11
Inspections
On record
7
With violations
Visits that cited something
4
Clean visits
Nothing cited
8
Violations cited
Individual findings
7
Standards cited
Distinct rules
3
Complaint visits
Prompted by a complaint

Discovery Commons Virginia Beach was inspected 11 times between November 8, 2021 and November 10, 2025 by the Virginia Department of Social Services. 7 of those visits ended with violations cited and 4 with none. Across that history VDSS cited 8 violations under 7 distinct standards. 3 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.

Every inspection listed here is currently published on the VDSS site.

Provider Information

Facility type
Assisted Living Facility
License type
One Year
License expires
11/11/2026
Administrator
Brooke Bravo
Licensing inspector
Lanesha Allen
Inspector phone
757-715-1499
Approved for
Special Care Unit · Assisted Living · Non-Ambulatory

Inspection History

11

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

November 10, 2025Complaint survey0 violations
Inspection dates
11/10/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-80 COMPLAINT INVESTIGATION
Comments
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: 11/10/2025 from 12:15pm-1:00pm. A complaint was received by VDSS Division of Licensing on 9/10/25 regarding allegations in the area(s) of: Resident Care And Related Services, and Resident Accommodations And Related Provisions. 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: 110 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 staff records reviewed:0 Number of interviews conducted with residents:1 Number of interviews conducted with staff: 1 Observations by licensing inspector: Resident interviews were completed for one resident. The following was reviewed: resident record. 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. Should you have any questions, please contact Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at Lanesha.allen@dss.virginia.gov
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
November 10, 2025Complaint survey0 violations
Inspection dates
11/10/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-80 COMPLAINT INVESTIGATION
Comments
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: 11/10/2025 from 11:30am-12:15pm. A complaint was received by VDSS Division of Licensing on 6/29/25 regarding allegations in the area(s) of: Resident Care And Related Services, and Buildings And Ground 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: 110 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed:0 Number of interviews conducted with residents:2 Number of interviews conducted with staff: 1 Observations by licensing inspector: Resident interviews were completed for two residents. The following was reviewed: resident and staff records. 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. Should you have any questions, please contact Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at Lanesha.allen@dss.virginia.gov
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
November 5, 2025Inspection0 violations
Inspection dates
11/05/2025
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 IMPAIRMENTS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS
Technical assistance
Buildings And Ground Emergency Preparedness
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: 11/05/2025 from 09:25am-05:05pm. 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: 110 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed:4 Number of interviews conducted with residents:4 Number of interviews conducted with staff: 5 Observations by licensing inspector: Breakfast, lunch and an activity were observed. A medication pass observation was completed for three residents. The following was reviewed: resident and staff records, 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: 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. Should you have any questions, please contact Lanesha Allen, Licensing Inspector at 757-715-1499 or by email at Lanesha.allen@dss.virginia.gov
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
May 8, 2025Inspection1 violation
Inspection dates
05/08/2025
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/08/2025 from 1:30 pm to 2:25 pm. 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 04/24/2025 regarding allegations in the area(s) of: Personnel and Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 104 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 staff records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. However, violation(s) not related to the self-report 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Violations
22VAC40-73-220-B
Based on interview, the facility failed to meet the requirements listed under subdivisions A 2 through A 6 of this section in addition to the requirements under subdivision B when private duty personnel who are not employees of a licensed home care organization provide direct care or companion services to residents.
Evidence
  1. Resident #1 utilizes private duty personnel who are not employees of a licensed home care organization who provide companion services to Resident #1.
  2. Staff #1 acknowledged and confirmed the facility does not have the requirements listed in the standard for the private duty personnel for Resident #1.
Plan of correction
1. This particular private duty aide was retrained on their duties as a private companion on 4/25/25 by Director of Health and Wellness (DHW) and Executive Director (ED). All current private duty aides who are servicing Discovery Commons Virginia Beach (DCVB) residents will be re-educated on their duties here at DCVB by 5/31/25 by Director of Resident Services (DRS). All staff have been retrained on the duties of all current private duty aides on 5/2/25 by Director of Health and Wellness (DWH) and Director of Resident Services (DRS). ED will audit to ensure compliance by 6/1/25. 2. An audit of all current private duty aide files has been completed as of 5/8/25 and all missing information will be obtained by 5/31/25. This will be completed by DRS and ED will audit to maintain compliance. 3. Going forward, community will ensure that all paperwork is provided prior to start of private duty services which will be overseen by DRS. ED will periodically audit to ensure compliance going forward.
January 14, 2025Inspection1 violation
Inspection dates
01/14/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 01/14/2025 from 10:30 am to 10:52 am. 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 01/08/2025 regarding allegations in the area(s) of: Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 105 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 staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Violations
22VAC40-73-460-D
Based on interview and record review, the facility failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs.
Evidence
  1. On 01/08/2025, Resident #1 went to an appointment at the facility outside of the safe, secure environment.
  2. Following their appointment, Resident #1 was unsupervised and walked to their previous AL apartment.
Plan of correction
Going forward, any outside vendor providing care to residents in Shine will go to shine and perform all services. Shine residents will stay behind the secured doors to prevent any further elopements. Should the family decide to take them outside of SHINE, a family member/SHINE team member will escort them. All staff will be retrained on the expectations of SHINE residents leaving our SHINE neighborhood. Going forward the SHINE Director and/or the Health and Wellness Director, when there is a vendor providing services to our SHINE residents, one or both will verify that services are being provided in our SHINE neighborhood.
November 7, 2024Inspection1 violation
Inspection dates
11/07/2024
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Technical assistance
22VAC40-73-460
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/07/2024 from 8:40 am to 2:12 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Two self-reported incidents were received by VDSS Division of Licensing on 10/15/2024 and 11/02/2024 regarding allegations in the area(s) of: Personnel and Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 95 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 staff records reviewed: 1 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the self-reports; area(s) of non-compliance with standard(s) or law were: Personnel. A violation notice was issued; any violation(s) not related to the self-reports but identified during the course of the investigation can also 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Violations
22VAC40-73-110-1
Based on record review and interview, the facility failed to ensure staff are considerate and respectful of the rights, dignity, and sensitivities of persons who are aged, infirm, or disabled.
Evidence
  1. On 10/12/2024, Staff #2 was verbally aggressive to Resident #1, Resident #2, and Resident #3 while performing care.
Plan of correction
This employee is no longer an employee of Discovery Commons Virginia Beach. All employees were re-trained on resident abuse, mandatory reporting and availability of employee assistance program to help manage stress on 10/17/24. Conduct quarterly abuse trainings for 6 months or until substantial compliance has been achieved by Executive Director. Interview 5% of alert and oriented residents monthly x 3 months or until substantial compliance has been achieved by Executive Director or other representative.
November 7, 2024Inspection1 violation
Inspection dates
11/07/2024
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: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/07/2024 from 8:40 am to 2:12 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: 95 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: 4 Number of interviews conducted with staff: 3 Observations by licensing inspector: Lunch and an activity were observed. A medication pass observation was completed for 4 residents. The following were reviewed: resident and staff records, medication carts, water temperatures, and the call bell system. 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
22VAC40-73-640-A
Based on observation, the facility failed to implement their written plan for medication management which includes methods to prevent the use of outdated medications and plan for proper disposal of medication.
Evidence
  1. The following expired medications were observed in the medication carts at the facility: PRN Cetirizine HCI 10mg tablets expired 09/30/2024 for Resident #4, PRN Acetaminophen 325mg tablets expired 08/31/2024, PRN Furosemide 40mg tablets expired 10/31/2024, PRN Ezetimibe 10mg tablets expired 09/30/2024, and PRN Trazodone Hydrochloride 50 mg tablets expired 09/30/2024 for Resident #9, and 2 cards of PRN Acetaminophen 325mg tablets expired 09/30/2024 and 10/31/2024 for Resident #10.
Plan of correction
The DHW will re-in-service current medication staff regarding existing medication pass protocols and the regulations which require that expired medication be disposed of and/or replaced. The training will be completed by 11/30/2024. New and current resident medication staff will monitor medication expiration dates concerning re-ordering or discontinuing. For the next 90 days the DHW or designee will complete random weekly med pass observations and medication cart audits for regulatory compliance and the Executive Director (ED) will be provided with a report from each weekly med pass observation. After the 90 days DHW or designee will check the carts monthly for expired medications and cart audits on random residents. Compliance concerns will be addressed with the employee and appropriate corrective action will be taken up to termination when warranted.
September 18, 2023Inspection1 violation
Inspection dates
09/18/2023
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: 09/18/2023. 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: 89 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 Observations by licensing inspector: Lunch and an activity were observed. A medication pass observation was completed. The following were reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, and medication carts. Water temperature was measured, and the call bell system was monitored. 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
22VAC40-73-640-A
Based on observation, the facility failed to implement their written plan for medication management which includes methods to prevent the use of outdated medications and plan for proper disposal of medication.
Evidence
  1. The following expired medications were observed in the medication carts at the facility: PRN Melatonin 3 mg tablets expired 09/09/2023 for Resident #3, 9 cards of Acetaminophen 500 mg caplets expired 08/31/2023 for Resident #7, and PRN Cetirizine HCL 10 mg tablets expired 08/31/2023 for Resident #8.
Plan of correction
The DHW will re-in-service current medication staff regarding existing medication pass protocols and the regulations which require that expired medication be disposed of and/or replaced. The training will be completed by 09/30/2023. New and current resident medication staff will monitor medication expiration dates concerning re-ordering or discontinuing. For the next 90 days the DHW or designee will complete random weekly med pass observations and medication cart audits for regulatory compliance and the Executive Director (ED) will be provided a report from each weekly med pass observation. Compliance concerns will be addressed with the employee and appropriate corrective action will be taken up to termination when warranted.
November 15, 2022Complaint survey0 violations
Inspection dates
11/15/2022
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
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: 11/15/2022 from 11:10 am to 12:20 pm. 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 11/09/2022 regarding allegations in the area(s) of: Part VI Resident Care and Related Services. 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 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Violations
No violations cited
The inspector documented no violation of standards at this inspection.
September 27, 2022Inspection1 violation
Inspection dates
09/27/2022, 09/28/2022
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
Technical assistance
The current on-site person in charge should to be posted in conspicuous place to the residents and the public.
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/27/2022 from 9:02 am to 3:53 pm and 09/28/2022 from 7:30 am to 10:00 am. 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: 104 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 Additional Comments/Discussion: LI observed resident council meeting, reviewed medication carts, and reviewed both the building and vehicle first aid kits. 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
22VAC40-73-610-B
Based on observation, the facility failed to ensure menu for meals for the current week are dated and posted in an area conspicuous to residents.
Evidence
  1. At the time of the inspection on 09/27/2022, the menu for 09/27/2022 was observed to be posted outside in the dining room; however, the menu for meals for the current week were not posted in an area conspicuous to residents.
Plan of correction
On 9/27/22 the Director of Culinary Services posted the weekly menu in a conspicuous place. Training will be provided by the Executive Director to the Director of Culinary Services and the Lead Server to assure compliance going forward. This training is to be completed by 10/4/22. The Director of Culinary Services and the Lead Server or designee will assure that the menu is posted appropriately per regulatory standards by this item being placed on the daily checklist for servers. Over the next 90 days, the Executive Director will complete random audits to assure compliance.
November 8, 2021Inspection2 violations
Inspection dates
11/08/2021
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 ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS
Comments
A renewal inspection was initiated on 11-08-2021 and concluded on 12-01-2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 106. The inspector emailed the Administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed 5 resident records, 5 staff records, staff schedule, activity calendar, fire and emergency drills, and menus submitted by the facility to ensure documentation was complete. Two inspectors conducted the on-site portion of the inspection on 12-01-2021. An exit interview was conducted with the Administrator on the date of inspection, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility.
Violations
22VAC40-73-980-B
Based on observation and interview, the facility failed to ensure a completed first aid kit without expired items in a motor vehicle that is used to transport residents.
Evidence
  1. A review of a first aid kit from one of the facility’s vehicles with Staff #7 contained hand cleaner expired 07-2020 and antiseptic wipes expired 12-2019.
  2. Staff #6 and Staff #7 acknowledged these two items were expired and removed from the first aid kit.
Plan of correction
The first aid kits were audited during survey utilizing the First Aid Kit Checklist available at the community. Those items required to be available per regulatory standard are accounted for in each first aid kit. The ED will provide training to the Engage Life Director (ELD) and Drivers on the items that are required to be available in the first aid kit per regulatory standard, and how to appropriately complete the monthly checklist to assure continued compliance. Using a checklist, the ELD or designee will complete a monthly review of the contents of the first aid kits available on the van to assure appropriate contents are available for continued compliance. ED will randomly audit for the next 90 days to monitor continued compliance of the monthly checklist being utilized.
22VAC40-73-450-C
Based on documentation review, the facility failed to ensure the Individualized Service Plan (ISP) included a description of the resident’s identified needs based on the Uniform Assessment Instrument (UAI).
Evidence
  1. Resident #4’s UAI dated 10-11-2021 documented the need of medication administration by professional nursing staff; however, the current ISP dated 10-11-2021 does not address the need.
Plan of correction
ISP for #4 was reviewed by RRD and updated to appropriately reflect this Resident #4 current needs including medication administration. An audit of current residents will be completed by RSD and LGD or designee to ensure that ISP's accurately reflect all residents' needs, and any discrepancies will be corrected at review time. Training will be provided by the Divisional Director of Care to RSD, LGD, RSS, RRD and ED on completing accurate and timely ISPs. For the next 90 days, Executive Director (ED) to check all ISPs after they are updated to ensure they accurately reflect that residents' current needs and any issues will be corrected at time of review.