Virginia DSS · Assisted Living Facility

Saint Francis Home

📍 65 West Clopton Street, Richmond, VA, 23225

ID 8126Two Year licenseActive
17
Inspections
On record
5
With violations
Visits that cited something
12
Clean visits
Nothing cited
10
Violations cited
Individual findings
8
Standards cited
Distinct rules
9
Complaint visits
Prompted by a complaint

Saint Francis Home was inspected 17 times between June 10, 2021 and May 28, 2026 by the Virginia Department of Social Services. 5 of those visits ended with violations cited and 12 with none. Across that history VDSS cited 10 violations under 8 distinct standards. 9 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. 16 of these 17 are still on the state's site; the other 1 has since dropped off it and is 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
03/13/2028
Administrator
Fajr Mills
Licensing inspector
Yvonne Randolph
Inspector phone
(804) 441-1180
Approved for
Assisted Living · Non-Ambulatory

Inspection History

17

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

May 28, 2026Complaint survey0 violations
Inspection dates
05/28/2026
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: 5/28/26, 10 am to 11:40 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 5/12/2026 regarding allegations in the area of: Resident Care And Related Services Number of residents present at the facility at the beginning of the inspection: 76 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: 1 Observations by licensing inspector: medication administration records, physician orders, postings, building updates 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.
January 21, 2026Inspection0 violations
Inspection dates
01/21/2026
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS
Comments
Type of inspection: Non-Mandated Monitoring Date of inspection the licensing inspector was on-site at the facility for each day of the inspection: 1/21/2026 The Acknowledgement of Inspection form was signed and emailed to the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 11/20/25 (followed by complaint on 11/24/25) regarding allegations in the area of: Admission Retention And Discharge. Number of residents present at the facility at the beginning of the inspection: 78 Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: Resident discharged Collateral Interview: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: file documentation, emails An exit meeting was conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standards or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Yvonne Randolph, Licensing Inspector at (804) 441-1180 or by email at yvonne.randolph@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
January 21, 2026Inspection0 violations
Inspection dates
01/21/2026
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 PREPAREDNESS
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: 1/20/26, 10:30 am to 1:45 pm The Acknowledgement of Inspection form was signed and emailed to the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 78 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 4 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: file documentation, lunch meal, medication storage, facility updates/renovations, fire drills, liability insurance, discharges, background checks, fire/health inspections Additional Comments/Discussion: The facility has plans to add a secure memory care environment in the future. The current building is being updated/renovated. An exit meeting was conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standards or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Yvonne Randolph, Licensing Inspector at (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.
January 21, 2026Complaint survey0 violations
Inspection dates
01/21/2026
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS
Comments
Type of inspection: Complaint. Date of inspection the licensing inspector was on-site at the facility for each day of the inspection: 1/21/2026 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 1/12/26 regarding allegations in the areas of: Admission Retention And Discharge, Of Residents, Administration And Administrative Services. Number of residents present at the facility at the beginning of the inspection: 78 Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: Resident discharged Collateral Interview: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: file documentation, emails An exit meeting was conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standards or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Yvonne Randolph, Licensing Inspector at (804) 441-1180 or by email at yvonne.randolph@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
November 13, 2025Inspection0 violations
Inspection dates
11/13/2025
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS
Comments
Type of inspection: Monitoring, Non-Mandated. Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/13/25, 9:30 am to 10:30 am The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 10/10/13 followed by a complaint regarding allegations in the area of: Admission, Retention And Discharge Of Residents 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 Additional Comments/Discussion: A 30 day discharge was not completed as the facility determined that the resident requires a level of care for which the facility is not licensed and does not provide. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the non-compliance with standards or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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.
August 13, 2025Complaint survey0 violations
Inspection dates
08/13/2025
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: 8/13/25, 12:45 pm to 1:30 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: file documentation, medication administration records 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. 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 survey0 violations
Inspection dates
07/21/2025
Areas reviewed
22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND
Comments
Type of inspection: Complaint Date the licensing inspector was on-site at the facility for each day of the inspection: 7/21/25 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. An anonymous complaint was received by VDSS Division of Licensing on 6/24/25 regarding allegations in the areas of: Building and Grounds and Resident Accommodations And Related Provisions The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with staff: 5 Observations by licensing inspector: laundry services, housekeeping, staff schedules, pest control services 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 standard 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.
May 16, 2025Complaint survey0 violations
Inspection dates
05/16/2025
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: 5/16/25, 12:55 pm to 1:35 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 4/25/25 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: Uniform Assessment Instrument 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) 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.
March 25, 2025Inspection3 violations
Inspection dates
03/25/2025
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 PREPAREDNESS
Comments
Type of inspection: Mandated Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 3/25/25 10:15 am to 1:00 pm The Acknowledgement of Inspection form was emailed to the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 93 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents:3 Number of interviews conducted with staff: 3 Observations by licensing inspector: medication passes/administration/storage, staff/resident interactions, lunch meal, required postings, food supply, file documentation Additional Comments/Discussion: Video recording in assisted living facilities 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 violations 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 violations will be addressed in order to return the facility to compliance and maintain future compliance with applicable standards or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Yvonne Randolph, Licensing Inspector at (804) 662-7454 or by email at yvonne.randolph@dss.virginia.gov
Violations
22VAC40-73-450-C
Based on file reviews, the facility did not ensure that the comprehensive individualized service plan include a description of identified needs and date identified based upon the UAI and physical examination.
Evidence
  1. The uniform assessment instrument (UAI) for resident # 2 identified bathing, transferring, medication administration and allergies as needs. The individualized service plan (ISP) for resident # 2 did not include a description or date identified for bathing, transferring, medication administration and allergies.
Plan of correction
DON and ADON will audit resident charts to ensure UAI and ISP reflect the same services. The resident's ISP will be updated to reflect all services being provided and coordination on care will ensue.
22VAC40-73-680-A
Based on file reviews, the facility did not ensure that staff who are licensed, registered, or acting as medication aides on a provisional basis shall administer drugs to those residents who are dependent on medication administration as documented on the UAI.
Evidence
  1. The UAI states that medication shall be administered by a lay person (described as ALF staff/med tech). The DON and Administrator stated during interviews that the resident self administers medications.
Plan of correction
An audit will be completed on each resident file and ISPs will be corrected and/or updated to reflect the residents current needs. Revisions and reviews will be completed timely and accurately. 10 charts will be done weekly until all files have been audited. DON and ADON will conduct 5% chart audits monthly to identify ISPs of concern and address accordingly.
22VAC40-73-320-B
Based on file reviews, the facility did not ensure that a risk assessment for tuberculosis shall be completed annually for each resident.
Evidence
  1. An annual risk assessment was not documented for resident # 5.
Plan of correction
Community created a tracking log to ensure all residents have current tuberculosis assessments.
March 17, 2025Complaint survey0 violations
Inspection dates
03/17/2025,03/25/2025
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: 3/13/25 9am to 1:55 pm and 3/25/25 10:15 am to 1 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Complaints were received by VDSS Division of Licensing on 1/28/25, 3/3/25, and 3/12/25 regarding allegations in the area of: Resident Care And Related Services. The licensing inspector completed a tour of the dining room, kitchen and food storage area Number of resident records reviewed: 3 Number of staff records reviewed: 0 Number of interviews conducted with residents: random in facility Number of interviews conducted with staff: 3 Observations by licensing inspector: snacks, food supply and storage, file documentation (discharge notices), staff/resident interactions Comments: Nutritionist report and menu reviewed. 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 yvonne.randolph@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
March 13, 2025Complaint survey0 violations
Inspection dates
03/13/2025
Areas reviewed
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: 3/13/25 9am to 1:55 pm and 3/25/25 10:15 am to 1 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Complaints were received by VDSS Division of Licensing on 2/21/25, 2/26/25 and 3/11/25 regarding allegations in the area of: Resident Care And Related Services. The licensing inspector completed a tour of the physical plant that included the building and grounds Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: random throughout the facility Number of interviews conducted with staff: 3 Observations by licensing inspector: medication administration and storage, file documentation (discharge notices), staff/resident interactions medication management system 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 yvonne.randolph@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
March 13, 2025Complaint survey0 violations
Inspection dates
03/13/2025
Areas reviewed
Resident Care And Related Services
Technical assistance
Information re: video taping in assisted living
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: 3/13/25 9am to 1:55 pm and 3/25/25 10:15 am to 1 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Complaints were received by VDSS Division of Licensing on 1/29/25, 2/4/25, 2/28/25 and 3/12/25 regarding allegations in the area of: Resident Care And Related Services. The licensing inspector completed a tour of the physical plant which 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: random throughout the facility Number of interviews conducted with staff: 5 Observations by licensing inspector: resident accommodations, file documentation, staff/resident interactions, video recordings, policies and procedures 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 yvonne.randolph@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
October 23, 2024Complaint survey3 violations
Inspection dates
10/23/2024
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Complaint Date and time of the licensing inspector was on-site at the facility for each day of the inspection: 10/25/24 10a to 11:35a The Acknowledgement of Inspection form was left at the facility for the date of the inspection A complaint was received by VDSS Division of Licensing on 9/20/24 regarding allegations in the area of Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 91 Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews w/community partners: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: medication administration records, file documentation An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area of non-compliance with standards or law was: Resident Care and Related 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 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
22VAC40-73-680-J
Based on file reviews, the facility did not ensure that in the event of a medication error (missed dosages) that a family member or other responsible person shall be notified as soon as possible.
Evidence
  1. The responsible person for resident # 1reported that there was no notification of missed dosages of amlodipine besylate in July 2024 and August 2024.
  2. A file review found no documentation of a notification.
Plan of correction
Staff have been educated about the importance of documentation and notifying families of resident care changes. DON will routinely send notifications to families with resident updates beginning 11/12-on going
22VAC40-73-650-A
Based on a file review, the facility did not ensure that no medication, dietary supplement, medical procedure or treatment shall be started, changed or discontinued without a valid order from a physician or other prescriber.
Evidence
  1. The August 2024 and July 2024 medication administration record (MAR) for resident # 1 document an original start date of 7/4/24 for amlodipine besylate 5mg. Amlodipine besylate was discontinued without a valid physician order and not given from 7/11/24 to 7/31/24 and from 8/1/24 to 8/5/24.
  2. The August 2024 and July 2024 medication administration record (MAR) for resident # 1 document a stop date of 8/5/24 at 12 pm
Plan of correction
Community will ensure that all medication, dietary supplement, medical procedure or treatment started, changed or discontinued have valid physician or other prescriber orders signed and on file prior to start or discontinuance. Don will run the missed medication administration report for staff accountability. Pull medication list for review during resident status change and care plan meetings. Resident chart audit will be conducted weekly to ensure compliance begins 11/12-ongoing. Responsibility : DON, Resident’s Care Provider, ADON, RCC and Administrator.
22VAC40-73-310-A
Based on file review, the facility did not ensure that no resident shall be admitted or retained who requires a level of care or service or type of service for which the facility is not licensed or for which the facility does not provide.
Evidence
  1. On 9/4/24 resident # 1 was admitted to a local hospital for AMS (altered mental state).
  2. On 9/5/24 resident # 1 was accepted back to the facility upon discharge from the hospital,
  3. The hospital’s discharge disposition was - discharge to skilled nursing facility.
  4. The facility is not licensed to provide skilled nursing services.
Plan of correction
Community will ensure ongoing communication with discharging facility, POA and resident prior to discharge. Community will reassess resident prior to return to community. Community will verify discharge paperwork for accuracy in collaboration with the resident’s care provider. Community will be reassessing all resident upon return to the facility after being admitted to places other than SFM. Begins 11/12- on going. Resident did not demonstrate change in service needs at the time of evaluation. Responsibility: DON, Resident’s Care Provider, ADON, RCC and Administrator.
February 5, 2024Inspection1 violation
Inspection dates
02/05/2024
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 PREPAREDNESS:
Comments
Type of inspection: Renewal Date and time of the licensing inspector was on-site at the facility for each day of the inspection: 2/5/24 10 a to 2:20 p The Acknowledgement of Inspection form was emailed for the date of the inspection Number of residents present at the facility at the beginning of the inspection: 91 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 9 Number of staff records reviewed:5 Number of interviews conducted with residents: 5 Number of interviews conducted with staff: 6 Observations by licensing inspector: lunch meal, activity, medication storage and administration, file documentation, cleanliness and maintenance, staff/resident interactions 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 10 resident files, three residents did not have an annual assessment using the uniform assessment instrument.
Evidence
  1. An annual uniform assessment instrument was not found in the files for residents # 2, # 5 and # 7,
Plan of correction
Obtain updated UAIs from Richmond Department of Social Services. Ensure future assessments are returned I a timely manner to maintain compliance.
June 5, 2023Inspection2 violations
Inspection dates
06/05/2023
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 PREPAREDNESS
Comments
Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 6/5/23 10:20 a to 1:15 p The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of residents present at the facility at the beginning of the inspection:84 Number of staff records reviewed: 5 Number of resident records reviewed: 10 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: Building, lunch meal, postings, medication storage and administration 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
22VAC40-73-870-A
Based on an inspection of the interior of the building, the is not maintained in good repair.
Evidence
  1. Licensing inspector observed scuff marks on the walls and scarred doors throughout the facility,
Plan of correction
St. Francis - Manchester maintenance team will round this facility and touch up and paint walls that have become scratched (actively and ongoing) St. Francis - Manchester maintenance team will repair scarred and scuffed doors and walls throughout the facility.
22VAC40-73-450-C
Based on an inspection of the interior of the building, the is not maintained in good repair.
Evidence
  1. Licensing inspector observed scuff marks on the walls and scarred doors throughout the facility, Based on a review of ten individualized service plans, an identified need was not addressed on four plans. Evidence:
  2. Residents # 1, 3 , 5 and 9 had fall risk assessments completed, the fall risk rating identified a need for fall intervention to reduce the risks of subsequent falls.
  3. The individualized service plans did not have a fall risk goal.
Plan of correction
St. Francis - Manchester updated residents 1, 3, 5 and 9 ISPs to reflect fall risk assessment. All fall risk assessments will be updated at every annual review of the ISP moving forward.
March 2, 2022Inspection1 violation
Inspection dates
03/2/2022
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 PREPAREDNESS63.2 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 PROCESS
Comments
An unannounced renewal inspection was conducted on March 03, 2022, from 12:48 p.m. to 4:50 p.m. for Saint Francis Home. At the time of entrance, the facility’s infection control monitoring policy was actively implemented for all visitors, staff members, and residents. The facility administration team reported the census as seventy eight (78) residents in care. Residents were observed during daily activities and direct care staff members were observed providing resident centered services. The sample size consisted of six (6) resident records and six (6) new staff records. Medication administration, meals, and snacks were observed during the inspection. Also during the renewal inspection, interviews were conducted with several staff members and residents. Areas of non-compliance were cited in the violation notice. You can contact the assigned inspector at (804) 662-9432 or send an email to Vashti. Colson @dss.virginia.gov to discuss any questions you may have. Thank you for your cooperation.
Violations
22VAC40-73-870-A
VIOLATION: Based upon the building tour and observation, the facility failed to maintain a small areas of the interior of the building.
Evidence
  1. The following items require repair:
  2. Room F-3 and Room L-6 tile flooring were water stained and discolored.
  3. The Liguori hallway flooring , located in the hall entrance, was chipped with a small portion of the subfloor exposed.
Plan of correction
1) F-3 - Completed. Stripping and waxing of the floor.-3/23/2022 2) L-6- Replace eight (8) damaged floor titles. -3/23/2022 3) Repaired, see attached picture. - 3/7/2022
June 10, 2021Inspection0 violations
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 LICENSE
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 06/10/2021 and concluded on 06/18/2021. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was seventy eight (78). The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed four (4) resident records, four (4) staff records, U.A.I.s, MARs, activities calendar, staff schedules, health care oversight, health inspection and fire inspection submitted by the facility to ensure documentation was complete. 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.