Virginia DSS · Assisted Living Facility

Commonwealth Senior Living At Charlottesville

📍 1550 Pantops Mountain Place, Charlottesville, VA, 22911

ID 41327Two Year licenseActive
21
Inspections
On record
11
With violations
Visits that cited something
10
Clean visits
Nothing cited
28
Violations cited
Individual findings
24
Standards cited
Distinct rules
12
Complaint visits
Prompted by a complaint

Commonwealth Senior Living At Charlottesville was inspected 21 times between May 4, 2021 and November 18, 2025 by the Virginia Department of Social Services. 11 of those visits ended with violations cited and 10 with none. Across that history VDSS cited 28 violations under 24 distinct standards. 12 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. 18 of these 21 are still on the state's site; the other 3 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
Two Year
License expires
03/28/2027
Administrator
Catherine Herzog
Licensing inspector
Coy Stevenson
Inspector phone
(804) 972-4700
Approved for
Non-Ambulatory · Assisted Living · Special Care Unit

Inspection History

21

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

November 18, 2025Complaint survey0 violations
Inspection dates
11/18/2025
Areas reviewed
22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An on-site inspection related to a complaint was conducted on November 18, 2025. 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 October 30, 2025, regarding allegations in the area(s) of: PERSONNEL, RESIDENT CARE AND RELATED SERVICES Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 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 Coy Stevenson, Licensing Inspector at (804) 972-4700 or by email at coy.stevenson@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
July 2, 2025Complaint survey0 violations
Inspection dates
07/02/2025
Areas reviewed
22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An on-site inspection was completed on July 02, 2025. 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 May 29, 2025, regarding allegations in the area(s) of: PERSONNEL, RESIDENT CARE AND RELATED SERVICES Number of resident records reviewed: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: Residents were noted to be appropriately dressed and groomed for the activities they were engaged in and for the time of day. Additional Comments/Discussion: The findings of the Adult Protective Services (APS) investigation and the provider’s internal investigation report were reviewed. 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 Coy Stevenson, Licensing Inspector at (804) 972-4700 or by email at coy.stevenson@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
July 1, 2025Complaint survey0 violations
Inspection dates
07/01/2025
Areas reviewed
22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An on-site inspection was completed on July 01, 2025. 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 May 13, 2025, regarding allegations in the area(s) of: RESIDENT CARE AND RELATED SERVICES Number of resident records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: Residents were noted to be appropriately dressed and groomed for the activities they were engaged in and for the time of day. The resident who was the subject of the complaint was noted to be appropriately dressed and groomed. There were no physical or dental health needs noted. Additional Comments/Discussion: 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 Coy Stevenson, Licensing Inspector at (804) 972-4700 or by email at coy.stevenson@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 12, 2025Complaint survey0 violations
Inspection dates
05/12/2025
Areas reviewed
22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An on-site inspection of the facility occurred on May 12, 2025 from approximately 11:45 AM – 2:00 PM. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on March 26, 2025, regarding allegations in the area(s) of: STAFFING AND SUPERVISION Number of interviews conducted with staff: 1 Observations by licensing inspector: Residents were appropriately dressed and groomed for the activity they were engaged in and for the weather conditions and time of day. Interactions amongst residents and with staff were appropriate. Additional Comments/Discussion: The facility has implemented appropriate communication systems amongst management and direct care staff to ensure staff for each shift are aware of issues that may have arisen from the previous shift. The facility conducts rounds on the secure unit every two hours in addition to have a call-alert system for resident assistance. A review of staffing schedules for the previous three months shows that the facility meets the staffing requirements for staff to resident ratios. 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 Coy Stevenson, Licensing Inspector at (804) 972-4700 or by email at coy.stevenson@dss.virginia.gov.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
March 6, 2025Inspection1 violation
Inspection dates
03/06/2025
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS63.2 GENERAL PROVISIONS63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE
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: The licensing inspector was on-site on March 06, 2025, from approximately 10:30 AM – 2:30 PM. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 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: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 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 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 Coy Stevenson, Licensing Inspector at (804) 972-4700 or by email at coy.stevenson@dss.virginia.gov.
Violations
22VAC40-73-580-A
Plan of correction
Not published by VDSS.
March 25, 2024Complaint survey1 violation
Inspection dates
03/25/2024
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: LI Poulter conducted an onsite inspection on October 11, 2023. LI Stevenson and LI Randolph conducted an onsite inspection on March 25, 2024. 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 June 20, 2023, regarding allegations in the area of: Background checks for assisted living facilities. Number of staff records reviewed: 1 Number of interviews conducted with staff: 1 Number of resident records reviewed: 0 Number of interviews conducted with residents: 0 Observations by licensing inspector: Additional Comments/Discussion: The designated manager on duty assisted LI Stevenson and LI Randolph during the onsite review conducted on 03/25/2024. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were issued. 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. 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 Coy Stevenson, Licensing Inspector at (804) 972-4700 or by email at coy.stevenson@dss.virginia.gov
Violations
22VAC40-90-40-C
Based on record review and interview, it was determined that the facility did not ensure that any person required by this chapter to obtain a criminal history record report shall be ineligible for employment if the report contains convictions of a barrier crime.
Evidence
  1. Employee #2’s date of hire was September 19, 2019. The criminal history report dated May 11, 2022, documented conviction of a barrier crime. Employee #2 continued to work at the facility until April 26, 2023.
  2. Employee #1 confirmed that employee #2 remained employed by the provider until April 26, 2023.
Plan of correction
What Has Been Done to Correct? Employee #2 has been separated from the organization. How Will Recurrence Be Prevented? All associate hired by the Community would undergo a VA State criminal background check per the CSL company policy. In the event of a documented conviction of a barrier crime, such associate will not be employees to work for the community. Person Responsible: Executive Director and Business Office Manager
March 25, 2024Inspection3 violations
Inspection dates
03/25/2024
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
An onsite monitoring inspection was conducted by LI Poulter on 10/11/23. An onsite inspection was conducted by LI Stevenson and LI Randolph on 03/25/24. 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 09/13/24 and 09/19/24 regarding allegations in the area(s) of: Personnel, staffing and supervision, and resident care and related services. Number of resident records reviewed: 2 Number of staff records reviewed: 3 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 Coy Stevenson, Licensing Inspector at 804-972-4700 or by email at coy.stevenson@dss.virginia.gov
Violations
22VAC40-73-680-D
Based on a review of the two records, it was determined that facility staff did not administer medications in accordance with the physician's or other prescriber’s instructions.
Evidence
  1. On September 07, 2023, staff #1 gave resident #1 medication that was not prescribed. The medication given to resident #1 was prescribed for resident #2.
  2. The facility made self-report that noted resident #1 was administered incorrect medication.
Plan of correction
What Has Been Done to Correct? Missed medication audit by community and Pharmacy. Also review "missed meds" each day, to address in real time and coach staff on proper documentations. How Will Recurrence Be Prevented? Medication oversight by Community and Pharmacy. Daily crossover medication cart audit and count, from the prior shift med tech. Person Responsible: Executive Director and Resident Care Director
22VAC40-73-680-I
Based on a review of documentation, it was determined that the provider did not document on the Medication Administration Record (MAR) any medications that occur.
Evidence
  1. The medication administration record (MAR) for resident #1 did not note a medication error occurred on September 07, 2023.
  2. The facility made self-report that noted resident #1 was administered incorrect medication.
Plan of correction
What Has Been Done to Correct? MAR review by community and Pharmacy also, in-service with med techs on proper documentation and reporting. How Will Recurrence Be Prevented? Medication oversight by Community and Pharmacy. Daily crossover medication cart audit and count, from the prior shift med tech. Person Responsible: Executive Director and Resident Care Director.
22VAC40-73-110-1
Based on a review of documentation, it was determined that the facility did not ensure that all staff shall be considerate and respectful of the rights, dignity, and sensitivities of persons who are aged, infirm, or disabled.
Evidence
  1. On September 19, 2023, staff #2 was involved a verbal incident with resident #3.
  2. In interview notes provided by the facility, staff #2 admitted to using profanity and derogatory language towards resident #3.
Plan of correction
What Has Been Done to Correct? Staff #2 was in-service on proper conduct and caring for residents in the community. Staff #2 has also been separated from the community and the CSL organization. How Will Recurrence Be Prevented? Community will conduct an in-service, train, and re-train associate on code of conduct per CSL- Company policy. Person Responsible: Executive Director and Business Office Manager
February 23, 2024Inspection3 violations
Inspection dates
02/23/2024
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 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS32.1 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
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An on-site inspection on February 23, 2024. The Licensing Inspectors were on-site between 10:35 AM – 2:15 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: At the time of the on-site review, Thirty-One clients were residing in the assisted living wing of the facility and Twenty-Seven clients were residing in the memory care wing of the facility. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: Five records of clients residing in the assisted living wing of the facility, and five records of clients residing in the memory care wing of the facility were reviewed. Number of staff records reviewed: Five records of employees working with clients residing in the assisted living wing of the facility, and five records of employees working with clients residing in the memory care wing of the facility were reviewed. Number of interviews conducted with residents: Four residents were interviewed during the on-site review. Number of interviews conducted with staff: Four employees were interviewed during the on-site review. Observations by licensing inspector: Observations of meal service, medication administration, client bedrooms and common areas, private and public restrooms, and areas of food preparation areas were noted. 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 Coy Stevenson, Licensing Inspector at 804-972-4700 or by email at coy.stevenson@dss.virginia.gov
Violations
22VAC40-73-330-B
Plan of correction
Residents’ charts have been audited, reviewed and violation corrected. Audit will be completed of current resident files and annual TB screening will be updated as appropriate to assure continued regulatory compliance. Annual Tuberculosis screening will be conducted by licensed staff, this process will be managed by the Resident Care Director & monitored Executive Director
22VAC40-73-320-A
Plan of correction
Residents’ charts have been audited and reviewed to ensure compliance. Annual Tuberculosis screening will be conducted by licensed staff. This process will be managed by the Resident Care Director and monitored by the Executive Director to ensure community is within compliance. Upon admission licensed staff will thoroughly review resident charts to ensure a negative tuberculosis test is obtained within thirty days preceding admission.
22VAC40-73-720-A
Plan of correction
Residents’ charts have been audited and reviewed to ensure compliance. 1.) Individualized Service Plan (ISP) reviewed and will be updated including the DNR order to be shown on the ISP. 2.) Individualized Service Plan (ISP) reviewed and will be updated including the DNR order to be shown on the ISP. Charts will be audited on a regular basis by staff that have been appropriately trained in completion of ISPs to ensure that they are current and up to date information is provided and included in the Individualized Service Plans. This process will be managed by the Resident Care Director (RCD) & monitored Executive Director (ED)
August 23, 2023Inspection0 violations
Inspection dates
08/23/2023
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: 8-23-2023, 12:51 – 1:15 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 7-20-2023 regarding allegations in the area of Resident Care and Related Services Additional Comments/Discussion: Staff witness statements, records, and interviews conducted. 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 Alex Poulter, Licensing Inspector at (804) 662-9771 or by email at alex.poulter@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
March 7, 2023Inspection2 violations
Inspection dates
03/07/2023
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES
Technical assistance
PRN oxygen therapy on care plan Dates outcome achieved on care plan TB Screening forms
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: 3-07-2023, 8:59 – 11:45 a.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: 8 Number of staff records reviewed: 3 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 Alexandra Poulter, Licensing Inspector at (804)662-9771 or by email at alex.poulter@dss.virginia.gov
Violations
22VAC40-90-40-C
Based on record review and interview with staff, the facility failed to ensure they did not continue to employee who has a conviction of any of the barrier crimes.
Evidence
  1. Upon review of staff records and confirmation with Staff #2 on 4-10-2023, the facility had hired Staff #6 who had a conviction of a barrier crime on record check dated 12-12-2022.
  2. Staff #2 confirmed that Staff #6 had the conviction in 2009 and was still employed as of 4-10-2023.
Plan of correction
Executive Director, Business Office Manager, and designee will ensure current employee files are audited for employees, sworn disclosure statement and their criminal background check to ensure we are following the appropriate regulatory standards and new hire employees will not be allowed to start until background check has been received and reviewed for barrier crimes that would disqualify employment.
22VAC40-73-700-1
Based on record review and interview with staff, the facility failed to ensure there was a valid physician’s order that included the oxygen source and delivery device deemed therapeutic for the resident.
Evidence
  1. Resident #1 admitted 3-10-2021. Resident #1’s record contained a physician’s order dated 12-13-2022 that documented, “PRN OXYGEN: 1-2 LITERS AS NEEDED FOR SHORTNESS OF BREATH”; however, the order did not specify the oxygen source (such as compressed gas or concentrators) or the delivery device (such as nasal cannula, reservoir nasal cannulas, or masks).
  2. Staff #1 acknowledged during interview regarding Resident #1’s physician’s order.
Plan of correction
Resident Care Director has received the corrected order addressing the oxygen source. The Executive Director, Resident Care Director or designee will audit files of current residents that utilize oxygen and review orders for new residents to ensure orders are properly documented addressing appropriate items per regulatory compliance.
March 7, 2023Complaint survey0 violations
Inspection dates
03/07/2023
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: March 7, 2023, 11:46 a.m. – 12:15 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 January 6, 2023 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 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 Alexandra Poulter, Licensing Inspector at (804)662-9771 or by email at alex.poulter@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
November 4, 2022Complaint survey2 violations
Inspection dates
11/04/2022
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNELXX 22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTSXX 22VAC40-73 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: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11-04-2022, 12:25 – 1:00 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 November 3, 2022 regarding allegations in the areas of: Staffing and Supervision; Resident Care and Related Services. 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, interviews with residents. Number of resident records reviewed: 0 Number of staff records reviewed: 1 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 1 Observations by licensing inspector: Resident room(s); Special Care Unit An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alexandra Poulter, Licensing Inspector at (804) 662-9771 or by email at alex.poulter@dss.virginia.gov
Violations
22VAC40-73-290-A
Based on interview with staff, the facility failed to maintain a copy of the written work schedule.
Evidence
  1. Staff schedules for staff worked during the time period of 9-1-2022 through 10-31-2022 were requested by licensing representative onsite on 11-04-2022 and 12-19-2022 by email. The staff schedules were not produced.
Plan of correction
Not published by VDSS.
22VAC40-73-560-F
Based on interview with staff, the facility failed to ensure that information was made available for inspection by the department's representative.
Evidence
  1. Resident #1’s record was requested on 11-04-2022 by the licensing representative and again on 12-19-2022. Staff #1 did not produce the record as requested to include: private duty paperwork, personal data, nurses notes, UAI/ISP, physical, dietician’s note, physician’s notes
  2. Staff schedules from September 2022 and October 2022 were requested on 11-04-2022 and again 12-19-2022. The staff schedules from this time frame were not sent to the department representative.
Plan of correction
Not published by VDSS.
November 4, 2022Complaint survey2 violations
Inspection dates
11/04/2022
Areas reviewed
22VAC40-73 GENERAL PROVISIONSXX 22VAC40-73 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: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11-04-2022, 1:01 – 2:00 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 September 26, 2022 regarding allegations in the areas of Administration and Administrative Services; Buildings and Grounds. 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, as well as interview with staff. 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 some, but not all of the allegation; 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. 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 Alexandra Poulter, Licensing Inspector at (804) 662-9771 or by email at alex.poulter@dss.virginia.gov
Violations
22VAC40-73-70-A
Based on interview with staff, the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident.
Evidence
  1. Staff #1 acknowledged as per the complaint that Covid cases had been present in the facility since September 2022; however, no incident report(s) were received by the facility between September and 11-04-2022, the date of inspection.
Plan of correction
Not published by VDSS.
22VAC40-73-100-A
Based on interview with staff, the facility failed to develop, in writing, and implement an infection control program addressing the surveillance, prevention, and control of disease and infection that is consistent with the federal Centers for Disease Control and Prevention (CDC) guidelines and the federal Occupational Safety and Health Administration (OSHA) bloodborne pathogens regulations.
Evidence
  1. The facility’s Infection Control policy regarding Covid-19 measures was requested 11-04-2022 as well as by email 12-19-2022 and was not received by the facility. There was no documented policy made available during or after the inspection.
Plan of correction
Not published by VDSS.
September 9, 2022Inspection3 violations
Inspection dates
09/09/2022
Areas reviewed
22VAC40-73 GENERAL PROVISIONSXX 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTSXX 22VAC40-73 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: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 9-09-2022, 9:59 a.m - noon 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 7-22-2022 regarding allegations in the area of Resident Care and Related Services. 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 Alexandra Poulter, Licensing Inspector at (804)662-9771 or by email at alex.poulter@dss.virginia.gov
Violations
22VAC40-73-460-B
Based on record review and interview, the facility failed to ensure care provision and service delivery included prompt response by staff to resident needs as reasonable to the circumstances.
Evidence
  1. Resident #1’s ISP dated 3-04-2022 documented “[Resident #1] unable to use the emergency response system. Direct care staff assist with 2 hour rounding to meet any unmet needs.”
  2. A self-reported incident was received by Staff #3 regarding a resident passing on 7-19-2022 (non-hospice death). Resident #1 passed away on 7-19-2022 per a Physician’s Visit note documented in the resident’s record. This licensing inspector interviewed Staff #1 (onsite on 9-09-2022) and Staff #3 (via email on 7-21-2022). The interview with Staff #1 confirmed based on video evidence reviewed that Resident #1 was last seen in their apartment at approximately 9:16 p.m. on 7-18-2022. Staff #1 stated the resident at 4 p.m. on 7-18-2022 reported to direct care staff, “Not feeling great”. Staff #1 stated that Resident #1 was not seen from approximately 9:16 p.m. to 7:20 a.m. the next morning during staff rounds where the resident was discovered deceased. Staff #3 in email stated, “…It was then discovered that Staff #2 had signed off on doing 2 hour checks for residents in our memory care when in fact, camera footage proved otherwise.” Staff #1 and Staff #3 confirmed that Staff #2 was assigned to check on Resident #1 during the overnight shift from 11 p.m. to 7:00 a.m. and failed to make rounds despite having signed round logs.
Plan of correction
Not published by VDSS.
22VAC40-73-40-A
Based on record review and interview, the facility failed to ensure the licensee ensured compliance with the facility's own policies regarding staff conducting rounds on the memory care unit.
Evidence
  1. The facility’s policy, “CL27 – Resident Two Hour Round Check (07/02/2020)” documented, “All residents residing in the Sweet Memory Neighborhood shall be checked on every 2 hours using the Two-Hour Round Check Log. The Caregiver should physically see each resident…”
  2. A self-reported incident was received on 7-19-2022 regarding a non-hospice death of a resident reported by Staff #3. A subsequent report was received on 7-21-2022 by Staff #4 regarding a disgruntled employee who was suspended (then terminated) for falsification of documentation. It was learned it was on the shift where the resident passed away and round logs were falsified regarding checking on Resident #1.
  3. Physician’s Visit notes on 7-19-2022 documented, “Per staff, patient [Resident #1] was found deceased in her chair this morning during AM [morning] rounds. Last seen at her baseline last night. No recent fall or changes in health noted. On exam at 0805 patient was sitting in her chair. No obvious trauma noted. No heart beat on auscultation, patient cold + in rigor. Estimated time of death midnight on 7-19-2022.”
  4. Staff #3 confirmed that Staff #2 was working the 11 p.m. to 7:00 a.m. shift 7-18-2022 through 7-19-2022 where Resident #1 passed away at some point during the shift, and camera footage reviewed by Staff #3 documented Staff #2 not making rounds every two hours to check on the resident; however, Staff #2 documented on Two Hour Round Checks that Staff #2 made rounds four times (12 a.m., 2 a.m., 4 a.m., and 6 a.m.) to see Resident #1.
  5. Staff #1 confirmed the facility’s policy was not followed by Staff #2.
Plan of correction
Not published by VDSS.
22VAC40-73-450-H
Based on record review and interview, the facility shall ensure that the care and services specified in the individualized service plan are provided to each resident.
Evidence
  1. Resident #1 admitted 9-14-2018. Resident #1’s ISP dated 3-04-2022 documents the need for 2 hour rounding on the resident by direct care staff under “Emergency and Evacuation” identified on 11-19-2021.
  2. A final self-report on 7-22-2022 documented, “Resident Care Associate entered resident’s [Resident #1’s] room at approximately 07:20AM to wake resident up for breakfast. Resident Care Associate noticed that resident was showing no signs of life. Resident was a DNR; therefore, no resuscitation efforts were attempted. House Physician, EMS and POA were notified.”
  3. Staff #2 failed to provide the ISP services of 2 hour rounding as identified on Resident #1’s ISP due to Staff #2 not making rounds overnight on 7-18-2022 to 7-19-2022.
Plan of correction
Not published by VDSS.
June 29, 2022Complaint survey0 violations
Inspection dates
06/29/2022
Areas reviewed
¿ 22VAC40-73 GENERAL PROVISIONS¿ 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES¿ 22VAC40-73 PERSONNEL¿ 22VAC40-73 STAFFING AND SUPERVISION¿ 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS¿ 22VAC40-73 RESIDENT CARE AND RELATED SERVICES¿ 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS¿ 22VAC40-73 BUILDINGS AND GROUND¿ 22VAC40-73 EMERGENCY PREPAREDNESS¿ 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS¿ ARTICLE 1 – SUBJECTIVITY¿ 32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS¿ 63.2 GENERAL PROVISIONS¿ 63.2 PROTECTION OF ADULTS AND REPORTING¿ 63.2 LICENSURE AND REGISTRATION PROCEDURES¿ 63.2 FACILITIES AND PROGRAMS¿ 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES¿ 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION¿ 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT¿ 22VAC40-80 THE LICENSE¿ 22VAC40-80 THE LICENSING PROCESS¿ 22VAC40-80 COMPLAINT INVESTIGATION¿ 22VAC40-80 SANCTIONS
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: 6/29/2022, 9:55 a.m. – 10:55 a.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 May 2, 2022 regarding allegations in the area(s) of Admission, Retention and Discharge of Residents (billing): 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 Alexandra Poulter, Licensing Inspector at (804)662-9771 or by email at alex.poulter@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
June 29, 2022Inspection0 violations
Inspection dates
06/29/2022
Areas reviewed
¿ 22VAC40-73 GENERAL PROVISIONS¿ 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES¿ 22VAC40-73 PERSONNEL¿ 22VAC40-73 STAFFING AND SUPERVISION¿ 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS¿ 22VAC40-73 RESIDENT CARE AND RELATED SERVICES¿ 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS¿ 22VAC40-73 BUILDINGS AND GROUND¿ 22VAC40-73 EMERGENCY PREPAREDNESS¿ 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS¿ ARTICLE 1 – SUBJECTIVITY¿ 32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS¿ 63.2 GENERAL PROVISIONS¿ 63.2 PROTECTION OF ADULTS AND REPORTING¿ 63.2 LICENSURE AND REGISTRATION PROCEDURES¿ 63.2 FACILITIES AND PROGRAMS¿ 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES¿ 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION¿ 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT¿ 22VAC40-80 THE LICENSE¿ 22VAC40-80 THE LICENSING PROCESS¿ 22VAC40-80 COMPLAINT INVESTIGATION¿ 22VAC40-80 SANCTIONS
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: 6/29/2022, 10:55 a.m. – 11:25 a.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 Alexandra Poulter, Licensing Inspector at (804)662-9771 or by email at alex.poulter@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
April 26, 2022Inspection5 violations
Inspection dates
04/26/2022
Areas reviewed
REVIEWED AREAS OF STANDARDS¿ 22VAC40-73 GENERAL PROVISIONS¿ 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES¿ 22VAC40-73 PERSONNEL¿ 22VAC40-73 STAFFING AND SUPERVISION¿ 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS¿ 22VAC40-73 RESIDENT CARE AND RELATED SERVICES¿ 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS¿ 22VAC40-73 BUILDINGS AND GROUND¿ 22VAC40-73 EMERGENCY PREPAREDNESS¿ 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS¿ ARTICLE 1 – SUBJECTIVITY¿ 32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS¿ 63.2 GENERAL PROVISIONS¿ 63.2 PROTECTION OF ADULTS AND REPORTING¿ 63.2 LICENSURE AND REGISTRATION PROCEDURES¿ 63.2 FACILITIES AND PROGRAMS¿ 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES¿ 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION¿ 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT¿ 22VAC40-80 THE LICENSE¿ 22VAC40-80 THE LICENSING PROCESS¿ 22VAC40-80 COMPLAINT INVESTIGATION¿ 22VAC40-80 SANCTIONS
Technical assistance
Administrator approval for placement in SCU
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: 4-26-2022 11:28 a.m. – 2:15 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 Alexandra Poulter, Licensing Inspector at (804)662-9771 or by email at alex.poulter@dss.virginia.gov
Violations
22VAC40-73-450-C
Based on record review, the facility failed to ensure the comprehensive individualized service plan (ISP) included the description of identified needs based upon the UAI [uniform assessment instrument] and admission physical examination.
Evidence
  1. Resident #1 admitted 4-1-2022. Resident #1’s UAI dated 3-29-2022 documented the resident is “incontinent less than weekly” for bladder and bowel assistance as an identified need; however, the resident’s comprehensive ISP dated 4-22-2022 did not address bowel and bladder incontinence.
  2. Resident #2 admitted 2-10-2022. Resident #2’s UAI dated 3-12-2022 documented bladder “incontinent less than weekly” as an identified need; however, Resident #2’s comprehensive ISP dated 3-1-2022 did not address bladder incontinence. Additionally, the same UAI documented, “mechanical help, human help, supervision” with mobility as an identified need; however, the same ISP did not address mobility assistance. Lastly, Resident #2’s Report of Resident Physical Examination dated 2-08-2022 documented resident’s allergy to “Meperidine causes anxiety”; however, the allergy and reaction were not on the ISP.
  3. Resident #3 admitted 12-27-2021. Resident #3’s UAI dated 3-03-2022 documented resident requires “mechanical help, human help physical assistance” with dressing as an identified need; however, the resident’s comprehensive ISP dated 3-03-2022 documented “resident requires assistance with dressing, caregiver dresses/undresses and selects clothing but resident is able to assist in task”. Additionally, the resident’s UAI documented a need for assistance with toileting “mechanical help, human help physical assistance”; however, the same ISP documented, “Adult Briefs Resident requires physical assistance with all tasks related to toileting. May require assistance with closed drainage system/catheter”.
  4. Resident #4 admitted 5-01-2021. Resident #4’s UAI dated 4-08-2022 documented “incontinent weekly or more” for bowel and bladder as identified needs; however, the comprehensive ISP dated 4-14-2022 documented “continent” for bowel and bladder assistance.
  5. Resident #5 admitted 9-14-2018. Resident #5’s UAI dated 3-04-2022 documented resident requires “mechanical help” with dressing as an identified need; however, the comprehensive ISP dated 11-20-2021 documented, “Resident can dress/undress and select clothing with physical assistance. Make sure [Resident #5] is odor free and dressed in appropriate clothing for season”.
  6. Resident #7 admitted 5-25-2021. Resident #7’s UAI dated 4-14-2022 stated “no” for assistance with money management; however, the comprehensive ISP dated 4-15-2022 documented “Resident is unable to handle financial business matters; resident has a designated person(s) to manage finances” as an identified need. Additionally, the UAI documented “mechanical help, human help physical assistance” for stairclimbing as an identified need; however the ISP did not address stairclimbing.
  7. Resident #8 admitted 8-28-2019. Resident #8’s UAI dated 1-19-2022 documented “physical assistance” with dressing as an identified need; however, the comprehensive ISP dated 1-26-2022 documented “Resident can dress/undress and select clothing but may need to be reminded/supervised” for dressing.
Plan of correction
What Has Been Done to Correct? The ISP and UAI for Residents #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #7, Resident #8 were reviewed and updated to reflect the residents current assessed needs. How Will Recurrence Be Prevented? Executive Director, Resident Care Director or designee will audit UAI and ISP upon completion to ensure all needs are addressed in real time. All current Resident UAI and ISP will be reviewed and updated as needed. All UAI’s and ISP’s will be reviewed by Executive Director and Resident Care director bi annually for compliance and accuracy. Person Responsible: Executive Director, Resident Care Director, or designee
22VAC40-73-560-F
Based on observation and interview with staff, the facility failed to ensure all records were made available for inspection by the department's representative.
Evidence
  1. During onsite inspection on 4-26-2022, Resident #2 through Resident #8’s records as well as Staff #3 through Staff #6 were locked in the administrative office (Staff #1’s office) that Staff #2 was not permitted access to due to Staff #1 being out of the community.
  2. Staff #1 stated during a phone call with the licensing inspector following the 4-26-2022 inspection date, “Typically the records are not kept locked in [Staff #1’s office]; however, they were doing a record-wide audit.”
Plan of correction
What Has Been Done to Correct? Files that were being audited were removed from the Executive Director’s office and placed in an accessible safe area for staff reference as needed. How Will Recurrence Be Prevented? A key to the Executive Director’s office was made and given to the Business Office Manager to keep onsite in case emergency access is needed. Person Responsible: Executive Director or designee
22VAC40-90-50-B
Based on record review and interview with staff, the facility failed to ensure each criminal history record report shall be verified by the operator of the facility by matching the name, social security number and date of birth to establish that all information pertaining to the individual cleared through the Central Criminal Records Exchange is exactly the same as another form of identification such as a driver's license. If any of the information does not match, a new criminal history record request must be submitted to the Central Criminal Records Exchange with correct information. 1. Staff #3 was hired 4-1-2020. The criminal history record report on file (dated 4-2-2020) was for a differently spelled name than Staff #3 and no report was resubmitted within 30 days with the correct name. 2. Staff #1 confirmed Staff #3’s report was not resubmitted until discovered during the inspection.
Plan of correction
What Has Been Done to Correct? The criminal history record report was resubmitted when it was discovered the spelling of an employee’s last name was wrong. How Will Recurrence Be Prevented? Executive Director and Business Office manager will continue to review pre-hire paperwork with staff to ensure all information is accurate. Review and audit all new employee files quarterly for compliance. Person Responsible: Executive Director, Business Office Manager, or designee
22VAC40-73-320-A
Based on record review and interview with staff, the facility failed to ensure the resident’s physical examination contained a descriptions of the person’s reactions to any known allergies.
Evidence
  1. Resident #1 admitted 4-01-2022. Resident #1’s Report of Resident Physical Examination dated 3-30-2022 documented allergies to “Fluoroquinolones, Mold, and Flagyl”; however, no reactions to the allergies were listed.
  2. Resident #3 admitted 12-27-2021. Resident #3’s Report of Resident Physical Examination dated 12-20-2021 documented allergies to “Ace inhibitors and Tetracyclines & related”; however, no reactions to the allergies were listed.
Plan of correction
What Has Been Done to Correct? Reactions to known allergies have been added to the care plan and face sheet for Resident #1 and Resident # 3 How Will Recurrence Be Prevented? Executive Director and Resident Care Director will ensure that History and Physical document is reviewed for required information and signatures prior to being admitted to the facility. Thorough medication and allergy audit and review of current residents by RCD, ED, house PCP and partnering pharmacy. Person Responsible: The Executive Director, Resident Care Director, or designee are responsible for ensuring any allergy has a listed reaction.
22VAC40-73-490-D
Based on record review and interview with staff, the facility failed to ensure the specific residents for whom the health care oversight was provided was identified.
Evidence
  1. The health care oversight dated 6-01-2021 through 6-30-2021 did not have a list of residents included in the oversight along with it.
  2. Staff #1 confirmed during interview that there was no list of residents included with the oversight as Staff #1 stated that it was known that this was required.
Plan of correction
What Has Been Done to Correct? Executive Director and Resident Care Director educated nurse consultant performing the healthcare oversight to ensure that a list of residents reviewed is identified and listed on the form. How Will Recurrence Be Prevented? Executive Director and Resident Care Director will audit Health Care Oversight paperwork before it is completed to ensure that a list of residents is captured. Person Responsible: Executive Director, Resident Care Director, or designee
March 16, 2022Complaint survey5 violations
Inspection dates
03/16/2022, 04/05/2022, 04/11/2022
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSArticle 1Subjectivity
Comments
An unannounced complaint investigation was conducted at the facility on March 16, 2022 by licensing staff from 10:04 a.m. to 1:43 p.m. A tour of the facility was conducted to observe residents. Resident records were reviewed and staff interviews were conducted. There were violations in the following areas: Resident Care and Related Services, Safe Secure Environment. Thank you for your cooperation during this inspection. I can be reached at alex.poulter@dss.virginia.gov or 804-662-9771.
Violations
22VAC40-73-450-D
Based on record review and interview with staff, the facility failed to ensure when hospice care is provided to a resident, the assisted living facility and the licensed hospice organization shall communicate and establish an agreed upon coordinated plan of care for the resident. The services provided by each shall be included on the individualized service plan.
Evidence
  1. Resident #1’s ISP dated 11-17-2021 documented, “Hospice will care for resident as scheduled by hospice” and listed the agency providing services; however, the ISP did not designate which services will be provided by hospice and which services will be provided by the facility.
  2. Resident #2’s ISP dated 4-30-2020 did not document hospice services; however, Resident #2 had a recertification as recent as 2-15-2022 through 4-15-2022 for hospice services.
  3. Resident #4’s ISP dated 11-15-2020 documented, “Hospice to provide support and ensure comfort care in place through end of life” and listed the agency providing services; however, the ISP did not designate which services will be provided by hospice and which services will be provided by the facility.
  4. Staff #1 confirmed during interview the services provided by each shall be included on the individualized service plan for the aforementioned residents.
Plan of correction
What Has Been Done to Correct? ISP was updated to reflect residents current assessed needs to include Hospice Services. How Will Recurrence Be Prevented? The Resident Care Director or designee will review all residents that have hospice services and ensure that their care plans reflect those services. Community will continue to complete Preliminary ISP and Comprehensive ISP in conjunction with resident, family, and/or caregivers while using the History and Physical, physician orders, UAI, and other support to ensure the individualized basic needs of the residents are adequately identified to include type of assistance needed to protect the resident's health, safety, type of assistance required by coordinated services if applicable, and required signatures. Executive Director will complete random monthly audits to ensure ongoing compliance Person Responsible: Executive Director, Resident Care Director, or designee Due Date: ED and RCD to review all resident charts by 5/31/22. Continue monthly chart audits
22VAC40-73-650-B
Based on record review, the facility failed to ensure physician or other prescriber orders, both written and oral shall identify the diagnosis, condition, or specific indications for administering each drug.
Evidence
  1. The following residents’ Physicians’ Orders did not identify the diagnosis, condition, or specific indications for administering each drug: a. Resident #2’s Physician’s Orders dated 11-16-2021 – Bisacodyl Rectal Suppository 10mg, Calmoseptine External Ointment 0.44 – 20.6%, Ensure Chocolate 24 cans, Gabapentin Oral Capsule 100 mg, Triple Antibiotic External Ointment; and b. Resident #4’s Physician’s Orders dated 10-21-2021 – Docusate Sodium Oral Capsule 100 mg, Loperamide HCI Oral Capsule 2 mg.
Plan of correction
What Has Been Done to Correct? All physician’s orders are being reviewed, updated, and signed to include a diagnosis for all medications. How Will Recurrence Be Prevented? Physician or other prescriber orders, both written and oral, for administration of all prescription and over-the-counter medications and dietary supplements will include the name of the resident, the date of the order, the name of the drug, route, dosage, strength, how often medication is to be given, and identify the diagnosis, condition, or specific indications for administering each drug. Person Responsible: The Resident Care Director and the Assistant Resident Care Director are responsible for ensuring physician’s orders include a diagnosis Due Date: RCD to review all resident orders by 5/6/22 and ongoing
22VAC40-73-440-A
Based on record review and interview with staff, the facility failed to ensure the uniform assessment instrument (UAI) was completed whenever there is a significant change in the resident's condition.
Evidence
  1. Resident #1’s ISP dated 11-17-2021 documented “catheter” under “Bladder Management”; however, Resident #1’s UAI dated 9-22-2021 documented “No” under continence – bladder for “Needs Help?”.
  2. Additionally, Resident #1’s UAI dated 11-17-2021 documented “No” under eating/feeding for “Needs Help?”; however, Resident #1’s ISP documented on 11-10-2021, “resident may need to be assisted with feeding and drinking give resident straws”.
  3. Staff #1 confirmed during interview that Resident #1’s UAI was not updated with the change in resident’s condition.
Plan of correction
What Has Been Done to Correct? Resident 1’s UAI and ISP was updated How Will Recurrence Be Prevented? All information will be reviewed prior to completion and ensure the UAI, and ISP match and the resident is receiving the care that is needed Person Responsible: Executive Director, Resident Care Director, or designee Due Date: ED and RCD to review all resident charts by 5/31/22. Continue monthly chart audits
22VAC40-73-1090-A
Based on record review and interview with staff, the facility failed to ensure prior to admission to a safe, secure environment (SSE), the resident shall have been assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare.
Evidence
  1. Resident #4 admitted to the SSE on 7-12-2019. Resident #4’s “Assessment of Serious Cognitive Impairment” documented, “No” to the question, “Is the individual above able to unable to recognize danger or protect his/her own safety and welfare?” by Physician #1.
  2. Staff #1 acknowledged during interview that Resident #4 was not assessed as unable to recognize danger or protect his own safety and welfare.
Plan of correction
What Has Been Done to Correct? This was in place at time of inspection. Resubmitted the document for review How Will Recurrence Be Prevented? Executive Director and Resident Care Director to review all paperwork prior to admission Person Responsible: Executive Director, Resident Care Director, or designee Due Date: 4/18/22
22VAC40-73-450-F
Based on record review and interview with staff, the facility failed to ensure individualized service plans (ISPs) were reviewed and updated at least once every 12 months.
Evidence
  1. Resident #2 admitted 6-08-2015 to the facility. On the date of inspection (3-16-2022), Resident #2’s most current ISP was dated 4-30-2020.
  2. Resident #4 admitted 7-12-2019 to the facility. On the date of inspection (3-16-2022), Resident #4’s most current ISP was dated 11-15-2020.
  3. Staff #1 acknowledged that documentation was still being updated and that Resident #2 and Resident #4’s ISPs were not reviewed and updated at least once every 12 months.
Plan of correction
What Has Been Done to Correct? Resident 2 and 4 were reviewed and ISP has been updated How Will Recurrence Be Prevented? The Resident Care Director or designee will ensure that each ISP is reviewed and updated annually or if there is a change in the resident condition Person Responsible: Executive Director, Resident Care Director, or designee Due Date: ED and RCD to review all resident ISPs by 5/31/22. Continue monthly audits
June 4, 2021Complaint survey0 violations
Areas reviewed
22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS22VAC40-80 COMPLAINT INVESTIGATION
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 unannounced focused inspection was conducted to investigate allegations concerning communication of resident behavor and discharge. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 62. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed the requested facility and resident record documents. There was no preponderance of evidence found to substantiate allegations. The information gathered during the inspection determined no violations with applicable standards or law. Please contact me by e-mail at T.Lesley@dss.virginia.gov if further assistance is needed.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
June 4, 2021Complaint survey0 violations
Areas reviewed
22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 BUILDING AND GROUNDS22VAC40-80 COMPLAINT INVESTIGATION
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 4, 2021Inspection1 violation
Inspection dates
May 4, 2021 , May 6, 2021 and May 10, 2021
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 renewal inspection was initiated on May 4, 2021 and concluded on May 10, 2021. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 63. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed 4 resident records, 4 staff records, physician's orders, Medication Administration Records (MARs), and other facility documentation submitted by the facility to ensure documentation was complete. A virtual tour of the facility was also conducted. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and a violation was documented on the violation notice issued to the facility. Please specify how the violation will be corrected. The plan must contain: 1) step(s) to correct the non-compliance with the standard(s), 2) measures to prevent the non-compliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s). Thank you for your cooperation during this inspection. I can be reached at Kimberly.M.Davis@dss.virginia.gov or (804) 662-7578.
Violations
22VAC40-73-320-A
Based on a review of resident records, the facility failed to ensure that the physical examination report for each resident contained a statement that specifies whether the individual is or is not capable of self-administering medication.
Evidence
  1. The physical examination report for Resident # 1 and Resident # 3 did not contain a statement that specifies whether the individual is or is not capable of self-administering medication.
Plan of correction
Effective immediately, Commonwealth Senior Living at Charlottesville will use the state provided form titled "Report of Resident Physical Examination" (02/18) that includes the verbiage "Is the person capable of self administering Resident Physical Examination (02/18) that includes the verbiage Is the person capable of self-administering medication ?" The Executive Director and Resident Care Director will be responsible for ensuring this.