Virginia DSS · Assisted Living Facility

Parsons Residential Care Center

📍 1005 Deep Creek Blvd, Chesapeake, VA, 23323

ID 51919One Year licenseActive
8
Inspections
On record
5
With violations
Visits that cited something
3
Clean visits
Nothing cited
13
Violations cited
Individual findings
10
Standards cited
Distinct rules
4
Complaint visits
Prompted by a complaint

Parsons Residential Care Center was inspected 8 times between August 12, 2025 and June 12, 2026 by the Virginia Department of Social Services. 5 of those visits ended with violations cited and 3 with none. Across that history VDSS cited 13 violations under 10 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
02/28/2027
Administrator
Julie Ann Kelley
Licensing inspector
Donesia Peoples
Inspector phone
757 353-0430
Approved for
Assisted Living · Non-Ambulatory

Inspection History

8

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

June 12, 2026Complaint survey3 violations
Inspection dates
06/12/2026
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 GROUND22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 06/12/2026 at 10:55 am to 1:38 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 04/20/2026 regarding allegations in the areas of: Personnel, Staffing and Supervision, and Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 16 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 2 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: Residents were observed in the common areas. The facility’s PPE supplies were observed and the staffing schedule was reviewed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: Personnel A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. 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
22VAC40-90-40-B
Based on the record review and staff interview the facility failed to ensure the criminal history report shall be obtained within 30 days of employment for each employee.
Evidence
  1. The record for staff #2, hire date 03/04/26, does not contain a criminal history report.
  2. During an interview on 06/12/26 with staff #3, staff #3 confirmed the facility has not obtained a completed criminal history report for staff #2.
Plan of correction
Employee personnel files were reviewed to identify any missing criminal history record reports. The Executive Director will ensure all criminal history record reports are obtained within 30 days of employment and maintained in employee personnel files in accordance with regulatory requirements. Systemic Changes to Prevent Recurrence: A personnel file audit process has been implemented. The Executive Director or designee will review personnel files monthly to ensure all required criminal history record reports are received and maintained within required timeframes.
22VAC40-73-450-G
Based on the record review and staff interview the facility failed to ensure the master service plan shall be filed in the resident’s record. A current copy shall also be maintained in a location accessible at all times to direct care staff.
Evidence
  1. The record for resident #2, admission date 02/28/26, contains a preliminary plan of care dated 02/28/26. The record does not contain a comprehensive individualized service plan (ISP).
  2. Upon request, and during an interview with staff #3, staff #3 stated an ISP was completed for resident #2, however staff #3 was not able to locate and provide a copy of the plan during the onsite inspection. Staff #3 confirmed the record for resident #2 did not contain an ISP nor was there a copy accessible to direct care staff.
Plan of correction
Resident records are being reviewed to locate the individualized service plan for the identified resident. If the individualized service plan cannot be located, a new individualized service plan will be completed and placed in the resident record. A copy will also be maintained in a location accessible to direct care staff. Systemic Changes to Prevent Recurrence: A resident record audit process has been implemented. The Executive Director or designee will conduct monthly audits of resident records to ensure individualized service plans are maintained in resident records and accessible to direct care staff.
22VAC40-73-120-A
Based on the record review and staff interview the facility failed to ensure the orientation and training required in subsections B and C of this section shall occur within the first seven working days of employment.
Evidence
  1. The record for staff #1, hire date 11/13/25 and first day of work 1/12/26, did not contain documentation of staff #1 completing an orientation and training within the first seven working days of employment.
  2. Upon request, and during an interview on 06/12/26 with staff #3, staff #3 stated staff #1’s first day of work was 1/12/26 and last day of work was 2/18/26. Staff #3 was not able to provide evidence of staff #1 completing orientation and training within the first seven working days of employment.
Plan of correction
Employee personnel files were reviewed for orientation and training documentation. The Executive Director will ensure all orientation and training requirements are completed, signed, dated, and maintained in employee personnel files within the first seven working days of employment. Systemic Changes to Prevent Recurrence: An orientation checklist review process has been implemented. The Executive Director or designee will conduct monthly personnel file audits to ensure compliance with orientation and training requirements.
March 10, 2026Complaint survey1 violation
Inspection dates
03/10/2026
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 PREPAREDNESS
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 03/10/2026 at 8:15 am to 10:00 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 02/26/2026 regarding allegations in the area(s) of: Resident Care and Related Services and Buildings and Grounds Number of residents present at the facility at the beginning of the inspection: 10 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: 4 Observations by licensing inspector: Residents were observed eating breakfast. 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 allegation(s) area(s) of non-compliance with standard(s) or law were: Building and Grounds 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
22VAC40-73-860-G
Based on measurement of the water temperatures, observations, and staff interviews the facility failed to ensure hot water at taps available to residents shall be maintained within a range of 105°F to 120°F.
Evidence
  1. During the onsite inspection on 03/10/2026 the Licensing Inspector (LI) with staff #1 measured the hot water temperature in two of the restrooms used by residents. The hot water temperature was measured to be 60 degrees Fahrenheit.
  2. During a tour of the facility, LI observed a posting in the facility dated 02/20/26 that stated: the facility currently does not have hot water due to the boiler being repaired.
  3. During an interview with staff #1 and staff #2 on 03/10/2026, staff #1 confirmed the facility has not had hot water since 02/20/26 due to awaiting a repair of the facility’s boiler.
Plan of correction
The facility identified that the lack of hot water was due to a malfunction of the boiler system beginning on or about 02/20/2026. Upon identification of the issue, the facility immediately contacted a licensed repair company, and repairs to the boiler system were initiated. Necessary replacement parts were ordered and installed as available. The boiler system has since been repaired and restored to proper working condition. Hot water temperatures throughout the facility have been tested and are now within the required regulatory range of 105°F to 120°F. Additionally, the local Health Department conducted follow-up visits and independently measured water temperatures, confirming temperatures were within compliant range. During the period in which hot water was unavailable, the facility implemented measures to ensure resident care and safety, including providing heated water for bathing and hygiene needs, completing bed baths with warmed water as needed, maintaining hand hygiene through sanitizer and alternative methods, educating staff on modified care procedures, and notifying residents and families of the temporary disruption and ongoing repair efforts. To prevent recurrence, the facility is implementing a preventative maintenance schedule for routine inspection and servicing of the boiler system. A water temperature monitoring log is being implemented to routinely verify that hot water temperatures remain within the required range. The facility will maintain an emergency response protocol for utility failures, including expedited vendor response and escalation procedures. A regulatory compliance tracking system is being implemented to ensure timely follow-up on all maintenance-related issues. The facility will continue to cooperate with external agencies, including the Health Department, to ensure continued compliance and verification when applicable. Person(s) Responsible: Executive Director, Maintenance Director, and designated staff Date to be Corrected: Completed on March 13, 2026
January 23, 2026Inspection4 violations
Inspection dates
01/23/2026
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS
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 01/23/26 at 8:00 am to 1:50 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: 9 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 2 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: A medication pass observation was completed for two residents. 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 (Donesia Peoples), Licensing Inspector at (757) 353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
22VAC40-73-450-E
Based on the record review and staff interview the facility failed to ensure the individualized service plan (ISP) shall 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 his legal representative.
Evidence
  1. Resident #1’s ISP dated 11/20/25 is not signed and dated by the person who developed the plan and the resident or legal representative.
  2. Resident #2’s ISP dated 11/15/25 is not signed and dated by the person who developed the plan and the resident or legal representative.
  3. During an interview on 01/23/26 with staff #3, staff #3 confirmed resident #1’s and resident #2’s ISPs were not signed and dated by the person who developed the plan and by the resident or legal representative.
Plan of correction
Corrective Action Taken: The identified service plans were reviewed and presented to the resident and/or legal representative for required signatures. Documentation now reflects appropriate signatures and dates. Systemic Changes to Prevent Recurrence: A verification step has been added to the service plan completion process to ensure all required signatures are obtained prior to filing. The Executive Director or designee will verify signatures during routine monthly record audits.
22VAC40-73-325-A
Based on the record review and staff interview the facility failed to ensure for residents who meet the criteria for assisted living care, by the time the comprehensive ISP is completed, a written fall risk rating shall be completed.
Evidence
  1. Upon request, and during an interview on 01/23/26 with staff #3, staff #3 confirmed a written fall risk rating has not been completed for resident #1.
  2. Upon request, and during an interview on 01/23/26 with staff #3, staff #3 confirmed a written fall risk rating has not been completed for resident #2.
Plan of correction
Corrective Action Taken: The identified resident service plans were reviewed and updated to reflect current care needs and required documentation. Any missing or incomplete information was corrected to ensure compliance with regulatory requirements. Systemic Changes to Prevent Recurrence: A Service Plan Tracking Calendar has been implemented to monitor initial, 30-day, and annual reviews. The Executive Director or designee will conduct monthly audits of resident records to ensure compliance with required timelines and documentation standards. Staff responsible for service plan development were re-educated regarding regulatory requirements.
22VAC40-73-680-I
Based on the record review and staff interview the facility failed to ensure the medication administration record (MAR) shall include date and time given, initials of direct care staff administering the medication and any medication errors or omissions.
Evidence
  1. Resident #1’s January 2026 MARs does not contain documentation of staff initials, nor documentation of any omissions on the following dates: • 01/01/26, 01/02/26 for Amlodipine, Donepezil, Metformin, Metoprolol, Miralax, Levodopa, Ketaconozale Cream, and Jabairte. • 01/04/26, 01/05/26, 01/07/26, 01/11/26, 01/12/26, 01/16/26, 01/17/26, 01/18/26, 01/19/26, 01/21/26 for Donepezil. • 01/04/26, 01/18/26 for Metoprolol • 01/15/26, 01/17/26 01/18/26 for Levodopa.
  2. Resident # 2’s January 2026 MARs does not contain documentation of staff initials, nor documentation of any omissions on the following dates: • 01/01/26, 01/02/26, 01/03/26, 01/04/26, 01/05/26, for Docusate Sodium • 01/05/26 for Fluticasone • 01/20/26 for Cetirizine
  3. During an interview on 01/23/26 with staff #3, staff #3 confirmed the January 2026 MARs for resident #1 and resident #2 was missing staff initials and documentation of omissions.
Plan of correction
Corrective Action Taken: The identified MARs were reviewed. Missing documentation was addressed and corrected as appropriate. Staff received re-education regarding proper medication documentation procedures, including documentation of omissions and required notations. Systemic Changes to Prevent Recurrence: Weekly MAR audits have been implemented. The Executive Director or designee will review medication documentation for accuracy and completeness. Ongoing monitoring will include periodic medication administration observations to reinforce compliance with documentation standards.
22VAC40-90-40-B
Based on the record review and staff interview the facility failed to ensure the criminal history report shall be obtained within 30 days of employment for each employee.
Evidence
  1. The record for staff #4, hire date 11/20/25, does not contain a criminal history report.
  2. The record for staff #5, hire date 11/20/25, does not contain a criminal history report.
  3. The record for staff #6, hire date 11/25/25, does not contain a criminal history report.
  4. The record for staff #7, hire date 12/08/25, does not contain a criminal history report.
Plan of correction
Corrective Action Taken: All personnel files were immediately audited. For employees whose criminal history documentation was not present in the file, formal written requests were submitted to the Virginia State Police to obtain copies of the previously processed criminal history results. Documentation of these requests will be placed in the respective personnel files pending receipt of the official reports. Systemic Changes to Prevent Recurrence: A Personnel File Compliance Log has been implemented to track hire dates and receipt of required background documentation. The Executive Director or designee will review this log weekly to ensure all required documentation is received and filed within regulatory timeframes. Personnel files will not be considered complete until all required background documentation is physically verified in the file.
January 23, 2026Complaint survey1 violation
Inspection dates
01/23/2026
Areas reviewed
22VAC40-73 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 GROUND22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 01/23/26 at 1:50 pm to 3:30 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 01/09/2026 regarding allegations in the area(s) of: Personnel and Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 9 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 2 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: The Call Bell system was monitored. Heat temperature was measured and monitored. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the (allegation(s)) of non-compliance with standard(s) or law. However, violation(s) not related to the complaint but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. 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
22VAC40-73-120-A
Based on the review and staff interview the facility failed to ensure the orientation and training required in subsections B and C of this section shall occur within the first seven working days of employment.
Evidence
  1. The record for staff #1, hire date 12/08/26, did not contain documentation of completion of orientation and training.
  2. Upon request, and during an interview on 01/23/26 with staff #3, staff #3 was not able to provide documentation of an orientation and training completed for staff #1.
Plan of correction
Not published by VDSS.
January 23, 2026Complaint survey0 violations
Inspection dates
01/23/2026
Areas reviewed
22VAC40-73 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 GROUND22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint An unannounced complaint inspection took place on 01/23/26 at 1:50 pm to 3:30 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 01/09/2026 regarding allegations in the area(s) of: Personnel and Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 9 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 2 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: The Call Bell system was monitored. Heat temperature was measured and monitored. Additional Comments/Discussion: 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.
December 11, 2025Inspection4 violations
Inspection dates
12/11/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND 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: An unannounced monitoring inspection took place on 12/11/25 from 1:08 pm to 4:15 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self- reported incident was received by VDSS Division of Licensing on 11/10/2025 regarding allegations in the area of: Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 12 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: 3 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: Observation of the medication carts was completed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were 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
22VAC40-73-250-C
Based on the record review and staff interview the facility failed to ensure personal and social data to be maintained on staff and included in the staff record are as follows: Verification that the staff person has received a copy of his current job description.
Evidence
  1. The record for staff #3, hire date 09/29/25, did not include verification staff #3 received a copy of a current job description.
  2. During an interview on 12/11/25 with staff #3, staff #3 was not able to confirm nor provide verification staff #3 received a copy of staff #3’s job description.
Plan of correction
Corrective Action Taken: The facility acknowledges that documentation verifying receipt of a current job description for Staff #3 was not present in the staff record at the time of inspection. This deficiency has been corrected. Staff #3 was provided a copy of their current job description, which was reviewed and signed on January 8, 2026. The signed job description is now maintained in the employee’s personnel file. Steps to Prevent Recurrence: 1. All newly hired staff receive a copy of their current job description during onboarding. 2. Signed verification of receipt of the job description is required prior to staff working independently. 3. Personnel files are reviewed to ensure documentation is complete. 4. Personnel files are audited upon hire and during annual reviews.
22VAC40-73-450-C
Based on the record review and staff interview the facility failed to ensure the comprehensive individualized service plan (ISP) shall be completed within 30 days after admission.
Evidence
  1. The record for resident #1, admission date 10/30/25, contains a preliminary plan of care dated 10/30/25. The resident’s record does not contain a comprehensive ISP.
  2. During an interview on 12/11/25 with staff #3, staff #3 confirmed a comprehensive ISP for resident #1 has not been completed.
Plan of correction
Corrective Action Taken: The facility acknowledges that the comprehensive individualized service plan (ISP) for Resident #1 was not completed within 30 days of admission. This deficiency has been corrected. The comprehensive ISP for Resident #1 was completed, reviewed, and placed in the resident’s record on December 14, 2025. In addition, all resident UAIs and ISPs were reviewed to ensure accuracy, consistency, and alignment across resident records. Steps to Prevent Recurrence: 1. A preliminary plan of care is completed upon admission. 2. A comprehensive ISP is completed within 30 days of admission in accordance with regulatory requirements. 3. ISP due dates are tracked to ensure timely completion. 4. Resident records are reviewed routinely for accuracy and consistency.
22VAC40-73-680-I
Based on the medication administration record (MAR) review and staff interview the facility failed to ensure the MAR shall include date and time given and initials of direct care staff administering the medication.
Evidence
  1. Resident #1’s October and November 2025 MARs did not include the date and time given and initials of direct care staff administering the resident’s Oxycodone 5mg (1 tab by mouth every 6 hours for pain) on the following dates: 10/31/25. 11/01/25, 11/02/25, 11/03/25, 11/04/25, and 11/05/25.
  2. During an interview on 12/11/25 with staff #3, staff #3 confirmed that resident #1’s MAR did not include date and time given and staff initials for Oxycodone administered on 10/31/25. 11/01/25, 11/02/25, 11/03/25, 11/04/25, and 11/05/25.
Plan of correction
Corrective Action Taken: The facility acknowledges that medication administration records (MARs) did not consistently include the date, time administered, and initials of the direct care staff administering oxycodone during the identified months. This deficiency has been corrected. Staff involved at the time of inspection are no longer employed at the facility. All current medication administration staff have been educated on proper MAR documentation requirements. MARs are now completed in full, including date, time, and staff initials for all medications, including controlled substances. Steps to Prevent Recurrence: 1. Medication administration staff document date, time, and initials for each medication administered. 2. MAR documentation requirements are reviewed with all medication administration staff. 3. MARs are routinely audited for accuracy and completeness. 4. Documentation issues are addressed promptly through re-education.
22VAC40-73-640-A
Based on the review of the facility’s controlled substance count sheet and staff interview the facility failed to implement a written plan for medication management to include: Methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes.
Evidence
  1. The facility’s medication management plan includes the following” “At the end of each shift, the staff member responsible for medications who is completing his/her shift, and the staff member responsible for medications who is starting his/her shift, count narcotic medications and confirm that the amount on hand matches what is listed on the Narcotic Count Sheet for each medication. Both staff members will sign a Narcotic Reconciliation Sheet to confirm the accurate count of narcotics on hand.”
  2. The facility’s-controlled substance count sheet for November 2025 does not include the oncoming and off going staff signatures to verify narcotic counts were completed on the following dates: 10/30/25, 10/31/25, 11/01/25, 11/02/25, 11/03/25, 11/04/25, 11/05/25, 11/06/25, 11/07/25, 11/08/25, 11/09/25.
  3. During an interview on 12/11/25 with staff #3, staff #3 confirmed the facility controlled substance count sheet did not include the ongoing and offgoing staff signatures verifying medications counts were completed the dates of 10/30/25 through 11/09/25.
Plan of correction
Corrective Action Taken: The facility acknowledges that controlled substance count documentation did not consistently include verification by both incoming and outgoing medication administration staff at shift change. This deficiency has been corrected. Staff involved at the time of inspection are no longer employed at the facility. All current medication administration staff have been educated on proper controlled substance counting procedures. The facility now consistently uses a controlled substance count sheet requiring both the off-going and oncoming staff to count controlled medications together and sign the count sheet at each shift change. Steps to Prevent Recurrence: 1. Controlled substance counts are completed at every shift change. 2. Both staff members sign the count sheet verifying accurate counts. 3. Controlled substance handling and documentation requirements are reviewed with medication administration staff. 4. Controlled substance count sheets are routinely reviewed by the Administrator or designee.
October 29, 2025Inspection0 violations
Inspection dates
10/29/2025
Areas reviewed
22VAC40-73 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: An Unannounced monitoring inspection took place on 10/29/2025 at 8:45 am to 10:15 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: 1 Observations by licensing inspector: Additional Comments/Discussion: The facility has no admissions currently at the facility. 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 (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.
August 12, 2025Inspection0 violations
Inspection dates
08/12/2025
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 REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS
Comments
Type of inspection: Initial Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An announced initial inspection took place on 08/12/2025 at 9:05 am to 10:20 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: 2 Observations by licensing inspector: An observation of bedrooms, restrooms, dining area, common areas, medication carts, and the kitchen were observed. The facility’s first aid kit was reviewed and the water temperature was measured. Additional Comments/Discussion: Measurements were completed in bedrooms that will be used for residents. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website should the facility be issued a license to operate. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of a licensed facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.