Virginia DSS · Assisted Living Facility

TerraBella Salem

📍 2001 Ridgewood Drive, Salem, VA, 24153

ID 52512One Year licenseActive
5
Inspections
On record
2
With violations
Visits that cited something
3
Clean visits
Nothing cited
20
Violations cited
Individual findings
19
Standards cited
Distinct rules
1
Complaint visits
Prompted by a complaint

TerraBella Salem was inspected 5 times between September 2, 2025 and June 2, 2026 by the Virginia Department of Social Services. 2 of those visits ended with violations cited and 3 with none. Across that history VDSS cited 20 violations under 19 distinct standards. 1 inspection was prompted by a complaint.

A violation is a licensing standard - a rule in the Virginia Administrative Code - that the inspector found the facility was not meeting. Each is shown with the evidence the inspector recorded and, where VDSS publishes it, the facility's own plan of correction.

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

Provider Information

Facility type
Assisted Living Facility
License type
One Year
License expires
03/31/2027
Administrator
Marvin W. Crump
Licensing inspector
Jennifer Stokes
Inspector phone
(540) 589-5216
Approved for
Assisted Living · Non-Ambulatory · Special Care Unit

Inspection History

5

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

June 2, 2026Complaint survey0 violations
Inspection dates
06/02/2026
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/02/2026 9:30AM to 11:15AM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 05/14/2026 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: 60 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
February 11, 2026Inspection10 violations
Inspection dates
02/11/2026
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS63.2- (1) GENERAL PROVISIONS22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS
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: 02/10/2026 8:45 to 16:15 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: 59 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 9 Observations by licensing inspector: Lunch Meal, Medication Cart Audits, Afternoon Activity 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 Angela Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov
Violations
22VAC40-73-660-B
Based on physical plant observation, staff interviews, and resident record reviews, the facility failed to ensure that a resident may be permitted to keep his own medication in an out-of-sight place in his room if the UAI has indicated that the resident is capable of self-administering medication. The medication and any dietary supplements shall be stored so that they are not accessible to other residents. This does not prohibit the facility from storing or administering all medication and dietary supplements.
Evidence
  1. The licensing inspector observed in Resident 6 room a container of Ultra Strength Antacid Calcium Carbonate 1000mg Tablets with multiple colored tablets inside of the container on the resident’s nightstand next to their bed during the medication pass with Staff 5 for Resident 6.
  2. Resident 6 record contained a Uniform Assessment Instrument, dated 7/6/2025, with documentation that the resident needs medications administered/monitored by a lay person.
Plan of correction
· Resident who does not self-administer medications was observed to have antacid tablets at bedside. DHW educated on this regulation. · DHW or designee to audit all resident rooms to ensure compliance with this regulation and address as applicable. · To assist with ongoing compliance, the ED or designee will audit resident rooms at random to ensure ongoing compliance, as well as new admissions weekly times four weeks beginning February 17th, 2026.
22VAC40-73-325-C
Based on resident record review and staff interview, the facility failed to ensure that should a resident who meets the criteria for assisted living care fall, the facility must show documentation of an analysis of the circumstances of the fall and interventions that were initiated to prevent or reduce risk of subsequent falls.
Evidence
  1. Resident 2 record contained a Uniform Assessment Instrument, dated 9/10/2025, with documentation that the resident is assisted living level of care.
  2. Resident 2 record contained a physician communication document, dated 1/28/2026, with documentation that the resident fell in room, hit their head on the nightstand, has laceration on their right side on top of head, and was sent to the local emergency room for evaluation.
  3. Resident 2 record contained the last fall analysis form, dated 12/8/2025.
  4. Interview with Staff 2 confirmed Resident 2 record to be current and that a fall analysis was not completed on 1/28/2026 after the most recent fall.
Plan of correction
· Resident medical record did not have documentation of a fall analysis post most recent fall and was not in adherence with this regulation. DHW educated on this requirement. · DHW or designee will audit all resident falls dating back 30 days to ensure community is within compliance with this regulation and all appropriate documentation is in place. · To assist with ongoing compliance, the ED or designee will audit this process for 30 days to verify required documentation is complete beginning February 17, 2026.
22VAC40-73-310-B
Based on resident record review and staff interview, the facility failed to ensure that assisted living facilities shall not admit an individual before a determination has been made that the facility can meet the needs of the individual. The facility shall make the determination based on all required information including a documented interview.
Evidence
  1. Resident 4 record, admission date 1/19/2026, did not contain a documented interview. 2.Interview with Staff 1 and Staff 2 confirmed Resident 4 record to be current.
Plan of correction
· Resident record did not contain required documented interview between the administrator or designee and the resident and or their responsible party. ED educated on this requirement. · ED or designee will audit all resident files to identify non-compliance and address if applicable. · BOM or designee will audit all new resident files weekly times four weeks to ensure compliance beginning February 17th, 2026. · To assist with ongoing compliance, the ED or designee will audit all new resident files for 30 days to verify required current resident agreements are present beginning March 20th, 2026.
22VAC40-73-290-B
Based on physical plant observation and staff interview, the facility failed to ensure that the facility shall develop and implement a procedure for posting the name of the current on-site person in charge, as provided for in this chapter, in a place in the facility that is conspicuous to the residents and the public.
Evidence
  1. Licensing Inspector observed there to not be a posting of the name of the current on-site person in charge of the facility.
  2. Interview with Staff 1 confirmed that the facility had not posted the name of the current on-site person in charge of the facility in a conspicuous place to the residents and the public. Staff 1 stated that they did not know of a procedure in place for the posting.
Plan of correction
· Facility did not have posted at the time of inspection the on-site person in charge. ED and DHW educated on this requirement. · DHW or designee will ensure on-site person in charge is posted in adherence with this regulation. · To assist with ongoing compliance, the ED or designee will audit this process daily for one week to ensure compliance.
22VAC40-73-870-B
Based on physical plant observation and staff interview, the facility failed to ensure that all buildings shall be well-ventilated and free from foul, stale, and musty odors.
Evidence
  1. Licensing Inspector noted a strong urine smell in Resident 6 apartment as soon as you walked through the door of the apartment.
  2. Interview with Staff 1 confirmed the strong urine smell in Resident 6 apartment.
Plan of correction
· Resident room was observed smelling of urine. ED and DHW educated on this regulation. · DHW or designee to audit all resident rooms to ensure compliance with this regulation and address as applicable. · To assist with ongoing compliance, the ED or designee will audit resident rooms at random to ensure ongoing compliance, as well as new admissions weekly times four weeks beginning February 17th, 2026.
22VAC40-73-450-A
Based on resident record review and staff interviews, the facility failed to ensure that on or within seven days prior to the day of admission, a preliminary plan of care shall be developed to address the basic needs of the resident that adequately protects his health, safety, and welfare. The preliminary plan shall be developed by a staff person with the qualifications specified in subsection B of this section and in conjunction with the resident, and, as appropriate, other individuals noted in subdivision B 1 of this section. The preliminary plan shall be identified as such and be signed and dated by the licensee, administrator, or his designee (i.e., the person who has developed the plan), and by the resident or his legal representative.
Evidence
  1. Resident 4 record, admission date 1/19/2026, contained an Individual Service Plan (ISP) one page document that did not identify that it was the preliminary and not signed and dated by any of the required persons.
  2. Interview with Staff 1 and Staff 2 confirmed Resident 4 record to be current.
Plan of correction
· Resident medical record did not contain a completed ISP per this regulation; it was unsigned and undated by completing professional. DHW educated on this requirement. · DHW or designee will audit all resident ISPs to ensure compliance and address as applicable. · To assist with ongoing compliance, the ED or designee will audit all new resident ISPs for four weeks beginning February 17. 2026.
22VAC40-73-320-B
Based on resident record review and staff interview, the facility failed to ensure that a risk assessment for tuberculosis shall be completed annually on each resident as
Evidence
  1. d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. EVIDENCE: 1.Resident 5 record contained the last risk assessment for tuberculosis dated 2/5/2025.
  2. Interview with Staff 1 and Staff 2 confirmed Resident 5 record to be current.
Plan of correction
· Resident medical record did not contain required annual tuberculosis evaluation. DHW educated on this requirement. · DHW or designee will audit all resident medical records to identify non compliance and address as applicable. · DHW or designee will audit all new resident files weekly times four weeks to ensure compliance beginning February 17, 2026. · To assist with ongoing compliance, the ED or designee will audit all new residents for 30 days to verify required documentation is present beginning February 17, 2026.
22VAC40-73-440-B
Based on resident record reviews and staff interviews, the facility failed to ensure that for private pay individuals, the Uniform Assessment Instrument (UAI) shall be completed by one of the required qualified assessors including an assisted living facility staff person who has successfully completed state- approved training on the uniform assessment instrument and level of care criteria for either public or private pay assessments, provided the administrator or the administrator's designated representative has successfully completed such training and approves and then signs the completed UAI, and the facility maintains documentation of completed training.
Evidence
  1. Resident 2 record contained a UAI, dated 9/10/2025, that contained the signature of an assisted living facility staff person but not the signature of the administrator or the administrator’s designated representative.
  2. Resident 3 record contained a UAI, dated 9/10/2025, that contained the signature of an assisted living facility staff person but not the signature of the administrator or the administrator’s designated representative.
  3. Resident 4 record contained a UAI, dated 1/5/2026, that contained the signature of an assisted living facility staff person but not the signature of the administrator or the administrators designated representative.
  4. Resident 5 record contained a UAI, dated 9/20/2025, that contained the signature of an assisted living facility staff person but not the signature of the administrator or the administrators designated representative.
  5. Staff 1 and Staff 2 confirmed Resident 2, Resident 3, Resident 4, and Resident 5 records to be current.
Plan of correction
· Resident record contained a UAI that was not signed by the administrator or designee. ED and DHW educated on this requirement. · ED or designee will audit all resident UAI’s to ensure compliance and address as applicable. · To assist with ongoing compliance, the ED or designee will audit this process for 30 days to verify all new admission UAI’s are compliant.
22VAC40-73-1180-B
Based on physical plant observation and staff interview, the facility failed to ensure that when there are indications that ordinary materials or objects may be harmful to a resident, these materials or objects shall be inaccessible to the resident except under staff supervision.
Evidence
  1. Licensing Inspector observed on the safe, secure unit a door that was propped open leading into a room that contained one open 5 gallon bucket full of paint, an aerosol bottle of a chemical, a caulk gun with caulk in it, and four 5 gallon buckets of paint with the lid on them. There were no staff in sight however two residents could be seen standing from the doorway.
  2. Interview with Staff 7 confirmed that the door should have been closed and locked, and not accessible to residents.
Plan of correction
· At the time of survey, memory care unit was observed with the nurse’s station door propped open and unmonitored containing paint supplies. Maintenance Director educated on this regulation. · Maintenance director or designee will complete a full round of this unit to ensure we are in compliance with this regulation and educate applicable staff to include third party contractors to this regulation. · ED or designee will at random audit this unit weekly times four weeks to ensure ongoing compliance with this regulation beginning February 17, 2026.
22VAC40-73-120-A
Based on staff record review, physical plant observation, and staff interview, the facility failed to ensure that the orientation and training required in subsections B and C of this section shall occur within the first seven working days of employment. Until this orientation and training is completed, the staff person may only assume job responsibilities if under the sight supervision of a trained direct care staff person or administrator.
Evidence
  1. Staff 5, first day of work 12/3/2025, was providing direct care on the Assisted Living floors on the day of inspection according to the daily assignment sheet and Licensing Inspector observation. Staff 5 was not under the sight super supervision of any staff member.
  2. Staff 5 record review did not contain documentation that orientation and training required had occurred.
  3. Interview with Staff 1 and Staff 3 confirmed Staff 5 had not had orientation and training required.
Plan of correction
· Staff member #5 did not have required orientation and training. ED and BOM educated on this requirement and that it applies to all staff including agency personnel. · BOM or designee will audit all associate files to verify completion and presence of required orientation and training. For those identified not to be in compliance, orientation and training will be scheduled promptly. · BOM or designee will audit all new associate files weekly times four weeks to ensure current disclosure is present and fully executed beginning February 17th, 2026. · To assist with ongoing compliance, the ED or designee will audit all new associate files for 30 days to verify completion of required fully executed disclosure beginning March 20th, 2026.
January 6, 2026Inspection0 violations
Inspection dates
01/06/2026
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 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: 01/06/2026 09:00 to 10:25 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 12/23/2025 regarding allegations in the area(s) of: Resident Care and Related Services, and Personnel 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 staff: 3 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the 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 A Marie Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
November 19, 2025Inspection10 violations
Inspection dates
11/19/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/19/2025 09:20 to 12:00 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: 63 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: 3 Number of interviews conducted with staff: 3 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 A Marie Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov
Violations
22VAC40-73-120-A
Based on staff record reviews and staff interviews, the facility failed to ensure that the orientation and training required in subsections B and C of this section shall occur within the first seven working days of employment. Until this orientation and training is completed, the staff person may only assume job responsibilities if under the sight supervision of a trained direct care staff person or administrator.
Evidence
  1. Staff 4, hire date 10/1/2025, did not contain documentation that the staff received the required orientation and training of the facility.
  2. Staff 5, hire date 10/1/2025, did not contain documentation that the staff received the required orientation and training of the facility.
  3. Staff 6, hire date 10/1/2025, did not contain documentation that the staff received the required orientation and training of the facility.
  4. Interview with Staff 1 and Staff 3 confirmed the facility did not provide the required orientation and training to Staff 4, Staff 5, and Staff 6 as required.
Plan of correction
· Staff records did not contain documentation pertaining to the required staff orientation and initial training post transition to the new company that occurred effective 10/1/2025. ED and BOM educated on this requirement. · BOM or designee will ensure training is implemented to comply with this requirement and audit all associate files to verify completion and presence of required updated staff orientation and initial training documents. · BOM or designee will audit all new associate files weekly times four weeks to ensure staff orientation and initial training documentation is present and fully executed beginning December 1st, 2025. · To assist with ongoing compliance, the ED or designee will audit all new associate files for 30 days to verify completion of required fully executed staff orientation and initial training documentation beginning December 1st. · Date of completion December 30, 2025.
22VAC40-73-390-A
Based on resident record reviews and staff interviews, the facility failed to ensure that at or prior to the time of admission, there shall be a written agreement or acknowledgment of notification dated and signed by the resident or applicant for admission or the appropriate legal representative and by the licensee or administrator with all of the required information.
Evidence
  1. Resident 1 record did not contain an agreement or acknowledgement of notification signed and dated with information about the current facility.
  2. Resident 2 record did not contain an agreement or acknowledgement of notification signed and dated with information about the current facility.
  3. Resident 3 record did not contain an agreement or acknowledgement of notification signed and dated with information about the current facility.
  4. Interview with Staff 1 and Staff 3 confirmed the facility did not complete written agreements for Resident 1, Resident 2, and Resident 3 when the change of ownership occurred on 10/1/2025 with a new licensee for the facility.
Plan of correction
· Resident records did not contain updated resident agreements post transition to the new community effective 10/1/2025. ED and BOM educated on this requirement. · BOM or designee will audit all resident files to ensure all residents have new resident agreements fully executed to satisfy this requirement. · BOM or designee will audit all new resident files weekly times four weeks to ensure compliance beginning December 1st, 2025. · To assist with ongoing compliance, the ED or designee will audit all new resident files for 30 days to verify required current resident agreements are present beginning December 1st. · Date of completion December 30, 2025.
22VAC40-73-250-C
Based on staff record reviews and staff interviews, the facility failed to ensure that personal and social data to be maintained on staff and included in the staff record included the verification that the staff person has received a copy of his current job description.
Evidence
  1. Staff 4, hire date 10/1/2025, did not contain documentation of verification that the staff person has received a copy of his current job description.
  2. Staff 5, hire date 10/1/2025, did not contain documentation of verification that the staff person has received a copy of his current job description.
  3. Staff 6, hire date 10/1/2025, did not contain documentation of verification that the staff person has received a copy of his current job description.
  4. Interview with Staff 1 and Staff 3 confirmed Staff 4, Staff 5, and Staff 6 records were current.
Plan of correction
· Staff records did not contain current job descriptions post transition to the new company effective 10/1/2025. ED and BOM educated on this requirement. · BOM or designee will ensure current job descriptions are distributed and signed for all associates in order to satisfy this requirement. · BOM or designee will audit all new associate files weekly times four weeks to ensure job descriptions are present and fully executed beginning December 1st, 2025. · To assist with ongoing compliance, the ED or designee will audit all new associate files for 30 days to verify completion of required fully executed job descriptions beginning December 1st. · Date of completion December 30, 2025.
22VAC40-80-120-E-2
Based on physical plant tour and staff interview, the facility failed to ensure that certain documents related to the terms of the license are required to be posted on the premises of each facility including the findings of the most recent inspection of the facility.
Evidence
  1. The most recent inspection of the facility was completed on 9/2/2025, with a signature from the administrator on the final inspection documents dated 9/8/2025 acknowledging receipt.
  2. Licensing Inspector did not observe the most recent inspection findings, dated 9/2/2025, posted on the premises.
  3. Interview with Staff 1 confirmed the facility had not posted the most recent inspection on 9/2/2025.
Plan of correction
· The most recent facility inspection was not posted in the community. ED educated on this requirement. · ED or designee will ensure the most recent inspection November 19th 2025 is posted. · To assist with ongoing compliance, the ED or designee will audit this process for 30 days to verify required documentation is posted beginning December 1st. · Date of completion December 30, 2025.
22VAC40-73-640-A
Based on facility record review and staff interviews, the facility failed to have, keep current, and implement a written plan for medication management. The facility's medication plan shall address procedures for administering medication and include all required information. 1. The Medication Policies, dated 11/12/2024 and 8/15/2025, provided by the facility, did not contain methods to ensure that staff who are responsible for administering medications are adequately supervised, including periodic direct observation of medication administration and methods to ensure that staff who are responsible for administering medications are trained on the facility's medication management plan. 2. Interview with Staff 1 and Staff 2 confirmed the Medication Policies, dated 11/12/2024 and 8/15/2025, to be the most current and missing those specific methods in the medication management plan.
Plan of correction
Our policies and procedures have been updated to fully align with 22VAC40-73-640 and 22VAC40-73-670. The updated plan now addresses all required elements, including staff training and supervisory oversight (including direct observation of medication administration) for those responsible for administering medications.
22VAC40-73-50-A
Based on resident record reviews and staff interviews, the facility failed to ensure that the assisted living facility shall prepare and provide a statement to the prospective resident and the prospective resident’s legal representative, if any, that discloses information about the facility. The statement shall be on a form developed by the department and shall include all required information.
Evidence
  1. Resident 1 record did not contain a disclosure statement with information about the current facility.
  2. Resident 2 record did not contain a disclosure statement with information about the current facility.
  3. Resident 3 record did not contain a disclosure statement with information about the current facility.
  4. Interview with Staff 1 and Staff 3 confirmed the facility did not prepare and provide a statement to Resident 1, Resident 2, or Resident 3 that discloses information about the facility after the change of ownership effective 10/01/2025 with a new licensee for the facility.
Plan of correction
· Residents 1, 2 and 3 records did not contain an updated disclosure post transition to the new company effective 10/1/2025. ED and BOM educated on this requirement. · BOM or designee will audit all resident files to verify completion and presence of required updated disclosures. · BOM or designee will audit all new resident files weekly times four weeks to ensure current disclosure is present and fully executed beginning December 1st, 2025. · To assist with ongoing compliance, the ED or designee will audit all new resident files for 30 days to verify completion of required fully executed disclosure beginning December 1st. · Date of completion December 30, 2026.
22VAC40-73-250-D
Based on staff record reviews and staff interviews, the facility failed to ensure that each staff person on or within seven days prior to the first day of work at the facility and each household member prior to coming in contact with residents shall submit the results of a risk assessment, documenting the absence of tuberculosis in a communicable form as
Evidence
  1. d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. EVIDENCE:
  2. Staff 4, hire date 10/1/2025, did not contain documentation of the results of a risk assessment documenting the absence of tuberculosis on or within 7 days prior to the first day of work at the facility.
  3. Staff 5, hire date 10/1/2025, did not contain documentation of the results of a risk assessment documenting the absence of tuberculosis on or within 7 days prior to the first day of work at the facility.
  4. Staff 6, hire date 10/1/2025, did not contain documentation of the results of a risk assessment documenting the absence of tuberculosis on or within 7 days prior to the first day of work at the facility.
  5. Interview with Staff 1 and Staff 3 confirmed Staff 4, Staff 5, and Staff 6 records were current.
Plan of correction
· Staff records did not contain current documentation of the results of a risk assessment documenting the absence of tuberculosis post transition to the new company effective 10/1/2025. ED and BOM educated on this requirement. · BOM or designee will collaborate with nursing to ensure all new TB risk assessments are completed with the result for all associates to satisfy this requirement. · BOM or designee will audit all new associate files weekly times four weeks to ensure compliance beginning December 1st, 2025. · To assist with ongoing compliance, the ED or designee will audit all new associate files for 30 days to verify required documentation is present beginning December 1st. · Date of completion December 30, 2025.
22VAC40-90-40-B
Based on staff record review and staff interviews, the facility failed to ensure that the criminal history record report shall be obtained within 30 days of employment for each employee.
Evidence
  1. Staff 4, hire date 10/1/2025, contained a criminal history record dated 11/18/2025.
  2. Staff 5, hire date 10/1/2025, contained a criminal history record dated 11/18/2025.
  3. Staff 6, hire date 10/1/2025, contained a criminal history record dated 11/18/2025.
  4. Interview with Staff 1 and Staff 3 confirmed Staff 4, Staff 5, and Staff 6 records were current.
Plan of correction
· Staff records did not contain current criminal history record reports post transition to the new company effective 10/1/2025. ED and BOM educated on this requirement. · BOM or designee will run criminal history record reports for all associates under the new companies Virginia State Police contract/account to satisfy this requirement. · BOM or designee will audit all new associate files weekly times four weeks to ensure compliance beginning December 1st, 2025. · To assist with ongoing compliance, the ED or designee will audit all new associate files for 30 days to verify required documentation is present beginning December 1st. · Date of completion December 30, 2025.
22VAC40-73-410-A
Based on resident record reviews and staff interviews, the facility failed to ensure that upon admission, the assisted living facility shall provide an orientation for new residents and their legal representatives, including emergency response procedures, mealtimes, and use of the call system. If needed, the orientation shall be modified as appropriate for residents with cognitive impairments. Acknowledgment of having received the orientation shall be signed and dated by the resident and, as appropriate, his legal representative, and such documentation shall be kept in the resident's record.
Evidence
  1. Resident 1 record did not contain documentation that the current facility provided orientation including emergency response procedures, mealtimes, and use of the call system of the facility.
  2. Resident 2 record did not contain documentation that the current facility provided orientation including emergency response procedures, mealtimes, and use of the call system of the facility.
  3. Resident 3 record did not contain documentation that the current facility provided orientation including emergency response procedures, mealtimes, and use of the call system of the facility.
  4. Interview with Staff 1 and Staff 3 confirmed the facility did not provide orientation for Resident 1, Resident 2, and Resident 3 when the change of ownership occurred on 10/1/2025 with a new licensee for the facility with new policies and procedures in place.
Plan of correction
· Resident records did not contain current documentation of resident orientation to the community post transition to the new company effective 10/1/2025. ED and BOM educated on this requirement. · BOM or designee will execute resident orientation to satisfy this requirement. · BOM or designee will audit all new resident files weekly times four weeks to ensure compliance beginning December 1st, 2025. · To assist with ongoing compliance, the ED or designee will audit all new residents for 30 days to verify required documentation is present beginning December 1st. · Date of completion December 30, 2025.
22VAC40-90-30-B
Based on staff record reviews and staff interviews, the facility failed to ensure that the sworn statement or affirmation shall be completed for all applicants for employment.
Evidence
  1. Staff 4, hire date 10/1/2025, did not contain documentation of a sworn statement or affirmation.
  2. Staff 5, hire date 10/1/2025, did not contain documentation of a sworn statement or affirmation.
  3. Staff 6, hire date 10/1/2025, did not contain documentation of a sworn statement or affirmation.
  4. Interview with Staff 1 and Staff 3 confirmed Staff 4, Staff 5, and Staff 6 records were current.
Plan of correction
· Staff records did not contain current Sworn Statements of Affirmation post transition to the new company effective 10/1/2025. ED and BOM educated on this requirement. · BOM or designee will ensure updated Sworn Statements of Affirmation are completed and on file for all associates to satisfy this requirement. · BOM or designee will audit all new associate files weekly times four weeks to ensure compliance beginning December 1st, 2025. · To assist with ongoing compliance, the ED or designee will audit all new associate files for 30 days to verify required documentation is present beginning December 1st. · Date of completion December 30, 2025.
September 2, 2025Inspection0 violations
Inspection dates
09/02/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS32.1 REPORTED BY PERSONS OTHER THAN 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 PROCESS
Comments
Type of inspection: Initial Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 9/2/2025 10:00 to 12:20 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: 65 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 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 A Marie Swink, Licensing Inspector at 276-623-6575 or by email at angela.swink@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.