations
Inspection dates
Feb. 10, 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 IMPAIRMENTS32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS3.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 02/10/2025 Arrival time: 11:30am Departure time: 4:00pm 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: 49 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 3 Number of interviews conducted with staff: 4 Observations by licensing inspector: A tour of the facility was conducted to include inside and outside building grounds. Lunch, weekly menu and resident activities were observed. A medication pass observation was completed. The following was reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, medication carts, fire inspection report, health inspection report, and a staffing schedule. Water temperature was measured, and the call bell system was monitored. 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 Shelby Haskins, Licensing Inspector at (804) 305-4876 or by email at Shelby.Haskins@dss.virginia.gov.
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
February 10, 2025Complaint survey0 violations
Inspection dates
Feb. 10, 2025
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES, 22VAC40-73 STAFFING AND SUPERVISION,22VAC40-73 RESIDENT CAREAND RELATED SERVICES,22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS, 22VAC40-73 BUILDINGS AND GROUND, 22VAC40-73 EMERGENCYPREPAREDNESS, 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: 02/10/2025 Arrival time 11:30am Departure time 4:00pm 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 01/17/2025 regarding allegations in the area(s) of: 22VAC40-73-(2) Administration and Administrative Services, 22VAC40-73-(4) Staffing and Supervision, 22VAC40-73-(6) Resident Care and Related Services, 22VAC40-73-(7) Resident Accommodations and Related Provisions, 22VAC40-73-(8) Buildings and Grounds, 22VAC40-73- (9) Emergency Preparedness and 22VAC40-80-(G7) Complaint Investigation Number of residents present at the facility at the beginning of the inspection: 49 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of staff records reviewed: 3 Number of interviews conducted with staff: 4 Observations by licensing inspector: Inspector reviewed 3 staff records, 4 staff interviews as well as the staff schedule for January 2025. Inspector was shown the abundance of PPE supplies in the facility’s storage closet. Inspector also reviewed the facility’s contract with the exterminator US Pest Control Inc which included the agreement to service the facility on a monthly basis. Additional Comments/Discussion: An exit meeting will be 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 Shelby Haskins Licensing Inspector at (804) 305-4876 or by email at Shelby.Haskins@dss.virginia.gov.
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
January 23, 2024Inspection0 violations
Inspection dates
Jan. 23, 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 Mandated Inspection Date of inspection the licensing inspector was on-site at the facility for each day of the inspection: 1/23/24, 10:30 am to 12:50p 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: 41 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: 4 Number of interviews conducted with staff: 3 Observations by licensing inspector: lunch meal, medication storage and administration, resident/staff interactions, facility maintenance and repair An exit meeting was conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Yvonne Randolph, Licensing Inspector at 804-662-7454 or by email at yvonne.randolph@dss.virginia.gov
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
August 7, 2023Complaint survey0 violations
Inspection dates
Aug. 7, 2023
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND
Comments
A complaint was received by VDSS Division of Licensing on 7/25/23 regarding allegations in the areas of: Administration and Administrative Services, Accommodations and Related Provisions, Building and Grounds. Number of residents present at the facility at the beginning of the inspection: 39 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: Building and grounds, resident rooms, facility maintenance and repair/cleanliness Comments: Inspected systems put in place to prevent elopement of resident. 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 or by email at Yvonne.randolph@dss.virginia.gov
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
May 22, 2023Complaint survey0 violations
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: 5/22/23 The Acknowledgement of Inspection form was emailed to the facility for each date of the inspection. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. A complaint was received by VDSS Division of Licensing on 5/16/23 regarding allegations in the Building and Grounds, Personnel, Staffing and Supervision, Resident Care and Related Services Accommodations and Resident Accommodations and Related Services. Number of staff records reviewed:0 Number of interviews conducted with residents: 5 Number of interviews conducted with staff: 3 Observations by licensing inspector: Resident rooms (i.e. sinks and toilets), staffing, physical plant An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Yvonne Randolph, Licensing Inspector at 804-662-7454 or by email at yvonne.randolph@dss.virginia.gov
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
January 10, 2023Inspection1 violation
Inspection dates
Jan. 10, 2023
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
Type of inspection: Renewal Date of inspection and time the licensing inspector was on-site at the facility on day of the inspection: 1/10/23, 9:30 am -12:45 pm The Acknowledgement of Inspection form was forwarded to the facility for the date of the inspection. Number of residents present at the facility at the beginning of the inspection: 44 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 6 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: Lunch meal, medication administration, availability of medications, physical plant (cleanliness), staff interactions with residents An exit meeting was conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and the violation is documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(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
22VAC40-73-1100-A
Based on a review of 6 resident files, the facility failed to obtain written approval prior to placing a resident in the safe, secure environment.
Evidence
  1. Documentation of written approval was not found during a review of the file of resident # 4.
Plan of correction
POA agreed and approved with physician's order for memory care at time of admission. However, the form was not completed at time of admission and was completed on 1/10/2023. Copy is attached.
October 27, 2022Complaint survey0 violations
Inspection dates
Oct. 27, 2022
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND
Comments
Type of inspection: Complaint Date of inspection and time the licensing inspector was on-site at the facility for the day of the inspection: 10/27/22, 11am-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 10/21/22 regarding allegations in the areas of: Staffing and Supervision, Personnel, Building and Grounds, Resident Care and Related Services and Resident Accommodations and Related Services. 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 residents: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: 3 resident rooms Additional Comments/Discussion: N/A 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 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 3, 2022Complaint survey0 violations
Inspection dates
Oct. 3, 2022
Comments
Date of inspection and time the licensing inspector was on-site at the facility for the inspection: 10/3//22 11:30 am - 12:15 am A complaint was received by VDSS Division of Licensing on 9/26/22 regarding allegations in the area of Staffing, Resident Care and Related Services; and Building and Grounds The Acknowledgement of Inspection form was provided on the date of the inspection.Number of staff records reviewed: 0 Number of interviews conducted with residents: O Number of interviews conducted with staff: 1 Additional Comments/Discussion: The allegations were investigated during a previous inspection on 8/29/2022: therefore, there was no determination of non-compliance with applicable standards or law. The department’s inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. An exit meeting was conducted to review the inspection findings. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
September 19, 2022Complaint survey7 violations
Inspection dates
Sept. 19, 2022
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND
Comments
Type of Inspection: Complaint Date of Inspection and time that the licensing inspector was on site: 9/19/2022, 2 pm - 5 pm The licensing inspector completed a tour of the physical plant that included the kitchen and resident rooms (3rd floor) 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 Additional Comments/Discussion: A monitoring inspection was completed to follow-up on a self-reported incident. A complaint was received by VDSS Division of Licensing on 9/12/2022 regarding allegations in the areas of Administration and Administrative Services, Personnel, Staffing and Supervision, Building and Grounds, Resident Accommodations and Related Services and Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 35 censing inspector completed a tour of the physical plant that included the kitchen and resident rooms (3rd floor) 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 Additional Comments/Discussion: A monitoring inspection was conducted to follow-up on a self reported incident on 8/29/2022. Subsequently, a complaint was received regarding the incident from the VDH. VDH is monitoring the situation. The evidence gathered during the inspection did not determine any non-compliance with applicable standards or law at this time. The department inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. An exit meeting was conducted to review the inspection findings. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Yvonne Randolph, Licensing Inspector at (804) 662-7454 or by email at yvonne.randolph@dss.virginia.gov
Violations
22VAC40-73-250-C
Based on a review of three staff files, the facility failed to maintain documentation and verification of medication aide provisional authorization from the Virginia Board of Nursing.
Evidence
  1. Documentation and verification of medication aide provisional authorization was not found during a review of the file for staff # 2.
Plan of correction
Documentation was misplaced and staff member had yet to take the board exam She was removed as a Medication Aide and placed on the schedule as a PCA.
22VAC40-73-260-A
Based on a review of direct care staff 1st Aid certifications, one staff does not have certification in 1st Aid.
Evidence
  1. The facility did not have documentation to support that staff # 7 had current 1st Aid certification.
Plan of correction
Direct care staff was scheduled to be in CPR/FA class on 9/13/22, however due to car issues was unable to attend. She is scheduled for the next class on 10/25/2022. She never worked without having someone working with her that is CPR/FA certified.
22VAC40-73-450-E
Based on a review of 5 resident files, the individualized service plan (ISP) for one resident was not signed and dated by the resident or legal representative of the resident.
Evidence
  1. A review of the file for resident# 1 found that the current ISP dated 3/31/22 was not signed or dated by the resident or the legal representative of the resident.
Plan of correction
ISP was emailed to family on individualized service plan 3/31/2022, however was never returned to GHS signed. ISP was reviewed with the family and signed on 9/22/2022.
22VAC40-73-680-A
Based on a review of three staff files, medications are being administered to residents by a staff person who is not currently registered with the Virginia Board of Nursing as a medication aide.
Evidence
  1. A review of the file for staff# 1 found an expired registration (expiration date is 5/31/22) with the Virginia Board of Nursing.
Plan of correction
Due to the medication aide recently moving, she had lost her PIN and had requested a new one from the Virginia Board of Nursing. PIN number was received and license was renewed
22VAC40-73-680-D
Based on a review of physician orders, medication administration records (MARs)and drug count sheets, medications were not administered in accordance with the physician's or other prescriber's instructions.
Evidence
  1. Medication was discovered by licensing staff in the facility's parking lot. As a result, licensing staff completed a review of medication storage, availability and administration for three residents. Licensing staff found medications that were not administered per physician orders:
  2. Resident # 10 has an order for Lorazepam Oral Concentrate: Give 0.25 ml sublingually 3 times a day - scheduled. Lorazepam scheduled for administration at 9 am on 9/19/22 was not given. There was a note "med not given-given early". The Drug Count sheet documents that the medication was given at 6 am on 9/19/22.
  3. Resident # 11 has an order for Lorazepam 1 mg: 1 tablet by mouth every 8 hours as needed for anxiety. Lorazepam was not given every 8 hours. The Drug Count sheet documents Lorazepam being administered on 8/25/22 at 3: 15 pm and 9:00 pm, on 8/28/22 being administered at 10:00 am and at 5:00 pm and on 9/20/22 being administered at 11 :00 am and 3:00 pm.
Plan of correction
Not published by VDSS.
22VAC40-73-680-I
Based on a review of medication administration records (MARs) for September 2022 for four residents, MARs did not have the date, time given and initials of staff administering medications/treatments medications/treatments.
Evidence
  1. The MAR for resident# 1 states knee brace -wear flexible knee brace every day and remove at bedtime. Placement of knee brace is not documented on 9/2, 9/ 6, 9/7, 9/8, 9/9 or 9/11. The box on the MAR to document that the placement occurred was blank.
  2. The MAR for resident # 2 states oxycodone 10 mg- 1 tab by mouth 3 times a day and gabapentin 100mg - 2 capsules (200 mg) by mouth 3 times a day. The administration of oxycodone and gabapentin is not documented as being administered on 9/6 and 9/8. The boxes on the MAR to document are blank.
Plan of correction
We have completed med pass observations on all medication aides as well as med cart audits. We have scheduled a Med Tech Refresher to include review of the narcotic sheet by our pharmacy, Family Care.
22VAC40-73-870-D
Based on an inspection of the building and a random resident rooms along with interviews and observations of residents, the facility is not free of infestations of insects and vermin and their breeding places.
Evidence
  1. A random inspection of resident rooms found evidence of bed bug infestation in two resident rooms:
  2. Two licensing inspectors observed excrement stains (dark spots) on the walls in the room of resident # 6.
  3. Two licensing staff observed blood-colored stains on the pillow and excrement stains (dark spots) on the walls and bed sheets of the resident of the room of resident # 2. Two licensing staff observed red, swollen areas on the arms, hands, fingers and upper chest of resident# 6.
Plan of correction
We are currently set up for monthly monitoring with Clean Heat Defense. If signs of bugs are seen in between services, then Clean Heat comes out for special services. Clean Heat was called the day of inspection and was out the next morning. They treated the two rooms where evidence was found as well as treated the entire third floor.
August 29, 2022Inspection0 violations
Inspection dates
Aug. 29, 2022
Areas reviewed
22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND
Comments
Type of Inspection: Monitoring Date and time that inspector was on site at the facility on the day of the inspection: 8/29/22 The licensing inspector completed a tour of the physical plant that included the kitchen and resident rooms (3rd floor) 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 Additional Comments/Discussion: A monitoring inspection was conducted to follow-up on a self reported incident on 8/29/2022. Subsequently, a complaint was received regarding the incident from the VDH. VDH is monitoring the situation. The evidence gathered during the inspection did not determine any non-compliance with applicable standards or law at this time. The department’s inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. An exit meeting was conducted to review the inspection findings. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Yvonne Randolph, Licensing Inspector at (804) 662-7454 or by email at yvonne.randolph@dss.virginia.gov
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
November 11, 2021Inspection0 violations
Inspection dates
Nov. 11, 2021 and Nov. 15, 2021
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 ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity
Comments
A monitoring inspection was initiated on 11/11/2021 and concluded on 11/15/2021. The administrator was contacted by email/telephone to initiate the inspection. The administrator reported that the current census is 43 residents. The inspector emailed the administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed three resident records, three staff records, medication administration records, staff certifications and training, background checks for new employees, sanitation inspection report, fire drills, etc. submitted by the facility to determine compliance. The inspector conducted the on-site portion of the inspection on 11/15/2021. An exit interview was conducted with the administrator) on the date of the inspection, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. The information gathered during the inspection determined no violations with applicable standards or law. No violations were issued.
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
January 19, 2021Inspection0 violations
Inspection dates
Jan. 19, 2021
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 ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity32.1 Reported by persons other than physicians63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Comments
This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A monitoring inspection was initiated on 1/19/2021 and concluded on 1/20/2021. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 46. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed three (3) resident records, three (3) staff records, and other required documents submitted by the facility to ensure compliance with assisted living standards and regulations. A review was completed of all background checks for staff hired since the last renewal inspection. The information gathered during the inspection determined no violations with applicable standards or law.
Violations
No violations cited
The inspector documented no violation of standards at this inspection.