Inspection Reports for Commonwealth Senior Living at Georgian Manor
VA, 23320
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Inspection Report
Renewal
Census: 78
Deficiencies: 2
Apr 21, 2025
Visit Reason
The inspection was a renewal visit to assess compliance with applicable standards and laws for the facility's continued licensing.
Findings
The inspection identified non-compliance with applicable standards, including failure to complete annual tuberculosis risk assessments for residents and issues with expired medication found during medication cart inspection.
Deficiencies (2)
| Description |
|---|
| Facility did not ensure annual tuberculosis risk assessment was completed for resident #1. |
| Expired medication (Furosemide 20mg) was found on the medication cart for resident #9. |
Report Facts
Number of residents present: 78
Number of resident records reviewed: 9
Number of staff records reviewed: 3
Number of resident interviews: 3
Number of staff interviews: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sean Regan | NP | Completed tuberculosis risk assessment for resident #1 as part of plan of correction |
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 0
Feb 25, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-01-23 regarding allegations in the area of 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 on 2025-01-23 regarding Resident Care and Related Services; investigation found no substantiated non-compliance.
Report Facts
Number of residents present: 70
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
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lanesha Allen | Licensing Inspector | Inspector conducting the complaint investigation |
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 1
Nov 13, 2024
Visit Reason
The inspection was conducted as a complaint investigation following a self-reported incident received by VDSS Division of Licensing on 2024-10-18 regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation supported the self-report of non-compliance with standards related to staff conduct. A violation was issued for failure to ensure staff were considerate and respectful of residents' rights and dignity, specifically involving inappropriate physical contact by a staff member with a resident.
Complaint Details
The complaint investigation was substantiated as the evidence supported the self-report of non-compliance and violation(s) were issued.
Deficiencies (1)
| Description |
|---|
| Facility did not ensure that all staff were considerate and respectful of the rights, dignity, and sensitivities of persons who are aged or infirm or who have disabilities. Staff #2 put her hands on a resident's face after the resident spat on another staff member. |
Report Facts
Number of residents present: 70
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of interviews conducted with staff: 1
Number of interviews conducted with residents: 0
Inspection Report
Renewal
Census: 62
Deficiencies: 3
May 21, 2024
Visit Reason
An unannounced renewal inspection was conducted to assess compliance with applicable standards and laws for license renewal.
Findings
The inspection identified non-compliance with several standards including individualized service plan implementation, medication management, and fire safety inspection requirements. Violations were documented and plans of correction were submitted.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure care and services specified in the individualized service plan (ISP) were provided to resident #3, who was observed feeding himself contrary to the ISP. |
| Facility failed to implement a written plan for medication management including proper disposal of discontinued medication; discontinued medication for resident #2 was still on the medication cart. |
| Facility failed to comply with Virginia Statewide Fire Prevention Code by not having an annual fire inspection completed; last inspection was dated 3/27/23. |
Report Facts
Number of residents present: 62
Number of resident records reviewed: 8
Number of staff records reviewed: 4
Number of resident interviews: 2
Number of staff interviews: 2
Date of last fire inspection: Mar 27, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lanesha Allen | Inspector | Current inspector conducting the inspection |
| Donesia Peoples | Licensing Inspector | Contact person for questions about the inspection |
Inspection Report
Monitoring
Census: 61
Deficiencies: 1
Feb 15, 2024
Visit Reason
An unannounced monitoring inspection was conducted to review compliance with applicable standards following a self-reported incident regarding personnel.
Findings
The investigation supported the self-report of non-compliance related to staff conduct, resulting in violations. Staff #1 was terminated for inappropriate behavior toward a resident, and re-education on resident abuse and neglect was implemented for staff.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure all staff were considerate and respectful of the rights, dignity, and sensitivities of persons who are aged, infirmed, or disabled. |
Report Facts
Number of residents present: 61
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of interviews conducted with staff: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff #1 | Named in finding related to resident abuse and terminated from employment | |
| Staff #2 | Provided written statement regarding incident involving Staff #1 and resident | |
| ED | Executive Director | Responsible for re-education and management actions to prevent recurrence |
| RCD | Resident Care Director | Responsible for re-education and management actions to prevent recurrence |
| BOM | Business Office Manager | Responsible for re-education and management actions to prevent recurrence |
Inspection Report
Monitoring
Census: 65
Deficiencies: 0
Aug 1, 2023
Visit Reason
An unannounced monitoring inspection was conducted to review compliance with various regulatory areas including personnel, staffing, resident care, and facility conditions.
Findings
The inspection included a tour of the physical plant and review of the facility's medication management plan. No evidence was found to support non-compliance with standards or laws.
Report Facts
Resident records reviewed: 1
Staff records reviewed: 3
Staff interviews conducted: 4
Resident interviews conducted: 0
Inspection Report
Renewal
Census: 64
Deficiencies: 4
May 18, 2023
Visit Reason
An announced renewal inspection was conducted to assess compliance with applicable standards and regulations for licensing renewal.
Findings
The inspection identified multiple violations including failure to report major incidents within 24 hours, lack of appropriate psychotropic medication treatment plans, missing annual TB risk assessments, and incomplete individualized service plans (ISP) within 30 days of admission.
Deficiencies (4)
| Description |
|---|
| 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. |
| Facility failed to ensure assisted living residents with psychotropic medications had appropriate diagnosis and treatment plans. |
| Facility failed to ensure annual TB risk assessments were completed for each resident. |
| Facility failed to ensure comprehensive individualized service plans (ISP) were completed within 30 days after admission and included all identified needs based on the uniform assessment instrument (UAI). |
Report Facts
Residents present: 64
Resident records reviewed: 8
Staff records reviewed: 4
Resident interviews: 3
Staff interviews: 3
Plan of correction audit deadline: Jun 30, 2023
Inspection Report
Renewal
Census: 49
Deficiencies: 13
Jun 30, 2022
Visit Reason
An unannounced renewal inspection was initiated and completed on June 30, 2022, to assess compliance with applicable regulations and licensing requirements for the assisted living facility.
Findings
The inspection identified multiple deficiencies including lack of documentation for resident placement approval in the special care unit, missing staff job description acknowledgments, incomplete tuberculosis screening documentation, lack of current first aid certifications for direct care staff, failure to post the current on-site person in charge, missing written assurances of licensing for residents, incomplete fall risk assessments, missing uniform assessment instruments prior to admission, unsigned individualized service plans, lack of licensed health care professional oversight, poor maintenance of building vents, failure to annually review the emergency preparedness plan, and incomplete sworn statements for employment applicants. Plans of correction were documented for all deficiencies.
Deficiencies (13)
| Description |
|---|
| No documentation of approval for placement of Resident #3 in the special care unit. |
| Facility failed to maintain verification that staff received a copy of their current job description for Staff #4 and Staff #5. |
| No documentation of initial tuberculosis examination and report for Staff #4. |
| Direct care staff Staff #4 and Staff #5 did not have current certification in first aid. |
| Facility failed to post the name of the current on-site person in charge in a conspicuous place. |
| Resident #3 did not have written assurance of appropriate license in their record. |
| Residents #1 and #2 did not have a written fall risk rating completed by the time the comprehensive ISP was completed. |
| Resident #3 record did not contain documentation of a completed Uniform Assessment Instrument prior to admission. |
| Individualized service plans for Residents #2 and #3 were not signed by the resident or legal representative. |
| Facility failed to employ a licensed health care professional onsite full-time to provide health care oversight at least every six months. |
| Interior and exterior of buildings were not maintained in good repair and free of rubbish; vents had black and grey substance. |
| Facility failed to review and document annual review of the emergency preparedness plan. |
| Staff #9 did not have a completed sworn statement or affirmation in the record. |
Report Facts
Number of residents present: 49
Number of resident records reviewed: 7
Number of staff records reviewed: 9
Number of resident interviews: 3
Number of staff interviews: 3
Inspection Report
Renewal
Census: 51
Deficiencies: 1
May 24, 2021
Visit Reason
A renewal inspection was initiated on May 24, 2021 and concluded on May 27, 2021 to assess compliance with applicable standards and laws for Commonwealth Senior Living at Georgian Manor.
Findings
The inspection found non-compliance related to the facility's failure to include hospice services provided on the individualized service plan (ISP) for a resident receiving hospice care.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure when hospice care is provided to a resident, the services provided by each is included on the individualized service plan (ISP). |
Report Facts
Resident records reviewed: 4
Staff records reviewed: 4
Inspection Report
Complaint Investigation
Deficiencies: 1
Apr 20, 2021
Visit Reason
A complaint inspection was initiated due to allegations regarding resident care and related services, specifically concerning staff response times to resident call bells.
Findings
The investigation found the facility failed to ensure prompt staff response to resident needs, with documented call bell response times ranging from 10 to 573 minutes and a resident fall resulting in hospitalization. The complaint was substantiated and a violation was issued.
Complaint Details
The complaint was valid and substantiated based on evidence including call bell logs, resident interviews, and incident reports.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure prompt response by staff to resident needs as evidenced by delayed call bell responses and a resident fall requiring hospitalization. |
Report Facts
Call bell response time range (minutes): 573
Call bell response time range (minutes): 10
Resident hospitalization duration (days): 2
Call bell response time delay (minutes): 31
Inspection Report
Complaint Investigation
Deficiencies: 2
Jan 25, 2021
Visit Reason
A complaint inspection was initiated on January 7, 2021 and concluded on January 27, 2021, regarding allegations about staff personal cell phone use and delayed resident care.
Findings
The investigation could not substantiate the complaint allegations; however, non-compliance with standards was cited, including failure to maintain written shift-to-shift communications and failure to update Individualized Service Plans (ISPs) as residents' conditions changed.
Complaint Details
A complaint was received regarding staff personal cell phone use and delayed resident care. The evidence gathered could not substantiate the allegation in the complaint.
Deficiencies (2)
| Description |
|---|
| Facility did not maintain written communications used for keeping direct care staff on all shifts informed of significant happenings or problems experienced by residents for at least the past two years. |
| Facility failed to ensure Individualized Service Plans (ISPs) were reviewed and updated as needed as the condition of the resident changes. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Nov 30, 2020
Visit Reason
A complaint inspection was initiated due to allegations related to staffing and call bell response times at Commonwealth Senior Living at Georgian Manor. The investigation was conducted remotely due to a state of emergency health pandemic.
Findings
The investigation substantiated non-compliance with standards related to medication administration records lacking diagnosis or indications and equipment not being kept in good repair, specifically the call bell system. The staffing allegation was not substantiated.
Complaint Details
The complaint was related to staffing and call bell response times. The staffing allegation was not substantiated, but the complaint was valid. The call bell system was found to have significant delays in response times and equipment issues.
Deficiencies (2)
| Description |
|---|
| Medication Administration Records (MAR) did not include the diagnosis, condition, or specific indications for administering drugs or supplements for multiple residents. |
| Facility failed to ensure all equipment, including the call bell system, was kept in good repair and condition, with documented staff response times ranging from 10 to 1403 minutes and equipment not working properly. |
Report Facts
Staff response times: 1403
Staff response times: 10
Staff response times: 130
Staff response times: 48
Staff response times: 859
Staff response times: 140
Staff response times: 285
Staff response times: 76
Staff response times: 357
Staff response times: 1014
Staff response times: 158
Staff response times: 366
Staff response times: 984
Staff response times: 41
Staff response times: 155
Staff response times: 509
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lanesha Allen | Inspector | Named as current inspector conducting the investigation |
| Staff #1 | Acknowledged call bell system issues and response time variations | |
| Staff #2 | Acknowledged missing diagnosis or indications on MARs | |
| Resident Care Director | Resident Care Director | Person responsible for plan of correction related to MAR and call bell system |
| Assistant Resident Care Director | Assistant Resident Care Director | Person responsible for plan of correction related to MAR |
| Maintenance Director | Maintenance Director | Person responsible for plan of correction related to call bell system repair |
| Concierge | Concierge | Person responsible for plan of correction related to call bell system |
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