1 Inspection Summary
Inspection Reports Summary
Covers 19 inspections · Feb 2021 – Apr 2026Visit Reason
This report covers 19 inspections of Commonwealth Senior Living at Cedar Manor from February 3, 2021 to April 30, 2026, including routine, complaint, and monitoring inspections.
Complaint Details
Nine inspections were prompted by complaints alleging issues in personnel, resident care, and related services. Some complaints resulted in violations, others found no violations.
Findings
Across that history VDSS cited 81 violations under 46 distinct standards. 16 of 19 inspections cited violations and 9 were complaint prompted.
Violations (77)
22VAC40-73-690-G: Failed to document actions taken in response to medication review recommendations.
22VAC40-73-680-D: Medications not administered according to physician’s instructions.
22VAC40-73-940-A: Annual fire inspection not completed after 03/25/25.
22VAC40-73-450-C: ISP not completed within 30 days after admission; missing description of identified needs.
22VAC40-73-320-A: Physical exam not within 30 days prior to admission or unsigned by physician.
22VAC40-90-40-B: Criminal history records not obtained on or before 30th day of employment.
22VAC40-73-130-A: Mandated reporters failed to report suspected abuse as required.
22VAC40-73-450-C: ISP not completed within 30 days after admission; missing description of identified needs based on UAI.
22VAC40-73-290-B: Failed to post name of current on-site person in charge conspicuously.
22VAC40-73-640-A: Medication management plan not implemented to ensure timely refills.
22VAC40-73-680-D: Medications not administered per physician’s instructions; documentation lacking.
22VAC40-73-970-E: Fire and emergency evacuation drill records missing date and time of drills.
22VAC40-73-410-A: Orientation for new residents and legal guardians not provided upon admission.
22VAC40-73-450-C: ISP not completed within 30 days after admission; missing description of identified needs and dated based on UAI and other sources.
22VAC40-73-325-B: Fall risk rating not reviewed and updated after resident falls.
22VAC40-73-350-B: Failed to ascertain and document sex offender registry check prior to admission.
22VAC40-73-680-D: Medications not administered according to physician’s instructions.
22VAC40-73-450-D: Hospice services not included in ISP as coordinated plan of care.
22VAC40-73-640-A: Medication management plan not implemented to prevent use of outdated medications.
22VAC40-73-450-D: Hospice services not included in ISP as coordinated plan of care.
22VAC40-73-640-A: Medication management plan not implemented to ensure accurate controlled substance counts at shift changes.
22VAC40-73-450-C: Preliminary plan of care not developed on or within 7 days prior to admission.
22VAC40-73-680-D: Medications not administered according to physician’s instructions.
22VAC40-73-440-A: UAI not completed prior to admission.
22VAC40-73-450-E: ISP not signed and dated by resident or legal guardian.
22VAC40-73-940-A: Annual fire inspection not completed.
22VAC40-73-450-F: ISP not reviewed and updated at least annually or as needed for significant change.
22VAC40-73-410-A: Orientation for new residents and legal representatives not provided upon admission.
22VAC40-73-660-A: Medications not stored locked; medication cart found unlocked and unstaffed.
22VAC40-73-320-A: Physical exam not within 30 days prior to admission or missing required elements.
22VAC40-73-680-D: Medications not administered according to physician’s instructions.
22VAC40-73-450-C: ISP not completed within 30 days after admission; missing description of identified needs based on UAI.
22VAC40-73-450-E: ISP not signed and dated by resident or legal guardian.
22VAC40-73-450-D: Hospice services not included in ISP as coordinated plan of care.
22VAC40-73-430-H-1: Discharge statement not provided to resident or legal representative at discharge.
22VAC40-73-660-A-1: Medication stored unlocked in resident room.
22VAC40-90-40-B: Criminal history record report not obtained on or before 30th day of employment.
22VAC40-73-200-D: Staff record missing certificate or documentation of meeting direct care staff requirements.
22VAC40-73-1110-B: Failed to perform six month and annual review of appropriateness of resident’s continued residence in safe, secure unit.
22VAC40-73-680-G: Over-the-counter medications not labeled with resident’s name.
22VAC40-73-130-A: Mandated reporters failed to report suspected abuse as required.
22VAC40-73-680-E: Medical procedures or treatments not provided or documented as ordered by physician.
22VAC40-73-640-A: Medication management plan not implemented to prevent use of outdated, damaged, or contaminated medications.
22VAC40-73-680-D: Medications not administered according to physician’s instructions.
22VAC40-73-450-C: ISP not completed within 30 days after admission; missing description of identified needs.
22VAC40-73-290-B: Failed to post name of current on-site person in charge conspicuously.
22VAC40-73-640-A: Medication management plan not implemented to ensure timely refills.
22VAC40-73-680-D: Medications not administered per physician’s instructions; documentation lacking.
22VAC40-73-970-E: Fire and emergency evacuation drill records missing date and time of drills.
22VAC40-73-410-A: Orientation for new residents and legal guardians not provided upon admission.
22VAC40-73-450-C: ISP not completed within 30 days after admission; missing description of identified needs and dated based on UAI and other sources.
22VAC40-73-325-B: Fall risk rating not reviewed and updated after resident falls.
22VAC40-73-350-B: Failed to ascertain and document sex offender registry check prior to admission.
22VAC40-73-680-D: Medications not administered according to physician’s instructions.
22VAC40-73-450-D: Hospice services not included in ISP as coordinated plan of care.
22VAC40-73-640-A: Medication management plan not implemented to prevent use of outdated medications.
22VAC40-73-450-D: Hospice services not included in ISP as coordinated plan of care.
22VAC40-73-640-A: Medication management plan not implemented to ensure accurate controlled substance counts at shift changes.
22VAC40-73-450-C: Preliminary plan of care not developed on or within 7 days prior to admission.
22VAC40-73-680-D: Medications not administered according to physician’s instructions.
22VAC40-73-440-A: UAI not completed prior to admission.
22VAC40-73-450-E: ISP not signed and dated by resident or legal guardian.
22VAC40-73-940-A: Annual fire inspection not completed.
22VAC40-73-450-F: ISP not reviewed and updated at least annually or as needed for significant change.
22VAC40-73-410-A: Orientation for new residents and legal representatives not provided upon admission.
22VAC40-73-660-A: Medications not stored locked; medication cart found unlocked and unstaffed.
22VAC40-73-320-A: Physical exam not within 30 days prior to admission or missing required elements.
22VAC40-73-680-D: Medications not administered according to physician’s instructions.
22VAC40-73-450-C: ISP not completed within 30 days after admission; missing description of identified needs based on UAI.
22VAC40-73-450-E: ISP not signed and dated by resident or legal guardian.
22VAC40-73-450-D: Hospice services not included in ISP as coordinated plan of care.
22VAC40-73-430-H-1: Discharge statement not provided to resident or legal representative at discharge.
22VAC40-73-660-A-1: Medication stored unlocked in resident room.
22VAC40-90-40-B: Criminal history record report not obtained on or before 30th day of employment.
22VAC40-73-200-D: Staff record missing certificate or documentation of meeting direct care staff requirements.
22VAC40-73-1110-B: Failed to perform six month and annual review of appropriateness of resident’s continued residence in safe, secure unit.
22VAC40-73-680-G: Over-the-counter medications not labeled with resident’s name.
Report Facts
Violations cited: 81
Distinct standards: 46
Inspections on page: 19
Inspections with violations: 16
Complaint visits: 9
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