Inspection Reports for
Commonwealth Senior Living at Churchland House
VA, 23703
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Inspection Reports Summary
Covers 16 inspections · Jan 2021 – Apr 2026Visit Reason
This report covers 16 inspections of COMMONWEALTH SENIOR LlVING AT CHURCHLAND HOUSE from January 4, 2021 to April 28, 2026, including complaint and renewal inspections.
Complaint Details
Seven inspections were prompted by complaints alleging issues in Resident Care and Related Services and Personnel. Investigations supported some but not all allegations, resulting in violations issued.
Findings
Across that history VDSS cited 43 violations under 27 distinct standards. 7 inspections were prompted by a complaint.
Violations (63)
22VAC40-73-470-F: Failed to ensure medical attention secured immediately and documented after serious incident.
22VAC40-73-300-B: Failed to keep direct care staff informed via written communication of significant resident incidents.
22VAC40-73-560-E: Failed to keep all resident records in a locked area.
22VAC40-73-1090-A: Failed to ensure prior assessment by licensed professional for serious cognitive impairment before admission to secure environment.
22VAC40-73-860-G: Hot water temperature not maintained within 105°F to 120°F range.
22VAC40-73-680-D: Medications not administered per physician's instructions.
22VAC40-73-460-B: Failed to provide prompt staff response to resident needs as reasonable to circumstances.
22VAC40-73-300-B: Failed to keep direct care staff informed via written communication of significant resident incidents.
22VAC40-73-290-B: Failed to post name of current on-site person in charge conspicuously.
22VAC40-73-450-C: ISP did not include description of needs and date identified based on UAI.
22VAC40-90-40-C: Employed person with convictions of barrier crimes.
22VAC40-73-640-A: Failed to ensure accurate counts of controlled substances when med staff changes.
22VAC40-73-680-I: MAR lacked documentation of symptoms, dosage, and effectiveness for PRN meds.
22VAC40-73-450-C: ISP not completed within 30 days after admission.
22VAC40-73-450-C: ISP not completed within 30 days after admission.
22VAC40-73-940-A: Failed to have annual fire inspection for 2023 as required.
22VAC40-73-680-D: Medications not administered per physician's instructions.
22VAC40-73-450-F: ISP not reviewed and updated for significant change in resident condition.
22VAC40-73-430-H-1: Discharge statement lacked documentation of assistance and destination.
22VAC40-73-440-A: UAI not completed prior to admission, annually, or with significant change.
22VAC40-73-300-B: Failed to keep direct care staff informed via written communication of significant resident incidents.
22VAC40-73-290-B: Failed to post name of current on-site person in charge conspicuously.
22VAC40-73-450-C: ISP did not include description of needs and date identified based on UAI.
22VAC40-90-40-C: Employed person with convictions of barrier crimes.
22VAC40-73-640-A: Failed to ensure accurate counts of controlled substances when med staff changes.
22VAC40-73-680-I: MAR lacked documentation of symptoms, dosage, and effectiveness for PRN meds.
22VAC40-73-450-C: ISP not completed within 30 days after admission.
22VAC40-73-460-H: Failed to provide bathing assistance at least twice a week as needed.
22VAC40-73-930-D: Failed to document rounds for residents unable to use signaling device.
22VAC40-73-440-A: UAI not completed prior to admission.
22VAC40-73-200-C: Direct care staff lacked required qualifications at time of employment.
22VAC40-73-450-C: ISP did not include description of needs and date identified based on UAI.
22VAC40-90-40-C: Employed person with convictions of barrier crimes.
22VAC40-73-640-A: Failed to ensure accurate counts of controlled substances when med staff changes.
22VAC40-73-680-I: MAR lacked documentation of symptoms, dosage, and effectiveness for PRN meds.
22VAC40-73-450-C: ISP not completed within 30 days after admission.
22VAC40-73-450-C: ISP did not include description of needs and date identified based on UAI.
22VAC40-73-860-G: Hot water temperature not maintained within 105°F to 120°F range.
22VAC40-73-410-A: Failed to provide orientation documentation upon admission.
22VAC40-73-560-E: Failed to keep all resident records current and retained at facility.
22VAC40-73-680-M: PRN medications not available, properly labeled, or stored.
22VAC40-73-470-A: Failed to meet health care service needs for one of five sampled residents.
22VAC40-73-310-H: Admitted or retained individuals with prohibitive conditions or care needs.
22VAC40-73-450-D: Hospice services not included on individualized service plan for one resident.
22VAC40-73-860-G: Hot water temperature not maintained within 105°F to 120°F range.
22VAC40-73-450-C: ISP did not include all assessed needs for four of five residents.
22VAC40-73-640-A: Failed to comply with medication management plan to avoid missed dosages.
22VAC40-73-700-2: Failed to post 'NO Smoking - Oxygen In Use' signs where oxygen is used.
22VAC40-73-1090-A: Failed to ensure prior assessment by licensed professional for serious cognitive impairment before admission to secure environment.
22VAC40-73-450-C: ISP did not include description of needs based on UAI.
22VAC40-73-860-G: Hot water temperature not maintained within 105°F to 120°F range.
22VAC40-73-410-A: Failed to provide orientation documentation upon admission.
22VAC40-73-560-E: Failed to keep all resident records current and retained at facility.
22VAC40-73-680-M: PRN medications not available, properly labeled, or stored.
22VAC40-73-470-A: Failed to meet health care service needs for one of five sampled residents.
22VAC40-73-310-H: Admitted or retained individuals with prohibitive conditions or care needs.
22VAC40-73-450-D: Hospice services not included on individualized service plan for one resident.
22VAC40-73-860-G: Hot water temperature not maintained within 105°F to 120°F range.
22VAC40-73-450-C: ISP did not include all assessed needs for four of five residents.
22VAC40-73-640-A: Failed to comply with medication management plan to avoid missed dosages.
22VAC40-73-700-2: Failed to post 'NO Smoking - Oxygen In Use' signs where oxygen is used.
22VAC40-73-320-A: Physical exam report lacked description of reactions to known allergies.
22VAC40-73-450-C: ISP lacked description of identified needs based on physical exam and UAI.
Report Facts
Violations cited: 43
Distinct standards: 27
Inspections on page: 16
Inspections with violations: 15
Complaint visits: 7
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