Deficiencies (last 4 years)
Deficiencies (over 4 years)
7.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
18% better than Virginia average
Virginia average: 9.1 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
60 residents
Based on a November 2025 inspection.
Census over time
Inspection Report
Monitoring
Census: 60
Deficiencies: 1
Nov 12, 2025
Visit Reason
The inspection was a monitoring visit conducted following a self-reported incident received by VDSS Division of Licensing regarding allegations in the area of resident care.
Findings
The investigation supported the self-report of non-compliance with standards or law related to medication administration errors. Violations were issued based on evidence including staff interviews and resident record reviews.
Deficiencies (1)
| Description |
|---|
| The facility failed to ensure that medications were administered in accordance with the physician's or other prescriber's instructions, including a medication error where Resident #1 was given medication prescribed for Resident #2. |
Report Facts
Number of residents present: 60
Number of resident records reviewed: 2
Number of staff records reviewed: 1
Number of interviews conducted with staff: 2
Inspection Report
Renewal
Census: 59
Deficiencies: 6
Nov 10, 2025
Visit Reason
The inspection was conducted as a renewal of the facility's license, with the licensing inspector on-site on November 10 and November 12, 2025.
Findings
The inspection found multiple violations of applicable standards and laws, including failures in staff training, resident assessments, record keeping, dietitian oversight, inclusion of DNR orders in service plans, and emergency procedure exercises. The facility was issued a violation notice and given the opportunity to submit a plan of correction.
Deficiencies (6)
| Description |
|---|
| Facility failed to ensure direct care staff attended six hours of cognitive impairment training within four months of employment. |
| Facility failed to ensure resident was assessed by an independent clinical psychologist or physician prior to admission to a safe, secure environment. |
| Facility failed to retain a copy of the written discharge statement in resident records. |
| Facility failed to ensure oversight at least every six months of special diets by a dietitian or nutritionist for residents with such diets. |
| Facility failed to include the written Do Not Resuscitate (DNR) order in the individualized service plan (ISP). |
| Facility failed to ensure all staff currently on duty participate in emergency procedure exercises at least every six months, with documentation maintained for two years. |
Report Facts
Number of residents present: 59
Number of resident records reviewed: 6
Number of staff records reviewed: 3
Number of resident interviews conducted: 3
Number of staff interviews conducted: 2
Date of last dietitian oversight report: Mar 20, 2025
Date of last documented emergency exercise: Apr 30, 2025
Inspection Report
Monitoring
Census: 59
Deficiencies: 5
Apr 29, 2025
Visit Reason
The inspection was a monitoring visit conducted on April 29, 2025 and May 2, 2025 to review compliance with applicable standards and laws at The Lodge at Old Trail assisted living facility.
Findings
The inspection found non-compliance with several standards including failure to provide written assurance of appropriate licensing prior to admission, incomplete emergency preparedness orientation and review for residents and volunteers, missing fire drills for March and April, expired items in the first aid kit, and missing criminal history record report for an employee. Plans of correction were submitted for each deficiency.
Deficiencies (5)
| Description |
|---|
| Failed to provide written assurance to resident prior to admission that the facility has the appropriate license to meet care needs. |
| Failed to develop and implement orientation and semi-annual review on emergency preparedness and response plan for all staff, residents, and volunteers. |
| Failed to ensure fire and emergency evacuation drill frequency and participation in accordance with Virginia Statewide Fire Prevention Code. |
| Failed to ensure first aid kits are checked monthly and items with expiration dates are not expired. |
| Failed to obtain criminal history record report on or prior to 30th day of employment for an employee. |
Report Facts
Number of residents present: 59
Number of resident records reviewed: 6
Number of staff records reviewed: 3
Number of resident interviews: 5
Number of staff interviews: 4
Date of last fire drill: Feb 27, 2025
Date of last first aid kit review: Mar 13, 2025
Date of hire for employee missing criminal history report: Aug 28, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Davis | Licensing Inspector | Inspector conducting the monitoring visit and contact person for questions |
Inspection Report
Monitoring
Census: 62
Deficiencies: 1
Jul 23, 2024
Visit Reason
The inspection was a monitoring visit conducted on July 23, 2024, following a self-reported incident regarding allegations in the area of resident care.
Findings
The investigation supported the self-report of non-compliance with regulations related to medication administration. A violation was issued due to the facility's failure to ensure medications were administered according to physician's orders, specifically involving the incorrect administration of insulin to residents.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure that medications were administered in accordance with the physician's or other prescriber's instructions, including an incident where insulin intended for one resident was administered to another. |
Report Facts
Number of residents present: 62
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of interviews conducted: 2
Inspection Report
Renewal
Census: 67
Deficiencies: 3
Oct 30, 2023
Visit Reason
The inspection was conducted as a renewal of the facility's license, with the licensing inspector on-site on October 30, 2023, and November 9, 2023.
Findings
The inspection found non-compliance with applicable standards and laws, resulting in documented violations related to infection control, staff training, and certification requirements. The facility was given the opportunity to submit a plan of correction to address these violations.
Deficiencies (3)
| Description |
|---|
| The facility failed to ensure the use of standard precautions for infection control during medication pass observation; the med tech did not sanitize or wash hands between each med pass. |
| The facility failed to ensure that all direct care staff attended at least 18 hours of annual training; Staff #2's record lacked documentation of required training. |
| The facility failed to ensure that each direct care staff member maintained current certification in first aid; Staff #1's record lacked documentation of first aid certification. |
Report Facts
Residents present: 67
Resident records reviewed: 10
Staff records reviewed: 5
Resident interviews: 3
Staff interviews: 3
Inspection Report
Monitoring
Census: 63
Deficiencies: 0
Jul 12, 2023
Visit Reason
The inspection was a monitoring visit conducted on July 12, 2023, to review resident care and related services at the facility.
Findings
The inspection found no violations with applicable standards or laws based on the evidence gathered during the visit.
Report Facts
Resident records reviewed: 1
Staff interviews conducted: 2
Resident interviews conducted: 0
Inspection Report
Monitoring
Census: 63
Deficiencies: 0
Jul 12, 2023
Visit Reason
The inspection was a monitoring visit conducted on July 12, 2023, to review resident care and related services at the facility.
Findings
The inspection found no violations with applicable standards or laws based on the evidence gathered during the visit.
Report Facts
Resident records reviewed: 1
Staff interviews conducted: 3
Inspection Report
Monitoring
Census: 62
Deficiencies: 9
May 8, 2023
Visit Reason
The inspection was a monitoring visit conducted on May 8 and May 16, 2023, to review compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection found non-compliance with several standards related to staff orientation and training, certification, resident assessments, individualized service plans, staff annual reviews, health inspections, and emergency drills. Violations were documented and plans of correction were provided by the facility.
Deficiencies (9)
| Description |
|---|
| Failed to ensure orientation and training occurred within first seven working days of employment for Staff #4. |
| Failed to ensure each direct care staff member maintained current certification in first aid (Staff #3 and Staff #4). |
| Failed to ensure the UAI was completed prior to admission, at least annually, and with significant changes for Residents #3 and #4. |
| Failed to ensure ISP contained written description of all identified needs based on UAI for Resident #9. |
| Failed to ensure ISP was signed and dated by licensee, administrator, or designee and resident or legal representative for Residents #8, #10, and #5. |
| Failed to ensure ISP was reviewed and updated at least once every 12 months and as needed for significant changes for Residents #3 and #4. |
| Failed to ensure rights and responsibilities of residents were reviewed annually with staff and documented for Staff #4. |
| Failed to ensure compliance with Virginia Department of Health regulations evidenced by initial and annual health inspection reports; last health inspection dated 3-22-22. |
| Failed to ensure all staff participated in emergency procedure exercises at least once every six months; no documentation of practice exercise for resident emergency. |
Report Facts
Number of residents present: 62
Number of resident records reviewed: 10
Number of staff records reviewed: 5
Number of interviews with residents: 4
Number of interviews with staff: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Davis | Licensing Inspector | Current inspector conducting the inspection |
| Staff #4 | Named in multiple findings related to orientation, first aid certification, annual review of resident rights | |
| Staff #3 | Named in finding related to first aid certification | |
| Health and Wellness Director | Named in plan of correction for ISP signing and review | |
| Administrative Services Director | Named in plans of correction related to staff orientation, documentation, and resident rights review | |
| Dining Services Director | Named in plan of correction related to health inspection scheduling |
Inspection Report
Monitoring
Deficiencies: 0
Nov 30, 2021
Visit Reason
An unannounced focus monitoring inspection was conducted remotely to follow up on a previously cited high risk violation regarding resident call bell response times.
Findings
A sample of 8 resident records were reviewed and no violations were cited during this inspection.
Report Facts
Resident records reviewed: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Davis | Licensing Inspector | Conducted the remote focus monitoring inspection |
Inspection Report
Renewal
Census: 61
Deficiencies: 3
Oct 29, 2021
Visit Reason
A renewal inspection was initiated on October 25, 2021 and concluded on October 29, 2021 to review compliance with applicable standards and laws for The Lodge at Old Trail assisted living facility.
Findings
The inspection identified non-compliance with several standards including failure to report a major event within 24 hours, failure to obtain an annual inspection report from the Virginia Department of Health, and failure to document resident participation in fire and emergency drills.
Deficiencies (3)
| Description |
|---|
| Facility failed to report to the regional licensing office within 24 hours a major event that negatively affected or threatened the life, health, safety, or welfare of a resident. |
| Facility failed to ensure that it obtained an annual inspection report from the Virginia Department of Health. |
| Facility failed to document the participation of residents in fire and emergency drills. |
Report Facts
Census: 61
Date of last Virginia Department of Health inspection: Jan 30, 2020
Number of resident records reviewed: 4
Number of staff records reviewed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maureen Davis | Executive Director | Named in plan of correction and responsible for implementing corrective actions |
| Rebecca Pierce | Resident Care Director | Named in plan of correction and responsible for implementing corrective actions |
| Alicia Doyle | Assistant Care Director | Named in plan of correction and responsible for implementing corrective actions |
| Tony Hughes | Executive Chef | Named in plan of correction and responsible for implementing corrective actions |
| Justin Martin | Sous Chef | Named in plan of correction and responsible for implementing corrective actions |
| James Morris | Maintenance Director | Named in plan of correction and responsible for implementing corrective actions |
Inspection Report
Complaint Investigation
Deficiencies: 1
Aug 18, 2021
Visit Reason
A non-mandated complaint inspection was initiated due to allegations regarding resident care. The investigation included resident interviews, review of call bell response logs, and on-site observation.
Findings
The investigation supported some allegations of non-compliance related to delayed staff response times to resident call bells, with multiple instances of response times ranging from 8 to 39 minutes documented in call bell logs for three residents. Violations were issued based on these findings.
Complaint Details
Complaint related: Yes. The complaint was substantiated with evidence supporting some allegations of non-compliance with resident care standards.
Deficiencies (1)
| Description |
|---|
| Facility failed to provide prompt response by staff to residents' needs as evidenced by delayed call bell response times documented in logs for multiple residents. |
Report Facts
Call bell response instances: 15
Call bell response instances: 13
Call bell response instances: 29
Call bell response instances: 13
Call bell response instances: 27
Call bell response instances: 4
Call bell response instances: 33
Call bell response instances: 19
Call bell response instances: 32
Call bell response instances: 8
Call bell response instances: 22
Call bell response instances: 10
Call bell response instances: 1
Call bell response instances: 72
Call bell response instances: 13
Call bell response instances: 60
Call bell response instances: 9
Call bell response instances: 35
Call bell response instances: 6
Call bell response instances: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alicia Doyle | Assistant Care Director | Responsible for implementing corrective steps and monitoring preventative measures |
| Rebecca Pierce | Resident Care Director | Responsible for implementing corrective steps and monitoring preventative measures |
| Maureen Davis | Executive Director | Responsible for implementing corrective steps and monitoring preventative measures |
Inspection Report
Monitoring
Deficiencies: 1
Apr 2, 2021
Visit Reason
A monitoring inspection was initiated due to a self-reported incident regarding allegations in the area of medication administration, conducted remotely due to a state of emergency health pandemic.
Findings
The investigation supported the self-report of non-compliance with standards related to medication administration documentation, resulting in a violation issued for failure to ensure the Medication Administration Record contained the initials of the direct care staff administering medication.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure that the Medication Administration Record (MAR) contained the initials of the direct care staff administering the medication. |
Report Facts
Medication administration dates discrepancy: 12
Medication administration dates initialed: 5
Plan of correction submission timeframe: 10
Inspection Report
Monitoring
Census: 61
Deficiencies: 0
Feb 9, 2021
Visit Reason
A monitoring inspection was initiated due to the state of emergency health pandemic declared by the Governor of Virginia, conducted remotely to ensure compliance with applicable standards and laws.
Findings
The inspection reviewed resident and staff records, physician's orders, Medication Administration Records, and other facility documentation, determining no violations with applicable standards or law. No violations were issued.
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