Inspection Reports for The Glebe Retirement Community

VA

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Inspection Report Monitoring Census: 51 Deficiencies: 0 May 8, 2025
Visit Reason
The inspection was a monitoring visit conducted following a self-reported incident received by VDSS Division of Licensing regarding allegations in resident care and related services and additional requirements for facilities that care for adults with serious cognitive impairments.
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.
Report Facts
Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1
Inspection Report Monitoring Deficiencies: 0 Mar 21, 2025
Visit Reason
The inspection was a monitoring visit conducted on March 21, 2025, following a self-reported incident received on March 17, 2025, regarding allegations in the areas of Safe, Secure Environment and Personnel.
Findings
The licensing inspector completed a tour of the physical plant and conducted interviews with residents and staff. The evidence gathered did not support the self-report of non-compliance with standards or law.
Report Facts
Number of staff records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3
Inspection Report Monitoring Census: 53 Deficiencies: 2 Mar 11, 2025
Visit Reason
The inspection was a monitoring visit to review compliance with applicable standards and laws at the assisted living facility.
Findings
The inspection found non-compliance with regulations related to the placement and admission procedures for residents with serious cognitive impairments. Violations were documented and a plan of correction was requested.
Deficiencies (2)
Description
The facility failed to obtain written approval of one required person prior to placing a resident with a serious cognitive impairment in a safe, secure environment.
The facility failed to ensure that the licensee, administrator, or designee determined in writing whether placement in the special care unit was appropriate prior to admitting a resident with a serious cognitive impairment.
Report Facts
Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 5
Employees Mentioned
NameTitleContext
Angela Marie SwinkLicensing InspectorInspector conducting the monitoring visit
Staff 2Staff member interviewed confirming resident record details related to deficiencies
Director of Health ServicesResponsible for reviewing documents to ensure compliance as part of plan of correction
Inspection Report Complaint Investigation Deficiencies: 0 Nov 20, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2024-11-09 regarding allegations in the area of Resident Care and Related Services.
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 and a copy is required to be posted on the facility premises.
Complaint Details
Complaint investigation related to Resident Care and Related Services; allegations were not substantiated.
Report Facts
Number of resident records reviewed: 1 Number of staff interviews conducted: 4
Inspection Report Monitoring Deficiencies: 0 Sep 3, 2024
Visit Reason
The inspection was a monitoring visit to review compliance with additional requirements for facilities that care for adults with serious cognitive impairments.
Findings
The inspection found no violations of applicable standards or laws during the tour of the physical plant and staff interview.
Employees Mentioned
NameTitleContext
Angela Marie SwinkLicensing InspectorConducted the inspection and named as the current inspector.
Inspection Report Renewal Census: 45 Deficiencies: 1 Apr 10, 2024
Visit Reason
The inspection was conducted as a renewal of the facility's license to ensure compliance with applicable standards and regulations.
Findings
The inspection found non-compliance related to the physical plant, specifically that a laundry room door with a keyless entry mechanism did not engage and lock, allowing residents access to harmful cleaning chemicals. The facility was cited for this violation and required to submit a plan of correction.
Deficiencies (1)
Description
The facility failed to ensure that ordinary materials or objects harmful to residents were inaccessible; specifically, a bottle of laundry stain remover was accessible in an unlocked cabinet in the laundry room.
Report Facts
Number of residents present: 45 Number of resident records reviewed: 5 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 4
Employees Mentioned
NameTitleContext
Angela Marie SwinkLicensing InspectorCurrent inspector conducting the inspection
Director of Facilities ServicesNotified immediately about the unlocked laundry room door and determined no reason for malfunction
Inspection Report Monitoring Census: 45 Deficiencies: 1 Apr 10, 2024
Visit Reason
The inspection was a monitoring visit conducted on April 10, 2024, following a self-reported incident received on March 21, 2024, regarding allegations in the areas of Personnel and Resident Care and Related Services.
Findings
The investigation supported some but not all of the self-report; non-compliance was found in the area of Personnel. A violation was issued related to failure to report suspected abuse to Adult Protective Services as required by Virginia law.
Deficiencies (1)
Description
The facility failed to ensure that all staff who are mandated reporters under § 63.2-1606 of the Code of Virginia report suspected abuse or neglect of residents in accordance with that section.
Report Facts
Number of residents present: 45 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
Employees Mentioned
NameTitleContext
Angela Marie SwinkLicensing InspectorConducted the inspection and re-educated the Director of Health Services on notification requirements
Director of Health ServicesNamed in plan of correction and re-education regarding notification to Adult Protective Services
Inspection Report Complaint Investigation Census: 47 Deficiencies: 0 Feb 12, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2024-02-09 regarding allegations in the area of Resident Care and Related Services.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law.
Complaint Details
Complaint related inspection triggered by allegations in Resident Care and Related Services; the complaint was not substantiated.
Report Facts
Resident records reviewed: 1 Staff records reviewed: 0 Resident interviews conducted: 1 Staff interviews conducted: 4
Employees Mentioned
NameTitleContext
Angela Marie SwinkLicensing InspectorCurrent inspector conducting the complaint investigation
Inspection Report Monitoring Deficiencies: 0 Jan 11, 2024
Visit Reason
The inspection was conducted as a monitoring visit following a self-reported incident received by VDSS Division of Licensing on 12/13/2023 regarding allegations in the areas of personnel and resident care and related services.
Findings
The evidence gathered during the inspection determined no violations with applicable standards or law. The inspection findings will be posted publicly and a copy is required to be posted on the premises.
Inspection Report Monitoring Deficiencies: 0 May 25, 2023
Visit Reason
The inspection was a monitoring visit conducted to review compliance with administrative services, resident care, and building and ground standards.
Findings
The inspection found no violations of applicable standards or laws during the visit.
Inspection Report Renewal Census: 48 Deficiencies: 6 Apr 18, 2023
Visit Reason
The inspection was a renewal inspection conducted to assess the facility's compliance with applicable standards and regulations.
Findings
The inspection identified multiple deficiencies including failure to implement infection control policies for blood glucose monitoring, improper medication labeling, medication administration errors, inadequate documentation of treatments, unsafe storage of hazardous materials, and failure to document required resident rounds. Plans of correction were submitted to address these issues.
Deficiencies (6)
Description
Failure to implement infection control policy regarding blood glucose monitoring practices consistent with CDC recommendations.
Failure to ensure medications remain in pharmacy issued container with prescription label until administered.
Failure to ensure medications are administered in accordance with physician's instructions.
Failure to ensure medical procedures or treatments ordered by a physician are provided and documented in the resident's record.
Failure to store cleaning supplies and hazardous materials in a locked area.
Failure to document required two-hour rounds for residents unable to use signaling device.
Report Facts
Number of residents present: 48 Number of resident records reviewed: 8 Number of staff records reviewed: 4 Number of resident interviews: 3 Number of staff interviews: 3 Audit frequency: 4 Audit frequency: 3
Employees Mentioned
NameTitleContext
Angela Marie SwinkCurrent InspectorNamed as the current inspector conducting the inspection.
Jennifer StokesLicensing InspectorContact person for questions regarding the inspection.
Inspection Report Monitoring Census: 43 Deficiencies: 0 Jun 2, 2022
Visit Reason
The inspection was a monitoring visit conducted to review the physical plant including the building and grounds of the assisted living facility.
Findings
The prior violation has been corrected and no violations with applicable standards or laws were found during the inspection.
Inspection Report Renewal Census: 46 Deficiencies: 3 Apr 27, 2022
Visit Reason
The inspection was a renewal study conducted to review compliance with state regulations, including resident and staff records, medication administration, and physical plant conditions.
Findings
The inspection identified deficiencies related to improper storage of medications in resident rooms, unsecured cleaning supplies and hazardous materials, and failure to conduct required emergency procedure exercises every six months.
Deficiencies (3)
Description
Medications kept in resident rooms were not stored out of sight and were present without physician orders for residents assessed as incapable of self-administering medications.
Cleaning supplies and other hazardous materials were stored in unlocked areas, including soiled utility rooms and food pantry.
Facility failed to hold emergency procedure practice exercises at least once every six months as required.
Report Facts
Residents in care: 46 Resident records reviewed: 8 Staff records reviewed: 4 Inspection duration: 4.67 Plan of correction re-education completion date: May 15, 2022 Keyless lock installation deadline: May 3, 2022
Employees Mentioned
NameTitleContext
Angela Marie SwinkInspectorNamed as current inspector conducting the inspection
Director of Facilities ServicesNotified to order and place keyless locks on soiled utility rooms
Director of Environmental ServicesRemoved cleaning products identified in soiled utility room
Food and Beverage ManagerRemoved cleaning supplies observed in Memory Care Pantry
Memory Care ManagerRemoved Micro-Kill Wipes from nursing station of Memory Care neighborhood
Inspection Report Monitoring Census: 47 Deficiencies: 0 Jun 10, 2021
Visit Reason
An annual monitoring inspection was initiated to review compliance with applicable standards and laws using an alternate remote protocol due to a state of emergency health pandemic.
Findings
The inspection reviewed resident and staff records, staff schedules, fire drill records, background checks, health care oversight, fire and health department reports, medication management, and infection control plans. No violations or deficiencies were found.
Report Facts
Resident records reviewed: 3 Staff records reviewed: 3
Inspection Report Complaint Investigation Deficiencies: 1 Dec 8, 2020
Visit Reason
A monitoring inspection was initiated due to a complaint received regarding personnel, resident care and related services, and additional requirements for facilities that care for adults with serious cognitive impairments.
Findings
The investigation found non-compliance with standards related to failure to update the uniform assessment instrument (UAI) when there was a significant change in a resident's condition, supported by resident record review and nursing notes.
Complaint Details
The complaint was substantiated as the evidence supported the allegation of non-compliance with standards or law regarding updating the UAI for resident 3.
Deficiencies (1)
Description
Facility failed to update the uniform assessment instrument (UAI) when there was a significant change in a resident's condition.
Employees Mentioned
NameTitleContext
Angela Marie SwinkInspectorNamed as the current inspector conducting the investigation.

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