Inspection Reports for Commonwealth Senior Living at Churchland House
VA, 23703
Back to Facility ProfileDeficiencies per Year
8
6
4
2
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Inspection Report
Monitoring
Census: 70
Deficiencies: 1
Aug 14, 2025
Visit Reason
An unannounced monitoring inspection was conducted to review compliance with regulations, including a self-report received regarding allegations in Resident Care and Related Services.
Findings
The investigation supported some but not all allegations of non-compliance. A violation unrelated to the self-report was identified involving delayed response to resident needs and communication failures regarding a resident's x-ray results and physician orders.
Deficiencies (1)
| Description |
|---|
| The facility failed to ensure prompt response by staff to resident needs, specifically a delay in treatment after x-ray results and physician orders were received but not promptly acted upon. |
Report Facts
Number of residents present: 70
Number of resident records reviewed: 1
Number of staff records reviewed: 2
Number of resident interviews conducted: 1
Number of staff interviews conducted: 5
Due date for plan of correction: Oct 24, 2025
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 1
Aug 14, 2025
Visit Reason
An unannounced complaint inspection was conducted following a complaint received on 2025-08-06 regarding allegations in the areas of Personnel and Resident Care and Related Services.
Findings
The investigation supported some but not all allegations of non-compliance. A violation was found related to failure to administer medications according to physician instructions, specifically the medication paroxetine was not administered to a resident as prescribed.
Complaint Details
Complaint related: Yes. The evidence gathered supported some but not all allegations of non-compliance with standards or law in the areas of Personnel and Resident Care and Related Services.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure medications were administered in accordance with the physician's instructions; resident #1 did not receive prescribed paroxetine from November 2024 through June 2025. |
Report Facts
Residents present: 70
Resident records reviewed: 2
Staff records reviewed: 2
Staff interviews conducted: 3
Medication administration timeframe: 8
Plan of correction due date: Oct 24, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donesia Peoples | Licensing Inspector | Inspector conducting the complaint investigation |
Inspection Report
Renewal
Census: 74
Deficiencies: 4
Jan 14, 2025
Visit Reason
An unannounced renewal inspection was conducted to evaluate the facility's compliance with applicable standards and licensing requirements.
Findings
The inspection identified multiple violations including failure to post the current on-site person in charge conspicuously, inadequate written communication among direct care staff regarding resident incidents, incomplete individualized service plans for residents, and employment of a staff member with disqualifying criminal convictions.
Deficiencies (4)
| Description |
|---|
| Facility failed to develop and implement a procedure for posting the name of the current on-site person in charge in a conspicuous place. |
| Facility failed to ensure written communication methods kept direct care staff informed of significant resident issues, including complaints and incidents. |
| Facility failed to complete comprehensive individualized service plans within 30 days after admission including all required needs. |
| Facility employed a person with convictions for barrier crimes, making them ineligible for employment. |
Report Facts
Residents present: 74
Resident records reviewed: 6
Staff records reviewed: 3
Resident interviews conducted: 2
Staff interviews conducted: 3
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 3
Oct 22, 2024
Visit Reason
An unannounced complaint inspection was conducted due to allegations received on 2024-09-30 regarding personnel and resident care and related services.
Findings
The investigation supported some but not all allegations of non-compliance. Several violations unrelated to the complaint were also identified, including staff qualification deficiencies, failure to complete the Uniform Assessment Instrument prior to admission, and inadequate documentation of resident rounds.
Complaint Details
Complaint was received by VDSS Division of Licensing on 2024-09-30 regarding allegations in personnel and resident care and related services. The evidence gathered supported some but not all allegations of non-compliance.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure direct care staff met required qualifications within two months of employment. |
| Uniform Assessment Instrument (UAI) was not completed prior to resident admission. |
| Facility failed to document required rounds for residents unable to use signaling devices, including date, time, and staff member. |
Report Facts
Residents present: 70
Resident records reviewed: 2
Staff records reviewed: 2
Staff interviews conducted: 3
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 3
Jul 25, 2024
Visit Reason
An unannounced complaint inspection was conducted due to a complaint received on 2024-07-01 regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation did not substantiate the complaint allegations; however, violations unrelated to the complaint were identified during the inspection, including failures related to individualized service plans, medication management, and medication administration records.
Complaint Details
Complaint was received by VDSS Division of Licensing on 2024-07-01 regarding allegations in Resident Care and Related Services. The evidence gathered did not support the allegation of non-compliance.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure the comprehensive individualized service plan (ISP) was completed within 30 days after admission. |
| Facility failed to implement a written plan for medication management to ensure accurate counts of controlled substances when medication administration staff changes. |
| Facility failed to ensure the Medication Administration Record (MAR) included symptoms for which PRN medications were given, exact dosage, and effectiveness. |
Report Facts
Residents present: 65
Resident records reviewed: 3
Staff records reviewed: 0
Resident interviews conducted: 1
Staff interviews conducted: 3
Missing narcotic shift count signatures: 8
Inspection Report
Monitoring
Census: 69
Deficiencies: 6
Feb 8, 2024
Visit Reason
An unannounced monitoring inspection was conducted to assess compliance with applicable standards and laws at the assisted living facility.
Findings
The inspection found multiple violations related to discharge documentation, completion and updating of Uniform Assessment Instruments (UAI) and Individualized Service Plans (ISP), medication administration not following physician orders, and failure to complete the annual fire inspection for 2023.
Deficiencies (6)
| Description |
|---|
| Failure to provide a dated discharge statement including actions taken to assist the resident in discharge and relocation process and the resident's destination. |
| Failure to complete the Uniform Assessment Instrument (UAI) prior to admission, annually, and when there is a significant change in condition. |
| Failure to complete the comprehensive individualized care plan (ISP) within 30 days after admission. |
| Failure to review and update ISPs at least once every 12 months and as needed for significant changes in condition. |
| Failure to administer medications in accordance with physician's instructions, specifically Midodrine administration when systolic blood pressure was less than 110. |
| Failure to comply with Virginia Statewide Fire Prevention Code by not completing the annual fire inspection for 2023. |
Report Facts
Number of residents present: 69
Number of resident records reviewed: 8
Number of staff records reviewed: 4
Number of resident interviews: 2
Number of staff interviews: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donesia Peoples | Licensing Inspector | Current inspector conducting the monitoring inspection |
| Staff 6 | Confirmed lack of ISP completion within 30 days after admission and acknowledged last fire inspection date | |
| Administrator | Responsible for ensuring discharge statements are updated | |
| Resident Care Director | Responsible for updating UAI and ISP records and ensuring medication administration compliance | |
| Maintenance Director | Contacted appropriate fire official to schedule annual fire inspection |
Inspection Report
Monitoring
Census: 62
Deficiencies: 0
Sep 25, 2023
Visit Reason
An unannounced monitoring inspection was conducted following a self-report received regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation did not support the allegation of non-compliance with standards or law. The inspection included a tour of the physical plant, review of staffing schedules, communication logs, and observation of the environment.
Report Facts
Number of resident records reviewed: 3
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 4
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 1
Jun 27, 2023
Visit Reason
An unannounced complaint inspection was conducted on June 27, 2023, following a complaint received on June 21, 2023, regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation supported some, but not all, of the allegations. The facility was found non-compliant in Resident Care and Related Services, specifically failing to ensure residents received personal assistance with bathing at least twice a week as required by their Individualized Services Plans.
Complaint Details
The complaint was substantiated in part; violations related to Resident Care and Related Services were found. A violation notice was issued and the licensee was given the opportunity to submit a plan of correction.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure personal assistance and care, including bathing at least twice a week or more often if needed, was provided to residents as required by their Individualized Services Plans. |
Report Facts
Residents present: 62
Resident records reviewed: 4
Staff records reviewed: 3
Resident interviews: 2
Staff interviews: 2
Inspection Report
Renewal
Census: 59
Deficiencies: 5
Dec 5, 2022
Visit Reason
An unannounced renewal inspection was conducted on December 5 and 6, 2022, to assess compliance with applicable standards and regulations for the assisted living facility.
Findings
The inspection identified multiple violations including failure to ensure proper assessment of serious cognitive impairment prior to admission, lack of documented resident orientation upon admission, incomplete individualized service plans reflecting resident needs, missing Do Not Resuscitate (DNR) orders in resident records, and water temperatures exceeding the required range. Plans of correction were submitted for each deficiency.
Deficiencies (5)
| Description |
|---|
| Failed to ensure prior to admission that residents were assessed by an independent clinical psychologist or physician for serious cognitive impairment. |
| Failed to provide and document orientation for new residents and their legal guardians upon admission. |
| Failed to ensure individualized service plans included all identified needs based on the uniform assessment instrument. |
| Failed to ensure all resident records were current and retained, including missing DNR orders. |
| Failed to maintain hot water temperature at taps within the required range of 105°F to 120°F. |
Report Facts
Number of residents present: 59
Number of resident records reviewed: 8
Number of staff records reviewed: 4
Number of resident interviews: 5
Number of staff interviews: 5
Water temperature in room 130: 127
Water temperature in room 131: 129
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donesia Peoples | Licensing Inspector | Current inspector conducting the inspection |
| Resident Care Director | Person responsible for reviewing and correcting assessments and resident records | |
| Administrator | Person responsible for ensuring resident orientation documentation | |
| Maintenance Director | Person responsible for adjusting water heater and ongoing water temperature monitoring | |
| Staff #6 | Acknowledged deficiencies related to resident records and assessments | |
| Staff #7 | Acknowledged deficiencies related to resident records and assessments | |
| Staff #10 | Acknowledged water temperature issues |
Inspection Report
Renewal
Census: 44
Deficiencies: 8
Jan 31, 2022
Visit Reason
An unannounced renewal inspection was conducted to assess compliance with assisted living facility standards, including medication pass observation, facility tour, meal observation, emergency preparedness, and record reviews.
Findings
The facility was found to have multiple deficiencies including failure to ensure psychotropic treatment plans were in place, incomplete individualized service plans (ISP), medication management issues such as unavailable medications at administration times, lack of oxygen use signage, and hot water temperature exceeding required limits. Plans of correction were initiated for all cited deficiencies.
Deficiencies (8)
| Description |
|---|
| Facility failed to ensure it did not admit or retain individuals with prohibitive conditions or care needs due to missing psychotropic treatment plans for four of five sampled residents. |
| Facility failed to ensure individualized service plans included all assessed needs for four of five records reviewed. |
| Facility failed to include hospice care services in the individualized service plan for one of five sampled records. |
| Facility failed to ensure health care service needs of a resident were met, specifically occupational and speech therapy documentation missing. |
| Facility failed to comply with medication management plan to ensure prescription and over-the-counter medications were filled and refilled timely to avoid missed dosages. |
| Facility failed to ensure PRN medications were available, properly labeled, and stored for specific residents. |
| Facility failed to post 'NO Smoking - Oxygen In Use' signs in rooms where oxygen therapy was provided. |
| Facility failed to maintain hot water temperature within required range of 105 to 120 degrees Fahrenheit; water temperature was 124 degrees F in one resident room. |
Report Facts
Facility census: 44
Inspection date: Jan 31, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donesia Peoples | Inspector | Named as current inspector conducting the inspection |
| Resident Care Director or designee | Responsible for implementing plans of correction and monitoring compliance | |
| Maintenance Director | Responsible for adjusting water heater and conducting water temperature checks |
Inspection Report
Complaint Investigation
Deficiencies: 1
Jun 22, 2021
Visit Reason
A complaint inspection was initiated due to allegations regarding the discharge of residents, specifically concerning failure to provide a final statement of account and return of personal property within 60 days of discharge.
Findings
The investigation found that the facility failed to ensure that Resident #1's legal representative received a final statement of account and the resident's personal belongings within 60 days of discharge, resulting in violations of regulatory standards.
Complaint Details
The complaint was substantiated; evidence showed non-compliance with standards regarding discharge notification and return of personal property for Resident #1.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure within 60 days of discharge that the resident or legal representative was given a final statement of account and returned any property or things of value held in trust or custody. |
Report Facts
Inspection dates: 2
Days until personal property returned: 86
Days until discharge notification provided: 6
Inspection Report
Complaint Investigation
Deficiencies: 1
Feb 2, 2021
Visit Reason
A complaint inspection was initiated due to allegations regarding medical care/nursing services and missed appointments at the facility.
Findings
The investigation did not substantiate the complaint allegations; however, violations related to the Individualized Service Plan (ISP) documentation were identified, including missing descriptions of identified needs, dates, and service details.
Complaint Details
A complaint was received regarding medical care/nursing services and missed appointments. The evidence gathered did not support the allegation, but violations unrelated to the complaint were issued.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure the Individualized Service Plan (ISP) included description of identified needs and date identified, and a written description of what services will be provided to address identified needs based upon the Uniform Assessment Instrument (UAI). |
Inspection Report
Complaint Investigation
Deficiencies: 2
Jan 21, 2021
Visit Reason
A complaint inspection was initiated due to allegations regarding notification of family members after an incident. The investigation was conducted remotely due to a state of emergency health pandemic.
Findings
The investigation did not substantiate the complaint allegations. However, violations unrelated to the complaint were identified, including failure to ensure Individualized Service Plans (ISP) included all identified needs and failure to update ISPs for significant changes in residents' conditions.
Complaint Details
A complaint was received regarding notification of family member after an incident. The evidence gathered did not support the allegation of non-compliance with standards or law.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure the Individualized Service Plan (ISP) included description of identified needs based upon the Uniform Assessment Instrument (UAI), specifically incontinence with bowel and bladder for Resident #1. |
| Facility failed to update the Individualized Service Plan as needed for a significant change of a resident’s condition, specifically a diet change for Resident #3. |
Inspection Report
Renewal
Census: 57
Deficiencies: 2
Jan 4, 2021
Visit Reason
A renewal inspection was initiated on January 4, 2021 and concluded on January 6, 2021 to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection found non-compliance with standards related to documentation of residents' physical examination reports, specifically failure to document reactions to known allergies and failure to include identified needs in Individualized Service Plans (ISP) based on physical examinations and assessments.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure the physical examination report documented the descriptions of the person’s reactions to known allergies. |
| Facility failed to ensure the Individualized Service Plan (ISP) included description of identified needs based upon the physical examination and/or Uniform Assessment Instrument (UAI). |
Report Facts
Resident census: 57
Resident records reviewed: 4
Staff records reviewed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donesia Peoples | Inspector | Current inspector conducting the inspection |
| Staff #5 | Acknowledged deficiencies related to residents' physical examination reports and ISPs |
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