Virginia DSS · Assisted Living Facility

Mennowood Retirement Community

📍 13030 Warwick Blvd., Newport News, VA, 23602

ID 21078One Year licenseActive
8
Inspections
On record
5
With violations
Visits that cited something
3
Clean visits
Nothing cited
22
Violations cited
Individual findings
18
Standards cited
Distinct rules
2
Complaint visits
Prompted by a complaint

Mennowood Retirement Community was inspected 8 times between June 26, 2020 and May 20, 2026 by the Virginia Department of Social Services. 5 of those visits ended with violations cited and 3 with none. Across that history VDSS cited 22 violations under 18 distinct standards. 2 inspections were prompted by a complaint.

A violation is a licensing standard - a rule in the Virginia Administrative Code - that the inspector found the facility was not meeting. Each is shown with the evidence the inspector recorded and, where VDSS publishes it, the facility's own plan of correction.

VDSS publishes inspections on a rolling window. 6 of these 8 are still on the state's site; the other 2 have since dropped off it and are reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type
Assisted Living Facility
License type
One Year
License expires
06/16/2026
Administrator
Thelma Shaffer
Licensing inspector
Alyshia Walker
Inspector phone
(757) 670-0504
Approved for
Special Care Unit · Non-Ambulatory · Assisted Living

Inspection History

8

Select an inspection to read the areas reviewed, the inspector's comments and any violations cited.

May 20, 2026Inspection7 violations
Inspection dates
05/20/2026,05/22/2026
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE
Comments
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: 5/20/2026 8:30 am- 4:30 pm, 5/22/2026 9:00 am- 5:44 pm 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: 60 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 9 Number of staff records reviewed: 5 Number of interviews conducted with residents:4 Number of interviews conducted with staff: 8 Observations by licensing inspector: Additional Comments/Discussion: 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. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). 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 these 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. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. 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 Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Violations
22VAC40-73-440-A
Based on a review of resident records, the facility failed to ensure that the Uniform Assessment Instrument (UAI) shall be completed prior to admission, at least annually, and whenever there is a significant change in the resident's condition.
Evidence
  1. The UAI for Resident #7 dated 4/14/2026 assessed the resident’s behavior as appropriate. Progress notes in the resident’s record dated 7/5/2025, 7/27/2025, 8/9/2025, 11/13/2025, 2/4/2026, 3/3/2026, 4/19/2026, and 5/1/2026 documented instances of the resident yelling and acting aggressively towards staff.
  2. Photographic evidence obtained during the inspection.
Plan of correction
Corrective Action: Director of Nursing corrected and documented behaviors on care plan for Resident #7. Resident’s UAI & ISP was corrected. How to Identify: Director of Nursing or designee will audit PCC to ensure behaviors are care planned and documented on resident’s ISP. Systemic Changes: Director of Nursing or designee will audit documentation of behaviors are done at time of admission/annual care plan meeting or significant changes to ensure they are documented. Monitoring Process[ls2.1]: During the six-month oversite visit. Charts will be reviewed by the RN.
22VAC40-73-860-G
Based on observation and staff and resident interviews, the facility failed to ensure the hot water taps available to residents shall be maintained within a range of 105 degrees Fahrenheit (F) to 120 degrees F.
Evidence
  1. During the inspection of the facility between 3:20 pm and 4:00 pm with Staff #3, the hot water temperature in three resident rooms was tested. In resident room #108, Staff #3 ran the hot water for over 15 minutes. The hot water never reached 105 degrees Fahrenheit. The water was tested in the resident’s bathroom and kitchen sinks. The hottest temperature was 100.5 degrees Fahrenheit. The resident stated she must start running the water at 3:30 am to have warm water for the shower.
  2. Staff #3 acknowledged the water temperature in room #108 did not reach 105 degrees. Fahrenheit and that the water in the other rooms took a long time to get hot.
Plan of correction
Corrective Action: Maintenance Director or designee will fix the valves to ensure water temperature checked in all rooms, kitchen and common areas are within range. How to Identify: Maintenance Director or designee will do a room inspection weekly to determine the problem. Systemic Changes: Maintenance Director or designee will monitor the rooms, kitchen and common area temperatures. Monitoring Process: Maintenance Director or designee will do a complete water temperature check in rooms, kitchen and common areas. Water valves to be replaced.
22VAC40-73-460-D
Based on resident record review and staff interviews, the facility failed to ensure supervision of specialized needs such as wandering.
Evidence
  1. Resident #5 has resided on the safe, secure unit since 2/23/2026.
  2. The UAI dated 3/23/2026 assessed Resident #5’s behavior pattern as wandering/passive weekly or more and disoriented to some spheres, some of the time.
  3. The ISP for Resident #5 dated 3/23/2026 states, “The resident is a risk for elopement due to wandering. Provide frequent checks for safety, redirection and one on one conversations for detraction.”
  4. The Progress note for Resident # 5 dated 5/10/2026 documented, “The fire alarm was set off, and the resident walked down the stairs to the lobby. Staff and firefighters quickly assisted the resident back to her unit. No further issues noted.”
  5. Interviews conducted with staff (Staff #2, #9, # 10, #11, #12, #13) assigned to both the safe, secure unit and the assisted living area of the facility indicated that the resident was able to exit the secure unit when the fire alarm was activated. Upon activation of the alarm, the doors to the safe, secure unit automatically unlocked, and staff did not observe the resident leaving the unit. Staff on the secure unit were first made aware of the resident’s absence when firefighters and assisted living staff returned the resident to the unit. It is estimated by facility staff that the resident was off the unit for approximately ten minutes.
Plan of correction
Corrective Action: Staff were immediately educated that when the fire alarm goes off the doors on the unit is unlock. The staff is to immediately make sure that the residents are accounted for to ensure no one has left the floor. How to Identify: Nursing staff on memory care floor will ensure that all residents are accounted for during fire alarms. Systemic Changes: Educate all new staff and other staff annually of risks of residents leaving the floor on memory care. Monitoring Process: Drills will be completed monthly to ensure staff know what to do. ED to ensure monthly audits are completed.
22VAC40-73-450-E
Based on resident record review, the facility failed to have the Individualized Service Plan (ISP) signed and dated by the resident or his legal representative.
Evidence
  1. The annual review of the ISP for Resident #6 dated 11/12/2025 did not contain a resident or resident’s representative signature.
  2. The annual review of the ISP for Resident #4 dated 10/7/2025 did not contain a resident or resident’s representative signature.
  3. Staff #2 acknowledged the ISP did not contain resident or resident’s representative signatures.
  4. Photographic evidence obtained during the inspection.
Plan of correction
Corrective Action: ISP’s will be signed at the time of care plan meeting or documentation of telephone or zoom meetings. If unable to obtain signature an email will be sent and/or documentation will be noted. Email was sent to Resident #6, but POA has not responded. How to Identify: Director of Nursing or designee will audit charts and obtain signatures on ISP’s that are missing. Systemic Changes: Director of Nursing or designee will monitor and assure care plans have signatures upon completion of meeting with resident/family members. Monitoring Process: Director of Nursing or designee will ensure signatures are on ISP’s checking the ISP’s monthly.
22VAC40-73-325-B
Based on a review of resident records, the facility failed to ensure that a fall risk rating shall be reviewed and updated after a fall.
Evidence
  1. The Progress notes for Resident #8 documented falls on 10/18/2025 and 10/21/2025. There were no fall risk assessments for the documented falls presented to the Licensing Inspector to review during the inspection.
  2. Photographic evidence was taken during the inspection.
Plan of correction
Corrective Action: Director of nursing or designee will do a current fall risk on resident #8 to ensure adequate care. How to Identify: Director of nursing or designee will do an audit of falls to ensure a fall risk assessment was completed. Systemic Changes: Director of nursing or designee will monitor falls weekly to ensure that proper fall risk documentation is completed. Monitoring Process: Director of nursing or designee will make sure that the proper assessments are completed weekly. ED to meet weekly with DON to go over fall assessments.
22VAC40-73-860-F
Based on observation and staff and resident interviews, the facility failed to supply ample hot and cold water from an approved source available to the residents at all times.
Evidence
  1. The Licensing Inspector tested the hot water in two resident bedrooms rooms with Staff #3. The hot water for each of the rooms eventually reached 105 degrees Fahrenheit, only after the water ran for over 10 minutes with both the bathroom and kitchen sinks running simultaneously.
  2. The Licensing Inspector interviewed the residents who acknowledged having difficulty with getting hot water in their rooms and that they reported the concern to staff previously.
Plan of correction
Corrective Action: Maintenance Director and local plumber will change the water valves to correct the water temperature issue in resident rooms. How to Identify: Maintenance Director or designee will make sure room water temperatures are checked monthly. Systemic Changes: Maintenance Director or designee will monitor the water temperatures weekly for the first month and monthly after problem is fixed. Monitoring Process: [ls1.1]Maintenance Director or designee will do a complete water temperature check using a temperature gauge in rooms, kitchen, and common areas weekly and then continue to do monthly random audits of resident rooms and common areas.
22VAC40-73-450-F
Based on a review or resident records and interviews with staff, the facility failed to ensure that individualized service plans shall be reviewed and updated at least once every 12 months and as needed for a significant change of a resident’s condition.
Evidence
  1. Resident #3 has been prescribed an antidepressant for depression prior to admission on 12/29/2025. The ISP for Resident #3 does not address the resident’s depression.
  2. Resident #4 receives speech therapy. The ISP for Resident #4 dated 10/07/2025 was not updated to reflect the speech therapy the resident is receiving.
  3. Staff #2 acknowledged the residents’ ISP did not reflect the needs.
  4. Photographic evidence obtained during the inspection.
Plan of correction
Corrective Action: The ISP was correct on resident #3 to include a depression diagnosis with a prescribed medication. Resident #4’ ISP was updated to reflect speech therapy. How to Identify: The Director of Nursing or designee will audit charts to ensure ISP’s match the resident’s needs and care. Systemic Changes: Director of Nursing or designee will ensure that the ISP’s match the care needs of current residents when due for annual review. Monitoring Process: During annual reviews or status changes the Director of Nursing or designee will ensure that ISP’s match resident’s care and treatment plan
March 24, 2025Inspection6 violations
Inspection dates
03/24/2025,03/25/2025
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Renewal An unannounced mandated renewal inspection was conducted on 3-24-25 (Ar. 07:15 a.m./dep 17:30 p.m.). Day 2, 3-25-25 (Ar. 11:53 a.m./dep 15:55 p.m.) 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: 66 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Yes Number of resident records reviewed: 7 Number of staff records reviewed: 4 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 8 Observations by licensing inspector: medication pass observation scu and assisted living units; emergency preparedness, first aid kit, breakfast meal, activity and water temps/ signaling- call bell checks. Additional Comments/Discussion: 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 (Willie Barnes), Licensing Inspector at (757)-439-6815 or by email at willie.barnes@dss.virginia.gov
Violations
22VAC40-73-660-B
Based on policy reviewed and staff and resident interviewed, the facility failed to ensure a resident permitted to keep medication in an -out of sight place in resident’s room was in compliance with the regulations and the facility’s self-administering policy.
Evidence
  1. On 3-24-25, resident #6 is assessed as being able to self-administer medications and keep medication in room. The facility’s “NF-110 Resident Medication Self-Administration Evaluation Form”, noted the resident is required to comply with regulation regarding the storage of medications. The medications in resident #6’s room were not stored in locked container or out of sight. The cabinet where some medications were stored was not locked. Medications were also observed on the dining table in various containers and a weekly pill container. Resident #6 stated keeping some medications on the table so that they were nearby when needed.
  2. Staff #1 and #2 acknowledged the aforementioned resident’s medication were to be stored in a locked area/container in the resident’s room.
Plan of correction
I. Corrective Action: Self-Administered residents will be educated on keeping medications locked. Resident# 6 was educated on the day of observation regarding keeping medicines stored in locked container and out of sight. Locks were replaced on her cabinet immediately. II. How to Identify: Director of Nursing or designee will do an audit of all the rooms to ensure that all medications are locked and secured. Ill. Systemic Changes: Staff will monitor daily that medications are kept in a locked area. IV. Monitoring Process: Director of Nursing and or designee will ensure that an audit will be done monthly to make sure medications are kept in a secure location. VI. Completion Date: May 1, 2025
22VAC40-73-680-M
Based on record reviewed, staff interviewed and observation, the facility failed to ensure that medications ordered for PRN (as needed) administration shall be available, properly labeled for the specific resident, and properly stored at the facility.
Evidence
  1. On 3-24-25, resident #2’s PRN Dental paste was not available on the medication cart during the medication cart check with staff #4.
  2. Resident #3’s PRN Zofran was not available on the medication cart during the medication cart check with staff #3.
  3. Staff #3 and #4 acknowledged the aforementioned residents’ PRN medication was not available, properly labeled and stored at the facility on 3-24-25.
Plan of correction
I. Corrective Action: Resident# 2 PRN dental paste was d/c'd immediately Resident# 3 was ordered immediately and delivered by pharmacy. II. How to Identify: Director of Nursing or designee will do an audit of all PRN medications for availability. Ill. Systemic Changes: Director of Nursing or designee will do weekly audits of all medications to ensure availability. IV. Monitoring Process: Director of Nursing or designee will ensure completion of audits are done within 30 days and then weekly thereafter. V. Completion Date: May 1, 2025
22VAC40-73-450-C
Based on record reviewed and staff interviewed, the resident’s individualized service plan (ISP) did not include all the resident’s assessed needs.
Evidence
  1. On 3-24-25, resident #1’s ISP dated 2-28-25 noted the resident is not to received Cardiopulmonary resuscitation (CPR)/ Do Not Resuscitate (DNR). The resident’s physician order dated 2-6-25 noted resident is a full code.
  2. Resident #6’s uniformed assessment instrument (UAI) dated 4-18-24 assessed the resident’s money need as help required. The ISP dated 5-11-24 noted the resident manages own money/self.
  3. Staff #2 acknowledged the residents’ ISP and the assessed need did not agree.
Plan of correction
1. Corrective Action: The ISP was corrected on resident #1 immediately regarding CPR. Resident's# 6 UAI was corrected immediately on the resident's money needing help required. 11. How to Identify: Director of Nursing or designee will audit charts to ensure ISP's match physicians orders and ISP matches Uniform Assessment Form. 111. Systemic Changes: Director of Nursing or designee will monitor during annual reviews or status changes to ensure UAI and ISP will be updated as a match. IV. Monitoring Process: During annual reviews or status changes the Director of Nursing or designee will ensure that ISP's match physician's order and UAI. V. Completion Date: May 1, 2025
22VAC40-73-650-A
Based on observation and staff interviewed, the facility failed to ensure no medication, dietary supplement, diet, medical procedure, or treatment was started, changed, or discontinued by the facility without a valid order from a physician or other prescriber. Medications include prescription, over-the-counter, and sample medications.
Evidence
  1. On 3-24-25, during a tour of the facility, water temperature and call bell check with staff #8, Refresh Tears eyedrops and Muscle Cramps foam were observed on the resident #8’s nightstand. The resident stated taking only two medications.
  2. According to staff #2, the resident did not have a physician’s order for the Refresh Tear eyedrops located in the room.
Plan of correction
This Plan of Correction is not to be construed as an admission of or agreement with the findings and conclusions in the Statement of Deficiencies, or the proposed administrative penalty (with the right to correct) on the community. Rather, it is submitted as confirmation of our ongoing efforts to comply with all statutory and regulatory requirements. In this document, we have outlined specific actions in response to each allegation or finding. We have not presented all contrary factual or legal arguments, nor have we identified all mitigating factors. I. Corrective Action: Over the counter medication, Refresh tears were removed until order could be obtained. II. How to Identify: Director of Nursing or designee will do a complete of all of assisted living apartments to ensure no medications are in the apartments without orders. Ill. Systemic Changes: Director of Nursing or designee will conduct monthly apartment checks for medications in rooms without orders. The administrator has sent a letter to families letting them know that all medications need to be brought to Manager on Duty or Director of Nursing including over the counter medications . There are to be no prescription medications in apartments or OTC without MD orders and appropriate assessment completed by DON. Care staff will be in-serviced on doing room checks and reporting accordingly on a daily basis. IV. Monitoring Process: Director of Nursing will ensure monthly sweeps will be completed of all apartments. II. Completion Date: May 1, 2025
22VAC40-73-380-B
Based on record reviewed and staff interviewed, the facility failed to ensure the resident’s personal and social data information was kept updated.
Evidence
  1. On 3-24-25, resident #1’s physician’s order dated 2-6-25 noted the resident is a full code. The resident’s personal and social data form noted the resident had a Do Not Resuscitate (DNR).
  2. Staff #2 acknowledged the resident’s personal and social data document was not updated.
Plan of correction
I. Corrective Action: Social data form was updated to match POS as resident was a full code. II. How to Identify: Director of nursing or designee will do an audit of residents' charts to make sure Resident Social Data matches medical information. Ill. Systemic Changes: Director of Nursing or designee will monitor new DNR orders and data on Social Data form. IV. Monitoring Process: Director of Nursing or designee will ensure completion of audits are done within 30 days of admission. Director of Nursing or designee will audit new files monthly for two months then ongoing as needed. Nursing staff will be made aware of any code status and MD information changes as social data forms are updated. V. Completion Date: May 1, 2025
22VAC40-73-450-E
Based on record reviewed and staff interviewed, the facility failed to ensure the resident’s individualized service plan (ISP) was signed and dated following the update by the resident, and/or legal representative.
Evidence
  1. On 3-24-25, resident #3, ISP was updated on 10-3-24. This ISP was not signed and dated by the resident and/or legal representative.
  2. Staff #2 acknowledged the resident’s updated ISP was not signed and dated by the resident/or legal representative.
Plan of correction
I. Corrective Action: ISP's will be signed and dated by resident/POA whenever there is an update required. II. How to Identify: Director of Nursing or designee will audit charts and obtain any necessary signatures on ISP's. Ill. Systemic Changes: Director of Nursing or designee will ensure ISP's are signed upon any updates that are noted. IV. Monitoring Process: During the six-month oversite visit. Charts will be reviewed by the RN. V. Completion Date: May 1, 2025
March 11, 2024Complaint survey0 violations
Inspection dates
03/11/2024;03/12/2024
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint An unannounced on-site complaint inspection was conducted on 3-11-2024 and 3-12-2024. 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 3-1-24 regarding allegations in the area of resident care and building and grounds. Number of residents present at the facility at the beginning of the inspection: 69 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Yes Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: call bell response observed 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 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 (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
March 11, 2024Inspection2 violations
Inspection dates
03/11/2024;03/12/2024
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Monitoring An unannounced on-site complaint inspection was conducted on 3-11-2024 by two inspectors from the Peninsula Licensing Office. (Ar 08:05 a.m./dep 16:45 p.m). The census was 69. Day two, one inspector (Ar 09:06 a.m./dep 12:25 p.m.) The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov
Violations
22VAC40-73-100-C-2
Based on observation and staff interviewed, the facility failed to ensure the blood glucose monitoring practices were consistent with CDC recommendations.
Evidence
  1. On 3-11-24 during the medication pass observed in the safe, secure unit with staff #3, resident #9’s glucometer was observed to not have a label.
  2. Staff #3 acknowledged the resident’s glucometer was not labeled.
Plan of correction
I. Corrective Action: Glucometer was labeled the day it was identified. II. How to Identify: Weekly cart audits to include verifying glucometer and storage container are both labeled with resident’s name. III. Systemic Changes: Director of nursing or designee will complete weekly audit. IV. Monitoring Process: Director of Nursing or designee will ensure completion of audits are done within 30 days of admission. V. Completion Date: April 31, 2024
22VAC40-73-450-E
Based on record reviewed and staff interviewed, the facility failed to ensure that the individualized service plan (ISP) was signed and dated by the licensee, administrator, or his designee, and by the resident or the legal representative.
Evidence
  1. On 3-11-24, resident #1’s ISP dated 10-18-23 was not signed and dated by the resident or the legal representative.
  2. Resident #2’s ISP dated 2-8-24 was not signed and dated by resident or the legal representative.
  3. Staff #1 and #2 acknowledged, the residents’ ISP was not signed and dated by the resident or legal representative.
Plan of correction
I. Corrective Action: Care plans will be signed at the time of care plan meeting or documentation of telephone or zoom meetings. If unable to obtain signature an email will be sent and/or documentation will be noted. II. How to Identify: Complete a chart audit to identify care plans with missing signatures and obtain signatures as warranted. III. Systemic Changes: Director of Nursing or designee will monitor and assure care plans have signatures upon completion of meeting with resident/family members. IV. Monitoring Process: The Ed and/or designee will ensure signatures are on care plans or documentation acquired. V. Completion Date: April 31, 2024
March 14, 2023Inspection3 violations
Inspection dates
03/14/2023,03/17/2023,03/22/2023
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Renewal An unannounced on-site renewal inspection was conducted on 3-14-23 (Ar 08:35 a.m./dep 3:45 p.m) and 3-17-23 (Ar 09:00 a.m./dep 3:45 p.m.). The facility census on day 1 was 93. A tour of the facility was conducted, staff and resident interviews, resident records reviewed and medication pass observation was conducted. A review of staff records and resident records were conducted on day 2. Emergency preparedness documents and internal audit documents were reviewed. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov
Violations
22VAC40-73-450-E
Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) was signed and dated by the licensee, administrator, or his designee and by the resident or the legal representative for three of ten records reviewed.
Evidence
  1. On 3-14-23, resident #1’s ISP dated 10-17-22, resident #2’s ISP dated 3-7-23 and resident #5’s ISP dated 2-27-23 were not signed and dated by the resident or the legal representative.
  2. Staff #2 acknowledged the ISPs were not signed and dated by the resident and/or legal representative.
Plan of correction
I. Corrective Action: Care plans will be signed at the time of care plan meeting or documentation of telephone or zoom meetings. If unable to obtain signature an email will be sent and/or documentation will be noted. II. How to Identify: Director of Nursing or designee will audit charts and obtain signatures on care plans. III. Systemic Changes: Director of Nursing or designee will monitor and assure care plans have signatures upon completion of meeting with resident/family members. IV. Monitoring Process: Director of Nursing or designee will ensure signatures are on care plans or documentation acquired. V. Completion Date: April 31, 2023
22VAC40-73-860-G
Based on observations and staff interviewed, the facility failed to ensure hot water at taps available to residents was maintained within a range of 105 degrees Fahrenheit (F) to 120 degrees F.
Evidence
  1. On 3-14-23, during a tour of the facility with staff #8, the water temperature in the bathroom in room #105 was 121 degrees F and the temperature in the kitchen was 123 degrees F.
  2. Staff #8 acknowledged the water temperatures were outside the required range.
Plan of correction
I. Corrective Action: Maintenance Director or designee will do a complete water temperature check in all rooms, kitchen, and common areas. II. How to Identify: Maintenance Director or designee will make sure rooms closest to the water heaters are checked monthly. III. Systemic Changes: Maintenance Director will create a log of rooms, kitchen, and common area temperatures. IV. Monitoring Process: Maintenance Director or designee will do a complete water temperature check in rooms, kitchen, and common areas and then continue to do monthly random audits of resident rooms and common areas. V. Completion Date: April 31, 2023
22VAC40-73-310-H
Based on record reviewed and staff interviewed, the facility failed to ensure in accordance with 63.2-1805 D Code of Virginia, it did not admit or retain individuals with any prohibitive conditions with required documentation for a resident.
Evidence
  1. On 3-14-23, resident #6’s record documented resident administered Zoloft. The resident’s current physical order sheet (POS) in the record noted the medication start date was noted as 9-20-22. The record did not include a psychotropic treatment plan for this medication.
  2. Staff #2 acknowledged the record did not include a psychotropic treatment plan.
Plan of correction
I. Corrective Action: Physician Order for the Psychopharmacologic medication treatment plan for resident #6 was corrected. II. How to Identify: Director of nursing or designee will do an audit of resident charts to make sure the medication treatment plan aligns with the physician order sheet. III. Systemic Changes: Director of Nursing or designee will monitor new orders and psychotropic treatment plan and treatment established. IV. Monitoring Process: Director of Nursing or designee will ensure completion of audits are done within 30 days of admission. Director of Nursing or designee will audit new files monthly for two months then ongoing as needed. Nursing staff will be in-service on the psychotropic treatment plans. V. Completion Date: April 31, 2023
June 9, 2022Inspection4 violations
Inspection dates
06/09/2022, 06/16/2022
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
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: 06/09/2022 from 9:23am to 3:10pm and 06/16/2022 from 8:25am to 9:47am. 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: 72 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 9 Number of staff records reviewed: 5 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Violations
22VAC40-90-40-B
Based on record review and discussion, the facility failed to obtain a criminal history record report on or prior to the 30th day of employment for each employee.
Evidence
  1. Staff #7, Staff #9, and Staff #10 do not have a completed criminal history record reports through the Virginia State Police.
  2. Staff #6 acknowledged the facility did not obtain a criminal history record reports within the required timeframe through the Virginia State Police.
Plan of correction
Staff #7, Staff #9 and Staff #10 criminal checks were redone. Business office manager or designee will do an audit of all employee files for compliance of criminal checks for employees. Business Office Manager or designee to monitor and log each new hire for completion of background check. Business Office Manager or designee will ensure completion of background checks are done on all new hires within 30 days of hire. BOM or designee will audit new files monthly for two months then ongoing as needed.
22VAC40-73-250-C
Based on record review and discussion, the facility failed to maintain personal and social data on staff to include verification that the staff person has received a copy of his current job description.
Evidence
  1. Staff #4 started a new role effective 05/02/2022; however, the record for Staff #4 did not include verification that the staff person has received a copy of his current job description.
  2. Staff #6 acknowledged the record did not include the missing item.
Plan of correction
Job description was immediately signed and placed in file. Business Office Manager will audit all employee files to ensure signed for job descriptions are in place. Business Office Manager or designee will complete log on each new hire to ensure compliance. Business Office Manager or designee will continue to do monthly audits of all new hire files for two months and then ongoing as needed.
22VAC40-73-260-A
Based on record review, the facility failed to ensure each direct care staff member maintain current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department.
Evidence
  1. Staff #5 works as direct care staff and does not have a current certification in first aid.
Plan of correction
Employee to complete First Aid training by August 30, 2022 Business Office Manager to monitor and log each new hire for completion of First Aid Training. Business Office Manager to ensure staff upon hire attend First Aid Training within first 60 days of employment. Business Office Manager/designee will conduct a monthly audit of employees files for current First Aid certificate for two months then ongoing as need to ensure compliance.
22VAC40-73-1090-A
Based on record review and interview, the facility failed to ensure prior to admission to a safe, secure environment, residents have been assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare.
Evidence
  1. Resident #4 admitted to the safe, secure environment on 4/15/2021; however, the Physician Assessment of Serious Cognitive Impairment for Admission to Memory Care Center completed was not dated.
  2. Staff #6 acknowledged the assessment for Resident #4 was not dated to ensure it was completed prior to admission.
Plan of correction
Physician dated form with the date that he assessed the resident for the Memory Care floor. Admissions/Marketing will audit all memory care files. Admissions/Marketing to ensure Cognitive Impairment form is signed and dated prior to admission will have DON to review completed assessment for accuracy prior to admitting resident to the secured unit. Admissions/Marketing Director or designee to audit Memory Care resident admission files monthly for two months and then ongoing as need to ensure accuracy and compliance.
June 15, 2021Inspection0 violations
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS22VAC40-73 EMERGENCY PREPAREDNESS
Comments
The inspection was conducted by Licensing Staff using alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 06/21/2021 and concluded on 06/21/2021. The director or in-charge person was contacted by telephone to initiate the inspection. The inspector reviewed 3 resident and 3 staff records and additional documentation provided by the facility to ensure compliance. The information gathered during the inspection determined no violations with applicable standards or law. no violations were issued.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
June 26, 2020Complaint survey0 violations
Inspection dates
June 26, 2020 , Sept. 14, 2020 and Nov. 9, 2020
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS
Comments
This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A complaint inspection was initiated on 06/26/2020 and concluded on 11/09/2020. A complaint was received by the department regarding allegations in the areas of 22VAC40-73-(7) RESIDENT ACCOMODATIONS AND RELATED PROVISIONS and 22VAC40-73-(6) RESIDENT CARE AND RELATED SERVICES . The Administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the Administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standards or law.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.