Virginia DSS · Assisted Living Facility

Tribute at The Glen

📍 4151 Old Bridge Road, Woodbridge, VA, 22192

ID 42596Two Year licenseActive
27
Inspections
On record
16
With violations
Visits that cited something
11
Clean visits
Nothing cited
39
Violations cited
Individual findings
32
Standards cited
Distinct rules
9
Complaint visits
Prompted by a complaint

Tribute at The Glen was inspected 27 times between October 8, 2020 and May 6, 2026 by the Virginia Department of Social Services. 16 of those visits ended with violations cited and 11 with none. Across that history VDSS cited 39 violations under 32 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. 24 of these 27 are still on the state's site; the other 3 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
01/15/2027
Administrator
Robert Reffell
Licensing inspector
Sarah Pearson
Inspector phone
(540) 680-9469
Approved for
Assisted Living · Special Care Unit · Non-Ambulatory

Inspection History

27

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

May 6, 2026Inspection2 violations
Inspection dates
05/06/2026
Areas reviewed
Resident Care and Related Services
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: 05/06/2026 from 12:00pm – 1:00pm. 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 02/23/2026 regarding allegations in the area of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 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: 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: Walked building and grounds 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. 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 Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov
Violations
22VAC40-73-1150-A
Based on self-reported incident, resident record review and staff interview, the facility failed to ensure doors that lead to unprotected areas were monitored or secured through devices that conform to applicable building and fire codes, including door alarms, cameras, constant staff oversight, security bracelets that are part of an alarm system, pressure pads at doorways, delayed egress mechanisms, locking devices, or perimeter fence gates.
Evidence
  1. Resident 1 (admitted 1/26/2026) resided in the secured special unit.
  2. A self-reported incident was received by the LI stating resident 1 was located in the front lobby at approximately 11:00am on 2/23/2026 during fire alarm testing.
  3. During the investigation on 5/5/2026 the LI reviewed resident 1’s resident record and observed a note that stated resident 1 was located on 3rd floor during fire alarm testing at approximately 11:00am.
Plan of correction
Staff Inservice performed on elopement & fire alarm testing, resident care plan updated Headcount during & post fire drill, collaboration with PT/OT, community walk club
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
  1. During an investigation on 5/5/2026 the LI was reviewing resident 1’s resident record and observed a progress note that stated resident 1, who resided in a safe, secure unit, was located on the 3rd floor during fire alarm testing.
  2. The LI asked staff 2 if this incident was reported to the regional licensing office and staff 2 stated she thought she sent a self-reported incident email to this LI, but it must not have been sent.
Plan of correction
Staff Inservice performed on elopement & fire alarm testing, resident care plan updated Headcount during & post fire drill, collaboration with PT/OT, community walk club
May 6, 2026Complaint survey2 violations
Inspection dates
05/06/2026
Areas reviewed
Resident Care and Related Services
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 5/6/2026, 9:30am to 12:00pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 9/3/2025 regarding allegations in the area(s) of: Resident Care and Related Services 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: 1 Number of staff records reviewed: NA Number of interviews conducted with residents: NA Number of interviews conducted with staff: 1 Observations by licensing inspector: NA Additional Comments/Discussion: 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: Resident Care and Related Services 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. 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 Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov
Violations
22VAC40-73-460-B
Based on a complaint received by the regional licensing office on 9/3/2025, facility policy, facility record review and staff interview, the facility failed to ensure prompt response by staff to resident needs as reasonable to the circumstances.
Evidence
  1. On the date of the inspection on 5/6/2026 the LI asked staff 1 for the call bell report for 8/30/2025 between 12:00am-11:59pm for resident 1. Staff 1 gave the LI the PalCare Event report for 8/30/2025 from 12:00am-11:59pm for resident 1 and the report indicated resident 1 requested assistance via waterproof pendant with an event start time of 00:54:08 (12:54am). The reports indicated the event was cleared at 02:06:30 (2:06am) with a response time of 72.1 minutes.
  2. Facility policy titled: Call light policy states staff will respond to calls for assistance as soon as possible and meet the resident’s needs.
  3. Staff 1 and 2 acknowledged the time it took on 8/30/2025 for staff to respond to resident 1’s call bell request.
Plan of correction
Staff retrained, documented coaching & in-service; PalCare reviewed. Daily reports, staffing adjustments, supervisor rounding.
22VAC40-73-300-B
Based on staff interview, the facility failed to ensure a method of written communication shall be utilized as a means of keeping direct care staff on all shifts informed of significant happenings or problems experienced by residents.
Evidence
  1. On the date of investigation on 5/6/2026 the LI asked staff 1 for written communication with staff for 8/30/2025 and 8/31/2025.
  2. Staff 1 stated there was no communication log available for 8/30/2025 or 8/31/2025.
Plan of correction
Shift communication logs implemented; staff re-educated. Daily audits, weekly leadership review, ongoing training.
May 6, 2026Inspection2 violations
Inspection dates
05/06/2026
Areas reviewed
Resident Care and Related Services
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: 5/6/2026 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 4/7/2026 regarding allegations in the area of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 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: 2 Number of staff records reviewed: NA Number of interviews conducted with residents: NA Number of interviews conducted with staff: 1 Observations by licensing inspector: NA 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. 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 Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov
Violations
22VAC40-73-450-E
Based on resident record review and staff interview, the facility failed to ensure the ISP shall be signed and dated by the licensee, administrator, or his designee and by the resident or his legal representative.
Evidence
  1. Resident 2 admitted 6/30/2021 had an ISP on filed dated 12/24/2025 that did not include signatures and dates by the licensee, administrator, or his designee or the resident or his legal representative.
  2. Staff 1 and 2 acknowledged the ISP for resident 2 did not include the required signatures and date of the signatures.
Plan of correction
Updated service planned signed UAI Tracker
22VAC40-73-450-F
Based on self-reported incident, resident record review and staff interview, the facility failed to update the Individualized Service Plan (ISP) as needed for a significant change of a resident’s condition.
Evidence
  1. A self-reported incident was received by the regional licensing office that stated resident 1 and resident 2 were in the lobby when resident 2 got upset because they were not included in a conversation between resident 1 and another resident. Resident 2 became irritated and hit resident 1 with her rollator. The report also stated resident 2 is becoming increasingly aggressive and agitated.
  2. Resident 2 admitted 6/30/2021 had an ISP on file dated 12/24/2025 that stated: resident does not require assistance with abusive/aggressive/disruptive behavior/resident is appropriate.
  3. Staff 1 and 2 acknowledged resident 2’s ISP did not include an update to the plan to include actions to minimize aggressive/agitated behaviors.
Plan of correction
ISPs updated. Weekly clinical review + HWD audit tool + 1:1 w/ED&HWD
May 6, 2026Inspection2 violations
Inspection dates
05/06/2026
Areas reviewed
22VAC40-73 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 Building and Grounds22VAC40-73 Emergency Preparedness22VAC40-73 Additional Requirements for Facilities that Care for Adults with Cognitive Impairments22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 Sworn Statement
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: 5/6/2026, 1:00pm to 2:00pm 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 12/31/2025 regarding allegations in the areas of: Resident Care and Related Services 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: 3 Number of staff records reviewed: NA Number of interviews conducted with residents: NA Number of interviews conducted with staff: 1 Observations by licensing inspector: NA 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. 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 Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov
Violations
22VAC40-73-680-D
Based on self-reported incident, resident record, facility record review and staff interview, the facility failed to administer medications in accordance with the physician’s or other prescriber’s instructions.
Evidence
  1. A self-reported incident was received by the LI on 12/13/2025 that stated medications were not administered on 12/13/2025 at 11pm-7am shift (12/13/2025 11:00pm-11:59pm-12/14/2025 12:00am-7:00am).
  2. Resident 1’s (admitted 7/23/2020) December 2025 Medication Administration Record (MAR) indicated the following medications were not administered: Carboxmethy sol 0.5% (instill 1 drop in both eyes twice daily, ordered 8/11/2025) at 6:00am on 8/14/2025 and at 6pm on 8/15/2025; Centrum Silv tab women 50 (take 1 tablet by mouth once daily, ordered 9/27/2025) at 6:00am on 8/14/2025; Escitalopram tab 5mg (take 1 tablet by mouth once daily, ordered 8/11/2025) at 6:00am on 12/14/2025; Furosemide tab 20mg (take 1 tablet by mouth once daily, ordered 9/26/2025 at 6:00am on 12/14/2024; Metformin tab 500mg (take 1 tablet by mouth once daily, ordered 9/26/2025) at 6:00am on 8/14/2025; Metroprol TAR tab 25mg (take 1 tablet by mouth twice daily hold for systolic blood pressure <100 and heart rate < 60, ordered 9/26/2025) at 6:00am on 8/14/2025 and Pot Chloride tab 20MEQ ER (take 1 tablet by mouth twice daily, ordered 8/11/2025) at 6:00am on 8/14/2025 and at 5:00pm on 8/15/2025.
  3. Resident 2’s (admitted 11/14/2023) December 2025 MAR indicated the following medications were not administered: Levothyroxin tab 50mcg (take 1 tablet by mouth every morning before breakfast, ordered 8/11/2025) at 6:00am on 8/14/2025.
  4. Staff 2 acknowledged these medications were not administered.
Plan of correction
Schedule Review/Confirmation weekly, in-service on company time & attendance policy Quarterly. Schedule audit on any changes
22VAC40-73-280-A
Based on facility record review and staff interview, the facility failed to ensure the assisted living facility shall have staff adequate in sufficient numbers to provide services to attain and maintain the physical, mental and psychosocial well-being of each resident.
Evidence
  1. On the date of the inspection on 5/6/2026 the LI asked staff 1 for the staff schedule for December 13th and 14th, 2025. Staff 1 provided the staff schedule for the month of December 2025. On 12/13/2025 the staff schedule titled: AL Medication Aide 11pm-7am had the name of one staff member and in parenthesis ‘vacation’ and a highlighted area with the word ‘open’.
  2. The LI asked staff 2 if there were no staff members available on 12/13/2025 from 11:00pm to 7:00am that were qualified to administer medications to the residents, staff 2 confirmed.
Plan of correction
Schedule Review/Confirmation weekly, in-service on company time & attendance policy Quarterly. Weekly weekend coverage confirmed
May 6, 2026Inspection0 violations
Inspection dates
05/06/2026
Areas reviewed
Resident Care and Related Services
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: May 6th, 2026, 11:00am to 12:09pm 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 2/27/2026 regarding allegations in the area(s) of: Resident Care and Related Services 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: 2 Number of staff records reviewed: NA Number of interviews conducted with residents: NA Number of interviews conducted with staff: 1 Observations by licensing inspector: NA Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 5, 2026Inspection1 violation
Inspection dates
05/05/2026
Areas reviewed
Resident Care and Related Services
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: 5/5/2026 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 2/23/2026 regarding allegations in the area(s) of: Resident Care and Related Services 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: 1 Number of staff records reviewed: NA Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: NA 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. 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 Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov
Violations
22VAC40-73-450-F
Based on self-reported incident and resident record review, the facility failed to update the Individualized Service Plan (ISP) as needed for significant change or a resident’s condition.
Evidence
  1. A self-reported incident was received by the regional licensing office on 2/23/2026 stating resident 1 was observed outside of the community heading towards chick fila, resident reports “looking for his car”.
  2. Resident 1 admitted 2/27/2020 had an ISP on file dated 12/2/2025 that did not include the incident that was self-reported on 2/23/2026 or any action to take to prevent a negative outcome.
  3. Staff 1 and 2 acknowledged this incident was not incorporated into resident 1’s ISP.
Plan of correction
ISPs updated. Weekly clinical review + HWD audit tool + 1:1 w/ED&HWD
May 5, 2026Complaint survey0 violations
Inspection dates
05/05/2026
Areas reviewed
Resident Care and Related Services
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: May 5, 2026, 12:30pm to 1:00pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 3/3/2026 regarding allegations in the area(s) of: Resident Care and Related Services 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: 1 Number of staff records reviewed: NA Number of interviews conducted with residents: NA Number of interviews conducted with staff: 1 Observations by licensing inspector: NA Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 5, 2026Inspection0 violations
Inspection dates
05/05/2026
Areas reviewed
Resident Care and Related Services
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: May 5th, 2026, 1:00pm to 2:000pm 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 10/6/2026 regarding allegations in the area(s) of: Resident Care and Related Services 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: 2 Number of staff records reviewed: NA Number of interviews conducted with residents: NA Number of interviews conducted with staff: 1 Observations by licensing inspector: NA Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 5, 2026Inspection0 violations
Inspection dates
05/05/2026
Areas reviewed
Resident Care and Related Services
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: 05/05/2026, 11:30am to 12:00am 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 3/3/2026 regarding allegations in the area(s) of: Resident Care and Related Services 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: 1 Number of staff records reviewed: NA Number of interviews conducted with residents: NA Number of interviews conducted with staff: 1 Observations by licensing inspector: NA Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
April 28, 2026Inspection7 violations
Inspection dates
04/28/2026; 04/29/2026; 04/30/2026
Areas reviewed
22VAC40-73 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 Building and Grounds22VAC40-73 Emergency Preparedness22VAC40-73 Additional Requirements for Facilities that Care for Adults with Cognitive Impairments22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 Sworn Statement
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: April 28, 2026, 9:30am to 1:10pm; 4/29/2026 9:15am to 3:30pm; 4/30/2026, 9:15am to 11:30am 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: 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: 2 Number of interviews conducted with staff: 4 Observations by licensing inspector: The LI observed residents participating in activity programs and eating meals. 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. 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 Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov
Violations
22VAC40-73-720-A
Based on resident record review and staff interview, the facility failed to ensue the Do Not Resuscitate Order is included in the Individualized Service Plan (ISP).
Evidence
  1. Resident 4 admitted 11/14/2023 had a Do Not Resuscitate (DNR) Order dated 4/7/2026.
  2. The ISP for resident 4 dated 5/4/2026 did not include the DNR order in the ISP.
  3. Staff 4 acknowledged the ISP for resident 4 did not include the DNR order.
Plan of correction
DNR obtained and added to chart. Established Clinical Checklist + HWD audit tool
22VAC40-73-450-B
Based on resident record review and staff interview, the facility failed to ensure licensee, administrator or designee who has successfully completed the department-approved individualized service plan (ISP) training provided by a licensed health care professional practicing within the scope of his profession, shall develop a comprehensive ISP to meet the resident’s service needs.
Evidence
  1. Resident 1 admitted 3/31/2026 had an ISP dated 4/21/2026, resident 2 admitted 11/30/2024 had an ISP dated 5/3/2026, resident 4 admitted 11/14/2023 had an ISP dated 5/4/2026 and resident 5 admitted 8/14/2025 had an ISP dated 5/3/2026.
  2. Resident 1, 2, 4 and 5’s ISPs were signed by staff 4. The LI asked staff 4 for their ISP training certificate, staff 4 stated she was not able to locate the requested training certificate.
Plan of correction
Training identified and registered for completion by HWD/MCC/ALC Quarterly audit + HR tracking.
22VAC40-73-450-F
Based on resident record review and staff interview, the facility failed to ensure the Individualized Service Plan (ISP) shall be updated as needed for a significant change of a resident’s condition:
Evidence
  1. Resident 2 admitted 11/30/2024 had an ISP dated 5/3/2026 that did not include the need for physical and occupational therapy due to weakness and difficulty walking. 2. Resident 2 had an order on file dated 3/25/2026 for PT/OT (physical therapy/occupational therapy). 3. Staff 4 acknowledged the ISP did not include resident 2’s need for PT/OT.
  2. Resident 5 admitted 8/14/2025 had a order for wound care dated 4/10/2026. 2. The ISP dated 5/3/2026 did not include resident 5’s need for wound care.
  3. Staff 4 acknowledged the ISP did not include resident 5’s need for wound care.
Plan of correction
ISPs updated. Weekly clinical review + HWD audit tool + 1:1 w/ED&HWD
22VAC40-73-970-A
Based on facility record review and staff interview, the facility failed to complete fire drill frequency in accordance with the current edition of the Virginia Statewide Fire Prevention Code (13.VAC5-51).
Evidence
  1. On 4/28/2026 the LI asked staff 5 for fire drills conducted since the last mandated inspection on 7/23/2025. Staff 5 provided the LI with the requested fire drills and found no documentation of fire drills conducted in July 2025 or March 2026.
  2. Staff 5 acknowledged there was no documentation available for fire drills conducted in July 2025 or March 2026.
Plan of correction
Fire drills completed; records updated. Monthly occurrence & audit, Annual schedule + tracking logs.
22VAC40-73-320-A
Based on resident record review and staff interview, the facility failed to ensure the physical examination by an independent physician shall contain any recommendations for care including medication.
Evidence
  1. Resident 1 admitted 4/15/2026 had a report of resident physical examination on file dated 4/8/2026. On page 3 of the report for medications a note was made to ‘see medication list’, however the medication list was not attached to the report. Staff 4 acknowledged the medication list was not attached to the report.
  2. Resident 5 admitted 8/14/2025 had a report of resident physical examination on file that did not include the date of examination or the date the physician signed the report.
  3. Staff 4 acknowledged the dates were missing from the report.
Plan of correction
Missing documents obtained. Chart audits + admission checklist.
22VAC40-73-680-I
Based on resident record review and staff interview, the facility failed to document on the medication administration record (MAR) the diagnosis, condition or specific indications for administering the drug or supplement.
Evidence
  1. Resident 1 admitted 4/15/2026 had the following medications or supplements listed on the April 2026 MAR that did not list a diagnosis, condition or specific indication for administering the drug or supplement: Coenzyme Q10 CAP 50MG, 1 capsule by mouth one time a day start 4/17/2026, Sodium Bicarb Tab 650MG: 1 tablet by mouth two times a day start 4/17/2026, Tamsulosin cap 0.4 MG caps: 1 capsule by mouth one time a day, start 4/17/2026, Lidocaine (topical) 4% medicated patch: take patch off from back at bedtime start 4/17/2026.
  2. Resident 2 admitted 11/30/2024 had the following medications or supplements listed on the April 2026 MAR that did not list a diagnosis, condition or specific indication for administering the drug or supplement: Cholestyramine pwd packet 4mg pack: mix 1 packet in 6 oz of fluid and administer by mouth tow times a day start 1/20/2026, Glipizide tab 5 mg tabs: 1 tablet by mouth two times a day start 1/20/2026.
  3. Resident 3 admitted 7/19/2019 had the following medications or supplements listed on the April 2026 MAR that did not list a diagnosis, condition or specific indication for administering the drug or supplement: Acetaminophen tab 325mg tabs: 3 tablets (975mg) by mouth two times a day, not to exceed 4,000mg in 24 hours start 2/18/2026, Ferrous Sulf EC tab 324mg TBEC: 1 tablet by mouth one time a day start 1/21/2026, Namzaric cap 28mg/10mg CP24: 1 capsule by mouth one time a day start 1/21/2026, Tamsulosin cap 0.4mg caps: 1 capsule by mouth one time a day after supper start 1/21/2026, Levothyroxine tab 175mcg tabs: 1 tablet by mouth one time a day start 1/21/2026, Ondansetron tab 4mg tabs: 1 tablet by mouth one time a day as needed max dose 1 tabs start 1/21/2026, Polyethylene gly pwd (510gm) 17gm/scoop powd: mix 17gm (see inside cap) in 8 oz of fluid and administer by mouth one time a day as needed start 1/21/2026.
  4. Resident 5 admitted 8/14/2025 had the following medications or supplements listed on the April 2026 MAR that did not list a diagnosis, condition or specific indication for administering the drug or supplement: amlodipine tab 5mg tabs: 1 tablet by mouth one time a day in the morning start 3/3/2026, Famotidine tab 20mg: 1 tablet by mouth one time a day start 3/3/2026, Ferrous Sulf FC tab 325mg tabs: 1 tablet by mouth one time a day for 60 days start 3/1/2026, Galantamine tab 4mg tabs: 1 tablet by mouth two times a day with breakfast and dinner start 3/3/2026.
  5. Staff 4 acknowledged the MARs were missing diagnosis, condition or specific indication for administering the drug or supplement for resident 1, 2, 3 and 5.
Plan of correction
MARs reviewed and updated. Monthly audits + pharmacy cross-check.
22VAC40-73-1180-A
Based on direct observation and staff interview, the facility failed to ensure special environmental precautions be taken by the facility to eliminate hazards to the safety and well-being of residents.
Evidence
  1. On 4/28/2026 during the entrance tour, the LI observed an oven in the safe, secured unit that was accessible to the residents. The LI pressed the power button on the oven and the interior oven light turned on and displayed 350 degrees with a fan symbol that began flashing. The LI waited approximately three minutes, opened the oven door and felt heating emitting from the oven element. The LI asked staff 6 if the oven was able to be turned on and staff 6 stated no. The LI and staff 6 opened the oven door and she acknowledged the oven was on but should have been in locked mode and not have been able to be turned on by pressing the power button.
  2. On 4/28/2026 during the entrance tour the LI observed a toaster oven on top of the counter in the secured unit that was accessible to the residents. The toaster oven was unplugged, but there was an electrical outlet within a few inches of the toaster oven.
  3. On 4/28/2026 during the entrance tour the LI observed a container of powder cleanser under the kitchen sink and a spray can of air deodorizer in an upper cabinet, both of which were accessible to the residents. Staff 6 acknowledged the cleaner and deodorizer were accessible to the residents.
  4. Photo/video evidence.
Plan of correction
Hazards removed/secured; Staff educated on using safety feature on oven Daily rounds + weekly audits.
July 23, 2025Complaint survey2 violations
Inspection dates
07/23/2025
Areas reviewed
Resident Care and Related ServicesBuilding and Grounds
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: 7/23/2025 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 6/23/2025 regarding allegations in the areas of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 85 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: NA Number of interviews conducted with residents: NA Number of interviews conducted with staff: 1 Observations by licensing inspector: NA Additional Comments/Discussion: 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 : Resident Care and Related Services 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 Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov
Violations
22VAC40-73-450-C
Based on resident record review, the facility failed to include hospice services on the Individualized Service Plan.
Evidence
  1. Resident 1 had an order for hospice written on 6/19/2025.
  2. Resident 1 had an Individualized Service Plan on file dated 5/15/2025 that did not include hospice services.
Plan of correction
Auditing in progress to ensure all care plans are updated and correct. Monthly review of care plans to ensure accuracy.
22VAC40-73-650-A
Based on resident record review, staff interview and video footage, the facility did not follow physician orders.
Evidence
  1. Resident 1 had an order written on 6/19/2025 that stated: Patient is NPO (nil per os), except liquid meds.
  2. Video footage shows staff 2 entering resident 1’s apartment with a small cup and spoon. Staff 2 stirs the contents of the cup, then staff 2 administers the contents from the cup into resident 1’s mouth with a spoon. Staff 2 states he is giving her medicine.
  3. Staff 1 stated the staff were educated about not giving residents their medications in applesauce if the resident has an NPO order.
  4. Video evidence
Plan of correction
Educate all staff on following diets as ordered and following medication policy.
July 23, 2025Complaint survey4 violations
Inspection dates
07/23/2025
Areas reviewed
Resident Care and Related Services
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: 7/23/2025 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 2/24/2025 regarding allegations in the area of: Administration and Administrative Services, and Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 85 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: NA Number of interviews conducted with residents: NA Number of interviews conducted with staff: 1 Observations by licensing inspector: NA Additional Comments/Discussion: 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: Administration and Administrative Services, and Resident Care and Related Services. 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 Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov
Violations
22VAC40-73-580-F
Based on resident record review, the facility failed to implement interventions as soon as nutritional problem is suspected. 1. Weighing residents at least monthly to determine whether the resident has significant weight loss (i.e, 5.0% weight loss in one month, 7.5% in three months, or 10% in six months) and 2. Notifying the attending physician if any resident who is not on a physician-approved weight reduction program and obtaining, documenting, and following physician’s instructions regarding nutritional care.
Evidence
  1. According to the Senior Resident Vital Sign Chart document for resident 1, the resident weighed 148 pounds in October 2024 and 121.8 pounds in December 2024, a 17.7% weight loss.
  2. Staff 1 was unable to find documentation of resident 1’s physician being notified of the 17.7% weight loss.
Plan of correction
Inservice will be provided for all Nursing staff that any weight gain or loss of 5lbs or more must be reported to residents' Physician, Nurse Practitioner or Physician Assistant immediately for evaluations.
22VAC40-73-450-B
Based on resident record review, the facility failed to ensure the Individualized Service Plan (ISP) was signed and dated by the resident or his legal representative.
Evidence
  1. The ISP on file for resident 1, developed on 12/11/2024, was not signed and dated by the person who developed the plan or the resident’s legal representative.
Plan of correction
Audit has been completed to have all care plans signed by families/residents. Family/Resident will be scheduled to review and sign all care plans. Review can be in-person, via email or video chat per family/residents' request.
22VAC40-73-450-C
Based on resident record review, the facility failed to update the Individualized Service Plan (ISP) to include hospice services.
Evidence
  1. Resident 1 had an order to ‘admit to hospice’ written on 2/8/2025.
  2. The ISP developed on 12/11/2024 did not include hospice services.
Plan of correction
Auditing in progress in ensure all care plans are updated and correct. Monthly review of care plans to ensure accuracy.
22VAC40-73-40-A
Based on resident record review, facility policy review and staff interview, the facility failed to ensue compliance with the facility’s own policies and procedures.
Evidence
  1. According to the facility’s Weights policy, the policy states, 1. The Health & Wellness Director will assign the task of measuring resident weights monthly to Resident Care Associates.
  2. The Senior Resident Vital Sign Chart document for resident 1 had weights recorded for August 2024, September 2024, October 2024 and December 2024. There was no weight recorded for resident 1 in November 2024.
  3. According to the facility’s Weights policy, the policy states, 5. Significant weight changes will be reported to the resident’s physician, including: a. Five (5) pounds or greater weight change in thirty (30) days, whichever is larger. B. 7.5% or greater in ninety (90) days. c. 10% or greater in six (6) months.
  4. According to the Senior Resident Vital Sign Chart document for resident 1, the resident weighed 148 pounds in October 2024 and 121.8 pounds in December 2024, a 17.7% weight loss.
  5. Staff 1 was unable to find documentation of resident 1’s physician being notified of the 17.7% weight loss.
Plan of correction
Charts and EHR reviewed, weights and vital signs will be added. Audits will be done monthly by 15th of month to ensure vital signs are weights have been completed and entered.
July 23, 2025Inspection2 violations
Inspection dates
07/23/2025
Areas reviewed
Resident Care and Related ServicesBuilding and Grounds
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: 7/22/2025 & 7/23/2025 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 2/21/2025 regarding allegations in the areas of: Resident Care and Related Services and Building and Grounds Number of residents present at the facility at the beginning of the inspection: 85 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: NA Number of interviews conducted with residents: NA Number of interviews conducted with staff: 2 Observations by licensing inspector: The LI observed residents participating in activity programs and eating lunch. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov
Violations
22VAC40-73-290-A
Based on staff interview, the facility failed to maintain a written work schedule that includes the names and job classifications of all staff working each shift, with an indication of whomever is in charge at any given time.
Evidence
  1. The LI asked staff 1 for the written work schedule for 2/12/2025 and staff 1 stated the schedule was no longer available.
Plan of correction
Educated through in-service to managers document retention requirements of the State of Virginia. Provide binder for completed schedules to be stored in ED office.
22VAC40-73-460-A
Based on self-reported incident and staff interviews, the facility failed to assume general responsibility for the health, safety, and well-being of the residents.
Evidence
  1. Self-reported incident, received on 2/12/2025, stated resident was observed on the floor outside the exit door stairwell of secured unit.
  2. Staff 2 stated on 2/12/2025 he was using the stairs to go downstairs, and he found resident 1 laying on the stairwell landing between two floors. Resident 1 resided in the secured unit.
  3. Staff 1 and 4 stated the doors are supposed to open once pressed for 15 seconds; staff are notified when the doors open without the use of a staff key fob.
  4. The LI was unable to open the door even after pressing on the door exit bar for greater than 15 seconds.
  5. Staff 4 was not sure how the door was opened without a key fob.
Plan of correction
Inservice will be provided to all staff for monitoring of residents, focused on monitoring of special care unit residents. Preventative maintenance on locking doors in memory care units. Random check for safety in MC units.
July 22, 2025Complaint survey2 violations
Inspection dates
07/22/2025; 07/23/2025
Areas reviewed
Administration and Administrative ServicesResident Care and Related Services
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: 7/22/2025 & 7/23/2025 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 4/30/2025 regarding allegations in the areas of: Administration and Administrative Services, and Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 85 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: NA Number of interviews conducted with residents: NA Number of interviews conducted with staff: 1 Observations by licensing inspector: NA Additional Comments/Discussion: 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: Administration and Administrative Services and Resident Care and Related Services. 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 Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov
Violations
22VAC40-73-150-B-1
Based on a complaint received 4/30/2025, email correspondence and staff record review, the facility failed to notify the department’s regional licensing office in writing within 14 days of a change in a facility’s administrator.
Evidence
  1. Complainant stated the administrator of record (Staff 4) “quit on Monday” (4/28/2025).
  2. Email received by LI on 5/19/2025 stated an interim administrator started 4/29/2025.
  3. Employee Update form in staff 4’s had a termination date of 4/29/2025.
Plan of correction
New ED sent a notification email to DSS on 7/15/2025. Through transparent communications with DSS.
22VAC40-73-110-1
Based on a complaint received 4/30/2025, video footage and staff interview, the facility failed to be considerate and respectful of the rights, dignity, and sensitivities of persons who are aged, infirm, or disabled.
Evidence
  1. Complainant stated she watched video footage of resident 1 being assisted by staff 1 to walk from her living room to the bathroom while resident 1’s pants were down around her ankles.
  2. Video footage was sent to this LI and LI observed a staff member assisting resident 1 to walk from the living room to the bathroom and resident 1’s pants were down around her ankles.
  3. Staff 2 verified the staff member in the video was staff 1.
Plan of correction
Staff member was terminated. Ongoing staff will receive customer service training.
July 22, 2025Inspection2 violations
Inspection dates
07/22/2025; 07/23/2025
Areas reviewed
PersonnelResident Care and Related Services
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: 7/22/2025 & 7/23/2025 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 6/20/2025 regarding allegations in the area of: Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 85 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: 1 Number of interviews conducted with residents: NA Number of interviews conducted with staff: 1 Observations by licensing inspector: NA 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 Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov
Violations
22VAC40-73-210-A
Based on staff record review and staff interview, the facility failed to ensure direct care staff who are licensed health care professionals or certified nurse aides shall attend at least 12 hours of annual training.
Evidence
  1. Staff 1 hired 5/5/2023 did not have 12 hours of annual training on file for the year.
  2. Staff 2 stated staff 1’s annual training was not available.
Plan of correction
Staff will complete training annually with Relias and Live Trainings as scheduled. Audits will be done monthly to ensure remains compliant with scheduled trainings.
22VAC40-73-550-G
Based on staff record review and staff interview, the facility failed to review resident rights annually with each staff person.
Evidence
  1. Staff 1 hired 5/5/2023 did not have documentation of resident rights review for the year on file.
  2. Staff 2 stated staff 1’s documented resident rights review for the year was not available.
Plan of correction
Not published by VDSS.
July 22, 2025Inspection1 violation
Inspection dates
07/22/2025
Areas reviewed
Resident Care and Related Services
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: 7/22/2025 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 2/6/2025 regarding allegations in the areas of: Personnel and Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 85 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: 1 Number of interviews conducted with residents: NA Number of interviews conducted with staff: 1 Observations by licensing inspector: NA Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov
Violations
22VAC40-73-670-2
Based on self-reported incident on 2/6/2025 and resident record review, the facility failed to ensure that staff who are responsible for administering medications meet the requirement of 22VAC40-73-670.
Evidence
  1. Self-reported incident stated staff 1 was not practicing within the parameters of the provisional medication aide letter she received from Virginia Department of Health Professionals.
  2. Staff 1 had an Eligibility to test with Provisional Status letter from Virginia Department of Health Professionals on file, dated 10/2/2024. The letter stated: Pursuant to 18 VAC 90-60-91, you are now authorized to practice on a provisional medication aide.
  3. Staff 1’s provisionary period to practice as a medication aide ended on 1/30/2025.
  4. Staff 1 did not have a Registered Medication Aide license on file and could not be located on the Department of Health Professionals’ website (license lookup feature).
  5. On the Medication Administration Record for resident 1 for February 2025, staff 1 administered the following medications on 2/2/2025: Carvedilol F/C 12.5 mg tablet (take 1 tablet by mouth twice daily for hypertension) at 5:00pm, Carvedilol F/C 6.25 mg tablet (take 1 tab by mouth twice daily for hypertension) at 5:00pm, Hydroxyzine HCL F/C 25 mg tablet (take 1 tab by mouth twice daily) at 5:00pm, Metformin HCL F/C 1000 mg tablet (take 1 tab by mouth twice daily for diabetes mellitus) at 6:00pm, and Minoxidil 2.5 mg tablet (take 1 tab by mouth daily for BPR greater than 140) at 4:00pm.
Plan of correction
Provisional licensee will not perform duties outside of 120 days. Provisional licensee will be required to test for permanent license by 60th day of provisional status.
July 22, 2025Complaint survey0 violations
Inspection dates
07/22/2025
Areas reviewed
Resident Care and Related Services
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: 7/22/2025 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 1/13/2025 regarding allegations in the area(s) of: Number of residents present at the facility at the beginning of the inspection: 85 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: NA Number of interviews conducted with residents: NA Number of interviews conducted with staff: 1 Observations by licensing inspector: NA Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the (allegation(s)/self-report) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
July 22, 2025Inspection0 violations
Inspection dates
07/22/2025
Areas reviewed
Resident Care and Related Services
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: 7/22/2025 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 3/5/2025 regarding allegations in the area(s) of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 85 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: NA Number of interviews conducted with residents: NA Number of interviews conducted with staff: 1 Observations by licensing inspector: The LI observed residents participating in activity programs and eating lunch. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
July 22, 2025Inspection0 violations
Inspection dates
07/22/2025
Areas reviewed
Resident Care and Related Services
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: 7/22/2025 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 4/10/2025 regarding allegations in the area(s) of: Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 85 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: NA Number of interviews conducted with residents: NA Number of interviews conducted with staff: 1 Observations by licensing inspector: The LI observed residents participating in activity programs and eating meals. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the (allegation(s)/self-report) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
December 3, 2024Complaint survey0 violations
Inspection dates
12/03/2024
Areas reviewed
Resident Care and Related ServicesPersonnel
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: 12/3/2024 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 9/17/2024 regarding allegations in the area(s) of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 101 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: 1 Number of interviews conducted with residents: NA Number of interviews conducted with staff: 1 Observations by licensing inspector: NA 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 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. 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 Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
December 3, 2024Inspection6 violations
Inspection dates
12/03/2024
Areas reviewed
Administration and Administrative ServicesPersonnelStaffing and SupervisionAdmission, Retention and Discharge of ResidentsResident Care and Related ServicesResident Accommodations and Related ProvisionsBuilding and GroundsEmergency PreparednessAdditional Requirements for Facilities that Care for Adults with Cognitive ImpairmentsBackground Checks for Assisted Living FacilitiesSworn Statement
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: December 3 & 5, 2024 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: 101 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: 1 Number of interviews conducted with staff: 4 Observations by licensing inspector: LI observed residents participating in activity programs and eating meals. 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 Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov
Violations
22VAC40-73-450-C
Based on resident record review, the facility failed to develop an Individualized Service Plan (ISP) that identified needs of the resident.
Evidence
  1. Resident 1 had a Morse Fall Scale completed on 10/5/2024 with a total score of 80. According to the scale the resident is a high risk for falls. The ISP developed on 10/5/2024 did not list any actions to minimize falls.
  2. Resident 2 had a Morse Fall Scale completed on 7/1/2024 with a total score of 70. According to the scale the resident is a high risk for falls. The ISP developed on 7/1/2024 did not list any actions to minimize falls.
Plan of correction
CORRECTION #1 The Health and Wellness Director (RN) updated the 2 identified resident ISPs to include intervention/action for high fall risk. DATE: 12/10/2024 CORRECTION #2 The Health and Wellness Director (RN) completed a review of all other current residents who are high fall risk to ensure their ISP included interventions/actions. Any deficiencies identified were corrected immediately. DATE: 12/13/2024 CORRECTION #3 The Health and Wellness Director (RN) was educated by the Executive Director (ALFA). Education included the Cogir Senior Living Clinical Policy Manual VA 06-01-2024, AS0S Individualized Service Plans policy. DATE: 12/10/20024 CORRECTION #4 The facility plans to monitor its performance to make sure that solutions are sustained. The Health and Wellness Director (RN) or designee will complete the ISP to include interventions/actions for high fall risk residents. The Regional Director of Health and Wellness Director (RN) or Executive Director (ALFA) will review a sample of current residents, weekly for 4 weeks, and monthly for 2 months to ensure the ISP is up-to-date and includes, as necessary, interventions for high fall risk residents. The Executive Director (ALFA) will report findings during the appropriate review meeting. Documentation of the review will be kept by the Executive Director (ALFA) in the Plan of Correction Book. DATE: 3/14/2024
22VAC40-73-350-B
Based on resident record review, the facility failed to ascertain, prior to admission, whether a potential resident is a registered sex offender if the facility anticipates the potential resident will have a length of stay greater than three days or in fact stays longer than three days and shall be documented in the resident’s records that this was ascertained and the date the information was obtained.
Evidence
  1. Resident 1, admitted on 10/4/2024, had search results from the Virginia State Police for Resident 1 obtained on 12/5/2024.
Plan of correction
CORRECTION #1 The Community Relations Director was educated by the Executive Director (ALFA). Education included the VA DSS Standards and Regulations For Licensed Assisted Living Facilities Chapter 73, 22VAC40- 73-350 Sex Offender Information DATE: 12/10/2024 CORRECTION #2 The facility plans to monitor its performance to make sure that solutions are sustained. The Community Relations Director or designee will obtain a sex offender registry report prior to admission and place in the resident's file. The Executive Director (ALFA) will review the New Resident Move-In Checklist for all new residents, weekly for 4 weeks, and monthly for 2 month! to ensure the sex offender registry report is obtained prior to admission. The Executive Director (ALFA) will report findings during the appropriate review month. Documentation o the review will be kept by the Executive Director (ALFA) in the Plan of Correction Book. DATE: 3/14/2024
22VAC40-73-1100-A
Based on resident record review, the facility failed to, prior to admitting a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia to a safe, secure environment, the licensee, administrator or designee shall determine whether placement in the special care unit is appropriate. The determination and justification for the decision shall be in writing and shall be retained in the resident’s file.
Evidence
  1. Resident 1 had an Approval for Placement in a Special Care Unit on file that was not dated by the ALF representative.
  2. Resident 2 had an Approval for Placement in a Special Care Unit on file that was not signed by the guardian or legal representative.
  3. Resident 5 had an Approval for Placement in a Special Care Unit on file that was not signed or dated by the legal representative.
Plan of correction
Correction # 1 The Executive Director (ALFA) will correct the 3 identified special care residents Approval for Placement in a Special Care Unit form. DATE: 12/27/2024 CORRECTION #2 The Executive Director (ALFA) will complete a review of all other current special care unit residents Approval for Placement in a Special Care Unit forms. Any deficiencies identified will be corrected immediately. DATE: 12/27/2024 CORRECTION #3 The Health and Wellness Director (RN) and Executive Director (ALFA) was educated by the Regional Director of Health and Wellness (RN). Education included the VA DSS Standards and Regulations For Licensed Assisted Living Facilities Chapter 73, 22VAC40-73-1100 Approval and Cogir Senior Living Memory Care Policy Manual VA 12-01- 2023, PO02 Memory Care Admissions Criteria policy. DATE: 12/10/2024 CORRECTION #4: The facility plans to monitor its performance to make sure that solutions are sustained. The Memory Care Director, Health and Wellness Director (RN), or designee will obtain the written approval prior to placing a resident with a serious cognitive impairment due to dementia in a safe, secured environment (special care unit). The Executive Director (ALFA) will review a sample of current memory care residents, weekly for 4 weeks, and monthly for 2 months to ensure the Approval for Placement in a Special Care Unit form is completed according to policy. The Executive Director (ALFA) will report findings during the appropriate review meeting. Documentation of the review will be kept by the Executive Director (ALFA) in the Plan of Correction Book. DATE: 3/21/2024
22VAC40-73-720-A
Based on resident record review, the facility failed to include the Do Not Resuscitate (DNR) order on the Individualized Service Plan (ISP).
Evidence
  1. Resident 1 had a DNR order on file dated 10/24/2024. The ISP developed on 10/5/2024 did not include the DNR order.
  2. Resident 2 had a Virginia Physician Orders for Scope of Treatment (POST) dated 6/22/2022 that stated, Do Not Attempt Resuscitation. The ISP developed on 7/1//2024 did not include the POST order to no attempt resuscitation.
  3. Resident 6 had a DNR order on file dated 1/6/2023. The ISP developed on 9/10/2024 did not include the DNR order.
  4. Resident 7 had a Virginia Physician Orders for Scope of Treatment (POST) dated 11/5/2024 that stated, Do Not Attempt Resuscitation. The ISP developed on 9/11/2024 did not include the POST order to no attempt resuscitation.
  5. Resident 8 had a DNR order on file dated 11/8/2024. The ISP developed on 8/22/2024 did not include the DNR order.
Plan of correction
CORRECTION #1 The Health and Wellness Director (RN) updated the 5 identified ISPs who have DNR orders and documented it in their ISP. DATE: 12/10/2024 CORRECTION #2 The Health and Wellness Director (RN) completed a review of all other current residents who have DNR orders. Any deficiencies identified were corrected immediately. DATE: 12/13/2024 CORRECTION #3 The Health and Wellness Director (RN) was educated by the Executive Director (ALFA). Education included the Cogir Senior Living Clinical Policy Manual VA 06-01-2024, AS05 Individualized Service Plans policy. DATE: 12/10/2024 CORRECTION #4 The facility plans to monitor its performance to make sure that solutions are sustained. The Health and Wellness Director or designee will include documentation in the ISP for all current residents who have an order for DNR. The Regional Director of Health and Wellness (RN) or Executive Director (ALFA) will review a sample of current residents, weekly for 4 weeks, and monthly for 2 months to ensure the ISP is up-to-date and include documentation of any resident who has an order for DNR. The Executive Director (ALFA) will report findings during the appropriate review meeting. Documentation of the review will be kept by the Executive Director (ALFA) in the Plan of Correction Book. DATE: 3/14/2024
22VAC40-90-40-B
Based on staff record review, the facility failed to obtain on or prior to the 30th day of employment for each employee a criminal record history report.
Evidence
  1. Staff 7 hired 1/19/2024 did not have a criminal record history report on file.
  2. Staff 8 hired 5/3/2024 did not have a criminal record history report on file.
  3. Staff 9 hired 5/16/2024 did not have a criminal record history report on file.
  4. Staff 10 hired 2/27/2024 did not have a criminal record history report on file. 5.
Plan of correction
CORRECTION #1 The Business Office Director completed the background checks for the 4 identified employees who did not have a copy in their personnel file and placed the returned background check in the employee's personnel file. There were no persons with convictions of barrier crimes on their criminal record history report. DATE: 12/10/2024 CORRECTION #2 The Business Office Director completed a review of the remaining list of new hires 1/2024- 12/2024 to identify any other background checks that are not present in the personnel file. Any deficiencies identified were corrected immediately. There were no persons with convictions of barrier crimes on their criminal record history report. DATE: 12/10/2024 CORRECTION #3 The Business Office Director was educated by the Executive Director (ALFA). Education included the VA DSS Standards and Regulations For Licensed Assisted Living Facilities Chapter 73, 22VAC40-90-40 Regulation For Background Checks. DATE: 12/10/2024 CORRECTION #4 The facility plans to monitor its performance to make sure that solutions are sustained. The Business Office Director or Business Office Specialist/designee will obtain a criminal background check on all new hires on or prior to the 30th day of employment for each employee. The Executive Director (ALFA) will review the New Hire Checklist to include the Background Check portion for all new hires, weekly for 4 weeks, and monthly for 2 months to ensure background checks are obtained on or prior to the 30th day of employment for each employee. The Executive Director (ALFA) will report findings during appropriate review meeting. Documentation of the review will be kept by the Executive Director (ALFA) in the Plan of Correction Book. DATE: 3/14/2025
22VAC40-73-950-E
Based on facility record review and staff interview, the facility failed to develop and implement an orientation and semi-annual review on the emergency preparedness and response plan for staff, residents and volunteers.
Evidence
  1. Staff 4 provide semi-annual review with the staff dated 12/4/2024, but there was no other documented review available.
  2. Staff 4 stated that she could not find the signature sheet for the previous review with staff.
Plan of correction
Correction #1 The Maintenance Director completed the 2nd staff education of the semi-annual emergency preparedness. Dated corrected 12/31/2024. Correction #2 The Maintenance Director and other maintenance personnel were educated by the Executive Director (ALFA). Education included the VA DSS Standards and Regulations For Licensed Assisted Living Facilities Chapter 73, 22VAC40-950 Emergency preparedness and response plan regulation and Cogir Policy: Disaster Drill Standards. DATE: 12/10/2024 CORRECTION #3 The facility plans to monitor its performance to make sure that solutions are sustained. The Maintenance Director or designee will conduct a semi-annual review. on the emergency preparedness and response plan for all staff. The review will be documented by signing and dating. The Executive Director (ALFA) will review the documentation semi­ annually. The Executive Director (ALFA) will report findings during appropriate review meeting. Documentation of the review will be kept by the Executive Director (ALFA) in the Plan of Correction Book. DATE: 7/1/2025
January 3, 2024Inspection1 violation
Inspection dates
01/03/2024
Areas reviewed
Administration and Administrative ServicesPersonnelStaffing and SupervisionAdmission, Retention and Discharge of ResidentsResident Care and Related ServicesResident Accommodations and Related ProvisionsBuilding and GroundsEmergency PreparednessAdditional Requirements for Facilities that Care for Adults with Cognitive ImpairmentsBackground Checks for Assisted Living FacilitiesSworn Statement
Comments
Date of Inspection: January 3 and 4, 2024 Type of Inspection: Monitoring Inspection Census: 109 Number of records reviewed and interviews conducted- 7 records, 5 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. The Licensing Inspector observed residents participating in activity programs and eating lunch. Licensing Inspector observed medication administration and compared physician orders to medications available to be administered to the residents. If you have any questions or email changes, please do not hesitate to contact me at sarah.pearson@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov. The Licensing Inspector and the Administrator discussed the risk assessment ratings for the violations for this inspection. Please complete the “plan of correction” and “date to be corrected” for each violation cited on the violation notice and returned it to the office. You will need to specify how the deficient practice will be or has been corrected. 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).
Violations
22VAC40-73-680-M
Based on resident record review and staff interview, it was determined that the facility failed to have available PRN medication ordered by the resident’ physician.
Evidence
  1. All prescribed PRN medications for Res C were not available in the facility to be administered.
Plan of correction
CORRECTION #1 Facility contacted pharmacy. All PRN medications for Res C were ordered and were made available by facility to be administered. DATE January 20, 2024 CORRECTION #2 Facility Resident Services Director (Registered Nurse) conducting in servicing of all Medication Care Partners on processes and protocols to follow when medications are not available for administration, including contacting pharmacy and notifying facility nurses so that appropriate action can be taken to make medications available by facility to be administered. DATE 2/3/2024 CORRECTION #3 Facility Resident Services Director (Registered Nurse) conducting in servicing of all Nurses (LPNs) on processes and protocols to follow when medications are not available for administration, including daily monitoring of medication management dashboard, communicating with Nurse Practitioners/Physicians as may be necessary for further orders, communicating with pharmacy, and notifying Resident Services Director to ensure that all medications are available by facility to be administered. DATE 2/3/2024 CORRECTION #4 Facility Resident Services Director (Registered Nurse) and LPN(s) will conduct a medication audit of all medication carts to ensure that all prescribed medications are available by facility to be administered. DATE 2/3/2024 CORRECTION #5 Facility Resident Services Director (Registered Nurse) will meet with Facility Executive Director (ALFA) at the conclusion of in servicing and medication audit to provide a report on status and to discuss any additional corrective action that may be needed to ensure that all medications are available by facility to be administered. DATE 2/10/2024
January 26, 2023Inspection2 violations
Inspection dates
01/26/2023
Areas reviewed
Administration and Administrative ServicesPersonnelStaffing and SupervisionAdmission, Retention and Discharge of ResidentsResident Care and Related ServicesResident Accommodations and Related ProvisionsBuildings and GroundsEmergency Preparedness
Comments
Date of Inspection: 1/26/23, 2/8/2023 Type of Inspection: Monitoring inspection If you have any questions or email changes, please do not hesitate to contact me at sarah.pearson@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov. Census 81 Number of records reviewed and interviews conducted- 6 records, 8 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. The Licensing Inspector and the Administrator discussed the risk assessment ratings for the violations for this inspection. Please complete the “plan of correction” and “date to be corrected” for each violation cited on the violation notice and returned it to the office. You will need to specify how the deficient practice will be or has been corrected. 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). The completed corrective action needs to be in the licensing office by February 15, 2023
Violations
22VAC40-73-650-B
Based on resident records review and staff interview, it was determined that the facility staff failed to obtain and document complete physician orders.
Evidence
  1. Resident B and C's Physician Order Sheets did not contain diagnosis, condition, or specific indication for every currently prescribed medication.
Plan of correction
Executive Director designated the Resident Services Director (RN) and Memory Care Director (LPN) to review the Medication Administration Records for all residents to ensure that each prescribed medication has a corresponding diagnosis identified. (Date completed 2/13/2023). a. The Medication Administration Record for Residents B and C was updated to reflect a diagnosis for each medication. b. The Medication Administration Record for all other residents was reviewed and updated as needed to reflect a diagnosis for each medication. c. The Resident Services Director (or designee) will review all new orders to ensure that a diagnosis is listed for each medication.
22VAC40-73-950-E
Based on record review and staff interview, it was determined that the facility staff failed to conduct an Emergency Preparedness Review with staff semi-annually.
Evidence
  1. Facility staff did not have record of Emergency Preparedness Review with staff within the last six months.
Plan of correction
1. Executive Director has established a schedule to conduct Emergency Preparedness Review with all staff each year, twice annually, during which the facility's Emergency Preparedness Plan will be reviewed. (date completed 2/22/2023). a. The initial Emergency Preparedness Plan Review for 2023 will take place during All Team Member Meetings in March 2023. b. The second bi-annual review will occur in September 2023. c. The Executive Director (or designee) will review staff roster and training records after each training. Any staff member who has not had training will be contacted to arrange for individual or small group review of the Emergency Preparedness Plan. d. The facility will maintain records of completion of the bi-annual Emergency Preparedness Review for all staff members.
December 6, 2021Inspection0 violations
Inspection dates
12/06/2021,12/10/2021
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity32.1 Reported by persons other than physicians63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Comments
Date of Inspection: December 6 and 10, 2021 Type of Inspection: Renewal Inspection If you have any questions or email changes, please do not hesitate to contact me at laura.lunceford@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov. Census 62 Number of records reviewed and interviews conducted- 10 records (staff and residents), 6 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. The Licensing Inspector reviewed the fire drills, the menus, the activities calendars, the Dietician report, Health Care Oversight and Pharmacy review. Residents were observed during breakfast, snack, at activities and medication pass.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
January 19, 2021Inspection0 violations
Inspection dates
Jan. 19, 2021 and Feb. 2, 2021
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity
Comments
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 renewal inspection was initiated on January 19, 2021 and concluded on February 2, 2021. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 58. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed 4 resident records, 4 staff records, staff schedules, etc. 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.
January 8, 2021Complaint survey0 violations
Inspection dates
Jan. 8, 2021 and Feb. 2, 2021
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS
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 complaint inspection was initiated on January 19, 2021 and concluded on February 2, 2021. A complaint was received by the department regarding allegations in the areas of resident care. The administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
October 8, 2020Complaint survey1 violation
Inspection dates
Oct. 8, 2020 and Oct. 9, 2020
Areas reviewed
22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS
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 complaint inspection was initiated on 10/08/2020 and concluded on 10/09/2020. A complaint was received by the department regarding allegations in the areas of resident care. The administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations were documented on the violation notice issued to the facility.
Violations
22VAC40-73-310-C
Based on interview with the administrator and record review, it was determined the facility retained individuals not permitted by its use and occupancy classification and certificate of occupancy.
Evidence
  1. The facility’s license has a stipulation that no more than 5 residents can require 2 person assist to transfer and exit the building. The facility has determined they have 12 residents in care that require two person assist to ambulate.
Plan of correction
Community will reassess all 12 residents identified as requiring the assistance of two people to ambulate. As 10 of these 12 residents are currently on therapy or hospice service and there is reason to believe their conditions will either improve or the resident will pass away, the reassessment will be completed on or after 10/23/20. Of the residents still identified as requiring the assistance of two people to ambulate, five will be identified to remain a resident of Tribute at the Glen, and the remaining residents will be notified that they have until 11/30/20 to find another place of residence, assuming on that date they are still requiring the assistance of two people to ambulate. Community will conduct an all-team re-education of fire/life safety expectation, completed on/before 10/16/20. Community will inform the new management company, to be in place on or about 11/1/20, of the ongoing expectation of the facility’s license stipulation that no more than 5 residents can require 2 person assist to transfer and exit the building. This will be completed on/before 10/16/20.