Commonwealth Senior Living at Chesterfield — Virginia Inspection Report

Inspections

On record

With violations

Visits that cited something

Clean visits

Nothing cited

Violations cited

Individual findings

Standards cited

Distinct rules

Complaint visits

Prompted by a complaint

Commonwealth Senior Living at Chesterfield was inspected 18 times between June 21, 2021 and March 31, 2026 by the Virginia Department of Social Services. 6 of those visits ended with violations cited and 12 with none. Across that history VDSS cited 12 violations under 12 distinct standards. 9 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.

VDSS publishes inspections on a rolling window. 16 of these 18 are still on the state's site; the other 2 have since dropped off it and are reproduced from Assisted Living Magazine's archive of the original VDSS reports.

Provider Information

Facility type

Assisted Living Facility

License type

One Year

License expires

05/09/2027

Administrator

Marc Raben

Licensing inspector

Tyia Venable

Inspector phone

(804) 393-2157

Approved for

Special Care Unit · Assisted Living · Non-Ambulatory

Inspection History

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

March 31, 2026Complaint survey1 violation

Inspection dates

03/31/2026

Areas reviewed

22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDINGS AND GROUND22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

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: 3/31/2026, 10:30am -1:30pm 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 3/9/2026 regarding allegations in the area(s) of: buildings and grounds, resident care and related services, staffing and supervision, admission, retention, and discharge of residents. Number of residents present at the facility at the beginning of the inspection: 67 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: 1 Number of interviews conducted with residents: 16 Number of interviews conducted with staff: 6 Observations by licensing inspector: Licensing inspector observed the buildings and grounds of the facility, the facility shower and laundry schedule, lunch, posted morning activity, and staff schedule. 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; area(s) of non-compliance with standard(s) or law were: resident care and related services and admission, retention, and discharge of resident. 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 Tyia Venable, Licensing Inspector at 804-393-2157 or by email at tyia.venable2@dss.virginia.gov

Violations

22VAC40-73-680-D

Based on a review of facility documentation, staff records, and interviews, the facility did not ensure medications were administered in accordance with the physician’s or other prescriber’s instructions and consistent with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing.

Evidence

Licensing inspector reviewed facility documentation and staff records and Staff 3 was terminated due to falsifying documentation related to the distribution of medication in accordance with the physician’s orders.
When asked, Staff 1 and Staff 2 stated Staff 3 was terminated on 3/4/2026 due to negligence or willful misconduct in performance of duties.

Plan of correction

Education has been given to all RMA’s related to appropriate medication administration and documentation MAR’s will be audited weekly for compliance and education will continue

March 2, 2026Inspection7 violations

Inspection dates

03/02/2026

Areas reviewed

Technical assistance

Licensing inspector provided technical assistance regarding medication administration best practices.

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: 3/2/2026, 10:15am- 2:45pm 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: 66 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 7 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: Licensing inspector observed facility postings, lunch, and a medication pass. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of these inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Tyia Venable, Licensing Inspector at 804-393-2157 or by email at tyia.venable2@dss.virginia.gov

Violations

22VAC40-73-950-E

Based on a review of facility documentation and interviews, the facility did not ensure a semi-annual review on the emergency preparedness and response plan for all residents.

Evidence

Licensing inspector reviewed available facility documentation and there was no record of a semi annual review of the emergency preparedness and response plan for all residents.
When asked, Staff 4 stated a review of the emergency preparedness and response plan was not conducted with all residents.

Plan of correction

The community did have an emergency preparedness and response plan located at the Concierge desk. We have scheduled an orientation to obtain signatures The community will conduct an orientation for all staff and residents on March 16th and 17th, 2026 and obtain signatures. Moving forward the review of emergency preparedness with staff, residents, and volunteers will be conducted at least every 6 months and as needed

22VAC40-73-680-C

Based on the observation of the medication pass, facility staff did not ensure medications were administered not earlier than one hour before and not later than one hour after the facility’s standard dosing schedule.

Evidence

Licensing inspector observed the afternoon medication pass at 12:04pm.
Licensing inspector observed medication given to Resident 9 and Resident 10 to be their morning medication as indicated on the pill packs and medication administration record.
When asked, Staff 4 stated the medication was not administered in accordance with the facility’s standard dosing schedule.

Plan of correction

RCD and ARCD have provided an in-service on proper administration RCD and ARCD will monitor proper administration and timing of medications daily

22VAC40-73-320-B

Based on a review of resident records, the facility did not ensure a risk assessment for tuberculosis was completed on each resident annually.

Evidence

Resident 2’s record (admit date: 2/25/19) did not contain a current tuberculosis risk assessment. Last assessment dated 2/18/2025.
Resident 4’s record (admit date: 8/30/24) did not contain a current tuberculosis risk assessment. Last assessment dated 2/18/25.
When asked, Staff 4 stated the tuberculosis risk assessments were not completed annually for Residents 2 and 4.

Plan of correction

Residents 2 and 4 have appropriate documentation in their charts RCD and ARCD will audit the charts to ensure that all residents have updated risk assessments for tuberculosis in their charts, and updates will be completed by nurse/medical provider. Moving forward, the TB Risk Assessment will be completed on an annual basis.

22VAC40-73-310-D

Based on a review of resident records, the facility did not provide written assurance to the residents that the facility has the appropriate license to meet his care needs at the time admission.

Evidence

Licensing inspector reviewed Resident 2’s record and there was no documentation of written assurance provided to the resident and/or the legal representative.
When asked, Staff 4 stated there was no documentation in the record of written assurance provided to Resident 2 or their legal representative.

Plan of correction

Resident 2 have the appropriate documentation in their charts The Executive Director and Business Office Manager will conduct an audit of current residents to ensure that each resident has a UAI Written Assurance available. Moving forward, the Executive Director/designee will assure that the UAI Written Assurance is appropriately signed and in the resident record.

22VAC40-73-990-C

Based on a review of facility documentation and interviews, the facility did not ensure at least once every six months, all staff participate in an exercise in which the procedures for resident emergencies are practiced.

Evidence

Licensing inspector reviewed available facility documentation and there was no record of staff participating in an exercise in which procedures for resident emergencies are practiced.
When asked, Staff 4 stated an exercise in which procedures for resident emergencies were not conducted with staff.

Plan of correction

Community will complete the resident emergency exercise with team members on March 16th and 17th, 2026 and obtain signatures Moving forward, the RCD/ARCD/designee will conduct semi-annual resident emergency drills to assure understanding by new and current staff.

22VAC40-73-610-B

Based on a tour of the facility, the facility did not ensure the menus for meals and snacks for the current week were dated and posted in an area conspicuous to residents.

Evidence

Licensing inspector toured the facility and observed the resident lunch and the menu posting, the menu posted was dated12/21/2025-1/10/2026.
When asked, Staff 4 stated there were staff changes in the dining department and there was not an updated menu.

Plan of correction

Daily menus have been posted in the dining room and weekly menus have been posted outside the dining room Daily audits by the Dining Services Director

22VAC40-73-1110-B

Based on a review of resident records, the facility did not ensure that six months after placement of the resident in the safe, secure environment and annually thereafter, the licensee, administrator, or designee performed a review of the appropriateness of each resident’s continued residence in the special care unit.

Evidence

Resident 4’s record (admit date: 8/30/24) did not have a record of review of the appropriateness of continued residence in the special care unit, six months or annually after placement. Resident 4’s record indicated it was reviewed 1/7/26.
Resident 5’s record (admit date: 5/17/24) did not have a record of review of the appropriateness of continued residence in the special care unit, six months or annually after placement. Resident 5’s record indicated it was reviewed 1/7/26.
When asked, Staff 4 stated there was no sixth month or annual review of appropriateness for Residents 4 and 5.

Plan of correction

Residents 4 and 5 have appropriate documentation in their charts RCD and ARCD will audit the charts to ensure that all residents have updated appropriateness of continued placement in their charts

March 2, 2026Complaint survey1 violation

Inspection dates

03/02/2026

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

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: 03/02/2026, 9:50am-10:15am 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 2/2/2026 regarding allegations in the area(s) of: RESIDENT CARE AND RELATED SERVICES and ADMINISTRATION AND ADMINISTRATIVE SERVICES Number of residents present at the facility at the beginning of the inspection: 66 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: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: Licensing inspector toured the memory care unit and observed the medication pass 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 allegations: area(s) of non-compliance with standard(s) or law were: Administration and administrative 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 Tyia Venable, Licensing Inspector at 804-393-2157 or by email at tyia.venable2@dss.virginia.gov

Violations

22VAC40-73-70-A

Based on a review of facility documentation, the facility did not ensure the licensing office received an incident report within 24 hours for any major incident that negatively affected or that threatened the life, health, safety, or welfare of any resident.

Evidence

Licensing inspector (LI) reviewed the facility internal resident incident log from 1/15/2026-2/21/2026, with a total of 11 medial emergency incident types.
Licensing inspector reviewed incident reports sent to LI from Staff 1, during the time period 1/15/2026-2/21/2026, only two incident reports were sent.
When asked Staff 1 stated the incident reports were not sent to the licensing inspector.

Plan of correction

Solid communication with Clinical Team members, clinical leadership, and ED has been put into place. RMA's will immediately enter an incident report and contact the RCD, ARCD and ED. ED then will send report to LI.

November 5, 2025Complaint survey0 violations

Inspection dates

11/05/2025

Areas reviewed

22VAC40-73 BUILDINGS AND GROUND

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: 11/5/2025, 12:24pm-1pm 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 9/10/2025 regarding allegations in the area(s) of: Building and Grounds Number of residents present at the facility at the beginning of the inspection: 59 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Licensing inspector toured the facility and three resident rooms. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation 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 Tyia Venable, Licensing Inspector at (804)393-2192 or by email at tyia.venable2@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

September 24, 2025Inspection0 violations

Inspection dates

Sept. 24, 2025

Areas reviewed

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

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: 6/12/2025, 10am-11:45am 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 6/3/2025 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: 56 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: Licensing inspector toured resident’s room Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self report 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 Tyia Venable, Licensing Inspector at (804)393-2157 or by email at tyia.venable2@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

March 11, 2025Inspection1 violation

Inspection dates

03/11/2025

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: On 03/11/2025 approximate time 10:30a.m-4:30p.m On 03/14/2025 approximate time 9:28a.m-1:27p.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: 61 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 staff records reviewed: 3 Number of interviews conducted with residents: 5 Number of interviews conducted with staff: 6 Observations by licensing inspector: Medication administration pass observed 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 Angela Rodgers-Reaves, Licensing Inspector at (804) 840-0253 or by email at Angela.r.reaves@dss.virginia.gov Violation Notice Issued: Yes

Violations

22VAC40-73-680-A

Based on observation the facility failed to ensure that the medication storage area was locked.

Evidence

During the walk through of the facility on 03/14/2025 and as evidenced by the photographs taken a medication cart on the assisted living side was not locked.

Plan of correction

FACILITY'S RESPONSE: "1. The medication cart on the Assisted Living side is locked. 2. 100% audit of all medication carts was completed by the Resident Care Director to ensure that all medication carts were locked. 3. The Resident Care Director and/or designee educated all Registered Medication Aides on ensuring that all medication carts are locked at all times when not in use. 4. The Resident Care Director and/or designee will randomly audit all medication carts every shift 3 days x 4 weeks, bi-weekly x 4 weeks, and monthly x 1 to ensure that all medication carts are locked at all times when not in use. Findings will be discussed with in weekly Higher Path meeting

March 11, 2025Complaint survey0 violations

Inspection dates

03/11/2025

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: On 03/11/2025 approximate time 10:30a.m-4:30p.m. On 03/14/2025 approximate time 9:20a.m-1:27pm. 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 01/24/2025 regarding allegations in the resident care and related services. Number of residents present at the facility at the beginning of the inspection: 61 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: Number of interviews conducted with residents: N/A Number of interviews conducted with staff: 5 Observations by licensing inspector: Additional Comments/Discussion: Identified resident no longer in care 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 Angela Rodgers-Reaves, Licensing Inspector at (804) 840-0253 or by email at Angela.r.reaves@dss.virginia.gov Violation Notice Issued: No

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

March 11, 2025Complaint survey0 violations

Inspection dates

03/11/2025

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: On 03/11/2025 approximate time 10:30a.m-3:30p.m. On 03/14/2025 approximate time 9:28a.m-1:27p.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 03/27/2025 regarding allegations in the area of resident care and related services. Number of residents present at the facility at the beginning of the inspection: 61 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: N/A Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 5 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Angela Rodgers-Reaves, Licensing Inspector at (804) 840-0253 or by email at Angela.r.reaves@dss.virginia.gov Violation Notice Issued: No

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

September 9, 2024Inspection0 violations

Inspection dates

09/09/2024

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: 09/09/2024 approximate time of 10:18a.m-1:42p.m The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-report was received by VDSS Division of Licensing on 08/22/2024 regarding allegations in the building and grounds and additional requirements for facilities that care for adults with serious cognitive impairments Number of residents present at the facility at the beginning of the inspection: 70 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: N/A Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: The inspector accompanied by staff observed how the facility’s alarm system works when engaged on the memory care unit of the facility. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Angela Rodgers-Reaves Licensing Inspector at (804) 840-0253 by email at Angela.r.reaves@dss.virginia.gov Violation Notice Issued: No

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

September 9, 2024Complaint survey0 violations

Inspection dates

09/09/2024

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: 09/09/2024 approximate time 10:18a.m-1:42p.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 09/05/2024 regarding allegations in the resident care and related services. Number of residents present at the facility at the beginning of the inspection: 70 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: N/A Number of staff records reviewed: N/A Number of interviews conducted with residents: N/A Number of interviews conducted with staff: 3 Observations by licensing inspector: Additional Comments/Discussion: The individual identified in the complaint has never been a resident at this facility. 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 Angela Rodgers-Reaves Licensing Inspector at (804) 840-0253 or by email at Angela.r.reaves@dss.virginia.gov Violation Notice Issued: No

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

June 26, 2024Complaint survey1 violation

Inspection dates

06/26/2024

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: On 06/26/2024 approximate time 9:13a.m-1:53p.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 06/24/2024 regarding allegations in the area 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: 1 Number of staff records reviewed: N/A Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: N/A Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. However, violation(s) not related to the complaint but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. 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 Angela Rodgers-Reaves, Licensing Inspector at (804) 840-0253 or by email at Angela.r.reaves@dss.virginia.gov Violation Notice Issued: Yes

Violations

22VAC40-73-450-C

Based on the review of facility records and interviews conducted the facility failed to ensure that the comprehensive individualized service plan for a resident included all of the required elements.

Evidence

Resident #1-Date of admission 08/10/2024 the resident’s 11/22/2023 wound care orders document that was submitted for the inspector’s review on 06/26/2024 notes that the facility is to “use prevalon boots to offset heals with laying in bed”. The resident’s 11/29/2023 ISP that was submitted for the inspector’s review on 06/26/2024 is not documented to identify a written description of what services will be provided to address identified needs and who will provide them.

Plan of correction

FACILITY S RESPONSE: "All staff in serviced on application of Prevalon boots and ISP updated"

June 26, 2024Inspection0 violations

Inspection dates

06/26/2024

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: 06/26/2024 approximate time 9:13a.m-1:33p.m The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self report was received by VDSS Division of Licensing on 06/14/2024 regarding allegations in the area 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: 1 Number of staff records reviewed: N/A Number of interviews conducted with residents: N/A Number of interviews conducted with staff: 2 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support 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 Angela Rodgers-Reaves, Licensing Inspector at (804) 840-0253 or by email at Angela Rodgers-Reaves@dss.virginia.gov. Violation Notice Issued: No

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

January 10, 2024Inspection0 violations

Inspection dates

01/10/2024

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: On 01/10/2024 approximate time of 10:08a.m-2:07p.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: 71 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 5 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 4 Observations by licensing inspector: Noon time medication administration pass observed Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Angela Rodgers-Reaves Licensing Inspector at (804) 840-0253 or by email at Angela.r.reaves@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

April 13, 2023Inspection1 violation

Inspection dates

04/13/2023; 04/18/2023

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 – SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS

Comments

Type of inspection: Renewal Date(s) of inspection: 04/13/2023; 04/18/2023 Time the licensing inspector was on-site at the facility for each day of the inspection: (1) 2:22 p.m. -3:50 p.m. (2) 1:01 p.m. -3:48 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: 63 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 06 Number of staff records reviewed:06 Number of interviews conducted with residents:02 Number of interviews conducted with staff: 02 Observations by licensing inspector: Buildings and grounds, MARs, training records, first aid kits, and 96 hours emergency food supply. Additional Comments/Discussion: 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 Vashti Colson, Licensing Inspector at (804) 662-9432 or by email at Vashti.Colson@dss.virginia.gov

Violations

22VAC40-73-290-A

VIOLATION: Based upon the document review, the facility failed to provide a schedule that includes indication of whomever is in charge at any given time.

Evidence

The shift assignments submitted by the facility on April 13, 2023, failed to identify the individual in charge of the facility at any given time.

Plan of correction

Not published by VDSS.

April 5, 2023Complaint survey0 violations

Inspection dates

04/05/2023

Areas reviewed

Comments

Type of inspection: Complaint Date(s) of inspection:04-05-2023 Time the licensing inspector was on-site at the facility for each day of the inspection: 3:52 pm- 5:03 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint reported incident was received by VDSS Division of Licensing on 2/3/2023, regarding allegations in the area(s) of: Resident Care Number of residents present at the facility at the beginning of the inspection: 64. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed:01. Number of staff records reviewed: 02. Number of interviews conducted with residents:0. Number of interviews conducted with staff: 01. Observations by licensing inspector: records Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation 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. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation 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,

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

April 5, 2023Complaint survey0 violations

Inspection dates

04/05/2023

Areas reviewed

Comments

Type of inspection: Complaint Date(s):04/05/2023 Inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 3:52 p.m. -5:05 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 regarding allegations in the area(s) of: Resident Care Number of residents present at the facility at the beginning of the inspection: The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 01 Number of staff records reviewed:0. Number of interviews conducted with residents: Number of interviews conducted with staff: 01. Observations by licensing inspector: N/A Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation 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 Vashti Colson, Licensing Inspector at (804) 662-9432 or by email at Vashti.Colson@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

June 9, 2022Inspection0 violations

Inspection dates

06/09/2022

Areas reviewed

22VAC40-73 GENERAL PROVISIONSv22VAC40-73 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 – SUBJECTIVITY22.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS1) GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS

Technical assistance

Technical assistance provided regarding staff TB risk assessment forms.

Comments

An unannounced monitoring inspection was completed for Commonwealth Senior Living at Chesterfield from 12:29 p.m. to 4:20 p.m. During the entrance conference the facility confirmed the census as seventy (70) residents in care. The Director of Maintenance and the Licensing Inspector completed a tour of the physical plant that included the building and the surrounding grounds of the facility. The monitoring inspection sample consisted of eight (8) resident records and six (6) staff records. Other components of the monitoring inspection consisted of a medication observation pass, meal observation, activities observation, resident interviews, staff interviews, the review of the emergency food supply, and the annual review of the health/ fire inspection. An exit meeting was completed to review the inspection findings with the facility’s administrator. The evidence gathered during the inspection determined no violations with applicable standard(s) or law. The inspection summary will be posted to the VDSS website within five (5) business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Vashti Colson (Licensing Inspector at (804) 662-9432 or by email at Vashti.Colson@dss.virginia.gov

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.

June 21, 2021Inspection0 violations

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 ACCOMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDING AND GROUNDS22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity32.1 Reported by persons other than physicians63.2 General Provisions63.2 Protection of adults and reporting63.2 Licensure and Registration Procedures63.2 Facilities and Programs22VAC40-90 Background Checks for Assisted Living Facilities22VAC40-90 The Sworn Statement or Affirmation22VAC40-90 The Criminal History Record Report22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS

Comments

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A monitoring inspection was initiated on 06/21/2021 and concluded on 06/22/2021. The administrator contacted by telephone to initiate the inspection. The administrator reported that the current census was sixty eight (68). The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed four (4) resident records, four (4) staff records, activities calendar, staff schedules, U.A.I.s, MARs, I.S.P.s, and training records submitted by the facility to ensure documentation was complete. The information gathered during the inspection determined no violations with applicable standards or law. No violations were issued.

Violations

✅

No violations cited

The inspector documented no violation of standards at this inspection.