Inspection Reports for Commonwealth Senior Living at Kings Grant House
VA, 23452
Back to Facility ProfileDeficiencies per Year
8
6
4
2
0
Severe
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Moderate
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Unclassified
Census Over Time
Inspection Report
Complaint Investigation
Census: 71
Deficiencies: 1
Aug 22, 2025
Visit Reason
The inspection was conducted as a complaint investigation following a self-reported incident received on 2025-07-11 regarding medication administration errors.
Findings
The inspection found non-compliance with medication administration standards, specifically that medications were administered to the wrong resident, resulting in an emergency room visit and subsequent monitoring. Violations were documented and a plan of correction was requested.
Complaint Details
The complaint was substantiated based on a self-reported incident from staff indicating a medication error on 2025-07-11. Resident #1 was transported to the emergency room and monitored hourly for 72 hours. Follow-up interviews and record reviews confirmed the incident.
Deficiencies (1)
| Description |
|---|
| Facility did not ensure that medications were administered in accordance with physician's or other prescriber's instructions, resulting in a medication error where resident #1 received medications belonging to resident #2. |
Report Facts
Residents present: 71
Resident records reviewed: 1
Staff records reviewed: 1
Staff interviews conducted: 2
Medication error incident date: Jul 11, 2025
Plan of correction due date: Oct 13, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lanesha Allen | Licensing Inspector | Inspector conducting the complaint investigation |
Inspection Report
Renewal
Census: 62
Deficiencies: 3
May 19, 2025
Visit Reason
The inspection was a renewal visit to assess compliance with applicable standards and regulations for the assisted living facility.
Findings
The inspection found non-compliance with several standards related to admission physical examinations, fall risk rating updates after falls, and completion of comprehensive individualized service plans within 30 days of admission. Violations were documented and a plan of correction was requested.
Deficiencies (3)
| Description |
|---|
| Facility did not ensure a physical examination by an independent physician within 30 days preceding admission, including a tuberculosis risk assessment. |
| Facility did not ensure the fall risk rating was reviewed and updated after a fall. |
| Facility did not ensure the comprehensive individualized service plan was completed within 30 days after admission. |
Report Facts
Number of residents present: 62
Number of resident records reviewed: 7
Number of staff records reviewed: 3
Number of resident interviews conducted: 3
Number of staff interviews conducted: 4
Due date for correction of physical exam deficiency: June 6, 2025
Due date for correction of fall risk rating deficiency: June 2, 2025
Due date for correction of individualized service plan deficiency: May 30, 2025
Inspection Report
Renewal
Census: 66
Deficiencies: 3
Jun 11, 2024
Visit Reason
The inspection was a renewal visit conducted to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection identified non-compliance with several standards including medication management, Do Not Resuscitate (DNR) order documentation, and timely completion of criminal history record reports for employees. Violations were documented and a plan of correction was requested.
Deficiencies (3)
| Description |
|---|
| Facility failed to implement their written plan for medication management including prevention of outdated medications; expired multivitamins found in medication cart. |
| Facility failed to ensure a valid written Do Not Resuscitate (DNR) order was issued by the attending physician and included in the individualized service plan. |
| Facility failed to obtain a criminal history record report on or prior to the 30th day of employment for each employee; missing or late reports for Staff #5 and Staff #6. |
Report Facts
Number of residents present: 66
Number of resident records reviewed: 8
Number of staff records reviewed: 4
Number of resident interviews conducted: 4
Number of staff interviews conducted: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| M. Tess Pittman | Licensing Inspector | Contact person for questions about the inspection |
Inspection Report
Monitoring
Census: 65
Deficiencies: 1
Apr 18, 2024
Visit Reason
The inspection was a monitoring visit conducted on April 18, 2024, to review compliance with regulations related to personnel, resident care and related services, and additional requirements for facilities caring for adults with serious cognitive impairments. The visit included review of self-reported incidents and investigation of allegations.
Findings
The investigation supported some, but not all, of the self-reported incidents and found areas of non-compliance related to resident care and related services. A violation notice was issued, including a deficiency for failure to assume general responsibility for the health, safety, and well-being of residents.
Deficiencies (1)
| Description |
|---|
| Based on record review and interview, the facility failed to assume general responsibility for the health, safety, and well-being of the residents. Evidence included an incident on 04/12/2024 where Staff #3 pushed Resident #1 down, resulting in pain and change in condition for Resident #1. |
Report Facts
Number of residents present: 65
Number of resident records reviewed: 2
Number of staff records reviewed: 1
Number of resident interviews conducted: 2
Number of staff interviews conducted: 2
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 1
Jan 31, 2024
Visit Reason
The inspection was conducted in response to a complaint received by the VDSS Division of Licensing on 2024-01-09 regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation supported some, but not all, of the allegations. Non-compliance was found in Resident Care and Related Services, specifically the facility failed to ensure the individualized service plan included a description of identified needs and date identified based on the fall risk rating for Resident #1.
Complaint Details
The complaint was substantiated in part; evidence showed Resident #1 had at least 7 falls in December 2023 and 1 fall in January 2024, and the facility did not update the individualized service plan with fall mitigation/prevention interventions despite completing fall risk ratings after each fall.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure the comprehensive individualized service plan included a description of identified needs and date identified based on the fall risk rating. |
Report Facts
Number of residents present: 70
Resident falls: 7
Resident falls: 1
Number of resident records reviewed: 1
Number of staff interviews conducted: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| M. Tess Pittman | Licensing Inspector | Contact person for questions regarding the inspection |
Inspection Report
Monitoring
Census: 70
Deficiencies: 0
Jan 4, 2024
Visit Reason
The inspection was a monitoring visit conducted on January 4, 2024, following a complaint received on December 27, 2023, regarding allegations in Resident Care and Related Services.
Findings
The investigation did not support the self-report of non-compliance with standards or law. The licensing inspector completed a tour of the facility and conducted interviews with residents and staff.
Complaint Details
A complaint was received by VDSS Division of Licensing on 12/27/2023 regarding allegations in Resident Care and Related Services. The evidence gathered did not substantiate non-compliance.
Report Facts
Number of residents present: 70
Number of staff records reviewed: 1
Number of interviews with residents: 1
Number of interviews with staff: 1
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 0
Aug 1, 2023
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2023-07-22 regarding allegations in the areas of Staffing and Supervision, Resident Care and Related Services, and Background Checks.
Findings
The evidence gathered during the investigation did not support the allegations or self-report of non-compliance with standards or law.
Complaint Details
Complaint received on 2023-07-22 regarding Staffing and Supervision, Resident Care and Related Services, and Background Checks. The investigation did not substantiate the allegations.
Report Facts
Number of residents present: 66
Number of staff records reviewed: 2
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 1
Inspection Report
Renewal
Census: 62
Deficiencies: 8
Jun 13, 2023
Visit Reason
The inspection was a renewal inspection conducted on June 13 and June 14, 2023, to assess compliance with applicable standards and laws for Commonwealth Senior Living at King's Grant House.
Findings
The inspection identified multiple violations including incomplete tuberculosis risk assessments, lack of licensed health care professional oversight, unsecured resident records, expired medications, missing valid Do Not Resuscitate orders, unchecked first aid kits, insufficient emergency water supply, and incomplete criminal history record reports for employees.
Deficiencies (8)
| Description |
|---|
| Failed to ensure admitting physical examination included a completed risk assessment documenting absence of tuberculosis in a communicable form. |
| Failed to retain a licensed health care professional with required experience to provide on-site health care oversight. |
| Failed to ensure all resident records were kept in a locked area; narcotic count book was unattended and accessible. |
| Failed to implement written plan for medication management including prevention of outdated medications; expired medications found in medication carts. |
| Failed to ensure valid written Do Not Resuscitate (DNR) orders issued by attending physician and included in individualized service plans. |
| Failed to ensure first aid kits were checked at least monthly; first aid kits had not been checked for several months. |
| Failed to ensure availability of a 96-hour supply of emergency drinking water with at least 48 hours on site; emergency water supply included expired water. |
| Failed to obtain criminal history record reports on or prior to the 30th day of employment for certain employees. |
Report Facts
Number of residents present: 62
Number of resident records reviewed: 8
Number of staff records reviewed: 4
Expired medications count: 6
First aid kit last checked dates: First aid kits last checked on 12/05/2022 and 02/05/2023
Background check missing for employees: 2
Inspection Report
Complaint Investigation
Deficiencies: 8
May 24, 2023
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2023-05-15 regarding allegations in the areas of Administration and Administrative Services, Resident Care and Related 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 and Resident Care and Related Services. Multiple violations were cited related to assessments, approvals, reporting incidents, and individualized service plans.
Complaint Details
The complaint investigation was substantiated in part, with non-compliance found in Administration and Administrative Services and Resident Care and Related Services. A violation notice was issued and the licensee was given the opportunity to submit a plan of correction.
Deficiencies (8)
| Description |
|---|
| Facility failed to ensure residents were assessed by an independent clinical psychologist or physician for serious cognitive impairment prior to admission to a safe, secure environment. |
| Facility failed to obtain written approval for placing a resident with serious cognitive impairment in a safe, secure environment. |
| Facility failed to ensure licensee, administrator, or designee determined appropriateness of placement in special care unit for resident with serious cognitive impairment. |
| Facility failed to report to the regional licensing office within 24 hours of a major incident negatively affecting or threatening resident safety. |
| Facility failed to ensure the Uniform Assessment Instrument (UAI) was completed for residents with significant changes in condition. |
| Facility failed to ensure individualized service plans were signed and dated by the licensee, administrator, or designee and by the resident or legal representative. |
| Facility failed to review and update individualized service plans as needed for significant changes in resident condition. |
| Facility failed to ensure immediate medical attention and notification to legal representative when resident suffered serious accident or illness. |
Report Facts
Number of resident records reviewed: 1
Number of interviews conducted with residents: 2
Number of interviews conducted with staff: 2
Date of resident transfer to safe, secure environment: Apr 6, 2023
Date of assessment completion for serious cognitive impairment: Apr 29, 2023
Date of incident requiring reporting: May 14, 2023
Date of last UAI completed: Sep 9, 2022
Date of ISP document: Nov 20, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lanesha Allen | Current Inspector | Inspector on-site during the inspection |
| M. Tess Pittman | Licensing Inspector | Contact person for questions about VDSS Licensing Programs |
| Executive Director | Named in multiple plans of correction and re-education efforts | |
| Resident Care Director | Named in multiple plans of correction and re-education efforts | |
| LPN | Named in re-education efforts | |
| Wellness Secretary | Named in re-education efforts | |
| Registered Medication Aide | Named in re-education efforts |
Inspection Report
Monitoring
Deficiencies: 2
Oct 21, 2022
Visit Reason
The inspection was a monitoring visit conducted following a self-reported incident received by VDSS Division of Licensing on 2022-10-07 regarding allegations in Resident Care and Related Services.
Findings
The investigation supported the self-report of non-compliance with regulations, resulting in violations issued related to volunteer supervision and resident supervision during activities, including incidents of residents wandering outside the secure environment.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure all volunteers were under the supervision of a designated staff person when residents were present. |
| Facility failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs such as wandering from the premises. |
Report Facts
Number of resident records reviewed: 2
Number of staff records reviewed: 1
Date of incident: Oct 6, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lanesha Allen | Licensing Inspector | Current inspector conducting the inspection |
| M. Tess Pittman | Licensing Inspector | Contact person for questions regarding the inspection |
Inspection Report
Renewal
Census: 52
Deficiencies: 5
Jun 29, 2022
Visit Reason
The inspection was a renewal visit conducted on June 29, 2022 and July 7, 2022 to assess compliance with applicable regulations and licensing requirements for the assisted living facility.
Findings
The inspection found multiple violations including admission and retention of residents with prohibited care needs, failure to complete required fall risk ratings, incomplete or unsigned assessments, inconsistencies in Do Not Resuscitate orders, and employment of staff with disqualifying criminal convictions. The facility was cited for non-compliance and given the opportunity to submit plans of correction.
Deficiencies (5)
| Description |
|---|
| Facility admitted and retained individuals with prohibited conditions or care needs. |
| Failed to ensure a written fall risk rating was completed for residents meeting assisted living criteria and after falls. |
| Failed to ensure the Uniform Assessment Instrument (UAI) was completed prior to admission, annually, and after significant changes. |
| Failed to ensure a valid written Do Not Resuscitate (DNR) order was issued by the attending physician and included in the individualized service plan. |
| Failed to ensure any person employed does not have a conviction of any barrier crimes. |
Report Facts
Residents present: 52
Resident records reviewed: 7
Staff records reviewed: 4
Staff hire date: Dec 7, 2021
Staff conviction date: Aug 2, 2021
Inspection Report
Complaint Investigation
Deficiencies: 2
Mar 29, 2022
Visit Reason
A non-mandated self-report inspection was initiated due to a self-reported incident regarding an allegation of neglect at the facility.
Findings
The facility failed to ensure resident-centered care with prompt staff response, as evidenced by a resident falling after staff refused to provide care. Additionally, the facility failed to ensure personal assistance and care were provided as necessary, with incomplete documentation of bathing assistance.
Complaint Details
The investigation was triggered by a self-reported incident alleging neglect. The complaint was not marked as substantiated or unsubstantiated in the report.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure care provision and service delivery were resident-centered with prompt staff response, resulting in a resident fall after staff refusal to provide care. |
| Facility failed to ensure personal assistance and care were provided as necessary, with incomplete documentation of bathing assistance. |
Report Facts
Shower assistance documentation dates: 7
Shower refusals: 3
Showers received: 4
Inspection Report
Complaint Investigation
Deficiencies: 1
Aug 6, 2021
Visit Reason
A non-mandated complaint inspection was initiated due to a complaint received regarding allegations in the areas of Resident Care and Related Services.
Findings
The investigation found that the evidence did not support the allegations of non-compliance with standards or law. However, the facility failed to report major incidents to the regional licensing office within 24 hours as required.
Complaint Details
Complaint related: Yes. A complaint was received regarding Resident Care and Related Services. The evidence gathered did not support the allegations of non-compliance.
Deficiencies (1)
| 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. |
Report Facts
Inspection Dates: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lanesha Allen | Inspector | Named as current inspector conducting the investigation |
| Staff #2 | Acknowledged incidents were not reported within required timeframe | |
| Resident Care Director | Re-in-serviced on incident reporting regulations as part of plan of correction |
Inspection Report
Renewal
Census: 48
Deficiencies: 2
Jul 2, 2021
Visit Reason
A renewal inspection was initiated on June 30, 2021 and concluded on July 2, 2021 to review compliance with applicable standards and laws for Commonwealth Senior Living at King's Grant House.
Findings
The inspection identified non-compliances including failure to ensure prior written physician assessment of serious cognitive impairment before admission to a secure unit, and failure to update Individualized Service Plans (ISPs) to reflect residents' changing conditions and needs.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure prior to admission to a safe, secure environment, the resident was assessed in writing by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia. |
| Facility failed to ensure the Individualized Service Plan (ISP) was reviewed and updated as needed as the condition of the resident changes. |
Report Facts
Resident records reviewed: 3
Staff records reviewed: 3
Inspection dates: 3
Inspection Report
Complaint Investigation
Deficiencies: 1
Apr 23, 2021
Visit Reason
A complaint investigation was initiated due to allegations regarding Personal Care Services and General Supervision of Care and Restorative, Habilitative, and Rehabilitative Services at the facility.
Findings
The investigation found no evidence to support the allegations of non-compliance with standards or law. However, unrelated violations were identified, including failure to document analysis of falls and interventions for residents meeting assisted living criteria.
Complaint Details
Complaint related to allegations in Personal Care Services and General Supervision of Care and Restorative, Habilitative, and Rehabilitative Services. The complaint was not substantiated based on evidence gathered during the investigation.
Deficiencies (1)
| Description |
|---|
| Facility failed to document an analysis of the circumstances of falls and interventions initiated to prevent or reduce risk of subsequent falls for residents meeting assisted living care criteria. |
Report Facts
Inspection dates: 2
Residents with documented falls: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lanesha Allen | Inspector | Current Inspector conducting the complaint investigation |
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