Virginia DSS · Assisted Living Facility

Charter Senior Living of Fredericksburg

📍 20 Heartfields Lane, Fredericksburg, VA, 22405

ID 45772Two Year licenseActive
11
Inspections
On record
3
With violations
Visits that cited something
8
Clean visits
Nothing cited
14
Violations cited
Individual findings
14
Standards cited
Distinct rules
4
Complaint visits
Prompted by a complaint

Charter Senior Living of Fredericksburg was inspected 11 times between May 14, 2021 and July 15, 2025 by the Virginia Department of Social Services. 3 of those visits ended with violations cited and 8 with none. Across that history VDSS cited 14 violations under 14 distinct standards. 4 inspections were prompted by a complaint.

A violation is a licensing standard - a rule in the Virginia Administrative Code - that the inspector found the facility was not meeting. Each is shown with the evidence the inspector recorded and, where VDSS publishes it, the facility's own plan of correction.

VDSS publishes inspections on a rolling window. 10 of these 11 are still on the state's site; the other 1 has since dropped off it and is 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
06/30/2026
Administrator
Elisha Fade
Licensing inspector
Patricia Koval
Inspector phone
(804) 621-6046
Approved for
Assisted Living · Special Care Unit · Non-Ambulatory

Inspection History

11

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

July 15, 2025Complaint survey0 violations
Inspection dates
07/15/2025
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7/15/2025 11:45 A.M. – 2:40 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 4/17/2025 regarding allegations in the area(s) of: resident care Number of residents present at the facility at the beginning of the inspection: 68 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: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Building and grounds, activities provided, dining services Additional Comments/Discussion: n/a 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 Jeff Marnien, Licensing Inspector at (540) 571-0189 or by email at Jeffrey.marnien@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
July 15, 2025Complaint survey1 violation
Inspection dates
07/15/2025
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7/15/2025 2:45 P.M – 4:30 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 6/26/2025 regarding allegations in the area(s) of: resident care Number of residents present at the facility at the beginning of the inspection: 68 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: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: Building and grounds, activities, and dining services. Additional Comments/Discussion: n/a 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 Jeff Marnien, Licensing Inspector at (540) 571-0189 or by email at Jeffrey.marnien@dss.virginia.gov
Violations
22VAC40-73-450-D
Based on record review and staff interview, the facility failed to ensure when hospice care is provided to residents, the assisted living facility and the licensed hospice organization shall communicate and establish an agreed upon coordinated plan of care for residents and services provided by each shall be included in the individualized service plan.
Evidence
  1. During document review on 7/15/2025, the Licensing Inspector (LI) observed that the individualized service plan (ISP), dated 4/4/2025, for resident 1 did not include the hospice services, started 3/17/2025, that were being provided.
  2. Staff 1 was interviewed on 7/15/2025 and confirmed that hospice services were not on the ISP staff used to reference care needs of resident 1.
Plan of correction
The Health and Wellness Director (HWD) or designee conducted an audit of the Individualized Service Plan (ISP) to ensure that all residents receiving hospice care have an established coordinated plan of care included in their ISP in compliance with state regulations. Any negative findings were promptly corrected. HWD or designee will conduct ISP audits monthly for the next 3 months. Issues Identified will be resolved and reported to the Executive Director (ED). The Executive Director will review the POC and the results of the audit with the Department Head. Additional improvement plans will be developed and implemented as necessary, including training to correct any deficient practices.
June 25, 2025Complaint survey0 violations
Inspection dates
06/25/2025
Areas reviewed
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 6/25/2025 1:00 p.m. – 5:20 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 6/2/2025 regarding allegations in the area(s) of: staffing, staff qualifications, and resident care. Number of residents present at the facility at the beginning of the inspection: 69 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: 2 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Observations by licensing inspector: Building and grounds, dining services, activities in Memory Care and Assisted Living, and resident rooms. Additional Comments/Discussion: N/A 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 Jeff Marnien, Licensing Inspector at (540) 571-0189 or by email at Jeffrey.marnien@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
March 26, 2025Inspection10 violations
Inspection dates
03/26/2025, 03/27/2025
Areas reviewed
22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND3.2- (17) LICENSURE AND REGISTRATION PROCEDURES22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT
Comments
Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 3/26/2025 11:00 a.m. – 5:20 p.m.; 3/27/2025 9:30 a.m. – 6:00 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: 44 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 3 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: Building and grounds, dining services, resident rooms, activities, resident council, and medication pass. Additional Comments/Discussion: N/A 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 Jeff Marnien, Licensing Inspector at (540) 571-0189 or by email at Jeffrey.marnien@dss.virginia.gov
Violations
22VAC40-73-640-A
Based on document review and staff interview, the facility failed to ensure the facilities medication management plan addressed methods to prevent outdated medications and the facilities standard dosing schedule.
Evidence
  1. During the review of the facility's medication management plan (Policy No. Med-012, effective 11/2024), LI observed that the plan did not include procedures to prevent the use of outdated, damaged, or contaminated medications, nor did it address the facility's standard dosing schedule.
  2. Staff 5 and Staff 6 confirmed, during interview with LI on 3/27/2025, those elements were missing from the facilities medication management plan.
Plan of correction
Medication management plan updated to include detailed procedures for preventing the use of outdated, damaged, or contaminated medications. HWD or designee will review the medication management plan periodically and make appropriate updates to ensure compliance with the regulations, The Executive Director will review the audit results and report findings to the Quality Assurance Committee at least quarterly.
22VAC40-73-690-F
Based on observation and staff interview, the facility failed to ensure the medication review by the licensed health care professional certified the requirements outlined in this subsection were met.
Evidence
  1. During record review the LI observed the medication reviews, dated 4/22/2024 and 10/23/2024, did not include a certification the criteria in this subsection were met.
  2. LI reviewed the document with staff 5 on 3/26/2025 who confirmed the certification was not provided.
Plan of correction
The certification is included in the current pharmacy medication review completed on 4/15/25. HWD or designee will ensure the pharmacy medication review includes the certification as required by the regulations when it is completed by the pharmacist. The Executive Director will review the audit results and report findings to the Quality Assurance Committee at least quarterly.
22VAC40-73-980-A
Based on observation and staff interview, the facility failed to ensure a complete first aid kit shall be on hand in each building at the facility, located in a designated place that is easily accessible to staff.
Evidence
  1. During tour of the building on 3/26/2025 the LI requested staff 7 to provide the first aid kit.
  2. A first aid kit taken from behind the concierge desk was provided for review. Missing from the first aid kit were triangular bandages.
  3. Staff 7 confirmed triangular bandages were missing from the first aid kit.
Plan of correction
The first aid kit for the building has been updated to include triangular bandages and made easily accessible to the staff. HWD or designee will conduct a monthly audit and complete the check list to ensure all the items are available in the kit in accordance with the regulations. The Executive Director will review the audit results and report findings to the Quality Assurance Committee at least quarterly.
22VAC40-73-980-C
Based on observation and staff interview, the facility failed to ensure first aid kits shall be checked at least monthly to ensure that all items are present.
Evidence
  1. During tour of the building on 3/26/2025 the LI reviewed the facilities first aid kit.
  2. The LI did not observe a completed monthly check ensuring all items are present.
  3. Staff 7 confirmed the monthly check was not completed for the first aid kit.
Plan of correction
HWD or designee completed the checklist to ensure all the items are available in accordance with the state regulations. HWD or designee will conduct a monthly audit and complete the check list monthly to ensure all the items are available in the kit in accordance with the regulations. The Executive Director will review the audit results and report findings to the Quality Assurance Committee at least quarterly.
22VAC40-73-680-C
Based on observation and staff interview, the facility failed to ensure medications were administered not earlier than one hour before and not later than one hour after the facility's standard dosing schedule.
Evidence
  1. During the medication pass at 10:00 a.m. on 3/27/2025, LI observed that the acetaminophen 325 mg tablet, scheduled for 10:00 a.m. for resident 2, admitted 1/10/2028, admitted, was administered at 11:13 a.m.
  2. Staff 2, hired 10/25/2024, confirmed with LI that the medication was administered more than one hour after the standard dosing schedule.
Plan of correction
No negative outcome to resident #2. The Health and Wellness Director (HWD) or designee provided education to the medication technicians and nurses on timely and safe medication administration on 3/28 and during their departmental meeting on 4/28 HWD or designee will conduct medication administration record audit weekly for the next three months The Executive Director will review the POC and the results of the audit with the Department Heads. Additional improvement plans will be developed and implemented as necessary, including training to correct any deficient practices.
22VAC40-73-640-D
Based on observation and staff interview, the facility failed to have readily accessible at least one pharmacy reference book, drug guide, or medication handbook for nurses that is no more than two years old as reference materials for staff who administer medications.
Evidence
  1. During tour of the building on 3/26/2025 the LI requested staff 7, to provide the drug guide or medication handbook.
  2. Staff 6 and staff 7 confirmed a drug guide or medication handbook could not be provided.
Plan of correction
The medication handbook that is no more than two years is readily accessible to the staff who administer medications. HWD or designee will review periodically to ensure the medication handbook that is no more than two years is readily accessible to the staff who administer medications. The Executive Director will review the audit results and report findings to the Quality Assurance Committee at least quarterly.
22VAC40-73-660-A
Based on observation and staff interview, the facility failed to ensure resident prescribed medications were stored in a medicine cabinet, container, or compartment when administered by the facility.
Evidence
  1. During the medication pass at 10:00 a.m. on 3/27/2025 for resident 5, admitted 11/21/2023, Licensing Inspector (LI) observed Sarna Sensitive 1% lotion was not in the medication cart.
  2. Staff 2, hired 10/25/2024, confirmed with LI the medication was not in the cart but was located in the resident’s bathroom.
Plan of correction
No negative outcome occurred to residents #5. The Health and Wellness Director (HWD) or designee did an audit of the medication cart to make sure all medications are properly stored in accordance with the state regulations. No other negative finding. HWD or designee will conduct medication audits monthly for the next 3 months. Issues Identified will be resolved and reported to the Executive Director (ED). The Executive Director will review the audit results and report findings to the Quality Assurance Committee at least quarterly.
22VAC40-73-680-M
Based on observation and staff interview, the facility failed to ensure medications ordered for PRN administration shall be available, properly labeled for the specific resident, and properly stored at the facility.
Evidence
  1. During a medication cart audit in the memory care unit on 3/27/2025, the LI and staff 2 observed nitroglycerin .4 mg, prescribed 2/27/2024, was missing for resident 5, admitted 3/17/2025.
  2. Staff 2 assisting with the cart audit confirmed the medication missing from the medication cart.
Plan of correction
No negative outcome occurred to residents #5. The Health and Wellness Director (HWD) or designee did an audit of the medication cart to make sure all medications are properly labeled and stored in accordance with state regulations. No other negative finding. HWD or designee will conduct medication audits monthly for the next 3 months. Issues Identified will be resolved and reported to the Executive Director (ED). The Executive Director will review the audit results and report findings to the Quality Assurance Committee at least quarterly.
22VAC40-73-680-K
Based on record review and staff interview, the facility failed to ensure when a medication is ordered for as needed (PRN) use and administered by registered medication aides that the physician order is a detailed order that includes directions as to what to do if symptoms persist.
Evidence
  1. LI observed resident 2, admitted 1/10/2028, PRN orders did not include physician instructions what to do if symptoms persist.
  2. Staff 7, hired 7/24/2024, confirmed during interview with LI on 3/27/2025, that all PRN orders for resident 2 did not include instructions what to do if symptoms persist.
Plan of correction
No negative outcome to resident #2. The Health and Wellness Director (HWD) or designee conducted an audit of the PRN medication orders. Negative findings were resolved. HWD or designee will ensure all PRN medication orders include instructions on what to do if symptoms persist. HWD or designee will audit at least 10% of resident files monthly for a period of six months to ensure compliance in accordance with the regulation. The Executive Director will review the audit results and report the findings to the Quality Assurance Committee at least quarterly.
22VAC40-73-50-A
Based on record review and staff interview, the facility failed to provide a disclosure statement with information that is accurate.
Evidence
  1. During record review the LI observed the disclosure statement provided to resident 1 was incomplete.
  2. On page 3 of the disclosure statement under section 5 General number, Position Types, and Qualifications of staff on each shift the number of direct care staff for the 7:00 a.m. – 3:00 p.m. shift was blank. Also missing was information for the 3:00 p.m. – 11:00 p.m. shift.
Plan of correction
The disclosure statement has been updated to reflect the position types, numbers and qualifications of staff on each shift. ED or designee will review periodically to make sure all elements of the disclosure are current in accordance with the regulations. The Executive Director will review the audit results and report findings to the Quality Assurance Committee at least quarterly.
March 26, 2025Complaint survey0 violations
Inspection dates
03/26/2025
Areas reviewed
22VAC40-80 COMPLAINT INVESTIGATION
Comments
Type of inspection: Complaint Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 3/26/2025 9:20 a.m. – 10:50 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 2/25/2025 regarding allegations in the area(s) of: resident care. Number of residents present at the facility at the beginning of the inspection: 44 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: 4 Observations by licensing inspector: Building and grounds, resident rooms, dining and kitchen area. Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact (Jeff Marnien), Licensing Inspector at (540) 571-0189 or by email at Jeffrey.marnien@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
January 10, 2025Inspection0 violations
Inspection dates
01/10/2025
Areas reviewed
22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS
Comments
Type of inspection: Other Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 1/10/2025 10:50am-1:10pm 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 12/10/2024 regarding allegations in the area(s) of: retention and discharge of a resident 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: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: n/a Additional Comments/Discussion: n/a 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 (Jeff Marnien), Licensing Inspector at (540) 571-0189 or by email at Jeffrey.marnien@dss.virginia.gov
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
December 11, 2024Inspection0 violations
Inspection dates
12/11/2024
Areas reviewed
22VAC40-73 RESIDENT CARE AND RELATED SERVICES
Comments
Type of inspection: Other Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 12/11/2024 4:00pm – 5:40pm 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: 73 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: 0 Number of interviews conducted with staff: 1 Observations by licensing inspector: Building and grounds presented well. Additional Comments/Discussion: n/a 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 (Jeff Marnien), Licensing Inspector at (540) 571-0189 or by email at Jeffrey.marnien@dss.virginia.gov Violation Notice Issued: No
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
June 24, 2024Inspection3 violations
Inspection dates
06/24/2024
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 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Comments
Type of inspection: Renewal Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 6/24/24, 10:15 a to 1:25 p 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: 65 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: 4 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: file documentation, required postings, medication pass, facility maintenance, staff/resident interaction Additional Comments/Discussion: The inspection was conducted by two licensing inspectors. 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 Yvonne Randolph, Licensing Inspector at 804-662-7454 or by email at Yvonne.randolph@dss.virginia.gov
Violations
22VAC40-73-250-D
Based on a review of staff files, it was determined that the facility did not ensure that each staff person or household member required to be evaluated shall annually submit the results of a risk assessment, documenting that the individual is free of tuberculosis in a communicable form as
Evidence
  1. d by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence:
  2. The results of an annual risk assessment for tuberculosis was not documented in the files of staff # 2. The screening form for staff # 2 did not have the results or a date.
  3. The results of an annual risk assessment for tuberculosis was not documented in the files of staff # 3. The screening form for staff # 3 did not have a date.
  4. The results of an annual risk assessment for tuberculosis was not documented in the files of staff # 4. The last screening for staff # 4 was dated 2-21-23.
Plan of correction
1.Staff records updated with the annual TB risk assessment. 2.All staff records to be audited by the Business office Manager or Designee to ensure the annual TB risk assessments are complete by 7/31/24. 3.Any personnel files found to be missing required annual TB risk assessments will be reported to ED for staff completion. 4.The Business Office Manager / designee will audit at least 10% of staff files monthly. The Executive Director will review the audit results and report findings to the Quality Assurance Committee at least quarterly.
22VAC40-73-1100-A
Based on a review of files for three residents in the safe, secure environment, it was determined that the facility did not ensure that prior to placing a resident with a serious cognitive impairment due to a primary diagnosis of dementia in a safe, secure environment, the facility shall document that written approval was obtained following the order of priority:
Evidence
  1. Documentation that the order of priority was followed was not found during a review of the files for residents # 3, and # 6.
  2. The Approval for resident # 5 was obtained after admission to the safe, secure environment. Staff # 1 reported that the resident was admitted and assessed on 6/8/22. The approval was dated 2/4/24.
  3. Staff # 1 reviewed the files and was unable to provide documentation of compliance.
Plan of correction
1.Health and Wellness Director or Designee will audit all special care unit resident files to ensure Approval for Placement in Special Care Unit form is signed prior to admission in SCU by 7/31/24. 2.Any resident files missing Approval for Placement in Special Care Unit form or missing signature of resident representative on form will be reported to Executive Director and resident’s representative to be completed. 3.Health and Wellness Director / designee will utilize move-in checklist for all future admissions and transfer of resident from Assisted living to SCU to ensure Approval for Placement in Special Care unit forms are signed prior to admission/transfer to SCU. 4.Health and Wellness Director / designee will audit at least 10% of resident files monthly for a period of six months to ensure compliance in accordance with the regulation. The Executive Director will review the audit results and report findings to the Quality Assurance Committee at least quarterly.
22VAC40-73-490-A-2
Based on a review of file documentation, it was determined that the facility did not ensure that health care oversight was provided at least every three months for residents at the assisted living level of care, by a health care professional practicing within the scope of his profession.
Evidence
  1. Documentation of health care oversight was requested of staff # 1. The last documented health care oversight was completed on 2/3/24.
  2. Staff # 1 was unable to provide any oversight completed after 2/3/24.
Plan of correction
1.Health and Wellness Director / designee will schedule health care oversight to be completed by 7/31/24. 2.Health and Wellness Director / designee will schedule health care oversights quarterly. 3.Health and Wellness Director / designee will audit health care oversights quarterly to ensure compliance in accordance with the regulation. The Executive Director will review the audit results and report findings to the Quality Assurance Committee at least quarterly.
February 8, 2023Inspection0 violations
Inspection dates
02/08/2023,02/09/2023
Areas reviewed
Administration and Administrative ServicesPersonnelStaffing and SupervisionAdmission, Retention and Discharge of ResidentsResident Care and Related ServicesBuildings and GroundsEmergency PreparednessAdditional Requirements for Facilities that care for Adults with Serious Cognitive ImpairmentMixed PopulationSafe Secure Environment
Comments
Date of Inspection: February 8 and 9, 2023 Type of Inspection: Monitoring inspection If you have any questions or email changes, please do not hesitate to contact me at laura.lunceford@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov. Census 57 Number of records reviewed and interviews conducted- 11 records both residents and staff, 9 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. The Licensing Inspector observed the residents during meals and activities. The Licensing Inspector reviewed the following at the time of inspection: pharmacy review, dietician report, fire drills, activity calendars and menus.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
June 2, 2022Inspection0 violations
Inspection dates
06/02/2022,06/06/2022
Areas reviewed
Administration and Administrative ServicesPersonnelStaffing and SupervisionAdmission, Retention and Discharge of ResidentsResident Care and Related ServicesBuildings and GroundsEmergency PreparednessMixed PopulationSafe, Secure Environment
Comments
Date of Inspection: June 2, 2022 Type of Inspection: Monitoring Inspection If you have any questions or email changes, please do not hesitate to contact me at laura.lunceford@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov. Census 57 Number of records reviewed and interviews conducted- 4 resident records and 4 staff records, 3 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. The Licensing Inspector reviewed the documentation for the following during the inspection: fire drills, healthcare oversight, resident council minutes, staff training, and the dietician report.
Violations
✅
No violations cited
The inspector documented no violation of standards at this inspection.
May 14, 2021Inspection0 violations
Inspection dates
May 14, 2021 and May 17, 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 PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
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 14, 2021 and concluded on May 17, 2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 76. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 4 resident records, 4 staff records, door signal checks, dietician's report, staff training 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.