Inspection Reports for
Cardinal Senior Communities
1350 Longwood Avenue, BEDFORD, VA, 24523
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
1% better than Virginia average
Virginia average: 9.1 deficiencies/yearDeficiencies per year
28
21
14
7
0
Census
Latest occupancy rate
34 residents
Based on a April 2025 inspection.
Occupancy over time
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 29, 2025
Visit Reason
The inspection was conducted in response to a complaint received on 2025-07-30 regarding allegations related to resident care and related services, specifically medication management.
Complaint Details
The complaint was substantiated in part; evidence supported non-compliance related to medication management. The facility failed to ensure timely delivery and administration of prescribed medications, resulting in missed doses documented in medication administration records.
Findings
The investigation found that the facility failed to implement its medication management plan, resulting in delayed delivery and missed dosages of prescribed medications for a resident. The facility did not ensure timely refill and delivery of medications, and inaccurate medication administration records were documented.
Deficiencies (1)
Failure to implement medication management plan to ensure timely refill/delivery of medications and accurate MAR documentation.
Report Facts
Resident records reviewed: 2
Staff records reviewed: 0
Staff interviews conducted: 2
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 24, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-07-16 regarding allegations in the area of resident care and related services.
Complaint Details
Complaint investigation related to resident care and related services; the complaint was not substantiated.
Findings
The evidence gathered during the investigation did not support the allegation of non-compliance with standards or law. The inspection findings will be posted publicly within 5 business days of receipt.
Report Facts
Resident records reviewed: 1
Staff records reviewed: 0
Resident interviews conducted: 1
Staff interviews conducted: 7
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 17, 2025
Visit Reason
A complaint was received by VDSS Division of Licensing on 06/16/2025 regarding allegations in the area of resident care and related services, prompting a complaint investigation inspection on 06/17/2025.
Complaint Details
Complaint related to resident care and related services; the allegations were not substantiated.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The inspection findings will be posted publicly within 5 business days.
Report Facts
Resident records reviewed: 1
Staff records reviewed: 0
Staff interviews conducted: 9
Resident interviews conducted: 0
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 9, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-04-23 regarding allegations in the area of resident care and related services.
Complaint Details
Complaint investigation related to resident care and related services; the complaint was not substantiated.
Findings
The evidence gathered during the investigation did not support the allegation of non-compliance with standards or law. No deficiencies were cited.
Report Facts
Resident records reviewed: 1
Staff records reviewed: 0
Resident interviews conducted: 1
Staff interviews conducted: 4
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 1
Date: Apr 8, 2025
Visit Reason
The inspection was conducted in response to a complaint received on 2025-04-01 regarding allegations in staffing and supervision, resident care and related services, buildings and grounds, and additional requirements for facilities caring for adults with serious cognitive impairments.
Complaint Details
Complaint related: Yes. The complaint was substantiated in part, with non-compliance found in resident care and related services.
Findings
The investigation supported some but not all allegations; non-compliance was found in resident care and related services. A violation notice was issued related to failure to ensure care and services specified in individualized service plans were provided to residents.
Deficiencies (1)
Facility failed to ensure that the care and services specified in the individualized service plan (ISP) were provided to each resident, specifically missing monthly weight recordings for resident 1 in February 2025.
Report Facts
Number of residents present: 34
Number of resident records reviewed: 4
Number of staff records reviewed: 0
Number of interviews conducted with residents: 2
Number of interviews conducted with staff: 4
Inspection Report
Renewal
Census: 34
Deficiencies: 6
Date: Apr 8, 2025
Visit Reason
The inspection was a renewal inspection conducted to assess compliance with applicable standards and laws for the facility's license renewal.
Findings
The inspection found multiple violations including improper medication storage, failure to submit timely incident reports, inadequate infection control training, incomplete resident assessments, failure to verify sex offender status prior to admission, and medication management deficiencies.
Deficiencies (6)
Facility failed to ensure harmful materials or objects were inaccessible to residents with serious cognitive impairment except under staff supervision.
Facility failed to submit a written report of each incident to the regional licensing office within seven days, including required signatures and details.
Facility failed to ensure at least two hours of required infection control training was completed by staff.
Facility failed to ascertain prior to admission whether a potential resident is a registered sex offender.
Facility failed to ensure the uniform assessment instrument (UAI) was completed prior to admission and annually, including documentation of behavior pattern and orientation.
Facility failed to implement medication management plan to prevent use of outdated, damaged, or contaminated medications and ensure accurate counts of controlled substances.
Report Facts
Residents present: 34
Resident records reviewed: 4
Staff records reviewed: 3
Resident interviews: 2
Staff interviews: 5
Incident report date: Feb 14, 2025
Resident death date: Feb 18, 2025
Staff infection control training hours completed: 0.25
Staff infection control training hours required: 2
Resident admission date: Mar 19, 2025
Sex offender search date: Mar 20, 2025
UAI record date: Mar 17, 2025
Medication management plan review date: 202108
Medication cart observation time: 928
Medication cart observation temperature range: 36-46
Medication cart observation time narcotics count: 812
Plan of correction completion date: Jul 14, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Stokes | Licensing Inspector | Current inspector conducting the inspection |
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 0
Date: Mar 7, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on March 7, 2025, regarding allegations in the areas of personnel and resident care and related services.
Complaint Details
Complaint related inspection with allegations in personnel and resident care and related services; the allegations were not substantiated.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The inspection summary will be posted to the VDSS website within 5 business days of receipt.
Report Facts
Number of residents present: 34
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 4
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 0
Date: Feb 18, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-02-13 regarding allegations in the area of resident care and related services.
Complaint Details
Complaint related inspection with allegations concerning resident care and related services; the complaint was not substantiated.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The inspection summary will be posted to the VDSS website within 5 business days of receipt.
Report Facts
Number of residents present: 33
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: 2
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 3
Date: Oct 29, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-10-02 regarding allegations in personnel, admission, retention and discharge of residents, resident care and related services, and additional requirements for facilities caring for adults with serious cognitive impairments.
Complaint Details
The complaint was substantiated in part, specifically regarding resident care and related services. A violation notice was issued and the licensee was given the opportunity to submit a plan of correction.
Findings
The investigation supported some but not all allegations, with non-compliance found in resident care and related services. Several violations were cited including failure to complete uniform assessment instruments accurately, incomplete individualized service plans, and medication administration by staff with expired licenses.
Deficiencies (3)
Facility failed to ensure the uniform assessment instrument (UAI) was completed prior to admission, at least annually, and whenever there was a significant change in the resident's condition.
Individualized service plan (ISP) was not signed and dated by the licensee, administrator, or designee, and by the resident or legal representative.
Staff who are licensed, registered, or acting as medication aides on a provisional basis administered drugs without a valid license as required.
Report Facts
Number of residents present: 39
Number of resident records reviewed: 5
Number of staff records reviewed: 1
Number of interviews conducted with residents: 2
Number of interviews conducted with staff: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff person 1 | Named in medication administration violation and ISP update finding; license was expired at time of inspection but renewed prior to inspection. | |
| Jennifer Stokes | Licensing Inspector | Conducted the inspection and is contact for questions. |
Inspection Report
Monitoring
Census: 37
Deficiencies: 1
Date: Sep 3, 2024
Visit Reason
The inspection was a monitoring visit conducted on September 3, 2024, following a self-reported incident received on August 8, 2024, regarding allegations in personnel and resident care and related services.
Findings
The investigation supported the self-report of non-compliance with standards or law, resulting in violations issued. Specifically, the facility failed to ensure that the individualized service plan (ISP) was followed for a resident with a foley and nephrostomy catheter, leading to improper catheter care and resulting harm.
Deficiencies (1)
Facility failed to ensure that the care and services specified in the individualized service plan (ISP) were provided to a resident with a foley and nephrostomy catheter, resulting in catheter leg bag not being emptied as required and causing circulation issues and welts.
Report Facts
Number of residents present: 37
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of interviews conducted with staff: 2
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 1
Date: Jul 11, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-07-05 regarding allegations related to personnel, resident care and related services, and additional requirements for facilities that care for adults with serious cognitive impairments.
Complaint Details
The complaint was not substantiated based on the evidence gathered during the investigation. The complaint related to personnel, resident care, and additional requirements for adults with serious cognitive impairments was not supported. However, a violation was found regarding mandated reporting of suspected abuse which was not related to the complaint.
Findings
The investigation did not substantiate the complaint allegations of non-compliance. However, violations unrelated to the complaint were identified during the inspection, including failure to report suspected abuse as required by law.
Deficiencies (1)
Failure to report suspected abuse, neglect, or exploitation of residents as mandated by Virginia Code 63.2-1606.
Report Facts
Number of residents present: 37
Number of resident records reviewed: 5
Number of staff records reviewed: 1
Number of resident interviews conducted: 5
Number of staff interviews conducted: 3
Inspection Report
Monitoring
Census: 33
Deficiencies: 1
Date: Apr 11, 2024
Visit Reason
The inspection was a monitoring visit conducted to review compliance with applicable standards and laws at the assisted living facility.
Findings
The inspection found non-compliance with applicable standards or laws related to physician or prescriber orders not being reviewed and signed within 14 days. A violation notice was issued and the licensee was given the opportunity to submit a plan of correction.
Deficiencies (1)
The facility failed to ensure physician's or other prescriber's oral orders were reviewed and signed by a physician or other prescriber within 14 days.
Report Facts
Number of residents present: 33
Number of resident records reviewed: 4
Number of staff records reviewed: 3
Number of interviews conducted with residents: 4
Number of interviews conducted with staff: 4
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 28, 2023
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 07/24/2023 regarding allegations in the area of resident care and related services.
Complaint Details
Complaint related visit triggered by allegations in resident care and related services; the complaint was not substantiated.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. An exit meeting will be conducted to review the inspection findings.
Inspection Report
Renewal
Census: 39
Deficiencies: 3
Date: Apr 20, 2023
Visit Reason
The inspection was conducted as a renewal of the facility's license to ensure compliance with applicable standards and laws.
Findings
The inspection found non-compliance with applicable standards or laws, resulting in documented violations related to resident assessments, individualized service plans, and annual staff reviews of resident rights.
Deficiencies (3)
The facility failed to ensure that a uniform assessment instrument (UAI) for a private pay individual was completed as required.
The facility failed to ensure that identified needs were addressed on individualized service plans (ISPs).
The facility failed to ensure that an annual review of resident rights was completed annually with all staff.
Report Facts
Number of residents present: 39
Number of resident records reviewed: 8
Number of staff records reviewed: 4
Number of interviews conducted with residents: 3
Number of interviews conducted with staff: 3
Inspection Report
Monitoring
Deficiencies: 0
Date: Jun 17, 2022
Visit Reason
The licensing inspector conducted a focused, non-mandated monitoring inspection to follow-up on two high-risk violations cited at the facility's renewal inspection on 2022-05-03.
Findings
No repeat violations or additional violations were found during the inspection. The evidence gathered determined no violations with applicable standards or law.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 3, 2022
Visit Reason
An unannounced complaint inspection was conducted in response to a complaint received by the licensing office on May 3, 2022, regarding allegations against resident rights at Cardinal Senior Communities.
Complaint Details
Complaint was investigated and determined to be not valid with no violations found.
Findings
The investigation did not support the allegation, and the complaint was determined to be not valid. No violations resulted from this complaint investigation.
Inspection Report
Routine
Deficiencies: 7
Date: May 3, 2022
Visit Reason
The inspection was a routine, non-complaint related visit to review compliance with various assisted living facility standards including administration, personnel, resident care, medication management, emergency preparedness, and licensing requirements.
Findings
The facility was found to have multiple deficiencies including failure to follow CDC infection control policies related to labeling glucometers, incomplete documentation of resident allergy reactions, medication management issues such as unlabeled insulin vials and unavailable PRN medications, incomplete physician orders for oxygen therapy, failure to post required oxygen safety signage, and incomplete employment documentation for staff.
Deficiencies (7)
Failure to ensure infection control policies consistent with CDC recommendations were followed; glucometers not labeled with resident names.
Physical examination reports for residents lacked documentation of reactions to allergies.
Failure to implement medication management plan; insulin vials not labeled with date opened.
Medications ordered for PRN administration were not available in the facility.
Physician's order for oxygen therapy did not include the source of oxygen.
Failure to post 'No Smoking-Oxygen in Use' signs when oxygen therapy is provided.
Failure to ensure a sworn statement or affirmation was completed for all applicants for employment.
Report Facts
Date of resident physical examination: Mar 10, 2022
Date of resident physical examination: Oct 21, 2021
Date of physician order: Apr 27, 2022
Date of physician order: Apr 6, 2022
Date of physician order: Apr 28, 2022
Date of hire: Apr 6, 2022
Inspection Report
Monitoring
Deficiencies: 0
Date: Nov 9, 2021
Visit Reason
A non-mandated monitoring inspection regarding an intensive plan of correction (IPOC) follow-up was initiated and concluded on 11/09/2021 to review resident care and related services.
Findings
The inspector reviewed documentation provided by the Administrator and Director of Nursing and observed the facility's wanderguard system was operable. No repeat violations or new violations were issued.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 23, 2021
Visit Reason
A non-mandated complaint inspection was initiated due to allegations regarding personnel, admission, retention and discharge of residents, and resident care and related services.
Complaint Details
Complaint related: Yes. The evidence gathered did not support the allegations of non-compliance with standards or law.
Findings
The investigation found no evidence to support the allegations of non-compliance with standards or law. However, a violation unrelated to the complaint was identified regarding failure to obtain a timely physician's order for emergency restraints.
Deficiencies (1)
Facility failed to ensure that when restraints are used in emergencies, an oral or written order was obtained from a physician within one hour of administration and documented.
Report Facts
Date of emergency restraint incident: Aug 5, 2021
Inspection Report
Monitoring
Census: 35
Deficiencies: 8
Date: May 28, 2021
Visit Reason
A monitoring inspection was initiated due to a state of emergency health pandemic declared by the Governor of Virginia, conducted remotely to ensure compliance with applicable standards.
Findings
The inspection found multiple violations including failure to review appropriateness of continued residence in the special care unit, inadequate night staffing, incomplete individualized service plans, failure to update ISPs with condition changes, incomplete medication management policy, invalid physician oxygen orders, incomplete documentation of resident rounds, and delayed criminal history record reports for staff.
Deficiencies (8)
Failed to ensure review of appropriateness of each resident's continued residence in the special care unit was performed as required.
Failed to ensure at least two direct care staff members are awake and on duty during night hours in the special care unit when 22 or fewer residents are present.
Failed to ensure individualized service plans included all required components.
Failed to ensure individualized service plans were reviewed and updated as the condition of a resident changes.
Medication management policy did not include the facility's standard dosing schedule.
Failed to ensure a valid physician's order for oxygen contained all required components.
Failed to document rounds for residents unable to use a signaling device, including name, date, time, and staff member making rounds.
Failed to ensure criminal history record reports were obtained on or prior to the 30th day of employment for each employee.
Report Facts
Resident census: 35
Residents in special care unit during night shift: 4
Staff with delayed criminal history reports: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Stokes | Inspector | Current inspector conducting the inspection |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: May 14, 2021
Visit Reason
A complaint inspection was initiated on 2021-03-11 and concluded on 2021-05-14 due to allegations regarding resident care and related services at Cardinal Senior Communities.
Complaint Details
The complaint was substantiated with evidence supporting non-compliance in resident care and related services, including inadequate supervision of a resident with dementia who wandered off the premises and incomplete incident reporting.
Findings
The investigation found violations of standards and laws related to incident reporting, supervision of a resident with dementia who wandered off the premises, and failure to make part of a resident record available for inspection. The facility contested the findings for all violations.
Deficiencies (3)
Facility failed to include all required information in an incident report, missing phone numbers and addresses of witnesses.
Facility failed to provide supervision of specialized needs of a resident, such as prevention of wandering off the premises.
Facility failed to make part of a resident record available for inspection to the department's representative.
Report Facts
Inspection dates: 4
Resident age: 86
Walking distance: 1.4
Walking time: 28
Temperature: 34
Inspection Report
Complaint Investigation
Deficiencies: 11
Date: May 5, 2021
Visit Reason
A complaint inspection was initiated due to allegations regarding administration, personnel, admission, retention and discharge of residents, and resident care and related services. The investigation was conducted remotely due to a state of emergency health pandemic.
Complaint Details
The complaint investigation was substantiated with three allegations supported by evidence. The complaint involved issues with resident care, administrative services, and documentation.
Findings
The investigation supported three allegations of non-compliance with standards or law, resulting in violations issued. Additional violations unrelated to the complaint were also identified during the investigation.
Deficiencies (11)
Facility failed to ensure the disclosure statement provided to prospective residents included all required components.
Facility failed to review the uniform assessment instrument prior to providing written assurance to the resident and legal representative.
Facility failed to document interventions to prevent or reduce risk of subsequent falls for residents after a fall.
Facility failed to obtain all required personal and social information on residents prior to or at admission.
Facility failed to ensure the written agreement/acknowledgment included all required components.
Facility failed to provide copies of the signed agreement/acknowledgment to residents and legal representatives.
Facility failed to provide monthly statements itemizing charges and payments to residents or legal representatives.
Facility failed to provide a discharge statement at the time of resident discharge.
Facility failed to ensure individualized service plans addressed all identified resident needs.
Facility failed to administer medications in accordance with physician's or prescriber's instructions.
Facility failed to ensure the written plan for resident emergencies included all required components.
Report Facts
Number of falls documented for resident 1: 3
Dates of medication administration contrary to physician order: 15
Number of resident records randomly audited monthly: 2
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Apr 22, 2021
Visit Reason
A complaint inspection was initiated due to allegations in the areas of administration and administrative services, including infection control and compliance with state laws.
Complaint Details
The complaint investigation was initiated on 2021-03-11 and concluded on 2021-04-26. The evidence supported the allegation of non-compliance with standards or law in administration and administrative services.
Findings
The investigation found the facility's infection control policy was not consistent with CDC COVID-19 guidelines and was not fully implemented. Additionally, the facility failed to include required infection prevention procedures and did not document required staff certifications as mandated by state law.
Deficiencies (4)
Facility's written infection control policy is not consistent with CDC COVID-19 guidelines and failed to implement the policy.
Facility failed to include most requirements under 'Procedures for other infection prevention measures related to Job Duties' in their infection control policy.
Facility failed to have a required section of their infection control plan regarding product specific instructions for cleaning and disinfecting agents.
Facility failed to ensure compliance with relevant state laws by not documenting written certification records for staff as required.
Report Facts
Inspection dates: Inspection conducted on April 22, 2021 and April 26, 2021
Complaint initiation date: Complaint inspection initiated on March 11, 2021
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Nov 9, 2020
Visit Reason
A complaint inspection was initiated due to allegations regarding admission and resident care and related services at Cardinal Senior Communities. The investigation was conducted remotely due to a state of emergency health pandemic.
Complaint Details
Complaint related: Yes. A complaint was received regarding admission and resident care and related services. The evidence gathered did not support the allegations of non-compliance with standards or law.
Findings
The investigation did not substantiate the complaint allegations; however, violations unrelated to the complaint were identified, including failure to provide timely access to facility records, lack of a policy to monitor residents for nutritional status changes, and medication administration not in accordance with physician orders.
Deficiencies (3)
Licensee failed to ensure that the department's representative was afforded reasonable opportunity to inspect all facility records.
Facility failed to develop and implement a policy to monitor each resident for warning signs of changes in physical or mental status related to nutrition.
Facility failed to ensure medications were administered in accordance with physician's or prescriber's instructions.
Report Facts
Dates of medication administration records reviewed: 2
Date of admission for resident 1: Oct 23, 2020
Date of physician's order for medications: Oct 22, 2020
Date of complaint inspection initiation: Nov 9, 2020
Date of inspection conclusion: Dec 8, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Stokes | Inspector | Current inspector conducting the complaint investigation |
| Staff 1 | Interviewed staff member involved in providing documentation and medication administration information |
Viewing
Loading inspection reports...
