Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 18, 2025
Visit Reason
An on-site inspection related to a complaint was conducted on November 18, 2025, following a complaint received on October 30, 2025, regarding allegations in the areas of personnel, resident care, and related services.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law.
Complaint Details
Complaint received by VDSS Division of Licensing on October 30, 2025, regarding allegations in personnel, resident care, and related services. Investigation found no substantiation of non-compliance.
Report Facts
Number of interviews with residents: 1
Number of interviews with staff: 1
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 2, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on May 29, 2025, regarding allegations in the areas of personnel, resident care, and related services.
Findings
The investigation, including review of Adult Protective Services findings and the provider's internal report, found no evidence to support the allegations of non-compliance with standards or law.
Complaint Details
Complaint was related to personnel, resident care, and related services. The evidence gathered did not support the allegations of non-compliance.
Report Facts
Resident records reviewed: 1
Staff interviews conducted: 1
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 1, 2025
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received on May 13, 2025, regarding allegations in the area of resident care and related services.
Findings
The investigation found that residents were appropriately dressed and groomed, and no physical or dental health needs were noted. The evidence did not support the allegations of non-compliance with standards or law.
Complaint Details
A complaint was received by VDSS Division of Licensing on May 13, 2025, regarding allegations in resident care and related services. The evidence gathered did not support the allegations of non-compliance.
Report Facts
Resident records reviewed: 1
Resident interviews conducted: 1
Staff interviews conducted: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Coy Stevenson | Licensing Inspector | Inspector conducting the complaint investigation |
Inspection Report
Complaint Investigation
Deficiencies: 0
May 12, 2025
Visit Reason
The inspection was conducted in response to a complaint received on March 26, 2025, regarding allegations related to staffing and supervision at the facility.
Findings
The investigation found that residents were appropriately dressed and groomed, staff-resident interactions were appropriate, and the facility met staffing requirements. The evidence did not support the allegations of non-compliance with standards or law.
Complaint Details
Complaint received on March 26, 2025, regarding staffing and supervision. The investigation did not substantiate the allegations.
Report Facts
Number of interviews conducted: 1
Inspection Report
Renewal
Census: 59
Deficiencies: 1
Mar 6, 2025
Visit Reason
The inspection was conducted as a renewal of the facility's license to ensure compliance with applicable standards and laws.
Findings
The inspection found non-compliance with applicable standards or laws, resulting in documented violations. The licensee was given the opportunity to submit a plan of correction to address the cited violations and maintain future compliance.
Deficiencies (1)
| Description |
|---|
| Violation of Standard #: 22VAC40-73-580-A |
Report Facts
Number of resident records reviewed: 6
Number of staff records reviewed: 3
Number of interviews conducted with staff: 2
Inspection Report
Monitoring
Deficiencies: 3
Apr 11, 2024
Visit Reason
The inspection was conducted as a monitoring visit following a self-reported incident received by VDSS regarding allegations in personnel, staffing and supervision, and resident care and related services.
Findings
The investigation supported the self-report of non-compliance with standards and violations were issued related to staff conduct and medication administration errors. The facility was found to have deficiencies in staff respectfulness and medication administration and documentation.
Deficiencies (3)
| Description |
|---|
| Facility did not ensure that all staff were considerate and respectful of the rights, dignity, and sensitivities of residents; staff used profanity and derogatory language towards a resident. |
| Facility staff did not administer medications in accordance with the physician's or prescriber's instructions; resident was given medication prescribed for another resident. |
| Provider did not document medication errors on the Medication Administration Record (MAR). |
Report Facts
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
Inspection Report
Complaint Investigation
Deficiencies: 1
Apr 11, 2024
Visit Reason
The inspection was conducted in response to a complaint received on June 20, 2023, regarding allegations related to background checks for assisted living facilities.
Findings
The investigation found non-compliance with regulations concerning criminal history record reports, specifically that an employee with a barrier crime conviction was allowed to remain employed. Violations were issued based on these findings.
Complaint Details
Complaint related: Yes. The evidence supported the allegation of non-compliance with background check requirements. The violation was substantiated.
Deficiencies (1)
| Description |
|---|
| Facility did not ensure that any person required to obtain a criminal history record report was ineligible for employment if the report contained convictions of a barrier crime. |
Report Facts
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
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Coy Stevenson | Licensing Inspector | Current inspector conducting the complaint investigation. |
| LI Poulter | Licensing inspector who conducted onsite inspection on October 11, 2023. | |
| LI Randolph | Licensing inspector who conducted onsite inspection on March 25, 2024. | |
| Employee #2 | Employee with barrier crime conviction who remained employed until April 26, 2023. | |
| Employee #1 | Confirmed employment status of Employee #2. | |
| Executive Director | Person responsible for plan of correction. | |
| Business Office Manager | Person responsible for plan of correction. |
Inspection Report
Renewal
Census: 58
Deficiencies: 3
Feb 23, 2024
Visit Reason
The inspection was a renewal inspection conducted on-site to review compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection found non-compliance with applicable standards or laws, resulting in documented violations. The licensee was given the opportunity to submit a plan of correction to address the cited violations and maintain future compliance.
Deficiencies (3)
| Description |
|---|
| Residents' charts had issues related to annual Tuberculosis screening compliance. |
| Residents' charts had violations corrected after audit and review. |
| Individualized Service Plans (ISP) needed updates including showing the DNR order. |
Report Facts
Number of residents present: 31
Number of residents present: 27
Number of resident records reviewed: 10
Number of staff records reviewed: 10
Number of resident interviews: 4
Number of staff interviews: 4
Inspection Report
Monitoring
Deficiencies: 0
Aug 23, 2023
Visit Reason
The inspection was a monitoring visit conducted on August 23, 2023, following a self-reported incident received on July 20, 2023, regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation gathered staff witness statements, records, and interviews, and found no evidence to support the self-report of non-compliance with standards or law. The inspection findings will be posted publicly.
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 0
Mar 7, 2023
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on January 6, 2023, regarding allegations in the area of Resident Care and Related Services.
Findings
The evidence gathered during the investigation did not support the allegation of non-compliance with standards or law. The inspection findings will be posted publicly and a copy is required to be posted on the facility premises.
Complaint Details
Complaint related to Resident Care and Related Services; the allegation was not substantiated based on the investigation.
Inspection Report
Renewal
Census: 61
Deficiencies: 2
Mar 7, 2023
Visit Reason
The inspection was conducted as a renewal inspection to assess compliance with applicable regulations and licensing standards for the assisted living facility.
Findings
The inspection found non-compliance with applicable standards and laws, resulting in documented violations related to incomplete physician oxygen orders and employment of a staff member with a barrier crime conviction.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure there was a valid physician's order that included the oxygen source and delivery device deemed therapeutic for the resident. |
| Facility failed to ensure they did not continue to employ a person who has a conviction of any of the barrier crimes. |
Report Facts
Number of residents present: 61
Number of resident records reviewed: 8
Number of staff records reviewed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff #1 | Acknowledged issues regarding Resident #1's physician order | |
| Staff #2 | Confirmed employment and conviction status of Staff #6 | |
| Staff #6 | Employee with a barrier crime conviction |
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 2
Nov 4, 2022
Visit Reason
The inspection was conducted in response to a complaint received by the VDSS Division of Licensing on September 26, 2022, regarding allegations in the areas of Administration and Administrative Services and Buildings and Grounds.
Findings
The investigation supported some, but not all, of the allegations. Areas of non-compliance were found in Administration and Administrative Services, including failure to develop and implement an infection control program consistent with CDC and OSHA guidelines, and failure to report major incidents within 24 hours to the regional licensing office.
Complaint Details
Complaint received on September 26, 2022 regarding allegations in Administration and Administrative Services and Buildings and Grounds. Evidence supported some allegations related to infection control and incident reporting failures.
Deficiencies (2)
| Description |
|---|
| Facility failed to develop, in writing, and implement an infection control program addressing surveillance, prevention, and control of disease and infection consistent with CDC and OSHA guidelines. |
| Facility failed to report to the regional licensing office within 24 hours any major incident that negatively affected or threatened the life, health, safety, or welfare of any resident. |
Report Facts
Number of residents present: 67
Number of staff interviews: 1
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 2
Nov 4, 2022
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on November 3, 2022, regarding allegations in the areas of Staffing and Supervision, and Resident Care and Related Services.
Findings
The investigation supported the allegation of non-compliance with standards or law, resulting in violations issued. The facility failed to maintain a copy of the written work schedule and failed to ensure information was made available for inspection by the department's representative.
Complaint Details
Complaint received on November 3, 2022 regarding allegations in Staffing and Supervision, and Resident Care and Related Services. The evidence gathered supported the allegations and violations were issued.
Deficiencies (2)
| Description |
|---|
| Facility failed to maintain a copy of the written work schedule. |
| Facility failed to ensure that information was made available for inspection by the department's representative. |
Report Facts
Residents present: 67
Staff records reviewed: 1
Resident records reviewed: 0
Resident interviews conducted: 2
Staff interviews conducted: 1
Inspection Report
Monitoring
Deficiencies: 3
Sep 9, 2022
Visit Reason
The inspection was a monitoring visit conducted on September 9, 2022, following a self-reported incident received on July 22, 2022, regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation supported the self-report of non-compliance with facility policies and regulations, specifically related to failure in conducting required two-hour rounds on a memory care resident, failure to provide individualized service plan (ISP) care, and failure to promptly respond to resident needs. Violations were issued based on these findings.
Deficiencies (3)
| Description |
|---|
| Failure to ensure compliance with facility policy requiring staff to conduct two-hour rounds on the memory care unit, including falsification of round logs. |
| Failure to ensure care and services specified in the individualized service plan were provided to the resident, specifically the two-hour rounding requirement. |
| Failure to ensure care provision and service delivery included prompt response by staff to resident needs as reasonable to the circumstances. |
Report Facts
Inspection date: Sep 9, 2022
Self-reported incident date: Jul 22, 2022
Resident admission date: Sep 14, 2018
ISP date: Mar 4, 2022
Resident death date: Jul 19, 2022
Inspection Report
Monitoring
Deficiencies: 0
Jun 29, 2022
Visit Reason
The inspection was a monitoring visit conducted to review compliance with various administrative, personnel, resident care, and licensing standards.
Findings
The inspection found no violations with applicable standards or laws during the visit.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 29, 2022
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on May 2, 2022, regarding allegations in the area of Admission, Retention and Discharge of Residents (billing).
Findings
The evidence gathered during the investigation did not support the allegation of non-compliance with standards or law. The inspection summary will be posted to the VDSS website within 5 business days of receipt.
Complaint Details
Complaint related to allegations in Admission, Retention and Discharge of Residents (billing); the complaint was not substantiated.
Inspection Report
Monitoring
Deficiencies: 5
Apr 26, 2022
Visit Reason
The inspection was a monitoring visit to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection identified multiple violations including incomplete documentation of residents' allergy reactions, incomplete individualized service plans not reflecting assessed needs, lack of identification of residents in health care oversight, restricted access to records during inspection, and errors in criminal history record reports.
Deficiencies (5)
| Description |
|---|
| Facility failed to ensure resident physical examinations contained descriptions of reactions to known allergies. |
| Facility failed to ensure comprehensive individualized service plans included descriptions of identified needs based on assessments and physical exams. |
| Facility failed to ensure specific residents for whom health care oversight was provided were identified. |
| Facility failed to ensure all records were made available for inspection by the department's representative. |
| Facility failed to ensure criminal history record reports were verified for accuracy and resubmitted when information did not match. |
Report Facts
Number of residents with ISP deficiencies: 7
Number of staff records locked: 4
Number of residents' records locked: 7
Days for plan of correction submission: 5
Days for supervisory review request: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Coy Stevenson | Current Inspector | Named as the inspector conducting the inspection. |
| Alexandra Poulter | Licensing Inspector | Contact person for questions regarding the inspection. |
| Staff #1 | Interviewed staff confirming lack of resident list in health care oversight and record access issues. | |
| Staff #3 | Staff member with incorrect criminal history record report that was not resubmitted timely. |
Inspection Report
Complaint Investigation
Deficiencies: 5
Mar 16, 2022
Visit Reason
An unannounced complaint investigation was conducted at the facility on March 16, 2022, to review compliance with resident care and related services, including care for adults with serious cognitive impairments.
Findings
The inspection found multiple violations related to resident care, including failure to ensure proper assessment prior to admission to a safe, secure environment, incomplete updates to the uniform assessment instrument (UAI) after significant changes in resident condition, lack of coordinated hospice care plans, failure to review and update individualized service plans (ISPs) annually, and incomplete physician orders lacking diagnosis or indications for medications.
Complaint Details
The visit was complaint-related as indicated. The investigation was unannounced and focused on allegations related to resident care and safety.
Deficiencies (5)
| Description |
|---|
| Facility failed to ensure prior to admission to a safe, secure environment, the resident was assessed by an independent clinical psychologist or physician for serious cognitive impairment. |
| Facility failed to ensure the uniform assessment instrument (UAI) was completed whenever there was a significant change in the resident's condition. |
| Facility failed to ensure hospice care was coordinated and included in individualized service plans. |
| Facility failed to ensure individualized service plans (ISPs) were reviewed and updated at least once every 12 months. |
| Facility failed to ensure physician or other prescriber orders identified the diagnosis, condition, or specific indications for administering each drug. |
Report Facts
Inspection dates: 3
Due dates for corrections: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Coy Stevenson | Current Inspector | Named as the current inspector conducting the inspection. |
| Alex Poulter | Licensing Staff | Conducted the unannounced complaint investigation and authored the report. |
| Staff #1 | Interviewed staff member who acknowledged deficiencies related to assessments, UAI updates, hospice care coordination, and ISP reviews. | |
| Executive Director | Responsible for reviewing paperwork prior to admission and ensuring compliance with plans of correction. | |
| Resident Care Director | Responsible for reviewing resident charts, updating ISPs, and ensuring physician orders include diagnoses. | |
| Physician #1 | Referenced in assessment of serious cognitive impairment for Resident #4. |
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 0
Jun 4, 2021
Visit Reason
An unannounced focused inspection was conducted to investigate allegations concerning communication of resident behavior and discharge.
Findings
There was no preponderance of evidence found to substantiate allegations. The information gathered during the inspection determined no violations with applicable standards or law.
Complaint Details
Complaint related visit with no substantiation of allegations found.
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 0
Jun 4, 2021
Visit Reason
A focused unannounced inspection was conducted to investigate allegations concerning credentials and training of the administrator, visitation policy, and cleanliness of the building.
Findings
No preponderance of evidence was found to substantiate the allegations. The inspection determined no violations with applicable standards or law.
Complaint Details
The inspection was complaint-related and investigated allegations about the administrator's credentials and training, visitation policy during resident end of life, and facility cleanliness. No specific resident was identified, and the allegations were not substantiated.
Report Facts
Current census: 62
Inspection Report
Renewal
Census: 63
Deficiencies: 1
May 4, 2021
Visit Reason
A renewal inspection was initiated on May 4, 2021 and concluded on May 10, 2021 to assess compliance with applicable standards and laws for Commonwealth Senior Living At Charlottesville.
Findings
The inspection found non-compliance with the requirement that physical examination reports for residents specify whether the individual is capable of self-administering medication. Specifically, reports for Resident #1 and Resident #3 lacked this statement.
Deficiencies (1)
| Description |
|---|
| The physical examination report for each resident failed to contain a statement specifying whether the individual is capable of self-administering medication. |
Report Facts
Resident records reviewed: 4
Staff records reviewed: 4
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