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Public Google reviewers rate Commonwealth Senior Living at Hampton highly. Reviewers highlight: compassionate and dedicated individual caregivers, welcoming, family-oriented atmosphere. Reviewer identity is not verified, and online reviews may not capture everything. Schedule a visit to assess the fit directly.
Families will find a community praised for its warm, family-like atmosphere and several standout individual caregivers who provide compassionate care. However, there are serious, recurring allegations regarding hygiene standards, staff training in memory care, and a critical reported pest issue involving bedbugs.
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Key Review Excerpts
“The staff is excellent! I witnessed one of the staff member calm a resident down. The resident ended up giving the staff member a hug.”
“CSL has far exceeded all our expectations. We are very pleased with the facility, with the leadership team and with staff… and Mom is adjusting well… it is truly a relief to visit, see the interactions and to leave trusting that Mom will be taken care of.”
“This is a special shout out to Elma Livingston the best nurse I’ve ever had the pleasure of knowing she literally saved my moms life twice and that is no exaggeration !!”
Source: VA State Licensing Agency
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: 09/12/2025 (arrival 11:30 a.m. / departure 2:35 p.m.) The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 07/09/2025 regarding allegations in the area(s) of: Building and Grounds Number of residents present at the facility at the beginning of the inspection: 75 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 interviews conducted with residents: 0 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Darunda Flint, Licensing Inspector at 757-807-9731 or by email at Darunda.a.flint@dss.virginia.gov
Based on facility documentation and staff interviewed, the facility failed to ensure the building was kept free of infestations of insects and vermin. Evidence: 1. On 09/12/2025 during an inspection regarding bedbugs in the facility, facility staff #1 acknowledged the facility had sought treatment for bedbugs. On 9/12/2025, pest control invoices provided documented treatment for bedbugs that was completed on the following dates: On 07/21/2025, bed bugs were noted during treatment in room 110 on the bed. On 07/22/2025, bed bugs were noted during treatment on the bed and box spring of room 110. 2. The kitchen was inspected and serviced for cockroaches on 09/12/2025. Pest control invoices documented that there were cockroaches noted during the service in the kitchen at the dishwasher.
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: 09/12/2025 (arrival 11:30 a.m. / departure 2:35 p.m.) The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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: 09/12/2025 (arrival 11:30 a.m. / departure 2:35 p.m.) 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 07/11/2025 regarding allegations in the area(s) of: Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 75 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 interviews conducted with residents: 3 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Darunda Flint, Licensing Inspector at (757) 807-9731 or by email at darunda.a.flint@dss.virginia.gov
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: 06/05/2025 ( arrival 9:55 a.m. / departure 1:38 p.m.) The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 05/30/2025 regarding allegations in the area(s) of: Personal care Services and general supervision and care. Number of residents present at the facility at the beginning of the inspection: 83 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: 1 Number of interviews conducted with staff: 5 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Darunda Flint, Licensing Inspector at (757) 807-9731 or by email at Darunda.a.flint@dss.virginia.gov
Based on records reviewed and staff interviewed, the facility failed to ensure individualized service plan ( ISP
Based on the record review the facility failed to ensure six months after placement and annually thereafter, the licensee, administrator or designee shall perform a review of the appropriateness of each resident?s continued residence in the special care unit. Evidence: 1. The record for resident #1 did not contain an annual review of appropriateness of placement and continued residence in the special care unit. The last documented review was dated 05/13/2023
Based on document reviewed and staff interviewed, the facility failed to ensure the findings of the most recent inspection of the facility was posted on the premises. Evidence: 1. On 06/05/2025 during a tour of the facility, the most recent inspection posted in the facility was dated 08/20/2024 and 08/29/2024. 2. Staff #2, acknowledged the most recent inspection was not posted on the premises.
Based on resident record review, the facility failed to ensure the Uniform Assessment Instrument ( UAI
Based on facility self-report and interviews, the facility failed to assume general responsibility for the health, safety and wellbeing of one resident. Evidence: 1. Staff #8 notified the licensing inspector (LI) on 05/30/2025 via an email regarding an incident that occurred at the facility on 05/29/2025 at approximately 8:56 pm. The incident involved memory care resident #1 who exited the gated memory care outdoor area. The resident was escorted back into the community at approximately 9:15 pm. 2. In an interview conducted on 06/05/2025, staff #1 reported it was believed resident #1 eloped out of the memory care courtyard through an unlocked gate. 3. The LI reviewed a 05/29/2025 facility video that showed resident #1 exit the open door in the memory care unit dining area that led to the memory care courtyard. 4.In an interview conducted on 06/10/2025, staff #9 confirmed in an interview with LI on 06/10/2025 that resident #1 eloped from the memory care unit on 05/29/2025. Staff #9 reported to the LI that staff #10 took the initial call report that alerted the facility that resident #1 had eloped from the facility. 5. In an interview conducted on 06/24/2025, a collateral contact reported resident #1 was on their property on 05/29/2025. The collateral contact reported that the resident appeared to be confused. The collateral contact reported that they took the resident into their building. The collateral contact advised staff to contact the facility to see if they had a missing resident by the name that resident #1 provided as their name. 6. In an interview conducted on 06/17/2025, staff #10 reported a call was received on 05/29/2025 from the business next door indicating there was a resident at their property who may live at the facility. Staff #10 accompanied staff #9 to the property next door. They retrieved resident #1 and returned to the facility.
Based on observation, the facility failed to develop and implement a procedure for posting the name of the current on-site person in charge, as provided for in this chapter, in a place in the facility that is conspicuous to the residents and the public. Evidence: 1. Upon entry on 06/05/2025, the facility did not have the designated current on-site person in charge posted. 2. Staff #2 acknowledged the aforementioned was not posted.
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: 04/01/2025 (arrival 10:03 a.m. / departure 3:36 p.m.) The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 03/31/2025 regarding allegations in the area(s) of: Part VIII Buildings and Grounds Number of residents present at the facility at the beginning of the inspection: 83 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: Number of interviews conducted with residents: Number of interviews conducted with staff: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Darunda Flint, Licensing Inspector at (757)-807-9731 or by email at Darunda.a.flint@dss.virginia.gov
Based on documents and staff interviewed, the facility failed to ensure the building was kept free of infestations of insects and vermin. Evidence: 1. On 04/01/2025 during an inspection regarding bedbugs in the facility, staff #1 and staff #2 acknowledged the facility was being treated for bedbugs. 2. On 04/01/2025, pest control invoices provided documented treatment for bedbugs was completed on 03/31/2025. 3. On 04/10/2025, the licensing inspector received pest control invoices from the facility that documented bed bugs were found in a resident?s room and the facilities main lobby.
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 04/01/2025 (arrival 10:03 a.m. / departure 3:36 p.m.) and 04/02/2025 ( arrival 9:36 a.m. / departure 3:52 p.m.) The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 83 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: Lunch was observed. A medication pass observation was completed for three residents. The following was reviewed: emergency preparedness drills, fire inspection report, health inspection report, first aid kit, and water temperatures were measured. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Darunda Flint, Licensing Inspector at (757) 807-9731 or by email at Darunda.a.flint@dss.virginia.gov
Based on record review, the facility failed to ensure a physical examination by an independent physician be completed within 30 days preceding admission and contain the items identified in the standard. Evidence: 1. Resident #2?s date of admit was 07/01/2024.The physical examination for resident #2 was completed on 04/25/2024.
Based on observation, the facility failed to develop and implement a procedure for posting the name of the current on-site person in charge, as provided for in this chapter, in a place in the facility that is conspicuous to the residents and the public. Evidence: 1. Upon entry on 04/01/2025, the facility did not have the designated current on-site person in charge posted.
Based on staff records reviewed, the facility failed to ensure each staff person?s tuberculosis (TB) risk assessment be completed annually. Evidence: 1.Staff #1?s record included a TB risk assessment that did not provide documentation of the assessment date, and the name and signature of the person completing the assessment. 2.Staff #4 acknowledged the staff #1?s TB risk assessment did not provide aforementioned.
Based on records reviewed and staff interviewed, the facility failed to ensure individualized service plan ( ISP
Based on the record review the facility failed to ensure six months after placement and annually thereafter, the licensee, administrator or designee shall perform a review of the appropriateness of each resident?s continued residence in the special care unit. Evidence: 1.Resident #1?s date of admit was 04/04/2024.The record for resident #1 did not contain a six-month review of appropriateness of placement; and the record for resident #1 did not contain an annual review. 2. Staff #4 acknowledge resident #1?s record did not contain the aforementioned reviews.
Based on observation and staff interviewed, the facility failed to ensure the first aid kit included all required items. Items with expiration dates must not have dates that have already passed. Evidence: 1. The first aid kit in the building was checked with staff #1. The first aid kit did not have a first aid manual and extra batteries. 2. Staff #1 acknowledged the items were not in first aid kit.
The facility failed to develop and implement an orientation and semi-annual review on the emergency preparedness and response plan for all staff, residents, and volunteers, with emphasis placed on an individual?s respective responsibilities. The review shall be documented by signing and dating. Evidence: 1. Staff #1 could not provide documentation of a semiannual review of the emergency preparedness and response plan for residents.
Based on staff record review, the facility failed to ensure in a facility licensed for both residential and assisted living care, all direct care staff shall attend at least 18 hours of training annually. Evidence: 1. Staff #3?s record did not contain 18 hours of training annually. 2. Staff #1 acknowledged that staff #3?s did not have the aforementioned annual training hours.
Based on staff interviewed and records reviewed, the facility failed to develop a written emergency preparedness and response plan that shall address documentation of initial and annual contact with the local emergency coordinator to determine (i) local disaster risks, (ii) communitywide plans to address different disasters and emergency situations, and (iii) assistance, if any, that the local emergency management office will provide to the facility in an emergency. Evidence: 1.Staff #1 could not provide annual documentation of emergency preparedness review with a local emergency coordinator.
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: 1/30/2025 (arrival 10:24 a.m. / departure 6:10 p.m.) The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 12/11/24 regarding allegations in the area(s) of: 1.) Resident Care and Related Services 2.) Staffing and Supervision Number of residents present at the facility at the beginning of the inspection: 86 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 : 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); 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) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Darunda Flint, Licensing Inspector at (757) 807-9731 or by email at Darunda.a.flint@dss.virginia.gov
Based on record review, the facility failed to ensure that on or within seven days prior to the day of admission a preliminary plan of care is developed. Evidence: 1. Resident #3 was admitted to the facility on 12/20/2024. There was no preliminary service plan in the resident record. 2. Staff #1 acknowledged there was no preliminary service plan in resident #3?s record.
Based on record reviewed and staff interviewed, the facility failed to ensure the resident?s physical examination and risk assessment was completed prior to admission. Evidence: 1. Resident #3?s TB assessment was incomplete and was not dated. The resident?s date of admit was noted as 12/20/2024.
Based on the record review the facility failed to ensure the individualized service plan ( ISP
Based on record reviewed and staff interviewed, the facility failed to ensure, prior to admission the assisted living facility, the administrator provided written assurance to the resident that the facility has the appropriate license to meet the care needs at the time of admission. A signed copy by the resident and or legal representative shall be kept in the resident?s record. Evidence: 1.Resident #3?s written assurance was not signed by the resident and/ or legal representative. The resident?s date of admit was noted as 12/20/2024.
Based on record review the facility failed to ensure that personal assistance and care are provided to each resident as necessary so that the needs of each resident are met, including assistance or care with bathing at least twice a week, but more often if needed or desired. Evidence: 1. Resident #1 was scheduled to receive baths on Mondays and Thursdays. The following are the documented completion or attempts of bathing for resident #1 in the month of December 2024: 12/02/2024, and 12/09/2024. 2. Resident #2 was scheduled to receive baths on Wednesdays and Saturdays. The following are the documented completion or attempts of bathing for resident #2 in the month of December 2024: 12/04/2024, 12/11/2024, 12/18/2024, and 12/21/2024. 3. Resident #4 was scheduled to receive baths on Mondays and Thursdays. The following are the documented completion or attempts of bathing for resident #4 in the month of December 2024: 12/12/2024, 12/26/2024, and 12/30/2024. 4. The documentation for resident #1, resident #2, and resident #4 does not indicate the resident received or attempted to receive bathing at least twice a week.
Based on the record review the facility failed to ensure six months after placement and annually thereafter, the licensee, administrator or designee shall perform a review of the appropriateness of each resident?s continued residence in the special care unit. Evidence: 1. The record for resident #2, did not contain a six-month review of appropriateness of placement for continued residence in the special care unit. Resident #2 admitted into the special care unit on 04/26/2024. 2. The record for resident #4 did not contain an annual review of appropriateness of placement and continued residence in the special care unit. The last documented review was dated 08/03/2023. 3. Staff #1 acknowledged the records for residents #2 and #4 did not contain the aforementioned documents.
Based on the record review the facility failed to ensure prior to placing a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia in a safe, secure environment, the facility shall obtain the written approval of one of the following persons: the resident, guardian, legal representative, or an independent physician Evidence: 1.Resident #2?s record includes an admission date of 04/26/24 into the safe, secure unit. During the record review, the record did not include documentation of a written approval of placement in the safe secure environment that was dated by the resident, guardian, or legal representative. Staff#1 acknowledged resident #2?s written approval of placement in the safe secure environment was not dated by the resident, guardian, legal representative, or relative. 2. Resident #3?s record includes an admission date of 12/20/2024 into the safe, secure unit. Resident #3?s record did not include documentation of a written approval of placement in the safe secure environment signed by the resident, guardian, or legal representative. Staff #1 acknowledged the record for resident #3 did not include a written approval for placement in the safe, secure unit signed by the resident, guardian, or legal representative,
Based on record review, the facility failed to ensure for private pay individuals, the administrator or the administrator's designated representative approves and then signs the completed UAI
Based on record reviewed and staff interviewed, the facility failed to ensure when hospice care is provided to a resident, the assisted living facility and the licensed hospice organization shall communicate and establish an agreed upon coordinated plan of care for the resident. The services provided by each shall be included on the individualized service plan ( ISP
Based on record review, the facility failed to ensure the licensee, administrator, or designee determine whether placement in the special care unit is appropriate for a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia to a safe, secure environment. Evidence: 1.Resident #3 did not have documentation of the determination and justification on whether placement in the special care unit is appropriate by the licensee, administrator, or designee in their record. 2. Staff #1 acknowledged there was no documentation of the aforementioned in #3?s record.
Based on observation, the facility failed to ensure the interior and exterior of all buildings shall be maintained in good repair and kept clean and free of rubbish. Evidence: 1. The ceiling tile in the hallway next to the beauty shop had a brown circular stain on it. The ceiling tile in the hallway next to the memory care unit?s dining area had a brown circular stained. 2. Staff #1 acknowledge the aforementioned ceiling tiles were stained.
Based on records reviewed and staff interviewed, the facility failed to ensure upon admission, it would provide an orientation for new residents and their legal representatives. Acknowledgement of having received the orientation shall be signed and dated by the resident and as, appropriate, his legal representative, and such documentation shall be kept in the resident?s record. Evidence: 1. Resident #3 was admitted to the facility on 12/20/2024. There was no acknowledgement of orientation in the resident?s record. 2. Staff #1 acknowledged there was no acknowledgement of orientation in resident #3?s record.
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: 08/29/2024 (arrival 10:30 a.m./ departure 5:00 p.m.) The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 08/15/2024 regarding allegations in the area(s) of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 82 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: 6 Number of interviews conducted with residents: N/A Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Darunda Flint, Licensing Inspector at (757) 807-9731 or by email at darunda.a.flint@dss.virginia.gov
Based on a review of a self-reported incident and staff interviewed the facility failed to assume general responsibility for the health, safety, and well-being of a resident in their care. Evidence: 1.As evidence by interview with staff #2 and record review, it has been determined that the facility failed to assume general responsibility for the wellbeing of residents. Per the incident report completed by staff #1 on 08/15/2024 and the final incident report completed by staff #2 on 08/27/2024, resident #1 was restrained with an unauthorized restraint from approximately 6:30am until 11:15 am on 08/15/2024. 2. On 09/16/2024, the LI received the facilities restraint policy from staff #2. Per the facilities policy ?staff will observe and respect the personal rights of all residents, including being free form physical and chemical restraints?. 3. On 9/17/2024 , the LI interviewed staff #7. Staff #7 acknowledged tying a sheet around resident #1?s body and resident #1?s wheelchair to restrain the resident #1. Resident #1 has an unsteady gait and had gotten out of their wheelchair two times prior that morning before staff #7 restrained resident #1 to the wheelchair. 4. On 9/17/2024 ,the LI interviewed staff #9. Staff #9 acknowledged seeing resident #1 on 8/15/2024 restrained to the wheelchair around 6:00 a.m. that morning.
Based on the record review the facility failed to ensure the individualized service plan ( ISP
Based on records reviewed and staff interviewed, the facility failed to ensure that a resident of an assisted living facility rights were met. Evidence: On 8/15/2024, the licensing inspector received an initial incident self-report from staff #1 which indicated that a report was received by staff that resident #1 was seen sitting in their wheelchair in the dining area with a sheet tied around their abdomen and the wheelchair, resident #1?s right to be treated with courtesy, respect, and consideration as a person of worth, sensitivity, and dignity were ignored by staff #4, staff #5, staff #6, staff #7, staff #8, and staff #9. (63.2-1808 A.11).
Based on record review and interview, the facility failed to ensure physical restraints shall not be used for purposes of discipline or convenience. Physical restraints may only be used as a medical/orthopedic restraint for support, according to a physician?s written order and with the written consent of the resident or his legal representative or in an emergency situation after less intrusive interventions have proven insufficient to prevent imminent threat of death or serious physical injury to the resident or others. Evidence: 1. On 08/15/2024, the licensing inspector (LI) received an initial incident self-report from staff #1 which indicated that a report was received by staff that resident #1 was seen sitting in their wheelchair in the dining area with a sheet tied around the abdomen area of the resident to the wheelchair. 2.On 08/28/2024, the LI received a final incident self-report from staff #2 which indicated that all staff involved with the 08/15/2024 initial incident self-report were no longer employed by the facility. 3. Staff #2 acknowledged there was not a physician?s order to restrain resident #1.
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: 08/20/2024 (arrival 9:52am / departure 1:05pm) , and 08/29/2024 (arrival 10:30am / departure 5:00pm) The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 08/08/2024 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: 81 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 5 Number of staff records reviewed: 4 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: Resident Care and Related Services A violation notice was issued; any violation(s) not related to the complaint(s) but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Darunda Flint, Licensing Inspector at (757) 807-9731 or by email at Darunda.a.flint@dss.virginia.gov
Based on record review and staff interview, the facility failed to ensure a fall risk rating was completed after a fall for a resident. Evidence: 1. Progress notes dated 05/12/2024 with a created date of 05/20/2024 for resident #1 documented a fall for resident #1. 2. The hospice notes dated 05/14/2024 for resident #1 documented the resident was sent to the ER (emergency room) for evaluation of pain from a fall several days ago. 3. On 05/16/2024, resident #1?s hospice note documented that resident #1 was discharged from acute care with a right femur fracture. 4. There was not a fall risk rating in the resident?s record for the aforementioned 05/12/2024 fall. 5. Staff #1 acknowledged the resident?s record did not include a fall risk rating, as required, for the fall that occurred on 05/12/2024.
Based on observation and staff interviewed, the facility failed to ensure cleaning supplies and other hazardous materials were stored in a locked area. Evidence: 1. On 08/20/2024, during a tour of the facility with staff #2, hazardous chemicals, Corrosive 8 and an electric power tool were being stored, in an unlocked area, outside on the porch in the resident courtyard. 2. Staff #2 acknowledged the aforementioned were being stored unlocked on the porch in the resident courtyard.
Based on record review, the facility failed to ensure that the facility shall notify the next of kin, legal representative, designated contact person, or, if applicable, any responsible social agency of any incident of a resident falling or wandering from the premises, whether or not it results in injury. This notification shall occur as soon as possible but no later than 24 hours from the time of initial discovery or knowledge of the incident. The resident's record shall include documentation of the notification, including date, time, caller, and person or agency notified. Evidence: 1. The review of facility documentation revealed that the facility did not notify resident #1?s legal representative regarding the resident?s 05/12/2024 fall. 2. Staff #1 acknowledged there was no documentation that the aforementioned resident?s family was notified of the resident falling on 05/12/2024.
Based on the record review the facility failed to ensure the individualized service plan ( ISP
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