Virginia DSS · Assisted Living Facility

Aviva Pembroke

📍 373 Constitution Drive, Virginia Beach, VA, 23462

ID 51368One Year licenseActive
9
Inspections
On record
6
With violations
Visits that cited something
3
Clean visits
Nothing cited
35
Violations cited
Individual findings
25
Standards cited
Distinct rules
4
Complaint visits
Prompted by a complaint

Aviva Pembroke was inspected 9 times between November 22, 2024 and May 14, 2026 by the Virginia Department of Social Services. 6 of those visits ended with violations cited and 3 with none. Across that history VDSS cited 35 violations under 25 distinct standards. 4 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
05/31/2026
Administrator
Jennifer Stell
Licensing inspector
Tiffany Jefferson
Inspector phone
(804) 317-0413
Approved for
Non-Ambulatory · Assisted Living · Special Care Unit

Inspection History

9

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

May 14, 2026Inspection12 violations
Inspection dates
05/14/2026
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
Technical assistance
None Provided
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 05/14/2026 at 8:18 a.m. to 5:05 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: 36 (1 in Rehab, 1 on Travel) 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: 4 Number of interviews conducted with staff: 8 Observations by licensing inspector: Breakfast, lunch, and two activities were observed. A medication pass observation was completed for two residents. The following were reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, first aid kit, medication cart, fire inspection report, health inspection report, health care supervision, nutrition supervision, and a staffing schedule. Emergency food and water were monitored. Water temperature was measured, and the call bell system was monitored. 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. 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 Tiffany Jefferson, Licensing Inspector at (804) 317-0413 or by email at T.Jefferson@dss.virginia.gov.
Violations
22VAC40-73-450-A
Based on the record review and staff interview the facility failed to ensure that on or within seven 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 03/01/26, does not contain a preliminary plan of care completed on or within seven days prior to the resident’s admission nor a comprehensive ISP completed on the date of admission. The record contains an ISP dated 02/12/26.
  2. The record for resident #3, admission date 01/12/26, does not contain a preliminary plan of care completed on or within seven days prior to the resident’s admission nor a comprehensive ISP completed on the day of admission. The resident’s record contains an ISP completed on 01/27/26.
  3. Upon request, and during an interview on 05/14/26 with staff #2 and staff #8, staff #2 and staff #8 could not provide a preliminary plan of care completed on or within seven days prior to the resident’s admission nor a comprehensive ISP completed on the day of admission for resident #1 and #3. Photographic evidence is available.
Plan of correction
All new residents will have a comprehensive ISP completed on the day of admission. The ED and HWD will review the UAI to ensure all resident needs and services are identified, and the ISP is signed by both the staff member creating the ISP and the ED. A clinical new resident checklist will be created to ensure compliance
22VAC40-73-450-D
Based on the record review and staff interview 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.
Evidence
  1. The record for resident #4 contains the following: A physical examination that documents the resident was admitted into hospice on 08/14/25. The residents’ ISP dated 12/04/25 does not include the services provided by the hospice organization and does not identify the residents’ need for hospice services. A hospice care plan effective 04/11/26 to 06/09/26. 2.During interview conducted on 05/14/26 with Staff #8, Staff #8 confirmed that resident #4’s ISP does not include the need for hospice services and services provided by the hospice agency. Photographic evidence is available.
Plan of correction
Resident needs and services will be identified and included on the ISP. The ISP will also reflect the services provided by various agencies that may be involved in the residents’ care. HWD will gather a list of residents who are receiving services from outside providers to ensure ISPs are updated.
22VAC40-73-970-A
Based on record review, and staff interviews, the facility failed to ensure fire and emergency evacuation drills were held in compliance with the current edition of the Virginia Statewide Fire and Prevention Code.
Evidence
  1. The facility’s record for fire and emergency evacuation drills dated 01/30/26, 02/28/26, 03/07/26, and 04/30/26 reports that zero (0) residents participated in fire and emergency evacuation drills. 2.During an interview on 05/14/26 with staff #7 and staff #8, it was confirmed that only staff, and no residents, participated in fire and emergency evacuation drills dated 01/30/26, 02/28/26, 03/07/26, and 04/30/26. Photographic evidence is available.
Plan of correction
Maintenance Coordinator will use the standard VDSS fire drill form to ensure compliance with the standard. ED will use state licensing requirements tickler to ensure monthly compliance.
22VAC40-73-390-A
Based on the record review and staff interview the facility failed to ensure that at or prior to the time of admission there should be a written agreement 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. The record for resident #1 contains an admission agreement dated 03/01/26 that did not have a signature or date by the licensee or administrator.
  2. During an interview on 05/14/26 with staff #8, staff #8 confirmed that the admission agreement did not contain a signature or date by the licensee or administrator. Photographic evidence is available.
Plan of correction
Every resident will have a signed residency agreement that is effective prior to or day of admission. ED will sign all residency agreements and utilize the new resident checklist to ensure compliance with the standard.
22VAC40-73-1090-A
Based on the record review the facility failed to ensure prior to his admission to a safe, secure environment, the resident shall have been assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare.
Evidence
  1. The record for resident #4, admission date 12/04/25 to the safe secure environment, contains an assessment for serious cognitive impairment that includes a response of No for the question does the resident have an inability to recognize danger or protect his own safety and welfare.
  2. During an interview on 05/14/26 with staff #8, staff #8 confirmed resident #4’s assessment for serious cognitive impairment does not include documentation the resident has an inability to recognize danger or protect his own safety and welfare. Photographic evidence is available.
Plan of correction
All residents who will potentially reside in SCU will have a serious cognitive assessment completed as part of their H&P. ED and HWD will ensure the physician has indicated the resident does have a serious cognitive impairment and is unable to recognize danger if they are to reside in SCU.
22VAC40-73-1140-B
Based on the record review and staff interview the facility failed to ensure within four months of the starting date of employment in the safe, secure environment, direct care staff shall attend at least 10 hours of training in cognitive impairment that meets the requirements of subsection C of this section.
Evidence
  1. The record for staff #3, hire date 11/24/25, contains a training record that documents 3 of 10 required hours of training in cognitive impairment.
  2. Upon request, and during an interview with staff #8, staff #8 confirmed staff #3’s hire date and confirmed staff #8 employment includes working in the safe secure environment. Staff #8 could not provide documentation of completion of 10 hours of training. Photographic evidence is available.
Plan of correction
All new care staff who will be working in SCU will have at least 10 hours of in-service or training on serious cognitive impairments within 4 months post start. ED and BOM will audit training records monthly to ensure compliance with the standard.
22VAC40-73-320-A
Based on the record review and staff interview the facility failed to ensure the physical examination shall contain the following: The date of the physical examination; Height, weight; Results of a risk assessment documenting the absence of tuberculosis in a communicable form; A statement that the individual does not have any of the conditions or care needs prohibited by 22VAC40-73-310.
Evidence
  1. Resident #3’s physical examination does not include the following: • Date the physical examination was completed. • Results of a risk assessment documenting the absence of tuberculosis in a communicable form. 2.Resident #4’s physical examination does not include the following: • Date the physical examination was completed. • The resident’s height and weight. • A statement that the individual does not require continuous licensed nursing care (condition or care need prohibited by 22VAC40-73-310).
  2. Resident #4’s physical examination includes a response of yes for the question asking if the resident requires continuous licensed nursing care.
  3. During an interview on 05/14/26 with staff #8, staff #8 confirmed the physical examination for resident #3 and resident #4 did not contain the required documentation. Staff #8 confirmed that Resident #4’s physical exam states that the resident requires continuous licensed nursing care. Photographic evidence is available.
Plan of correction
All new residents will have a thoroughly completed H&P prior to admission dated not more than 30 days prior to admission. All required information will be obtained, the TB risk assessment will be completed, and the resident will be free of any prohibitive conditions. ED or HWD will review all H&Ps prior to admission for compliance.
22VAC40-73-490-B
Based on review of the healthcare oversight and the staff interview the facility failed to ensure the licensed health care professional should provide health care oversight of the following and make recommendations for change as needed: Ascertain whether a resident's service plan appropriately addresses the current health care needs of the resident; Monitor direct care staff performance of health-related activities; Monitor conformance to the facility's medication management plan and the maintenance of required medication reference materials; Evaluate the ability of residents who self-administer medications to continue to safely do so.
Evidence
  1. The facility’s health care oversight dated 10/07/2025 does not include the following: A review of the resident’s service plan. Monitoring of direct care staff performance of health-related activities. Monitoring of the facility’s conformance of the medication management plan and the maintenance of required medication reference materials. An evaluation of the ability of residents who self-administer medications.
  2. Upon request, and during an interview on 05/14/26 with staff # 8, staff # 8 confirmed the health care oversight dated 10/07/25 did not include the following items: A review of the resident’s service plan Monitoring of direct care staff performance of health-related activities. Monitoring of the facility’s conformance of the medication management plan and the maintenance of required medication reference materials. An evaluation of the ability of residents who self-administer medications. Photographic evidence is available.
Plan of correction
HWD will be retrained on the requirements of the healthcare oversight including UAI/ISP review and proper documentation of the Healthcare Oversight. ED and regional nurse will provide consultation and training as needed. ED will review the healthcare oversight for compliance with the standard. ED has created a compliance tickler for monthly, quarterly, semi-annual, and annual licensing requirements to ensure compliance with the standards.
22VAC40-73-250-D
Based on record review and staff interview the facility failed to ensure each staff person submits the results of a risk assessment, documenting the absence of tuberculosis 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 on or within seven days prior to the first day of work at the facility. Evidence: 1.Staff #2’s record, hire date: 04/27/26, shows the results of a tuberculosis screening dated 04/29/26. 2.During an interview on 05/14/26, staff #2 and staff #8 confirmed that staff #2’s first date of work was 04/27/26, and staff #2’s tuberculosis screening is dated 04/29/26. Photographic evidence is available.
Plan of correction
All new hires will have a PPD or TB assessment prior to their start date. ED or BOM will ensure compliance by utilizing the new hire checklist.
22VAC40-73-450-C
Based on the record review and staff interview the facility failed to ensure the comprehensive ISP shall include the following: Date the need identified; The expected outcome and time frame for expected outcome.
Evidence
  1. Resident #1’s ISP dated 02/12/26 does not include the date the needs were identified and the expected outcome and timeframe for expected outcome for each identified need. Photographic evidence is available.
  2. Resident #2’s ISP dated 04/27/26 does not include the date the needs were identified and the expected outcome and timeframe for expected outcome for each identified need.
  3. Resident #3’s ISP dated 01/27/26 does not include the date the needs were identified and the expected outcome and timeframe for expected outcome for each identified need. Photographic evidence is available,
  4. Resident #4’s ISP dated 12/04/25 does not include the date the needs were identified and the expected outcome and timeframe for expected outcome for each identified need.
  5. During an interview on 05/14/26 with staff #8, staff #8 confirmed residents #1, #2, #3, and #4 ISPs does not include the date the needs were identified and the expected outcome and timeframe for expected outcome for each identified need. Photographic evidence is available.
Plan of correction
All residents’ ISPs will be audited and/or redone to ensure resident needs and services are identified and date identified included on the ISP. The review date or expected outcome date will also be included on the ISP. Upon completion, the ED will review all ISPs to ensure compliance with the standard.
22VAC40-90-40-B
Based on the staff record review and staff interview the facility failed to ensure the criminal history record report shall be obtained within 30 days of employment for each employee.
Evidence
  1. The record for staff #9, hire date 04/07/26, does not contain a criminal record check completed for staff #9. The staff record contains a criminal record check dated 04/06/26, however the staff name is spelled incorrectly.
  2. During an interview on 05/14/26, with staff #8, staff #8 confirmed the correct spelling of staff #9’s name and confirmed the criminal record check in the staff record was not completed with the correct spelling of staff #9’s name.
  3. The record for staff #10, hire date 11/18/25, contains a criminal history report dated 02/23/26.
  4. The record for staff #11, hire date 12/09/25, contains a criminal history report dated 02/23/26.
  5. During an interview on 05/14/26, with staff #8, staff #8 confirmed the hire dates for staff #10 and staff #11. Staff #8 confirmed the criminal history report for staff #10 and staff #11 was completed more than 30 days after their hire dates. Photographic evidence is available.
Plan of correction
All employees will have a Virginia State Police criminal background check initiated prior to commencement of employment. ED and BOM have a new hire checklist that will be utilized to ensure compliance with the standard and will ensure all documents are in the employee files
22VAC40-90-40-C
Based on the staff record review and staff interview the facility failed to ensure any person required by this chapter to obtain a criminal history record report shall be ineligible for employment if the report contains convictions of the barrier crimes.
Evidence
  1. The record for staff #12, hire date 7/23/25, contains a criminal history report dated 07/10/25 that includes the following two barrier crime convictions: • 18.2-57 on 12/10/08 • 18.2-57 on 01/22/09
  2. During an interview on 05/14/26 with staff #8, staff #8 acknowledged that staff #12 was found guilty of two barrier crime convictions and is currently employed by the facility. Photographic evidence is available.
Plan of correction
E.D. will review all background checks once received to ensure no staff working in the community have barrier crimes as it relates to the standard for assisted living facilities. All new hires whose background checks are pending prior to employment will be flagged to ensure their background check is received within the 30-day window.
January 29, 2026Complaint survey1 violation
Inspection dates
01/29/2026
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 IMPAIRMENTS
Comments
Type of inspection: Complaint Date 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 01/29/2026 at 10:00 am to 12:47 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 01/07/26 regarding allegations in the areas of: Resident Care and Related Services and the Safe Secure Environment. Number of residents present at the facility at the beginning of the inspection: 39 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents:2 Number of interviews conducted with staff: 2 Observations by licensing inspector: An activity in the safe secure unit was observed. 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 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. 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-930-D
Based on the record review and staff interview the facility failed to ensure for each resident with an inability to use the signaling device, in addition to any other services the following shall be met: The facility shall document the rounds that were made, which shall include the name of the resident, the date and time of the rounds, and the staff member who made the rounds.
Evidence
  1. The record for resident #1 contains an Individualized Service Plan dated 12/31/25 that documents the resident needs a secured unit and safety checks every 2 hours.
  2. Resident #1’s 2-hour check logs do not include documentation of the time checks/rounds were made on the dates of 01/01/26 through 01/28/2026.
Plan of correction
Not published by VDSS.
December 16, 2025Complaint survey2 violations
Inspection dates
12/16/2025
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 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 12/16/25 at 10:33 am to 1:46 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 11/11/2025 regarding allegations in the areas of: Resident Care and Related Services and the Safe Secure Environment. Number of residents present at the facility at the beginning of the inspection: 38 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: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 6 Observations by licensing inspector: Lunch and activity were observed. 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 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
22VAC40-73-450-C
Based on the record review and staff interview the facility failed to ensure the comprehensive individualized service plan (ISP) shall include a description of identified needs and date identified based upon the Uniform Assessment Instrument (UAI).
Evidence
  1. The record for resident #3 contains a UAI dated 01/20/25 that documents a need for physical assistance with eating to include spoon fed to be performed by others. Resident #3’s ISP dated 4/16/25 does not include the resident’s need for physical assistance with eating.
  2. Staff #6 reviewed resident #3’s UAI and ISP and confirmed the ISP does not include the resident’s need for eating.
Plan of correction
The facility identified that previously used ISPs created in the Aline format did not include a designated section for feeding assistance, which contributed to the omission. All existing ISPs originally completed in the Aline format will be reviewed and adopted into the DSS-approved ISP format to ensure all UAI-identified needs, including feeding assistance, are accurately captured and documented. Any missing or omitted needs identified during this review will be immediately added to the resident’s ISP.
22VAC40-73-920-D
Based on observation and staff interview the facility failed to ensure the following sturdy safeguards shall be provided with installation in compliance with the Virginia Uniform Statewide Building Code: Grab bars by toilets.
Evidence
  1. During a tour of the safe secure environment on 12/16/25, the Licensing Inspector (LI) observed the bathrooms in the following resident rooms do not have grab bars installed by the toilets: • Resident # 3 • Resident #5 • Resident #6 • Resident #7 • Resident #8 • Resident #9 • Resident #10
  2. During an interview on 12/16/25 with staff #5, staff #5 confirmed the grab bars in 7 out of the 9 occupied rooms in the safe secure unit do not have grab bars installed by the toilets.
Plan of correction
Immediately following identification of the deficiency, room audits were conducted in the safe secure unit to identify all bathrooms without grab bars installed by the toilets. Grab bars have since been installed in the bathrooms of Resident #3, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, and Resident #10 to ensure compliance with the Virginia Uniform Statewide Building Code.
October 10, 2025Complaint survey0 violations
Inspection dates
10/10/2025
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 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 10/10/25 at 8:35 am to 10:56 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 09/16/25 regarding allegations in the areas of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 33 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 4 Observations by licensing inspector: Breakfast was observed. 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 allegations of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact 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.
September 9, 2025Complaint survey1 violation
Inspection dates
09/09/2025
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
Technical assistance
Sworn Disclosure Statement
Comments
Date 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 09/09/25 at 10:00 am to 2:55 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 08/16/2025 regarding allegations in the areas of: Staffing and Supervision, Resident Care and Related Services, and the Safe Secure Environment. Number of residents present at the facility at the beginning of the inspection: 34 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: 2 Observations by licensing inspector: Medication pass observations were completed for two residents. Lunch and activity were observed. The facility’s emergency alert system was monitored. Required postings to include resident rights and the activity calendar was observed to be posted in the facility. 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 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
22VAC40-73-680-C
Based on the record review, medication pass observation, review of the facility’s medication administration procedures, and staff interview the facility failed to ensure medications shall be administered not earlier than one hour before and not later than one hour after the facility's standard dosing schedule, except those drugs that are ordered for specific times, such as before, after, or with meals.
Evidence
  1. The facility’s procedures for medication administration state that medication shall be administered not earlier than one hour before and not later than one hour after the time they are scheduled.
  2. Resident #1’s September 2025 Medication Administration Record (MAR) documents the following medications are scheduled to be administered at 9:00am, however during the medication pass observation completed on 09/09/25 with staff #2 the medications were administered at 10:30am: • Acetaminophen 325 mg for pain • Aspirin 81mg for heart health • Bupropion SR 150 mg for depression • Buspirone 7.5mg for anxiety • Calcium 600 mg for bone health • Chlorhexidine SOL 0.12% for dental care • Escitalopram 10mg for depression • Famotidine 20mg for Gastro-reflux • Fish Oil 500 mg for Vitamin D supplement • Gabapentin 300 mg for pain • Letrozole 2.5mg for breast cancer • Lubiprostone 8mcg for constipation • Restasis 0.05% for dry eye • Sodium Chloride 1gm for hyperosmolality and hypernatremia • Theratrum for Vitamin D deficiency • Vitamin C 500mg for Vitamin deficiency • Vitamin D3 25mcg for Vitamin deficiency
  3. Resident #2’s September 2025 Medication Administration Record (MAR) documents the following medications are scheduled to be administered at 9am, however during the medication pass observation with staff #2 on 09/09/2025 the medications were administered to the resident at 10:53 am. • Deep Sea Nasal Spray 0.65% for allergic rhinitis • Diphen/Atrop 2.5mg for diarrhea • Ferrous Sulfate 325mg for Iron deficiency • Fludrocortisone 0.1mg for hypotension • Fluticasone 50mcg for allergic rhinitis • Multivitamin for Vitamin Deficiency • Propranolol 10 mg for hypertension • Solifenacin 5mg for mixed incontinence • Vitamin C 500mg for Vitamin deficiency • Vitamin D3 25mcg for Vitamin D deficiency
  4. During an interview on 09/09/25 with staff #2, staff #2 confirmed the medications administered to resident #1 and resident #2 was administered more than one hour after the scheduled time of 9am on 09/09/25.
Plan of correction
All medication administrations will be moved to a liberalized medication pass schedule unless a specific time is ordered by the provider. All nursing staff will receive re-education on the facility’s Medication Management Plan, including proper medication pass procedures, documentation requirements, and adherence to provider-specific orders. The Director of Health and Wellness will conduct weekly medication pass audits for the next 30 days, completing a minimum of two audits per week during different shifts. Audit results will be documented by the Director of Health & Wellness and reviewed by the Executive Director weekly.
April 24, 2025Inspection11 violations
Inspection dates
04/24/2025
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 IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Technical assistance
22VAC40-73-50 22VAC40-73-210
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: 04/24/2025 from 8:35 am to 2:50 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: 28 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: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: Lunch and an activity were observed. A medication pass observation was completed for 2 residents. The following were reviewed: resident and staff records, medication carts, 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Violations
22VAC40-73-450-E
Based on record review, the facility failed to ensure the individualized service plan be signed and dated by the licensee, administrator, or his designee, (i.e., the person who has developed the plan), and by the resident or their legal representative when reviews and updates of the plan have been made.
Evidence
  1. The ISPs of Resident #1 (dated 02/27/2025), Resident #2 (dated 03/25/2025), Resident #3 (dated 02/23/2025), and Resident #4 (dated 02/23/2025) were not signed and dated by the licensee, administrator, or his designee, (i.e., the person who has developed the plan), and by the resident or their legal representative.
Plan of correction
Reinstate previous plan of correction, per inspection on 1.28.25
22VAC40-73-680-I
Based on record review, the facility failed to ensure the MAR include dosage and a diagnosis, condition, or specific indications for administering the drug or supplement.
Evidence
  1. None of the scheduled or PRN medications (total of 18) on Resident #1’s April 2025 MAR included a diagnosis. Resident #1 has a PRN physician’s order for Midodrine 5mg tablet with a parameter to hold if SBP<110; however, Resident #1’s MAR indicates the parameter as hold if SBP>110. Resident #1 has a physician’s order to take 2 Diphenoxylate tablets 3 times a day with meals and to hold for constipation; however, the parameter to hold for constipation is not on Resident #1’s MAR. Resident #1 has a physician’s order to take Tamsulosin .4mg capsule daily and call MD if SBP<100 or HR<60; however, Resident #1’s MAR does not indicate or document the resident’s HR at administration. Resident #1 has a PRN physician’s order to take 2 Senna 8.6mg tablets and hold for loose stools; however, Resident #1’s MAR does not include the parameter to hold for loose stools.
  2. None of the scheduled medications (total of 8) on Resident #3’s April 2025 MAR included a diagnosis.
  3. None of the scheduled medications (total of 13) on Resident #4’s April 2025 MAR included a diagnosis. Resident #4 has a physician’s order to take Midodrine 2.5mg tablet at 9am with a parameter to hold if SBP>150 or DBP>90; however, Resident #4’s MAR indicates the parameter as hold if BP greater than 150/90.
Plan of correction
DON manually audited all existing diagnosis and implemented the 24 hour chart audit for all new admits.
22VAC40-73-450-C
Based on record review, the facility failed to ensure the comprehensive ISP include description of identified needs and date identified based on the UAI and other sources.
Evidence
  1. Resident #1’s ISP (dated 02/27/2025) indicates the resident has a DNR; however, Staff #5 was unable to provide a DNR for Resident #1. Additionally, the ISP for Resident #1 does indicate the resident has allergies; however, it does not identify their specific allergy to Remeron.
  2. Resident #2’s ISP (dated 03/25/2025) indicates the resident as a full code; however, Resident #2’s record includes a DNR dated 03/31/2025.
  3. Resident #3’s ISP (dated 02/23/2025) indicates the resident has a DNR; however, Staff #5 was unable to provide a DNR for Resident #3. Additionally, Resident #3’s UAI (dated 01/20/2025) does not indicate a need for assistance with transferring, walking, and mobility; however, Resident #3’s ISP does indicate a need for supervision with transferring, walking, and mobility. The ISP for Resident #3 also does indicate the resident has allergies; however, it does not identify their specific allergy to codeine, macrocrystalline, nitrofurantoin, and penicillin. The ISP for Resident #3 does not address the resident’s need for assistance with housekeeping, laundry, meal preparation, and money management per their UAI.
  4. Resident #4’s ISP (dated 02/23/2025) does not address the resident’s need for assistance with housekeeping, laundry, meal preparation, and money management per their UAI (dated 01/21/2025).
Plan of correction
Reinstate previous plan of correction, per inspection on 1.28.25
22VAC40-73-680-D
Based on record review, the facility failed to ensure medications be administered in accordance with the physician's or other prescriber’s instructions.
Evidence
  1. The following medications were not available for administration for Resident #1 on the following days: Propranolol 10 mg tab on 04/01/2025-04/03/2025, Diphenoxylate 2.5-.025mg tab on 04/03/2025 and 04/13/2025, and Saline nasal gel spray on 04/23/2025-04/24/2025.
  2. Resident #4 has a physician’s order to take Midodrine 2.5mg tablet at 9am with a parameter to hold if SBP>150 or DBP>90; however, Resident #4’s MAR indicates the medication was administered on 04/04/2025 despite their SBP of 157.
Plan of correction
An in-service will be conducted with the consulting pharmacy to educate nursing staff on the required processes, and daily MAR audits will be carried out by the supervisor on duty. A weekly audit will be performed by the DON.
22VAC40-73-300-B
Based on interview and observation, the facility failed to ensure a method of written communication 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. The information shall be included in the records of the involved residents.
Evidence
  1. Staff #5 acknowledged the facility does not currently utilize a written communication 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.
Plan of correction
Establish a communication log to be reviewed daily by the on-duty supervisor for consistent oversight and coordination.
22VAC40-73-250-D
Based on record review and interview, the facility failed to ensure each staff person on or within seven days prior to the first day of work at the facility and each household member prior to coming in contact with residents submit the results of a risk assessment, documenting the absence of tuberculosis 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. The risk assessment shall be no older than 30 days. Evidence:
  2. Staff #3 was hired on 03/24/2024; however, Staff #3’s record did not include a completed TB risk assessment.
  3. Staff #6 confirmed Staff #3 does not have a completed TB risk assessment.
Plan of correction
Reinstate previous plan of correction, per inspection on 1.28.25
22VAC40-73-220-B
Based on interview, the facility failed to meet the requirements listed under subdivisions A 2 through A 6 of this section in addition to the requirements under subdivision B when private duty personnel who are not employees of a licensed home care organization provide direct care or companion services to residents.
Evidence
  1. Staff #5 acknowledged and confirmed Resident #1, Resident #3, Resident #4, and Resident #5 utilize private duty personnel who are not employees of a licensed home care organization who provide direct care or companion services to the residents.
  2. Staff #5 acknowledged and confirmed the facility does not have the requirements listed in the standard for the private duty personnel for Resident #1, Resident #3, Resident #4, and Resident #5.
Plan of correction
All current private duty aides will be oriented and have completed background checks and PPD testing with compliance monitored by the Human Resources Manager to ensure regulatory standards are met.
22VAC40-73-1120-B
Based on observation and interview, the facility failed to ensure there are at least 21 hours of scheduled activities available to the residents each week for no less than two hours each day.
Evidence
  1. The posted activity calendar in the safe, secure environment for April 2025 does not include activities on Sundays.
  2. Staff #4 confirmed there are no scheduled activities on Sundays in the safe, secure environment.
Plan of correction
Hire a dedicated Life Enrichment Coordinator to develop and lead programming for both Memory Care and Assisted Living residents. Revise current programming schedules to ensure sufficient coverage.
22VAC40-73-930-D
Based on record review, the facility failed to ensure that for each resident with an inability to use the signaling device, in addition to any other services, once the resident has gone to bed each evening until the resident has arisen each morning, at a minimum, direct care staff make rounds no less often than every two hours, except that rounds may be made on a different frequency if requested by the resident and agreed to by the facility.
Evidence
  1. The “Memory Care 2-hour Check” logs are not consistently completed to document rounds no less often than every two hours for each resident with an inability to use the signaling device for review during the onsite inspection.
  2. For April 2025, the following logs for the following residents do not document rounding during the following timeframes: Resident #3, Resident #4, Resident #7, and Resident #8 from 11p-7a on 04/01/2025-04/06/2025, 04/14/2025, and 04/18/2025-04/22/2025 and Resident #6 from 11p-7a on 04/01/2025-04/06/2025, 04/14/2025, and 04/18/2025.
Plan of correction
Provide education to all staff on rounding requirements. Supervisor on duty to perform daily audits of the rounding logs.
22VAC40-73-520-E
Based on observation and interview, the facility failed to ensure there are at least 14 hours of scheduled activities available to the residents each week for no less than one hour each day.
Evidence
  1. The posted activity calendar in the assisted living for April 2025 does not include activities on Saturdays.
  2. Staff #4 confirmed there are no scheduled activities on Saturdays in the assisted living.
Plan of correction
Hire a dedicated Life Enrichment Coordinator to develop and lead programming for both Memory Care and Assisted Living residents. Revise current programming schedules to ensure sufficient coverage.
22VAC40-73-970-E
Based on record review, the facility failed to ensure a record of the required fire and emergency evacuation drills include the items identified in the standard.
Evidence
  1. The record of the required fire and emergency evacuation drills did not include the name of the person conducting the drill, the number of residents participating, the time it took to complete the drill, and the weather conditions.
Plan of correction
Issue the DSS-approved fire safety drill form and provide education to the administering staff member.
March 27, 2025Inspection0 violations
Inspection dates
03/27/2025
Areas reviewed
22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 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: 03/27/2025 from 9:30 am to 9:45 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: 31 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: 0 Observations by licensing inspector: LI measured units for license modification request. 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
January 28, 2025Inspection8 violations
Inspection dates
01/28/2025
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 IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 01/28/2025 from 8:30 am to 2:10 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: 21 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: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: Lunch and an activity were observed. A medication pass observation was completed for 3 residents. The following were reviewed: resident and staff records, medication carts, 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Violations
22VAC40-73-1130-A
Based on observation and interview, the facility failed to ensure except during night hours, when 20 or fewer residents are present, at least two direct care staff members shall be awake and on duty at all times in each special care unit who shall be responsible for the care and supervision of the residents.
Evidence
  1. During the inspection held on 01/28/2025, there was only 1 direct care staff on the special care unit.
Plan of correction
Two direct care staff are assigned to memory care and will be present at all times.
22VAC40-73-930-D
Based on record review, the facility failed to ensure that for each resident with an inability to use the signaling device, in addition to any other services, once the resident has gone to bed each evening until the resident has arisen each morning, at a minimum, direct care staff make rounds no less often than every two hours, except that rounds may be made on a different frequency if requested by the resident and agreed to by the facility.
Evidence
  1. Staff were unable to provide documentation of rounds no less often than every two hours for each resident with an inability to use the signaling device for review during the onsite inspection. There was no evidence indicating the rounds are completed at this time.
Plan of correction
Implementing a new rounding log system that staff must complete during night hours. Providing staff training on proper rounding procedures and documentation Having charge nurses audit rounding logs daily to ensure compliance Documenting any resident-requested changes to rounding frequency in their care plan
22VAC40-73-660-A-1
Based on observation, the facility failed to ensure the medication cart be locked.
Evidence
  1. Upon a tour of the safe, secure environment around 8:35 am, the medication cart was noted to be unlocked and unattended.
Plan of correction
All nursing personnel who administer medications have been in-serviced and educated on proper protocols regarding the medication cart to include locking it for safety.
22VAC40-73-450-A
Based on record review, the facility failed to ensure on or within seven days prior to the day of admission, a preliminary plan of care be developed to address the basic needs of the resident that adequately protects their health, safety, and welfare.
Evidence
  1. Resident #2 (admitted 12/27/2024) did not have a completed preliminary plan of care in their record.
Plan of correction
All preliminary plans of care will be developed to address the basic needs of the resident that adequately protects their health, safety, and welfare within 7 days of admission.
22VAC40-73-250-D
Based on record review, the facility failed to ensure each staff person on or within seven days prior to the first day of work at the facility and each household member prior to coming in contact with residents submit the results of a risk assessment, documenting the absence of tuberculosis 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. The risk assessment shall be no older than 30 days. Evidence:
  2. Staff #1 was hired on 11/25/2024; however, Staff #1’s record included a chest x-ray completed 06/25/2020.
  3. Staff #3 was hired on 01/06/2025; however, Staff #3’s TB test was completed 01/28/2025.
Plan of correction
The facility will ensure all staff members submit tuberculosis risk assessment results within 7 days prior to their first workday, and all household members will submit results prior to resident contact. The facility will: 1. Immediately audit all current staff/household member files for compliant TB risk assessments using the Virginia Department of Health form. 2. Obtain current TB risk assessments (no older than 30 days) for any non-compliant individuals 3. Update hiring procedures to require TB screening documentation before work start date.
22VAC40-73-680-I
Based on record review, the facility failed to ensure the MAR include dosage and a diagnosis, condition, or specific indications for administering the drug or supplement.
Evidence
  1. Resident #1’s January 2025 MAR did not include a diagnosis for Metformin 500 mg tab.
  2. The following medications for Resident #3 did not include a diagnosis on the January 2025 MAR: Multiple Vitamin tab, Acetaminophen 500mg caplet, Aspir-low 81 mg tab, Calcium Carbonate 648 mg tab, Januvia 25 mg tab, Lisinopril 20 mg tab, Melatonin 3 mg tab, Metformin 1000 mg tab, Metoprolol tartrate 25 mg tab, Miralax, Vitamin C 1000 mg tab, and Vitamin D3 25 mcg tab.
  3. The following medications for Resident #4 did not include a diagnosis on the January 2025 MAR: Basaglar 100u/ml, Budesonide 3mg capsule, famotidine 20 mg tab, Furosemide 40 mg tab, Humalog 100u/ml, Januvia 100 mg tab, K-Dur 20 meq tablet, Lactaid tab, Levothyroxine 25 mcg tab, Multivit-Minerals tab, Pentasa 500 mg capsule, Simbrinza eye drops, Tylenol 325 mg tab, Vitamin B12 tab, and Vitamin D3 tab. Resident #4 also has a sliding scale order of Humalog 3 times daily. The MAR does not indicate the number of units administered based on the resident’s blood glucose level.
  4. The following medications for Resident #5 did not include a diagnosis on the January 2025 MAR: Amlodipine 2.5 mg tab, Duloxetine 60 mg cap, Miralax, Ocean nasal spray, Carvedilol 6.25 mg tab, Flonase nasal spray, Montelukast 10 mg tab, Oxcarbazepine 150 mg tab, Oxybutynin 10 mg tab, Vitamin D3 50 mcg tab, Sennoside-Docusate sodium 8.6-50 mg tab, Sodium Chloride 1 gm tab, and Prednisone 5 mg tab.
Plan of correction
All nursing staff have been educated on MAR protocols regarding new orders dosage and a diagnosis, condition, or specific indications for administering the drug or supplement. It has been established that the evening nurse will facilitate a 24 hour chart audit on all new orders.
22VAC40-73-450-E
Based on record review, the facility failed to ensure the individualized service plan be signed and dated by the licensee, administrator, or his designee, (i.e., the person who has developed the plan), and by the resident or their legal representative when reviews and updates of the plan have been made.
Evidence
  1. The ISPs of Resident #1, Resident #3, and Resident #4 were not signed and dated by the licensee, administrator, or his designee, (i.e., the person who has developed the plan), and by the resident or their legal representative.
Plan of correction
The facility will immediately audit all current residents' service plans for required signatures. Any missing signatures will be obtained from the licensee/administrator/designee and resident/legal representative. To prevent recurrence, the Administrator will: 1. Create a signature checklist for all service plan reviews 2. Conduct monthly audits of service plans to ensure compliance
22VAC40-73-450-C
Based on record review, the facility failed to ensure the comprehensive ISP include a description of identified needs and date identified.
Evidence
  1. Resident #1’s ISP (dated 12/17/2024) did not include a date identified for the following needs: eating, meal preparation, housekeeping, laundry, wound care, and medication administration. Resident #1’s ISP also did not address the following needs: bladder incontinence and money management. Additionally, Resident #1’s UAI (dated 10/31/2024) indicated the resident requires mechanical assistance with walking and mobility, does not require assistance with toileting; however, Resident #1’s ISP indicates the resident requires mechanical assistance and supervision with walking and mobility and supervision with toileting.
  2. Resident #4’s ISP (dated 12/06/2024) does not address the following needs: toileting, walking, and stairclimbing.
Plan of correction
All current residents' ISPs will be reviewed and updated to include: • Complete documentation of all identified needs • Dates of identification for each need • Reconciliation of UAI and ISP information The UAI will match the ISP regarding all needs to ensure and address that all needs are being met appropriately. Director of Nursing will audit new ISPs weekly for 3 months to ensure compliance.
November 22, 2024Inspection0 violations
Inspection dates
11/22/2024
Technical assistance
22VAC40-73-860 22VAC40-73-960
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: 11/22/2024 from 9:00 am to 9:52 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: 0 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: 0 Observations by licensing inspector: Measurements of the apartments were completed. Additional Comments/Discussion: The first aid kits and required postings were reviewed. 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.