1 Inspection Summary
Inspection Reports Summary
Covers 25 inspections · Dec 2020 – May 2026Visit Reason
This report covers 25 inspections of Tall Oaks Assisted Living from December 18, 2020 to May 26, 2026 by the Virginia Department of Social Services, including complaint and monitoring inspections.
Complaint Details
Nine inspections were prompted by complaints alleging issues in areas such as Resident Care and Related Services, Staffing and Supervision, Building and Grounds, Emergency Preparedness, and Medication Administration. Investigations supported some but not all allegations, resulting in violations issued in several complaint inspections.
Findings
Across that history VDSS cited 28 violations under 24 distinct standards. 11 of 25 visits ended with violations cited and 14 with none. 9 inspections were prompted by a complaint.
Violations (29)
22VAC40-73-700-1: Facility failed to have valid physician's order specifying oxygen source.
22VAC40-73-750-E: Facility failed to ensure sufficient bed and bath linens in good repair.
22VAC40-73-350-A: Facility failed to register with State Police for sex offender notifications.
22VAC40-73-450-A: Facility failed to develop ISP on or within seven days prior to admission.
22VAC40-73-450-E: ISP lacked signature and date of resident or legal representative.
22VAC40-73-490-D: Healthcare oversight did not identify specific residents reviewed.
22VAC40-73-300-B: Facility failed to keep direct care staff informed of significant resident issues.
22VAC40-73-880-C: Facility failed to provide air conditioning with temperatures not exceeding 80°F.
22VAC40-73-880-D: Facility failed to implement plan to protect residents from heat/cold illnesses.
22VAC40-73-40-A: Facility failed to suspend accused employee pending abuse investigation outcome.
22VAC40-73-870-A: Facility failed to maintain building interior in good repair and clean.
22VAC40-73-450-E: ISP not signed and dated by licensee, administrator, or designee.
22VAC40-73-450-E: ISP not signed and dated by resident or legal representative.
22VAC40-73-270-1: Facility failed to provide staff training on managing aggressive behavior.
22VAC40-73-480-E: Facility failed to document rehabilitative services in resident record.
22VAC40-73-680-D: Medications not administered per physician's instructions and standards.
22VAC40-73-720-A: DNR orders not included in individual service plan.
22VAC40-73-1110-B: Review of continued appropriateness not completed six months after placement.
22VAC40-90-40-B: Criminal history record report not obtained within 30 days of hire.
22VAC40-73-870-A: Facility failed to maintain building interior in good repair and clean.
22VAC40-73-440-A: Uniform assessment instrument not completed at least annually.
22VAC40-73-260-A: Direct care staff lacked current first aid certification within 60 days of hire.
22VAC40-73-680-D: Medications not administered per physician's instructions and standards.
22VAC40-73-450-F: Individualized service plans not reviewed and updated at least annually.
22VAC40-73-660-B: Medication storage not limited to out-of-sight place for self-administering residents.
22VAC40-73-1090-A: Resident not assessed by licensed psychologist or physician for serious cognitive impairment prior to admission.
22VAC40-73-680-K: Medication order lacked required details for PRN medication administration.
22VAC40-73-680-D: Medications not administered per physician's instructions and standards.
22VAC40-73-480-E: Facility failed to document rehabilitative services in resident record.
Report Facts
Violations cited: 28
Distinct standards: 24
Inspections on page: 25
Inspections with violations: 11
Complaint visits: 9
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