Inspection Reports for
Woods Cove Assisted Living
201 W. Criser Road, FRONT ROYAL, VA, 22630
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
5.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
43% better than Virginia average
Virginia average: 9.1 deficiencies/year
Deficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
38 residents
Based on a April 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 6
Date: Apr 2, 2025
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received on 2025-03-07 regarding allegations in the area of resident care at Woods Cove Assisted Living.
Complaint Details
The complaint was received by VDSS Division of Licensing on 2025-03-07 regarding allegations in the area of resident care. The evidence gathered supported the allegation of non-compliance with standards or law, resulting in violations being issued.
Findings
The investigation found multiple violations including failure to ensure protective devices on bedroom windows, inadequate shift-to-shift communication regarding resident care, incomplete individualized service plans, failure to provide specified care services, lack of required furniture in resident rooms, and insufficient bathing facilities. Some violations were corrected immediately, while others required further action.
Deficiencies (6)
Facility failed to ensure protective devices were on bedroom windows of residents with serious cognitive impairments to prevent windows from being opened wide enough for a resident to crawl through.
Facility failed to ensure staff followed procedures for use of the shift-to-shift communication log to keep staff on all shifts informed.
Facility failed to ensure the individualized service plan (ISP) included a description of who would provide shower service.
Facility failed to ensure that the care and services specified in the ISP were provided to the resident.
Facility failed to ensure that the bedroom for resident 1 had a chair as required.
Facility failed to ensure that at least one bathtub or shower for each ten persons was available.
Report Facts
Number of residents present: 38
Number of resident records reviewed: 3
Number of staff records reviewed: 0
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 3
Current census in secured unit: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill James | Licensing Inspector | Current inspector conducting the inspection |
Inspection Report
Renewal
Census: 38
Deficiencies: 4
Date: Feb 24, 2025
Visit Reason
The inspection was a renewal inspection conducted to evaluate compliance with applicable standards and laws for Woods Cove Assisted Living.
Findings
The inspection identified non-compliance with several standards including failure to provide staff with current job descriptions, incomplete work schedules lacking designation of person-in-charge, lack of registration with the Virginia Department of State Police for sex offender notifications, and failure to post the weekly meal menu in a conspicuous area.
Deficiencies (4)
Facility failed to ensure that each staff person had received a copy of his or her current job description.
Facility failed to ensure the written work schedule included an indication of who was in charge at any given time.
Facility failed to ensure registration with the Virginia Department of State Police to receive notice of any sex offender within the same or contiguous zip code area.
Facility failed to ensure the menu for meals and snacks for the current week was posted in an area conspicuous to residents.
Report Facts
Number of residents present: 38
Number of resident records reviewed: 4
Number of staff records reviewed: 4
Number of staff records partially reviewed: 1
Number of resident interviews conducted: 1
Number of staff interviews conducted: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill James | Licensing Inspector | Current inspector conducting the inspection |
| Staff 1 | Acknowledged deficiencies related to job descriptions, work schedule, and VDSP registration | |
| Staff 2 | Staff record reviewed; lacked signed job description | |
| Staff 3 | Staff record reviewed; lacked signed job description | |
| Staff 6 | Staff record reviewed; lacked signed job description | |
| Staff 7 | Acknowledged facility practice regarding meal menu posting |
Inspection Report
Monitoring
Census: 41
Deficiencies: 7
Date: Jun 7, 2024
Visit Reason
The inspection was a monitoring visit to review compliance with various assisted living facility regulations including personnel, staffing, resident care, emergency preparedness, and background checks.
Findings
The inspection found multiple violations including failure to post the current on-site person in charge, incomplete annual uniform assessment instruments for residents, failure to post the weekly menu correctly, lack of biannual dietary oversight, non-operational resident signaling devices, an outdated fire inspection, and insufficient emergency water supply.
Deficiencies (7)
Facility failed to post the name of the current on-site person in charge conspicuously.
Facility did not ensure updated uniform assessment instruments were completed annually for residents.
Facility failed to post the weekly menu with meals and snacks for the current week.
Facility failed to ensure dietary oversight was conducted every six months by a dietitian or nutritionist.
Facility failed to ensure signaling devices in resident rooms were operational and connected to a continuously staffed central location.
Facility failed to ensure the annual fire inspection was completed and current.
Facility failed to ensure availability of a 96-hour supply of emergency drinking water with at least 48 hours on site.
Report Facts
Number of residents present: 41
Number of resident records reviewed: 2
Number of staff records reviewed: 3
Number of interviews with residents: 1
Number of interviews with staff: 2
Date of last fire inspection: Jun 16, 2022
Dates of dietary oversight: 2023-03-13 and 2024-05-21
Date of last UAI for Resident 1: Apr 28, 2023
Date of last UAI for Resident 4: Apr 27, 2023
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 0
Date: Mar 27, 2024
Visit Reason
The inspection was conducted as a complaint investigation to determine compliance with standards or laws based on an allegation.
Complaint Details
The inspection was complaint-related. The evidence did not substantiate the allegation of non-compliance.
Findings
The evidence gathered during the investigation did not support the allegation of non-compliance with standards or law. No deficiencies were cited.
Inspection Report
Renewal
Census: 43
Deficiencies: 2
Date: Mar 16, 2023
Visit Reason
The inspection was a renewal inspection conducted to assess compliance with applicable standards and regulations for Woods Cove Assisted Living.
Findings
The inspection found much improvement in medication management and documentation. Two violations were documented related to staff job descriptions and annual resident rights review. Previously identified issues had been corrected.
Deficiencies (2)
One medication tech and three direct care staff did not have job descriptions; two direct care staff lacked complete orientation documentation within required time.
One staff member who worked over one year had not had their annual resident rights review; three new staff had no documentation of resident rights review.
Report Facts
Number of residents present: 43
Number of resident records reviewed: 7
Number of staff records reviewed: 5
Number of resident interviews conducted: 3
Number of staff interviews conducted: 2
Inspection Report
Monitoring
Census: 46
Deficiencies: 5
Date: Mar 16, 2022
Visit Reason
An unannounced monitoring inspection was conducted to review compliance with regulations related to medication administration and management, staff records, staff training, resident admission records, and service plans.
Findings
Five areas of noncompliance were identified involving medication administration and management, staff records, staff training, resident admission records, and service plans. The facility is undergoing remodeling and has a new administrator who started a week prior to the inspection.
Deficiencies (5)
Staff A and D did not have 10 hours of training in cognitive impairment within the first four months or first year of employment; Staff B and C had less than one hour of documented training related to cognitive impairments; mental health and behavior management training requirements were not met for any staff.
Staff B and C records missing signed orientation, CPR/First Aid completion within 60 days, and timely background checks.
Resident records missing agreements, disclosures, resident rights documentation, fall assessments, physical or TB exams, serious cognitive impairment forms, and documentation of resident orientation.
Resident C did not have a comprehensive service plan; Resident D's service plan lacked special diet directions and was not reviewed after six months; Resident O's service plan did not address multiple medications given for stealing as a sign of anxiety.
Medication administration records showed multiple violations including medication not available, self-administration without order, missed dosages, incorrect administration timing and order, failure to contact physician for refusals, missing orders, and inadequate documentation.
Report Facts
Staff records reviewed: 4
Resident records reviewed: 5
Medication administration records reviewed: 12
Facility census: 46
Inspection Report
Renewal
Census: 40
Deficiencies: 2
Date: Feb 25, 2021
Visit Reason
A renewal inspection was initiated on February 25, 2021 and concluded on March 11, 2021 to assess compliance with applicable standards and laws for Woods Cove Assisted Living.
Findings
The inspection identified non-compliance with two applicable standards related to medication administration and documentation. Violations were documented and reviewed with the administrator and assistant director.
Deficiencies (2)
Resident J has an order for Lantus 22 units at bedtime and Lispro insulin 10 units with breakfast without parameters for holding medication; documentation did not follow physician's order.
Resident H has an order for application of a salonpas each morning and removal each night, but documentation indicates refusals and inconsistent staff initials without explanation.
Report Facts
Inspection duration days: 15
Resident census: 40
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