Virginia DSS · Assisted Living Facility

Hampton Manor of Chesapeake

📍 1909 Edinburgh Parkway, Chesapeake, VA, 23322

ID 52653Conditional licenseActive
9
Inspections
On record
5
With violations
Visits that cited something
4
Clean visits
Nothing cited
22
Violations cited
Individual findings
18
Standards cited
Distinct rules
6
Complaint visits
Prompted by a complaint

Hampton Manor of Chesapeake was inspected 9 times between September 10, 2025 and April 21, 2026 by the Virginia Department of Social Services. 5 of those visits ended with violations cited and 4 with none. Across that history VDSS cited 22 violations under 18 distinct standards. 6 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
Conditional
License expires
03/11/2026
Administrator
Steven Wilson
Licensing inspector
Donesia Peoples
Inspector phone
757 353-0430
Approved for
Assisted Living · Special Care Unit

Inspection History

9

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

April 21, 2026Complaint survey0 violations
Inspection dates
04/21/2026
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 IMPAIRMENTS22VAC40-80 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 04/21/2026 at 1:07 pm 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 03/17/2026 regarding allegations in the areas of: Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 32 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: 0 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 3 Observations by licensing inspector: The facility's call signaling system was 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 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.
March 5, 2026Complaint survey1 violation
Inspection dates
03/05/2026
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 IMPAIRMENTS22VAC40-80 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 03/05/2026 at 9:16 am to 2:20 pm. A (complaint) was received by VDSS Division of Licensing on 02/16/2026 regarding allegations in the area(s) of: Staffing and Supervision and Resident Care and Related Services 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: 35 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: 1 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: Medication Pass observation completed. Additional Comments/Discussion: 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)/self-report); 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(s)/self-report) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. 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
22VAC40-73-680-C
Based on the record review 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 medication management plan dated 8/26/21 page 86 states “Medications may be given up to one hour before or up to one hour after the prescribed time to accommodate resident schedules, unless otherwise indicated by the physician.” Photographic evidence is available
  2. Resident’s #1 Medication Variance report for Medication Administration documents resident’s medication: • Amlodipine for Hypertension, • Aspirin for healthy heart, • Buspirone for anxiety/depression, • Centrum for Vitamin D deficiency, • Clopidogrel for cerebrovascular accident, • Donepezil for Alzheimer’s/dementia, • Glipizide for Type 2 diabetes, • Hydrocort for inflammation, • Insulin lispro for Type 2 Diabetes • Lantus Injection for Type 2 Diabetes • Levothyroxin for Hypothyroidism were administered more than one hour after the scheduled times of 6am, 7 am, 8am, and 12 pm on the following dates: 02/07/26, 02/13/26, 02/14/26, 02/18/26, 02/19/26, 02/20/26, 02/22/26, 02/26/26,02/27/26. Photographic evidence is available
  3. During the medication pass observation on 03/05/2026 with staff #1, staff #1 administered the following medications to resident # 2 at 9:18 am, more than one hour after the scheduled time of 8am: • Loratadine for Allergies • Fluoxetine for anxiety/depression • Amlodipine for hypertension • Aspiring Chew Tab • Vitamin B 1 • Vitamin B12 for B12 deficiency • Vitamin D3 for Low Vitamin D • Potassium Chloride for hypokalemia • Multivitamin • Magnesium Oxide for hypomagnesemia • Lorazepam for anxiety
  4. Resident #2’s Medication Variance Report documents the resident was administered medications more than one hour after the scheduled time of 8 am on the following dates: 02/03/26, 02/04/26, 02/12/26, 02/13/26, 02/14/26, 02/18/26, 02/20/26, 02/23/26, 02/24/26, 02/26/26, 02/27/26, 02/28/26, 03/02/26, 03/05/26. Photographic evidence is available
  5. During an interview on 03/05/26 with staff #2, staff #2 confirmed that the medication variance report for resident #1 and resident #2 documents the resident’s medications were administered late during the month of February 2026 and March 2026.
  6. During an interview with resident #3 on 03/05/26 at 10:40 am, resident #3 stated resident #3 had not received their scheduled 8 am medications on 03/05/26.
  7. During an interview with staff #1 on 03/05/26 at 10:50 am, staff #1 confirmed resident #3 had not received their scheduled 8 am medications and staff #1 confirmed resident #3 will be receiving the medications late on 03/05/26 due to staff #1 being assigned to administer morning medications to at least 28 residents in assisted living.
  8. Resident #3’s Medication Variance Report documents resident #3 received the following medications on 03/05/26 at 11:14 am, more than one hour after the scheduled time of 8:00 am: • AZO Cranberry • BC Fast Pain Relief • Energy B12 • Metoprol for hypertension • Multivitamin for supplement • Vitamin D3 for Vit. D Deficiency Photographic evidence is available
Plan of correction
1. Corrective Action Taken • Identified residents (#1, #2, #3) were immediately assessed on 03/05/2026 to ensure no adverse effects from late medication administration. No negative outcomes were noted. • Medications for resident #3 were administered immediately upon discovery of missed/late dose on 03/05/2026. • Medication administration schedules were reviewed and adjusted the same day to ensure timely delivery. 2. Systemic Changes to Prevent Recurrence • The facility revised its medication administration workflow to ensure assignments are balanced and safe, reducing the number of residents assigned per medication aide/nurse during peak medication pass times. • A medication pass audit tool/log has been implemented to track timeliness in real time. • The facility will ensure compliance with its medication management plan and physician orders regarding specific timing requirements (e.g., before/after meals). • More staff were hired and trained. 3. Staff Training • All medication aides and nursing staff received re-education on medication administration policies, including the one-hour before/after rule, on or before April 20, 2026 • Training included time management strategies, prioritization of time-critical medications (e.g., insulin), and documentation requirements. • New hires will receive this training during orientation, and all staff will complete annual competency validation. Staff Training • All medication aides and nursing staff received re-education on medication administration policies, including the one-hour before/after rule, on or before April 20, 2026 • Training included time management strategies, prioritization of time-critical medications (e.g., insulin), and documentation requirements. • New hires will receive this training during orientation, and all staff will complete annual competency validation. 4. Responsible Party • Administrator • Resident Care Director • Licensed Nurse/Resident Services Manager Monitoring Plan • The Resident Care Director or designee will conduct daily medication pass observations for 14 days to ensure compliance with timing requirements. • Weekly medication administration audits (minimum of 10 residents) will be conducted for 60 days. • After 60 days, audits will be conducted monthly for ongoing compliance. • Any identified variances will result in immediate corrective action and retraining of staff as needed. • Audit results will be reviewed in Quality Assurance/Performance Improvement (QAPI) meetings. 5. Date of Compliance Full compliance achieved by: May 10, 2026
March 5, 2026Complaint survey1 violation
Inspection dates
03/05/2026
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 IMPAIRMENTS22VAC40-80 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 03/05/2026 at 7:56 am to 9:15am. 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 02/27/2026 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: 35 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:5 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: Breakfast was observed, and the staffing schedule were 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: 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
22VAC40-73-1130-A
Based on observation and staff interviews 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. For every additional 10 residents, or portion thereof, at least one more direct care staff member shall be awake and on duty in the unit.
Evidence
  1. During the observation of the special care unit on 03/05/26 at 8:00 am to 8:11 am, the Licensing Inspector (LI) observed only one direct care staff (staff #1) on duty in the special care unit. The facility census documents a total of 7 residents on site in the special care unit.
  2. During an interview with staff #1 on 03/05/26 at 8:00 am, staff #1 confirmed to be the only staff on duty in the special care unit starting at 7:00 am on 03/05/26. Staff #1 confirmed 7 residents are on site in the special care unit.
  3. The LI observed staff #2 to arrive on duty in the safe secure unit at 8:11 am on 03/05/26.
  4. During an interview with staff #2 on 03/05/26, staff #2 confirmed staff #2 arrived on duty in the special care unit at 8:11 am and not at the scheduled time of 7:00 am.
Plan of correction
Plan of Correction 1.Immediate Correction: Hampton Manor immediately increased staffing to meet the required ratios for the memory care unit. This involved hiring and training staff who understand dementia care. 2.Correction Including Root Cause Analysis: On the day of the inspection, the third shift staff left the facility before the five staff members scheduled to come in at 7AM arrived. The third shift staff have been retrained, and they and all incoming staff understand they may not leave until the next shift arrives. 3.Systemic Changes: Review and Revision: the facility’s staffing schedule to ensure it consistently meets or exceeds 22VAC40-73-1130 requirements. Scheduler and staff are aware of specific staffing requirements related to 22VAC40-73-1130. 4.Responsible Party: Scheduler responsible for ensuring staffing levels meet or exceed 22VAC40-73-1130. Administrator or designee will audit staff schedules weekly for 90 days, then monthly, to ensure two staff are present on every shift in the special care unit. 5.Completion Date: 5/20/2026
February 10, 2026Complaint survey5 violations
Inspection dates
02/10/2026
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 PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 02/10/2026 at 7:23 am to 2:17 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 01/20/2026 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: 35 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: 4 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 6 Observations by licensing inspector: Breakfast was observed, medication pass observations were completed, and the staffing schedule were 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: 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
22VAC40-73-660-A-1
Based on observation and staff interviews, the facility failed to ensure that the medication cabinet, container, or other designated storage areas for medications and dietary supplements prescribed for residents were kept locked.
Evidence
  1. During the medication pass observation on 02/10/26 at 7:38 am with staff #1, staff #1 left the medication cart located in the safe secure unit, unlocked and unattended.
  2. During an interview with staff #1 on 02/10/26, staff #1 confirmed leaving the medication cart unlocked and unattended in the unlocked medication storage room while the staff left the medication storage room to administer medications to a resident. Photographic evidence is available.
Plan of correction
1. Immediate correction was made with staff #1 upon notification of observation. All staff who distribute medications were in-serviced on this deficiency. 2. Routine cart checks will be conducted by the Director of Nursing and Executive Director while rounding Monday to Friday. Random cart checks will be conducted on weekends and after hours. Any deficient practices will be corrected on the spot in accordance with Hampton Manor policy. 3. The Director of Nursing will be responsible for continuing monitoring of this deficient practice with the Executive Director as an alternative. 4. In-service sheets for current staff will be maintained by the Director of Nursing for this deficiency.
22VAC40-73-670-1
Based on staff record review, resident record review, observation, and staff interview the facility failed to ensure each staff person who administers medication shall be licensed by the Commonwealth of Virginia to administer medications or be registered with the Virginia Board of Nursing as a medication aide.
Evidence
  1. The record for staff #1, hired 12/20/25, does not contain documentation staff #1 meets the standards to administer medications.
  2. During the medication pass observation on 02/10/26 with staff #1, staff #1 administered the following medications to resident #1: • Olanzapine 7.5 mg Tab for Memory • Sertraline 50mg Tab for Depression/Anxiety • Energy B12 for Low Vitamin B12
  3. Resident #1’s medication administration records (MARS) for December 2025, January and February 2026 documents staff #1 administered medications to resident #1 on the following dates: • 12/24/25; 12/25/25 • 01/03/26; 01/08/26; 01/15/26 • 02/05/26; 02/10/26 Photographic evidence is available.
  4. Resident #3’s MARs for January 2026 and February 2026 documents staff #1 administered Humalog KwikPen 100unit/ml for diabetes management on the following on the following dates: • 01/03/26, 01/12/26, 01/20/26, 01/26/27, and 01/27/26, and 02/03/26. Photographic evidence is available.
  5. During an interview on 02/10/26 with staff #1, staff #1 confirmed staff #1 has not been authorized by the Virginia Board of Nursing to administer medications.
  6. The record for staff #2, hired 01/08/26, does not contain documentation staff #2 meets the standards to administer medications.
  7. During the medication pass observation on 02/10/26 with staff #2, staff #2 administered the following medications to resident #2: • Zonisamide CAP 100mg for Seizures • Aspirin 81mg Tab for Healthy Heart • Acetaminophen 325mg Tab for Hip Pain • Levothyroxine 50mcg Tab for Hyperthyroid • Sertraline 50mg Tab for Anxiety • Cetirizine Tab 10mg for Seasonal Allergies • Fluticasone AER 250/50 inhaler for allergies
  8. Resident # 2’s medication administration records (MARS) for January 2026 and February 2026 documents staff #2 administered medications to resident #2 on the following dates: • 01/15/26; 01/16/26; 01/19/26; 01/20/26; 01/22/26; 01/28/26 • 02/02/26; 02/05/26; 02/09/26; 02/10/26 Photographic evidence is available.
  9. Resident #3’s MARs for January 2026 and February 2026 documents staff #2 administered Humalog KwikPen 100unit/ml for diabetes management on the following on the following dates: • 01/22/26, 01/28/26, 02/02/26, 02/09/26, and 02/10/26. Photographic evidence is available.
  10. During an interview on 02/10/26 with staff #2, staff #2 confirmed staff #2 has not been authorized by the Virginia Board of Nursing to administer medications.
  11. The record for staff #3, hired 11/25/25, does not contain documentation staff # 3 meets the standards to administer medications.
  12. Resident #1’s November 2025, December 2025, January 2026, and February 2026 documents staff #3 administered medications to resident #1 on the following dates: • 11/29/25; 11/30/25 • 12/01/25 through 12/13/25 • 12/17/25; 12/18/25; 12/22/25; 12/31/25 • 01/01/26; 01/04/26; 01/06/26 Photographic evidence is available.
  13. The record for staff #5, hired 12/24/25, does not contain documentation staff #5 meets the standards to administer medications.
  14. Resident #1’s December 2025 and January 2026 MARs documents staff #5 administered medication to resident #1 on the following dates: • 12/06/25; 12/31/25 • 01/05/26; 01/07/26; 01/09/26; 01/10/26; 01/19/26 Photographic evidence is available.
  15. Upon request on 02/10/26, and during an interview with staff #4, staff #4 was not able to provide documentation of Staff #1, staff #2, staff #3, and staff #5 as licensed by the Commonwealth of Virginia to administer medications or be registered with the Virginia Board of Nursing as a medication aide and confirmed the staff did not receive authorization from the Virginia Board of Nursing to administer medication.
Plan of correction
1. Immediate correction was made with staff #1, #2, and #3 by removal from medication carts. No staff without the proper certification will be allowed to operate a medication cart. 2. Current staff who wish to operate a medication cart will be required to obtain the proper certification to administer medications. New staff will be required to present appropriate certification to administer medications upon hire. 3. The Director of Nursing will be responsible for continuing monitoring of this deficient practice with the Executive Director as an alternative. 4. Employee certifications will be checked prior to employment and made available upon request.
22VAC40-73-680-D
Based on the record review and staff interview the facility failed to ensure medications shall be administered in accordance with the physician's or other prescriber’s instructions.
Evidence
  1. The record for resident #1 contains the following physician order dated 02/01/26: • Cyanocobalam Injection 1000MCG, Inject 1 ML (1000MCG) intramuscularly every month for Low Vitamin B-12, May only be given by a licensed health professional. Photographic evidence is available.
  2. Resident #1’s December 2025 and January 2026 MARs documents the following: • staff #3 administered the Cyancolobalam injection to resident #1 on 12/06/25. • Staff #5 administered the Cyancolobalam injection to resident #1 on 01/05/26. Photographic evidence is available.
  3. The record for staff #3 does not contain documentation staff #3 is a licensed health professional.
  4. The record for staff #5 does not contain documentation staff #5 is a licensed health professional
  5. Upon request on 02/10/26, and during an interview with staff #4, staff #4 was not able to provide documentation staff #5 is a licensed health professional and confirmed staff #5 is not a licensed health professional.
  6. Resident #3’s physician order dated 02/04/26 includes the following instructions: Humalog Pen 100 unit-Check Blood Sugar (BG) twice daily with meals, Subcutaneously if BG 150-200= 2 Units, 201-250 =4 Units, 251-300=6 Units, 301-350=8 Units, 351-400=10 Units, If Greater 401=12 Units for Diabetes Management. Photographic evidence is available.
  7. Resident #3’s December 2025, January 2026 and February 2026 MARs, documents resident #3 was not administered Humalog according to the physician order on the following dates: • 12/03/26, BG (242) 6 Units Given • 12/29/26, BG (205) 2 Units Given • 01/23/26, BG (153), 1 Unit Given • 01/28/26, BG (216) 2 Units Given • 02/03/26, BG (227) 2 Units Given • 02/08/26, BG (201) 2 Units Given • 02/10/26, BG (146) 2 Units Given Photographic evidence is available.
  8. Staff # 6 reviewed the MARs for resident #3 and confirmed the documentation of the administration of the Humalog was not according to the physician order.
Plan of correction
1. Immediate corrective action was made with staff #3 and #5 by removal from medication carts. No staff without the proper certification will be allowed to operate a medication cart. 2. Current staff who wish to operate a medication cart will be required to obtain the proper certification to administer medications. New staff will be required to present appropriate certification to administer medications upon hire. 3. The Director of Nursing will be responsible for continuing monitoring of this deficient practice with the Executive Director as an alternative. 4. Employee certifications will be checked prior to employment and made available upon request.
22VAC40-73-870-C
Based on observation and staff interview the facility failed to ensure adequate provisions for the collection and legal disposal of garbage, ashes, and waste material shall be made.
Evidence
  1. During observation on 02/10/26 of the outside grounds of the premises of the facility, the Licensing Inspector observed an overflow of trashbags on the outside of the facility’s trash dumpster. Photographic evidence is available.
  2. During an interview with staff #4 on 02/10/26, staff #4 confirmed the trash has not been removed from the inside and outside of the dumpster.
  3. During an interview with staff #7 on 02/10/26, staff #7 confirmed the facility trash pickup has not been completed for at least one month.
Plan of correction
1. Immediate corrections were made with staff #4 contacting the waste management company to satisfy overdue invoices and have refuse collected. 2. The refuse container is on an auto-pay schedule to prevent future disruptions to removal. 3. The Maintenance Director will be responsible for monitoring of refuse area with the Executive Director responsible for ensuring payment of invoices. 4. Routine checks will be made by all staff utilizing the refuse container and visual inspection is available at any time.
22VAC40-73-680-I
Based on the record 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; Any medication errors or omissions.
Evidence
  1. Resident #1’s December 2025, January 2026, and February 2026 MARs does not include staff initials to indicate if the following medications were administered or reason for any omissions on the following dates: • October 2025 and November 2025, one monthly injection of Cyanocobalam for Low Vitamin B-12 • 12/10/25, Doxephin for Sleep and Melatonin for insomnia Photographic evidence is available.
  2. Resident # 2’s December 2025, January 2026, and February 2026 MARs does not include staff initials to indicate if the following medications were administered or reason for any omissions on the following dates: • 12/22/25, 12/24/25, Acetaminophen for Pain; • 12/22/25, 12/24/25, 12/27/25, 12/29/25, Clonazepam for Anxiety; • 12/22/25, 12/24/25, Fluticasone for Allergies, Montelukast for Allergies, Rosuvastatin for Hyperlipidemia. • 01/19/26, Clonazepam for Allergies • 02/07/26, Clonazepam for Allergies Photographic evidence is available.
  3. Resident # 3’s December 2025 and January 2026 MARs does not include staff initials to indicate if the following medications were administered or reason for any omissions on the following dates: • 12/16/25, 12/17/25, 12/25/25, 01/18/26, 01/19/26 for Aspirin; Amlodipine; Calcium Cetirizine; Clopidogrel CO Q 10 CAP; Glimepride; Januvia; Humalog; Levothyroxine; Losartan; Melatonin; Metoprol Pantoprazole; Miralax; Myrebetriq; Pioglitazone, Pregabalin; Quetiapine; Sodium Chloride; Thick It Powder; Vitamin D 3 • 12/22/25, 12/27/25, 12/29/25, 12/20/25, 01/01/26, 01/02/26 01/05/26 for Humalog. Photographic evidence is available
Plan of correction
1. Immediate correction was made with staff responsible for this deficient practice were removed from medication carts. The Primary Care Provider for each resident was notified and follow-up was completed. 2. Current staff who wish to operate a medication cart will be required to obtain the proper certification to administer medications. New staff will be required to present appropriate certification to administer medications upon hire. 3. The Director of Nursing will be responsible for continuing monitoring of this deficient practice with the Executive Director as an alternative. 4. Employee certifications will be checked prior to employment and made available upon request.
February 10, 2026Inspection9 violations
Inspection dates
02/10/2026, 02/11/2026
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced renewal inspection took place on 02/10/26 at 3:15 pm to 4:15pm and 02/11/2026 at 7:50 am to 6:00 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: 35 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 4 Observations by licensing inspector: Breakfast, lunch, and an activity were observed. A medication pass observation was completed for two residents. The following were reviewed: staffing schedule, emergency preparedness drills, medication carts, first aid kits, fire inspection report, certificate of liability insurance, and a health inspection report. 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
22VAC40-73-970-E
Based on the fire drill record review and staff interview the facility failed to ensure a record of the required dire and emergency evacuations drills shall include: • The method used for notification of the drill • Any special conditions stimulated • Weather conditions and problems occurred if any
Evidence
  1. The facility’s fire drill record completed on 01/15/26 does not include the following: • The method used for notification of the drill • Any special conditions stimulated • Weather conditions and problems occurred if any Photographic evidence is available.
  2. During an interview on 02/11/26 with staff #1, staff #1 confirmed the fire drill records did not contain the required documentation.
Plan of correction
1. Immediate Corrective Action Taken • The fire drill conducted on 01/15/2026 was reviewed. • A corrected fire drill record was completed to include: o Method of notification used during the drill o Any special conditions simulated o Weather conditions at the time of the drill o Any problems encountered during the drill • The corrected documentation has been placed on file with the facility’s fire drill records. 2. Correction for All Records A 100% review of all fire and emergency evacuation drill records for the past 12 months was conducted, and new forms created. • Any drill records found to be missing required elements were updated to include: • Method of notification • Special conditions simulated • Weather conditions • Problems encountered (if applicable) • Any missing information that could not be verified was documented as such, and staff were counseled accordingly. 3. Systemic Changes to Prevent Recurrence • The facility has implemented a revised Fire Drill Documentation Form that includes required fields for: • Method of notification • Special conditions simulated • Weather conditions • Problems encountered • A standardized procedure has been established requiring the staff member conducting the drill to complete all sections immediately following each drill. • The Administrator or designee will review each fire drill record within 24 hours of completion to ensure all required documentation is present. Staff Education • All staff responsible for conducting fire and emergency evacuation drills have been re-educated on: o Requirements of 22VAC40-73-970.E o Proper completion of fire drill documentation • Initial training was completed and is ongoing. • Documentation of training attendance is maintained. 4. Responsible Person(s) • Administrator • Maintenance Director 5. Date of Compliance • Full compliance achieved by: May 20, 2026
22VAC40-73-450-C
Based on the record review and staff interview the facility failed to ensure the comprehensive ISP shall include a description of identified needs based upon the UAI.
Evidence
  1. Resident #1’s ISP dated 01/01/26 does not include the following needs identified on the resident’s UAI dated 12/22/25: • mechanical help needed for bathing, toileting, walking, and mobility. Photographic evidence is available.
  2. Resident #4’s ISP dated 12/11/25 does not include the following needs identified on the resident’s UAI dated 8/27/25: • mechanical help in the areas of dressing, toileting, transferring, and eating/feeding. • mechanical and human help in the areas of walking, wheeling, and mobility. • Help needed for housekeeping, laundry, money management, and medication administration. Photographic evidence is available.
Plan of correction
. Immediate Corrective Action Taken Resident #1 and Resident #4’s ISPs were reviewed and updated to include all needs identified in their most current UAIs. 2. Correction for All Records • Care staff were notified of updated ISPs to ensure services are provided according to identified needs. • A full audit of all current resident ISPs will be completed to ensure alignment with each resident’s UAI; any discrepancies found will be corrected immediately.. 3. Systemic Changes to Prevent Recurrence • The facility implemented a UAI-to-ISP crosswalk process to ensure all identified needs are accurately transferred to the ISP. • A standardized ISP Review Checklist has been implemented requiring verification that all UAI-identified needs (including mechanical/human assistance and support services) are addressed in the ISP. • ISPs will be reviewed and updated: • At admission • With any significant change • At least annually • The Resident Services Manager or designee must review and approve all ISPs for completeness prior to implementation for: • Proper interpretation of the UAI • Accurate development of ISPs reflecting all identified needs • Use of the ISP checklist and crosswalk tool Monitoring Plan • The Resident Care Director or designee will conduct weekly audits of 5 resident ISPs for 60 days to ensure all UAI-identified needs are included. • After 60 days, audits will be conducted monthly for continued compliance. • Any discrepancies will be corrected immediately and result in staff retraining as needed. • Audit results will be reviewed through the facility’s Quality Assurance/Performance Improvement (QAPI) process. 4. Responsible Person(s) • Administrator • Resident Services Manager 5. Date of Compliance • Full compliance achieved by: May 20, 2026
22VAC40-73-350-B
Based on the record review and staff interview the facility failed to ensure the assisted living facility shall ascertain, prior to admission, whether a potential resident is a registered sex offender if the facility anticipates the potential resident will have a length of stay greater than three days or in fact stays longer than three days and shall document in the resident's record that this was ascertained and the date the information was obtained.
Evidence
  1. The record for resident # 3, admission date 1/30/26, does not contain record of a sex offender search.
  2. During an interview on 02/11/26 with staff #1, staff #1 confirmed the record for resident #3 did not contain a sex offender search and staff #1 was not able to provide documentation of a sex offender search completed for resident # 3.
Plan of correction
1. Immediate Corrective Action Taken • A sex offender registry search for resident #3 was completed on March 6 and documentation of the search results, including the date obtained, was placed in the resident’s record. 2. Correction for All Records • All current resident records were audited by March 10 to ensure a sex offender registry search had been completed and documented; any missing searches were completed immediately and filed in the record. 3. Systemic Changes to Prevent Recurrence • The facility implemented a mandatory pre-admission checklist that includes completion and documentation of the sex offender registry search prior to admission. • Admissions will not be finalized until verification of the search is completed and documented in the resident record. • A standardized Sex Offender Registry Verification Form has been created to ensure consistent documentation, including date of search and staff signature. • The Administrator or designee will review all admission packets for completeness prior to final acceptance. 4. Responsible Person(s) • Administrator 5. Date of Compliance • Full compliance achieved by: May 1, 2026
22VAC40-73-320-A
Based on the record review and staff interview the facility failed to ensure within the 30 days preceding admission, a person shall have a physical examination by an independent physician. The report of such examination shall be on file at the assisted living facility and shall contain the following: A statement that the individual does not have any of the conditions or care needs prohibited by 22VAC40-73-310 H; 11; A statement that specifies whether the individual is considered to be ambulatory or nonambulatory as defined in this chapter; A statement that specifies whether the individual is or is not capable of self- administering medication.
Evidence
  1. The record for resident #1, admission date 12/23/25, does not contain a physical examination completed within 30 days prior to the resident’s admission to the facility. The physical exam in the record is dated as completed on 11/11/25. Photographic evidence is available.
  2. Upon request on 02/11/26, staff #1 was not able to provide a physical examination completed 30 days prior to resident #1’s admission to the facility.
  3. The record for resident #3 contains a physical examination report dated 01/06/26, 01/07/26, and 01/27/26. • The physical examination reports does not include the following: A statement that the individual does not have any of the conditions or care needs prohibited by 22VAC40-73-310 H; 11; • A statement that specifies whether the individual is considered to be ambulatory or nonambulatory as defined in this chapter; • A statement that specifies whether the individual is or is not capable of self- administering medication. Photographic evidence is available.
  4. Upon request on 02/11/26, staff #1 confirmed the physical examination reports for resident #3 did not contain a statement that specified the following: • A statement that the individual does not have any of the conditions or care needs prohibited by 22VAC40-73-310 H; 11; • A statement that specifies whether the individual is considered to be ambulatory or nonambulatory. • A statement that specifies whether the individual is or is not capable of self- administering medication.
Plan of correction
1. Immediate Corrective Action Taken • Resident #1 Current Resident Services Manager will reach out to PCP to obtain most Recent Progress note to confirm current diagnosis, PMHX, Ambulatory status, Allergies, DNR status, Diet and Medication reconciliation. • Resident #3’s POS was reviewed on April 14th, 2026 by internal NP. 2. Corrective Action for all Records All current resident records will be audited to verify that physical examinations were completed timely and contain all required elements; any deficiencies identified will have follow-up with physicians. 3. Systemic Changes to Prevent Recurrence • The facility implemented a pre-admission checklist requiring verification of a complete physical examination within 15 days prior to admission before a resident is accepted. • A standardized Physical Examination Review Form has been implemented to ensure all required components are present: o Statement regarding prohibited conditions o Ambulatory/non-ambulatory status o Ability to self-administer medications • Admissions will not be finalized until all required documentation is complete and verified by the Administrator or designee. Staff Training • Administrative staff and those responsible for admissions were re-educated on 22VAC40-73-320(A) requirements. • Training included review of required physical exam components, timelines, and documentation standards. • Staff were trained on use of the new admission checklist and audit tools. • Ongoing training will occur during orientation and annually thereafter. 4. Responsible Person(s) • Administrator • Resident Services Manager • Admissions and Marketing Manager Monitoring Plan • The Administrator or designee will review 100% of all new admissions for 60 days to ensure compliance with physical examination requirements. • A monthly audit of 10% of resident records will be conducted for 3 months to ensure continued compliance. • Any discrepancies will be addressed immediately with corrective action and staff retraining. • Results will be reviewed during Quality Assurance/Performance Improvement (QAPI) meetings. 5. Date of Compliance • Full compliance achieved by: May 20, 2026
22VAC40-73-450-E
Based on the record review the facility failed to ensure the individualized service plan (ISP) shall be signed and dated by the licensee, administrator, or his designee (i.e., the person who has developed the plan), and by the resident or his legal representative.
Evidence
  1. The record for resident #4 contains an ISP dated 12/11/25. The ISP is not signed and dated by the person who developed the plan and the resident or legal representative. Photographic evidence is available.
  2. During an interview on 02/11/26 with staff #2, staff #2 confirmed the ISPs for resident #4 was not signed by the person who signed the plan and the resident or legal representative.
Plan of correction
1. Immediate Corrective Action Taken Resident #4’s ISP was reviewed, and will be updated as needed, and properly signed and dated by the responsible staff member and the resident/legal representative. 2. Correction for All Records A full audit of all current resident ISPs will be completed to ensure all ISPs are signed and dated appropriately; any missing signatures were obtained immediately. 3. Systemic Changes to Prevent Recurrence • The facility implemented a standardized ISP completion checklist requiring verification of all required signatures and dates prior to finalizing the ISP. • ISPs will not be considered complete or implemented until all required signatures are obtained. • A tracking log has been established to monitor ISP completion, including signature compliance. • The Resident Care Manager or designee will review and approve all ISPs for completeness, including required signatures, prior to filing. 4. Responsible Person(s) • Administrator • Resident Services Manager • Resident Care Coordinator 5. Date of Compliance • Full compliance achieved by: May 20, 2026
22VAC40-73-720-A
Based on the record review and staff interview the facility failed to ensure Do Not Resuscitate (DNR) Orders for withholding cardiopulmonary resuscitation from a resident in the event of cardiac or respiratory arrest may only be carried out in a licensed assisted living facility when the written order is included in the individualized service plan.
Evidence
  1. The record for resident #4 contains a DNR order dated 10/26/2021. The DNR is not included in the resident’s ISP dated 12/11/25. Photographic evidence is available.
  2. During an interview on 02/11/26 with staff #2, staff #2 confirmed the ISP for resident #4 does not include the resident’s DNR order.
Plan of correction
1. Immediate Corrective Action Taken • For Resident #4: A legible copy of the DNR was obtained, placed in the record, and provided to hospice. 2. Correction for All Records • A 100% audit of all current residents’ AD and DNR choices will be reviewed an updated, as necessary. 3. Systemic Changes to Prevent Recurrence Staff Education • All relevant staff have been educated on: o Requirements of DNR 4. Responsible Person(s) • Resident Services Manager • Resident Care Coordinator 5. Date of Compliance • Full compliance achieved by: May 20, 2026
22VAC40-73-690-G
Based on the record review and staff interview the facility failed to ensure action taken in response to the recommendations noted in subsection F of this section (medication review) shall be documented in the resident’s record. 1. The record for resident #2 contains a pharmacy review dated 01/08/26 that includes a recommendation to clarify location of administration for the following physician order: Dicolefenac gel 1% apply 2 GM topically to affected area four times a day. The resident’s record did not include documentation of any action taken in response to the recommendations on the medication review. Photographic
Evidence
  1. is available.
  2. Resident #2’s physician orders dated 02/01/26, January and February 2026 Medication Administration Records (MARS) did not include an update based upon the medication review completed 01/08/26. Photographic evidence is available.
  3. During an interview on 02/11/26 with staff #2, staff #2 was not able to provide documentation of the actions taken in response to resident #2’s medication review recommendations dated 01/08/26.
Plan of correction
1. Immediate Corrective Action Taken for Resident #2: • The pharmacy recommendation dated 01/08/2026 regarding clarification of the administration site for Diclofenac gel 1% was reviewed. • The prescribing physician was contacted and clarification was obtained specifying the exact location of application. • The physician’s order was updated to include the clarified administration site. • The Medication Administration Record (MAR) was updated to reflect the revised order. • Documentation of the action taken in response to the pharmacy recommendation has been completed and entered into Resident #2’s record. 2. Correction for All Records Identification of Other Residents with Potential for Same Deficiency • A 100% audit of all resident records was conducted. All POS for internal NP were reviewed and provided on April 8, 2026. POS have been returned signed. Awaiting return of external POS from external providers. 3. Systemic Changes to Prevent Recurrence • The facility has implemented a standardized process for handling pharmacy medication reviews that includes: • Logging all pharmacy recommendations upon receipt • Reviewing recommendations within 72 hours • Documenting actions taken directly in the resident record 4. Responsible Person(s) • Resident Services Manager • Administrator 5. Date of Compliance • Full compliance achieved by: May 20, 2026
22VAC40-73-680-D
Based on the medication pass observation, record review, and staff interview the facility failed to ensure medications shall be administered in accordance with the physician's or other prescriber’s instructions.
Evidence
  1. During the medication pass observation on 02/11/26 with staff # 3. The Licensing Inspector (LI) observed staff #3 crush the following medications and mix the crushed medications in applesauce prior to administering medications to resident #2: • Vitamin D3 1000U Tab for Vitamin D deficiency • Bupropion 300MG XL Tab for Major Depression • Amlodipine 5mg Tab for Hypertension • Buspirone 10mg Tab for Anxiety • Quetiapine 50mg Tab for Dementia The resident’s record does not contain a physician order to crush the above referenced medications and to mix with applesauce.
  2. Resident #2’s physician order dated 02/01/26 includes the following do not crush order: • Bupropion 300mg XL Tab, Do Not Crush Photographic evidence is available.
  3. The facility’s medication management plan states the Resident Care Manager/Nurse shall obtain a physician’s order prior to crushing a resident’s medication. Photographic evidence is available.
  4. During an interview on 02/11/26 with staff #2, staff #2 confirmed the facility did not have record of a physician order to crush medications for resident #2.
Plan of correction
1. Immediate Corrective Action Taken • Immediate intervention occurred, and staff were instructed to stop crushing medications without a physician’s order. • Resident #2’s physician was notified, and clarification orders regarding medication administration (including crushing, if appropriate) were obtained on April 14, 2026. • Resident #2 was assessed for any adverse effects from improper medication administration; no adverse outcomes were identified. 2. Correction for All Records A full audit of all residents receiving crushed medications was completed by April 20, 2026 to ensure physician orders were in place; any discrepancies were corrected immediately. 3. Systemic Changes to Prevent Recurrence • The facility implemented a Medication Crushing Verification Process requiring: • Verification of a physician’s order prior to crushing any medication • Review of medication labeling for “Do Not Crush” status • The Medication Administration Record (MAR) review process now includes verification of special instructions (e.g., crushing, food mixing). • The Resident Care Manager or designee will review all new physician orders for clarity regarding medication administration methods. • The designation “crushed in pudding or apple sauce” was added to applicable orders. Staff Training • All medication aides and licensed staff were re-educated on 22VAC40-73-680(D) requirements. • Training included: o Adherence to physician orders o Risks associated with crushing medications (especially extended-release medications like Bupropion XL) o Proper procedures for obtaining physician authorization o Review of the facility’s medication management plan • Competency evaluations were completed following training. • Ongoing education will be provided annually and as needed. 4. Responsible Person(s) • Administrator • Resident Services Manager • Resident Care Coordinator 5. Date of Compliance • Full compliance achieved by: May 20, 2026
22VAC40-73-450-A
Based on the record review and staff interview the facility failed to ensure 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 is developed, in conformance with this section, on the day of admission.
Evidence
  1. The record for resident #1, admission date 12/23/25 does not contain a preliminary plan of care completed on or within 7 days prior to the day of admission nor a comprehensive ISP completed on the day of admission. The ISP in the record is dated as completed on 01/01/26, after the resident’s admission. Photographic evidence is available.
  2. During an interview on 02/11/26 with staff #2, staff #2 confirmed a preliminary plan of care on or within 7 days prior to the day of admission nor a comprehensive ISP on the day of admission was not completed for resident #1.
Plan of correction
1. Immediate Corrective Action Taken • Resident #1’s comprehensive ISP was reviewed and updated to ensure all current needs are addressed and services are being provided appropriately. • A retrospective review confirmed no adverse outcomes occurred related to the absence of a preliminary plan of care. 2. Correction for All Records • A full audit of all residents admitted within the past 60 days will be completed to verify compliance with preliminary plan of care and ISP timing requirements; any identified deficiencies were corrected immediately. 3. Systemic Changes to Prevent Recurrence • The facility implemented a mandatory admission protocol requiring: • Completion of a preliminary plan of care within 7 days prior to admission OR • Completion of a comprehensive ISP on the day of admission • A standardized Preliminary Plan of Care Form has been implemented to ensure all basic needs (health, safety, and welfare) are addressed prior to admission. • Admissions will not be finalized until required documentation is verified as complete by the Administrator or designee. • An admission tracking log has been established to monitor timelines and ensure compliance with all admission requirements. 4. Responsible Person(s) • Administrator • Resident Services Manager 5. Date of Compliance • Full compliance achieved by: May 20, 2026
February 10, 2026Complaint survey0 violations
Inspection dates
02/10/2026
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 PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 02/10/2026 at 2:18 pm to 3:15 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 01/18/2026 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: 35 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: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: The facility's call signaling system was 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 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.
February 10, 2026Complaint survey0 violations
Inspection dates
02/10/2026
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 PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 02/10/2026 at 3:16 pm to 3:50 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 01/15/2026 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: 35 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: 1 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: An activity 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.
November 7, 2025Inspection6 violations
Inspection dates
11/07/2025
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 IMPAIRMENTSARTICLE 1 – SUBJECTIVITY22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE
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 11/07/2025 from 10:50 am to 2:40 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: 23 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: 2 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: Lunch and an activity were observed. A medication pass observation was completed. The following were reviewed: staffing schedule, and first aid kits. The 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. 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-A
Based on the review and staff interview the facility failed to ensure the preliminary plan of care shall be signed and dated by the resident or his legal representative.
Evidence
  1. Resident #1’s preliminary plan of care completed on 09/26/25 is not signed and dated by the resident or legal representative.
  2. Resident # 2’s preliminary plan of care completed on 10/03/25 is not signed and dated by the resident or legal representative.
  3. Resident # 3’s preliminary plan of care completed on 10/01/25 is not signed and dated by the resident or legal representative.
  4. During an interview on 11/07/25 with staff #4, staff #4 confirmed the preliminary plan of care for residents #1, #2, and #3 are not signed by the resident or legal representative.
Plan of correction
1. Immediate Correction: Preliminary care plans for Residents #1, #2, and #3 are being re-issued and will be signed and dated by the residents or legal representatives. 2. Correction for All Records: All residents’ charts were reviewed. Unsigned preliminary care plans are being corrected and will be filed upon receipt. 3. Systemic Prevention: A new Admissions Signature Verification Form has been added for verification of preliminary care plans and signatures. 4. Responsible Party: Administrator / DON / Admissions Coordinator 5. Completion Date: 12/21/2025
22VAC40-73-250-D
Based on the record review and staff 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 prior to coming in contact with residents shall 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. The record for staff #1, first day of work with residents (09/15/25), contains a risk assessment for TB dated as completed 03/23/25. The staff record did not contain a risk assessment for TB no older than 30 days from the first day of work with residents.
  3. The record for staff #2, first day of work with residents (09/15/25), did not contain a risk assessment for TB.
  4. Upon request, and during an interview with staff #4. Staff #4 was not able to provide a risk assessment for TB completed for staff #1 completed no older than 30 days and a risk assessment for TB completed for staff #2.
Plan of correction
1. Immediate Correction: Staff #1 and #2 are no longer working for the facility: TB risk assessments and screening forms for Staff #1 and #2 are not being requested. 2. Correction for All Records: A TB record audit was completed. Any missing or outdated TB assessments are being completed and filed upon receipt. A 30-Day New Hire Medical Compliance Checklist has been added to onboarding. 3. Systemic Prevention: 3. Weekly audits for 30 days will ensure TB risk assessments are completed before the first day of resident contact. 4. Responsible Party: Director of Nursing (DON) / Administrator 5. Completion Date: 12/21/2025
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 #5, hire date 08/25/25, does not contain a criminal history report. The staff record contains a criminal history search on 09/13/25, however the results are not included.
  2. The record for staff #6, hire date 07/14/25 does not contain a criminal history report.
  3. Upon request, and during an interview on 11/07/25 with staff #4. Staff #4 was not able to provide a criminal history report for staff #5 and staff #6.
Plan of correction
1. Immediate Correction: Criminal history results for Staff #5 and #6 have not been obtained or re-requested as the staff members no longer work at the facility. Any staff no longer employed were removed from active roster and documented as such. 2. Correction for All Records: A full review of all personnel files was conducted. Any criminal history results missing from the files were re-run and will be filed upon receipt. 3. Systemic Prevention: Criminal history checks are submitted within 24 hours of hire and documented in files upon receipt of results. 4. Responsible Party: Administrator / HR Coordinator 5. Completion Date: 12/10/2025
22VAC40-73-450-C
Based on the record review and staff interview the facility failed to ensure the comprehensive individualized service plan (ISP) shall be completed within 30 days after admission.
Evidence
  1. The record for resident #1, admission date 09/26/25, contains a preliminary plan of care completed on 09/26/25. The resident’s record does not contain a comprehensive ISP.
  2. The record for resident #2, admission date 10/03/25, contains a preliminary plan of care completed on 10/03/25. The resident’s record does not contain a comprehensive ISP.
  3. The record for resident #3, admission date 10/01/25, contains a preliminary plan of care completed on 10/01/25. The resident’s record does not contain a comprehensive ISP.
  4. Upon request, and during an interview on 11/07/25 with staff #4, staff #4 confirmed a comprehensive ISP was not completed for residents #1, #2, and #3.
Plan of correction
1. Immediate Correction: Comprehensive ISPs for Residents #1, #2, and #3 are being completed and signed and will be filed upon receipt. 2. Correction for All Records: A full audit was conducted to verify ISP completion dates. 3. Systemic Prevention: The DON/Designated Person will maintain a 30-Day ISP Tracker for every new admission. The Administrator will conduct a weekly ISP compliance audit. 4. Responsible Party: DON / Administrator 5. Completion Date: 12/21/2025 Certification Hampton Manor of Chesapeake affirms that all corrections will remain in compliance and staff will be trained on all updated admission, HR, and compliance processes.
22VAC40-90-30-B
Based on the record review and staff interview the facility failed to ensure the sworn statement or affirmation shall be completed for all applicants for employment.
Evidence
  1. The record for staff #7, hire date 08/01/25, does not contain a sworn statement or affirmation.
  2. Upon request, and during an interview on 11/07/25 with staff #4. Staff #4 was not able to provide a sworn statement or affirmation completed for staff #7.
Plan of correction
1. Immediate Correction: Sworn statements/affirmations for Staff #7 are complete and filed as of 12/05/2025. 2. Correction for All Records: A full audit of all employee files was completed on 12/05/2025 to identify any missing sworn statements or affirmations. All missing sworn statements are in the process of being obtained and placed in current personnel files. 3. Systemic Prevention: A new Pre-Employment Compliance Checklist has been implemented. HR and the Administrator must verify sworn statements are completed before the employee’s first day of work. No employee will be added to the schedule until the checklist is complete. 4. Responsible Party: Administrator / HR Coordinator 5. Completion Date: 12/21/2025
22VAC40-73-320-A
Based on the record review and staff interview the facility failed to ensure within 30 days preceding admission, a person shall have a physical examination by an independent physician. The report of such examination shall be on file at the assisted living facility and shall contain the following: Results of a risk assessment documenting the absence of tuberculosis (TB) in a communicable form as
Evidence
  1. d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence:
  2. The record for resident #1, admission date 09/26/25, does not contain a physical exam and a risk assessment for TB completed 30 days prior to the resident’s admission.
  3. Resident #1’s physical exam and risk assessment for TB is dated as completed on 03/18/25.
  4. Upon request and during an interview on 11/07/25 with staff # 4. Staff #4 was not able to provide a physical exam and risk assessment for TB completed within 30 days prior to resident #1’s admission to the facility.
Plan of correction
1. Immediate Correction: Resident #1’s physical exam and TB assessment has been requested from the physician and will be added to the record upon receipt. Any residents missing pre-admission medical forms were contacted and required forms will be filed upon receipt. 2. Correction for All Records: A full audit of all current residents’ medical admission files has been completed. Missing physicals or TB assessments are being requested and will be filed upon receipt. 3. Systemic Prevention: A mandatory Admission Packet Checklist will be completed before a resident moves in. Admissions will not proceed until physical exam and TB assessment (no older than 30 days) are in hand. 4. Responsible Party: Administrator / Admissions Coordinator / DON 5. Completion Date: 12/21/2025
September 10, 2025Inspection0 violations
Inspection dates
09/10/2025
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 IMPAIRMENTS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS
Technical assistance
22VAC40-73-850-G General Requirements
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 09/10/2025 at 9:30 am to 12:16 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: 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 call signaling system was monitored. 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.