31
Inspections
On record
21
With violations
Visits that cited something
10
Clean visits
Nothing cited
63
Violations cited
Individual findings
46
Standards cited
Distinct rules
23
Complaint visits
Prompted by a complaint
Cardinal Senior Communities was inspected 31 times between November 9, 2020 and February 19, 2026 by the Virginia Department of Social Services. 21 of those visits ended with violations cited and 10 with none. Across that history VDSS cited 63 violations under 46 distinct standards. 23 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. 26 of these 31 are still on the state's site; the other 5 have since dropped off it and are reproduced from Assisted Living Magazine's archive of the original VDSS reports.
Provider Information
Facility type
Assisted Living Facility
License type
Two Year
License expires
06/30/2027
Administrator
Hollie Bruffy
Licensing inspector
Mari Gentry
Inspector phone
(804) 845-0851
Approved for
Assisted Living · Non-Ambulatory
Inspection History
31Select an inspection to read the areas reviewed, the inspector's comments and any violations cited.
February 19, 2026Complaint survey
Inspection dates
02/19/2026, 02/27/2026
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 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: 02/19/2026 9:30AM to 4:45PM & 02/27/2026 9:05AM to 11:20AM
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
A complaint as received by VDSS Division of Licensing on 01/15/2026 regarding allegations in the area of: resident care and related services
Number of resident records reviewed: 1
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 2
An exit meeting will be conducted to review the inspection findings.
The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. However, violation(s) not related to the complaint but identified during the course of the investigation can 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. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s).
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 these 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. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem-solving conference.
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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-440-D
Based on resident record review and staff interview, the facility failed to ensure for private pay individuals that the uniform assessment instrument (UAI) is completed as required by 22VAC30-110.
Evidence
- The UAI for resident 1, dated 02/12/2026, states that the resident requires mechanical and human physical assistance with mobility and that stairclimbing is not performed by the resident; however, the resident’s individualized service plan (ISP), dated 02/12/2026, states that the resident requires mechanical and human supervision assistance with mobility – resident will have human supervision during mobility with mechanical assistance as needed by walker and requires mechanical and physical assistance when stair climbing for safety.
- Interview with staff person 1 revealed that the resident’s ISP is correct in regard to mobility and stairclimbing and the resident’s UAI is incorrect.
Plan of correction
Not published by VDSS.
December 16, 2025Complaint survey
Inspection dates
12/16/2025, 02/19/2026
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 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: 12/15/2025 9:30AM to 3:30PM & 02/19/2026 9:30AM to 4:45PM
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 12/05/2025 regarding allegations in the area of: resident care and related services
Number of residents present at the facility at the beginning of the inspection: 37
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 2
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. However, violation(s) not related to the complaint but identified during the course of the investigation can 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. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s).
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 these 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. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem-solving conference.
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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-325-B
Based on resident record review and staff interview, the fall risk rating shall be reviewed and updated after a fall.
Evidence
- The record for resident 1 contains hospital paperwork, dated 12/01/2025, that the resident was brought to the emergency department for evaluation of head injury because the resident was bending over from a chair a pick up her Bible that fell on the floor when she lost her balance falling forward, striking her head and was found awake lying on the floor.
- The record for resident 1 does not contain an updated fall risk rating for this fall and staff person 1 confirmed this is accurate.
Plan of correction
This plan of correction is not construed as an admission of or agreement with the findings and conclusions in the Statement of Deficiencies, or the proposed administrative penalty (with right to correct) on the community. Rather, it is submitted as confirmation of our ongoing efforts to comply with all statutory and regulatory requirements. In this document, we have outlined specific actions in response to each allegation or finding. We have not presented all contrary factual or legal arguments, nor have we identified all mitigating factors.
I. The administrator or designee will review all fall incidents to ensure Fall risk reassessment is completed.
II. The Administrator and/or designee will review all Incident Reports to ensure proper documentation.
III. The Administrator and/or designee will audit incident reports and resident records to ensure fall risk assessments are reviewed and updated when required.
IV. 4-3-26
22VAC40-73-70-C
Based on resident record review and staff interview, the facility failed to submit a written report of each incident specified in subsection A of this section to the regional licensing office within seven days from the date of the incident that contained a description of the incident, the circumstances under which it happened, and, when applicable, extent of injury or damage.
Evidence
- Staff person 1 emailed the licensing inspector (LI) a self-reported incident on 12/02/2025 that at 7:15AM on 12/01/2025 resident 1 was found on the floor of her room, was sent to the emergency room for assessment and evaluation, and the resident returned to the facility from the hospital with no new orders and a clear report.
- The record for resident 1 contains hospital paperwork, dated 12/01/2025, that the resident had a hematoma to her left frontal forehead and a small, superficial laceration to the bridge of her nose from her glasses; however, this information was not included in the self-reported incident. Staff person 1 confirmed this is accurate.
Plan of correction
This plan of correction is not construed as an admission of or agreement with the findings and conclusions in the Statement of Deficiencies or any proposed administrative penalty. Rather, it is submitted as confirmation of the community’s ongoing commitment to comply with all applicable statutory and regulatory requirements. This document outlines actions the community will take in response to the cited findings. The community has not presented all contrary factual or legal arguments, nor identified all mitigating factors.
I. Corrective Action for the Specific Instance
Upon identification of the concern, the Administrator will review the incident involving Resident #1 that occurred on 12/01/2025. The review will confirm the details of the event, including that the resident sustained a hematoma to the left frontal forehead and a superficial laceration to the bridge of the nose following the fall.
The Administrator will ensure that all required information, including injuries and outcomes, will be incorporated into incident reports in accordance with regulatory requirements.
II. Measures to Prevent Recurrence
To prevent similar occurrences, the community will implement the following measures:
• The Administrator, Director of Nursing, and designees will receive re-education on Virginia Assisted Living Facility reporting requirements, including incidents requiring submission, required timeframes, and inclusion of all injuries and outcomes.
• An Incident Reporting Checklist will be implemented to ensure all reportable elements, including injury details, will be reviewed prior to submission.
• All incidents requiring licensing notification will be reviewed by the Regional Director of Nursing (DON) prior to submission to ensure reports are complete, accurate, and compliant.
III. Monitoring and Responsibility
The Administrator and/or designee will be responsible for ensuring that all reportable incidents are submitted timely, include complete and accurate information, and comply with Virginia Department of Social Services Assisted Living Facility regulations.
Ongoing monitoring will include periodic audits of incident reports to ensure continued compliance.
IV. Date of Compliance
07/03/2026
December 16, 2025Complaint survey
Inspection dates
12/16/2025, 02/19/2026
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 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: 12/16/2025
8:45AM to 2:45PM & 02/19/2026 9:30AM to 4:45PM
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 12/08/2025 regarding allegations in the area of: resident care and related services
Number of residents present at the facility at the beginning of the inspection: 37
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 2
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. However, violation(s) not related to the complaint but identified during the course of the investigation can 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. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s).
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 these 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. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem-solving conference.
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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-70-A
Based on resident record review and staff interview, the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident.
Evidence
- The record for resident 1 contains a charting note by staff person 3 at 9:51PM on 10/24/2025 that resident 1 was observed in the floor of the bathroom on South hall, resident’s upper body was in the shower and his lower body was in front of the toilet and resident was sent to the emergency department. Hospital discharge instructions for the resident, dated 10/24/2025, contain documentation that the resident was diagnosed with a head injury.
- The aforementioned incident involving resident 1 was not reported to the regional licensing office. Interview with staff person 1 confirmed this is accurate.
Plan of correction
This plan of correction is not construed as an admission of or agreement with the findings and conclusions in the Statement of Deficiencies, or the proposed administrative penalty (with right to correct) on the community. Rather, it is submitted as confirmation of our ongoing efforts to comply with all statutory and regulatory requirements. In this document, we have outlined specific actions in response to each allegation or finding. We have not presented all contrary factual or legal arguments, nor have we identified all mitigating factors.
22VAC40-73-70-A
I. The facility will report to the regional licensing office any major incidents that negatively affect the residents within 24 hours
II. The Director of Operations has reviewed the requirements in relation to The Virginia Department of Social Services reporting requirements, specifically the requirement to report qualifying incidents to the regional licensing office within 24 hours.
III. The Administrator or designee will review all incident reports to ensure that any reportable incidents are submitted to the regional licensing office within the required timeframe. Compliance will be monitored on an ongoing basis.
IV. Date of Completion: 4-3-26
22VAC40-73-325-C
Based on resident record review and staff interview, the facility failed to ensure should a resident who meets criteria for assisted living care fall, the facility must show documentation of an analysis of the circumstances of the fall and interventions that were initiated to prevent or reduce risk of subsequent falls.
Evidence
- The record for resident 1 contains documentation on universal incident reports stating that resident 1 had a fall on 11/12/2025 and 11/14/2025. This document also contains a section labeled “Steps Taken to Prevent Recurrence” which the facility utilizes for documentation of interventions that are to be initiated to prevent recurrence of falls; however, this section was not completed on the two aforementioned universal incident reports.
- During on-site inspection on 02/19/2026, staff person 1 was unable to provide documentation of interventions that had been initiated to prevent or reduce subsequent falls for resident 1 for these two falls.
Plan of correction
Not published by VDSS.
December 15, 2025Complaint survey
Inspection dates
12/15/2025, 02/19/2026
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 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: 12/15/2025 9:30AM to 3:30PM & 02/19/2026 9:30AM to 4:45PM
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 12/05/2025 regarding allegations in the area of: resident care and related services
Number of residents present at the facility at the beginning of the inspection: 37
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 2
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. However, violation(s) not related to the complaint but identified during the course of the investigation can 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. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s).
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 these 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. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem-solving conference.
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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-70-C
Based on facility documentation, resident record review and staff interview, the facility failed to submit a written report of an incident with all required information to the regional licensing office within seven days from the date of the incident.
Evidence
- The licensing inspector (LI) received a self-reported incident via email from staff person 1 on 11/19/2025 at 4:53PM regarding resident 1. Staff person 1 stated in the incident report that at 3:30PM on 11/18/2025, resident 1 fell out of her wheelchair while going down the hall, the resident was sent to the emergency department for assessment and evaluation and the resident returned to the facility with a clear report, no new orders and hospice to resume services.
- The record for resident 1 contains a universal incident report by staff person 2, dated 11/18/2025 at 3:30PM, that the resident fell out of her wheelchair while the resident was being pushed down the hallway, resident hit her head on the floor, and a large knot was observed on the left side of the resident’s forehead. The record for resident 1 also contains hospital discharge instructions, dated 11/18/2025, that the resident was diagnosed with traumatic hematoma of forehead and hospice documentation, dated 11/18/2025, states on page 3 of 4 that the resident has a large hematoma on the left side of her forehead.
- Interview with staff person 1 on 02/19/2026 verified that it had not been reported to the LI that the resident obtained a hematoma from the fall that occurred on 11/18/2025.
Plan of correction
This plan of correction is submitted in response to the Statement of Deficiencies. It is not intended to be, nor should it be construed as, an admission of the truth of the findings, conclusions, or alleged deficiencies. This document is provided as the facility’s plan to maintain and achieve compliance with all applicable federal and state regulations. The facility reserves the right to provide additional information, evidence, or argument relevant to the findings.
I. Corrective Action for the Specific Situation
Upon review, the Administrator confirmed that an incident involving Resident #1 occurred on 11/18/2025. Documentation and internal processes related to the reporting of this incident were reviewed promptly upon identification of the cited concern.
The Administrator ensured that all relevant documentation will be evaluated for completeness and clarity, and that appropriate internal follow-up actions will be taken in accordance with facility protocols.
II. Measures to Prevent Recurrence
To support ongoing compliance with reporting requirements, the facility will implement the following measures:
1. Education and Training
The Administrator, Director of Nursing, and designated leadership staff will be re-educated on applicable Virginia Assisted Living Facility reporting requirements, including criteria for reportable incidents and required timeframes.
2. Standardized Reporting Review Process
Staff will use an approved incident reporting tool to guide review of all required components prior to submission. This will include verification that all applicable details, including outcomes, are appropriately documented.
3. Secondary Oversight Review
All incidents requiring notification to the Regional Licensing Office will undergo a secondary review by the Regional Director of Nursing or designee prior to submission to promote accuracy and completeness.
4. Ongoing Monitoring
The facility will conduct periodic audits of incident reports to ensure adherence to established procedures and identify opportunities for continued improvement.
III. Person(s) Responsible
The Administrator and/or designee will be responsible for implementation and oversight of the corrective actions outlined above. Leadership staff, including the Director of Nursing and Regional Director of Nursing, will support compliance monitoring and ongoing staff education.
IV. Date of Compliance
07/03/2026
December 15, 2025Complaint survey
Inspection dates
12/15/2025, 02/19/2026
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 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: 12/15/2025 9:30AM to 3:30PM & 02/19/2026 9:30AM to 4:45PM
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 10/12/2025 regarding allegations in the area of: resident care and related services
Number of residents present at the facility at the beginning of the inspection: 37
Number of resident records reviewed: 1
Number of staff records reviewed: 4
Number of interviews conducted with residents: N/A
Number of interviews conducted with staff: 2
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. However, violation(s) not related to the complaint but identified during the course of the investigation can 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. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s).
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 these 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. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem-solving conference.
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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-560-A
Based on resident record review and staff interview, the facility failed to implement its written policy and procedures for documentation and recordkeeping to ensure that the information in resident records is accurate and clear.
Evidence
- The facility’s policy, resident records 22VAC40-73-560, states that the community will maintain written and/or electronic records for each resident and resident records will be kept in an accurate, organized and confidential manner, stored in a locked area, and follow HIPPA requirements for safe-guarding personal information.
- Resident 1’s October 2025 electronic medication administration record (EMAR) contains staff person 3’s initials as conducting safety checks on resident 1 at 12:00AM, 2:00AM, 4:00AM and 6:00AM on 10/12/2025; however, staff person 3 was terminated from the facility on 10/14/2025 due to “violation of facility code of conduct falsifying document”. Interview with staff persons 1 and 2 revealed that staff person 4 was the staff person who conducted the safety checks on resident 1 during the aforementioned times on 10/12/2025 not staff person 3; however, staff person 4 was unable to document on resident 1’s EMAR due to not having access to the EMAR system. Staff person 3 was the only staff person during this time that had access to the resident’s EMAR and documented that the safety checks were done; however staff person 3 used their own initials and did not document that staff person 4 was the direct care staff person that conducted the rounds.
Plan of correction
This plan of correction is not construed as an admission of or agreement with the findings and conclusions in the Statement of Deficiencies, or the proposed administrative penalty (with right to correct) on the community. Rather, it is submitted as confirmation of our ongoing efforts to comply with all statutory and regulatory requirements. In this document, we have outlined specific actions in response to each allegation or finding. We have not presented all contrary factual or legal arguments, nor have we identified all mitigating factors.
I. The facility reviewed the resident record identified during the survey and relevant staff were reminded of documentation expectations and recordkeeping requirements. Facility policies regarding resident records and documentation were reviewed with appropriate staff.
II. To prevent future occurrences, the facility will:
• Review documentation and recordkeeping expectations with applicable staff.
• Review resident record documentation procedures during staff meeting and orientation of newly hired employees.
• Conduct periodic audits of documentation records to ensure compliance with facility policies and regulatory requirements.
III. The Administrator and/or designee is responsible for implementation and oversight of this Plan of Correction.
IV. Date of Completion: 7-3-2026
22VAC40-73-450-F
Based on resident record review and staff interview, the facility failed to ensure the individualized service plan (ISP) shall be reviewed and updated at least once every 12 months and as needed for a significant change of a resident’s condition.
Evidence
- The ISP in the record for resident 1, dated 06/25/2025, contains documentation that resident 1 is a fall risk and services to be provided for this identified need are for direct care staff to monitor for unstable gait patterns, alert therapy as needed and remove rugs to reduce fall risk. Fall risk evaluation tools for resident 1, dated 06/23/2025, 06/25/2025, 07/10/2025, 08/12/2025, 08/25/2025, 08/29/2025, 09/27/2025, and 10/12/2025 all contain documentation that the resident is a fall risk. 2. The record for resident 1 contains a universal incident report written by staff person 5, dated 06/25/2025 at 3:40PM, that resident 1 had an unwitnessed fall and staff person 5 observed the resident on the floor in her room. The universal incident report contains documentation of supplemental training (call bell) and resident counseling as the steps taken to prevent recurrence. Interview with staff person 1 on 02/19/2026 revealed that the supplemental training and resident counseling consisted of direct care staff education/counseling on ensuring the resident has her call bell within reach and education/counseling to resident 1 on keeping her call bell within reach to prevent subsequent falls; however, the resident’s ISP was not updated to reflect that direct care staff should be providing this service in regard to the resident being a fall risk. 3. The record for resident 1 contains a universal incident report written by staff person 6, dated 07/10/2025 at 9:50AM, that resident 1 had an unwitnessed fall and the resident informed staff person 6 that she was moving off the bedside commode to her wheelchair and lost her balance. Staff person 6 documented that she observed the resident lying on the floor on her right side, noted a knot on the back of her head, scratch on the right side of her neck and a skin tear to her right elbow. The universal incident contains documentation of resident counseling as the step taken to prevent recurrence and the self-reported incident that was received by the licensing inspector (LI) from staff person 1 on 07/10/2025 contains documentation that the resident was educated on wheelchair safety and positioning as an action to prevent recurrence. Interview with staff person 1 on 02/19/2026 revealed that the resident was educated/counseled on locking the breaks on her wheelchair and the placement of her wheelchair and that direct care staff were educated/counseled on informing the resident of when the breaks should be locked on her wheelchair and the positioning of the resident’s wheelchair; however, the resident’s ISP was not updated to reflect that direct care staff should be providing this service in regard to the resident being a fall risk. 4. The record for resident 1 contains a universal incident report written by staff person 5, dated 08/25/2025 at 3:48PM, that resident 1 had an unwitnessed fall and staff person 5 observed resident 1 at bedside on the floor. The universal incident report contains documentation of resident counseling and procedure review as the steps taken to prevent recurrence. Interview with staff person 1 on 02/19/2026 revealed that the resident was educated/counseled on locking the breaks on her wheelchair and the placement of her wheelchair and that direct care staff were educated on informing the resident of when the breaks should be locked on her wheelchair and the positioning of the resident’s wheelchair; however, the resident’s ISP was not updated to reflect that direct care staff should be providing this service in regard to the resident being a fall risk.(Due to limited space allowed by the DSS computer licensing system, the remainder of the violation is on a separate document and available upon request.)
Plan of correction
This plan of correction is not construed as an admission of or agreement with the findings and conclusions in the Statement of Deficiencies, or the proposed administrative penalty (with right to correct) on the community. Rather, it is submitted as confirmation of our ongoing efforts to comply with all statutory and regulatory requirements. In this document, we have outlined specific actions in response to each allegation or finding. We have not presented all contrary factual or legal arguments, nor have we identified all mitigating factors.
22VAC40-73-450-F
I. Resident Individualized Service Plan (ISP) have been reviewed and updated at least once every twelve months and as needed for a significant change of a resident’s condition.
II. The Administrator and/or designee to review ISP’s documentation requirements.
III. The Administrator and/or designee will audit resident ISPs and incident reports to ensure that any changes in care or interventions are promptly incorporated into the ISP.
IV. 4-3-26
December 15, 2025Complaint survey
Inspection dates
12/15/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 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: 12/15/2025 9:40AM to 3:30PM
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 11/26/2025 regarding allegations in the area of: resident care and related services
Number of residents present at the facility at the beginning of the inspection: 33
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 2
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. However, violation(s) not related to the complaint but identified during the course of the investigation can 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-390-A
Based on resident record review and staff interview, the facility failed to ensure at or prior to the time of admission, there shall be a written agreement or acknowledgment of notification dated and signed by the resident or applicant for admission or the appropriate legal representative and by the licensee or administrator that includes the resident has been informed of the policy or guidelines regarding visiting in the facility if the facility has such a policy or guidelines (22VAC40-73-540-C).
Evidence
- During on-site inspection on 12/15/2025, the licensing inspector (LI) was provided with a copy of the facility’s policy regarding visitation and guests. The policy includes documentation that the community encourages regular family involvement with the resident and provides ample opportunities for participation in community activities; however, should visitors become disruptive to the resident or others, they may be asked to leave if behavior is not corrected.
- The signed agreement in the record for resident 1, signed 04/02/2025, does not include the aforementioned information regarding visitation and guests. Staff persons 1 and 2 confirmed this is accurate.
Plan of correction
Corrective Action: The Administrator and/or designee will ensure that families understand the Code of Conduct outlined in the Resident Agreement applies to them as well as to the residents. Cardinal has had a visitation policy in place and this policy was provided to the inspector on the day of the inspection. However, she felt that it should be part of “The Resident Agreement”.
Plan to Prevent: The facilities Visitation and Guest Policy was added to the Resident Agreement on the day of this inspection and incorporated into the Move-In documentation. This policy informs families of the expected Code of Conduct within the facility and clarifies that all rules apply equally to residents, their families, and their guests.
December 15, 2025Complaint survey
Inspection dates
12/15/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 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: 12/15/2025 9:30AM to 9:40AM
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 10/09/2025 regarding allegations in the area of: resident care and related services
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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
August 29, 2025Complaint survey
Inspection dates
08/29/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 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: 08/29/2025 10:30AM to 11:45AM
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 07/30/2025 regarding allegations in the area of: resident care and related services
Number of resident records reviewed: 2
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 2
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(s) of non-compliance with standard(s) or law were: medications
A violation notice was issued; any violation(s) 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
22VAC40-73-640-A
Based on resident record review, collateral interview and staff interview, the facility failed to implement its medication management plan in regard to methods to ensure that each resident’s prescription medications and any over-the-counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages.
Evidence
- The facility’s medication management plan, reviewed and updated August 2021, contains the following on page 5: If a new med is ordered the pharmacy will package that medication and send with the following delivery and meds are packaged in a card per individual med and a full card of 30 tabs, pill, capsules, etc. are sent and they are reordered as needed.
- The record for resident 1 contains a signed physician’s order, dated 07/22/2025, start APAP (acetaminophen) 1000MG two times daily for pain and start Ibuprofen 200MG two times daily PRN (as needed) for pain.
- The resident’s July and August 2025 medication administration records (MARs) contain documentation for Acetaminophen 500MG take two tablets = 1000MG two times daily for pain and is scheduled for 8:00AM and 8:00PM and the order was written on 07/22/2025 and Ibuprofen 200MG take one tablet two times daily as needed (PRN) for pain and the order was written on 07/22/2025.
- During on-site inspection on 08/29/2025, staff person 2 spoke with Collateral 2. Collateral 2 informed staff person 2 they received the physician’s order on 07/22/2025 for Acetaminophen and PRN Ibuprofen; however, Acetaminophen was not delivered to the facility for resident 1 until 12:00AM on 08/02/2025 and PRN Ibuprofen was not delivered to the facility for resident 1 until 1:14AM on 07/29/2025.
- The resident’s July and August 2025 MARs contain documentation at 8:00AM on 07/25/2025, 07/28/2025, 07/29/2025, and 08/01/2025 and at 8:00PM on 07/29/2025 that Acetaminophen was not administered to the resident due to “MEDICATION NOT AVAILABLE FROM PHARMACY/CONTACTED PHARMACY AND AWAITING MEDICATION”. Also, the July and August 2025 MARs contain documentation that Acetaminophen was administered to the resident at 8:00AM on 07/23/2025, 07/24/2025, 07/26/2025, 07/30/2025 and 07/31/2025 and at 8:00PM on 07/23-28/2025, 07/30/2025, 07/31/2025 and 08/01/2025; however, based on the interview with Collateral 2, the aforementioned medication was not in the facility for staff to administer to the resident during these dates/times. The resident’s July 2025 MAR contains documentation that at 3:09AM on 07/27/2025 staff person 3 administered PRN Ibuprofen 200MG to the resident; however, at 4:49AM on 07/28/2025, staff person 3 documented “Didnt give medicine. Reordered from pharmacy” in regard to the PRN Ibuprofen. Based on the interview with Collateral 2, the aforementioned medication was not in the facility for staff person 3 to administer to resident 1 on 07/27/2025.
- Interview with staff person 2 confirmed that the facility did not follow its medication management plan in regard to ensuring the resident’s prescription medications and any over-the-counter drugs and supplements ordered for the resident were filled in a timely manner to avoid missed dosages.
Plan of correction
Violation: 22VAC40-73-640-A – Failure to implement medication management plan to ensure timely refill/delivery of medications and accurate MAR documentation.
I. Corrective Action: Administrator and/or designee will review all doctors’ orders and conduct a medication cart audit to ensure that all medications are available to fulfill the doctor’s order.
II. Plan to prevent repeat error:
1. The administrator/designee will review all new physician orders to confirm timely transmission to the pharmacy.
2. All medication refills will be requested in a timely manner and administrator/designee will follow up to ensure delivery to prevent lapses in availability.
3. Staff will receive mandatory in-service training on:
o Accurate MAR documentation
o Procedures for timely medication ordering and follow-up with pharmacy
o Steps for escalating when medications are not available.
III. Completion date: 10-5-2025
July 24, 2025Complaint survey
Inspection dates
07/24/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 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: 07/24/2025 2:15PM to 3:30PM
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 07/16/2025 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: 1
Number of interviews conducted with staff: 7
An exit meeting will be conducted to review the inspection findings.
The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary.
The department's inspection findings are subject to public disclosure.
Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility.
For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov
Should you have any questions, please contact Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
June 17, 2025Complaint survey
Inspection dates
06/17/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 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: 06/17/2025 12:45PM to 2:50PM
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
Use this statement only if the inspection is related to a complaint or self-reported incident: A complaint was received by VDSS Division of Licensing on 06/16/2025 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: 9
Observations by licensing inspector: medication cart
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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
No violations cited
The inspector documented no violation of standards at this inspection.