Inspection Report Summary
The most recent inspection on March 20, 2025, identified deficiencies related to incomplete physical statements and missing annual tuberculosis risk assessments for a resident. Earlier inspections showed a pattern of issues involving staff training and orientation, resident physical examinations, individualized service plans, medication administration, and documentation. Complaint investigations in 2022 were unsubstantiated except for one substantiated case involving inadequate supervision of a wandering resident, which led to corrective actions by the facility. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s deficiencies have been consistent over time, with no clear pattern of significant improvement or worsening.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
4.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
54% better than Virginia average
Virginia average: 9.1 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
69 residents
Based on a March 2025 inspection.
Occupancy over time
Inspection Report
Monitoring
Census: 69
Deficiencies: 2
Date: Mar 20, 2025
Visit Reason
The inspection was a monitoring visit to review compliance with applicable standards and laws at Westminster Canterbury on Chesapeake Bay.
Findings
The inspection found non-compliance with applicable standards or laws, resulting in documented violations related to incomplete physical statements and missing tuberculosis risk assessments for a resident. The licensee was given the opportunity to submit a plan of correction.
Deficiencies (2)
The facility did not ensure that the physical statement includes a statement that the individual does not have any of the conditions or care needs prohibited by 22VAC40-73-310 H; or a statement specifying ambulatory status.
The facility did not ensure that a risk assessment for tuberculosis was completed annually on each resident as evidenced by the absence of a TB screening at admission and annual TB for 2024 for resident #1.
Report Facts
Number of residents present: 69
Number of resident records reviewed: 6
Number of staff records reviewed: 3
Number of interviews conducted with residents: 3
Number of interviews conducted with staff: 3
Inspection Report
Renewal
Census: 68
Deficiencies: 3
Date: Feb 27, 2024
Visit Reason
An unannounced renewal inspection was conducted to assess compliance with applicable standards and regulations for the facility's license renewal.
Findings
The inspection identified non-compliance with several standards related to staff orientation and training, resident physical examinations, and preliminary plans of care. Violations were documented and a plan of correction was requested from the licensee.
Deficiencies (3)
Failed to ensure orientation and training occurred within the first seven working days of employment for staff.
Failed to ensure a physician examination report within 30 days preceding admission included required statements about resident conditions.
Failed to ensure a preliminary plan of care was developed on or within 7 days prior to admission for residents.
Report Facts
Number of residents present: 68
Number of resident records reviewed: 8
Number of staff records reviewed: 4
Number of resident interviews conducted: 2
Number of staff interviews conducted: 2
Inspection Report
Renewal
Census: 66
Deficiencies: 3
Date: Feb 15, 2023
Visit Reason
An unannounced renewal inspection was conducted to assess compliance with applicable standards and regulations for the facility's license renewal.
Findings
The inspection identified non-compliance with several standards including staff first aid certification, missing signatures on individualized service plans (ISPs), and medication administration not following physician orders. Plans of correction were proposed to address these deficiencies.
Deficiencies (3)
Facility failed to ensure each direct care staff member had current certification in first aid within 60 days of employment.
Individualized service plans (ISP) were not signed and dated by the resident or legal representative.
Medications were not administered according to physician orders and standards of practice.
Report Facts
Residents present: 66
Resident records reviewed: 8
Staff records reviewed: 4
Resident interviews conducted: 3
Staff interviews conducted: 3
Staff #2 hire date: Oct 3, 2022
First aid certification completion date for Staff #2: Mar 6, 2023
Resident #1 ISP date: Apr 20, 2022
Resident #3 ISP date: Jul 21, 2022
Resident #5 ISP date: Jan 5, 2022
Physician order date for Resident #1: May 28, 2021
Medication administration non-compliance dates: 3
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 0
Date: Oct 21, 2022
Visit Reason
The inspection was conducted due to a complaint received by VDSS Division of Licensing on 2022-10-20 regarding allegations in the area of Resident care and Related Services.
Complaint Details
Complaint received on 2022-10-20 regarding Resident care and Related Services; investigation did not substantiate non-compliance.
Findings
The evidence gathered during the investigation did not support the complaint of non-compliance with standards or law. The inspection included a tour of the physical plant, review of resident and staff records, and observation of emergency preparedness and staffing.
Report Facts
Residents present: 68
Resident records reviewed: 2
Staff records reviewed: 5
Staff interviews conducted: 6
Resident interviews conducted: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lanesha Allen | Inspector | Current Inspector conducting the inspection |
| Donesia Peoples | Licensing Inspector | Contact person for questions regarding the inspection |
Inspection Report
Monitoring
Census: 68
Deficiencies: 0
Date: Oct 21, 2022
Visit Reason
An unannounced monitoring inspection was conducted following a self-reported incident received by VDSS Division of Licensing regarding allegations in the area of Resident care and Related Services.
Findings
The licensing inspector completed a tour of the facility, reviewed resident and staff records, and conducted staff interviews. The evidence gathered did not support the self-report of non-compliance with standards or law.
Report Facts
Resident records reviewed: 1
Staff records reviewed: 4
Staff interviews conducted: 6
Resident interviews conducted: 0
Inspection Report
Renewal
Census: 62
Deficiencies: 7
Date: Jun 21, 2022
Visit Reason
An unannounced renewal inspection was conducted on June 21 and June 22, 2022, to assess compliance with regulatory standards for the assisted living facility.
Findings
The inspection identified multiple deficiencies including failure to complete Uniform Assessment Instruments (UAI) prior to admission and annually, delayed completion of individualized service plans (ISP), inadequate oversight of special diets, incomplete documentation of fire drill times, failure to post inspection findings, incomplete sworn statements for staff, and missing criminal history record reports for staff.
Deficiencies (7)
Failure to ensure the Uniform Assessment Instrument (UAI) was completed prior to admission and at least annually.
Failure to ensure the comprehensive individualized service plan was completed within 30 days after admission.
Failure to ensure oversight of special diets included review of physician orders, preparation and delivery, evaluation of adequacy and resident acceptance, notification to administrator, and documentation signed and dated by dietician or nutritionist.
Failure to document the time it took to complete the required fire and emergency evacuation drills.
Failure to post findings of the most recent inspection on the premises as required.
Failure to complete sworn statement or affirmation for all applicants for employment.
Failure to ensure the criminal history record report was obtained on or prior to the 30th day of employment for each staff person.
Report Facts
Number of residents present: 62
Number of resident records reviewed: 9
Number of staff records reviewed: 9
Number of resident interviews conducted: 5
Number of staff interviews conducted: 5
Number of residents with missing UAI prior to admission: 4
Number of residents with ISP completed late: 3
Number of residents with quarterly nutrition assessments missing signatures: 15
Inspection Report
Routine
Census: 62
Deficiencies: 1
Date: Jun 21, 2022
Visit Reason
An unannounced routine inspection was conducted on June 21-22, 2022, to review resident care and related services following a complaint/self-reported incident received on May 11, 2022.
Complaint Details
The visit was complaint-related but marked as 'No' for complaint related in the header; however, the inspection was triggered by a complaint/self-reported incident received on 05/11/22 regarding resident care and related services. The complaint was substantiated by the finding of resident elopement.
Findings
The facility failed to provide adequate supervision for one resident with wandering risk, who exited the secure memory care unit and left the campus unnoticed for over an hour. The facility implemented multiple corrective actions including increased monitoring, security enhancements, and staff training.
Deficiencies (1)
Failure to provide supervision of resident schedules, care, and activities including attention to the specialized need of wandering from the premises for one resident in care.
Report Facts
Number of residents present: 62
Number of resident records reviewed: 1
Number of staff interviews conducted: 3
Distance: 3168
Inspection Report
Renewal
Census: 66
Deficiencies: 7
Date: Feb 25, 2021
Visit Reason
A renewal inspection was initiated on 02-25-2021 and concluded on 03-01-2021 to assess compliance with applicable standards and regulations for Westminster Canterbury on Chesapeake Bay.
Findings
The inspection identified multiple non-compliances including failure to report major incidents within 24 hours, incomplete or outdated Uniform Assessment Instruments (UAI), deficiencies in Individualized Service Plans (ISP), missing diagnosis or indications on physician's medication orders, delayed physician review of oral orders, and medication administration not in accordance with physician instructions.
Deficiencies (7)
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 the Uniform Assessment Instrument (UAI) was completed whenever there was a significant change.
Facility failed to ensure the Uniform Assessment Instrument (UAI) was completed as required by 22VAC30-110, including missing assessor signatures and incorrect level of care assessments.
Facility failed to ensure the Individualized Service Plan (ISP) included a description of the resident's identified needs based on the UAI.
Facility failed to ensure physician's orders for administration of all prescription and over-the-counter medications identified the diagnosis or specific indications for each drug.
Facility failed to ensure physician's oral orders were reviewed and signed by a physician within 14 days.
Facility failed to ensure medications were administered in accordance with the physician's instructions.
Report Facts
Inspection duration days: 5
Resident census: 66
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lanesha Allen | Inspector | Named as current inspector conducting the inspection |
| Director of Quality Management | Referenced in multiple plans of correction related to oversight and review of findings |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Dec 10, 2020
Visit Reason
A complaint investigation was initiated due to allegations regarding Personal Possessions at the assisted living facility. The investigation was conducted remotely due to a state of emergency health pandemic.
Complaint Details
Complaint related to allegations in the area of Personal Possessions. The evidence gathered did not support the allegations of non-compliance.
Findings
The investigation found no evidence to support the allegations of non-compliance with standards or law. However, two deficiencies were identified related to the resident written agreement and annual review of residents' rights and responsibilities.
Deficiencies (2)
Facility failed to ensure the resident written agreement/acknowledgment included the required information as outlined in the standard 22VAC40-73-390-A.
Facility failed to ensure the rights and responsibilities of residents in assisted living facilities are reviewed annually with each resident, with evidence of resident's written acknowledgment.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lanesha Allen | Inspector | Named as the current inspector conducting the complaint investigation. |
| Staff #1 | Provided documentation and acknowledged deficiencies related to resident agreements and rights reviews. |
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