Heritage Green Assisted Living

Type of inspection: Other Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/16/2025 arrival time: 12:00pm departure time: 1:30pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 11/19/2025 regarding allegations in the area(s) of: 22VAC40-73-(6) RESIDENT CARE AND RELATED SERVICES and 22VAC40-73-(7) RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS Number of residents present at the facility at the beginning of the inspection: 71 Number of resident records reviewed: 2 Number of staff records reviewed: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: Inspector Reviewed Medication Administration Records ( MAR

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/16/2025 Arrival time: 12:00pm Departure time: 1:30pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 11/30/2025 regarding allegations in the area(s) of: 22VAC40-73-(4) STAFFING AND SUPERVISION 22VAC40-73-(5) ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73-(6) RESIDENT CARE AND RELATED SERVICES 22VAC40-73-(7) RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73-(8) BUILDINGS AND GROUND Number of residents present at the facility at the beginning of the inspection: 71 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of interviews conducted with staff: 1 Observations by licensing inspector: Inspector interviewed with facility?s Administrator, observed locked cabinets on the Memory Care Unit where toiletries are located in which only staff has access to utilize the keys to those cabinets. Inspector also reviewed the facility?s monthly pest control invoice for October 2025 and November 2025. Inspector completed a tour of building and grounds which no pest/insect infestation was observed. Inspector also reviewed the staff training for those staff who are equipped to operate Sit to Stand. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Shelby Haskins, Licensing Inspector at (804) 305-4876 or by email at shelby.haskins@dss.virginia.gov. Violation Notice Issued: No A copy of this document will be sent to the licensee/provider for signature. Inspector Name: Shelby Haskins Date Inspection Summary Issued: 1/7/2026

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/02/2025 arrival time 10:45am departure 11:45am The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 06/23/3035 regarding allegations in the area(s) of: 22VAC40-73-(3) PERSONNEL, 22VAC40-73-(4) STAFFING AND SUPERVISION, 22VAC40-73-(6) RESIDENT CARE AND RELATED SERVICES and 22VAC40-80-(G7) COMPLAINT INVESTIGATION Number of residents present at the facility at the beginning of the inspection: 71 Number of staff records reviewed: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: Inspector reviewed staff record and credentials, interviewed Regional Director of Operations along with reviewing the facility?s job description for Residential Care Director. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the (allegation(s)/self of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Shelby Haskins, Licensing Inspector at (804) 305-4876 or by email at shelby.haskins@dss.virginia.gov. Violation Notice Issued: No A copy of this document will be sent to the licensee/provider for signature. Inspector Name: Shelby Haskins Date Inspection Summary Issued: 7/9/2025

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/02/2025 arrival time: 10:45 am departure time: 11:45am The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 06/20/2025 regarding allegations in the area(s) of: 22VAC40-73-(6) RESIDENT CARE AND RELATED SERVICES, 22VAC40-73-(7) RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS and 22VAC40-80-(G7) COMPLAINT INVESTIGATION Number of residents present at the facility at the beginning of the inspection: 71 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: Inspector reviewed resident?s record, resident?s Fall Risk Assessment, nurses notes and resident?s incident report in reference to resident?s fall. Inspector also reviewed the facility?s policy on restraints Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the (allegation(s)/self-report) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Shelby Haskins, Licensing Inspector at (804) 305-4876 or by email at shelby.haskins@dss.virginia.gov. Violation Notice Issued: No A copy of this document will be sent to the licensee/provider for signature. Inspector Name: Shelby Haskins Date Inspection Summary Issued: 7/9/2025

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/30/2025 arrival time: 9:58am departure time: 2:50pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 70 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: Inspector observed a medication pass, water temperature tested, reviewed resident menus and activities calendar, reviewed fire inspection, reviewed health inspection and had a tour of the building and grounds. Inspector also reviewed required liability insurance for the facility. Residents were observed having a cookout that was being held on the facility grounds as well as a Bible study group and residents participating in chair exercises. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Shelby Haskins, Licensing Inspector at (804) 305-4876 or by email at Shelby.haskins@dss.virginia.gov.

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 02/03/2025 Arrival time-11:00am Departure time-12:15pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 12/10/2024 regarding allegations in the area(s) of: 22VAC40-73-(6) Resident Care and Related Services, 22VAC40-73-(7) Resident Accommodations and Related Provisions 22VAC40-73-(8) Buildings and Grounds Number of residents present at the facility at the beginning of the inspection: 68 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of interviews conducted with staff: 3 Observations by licensing inspector: Inspector reviewed the facility?s Direct Care staff schedule for the month of December 2024 (to include December 8, 2024). In reviewing the staff schedule for December 2024, the inspector also noted those staff present for the 12/8/24 morning shift, in addition to staff who called out and the PRN

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/22/2024 arrival time: 10:15am departure 12:05pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint/self-reported incident) was received by VDSS Division of Licensing on 04/22/2024 regarding allegations in the area(s) of: Personnel, Staffing and Supervision, Resident Care and Related Services, Protection of Adults and Reporting, Complaint Investigation Number of residents present at the facility at the beginning of the inspection: 68 Number of resident records reviewed: 9 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. However, violation(s) not related to the complaint but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Shelby Haskins, Licensing Inspector at (804) 305-4876 or by email at Shelby.Haskins@dss.virginia.gov. Violation Notice Issued: Yes A copy of this document will be sent to the licensee/provider for signature. Inspector Name: Shelby Haskins Date Inspection Summary Issued: 5/31/2024

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/10/2024 arrival time 10:05am departure time 3:05pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 70 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 5 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: A tour of the facility was conducted to include inside and outside building grounds. Lunch, weekly menu and resident activities were observed. A medication pass observation was completed. The following was reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, medication carts, fire inspection report, health inspection report, and a staffing schedule. Water temperature was measured, and the call bell system was monitored. Additional Comments/Discussion: Inspector observed some of the residents engaged in an activity acknowledging Mother?s Day. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Shelby Haskins, Licensing Inspector at (804) 305-4876 or by email at Shelby.Haskins@dss.virginia.gov.