Inspection Report
Monitoring
Census: 114
Deficiencies: 0
Oct 29, 2025
Visit Reason
The inspection was a monitoring visit conducted to review resident care and related services following a self-reported incident received by VDSS Division of Licensing regarding allegations in resident care.
Findings
The inspection found no violations of applicable standards or laws based on the evidence gathered during the visit.
Report Facts
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
Monitoring
Census: 114
Deficiencies: 1
Oct 29, 2025
Visit Reason
The inspection was conducted as a monitoring visit following a self-reported incident received by VDSS Division of Licensing on 2025-10-09 regarding allegations in the area of Resident Care and Related Services.
Findings
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.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure a method of written communication to keep direct care staff on all shifts informed of significant happenings or problems experienced by residents, including complaints and incidents or injuries related to physical or mental conditions. |
Report Facts
Number of residents present: 114
Number of resident records reviewed: 1
Number of staff records reviewed: 4
Number of interviews conducted with staff: 3
Inspection Report
Complaint Investigation
Census: 109
Deficiencies: 2
Sep 4, 2025
Visit Reason
The inspection was conducted in response to three complaints received by VDSS Division of Licensing regarding allegations in the areas of Direct Care and Related Services, Building and Grounds, Emergency Preparedness, and Complaint Investigation.
Findings
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.
Complaint Details
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.
Deficiencies (2)
| Description |
|---|
| Facility failed to provide air conditioning system for all areas used by residents, with temperatures exceeding 80°F in multiple locations. |
| Facility failed to develop and implement a plan to protect residents from heat-related and cold-related illnesses in the event of loss of air-conditioning or heat due to emergency situations or malfunctioning equipment. |
Report Facts
Number of residents present: 109
Temperature readings (°F): 86.7
Temperature readings (°F): 86.5
Temperature readings (°F): 86.4
Temperature readings (°F): 82.3
Temperature readings (°F): 80.6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jacquelyn Kabiri | Licensing Inspector | Conducted the inspection and temperature survey |
| Staff 1 | Accompanied the licensing inspector and provided information about air conditioning failure |
Inspection Report
Monitoring
Census: 110
Deficiencies: 0
Aug 19, 2025
Visit Reason
The inspection was a monitoring visit following a self-reported incident received by VDSS Division of Licensing on 2025-08-09 regarding allegations in staffing and supervision and resident care and related services.
Findings
The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law. The licensing inspector completed a tour of the facility and reviewed records with no deficiencies noted.
Report Facts
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of interviews conducted with staff: 1
Number of interviews conducted with residents: 0
Inspection Report
Monitoring
Census: 110
Deficiencies: 0
Aug 19, 2025
Visit Reason
The inspection was conducted as a monitoring visit following a self-reported incident received by VDSS Division of Licensing on 08/05/2025 regarding allegations in the areas of Staffing and Supervision and Resident Care and Related Services.
Findings
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.
Report Facts
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of interviews conducted with staff: 1
Number of interviews conducted with residents: 0
Inspection Report
Complaint Investigation
Census: 113
Deficiencies: 0
Jul 2, 2025
Visit Reason
The inspection was conducted in response to a complaint received by the VDSS Division of Licensing on 2025-06-26 regarding allegations in the area of Resident Care and Related Services.
Findings
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.
Complaint Details
A complaint was received on 2025-06-26 concerning Resident Care and Related Services. The evidence gathered did not substantiate the allegations.
Report Facts
Residents present: 113
Resident records reviewed: 1
Staff records reviewed: 1
Staff interviews conducted: 2
Resident interviews conducted: 0
Inspection Report
Monitoring
Census: 113
Deficiencies: 1
Jun 25, 2025
Visit Reason
The inspection was a monitoring visit conducted on June 25, 2025, following a self-reported incident received on May 15, 2025, regarding allegations in the areas of resident care and related services and personnel.
Findings
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.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure compliance with all regulations for licensed assisted living facilities and terms of the license issued by the department and the facility's own policies and procedures, specifically failing to suspend the accused employee pending investigation as required by policy. |
Report Facts
Number of residents present: 113
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of staff interviews conducted: 3
Inspection Report
Monitoring
Census: 113
Deficiencies: 2
Apr 30, 2025
Visit Reason
The inspection was a monitoring visit to review compliance with various resident care, accommodations, building maintenance, emergency preparedness, and background check regulations for an assisted living facility.
Findings
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.
Deficiencies (2)
| Description |
|---|
| The facility failed to ensure that the individualized service plan (ISP) is signed and dated by the licensee, administrator, or their designee. |
| The facility failed to ensure the interior of the building was maintained in good repair and kept clean, including worn chairs, stained carpet, hanging ceiling tile, broken blinds, holes in drywall, scuff marks, torn wallpaper, and food debris on the floor. |
Report Facts
Number of residents present: 113
Number of resident records reviewed: 8
Number of staff records reviewed: 3
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 2
Number of brown spots on ceiling: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jacquelyn Kabiri | Licensing Inspector | Inspector conducting the monitoring visit |
| Maintenance Director | Responsible for daily walkthroughs and oversight of facility maintenance | |
| Executive Director | Responsible for oversight of ongoing compliance and review of ISPs and environmental issues |
Inspection Report
Monitoring
Census: 112
Deficiencies: 0
Mar 19, 2025
Visit Reason
The inspection was conducted as a monitoring visit following a self-reported incident received by VDSS Division of Licensing regarding allegations in the area of Resident Care and related services.
Findings
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.
Report Facts
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
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jacquelyn Kabiri | Licensing Inspector | Named as the current inspector conducting the inspection |
Inspection Report
Monitoring
Census: 112
Deficiencies: 0
Mar 19, 2025
Visit Reason
The inspection was conducted as a monitoring visit following a self-reported incident received by VDSS Division of Licensing regarding allegations in the area of Resident Care and related services.
Findings
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.
Report Facts
Number of resident records reviewed: 2
Number of staff records reviewed: 3
Number of interviews conducted with staff: 2
Number of interviews conducted with residents: 0
Inspection Report
Complaint Investigation
Census: 116
Deficiencies: 2
Mar 19, 2025
Visit Reason
The inspection was conducted in response to a complaint received on 2025-03-17 regarding allegations related to staffing and resident care and related services at the facility.
Findings
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.
Complaint Details
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.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure that training prior and annually for staff included demonstration in self-protection and in the prevention and de-escalation of aggressive behavior. |
| Facility failed to ensure the Individual Service Plan (ISP) is signed and dated by the resident or their legal representative. |
Report Facts
Number of residents present: 116
Number of resident records reviewed: 1
Number of staff records reviewed: 2
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jacquelyn Kabiri | Licensing Inspector | Inspector conducting the complaint investigation |
| Staff 1 | Acknowledged staff providing care and confirmed lack of training documentation; confirmed ISP details | |
| Director of Nursing | Director of Nursing | Responsible for oversight and corrective actions related to ISP deficiencies |
Inspection Report
Complaint Investigation
Census: 111
Deficiencies: 0
Dec 27, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-10-28 regarding allegations related to medication and timeliness specific to a condition.
Findings
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.
Complaint Details
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.
Report Facts
Number of residents present: 111
Number of resident records reviewed: 5
Number of staff records reviewed: 1
Number of interviews conducted with staff: 1
Number of interviews conducted with residents: 0
Inspection Report
Renewal
Census: 98
Deficiencies: 0
Mar 7, 2024
Visit Reason
The inspection was conducted as a renewal inspection to evaluate compliance with licensing requirements for Tall Oaks Assisted Living.
Findings
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.
Report Facts
Number of resident records reviewed: 10
Number of staff interviews conducted: 3
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 13, 2023
Visit Reason
The inspection was conducted in response to a complaint received on 2023-10-12 regarding Building and Grounds at the facility.
Findings
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.
Complaint Details
Complaint related to Building and Grounds; the complaint was not substantiated.
Inspection Report
Complaint Investigation
Deficiencies: 1
Aug 3, 2023
Visit Reason
The inspection was conducted in response to a complaint received on June 28, 2023, regarding staffing and supervision, and resident care and related services at Tall Oaks Assisted Living.
Findings
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.
Complaint Details
The complaint was substantiated in part, specifically regarding Resident Care and Related Services. The violation notice was complaint-related.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure that rehabilitative services and other pertinent information were documented in the resident record for wound care services ordered for Residents #1 and #2. |
Report Facts
Inspection dates: 3
Order dates for wound care: 61123
Order dates for wound care: 63023
Plan of correction submission timeframe: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jacquelyn Kabiri | Licensing Inspector | Current inspector conducting the complaint investigation |
| Marshall Massenberg | Licensing Inspector | Contact person for questions regarding the inspection |
| Director of Nursing | Named in plan of correction for contacting rehabilitative professional to ensure documentation |
Inspection Report
Renewal
Census: 96
Deficiencies: 4
Mar 15, 2023
Visit Reason
An unannounced renewal inspection was conducted to assess compliance with applicable standards and laws, including review of resident care, medication administration, activities, building and grounds, and records.
Findings
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.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure a review of continued appropriateness was completed six months after a resident was placed in the safe, secure environment. |
| Physical examination reports did not include all required information, such as resident reactions to known allergens. |
| DNR orders were not included in the individual service plan for a resident. |
| Criminal history record report was not obtained within 30 days of hiring an employee. |
Report Facts
Residents in care: 96
Resident records reviewed: 10
Staff records reviewed: 5
New employee hires since previous inspection: 17
Days late for criminal history check: 127
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marshall Massenberg | Licensing Inspector | Contact person for questions about the inspection |
Inspection Report
Complaint Investigation
Deficiencies: 1
Jul 8, 2022
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2022-05-16 regarding allegations in the area of Resident Care and Related Services.
Findings
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.
Complaint Details
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.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure medications were administered according to physician's instructions and standards, specifically crushing Metoprolol Succinate which should not be crushed. |
Inspection Report
Renewal
Census: 91
Deficiencies: 5
Mar 10, 2022
Visit Reason
An unannounced renewal inspection was conducted to assess compliance with licensing standards, including review of resident care, medication administration, activities, building and grounds, and records.
Findings
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.
Deficiencies (5)
| Description |
|---|
| Facility failed to ensure direct care staff members maintain current certification in first aid within 60 days of employment. |
| Facility failed to ensure that the uniform assessment instrument (UAI) is completed at least annually. |
| Facility failed to ensure that individualized service plans (ISPs) are reviewed and updated at least once every 12 months. |
| Facility failed to ensure medication storage is limited to an out-of-sight place in rooms of residents capable of self-administering medication. |
| Facility failed to ensure medications are administered in accordance with physician's instructions and standards of practice. |
Report Facts
Residents in care: 91
Sample size of resident records reviewed: 10
Sample size of staff records reviewed: 5
Days late for first aid certification: 4
Inspection Report
Complaint Investigation
Deficiencies: 0
May 14, 2021
Visit Reason
A complaint inspection was initiated due to an allegation related to Background Checks at the facility.
Findings
The investigation did not find evidence to support the allegation of non-compliance with standards or law.
Complaint Details
A complaint was received regarding Background Checks. The administrator was contacted and documentation was requested. The evidence gathered did not support the allegation.
Inspection Report
Renewal
Census: 85
Deficiencies: 0
Mar 15, 2021
Visit Reason
A renewal inspection was initiated to assess compliance with applicable standards and laws for Tall Oaks Assisted Living.
Findings
The inspection found no violations with applicable standards or law; no deficiencies were issued.
Inspection Report
Complaint Investigation
Deficiencies: 3
Dec 18, 2020
Visit Reason
A complaint inspection was initiated due to allegations regarding Personnel, Staffing and Supervision, Resident Care and Related Services, and Requirements for Facilities that Care for Adults with Serious Cognitive Impairments.
Findings
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.
Complaint Details
Complaint related inspection with substantiated violations in areas of personnel, staffing, resident care, and medication administration.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure each resident is assessed by an independent clinical psychologist or physician for serious cognitive impairment prior to admission to the safe, secure environment. |
| Facility failed to ensure medications are administered in accordance with physician's instructions and standards of practice. |
| Facility failed to obtain a detailed medication order for PRN medication including symptoms, dosage, time frames, and directions if symptoms persist. |
Report Facts
Medication administration dates: 4
Medication administration dates: 1
Medication administration dates: 1
Dates of resident placement and assessments: 1
Dates of evaluations: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jacquelyn Kabiri | Inspector | Named as current inspector conducting the investigation. |
| Assistant Executive Director | Involved in locating appropriate forms during review. | |
| Director of Nursing | Responsible for training, medication administration oversight, and corrective actions. |
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