Inspection Reports for
Tall Oaks Assisted Living

The investigation supported the self-report of non-compliance with standards related to failure in written communication to keep direct care staff informed of significant resident issues, including complaints and incidents. A violation was issued for failure to document and communicate resident 1's wound conditions across all shifts.

Three complaints were received on 08/26/2025, 08/28/2025, and 09/02/2025. The evidence gathered supported the allegations of non-compliance, and violations were issued.

The facility failed to provide adequate air conditioning in all resident areas, with temperatures exceeding 80°F in multiple locations. Additionally, the facility lacked a documented emergency preparedness plan to protect residents from heat-related illnesses during air conditioning failures.

The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law. No deficiencies or non-compliance were found during the inspection.

A complaint was received on 2025-06-26 concerning Resident Care and Related Services. The evidence gathered did not substantiate the allegations.

The investigation found no evidence to support the allegations of non-compliance with standards or law. The inspection included a tour of the facility, review of one resident and one staff record, and interviews with two staff members.

The investigation supported some but not all of the self-report; non-compliance was found in resident care and related services. A violation notice was issued for failure to comply with regulations and facility policies, specifically related to the failure to suspend an accused staff member pending investigation as required by policy.

The inspection identified non-compliance with standards related to individualized service plan signatures and the maintenance and cleanliness of the facility's interior. Immediate corrective actions were taken and a routine monitoring schedule was implemented to ensure ongoing compliance.

The investigation did not support the self-report of non-compliance with standards or law. No deficiencies or observations were noted by the licensing inspector during the inspection.

The complaint was substantiated in part; the evidence supported some allegations related to resident care and related services but not all. The complaint involved staffing and resident care and related services.

The investigation supported some of the allegations, specifically non-compliance in resident care and related services. Violations included failure to ensure staff received required training on managing aggressive behavior and failure to ensure the Individual Service Plan (ISP) was signed and dated by the resident or their legal representative.

A complaint was received by VDSS Division of Licensing on 10/28/2024 regarding allegations in the area(s) of medication and timeliness. The evidence gathered during the investigation did not support the allegations of non-compliance.

The investigation found no evidence to support the allegations of non-compliance with standards or law. No violations were noted and no violation notice was issued.

The inspection found no violations of applicable standards or laws. The licensing inspector completed a tour of the physical plant, reviewed resident records, conducted staff interviews, and observed meals, medication administration, and activities.

Complaint related to Building and Grounds; the complaint was not substantiated.

A facility walkthrough and interviews were conducted, and the evidence gathered during the investigation did not support the allegation of non-compliance with standards or law.

The complaint was substantiated in part, specifically regarding Resident Care and Related Services. The violation notice was complaint-related.

The investigation supported some but not all allegations; non-compliance was found in Resident Care and Related Services. A violation notice was issued for failure to document rehabilitative services and other pertinent information in resident records.

The inspection found multiple violations related to record keeping, physical examination documentation, inclusion of DNR orders in service plans, and timely completion of criminal history background checks for new staff.

A complaint was received on 2022-05-16 regarding Resident Care and Related Services. The evidence supported some allegations related to medication administration but not all. No violations were found in care planning.

The investigation supported some, but not all, of the allegations. Non-compliance was found in medication administration, specifically related to crushing medications that should not be crushed. No violations were cited in care planning.

The inspection identified multiple violations including failure to ensure direct care staff maintained current first aid certification, incomplete annual uniform assessment instruments (UAI), outdated individualized service plans (ISP), improper medication storage, and medication administration not consistent with physician orders.

A complaint was received regarding Background Checks. The administrator was contacted and documentation was requested. The evidence gathered did not support the allegation.

The investigation did not find evidence to support the allegation of non-compliance with standards or law.

The inspection found no violations with applicable standards or law; no deficiencies were issued.

Complaint related inspection with substantiated violations in areas of personnel, staffing, resident care, and medication administration.

The investigation supported allegations of non-compliance with standards or law, resulting in violations related to resident assessment for serious cognitive impairment and medication administration practices.