Virginia DSS · Assisted Living Facility

Commonwealth Senior Living at the Devonshire

📍 2220 Executive Drive, Hampton, VA, 23666

ID 50767One Year licenseActive
7
Inspections
On record
5
With violations
Visits that cited something
2
Clean visits
Nothing cited
23
Violations cited
Individual findings
19
Standards cited
Distinct rules
0
Complaint visits
Prompted by a complaint

Commonwealth Senior Living at the Devonshire was inspected 7 times between July 10, 2024 and February 5, 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 19 distinct standards.

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
02/20/2027
Administrator
Paula Taylor
Licensing inspector
Darunda Flint
Inspector phone
(757) 807-9731
Approved for
Assisted Living

Inspection History

7

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

February 5, 2026Inspection9 violations
Inspection dates
02/05/2026. 02/09/2026
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD 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: 02/05/2026 (arrival 8:89 a.m. / departure 2:10 p.m.) and 02/09/2026 (arrival 8:40 a.m. arrival / departure 2:00 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: 49 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 3 Number of interviews conducted with residents:1 Number of interviews conducted with staff: 3 Observations by licensing inspector: Breakfast was observed. A medication pass observation was completed for three residents. The following were reviewed: emergency preparedness drills, resident fire and resident emergency drills, fire inspection report, health inspection report, activities, and water temperatures were measured. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of these inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Darunda Flint, Licensing Inspector at (757) 807-9731 or by email at darunda.a.flint@dss.virginia.gov
Violations
22VAC40-73-450-A
Based on record review and staff interview, the facility failed to ensure a resident’s preliminary plan developed addressed the basic needs of the resident that adequately protect the health, safety, and welfare.
Evidence
  1. On February 9, 2026, resident #2’s UAI dated 01/12/2026, and the Preliminary Individualized Service Plan (ISP) dated 01/19/2026 noted resident #2’s needs as follows: UAI noted bathing need assessed as mechanical and human help, ISP noted need as physical assistance, no mechanical help was referenced; UAI noted dressing need assessed as mechanical help, ISP noted need assessed as physical assistance; UAI noted toileting need as human help supervision, ISP noted need assessed as physical assistance; UAI noted transferring need as mechanical help only, ISP noted assessed need as physical assistance; UAI noted no help needed with bowel, ISP noted assessed need as incontinent of bowel and staff to assist with bathroom; UAI noted walking need assessed as mechanical help only, ISP noted assessed need as physical assistance by direct care staff; UAI noted no help with wheeling, ISP noted assessed need as physical assistance by direct care staff; UAI noted mobility need assessed as mechanical and human help supervision, ISP did not list an assessed for mobility.
  2. Staff #1 acknowledged the aforementioned residents’ ISP did not include all assessed needs.
Plan of correction
The ISPs for the resident #2 cited in the inspection report have been updated to include the required documentation to address current needs as noted on the UAI on 2-10-26 The RCD/Designee will complete a review of current ISPs will be conducted to ensure they align with the needs identified in the corresponding UAIs. RCD/designee will conduct random audits x3 months to ensure UAI and ISP align to meet identified needs.
22VAC40-73-960-C
Based on observation and staff interviewed, the facility failed to ensure the telephone numbers for the fire department, rescue squad or ambulance, police, and Poison Control Center shall be posted by each telephone shown on the fire and emergency evacuation plan.
Evidence
  1. On February 5, 2026, during a tour of the facility with staff #2, a listing of the telephone numbers for the fire department, rescue squad or ambulance, police, and Poison Control Center were not posted by each telephone shown on the fire and emergency evacuation plan.
  2. Staff #2 confirmed the telephone numbers for the fire department, rescue squad or ambulance, police, and Poison Control Center were not posted by each telephone shown on the fire and emergency evacuation plan.
Plan of correction
The Poison Control center number was added to the list of emergency contacts, and the updated version of emergency contacts was placed by all phones on 2-5-26. The Business Office Manager/Designee will ensure that the list is kept up to date. The Business Office Manager/designee will complete an audit monthly for the next 90 days to ensure that the emergency contact list is current.
22VAC40-73-610-B
Based on observation and staff interviewed, the facility failed to ensure menus for meals and snacks for the current week were dated and posted in an area conspicuous to residents.
Evidence
  1. During the inspection on February 5, 2026, the weekly menu was not posted in the assisted living unit nor the secure unit.
  2. Staff #2 acknowledged that the current weekly menu was not posted in the assisted living unit nor the secure unit.
Plan of correction
The current weekly menu’s were posted on both units on 2-9-26. The dining service director/designee will ensure that the menu’s are posted on each unit daily. The Executive Director/designee will conduct a weekly audit for the next 90 days to ensure compliance.
22VAC40-73-450-D
Based on record reviewed and staff interviewed, the facility failed to ensure when hospice care is provided to a resident, the assisted living facility and the licensed hospice organization shall communicate and establish an agreed upon coordinated plan of care for the resident. The services provided by each shall be included on the individualized service plan (ISP).
Evidence
  1. On 02/09/2026, resident #3’s record included hospice progress notes from 01/29/2026, 03/03/2026, and 02/05/2026 for hospice for services provided to the resident. Those services include incontinence care, health care monitoring, and follow-up services.
  2. Staff #1 acknowledged resident #3’s ISP did not document hospice services provided to resident #3.
Plan of correction
The ISPs for the resident #3 cited in the inspection report has been updated to include the required documentation to address current services being provided from hospice as noted on 2-9-26. The RCD/Designee will complete a review of current residents who are using an outside provider to ensure that the ISP reflects services rendered. RCD/designee will conduct random audits x3 months to ensure ISP identifies all services.
22VAC40-73-950-A
Based on staff interviewed and records reviewed, the facility failed to develop a written emergency preparedness and response plan that shall address documentation of initial and annual contact with the local emergency coordinator to determine (i) local disaster risks, (ii) communitywide plans to address different disasters and emergency situations, and (iii) assistance, if any, that the local emergency management office will provide to the facility in an emergency.
Evidence
  1. During the inspection conducted on February 5, 2026, Staff #1 could not provide annual documentation of emergency preparedness review with a local emergency coordinator.
Plan of correction
The emergency preparedness plan was sent over to the local emergency coordinator for review on 2-26-26. The Executive Director will ensure the plan is up to date and signed off on annually. The Executive Director will conduct an audit annually to ensure that the plan has been reviewed by the emergency coordinator.
22VAC40-73-640-A
Based on records reviewed and staff interviewed, the facility failed to implement the medication management plan to ensure resident’s prescription medications, and any over-the-counter drugs and supplements ordered are filled and refilled in a timely manner to avoid missed dosages.
Evidence
  1. During the inspection conducted on February 9, 2026, Resident #3’s Acetaminophen, 500 mg tablets, were not available during the 8:00 a.m. medication pass observation with staff #5.
  2. Resident #3’s medication administration record (MAR) dated 02/09/2026 noted the acetaminophen, 500 mg tablet, was waiting on pharmacy reorder from backup pharmacy.
  3. Staff #5 acknowledged the aforementioned resident’s medication was not available.
Plan of correction
Resident #3’s Acetaminophen 500mg tabs was ordered and delivered to the community 2-9-26. An initial MAR-to-med-cart audit for current residents was conducted by RCD/ARCD to ensure medications are in accordance with physician orders. The Resident Care Director/ Designee will conduct a MAR-to-med-cart audit for current residents completed monthly for 3 months then randomly to ensure compliance.
22VAC40-73-290-B
Based on observation, the facility failed to develop and implement a procedure for posting the name of the current on-site person in charge, as provided for in this chapter, in a place in the facility that is conspicuous to the residents and the public.
Evidence
  1. Upon entry to the facility on February 5, 2026, the facility did not have the name of the designated current on-site person in charge posted in the facility.
  2. Staff #2 acknowledged the name of the designated current on-site person in charge was not posted.
Plan of correction
Person in Charge sign was place in the designated area so that it is conspicuous to the residents and the public on 2-5-26. Daily prior to shift change the on-coming manager on duty will ensure that the posting is correct. The Business office manager/designee will complete a daily audit for the next 60 days to ensure compliance.
22VAC40-73-450-C
Based on record reviewed and staff interviewed, the facility failed to ensure the comprehensive individualized service plan (ISP) shall include all assessed needs for residents.
Evidence
  1. On 02/09/2026, resident #3’s uniformed assessment instrument (UAI) dated 11/21/2025 and ISP dated 01/16/2026 noted the following : UAI transferring assessed need noted as mechanical and human help, ISP did not note the assessed need.; UAI bowel assessed need noted as incontinent less than weekly 1, ISP did not note the assessed need; UAI bladder noted assessed need as incontinent weekly or more 3, ISP did not note the assessed need; UAI wheeling noted human help, ISP did not note the assessed need; UAI mobility noted assessed need as human help, ISP noted the assessed need as human help and mechanical.
  2. Staff #1 acknowledged the resident #3’s UAI and ISP did not agree.
Plan of correction
The ISPs for the resident #3 cited in the inspection report have been updated to include the required documentation to address current needs as noted on the UAI on 2-10-26 The RCD/Designee will complete a review of current ISPs will be conducted to ensure they align with the needs identified in the corresponding UAIs. RCD/designee will conduct random audits x3 months to ensure UAI and ISP align to meet identified needs.
22VAC40-73-260-A
Based on record reviewed and staff interviewed, the facility failed to ensure that direct care staff members maintain current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department, Each direct care staff member who does not have current certification in first aid, shall receive certification in first aid within 60 days of employment.
Evidence
  1. During inspection conducted on February 9, 2026, a record review of direct care staff member #3’s record did not include docuemtnation of current first aid certification. The first aid certification in the record expired 01/2026. Staff #3’s start date noted as September 7, 2025.
  2. Staff # 1 acknowledged the aforementioned staff member’s first aid certification expired January 2026. Photographic evidence obtained.
Plan of correction
Staff member #3 is signed up to complete First Aid on 4-6-26. The Business Office Manager completed an audit for all staff to ensure that all staff are in compliance. The Business Office Manager/Designee will complete a monthly audit x3 months to ensure that all staff are up to date with first aid.
August 4, 2025Inspection0 violations
Inspection dates
08/04/2025
Areas reviewed
22VAC40-73 BUILDINGS AND GROUND
Comments
Type of inspection: Other Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 08/04/2025 (arrival 10:06 am / 1:12 pm) The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Darunda Flint, Licensing Inspector at (757) 807-9731 or by email at Darunda.a.flint@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
June 30, 2025Inspection0 violations
Inspection dates
06/30/2025
Areas reviewed
22VAC40-73 BUILDINGS AND GROUND
Comments
Type of inspection: Other Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/30/2025 (arrival 10:00 am / 11:50 am). The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Darunda Flint, Licensing Inspector at (757) 807-9731 or by email at Darunda.a.flint@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
January 2, 2025Inspection7 violations
Inspection dates
01/02/2025
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-90 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: 01/02/2025 (arrival 9:24 a.m. / departure 3:31 p.m.) The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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: 01/02/2025 (arrival 9:24 a.m. / departure 3:31 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: 25 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed:3 Observations by licensing inspector: Lunch and an activity was observed. A medication pass observation was completed for 3 residents. The following were reviewed: resident and staff records and water temperatures. 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 Darunda Flint, Licensing Inspector at (757) 807-9731 or by email at Darunda.a.flint@dss.virginia.gov
Violations
22VAC40-73-260-A
Based on record review, the facility failed to ensure each direct care staff member maintain current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department.
Evidence
  1. Staff #3 (hire date 09/10/2024) works as direct care staff and did not have documentation of a current certification in first aid in their staff record.
Plan of correction
Plan of Correction: 1. Audit for Certifications: The Business Office Manager has completed an audit of all direct care staff member files to determine who needed their CPR certification. 2 .Education: The administrator or designee will provide training to the BOM on training requirements surrounding first aid as stated in 22VAC40-73-260-A. 3. Certification Training: Any direct care staff who did not have a current first aid certification has completed a first aid/CPR class given by Southern Pharmacy on January 14, 2025. 4. Ongoing Compliance Monitoring: The Executive Director or designee will complete an audit monthly for the next three months to ensure all direct care staff maintain current certifications.
22VAC40-73-310-D
Based on record review and staff interviewed, the facility failed to ensure prior to admission of a resident, the facility administrator provided written assurance to the resident that the facility has the appropriate license to meet the care needs at the time of admission. Acknowledgement of this document should be signed by the resident or a legal representative and kept in the resident’s record.
Evidence
  1. Records for residents #1, #2, and #3 did not contain a signed written assurance by the resident or the resident’s representative.
  2. Staff #2 acknowledged the residents #1, #2, #3 files did not contain the written assurance.
Plan of correction
Plan of Correction: 1. Audit of Resident Files: An audit will be completed on all assisted living residents to ensure they have written assurance forms in their files. 2. Education and training. 2/4/2025D Education will be provided to the ED on providing the Letter of Written Assurance upon admission and that it is signed by the resident or legal representative. 3. Signature Collection: The Business Office Manager, Executive Director, or designee will meet with each resident/POA who does not have a written assurance in their file to review and obtain signatures. 4. Ongoing Compliance Monitoring: The Executive Director will conduct an audit monthly for two months to ensure all residents have signed the written assurance forms.
22VAC40-73-40-B-8
Based on observation and staff interviewed, the facility failed to ensure that the current license was posted in the facility in a place conspicuous to the residents and the public.
Evidence
  1. A change in ownership for the facility occurred on 08/21/2024. On 01/02/2025, the current licensed was not posted in the facility.
  2. Staff #2 acknowledged during the course of the inspection process the facility did not have the current license posted.
Plan of correction
Plan of Correction: 1. Immediate Action: The Executive Director has posted the current license in a place conspicuous to the residents and the public. 2. Staff Education: Education will be provided for all relevant staff on the importance of maintaining visible licensing information within the facility. 3. Regular Audits: The Executive Director will conduct regular audits to ensure the license remains conspicuously posted and compliance with these practices is maintained.
22VAC40-80-120-E-2
Based on observation and staff interviewed, the facility failed to ensure certain documents related to the terms of the license are required to be posted on the premises of each facility. These are: The findings of the mot recent inspection of the facility.
Evidence
  1. Staff #2 acknowledged during the course of the inspection process the facility did not have the findings of the most recent inspection of the facility posted.
Plan of correction
1..Binder Creation: The Executive Director has created a new binder for Commonwealth Senior Living at the Devonshire to insert new inspection documents for each inspection which will remain accessible to the public. The binder is placed in the assisted living side of the community for easy access and visibility. 2.Education: Education will be provided for all relevant staff on the importance of maintaining visible survey results as per 22VAC40-80-120-E-2. 3. Maintenance of Binder: The Executive Director, Business Office Manager, or designee will keep the binder updated after each inspection. 4. Ongoing Audits: The Executive Director will conduct random audits for the next two quarters to ensure the binder is properly maintained and accessible.
22VAC40-73-860-G
Based on observation and staff interviewed, the facility failed to ensure the hot water at taps available to residents shall be maintained within a range of 105 degrees Fahrenheit (F) to 120 degrees F.
Evidence
  1. During a tour of the facility with staff #2, the hot water temperature was checked in room #175. The temperature reading was 122.3 degrees F. The hot water temperature reading in room #167 was 128.1 degrees F.
  2. Staff acknowledged the water temperatures were not within the required range.
Plan of correction
Plan of Correction: 1. Immediate Adjustment: The Maintenance Director (MD) will turn the water heater down by 10 degrees to ensure the temperature falls within the required range. 2. Education: ED will provide education to Maintenance Director regarding maintained within a range of 105 degrees Fahrenheit (F) to 120 degrees F per 22VAC40-73-860-G 3. Monthly Checks: The Maintenance Director will check the water temperature in resident rooms monthly to ensure ongoing compliance. 4. Ongoing Audits: The Maintenance director will report water temperature audits monthly to the ED for the next two months to ensure that the adjusted settings are consistently maintained.
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 representative. The statement shall disclose the following information which shall be kept current: The name of the facility; the name of the licensee.
Evidence
  1. A change in ownership for the facility occurred on 08/21/2024. Residents #1, #2 and #3 did not have disclosures statements in their records that included the name of the facility and the name of the licensee.
  2. Staff #2 acknowledged there were no disclosure statements for residents #1, #2, and #3.
Plan of correction
Plan of Correction: 1. Audit of Resident Files: The Executive Director, Business Office Manager, or designee will complete an audit of all assisted living residents’ files to ensure that each resident has a disclosure statement. 2. Education and Training: Education will be provided to the Admin and Business Office Manager on properly preparing and providing timely statements to prospective residents and their legal representatives. 3. Obtaining Missing Signatures: The same individuals (Executive Director, Business Office Manager, or designee) will review and obtain signatures from each resident or Power of Attorney who does not have a disclosure statement on file. 4. Ongoing Compliance Monitoring: The Executive Director will perform an audit monthly for two months to confirm that all residents have signed disclosure statements.
22VAC40-73-390-A
Based on review of resident records, the facility failed to have an admission agreement with residents.
Evidence
  1. Resident #1, resident #2, and resident #3 records did not contain documentation of the resident agreement with the facility when there was a change in ownership on 08/21/2024.
  2. Staff #2 acknowledged that resident #1, resident #2, and resident #3 records did not include the aforementioned.
Plan of correction
Plan of Correction: 1) Audit was completed to determine which residents needed admission agreements completed.2 2) Education has been provided to the BOM and Admin on being compliant with 22VAC40-73- 390-A. 3) The current Executive Director, prior Interim Executive Director and Business Office Manager will complete the remaining lease agreements with residents and/or their power of attorneys. 4) Executive Director to complete an audit weekly x1 month, monthly x3 months, and randomly as needed to ensure all residents have signed admission agreements.
January 2, 2025Inspection1 violation
Inspection dates
01/02/2025
Areas reviewed
22VAC40-73 BUILDINGS AND GROUND
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: 01/02/2025 (arrival 9:24 a.m. / departure 3:31 p.m.) 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 12/17/2024 regarding allegations in the area(s) of: Building and Grounds Number of residents present at the facility at the beginning of the inspection: 25 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: Number of interviews conducted with residents: Number of interviews conducted with staff: Observations by licensing inspector: 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 Darunda Flint, Licensing Inspector at (757) 807-9731 or by email at darunda.a.flint@dss.virginia.gov
Violations
22VAC40-73-870-D
Based on documents and staff interviewed, the facility failed to ensure the building was kept free of infestations of insects and vermin.
Evidence
  1. On 01/02/2025 during an inspection regarding bedbugs in the facility, staff #1 acknowledged the facility did have an issue with bedbugs.
  2. On 1/02/2025, pest control invoices provided documented treatment for bedbugs were completed on 12/19/2024 and 1/2/2025.
  3. Staff #2 acknowledged the facility was being treated for bed bugs.
Plan of correction
Plan of Correction: 1.Initial Response: Upon notification of a bedbug infestation, the Maintenance Director contacted Impressive K9 and Pest. The K-9 dogs conducted searches on December 10, 2024, and December 11, 2024. 2.Treatment: Paramount Pest provided heat chemical treatments in all 4 rooms on December 18, 2024, followed by heat treatments on all 4 rooms on January 2nd, 3rd, and 4th, 2025. 3. Long-Term Pest Control: The Maintenance Director initiated a pest control program that will last for 12 months to prevent future infestations. 4. Monitoring and Evaluation: The effectiveness of the pest control measures will be evaluated regularly throughout the program duration.
October 24, 2024Inspection4 violations
Inspection dates
10/24/2024
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 PREPAREDNESS
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: 10/24/2024 ( arrival 9:53 am/ departure 2:20 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: 30 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 1 Observations by licensing inspector: Lunch was observed. A medication pass observation was completed on 2 residents. The following were reviewed: resident records, staff records, and medication cart. 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 Darunda Flint, Licensing Inspector at (757) 807-9731 or by email at Darunda.a.flint@dss.virginia.gov
Violations
22VAC40-73-260-C
Based on observation and staff interviewed, the facility failed to ensure a listing of all staff who have current certification in first aid or CPR was kept current.
Evidence
  1. The first aid and CPR posting was not kept current. The list included employees with expired first aid/CPR dates.
  2. Staff #4 and staff #5 acknowledged the posting was not kept current.
Plan of correction
Not published by VDSS.
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. A change in ownership for the facility occurred on 08/21/2024. Residents #1, #2, and #3 disclosure statements did not include the name of the facility and the name of the licensee.
  2. Staff #4 and staff#5 acknowledged the disclosure statements for residents #1, #2, and #3 did not include the new name of the facility and the licensee.
Plan of correction
Not published by VDSS.
22VAC40-73-390-A
Based on review of resident records, the facility failed to have an admission agreement with residents.
Evidence
  1. Resident #1, resident #2, and resident #3 records did not contain documentation of the resident agreement with the facility dated when there was a change in ownership on 08/21/2024.
  2. Staff #4 and staff #5 acknowledged that resident #1, resident #2, and resident #3 records did not include the aforementioned.
Plan of correction
Not published by VDSS.
22VAC40-73-520-I
Based on observation and staff interviewed, the facility failed to ensure that the activity noted on the schedule was provided.
Evidence
  1. The activity calendar posted noted, Oktoberfest Music scheduled for 11:00 a.m. There was no activity or substitution of an activity provided to the residents present on that morning at 11:00 a.m.
Plan of correction
Not published by VDSS.
July 10, 2024Inspection2 violations
Inspection dates
7/10/2024
Areas reviewed
22VAC40-73 BUILDINGS AND GROUNDType of inspection: InitialDate(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/10/2024 ( 9:59 am arrival/ 1:15 pm departure)The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspectionThe licensing inspector completed a tour of the physical plant that included the building and grounds of the facilityAn exit meeting will be conducted to review the inspection findingsThe 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 lawIf 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 interviewCompliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be correctedWithin 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 areaRegardless 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 NoticeThe department's inspection findings are subject to public disclosurePlease Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facilityFor more information about the VDSS Licensing Programs, please visit: www.dss.virginia.govShould you have any questions, please contact Darunda Flint, Licensing Inspector at (757) 807-9731 or by email at Darunda.a.flint@dss.virginia.gov
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: 07/10/2024 ( 9:59 am arrival/ 1:15 pm departure) The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. 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 Darunda Flint, Licensing Inspector at (757) 807-9731 or by email at Darunda.a.flint@dss.virginia.gov
Violations
22VAC40-73-870-A
Based on observation, the facility failed to ensure the interior and exterior of all buildings shall be maintained in good repair and kept clean and free of rubbish.
Evidence
  1. During a tour of the facility, the patio door screen, located in the resident dining area, was observed to be torn and propped against the patio door.
  2. The window screen in the courtyard that is located in the hallway next to the kitchenette was torn.
  3. The window screen in room #177 was torn.
  4. The carpet across from room #159 and the activity room was visibly dirty and in need of cleaning.
  5. Staff #2 acknowledged the torn patio door screen and aforementioned torn window screens.
  6. Staff #1 acknowledged the carpet was dirty.
Plan of correction
1. The window screen in the courtyard was replaced on 8/10/2024 2. All carpets for assisted living were cleaned on 8/7/2024; 8/8/2024 and 8/9/2024 3. Anticipated date of repair for other window screens 10/30/2024 due to the availability of vendor to complete repairs. 4. Maintenance director will tour building and grounds daily to ensure community remains in good repair and kept clean and free of rubbish.
22VAC40-73-870-D
Based on observation, the facility failed to ensure the building was kept free of infestations of insects and vermin.
Evidence
  1. During a tour of the facility, there were several wasp nests with live wasp activity located on the outside of the building’s rear exterior. 2.Staff #2 acknowledged the aforementioned wasp nest.
Plan of correction
1. Pest control company removed and sprayed all wasp nest located exterior of assisted living. Pest control company will continue to spray on a monthly basis starting august for the next three months. 2. Pest control company will continue to spray and treat wasp nest starting 8/9/2024 for 90 days thereafter.