Virginia DSS · Assisted Living Facility

Nans Pointe Rehabilitation and Nursing LLC

📍 200 West Constance Road, Suffolk, VA, 23434

ID 50516One Year licenseActive
7
Inspections
On record
5
With violations
Visits that cited something
2
Clean visits
Nothing cited
23
Violations cited
Individual findings
21
Standards cited
Distinct rules
2
Complaint visits
Prompted by a complaint

Nans Pointe Rehabilitation and Nursing LLC was inspected 7 times between April 2, 2024 and January 14, 2026 by the Virginia Department of Social Services. 5 of those visits ended with violations cited and 2 with none. Across that history VDSS cited 23 violations under 21 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.

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

Provider Information

Facility type
Assisted Living Facility
License type
One Year
License expires
10/31/2026
Administrator
Christopher Calloway
Licensing inspector
Donesia Peoples
Inspector phone
757 353-0430
Approved for
Non-Ambulatory · Assisted Living

Inspection History

7

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

January 14, 2026Complaint survey0 violations
Inspection dates
01/14/2026
Areas reviewed
22VAC40-73 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 GROUND22VAC40-80 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: An unannounced complaint inspection took place on 01/14/2026 at 9:45 am to 11:40 am. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 12/10/2025 regarding allegations in the area of: Resident Care and Related Services/ Number of residents present at the facility at the beginning of the inspection: The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 0 Number of interviews conducted with residents:1 Number of interviews conducted with staff: 2 Observations by licensing inspector: Residents were observed in the dining area. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the (allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-353-0430or by email at donesia.peoples@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
October 2, 2025Inspection6 violations
Inspection dates
10/02/2025
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 PREPAREDNESS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE
Technical assistance
22VAC40-73-520-I Activity and recreational requirement 22VAC40-73-950-F Emergency preparedness and response plan.
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: An unannounced renewal inspection took place on 10/02/2025 at 8:15 am to 12:25 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: 16 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 2 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 5 Observations by licensing inspector: An observation of breakfast was completed. A medication pass observation was completed with 2 residents. A review of the facility’s staffing schedule was completed. The call signaling system was monitored and the water temperature was measured. Additional Comments/Discussion: None 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 Donesia Peoples, Licensing Inspector at (757) 353-0430 or by email at Donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-320-A
Based on the record review and staff interview the facility failed to ensure within 30 days preceding admission, a person shall have a physical examination by an independent physician. The report of such examination shall be on file at the assisted living facility and shall contain the following: Results of a risk assessment documenting the absence of tuberculosis (TB) in a communicable form as
Evidence
  1. d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence:
  2. The record for resident #1 admission date of 07/19/25, does not contain documentation of the results of a risk assessment for TB that was completed within 30 days prior to the resident’s admission. Resident #1’s risk assessment for TB is documented as being completed on 09/01/25.
  3. During an interview on 10/02/25 with staff #4, staff #4 confirmed the record for resident #1 did not contain a risk assessment for TB completed within 30 days prior to the resident’s admission.
Plan of correction
The TB risk assessment was completed on Resdent #1 was completed on 10/2/25. A 100% audit of current resident records was completed to verify or complete needed TB risk assessments on 10/2/25. The resident care coordinator will review record of new admissions to verify the resident has a TB risk assessment completed within 30 days prior to admission or is completed upon admission.
22VAC40-73-680-G
Based on observation and staff interview the facility failed to ensure over-the-counter medication shall remain in the original container, labeled with the resident's name, or in a pharmacy-issued container, until administered.
Evidence
  1. During the medication cart observation with staff #1, the following over the counter medications were observed to not be labeled with the resident’s name and staff #2 confirmed the medications were not labeled with the resident’s name: • Collagen Peptides 2500mg • Tylenol 325mg tablets • Bayer 81 mg tablets • PreserVision Soft gels
Plan of correction
The over-the-counter (OTC) medications, collagen peptides, Tylenol, Bayer Aspirin, and PreserVisions soft gels were labeled with residents’ names on 10/2/25. The resident care coordinator will ensure random monthly audits of medication carts are conducted to ensure compliance with standards including the labeling of OTC medications with resident names.
22VAC40-73-260-C
Based on observation and staff interviews the facility failed to ensure a listing of all staff who have current certification in first aid or CPR, in conformance with subsections A and B of this section, shall be posted in the facility so that the information is readily available to all staff at all times. The listing must indicate by staff person whether the certification is in first aid or CPR or both and must be kept up to date.
Evidence
  1. During a tour of the facility on 10/02/2025 the Licensing Inspector (LI) did not observe a listing of all staff who have current certification in first aid or CPR posted in the facility.
  2. During an interview on 10/02/2025 with staff #3 and staff #4, staff #3 and staff #4 confirmed a list of all staff certified in first aid or CPR was not posted in the facility.
Plan of correction
A list of current employees, their CPR and First Aid certification dates was completed and posted inside the nurses station. Staff will be educated on the location of the list. The resident care coordinator will update the posted list at least monthly with new hires and certification renewals to keep the list current.
22VAC40-73-250-D
Based on the staff record review and staff interview the facility failed to ensure health information required by these standards shall be maintained at the facility and be included in the staff record for each staff person. Initial tuberculosis (TB) examination and report and subsequent (TB) evaluations and reports.
Evidence
  1. The record for staff #1, hire date 4/12/24, did not contain documentation of an initial and annual risk assessment for TB.
  2. Upon request on 10/02/25, staff #4 was not able to provide documentation of an initial and annual risk assessment for TB completed for staff #1.
Plan of correction
The TB risk assessment was completed Staff #1 on 10/6/25 A 100% audit will be conducted of current staff files to ensure each employee has a current TB risk assessment and complete needed assessments by 10/13/25. The Resident Care Coordinator will maintain a roster of employees and the dates of the TB assessments and review monthly to ensure needed annual assessments are completed in a timely manner.
22VAC40-73-490-A
Based upon staff interviews the facility failed to ensure if a facility employs a licensed health care professional, who is onsite on a full time basis, a licensed health care professional, practicing within the scope of the health care professional’s profession, shall provide health care oversight at least every six months.
Evidence
  1. Upon request and during an interview on 10/02/2025 with staff #4, staff #4 was not able to provide documentation of a health care oversight completed at least every six months.
  2. During an interview on 10/02/2025 with staff #6, staff #6 confirmed the facility has employed a licensed health care professional during the current licensure period and confirmed a health care oversight has not been completed at least every six months.
Plan of correction
The resident care coordinator will complete a health care oversight review of current residents by 10/27/25. The resident care coordinator will maintain a schedule and completed health care oversight at least every three months and ensure healthcare oversight is completed on each resident at least every six months. The RDCS will conduct random resident reviews quarterly to verify healthcare oversight has been completed.
22VAC40-73-940-A
Based on review of the facility’s fire inspection report and staff interview the facility failed to ensure the facility shall comply with the Virginia Statewide Fire Prevention Code (13VAC5-51) as determined by at least an annual inspection by the appropriate fire official.
Evidence
  1. Upon request, and during an interview on 10/02/25 with staff #5, staff #5 provided a fire inspection report completed on 12/12/23. Staff #5 confirmed the facility did not have record of a fire inspection completed at least annually after the date of 12/12/23.
Plan of correction
The fire inspection has been scheduled for 10/22/25. The report will be submitted to DSS upon receipt. The administrator will contact the fire department to schedule a fire inspection to ensure occurs at least annually compliance with the Virginia Statewide Fire Prevention Code.
March 31, 2025Inspection3 violations
Inspection dates
03/31/2025, 04/22/2025
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 PREPAREDNESS22VAC40-90 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: An unannounced monitoring inspection took place on 03/31/2025 at 1:40 pm to 4:15 pm and 04/22/2025 at 9:14 am to 11:25 am. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-report was received by VDSS Division of Licensing on 03/14/2025 regarding allegations in the area of: Personnel and Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 15 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: 2 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: Residents were observed in the common and dining areas. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: Personnel A violation notice was issued; any violation(s) not related to the complaint 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-110-1
Based on the record review and staff interview the facility failed to ensure all staff shall be considerate and respectful of the rights, dignity, and sensitivities of persons who are aged or infirm or who have disabilities.
Evidence
  1. Resident’s #1 incident report dated 03/14/25 documents alleged abusive behavior by staff #1 towards resident #1.
  2. The facility’s final investigation report dated 04/10/25 for resident’s #1 incident report dated 03/14/25 documents “the community has substantiated the allegation of verbal abuse. The employee has been terminated.”
  3. Resident’s #1 audio recording dated 01/10/25 includes the following: Staff #1 tells resident #1 to “stop ringing the call bell all night, it’s not time to get up,” and uses a curse word when communicating to the resident.
  4. Resident’s #1 audio recording dated 01/28/25 includes the following: Resident #1 asks for assistance from staff #1 to use the bathroom, staff #1 responds by saying, “no” and “I don’t care.”
  5. Resident’s #1 audio recording dated 03/12/2025 includes the following: Staff #1 telling resident #1 to “stop grabbing”, and staff #1 using a curse word when communicating to resident #1.
  6. During an interview on 04/22/25 with staff #5, staff #5 acknowledged that staff #1 is the staff person heard verbally abusing resident #1 on the audio recordings dated 01/10/25, 01/28/25, and 03/12/25.
Plan of correction
Per Evidence submitted in items #1- 5 of notice File# 1105160, the following actions were taken immediately: 1.Immediate suspension of the alleged staff involved with the abuse allegation. Corrected Date: 4/10/2025 2.A thorough investigation was initiated by Facility administration and assigned oversight reviewer. Completion Date: 4/29/2025 3.Upon completion of the internal investigation and collaboration with the assigned oversight reviewer and the finding that the community had substantiated the allegation of verbal abuse, the involved staff member was immediately terminated. Completion Date: 4/29/2025 4.Executive Director, Director of Nursing, Resident Care Coordinator or designee shall meet with residents of the community at least monthly to monitor for any alleged abuse allegations. Completion Date: Ongoing Monthly 5.All active staff members of the community shall attend and have documented in their individual personnel records that each has reviewed and been reinforced by facility administration of the "Resident Rights" per 22VAC-73-550. A signed affidavit shall be placed in each staff member's personnel file attesting to this training. Completion Date: 5/23/2025 6.The rights and responsibilities of residents shall be reviewed with each resident residing in the community to ensure subsection H of this section complies with this requirement as evidenced by a signed acknowledgement by each resident, his legal representative or responsible individual. Completion Date 5/20/2025
22VAC40-73-325-B
Based on the record review and staff interview the facility failed to ensure the fall risk rating shall be reviewed and updated after a fall.
Evidence
  1. Resident’s #1 progress notes documents the resident experienced a fall on the following dates: 01/12/25, 01/29/25, 02/18/25, 03/08/25, 03/10/25. The resident’s record did not contain a fall risk rating completed after the documented falls. The last fall risk rating in the record is dated 09/26/24.
  2. Upon request on 03/31/25, staff # 3 acknowledged the record for resident #1 did not contain a fall risk rating completed after the documented falls on 01/12/25, 01/29/25, 02/18/25, 03/08/25, 03/10/25.
Plan of correction
1. A review/ audit of each resident chart will be conducted to complete/ update everyone's fall risk using fall risk assessment tool to identify resident(s) who pose risk to falls. The completed or updated fall risk tool will be added to each resident's chart to identify the resident's potential for falls along with any identified contributing factors which may increase the likely hood of falls. 2.lnservice training will be completed with each member of staff who provides resident care which shall include a review of fall risk factors and identifying high risk residents within the community. Assessment document and ratings shall become a part of each residents file once completed. Completion Date 05/30/25 3.Residents shall receive individual awareness training which shall provide heightened awareness of potential fall hazards and how to report any such hazard identified to appropriate staff immediately. Completion Date 05/15/2025 4.Residents who pose a fall risk shall be encouraged to use and shall be monitored for proper use of assistive devices needed for ambulating. Use of bed leveling controls shall be used to adjust the heights of beds as needed to reduce potential for harm should a fall from bed occur. Fall mats shall be implemented as needed after falling from bed. Floors shall be kept clear of clutter, dry and in good repair to include removal of any rug which is deemed to create a fall hazard. Completion date 5/23/2025
22VAC40-73-450-C
Based on the record review and staff interview the facility failed to ensure the comprehensive individualized service plan (ISP) shall be completed within 30 days after admission and shall a description of identified needs and date identified based upon the UAI.
Evidence
  1. Resident’s #1 UAI dated 03/10/25 documents a need for mechanical and human help (physical assistance) for toileting. The resident’s ISP dated 03/10/25 does not include the physical assistance needs for toileting.
  2. During an interview on 03/31/25 with staff #3, staff #3 acknowledged resident’s #1 ISP did not include the physical assistance needs for toileting as documented on the UAI.
Plan of correction
1. Individualized Service Plans for each Resident of the community shall be audited to determine compliance with Regulations. Any identified revisions/ updates needed for a resident's ISP shall be completed and added to the resident's chart. 2. Any Individualized Service Plan noted to be more than 12 months old shall be updated and as per Regulation and required signatures obtained. 3. All Individualized Service Plans shall be made accessible to direct care staff at all times. 4. When outside providers are involved in the care of any resident, there shall be a coordinated plan of care for the residents and that information shall be included as part of the individualized service plan. 5. A tracking tool shall be utilized to monitor individualized treatment plans due dates to eliminate plan from expiring before new plan is created/ initiated.
February 11, 2025Complaint survey2 violations
Inspection dates
02/11/2025
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 IMPAIRMENTS22VAC40-80 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: An unannounced complaint inspection took place on 02/11/25 at 9:18 am to 12:30 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 02/07/2025 regarding allegations in the area of: Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 17 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: 3 Number of interviews conducted with staff: 4 Observations by licensing inspector: Residents were observed eating breakfast in the dining area. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: Resident Care and Related Services and Staffing and Supervision. A violation notice was issued; any violation(s) not related to the complaint 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-460-E
Based on the record review the facility failed to ensure the facility shall regularly observe each resident for changes in physical, mental, emotional, and social functioning. Any notable change in a resident’s condition or functioning, including illness, injury, or altered behavior, and any corresponding action taken shall be documented in the resident’s record.
Evidence
  1. The record for resident #2 contains a progress note dated 9/28/24 that documents the following: “resident was confused the entire shift. Resident kept walking up and down the hallway looking for her truck. Resident is also forgetting how to feed herself.” Resident’s #2 record did not include documentation of any corresponding action taken by the facility to address the resident’s behaviors included in the progress note dated 9/28/24.
  2. The record for resident #2 contains a progress note dated 12/21/24 that documents the following: “Resident continues to be confused and says she don’t know how to walk. 4:30 this morning during rounds, resident was laying in dining room on activity table. Resident was taking back to her room.” Resident’s #2 record did not include documentation of any corresponding action taken by the facility to address the resident’s behaviors included in the progress note dated 12/21/24.
Plan of correction
1. On 2/27/25 and 2/28/25 the Program Director educated all direct care staff regarding proper documentation in the resident record and 24-hour report for residents who have a change in condition or functioning, including illness, injury, or altered behavior; document immediate action taking to ensure the safety of the residents. Direct care staff was also educated on follow up documentation on any aforementioned events. 2. The Program Directions will review the 24-hour report to ensure the documentation is completed, take and document additional actions as needed and update the ISP as indicated.
22VAC40-73-300-B
Based on the record review and the staff interview the facility failed to ensure a method of written communication shall be utilized as a means of keeping direct care staff on all shifts informed of significant happenings or problems experienced by residents, including complaints and incidents or injuries related to physical or mental conditions.
Evidence
  1. During an interview with staff #1, and staff #2, Staff #1 and staff #2 stated during the month of Dec. 2024 resident #1 used his call bell alert system to notify the staff that resident #2 was in resident’s #1 room unannounced and uninvited. The incident was not documented in the records for resident #1 and resident #2.
  2. During an interview with staff #1, staff #1 stated the physician for resident #1 informed staff #1 that during a physician visit in December 2024, resident #1 reported to the physician concerns of resident #2 entering the room of resident #1 unannounced and uninvited. Resident’s #1 complaints of resident #2 entering the room of resident #1 was not documented in the records of resident #1 and resident #2.
Plan of correction
1. A written 24-hour report of resident’s condition book has been implemented for staff to document any significant changes, incidents, behaviors and complaints. The Program Director had an in-service on 2/27/25 and 2/28/25 with all direct care staff to include to include what information needs to be written in the book. The Program Director will audit the book for accuracy. 2. On 2/12/2025 resident # 1 was moved to a new room directly across from the nurse’s station. Since the move the resident has reported that there have not been any more uninvited residents in his room. 3. The staff was educated that they must document any significant changes, incidents, behaviors and complaints in residents’ chart and the 24-hour book. The Program Director will monitor all staff documentation to ensure staff compliance.
October 1, 2024Inspection5 violations
Inspection dates
10/01/2024
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 PREPAREDNESS63.2 GENERAL PROVISIONS63.2 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 LICENSE
Technical assistance
22VAC40-73-490 Health care oversight 22VAC40-73-990 Plan for resident emergencies and practice exercise
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: An unannounced renewal inspection took place on 10/01/2024 at 8:37 am to 2:09 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: 19 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: 2 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: An observation of breakfast was completed. A medication pass observation was completed with 2 residents. A review of the facility’s staffing schedule was completed. Additional Comments/Discussion: None 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 Donesia Peoples, Licensing Inspector at (757) 353-0430 or by email at Donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-250-D
Based on the onsite record review, the facility failed to ensure health information required by these standards shall be maintained at the facility and shall be included in the staff record for each staff person. Subsequent tuberculosis (TB) evaluations and reports.
Evidence
  1. The record for staff #2, hire date 5/24/19 and 5/31/24, does not contain a current annual risk assessment for TB. The record for staff #2 contains a risk assessment for TB dated 2/07/2020.
Plan of correction
Staff #2, and all staff will have updated TB upon hire and annually. All current resident’s records will be audited by the Program Director and Administrator to include evidence of subsequent tuberculosis (tb) evaluations and reports with facility. The Program Director and Administrator will audit staff charts disclosure records every 6months and yearly to ensure compliance
22VAC40-73-660-A
Based on observation the facility failed to ensure medications shall be stored in a manner consistent with current standards of practice. The storage area shall be locked.
Evidence
  1. During the onsite inspection on, 10/01/24, the Licensing Inspector (LI) observed medications in a plastic bag in an unlocked office.
  2. Staff #3 stated the medications located in the unlocked office room, were removed from the medication cart the day prior and the medications will be returned to the pharmacy.
Plan of correction
All medications are stored and locked in their proper location for the safety of the residents. All medication will be stored in a locked area until deposition of medication. The facility will dispose of medication in a timely manner to ensure the safety of residents. This will be checked by the Program Director and oversea by the administrator daily.
22VAC40-73-680-I
Based on the record review the facility failed to ensure the Medication Administration Record (MAR) should include: Any medication errors or omissions.
Evidence
  1. Resident’s #2 MAR did not contain staff initials and/or reason for omissions on the following dates for the following medications: 9/17/24 for Loratadine, Metamucil, and Atorvastatin;
Plan of correction
Resident #2 had no adverse reaction effects from the practice. The facility failed to ensure the Medication Record should include medication errors or omissions by not contain staff initials or reason for not given medication for resident #2 staff was in-service that prior to end of shift to check (MAR) for missing signature and educated to always put reason for not given medication and report to program Director. The Program Director will check MAR every morning and run a report to reason why medications were not given and to ensure all (MAR) was signed to ensure compliance.
22VAC40-73-450-E
Based on the record review the facility failed to ensure the individualized service plan (ISP) shall be signed and dated by the licensee, administrator, or his designee, and by the resident or his legal representative.
Evidence
  1. Resident’s #1 ISP dated 9/30/24 does not include the signature and date of the licensee, administrator, or his designee, and the resident or his legal representative. 2.. Resident’s #2 ISP dated 8/23/24 does not include the signature and date of the resident or his legal representative.
Plan of correction
All current residents have their ISP completed signed and dated by the resident. License, administrator, or his designee the resident or legal representative. The Program Director will ensure that all ISPs are signed and have a date of by the license, administrator, or his designee and the resident or his legal representative by doing a chart audited 2 days before admission to ensure the documents have been completed.
22VAC40-73-450-A
Based on the record review the facility failed to ensure on or within 7 days prior to the day of admission, a preliminary plan of care shall be developed to address the basic needs of the resident that adequately protects his health, safety, and welfare. Exception: A Preliminary plan of care is not necessary if a comprehensive individualized service plan (ISP) is developed, in conformance with this section, on the day of admission.
Evidence
  1. The record for resident #1, admission date of 9/28/24, does not contain a preliminary plan of care completed on or within 7 days of admission or an ISP completed on the day of admission. Resident’s #1 ISP is dated as completed on 9/30/24.
Plan of correction
All current residents will have a care plan completed within 7 days prior to admission for their health and safety, and welfare and to address their needs. The Program Director will ensure that a template is available for care plans and will audit charts 2 days prior to admission to ensure all documents are completed.
June 26, 2024Inspection7 violations
Inspection dates
06/26/2024
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 PREPAREDNESS63.2 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 LICENSE
Technical assistance
Resident Rights Posting
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: An unannounced monitoring inspection took place on 06/26/24 at 8:38 am to 3:10 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: 17 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: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: An observation of breakfast was completed. A medication pass observation was completed with 2 residents. A review of the facility’s staffing schedule was completed. Additional Comments/Discussion: None 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 Donesia Peoples, Licensing Inspector at (757) 353-0430 or by email at Donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-310-D
Based upon review of the UAI prior to admission of a resident, the assisted living facility administrator shall provide written assurance to the resident that the facility has the appropriate license to meet his care needs at the time of admission. Copies of the written assurance shall be given to the legal representative and case manager, if any, and a copy signed by the resident or his legal representative shall be kept in the resident’s record.
Evidence
  1. The record for resident #1, admission date 05/08/2024, did not contain a written assurance the facility has the appropriate license to meet his or her care needs at the time of admission.
Plan of correction
Not published by VDSS.
22VAC40-73-640-A
Based on the record review and staff interview the facility failed to ensure the facility shall implement a written plan for medication management to include methods to ensure each resident’s prescription medication and any over the counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages.
Evidence
  1. During the medication pass observation on 06/26/24 with staff #4, the following medication was not located and available to administer to resident # 4: Physician order dated 04/12/24 “Magnesium Oxide-Supplement 400 (240mg) take 0.5 tablet by mouth once daily for anemia.”
  2. Resident’s #4 medication administration record (MAR) documents on 06/24/24 the resident’s Magnesium Oxide Supplement was exhausted and re-ordered on 06/24/24.
Plan of correction
1. Facility failed to ensure the facility shall implement a written plan for medication management to include methods to ensure each resident has prescription medication and over the counter drugs and supplements ordered for refill and are filled in a timely manner to avoid missed dosages by staff #4, currently reside in the facility currently and have no adverse effects. 2. Residents #4 Magnesium Oxide were not given according to physician’s orders. 3. All staff were in service following physician’s orders for proper medication administration and ordering medications within the last 7 days of doses. 4. Program Director or designee will perform random medication pass weekly for 4 weeks. 5.The Program Director will monitor all staff for accuracy to maintain compliance. 6.Date of Compliance 7/15/24.
22VAC40-73-320-A
Based on the record review the facility failed to ensure within the 30 days preceding admission, a person shall have a physical examination by an independent physician. The report of such examination shall be on file at the assisted living facility and shall contain the following as listed in the subsection.
Evidence
  1. The record for resident #1, admission date 05/08/24, did not contain documentation of a physical examination completed within 30 days preceding admission.
  2. Staff #2 confirmed the record for resident #1 did not contain documentation of a physician exam completed within 30 days prior to the resident’s admission date.
Plan of correction
1. Facility failed to disclose a written physically within 30 days prior to the resident admission resident #1, #2, currently reside in the facility and currently have no adverse effects. 2. Facility will have a physical completed 30 days prior to residents’ admission. 3. All current resident’s records will be audited by the Program Director and Administrator to include evidence of a physical completed 30 days prior to residents’ admission 4. The Program Director and Administrator will audit residents’ charts upon admission and annually . 5. Date of Compliance 7/15/24.
22VAC40-73-50-A
Based on the onsite record review the facility failed to ensure the assisted living facility shall prepare and provide a statement to the prospective resident and his legal representation. The statement shall disclose the following information which shall be kept current: The name of the facility; the name of the licensee.
Evidence
  1. Residents #1, #2, #3, #4, #5, and #6 disclosure statements did not include the name of the facility and the name of the licensee.
  2. Staff #2 confirmed the disclosure statements for residents #1, #2, #3, #4, #5, and #6 did not include the new name of the facility and the licensee.
  3. A change in ownership for the facility occurred on 05/01/24. The facility was notified on 04/02/24 via email to update the disclosure statement for all residents to include the new name of the facility and licensee effective 05/01/24.
Plan of correction
1. Facility failed to disclose their disclosure statements that include the new name of facility for resident #1, #2, #3, #4, #5 and#6 currently reside in the facility currently and have no adverse effects. 2. Residents #1, #2, #3, #4, #5 and#6 statements will be updated to include the new name of the facility. 3. All current resident’s records will be audited by the Program Director and Administrator to include evidence of statement disclosures with facility new name. 4. The Program Director and Administrator will audit residents’ disclosure statements records yearly to ensure compliance. 5. Date of Compliance 7/15/24.
22VAC40-73-390-A
Based on the record review the facility failed to ensure at or prior to the time of admission, there shall be a written agreement/acknowledgement of notification dated and signed by the resident or applicant for admission or the appropriate legal representative, and by the licensee or administrator.
Evidence
  1. Resident’s #1 admission agreement dated 05/08/24 did not include the licensee or administrator’s signature.
Plan of correction
1. Facility failed to ensure at or prior to the time of admission an agreement/acknowledgement of notification dated and signed by the resident or applicant for admission or the appropriate legal representative, and by the licensee or administrator for resident #1 currently reside in the facility currently and have no adverse effects. 2. Residents #1 admission an agreement/acknowledgement will be signed and dated by the resident or applicant for admission or the appropriate legal representative, and by the licensee or administrator on admission or prior. 3. All current residents’ records will be audited by the Program Director and Administrator charts upon admission and annually. 4.The Program Director and Administrator will audit residents’ admission agreement /acknowledgement records yearly to ensure compliance. 5.Date of Compliance 7/15/24.
22VAC40-73-390-C
Based on the record review the facility failed to ensure the original agreement/ acknowledgement shall be updated whenever there are changes to any of the policies or information referenced or identified in the agreement/acknowledgement and dated and signed by the licensee or administrator and the resident or his legal representative.
Evidence
  1. Resident’s #2 original agreement dated 10/14/23 was not updated to reflect the new name of the facility and licensee for the change in ownership effective 05/01/24.
  2. Resident’s #3 original agreement dated 03/16/24 was not updated to reflect the new name of the facility and licensee for the change in ownership effective 05/01/24.
  3. Resident’s #4 original agreement dated 04/01/24 was not updated to reflect the new name of the facility and licensee for the change in ownership effective 05/01/24.
  4. Resident’s #5 original agreement dated 2/24/22 was not updated to reflect the new name of the facility and licensee for the change in ownership effective 05/01/24.
  5. Resident’s #6 original agreement dated 01/09/23 was not updated to reflect the new name of the facility and licensee for the change in ownership effective 05/01/24.
  6. A change in ownership for the facility occurred on 05/01/24. The facility was notified via email on 04/02/24 to provide a new resident agreement to all residents when the new license became effective 05/01/24.
Plan of correction
1. Facility failed to ensure originally admission an agreement/acknowledgement admission was updated whenever there are changes to any of the policies or information referenced or identified in the agreement/acknowledgement dated and signed by the resident or applicant for admission or the appropriate legal representative, and by the licensee or administrator for resident #1,#2,#3,#4,#5 and #6 currently reside in the facility currently and have no adverse effects. 2. Residents #1, #2, #3, #4, #5 and #6 admission an agreement/acknowledgement will be signed and dated by the resident or applicant for admission or the appropriate legal representative, and by the licensee or administrator will be updated whenever changes occur. 3. All current residents’ records will be audited by the Program Director and Administrator charts annually and upon name change. 4.The Program Director and Administrator will audit residents’ admission agreement /acknowledgement records yearly to ensure compliance. 5.Date of Compliance 7/15/24.
22VAC40-73-410-A
Based on the record review the facility failed to ensure upon admission, the assisted living facility shall provide an orientation for new residents and their legal guardian including emergency response procedures, mealtimes, and use of the call system. Acknowledgement of receiving the orientation shall be signed and dated by the resident and, as appropriate his legal guardian, and such documentation shall be kept in the resident’s record.
Evidence
  1. The record for resident #1, admission date 05/08/24, did not contain documentation the facility provided an orientation to the resident and/ or their legal guardian.
  2. Resident’s #2, #3, #4, #5, and #6 resided at the facility prior to the change in ownership eff. 05/01/24. The residents’ records did not include documentation the facility provided an orientation to the resident and/ or their legal guardian.
  3. A change in ownership for the facility occurred on 05/01/24. The facility was notified via email on 04/02/24 to provide an orientation for all residents when the new license became effective 05/01/24.
  4. Staff #2 confirmed the records for residents #1, #2, #3, #4, #5, and #6 did not contain documentation the facility provided an orientation to the residents.
Plan of correction
1. Facility failed to ensure upon admission, the assisted living facility orientation for new residents and their legal guardian including emergency response procedures, mealtimes, and use of call bell system signed and dated by the resident or legal guardian and kept in the resident’s records for resident #1. Addition residents #2, #3, #4, #5 and#6 to included current name change on orientation. Currently reside in the facility and have no adverse effects. 2. Residents #1, #2, #3, #4, #5 and#6 facility orientation for new residents and their legal guardian including emergency response procedures, mealtimes, and use of call bell system will be signed and dated by the resident or legal guardian and kept in the resident’s records with new name of the facility. 3. All current resident’s records will be audited by the Program Director and Administrator to include evidence of facility orientation for new residents and their legal guardian including emergency response procedures, mealtimes, and use of call bell system will be signed and dated by the resident or legal guardian with facility new name. 4. The Program Director and Administrator will audit residents’ records yearly to ensure compliance. 5. Date of Compliance 7/15/24.
April 2, 2024Inspection0 violations
Inspection dates
04/02/2024
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 BUILDINGS AND GROUND
Comments
Type of inspection: Initial Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An announced mandated inspection took place on 04/02/2024 at 8:50 am to 9:12 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: 16 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: Resident rooms and floor plans was observed and confirmed. Additional Comments/Discussion: None 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 should the facility be issued a license to operate. 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 a licensed facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at Donesia.peoples@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.