Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 1
Jul 15, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-06-26 regarding allegations in the area of resident care.
Findings
The investigation did not substantiate the complaint allegations of non-compliance; however, a violation unrelated to the complaint was identified regarding failure to include hospice services in the individualized service plan for a resident receiving hospice care.
Complaint Details
Complaint related to resident care was investigated and found not substantiated.
Deficiencies (1)
| Description |
|---|
| The facility failed to ensure that hospice services were included in the individualized service plan for a resident receiving hospice care. |
Report Facts
Number of residents present: 68
Number of resident records reviewed: 1
Number of staff records reviewed: 0
Number of staff interviews conducted: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Pearson | Licensing Inspector | Conducted the inspection and investigation |
| Jeff Marnien | Licensing Inspector | Contact person for questions related to the inspection |
| Health and Wellness Director | Health and Wellness Director | Responsible for conducting audits and implementing plan of correction |
| Staff 1 | Interviewed staff who confirmed hospice services were not included in the individualized service plan |
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 0
Jul 15, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-04-17 regarding allegations in the area of resident care.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The inspection findings were reviewed and will be posted publicly.
Complaint Details
Complaint related to resident care; the allegations were not substantiated based on the investigation.
Report Facts
Number of residents present: 68
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
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 0
Jun 25, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-06-02 regarding allegations related to staffing, staff qualifications, and resident care.
Findings
The investigation found no evidence to support the allegations of non-compliance with standards or law. The licensing inspector completed a tour of the facility, reviewed resident and staff records, and conducted interviews with residents and staff.
Complaint Details
Complaint related to staffing, staff qualifications, and resident care; evidence gathered did not support the allegations of non-compliance.
Report Facts
Number of residents present: 69
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
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 0
Mar 26, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-02-25 regarding allegations in the area of resident care.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. No deficiencies were cited.
Complaint Details
Complaint related to resident care; the complaint was not substantiated based on the investigation findings.
Inspection Report
Monitoring
Census: 44
Deficiencies: 10
Mar 26, 2025
Visit Reason
The inspection was a monitoring visit conducted on March 26 and 27, 2025, to review compliance with applicable standards and regulations at Charter Senior Living of Fredericksburg.
Findings
The inspection identified multiple violations related to incomplete disclosure statements, deficiencies in medication management plans, lack of accessible medication reference materials, improper medication storage and administration, missing medication orders details, incomplete first aid kits, and failure to conduct required monthly checks. Plans of correction were submitted for all deficiencies.
Deficiencies (10)
| Description |
|---|
| Facility failed to provide a disclosure statement with accurate information, missing staff numbers and qualifications for shifts. |
| Medication management plan did not address prevention of outdated medications or standard dosing schedule. |
| No readily accessible pharmacy reference book, drug guide, or medication handbook for nurses within two years old. |
| Resident prescribed medications were not stored in a medicine cabinet, container, or compartment when administered. |
| Medications were administered more than one hour after the facility's standard dosing schedule. |
| PRN medication orders lacked detailed physician instructions for persistent symptoms. |
| Medications ordered for PRN administration were missing, improperly labeled, or improperly stored. |
| Medication reviews did not include required certification by licensed health care professional. |
| First aid kit was incomplete, missing triangular bandages. |
| First aid kits were not checked monthly to ensure all items were present. |
Report Facts
Number of residents present: 44
Number of resident records reviewed: 4
Number of staff records reviewed: 3
Number of resident interviews conducted: 1
Number of staff interviews conducted: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 2 | Confirmed medication storage and administration issues during interviews and medication cart audits | |
| Staff 5 | Confirmed missing elements in medication management plan and medication review certification | |
| Staff 6 | Confirmed missing elements in medication management plan and lack of medication handbook | |
| Staff 7 | Confirmed missing medication handbook, missing first aid kit items, and incomplete monthly checks | |
| Health and Wellness Director | HWD | Responsible for conducting audits, education, and corrective actions related to medication and first aid kit deficiencies |
| Executive Director | ED | Reviews audit results and reports findings to the Quality Assurance Committee |
Inspection Report
Census: 70
Deficiencies: 0
Jan 10, 2025
Visit Reason
The inspection was conducted following a self-reported incident received by VDSS Division of Licensing regarding allegations in the area of retention and discharge of a resident.
Findings
The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law. No deficiencies or non-compliance were found.
Report Facts
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
Inspection Report
Census: 73
Deficiencies: 0
Dec 11, 2024
Visit Reason
The inspection was conducted as a regulatory oversight visit categorized as 'Other' to review resident care and related services at the assisted living facility.
Findings
The licensing inspector toured the physical plant and found the building and grounds presented well. The investigation did not support any self-reported non-compliance with standards or law, and no violation notice was issued.
Report Facts
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
Inspection Report
Renewal
Census: 65
Deficiencies: 3
Jun 24, 2024
Visit Reason
The inspection was a renewal inspection conducted to assess compliance with applicable standards and laws for the facility's license renewal.
Findings
The inspection found non-compliance with several standards including documentation for placement of residents with serious cognitive impairments, annual tuberculosis risk assessments for staff, and timely health care oversight for residents. Violation notices were issued with plans of correction required.
Deficiencies (3)
| Description |
|---|
| Facility did not ensure written approval was obtained prior to placing residents with serious cognitive impairment in a safe, secure environment as required. |
| Facility did not ensure annual tuberculosis risk assessments were documented for all required staff. |
| Facility did not ensure health care oversight was provided at least every three months for residents at the assisted living level of care. |
Report Facts
Number of residents present: 65
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
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Pearson | Licensing Inspector | Current inspector conducting the inspection |
| Yvonne Randolph | Licensing Inspector | Contact person for questions regarding the inspection |
| Staff #1 | Referenced in findings related to resident placement and health care oversight | |
| Staff #2 | Referenced in findings related to tuberculosis risk assessment | |
| Staff #3 | Referenced in findings related to tuberculosis risk assessment | |
| Staff #4 | Referenced in findings related to tuberculosis risk assessment |
Inspection Report
Monitoring
Census: 57
Deficiencies: 0
Feb 8, 2023
Visit Reason
The inspection was a monitoring visit to review various areas including administration, personnel, resident care, emergency preparedness, and additional requirements for adults with serious cognitive impairment.
Findings
The Licensing Inspector reviewed records, conducted interviews, observed residents during meals and activities, and reviewed pharmacy, dietician reports, fire drills, activity calendars, and menus. No complaint was related to this inspection.
Report Facts
Records reviewed and interviews conducted: 11
Interviews conducted: 9
Inspection Report
Monitoring
Census: 57
Deficiencies: 0
Jun 2, 2022
Visit Reason
The inspection was a monitoring inspection conducted to review various areas including administration, personnel, resident care, buildings and grounds, emergency preparedness, and safety.
Findings
The inspection included review of resident and staff records, interviews, and documentation of incidents, fire drills, healthcare oversight, resident council minutes, staff training, and dietician reports. No complaint was related to this inspection.
Report Facts
Number of resident records reviewed: 4
Number of staff records reviewed: 4
Number of interviews conducted: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Pearson | Inspector | Current Inspector conducting the inspection |
Inspection Report
Renewal
Census: 76
Deficiencies: 0
May 14, 2021
Visit Reason
A renewal inspection was initiated on May 14, 2021 and concluded on May 17, 2021 to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection determined no violations with applicable standards or law. No violations were issued.
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