Our Lady Of Peace — Virginia Inspection Report

Inspections

On record

With violations

Visits that cited something

Clean visits

Nothing cited

Violations cited

Individual findings

Standards cited

Distinct rules

Complaint visits

Prompted by a complaint

Our Lady Of Peace was inspected 8 times between April 26, 2022 and January 15, 2026 by the Virginia Department of Social Services. 2 of those visits ended with violations cited and 6 with none. Across that history VDSS cited 10 violations under 10 distinct standards. 3 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.

Every inspection listed here is currently published on the VDSS site.

Provider Information

Facility type

Assisted Living Facility

License type

Two Year

License expires

10/31/2026

Administrator

Rachel Lindberg

Licensing inspector

Tyia Venable

Inspector phone

(804) 393-2157

Approved for

Assisted Living · Special Care Unit · Non-Ambulatory

Inspection History

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

January 15, 2026Inspection2 violations

Inspection dates

01/15/2026

Areas reviewed

22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION

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: 1/15/2026 10:25am -3pm 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: 139 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: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: Licensing inspector observed required facility postings, medication pass, lunch and scheduled posted activities. Additional Comments/Discussion: 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 Tyia Venable, Licensing Inspector at 804-393-2157 or by email at tyia.venable2@dss.virginia.gov

Violations

22VAC40-73-50-B

Based on a review of resident records, the facility did not ensure that there was written acknowledgement of the receipt of the disclosure by the resident or the resident’s legal representative was retained in the resident’s record.

Evidence

Resident 6's record (admit date 7/7/21) did not contain a disclosure statement signed by the resident or the resident’s legal representative.
When asked Staff 5 was unable to provide a signed copy of the disclosure statement for Resident 6.

Plan of correction

100% audit was completed on 1/21/2026. Records without written acknowledgement of the receipt of the disclosure by the resident or the resident’s legal representative were corrected. Acknowledgement of the receipt of the disclosure will be signed and retained in the electronic health record system prior to admission.

22VAC40-73-970-A

Based on a review of facility documentation, the facility did not ensure fire and emergency drills were conducted each shift in a quarter.

Evidence

Licensing inspector reviewed the facility’s record of fire and evacuation drill documents, 12/29/25 a fire drill was conducted on 2nd shift, 11/18/25 a fire drill was conducted on 2nd shift, and 10/9/25 a fire drill was conducted on 1st shift.
When asked Staff 5 stated, there was no documentation of a fire and evacuation drill completed on the overnight shift.

Plan of correction

Executive Director or designee will audit fire emergency drill log monthly for the next four quarters. Any concerns identified will be corrected. Monthly audit report will be submitted to the QAPI committee on a quarterly basis for four quarters

October 11, 2024Inspection0 violations

Inspection dates

10/11/2024

Comments

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: Onsite on 10/11/2024-Approximate time 11:21a.m-3:19p.m 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: 139 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 5 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 5 Observations by licensing inspector: Noon time medication administration pass was observed Additional Comments/Discussion: 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. 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 Angela Rodgers-Reaves, Licensing Inspector at (804) 840-0253 or by email at Angela.r.reaves@dss.virginia.gov Violation Notice Issued: No

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

January 31, 2024Complaint survey0 violations

Inspection dates

01/31/2024

Comments

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: On 01/31/2024 approximate time 10:28a.m-12:30p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 12/13/2023 regarding allegations in the admission, retention, and discharge of residents. Number of residents present at the facility at the beginning of the inspection: 128 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: N/A Number of interviews conducted with residents: N/A Number of interviews conducted with staff: 2 Observations by licensing inspector: N/A Additional Comments/Discussion: Resident identified in the complaint is no longer in care. 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 Angela Rodgers-Reaves, Licensing Inspector at (804) 840-0253 or by email at Angela.r.reaves@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

October 17, 2023Inspection0 violations

Inspection dates

10/17/2023

Comments

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: On 10/17/2023-approximate time of 10:14a.m-3:41p.m. 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: 120 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: 4 Number of interviews conducted with residents: 10 Number of interviews conducted with staff: 5 Observations by licensing inspector: Additional Comments/Discussion: 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. An exit meeting will be 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 Angela Rodgers-Reaves, Licensing Inspector at (804) 840-0253 or by email at Angela.r.reaves@dss.virginia.gov Violation Notice Issued: No

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

November 1, 2022Inspection8 violations

Inspection dates

11/01/2022

Comments

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/01/2022 approximate times of 10:54 a.m. – 4:22p.m 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: The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 5 Number of interviews conducted with residents:3 Number of interviews conducted with staff: 4 Observations by licensing inspector: Additional Comments/Discussion: 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 Angela Rodgers-Reaves, Licensing Inspector at (804) 840-0253 or by email at angela.r.reaves@dss.virginia.gov

Violations

22VAC40-73-580-A

Based on the review of facility records and staff interviews the facility failed to ensure that when any portion of an assisted living facility is subject to inspection by the Virginia Department of Health, the facility shall be in compliance with those regulations, as

Evidence

d by an initial and subsequent annual reports from the Virginia Department of Health. The report shall be retained at the facility for a period of at least two years. Evidence: Upon request the facility did not submit for the inspector’s review that an annual health inspection was conducted at the facility

Plan of correction

FACILITY'S RESPONSE: "Last health department inspection was 09/03/2021. Health Department visit scheduled for 11/16/2022. Executive director or designee will request annual health inspection as needed."

22VAC40-73-690-E

Based on the review of facility records and staff interviews the facility failed to ensure that upon receipt the resident’s attending physician was informed of the recommendation of any concerns or problems and document the notification.

Evidence

Upon request the facility did not submit for the inspector’s review documented evidence that the physician’s for the residents identified in the 09/21-22/2022 medication review report were made aware of the pharmacist recommendations and what action was taken in response to the recommendations.

Plan of correction

Review of submitted document given to inspector noted to be Pharmacy QA Nurse Audit and not Pharmacist Recommendation Report requiring physician notification. FACILITY'S RESPONSE: "Administrator and ADON reviewed most recent Pharmacist Recommendation Report and audited resident charts. All recommendations were followed up with the residents’ physicians and resolutions were documented as appropriate. Administrator or designee will continue to review Pharmacist Recommendation Report and audit resident charts in next quarter to ensure recommendations and actions are followed up as needed. Pharmacist will also continue to follow up as appropriate quarterly."

22VAC40-73-430-H-1

Based on the review of facility records the facility failed to ensure that a copy of the written statement of discharge was maintained in the resident's record.

Evidence

Resident #10 During interviews facility staff confirmed that the resident was no longer in care but did not submit upon request documented evidence that a discharge statement was maintained.

Plan of correction

Administrator or designated representative will be responsible for issuing the written statement of discharge and filing it in the resident’s business file. Executive director or designee will audit discharged resident files for documentation by 11/18/2022. Executive director or designee will conduct audit of discharged resident files in next quarter and report findings to QA committe

22VAC40-73-680-C

Based on the review of facility records and observation the facility failed to ensure that medications are administered not earlier than one hour before and not later than one hour after the facility's standard dosing schedule.

Evidence

Resident #11 Observation of the morning medication administration pass with facility staff #5 revealed that on 11/01/2022 the resident was not administered the 9:00a.m medications until the approximate time of 10:51 a.m.

Plan of correction

FACILITY'S RESPONSE: "Education provided to RMA on medication administration on 11/01/2022. All RMAs and Nurses will be educated on proper medication administration by 11/30/2022. Report of medication administration will be reviewed per policy to ensure compliance. Med pass audits will be conducted on all Nurses and RMAs by 11/30/2022. Findings will be reported to QA committee by ADON or designee."

22VAC40-73-940-A

Based on the review of facility records and staff interviews the facility failed to ensure that an assisted living facility complied with the Virginia Statewide Fire Prevention Code (13VAC5-51) as determined by at least an annual inspection by the appropriate fire official. Reports of the inspections shall be retained at the facility for at least two years.

Evidence

Upon request the facility did not submit for the inspector’s review that an annual fire inspection was conducted at the facility.

Plan of correction

FACILITY'S RESPONSE: "Last fire inspection was 04/01/2021. Fire Department visit scheduled for 11/10/2022. Executive director or designee will request annual inspections as needed."

22VAC40-73-325-B

Based on the review of facility records the facility failed to ensure that for residents who meet the criteria for assisted living care, by the time the comprehensive ISP is completed, a written fall risk rating is completed.

Evidence

Resident #3: Documented date of admission 09/14/2022 The resident’s comprehensive ISP is dated 10/26/2022. Upon request the facility did not submit for the inspector’s review documented evidence that a fall risk rating was completed by the time or since the resident’s comprehensive ISP was developed.

Plan of correction

All resident records were audited for completed fall risk assessments and those identified as incomplete were completed. ADON or designee will complete fall risk assessments per facility policy including by the time the comprehensive ISP is complete. Administrator or designee will complete fall risk assessment audit in current quarter and report findings to QA committee."

22VAC40-73-320-B

Based on the review of facility records the facility failed to ensure that a risk assessment for tuberculosis shall be completed annually on each resident as

Evidence

d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: Resident #1-Documented date of admission 02/21/2018. The most recent TB assessment that was submitted for the inspector’s review is dated 02/13/2021. Resident #2-Documented date of admission 09/01/2020. The most recent TB assessment that was submitted for the inspector’s review is dated 09/01/2021.

Plan of correction

FACILITY'S RESPONSE: "All resident records were audited for updated TB assessments and those identified as incomplete were completed. DON or designee will complete TB assessments annually. Administrator or designee will complete an audit quarterly and report findings to QA committee for current quarter."

22VAC40-73-620-B

Based on the review of facility records and staff interviews the facility failed to ensure that upon receipt of recommendations noted in subdivision 3 of this subsection, the administrator, dietitian, or nutritionist must report them to the resident's physician. Documentation of the report shall be maintained in the resident's record. Upon request the facility did not submit for the inspector’s review documented

Evidence

that the physician’s for the residents identified in the 09/01/2022 dietician report were made aware of the dietician’s recommendation and what action was taken in response to the recommendations

Plan of correction

FACILITY'S RESPONSE: "Dietitian recommendations from 09/01/22 report were reviewed, and physicians were notified of findings as indicated. Administrator or designee will complete an audit of Registered Dietitian recommendations and actions documented in resident records in next quarter and report findings to QA committee."

November 1, 2022Complaint survey0 violations

Inspection dates

11/01/2022

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: 11/01/2022 approximate times of 10:54 a.m. – 4:22p.m 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 08/23/2022 regarding allegations in the medication administration. Number of residents present at the facility at the beginning of the inspection: The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. N/A Number of resident records reviewed: 1 Number of staff records reviewed: N/A Number of interviews conducted with residents: N/A Number of interviews conducted with staff: 3 Observations by licensing inspector: 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 Angela Rodgers-Reaves, Licensing Inspector at (804) 840-0253 or by email at angela.r.reaves@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

November 1, 2022Complaint survey0 violations

Inspection dates

11/01/2022

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: On 11/01/2022 during the approximate time of 10:54a.m. – 4:22p.m. on 11/03/2022 during the approximate time of 2:02p.m -2:15p.m 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 10/19/2022 regarding allegations in the resident care and related services 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 Angela Rodgers-Reaves, Licensing Inspector at (804) 8400254 or by email at angela.r.reaves@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

April 26, 2022Inspection0 violations

Inspection dates

04/26/2022

Comments

An unannounced monitoring inspection was conducted at the facility on 04/26/2022 between the approximate time of 2:24p.m and concluded at approximately 4:45p.m. During the entrance interview the facility Administrator offered 133 residents in care. Based on the census offered the inspector reviewed five resident records, five staff records and other facility documentation for compliance. Based on the observation of a medication observed in the medication cart; technical assistance was offered. Information gathered during the inspection determined compliance(s) with applicable standards or law, and no violations were issued to facility. An exit interview was conducted 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. Please contact me at Angela.r.reaves@dss.virginia.gov or (804) 840-0253 if you have any questions.

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.