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Public Google reviewers rate Commonwealth Senior Living at Cedar Manor highly. Reviewers highlight: warm and attentive nursing and care staff, clean and well-maintained environment. Reviewer identity is not verified, and online reviews may not capture everything. Schedule a visit to assess the fit directly.
Families considering Cedar Manor can expect a highly welcoming environment characterized by a warm, attentive staff and a clean, upscale facility. Reviewers frequently highlight the compassionate care provided in the memory care wing and the engaging community events, though most reviews focus on the facility's positive atmosphere rather than specific clinical outcomes.
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Key Review Excerpts
“My father has been living at Cedar Manor for a little over a year and the staff has done an excellent job helping him (and us!) feel at home.”
“The care teams are kind, considerate, attentive, patient, and genuinely care about the residents. The facility is clean, meals are great, and the decor is upscale.”
“I don’t have a family member who goes there but I do come in 2 times out the week to service the community and they are always nice the community is always clean and smells nice.”
Source: VA State Licensing Agency
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced monitoring inspection took place on 12/18/2025 at 10:30 am to 12:15 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 11/24/25 regarding allegations in the area(s) of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 92 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 2 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: Additional Comments/Discussion: Residents were observed in the common areas. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the self-report area(s) of non-compliance with standard(s) or law were: Resident Care and Related Services A violation notice was issued; any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of these inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Refer to General Procedures and Information for Licensure, 22VAC40-80-260-B for information on requesting a problem solving conference. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact (Donesia Peoples), Licensing Inspector at (757) 353-0430 or by email at donesia.peoples@dss.virginia.gov
Based on the record review, resident interview, and staff interview the facility failed to ensure the care and services specified in the individualized service plan ( ISP
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 11/19/2025 at 11:00 am to 2:10 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 10/07/2025 regarding allegations in the area(s) of: Personnel and Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 81 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 2 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: Lunch was observed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the (allegation(s)/self-report) of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 09/15/2025 at 11:30 am to 1:38 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 09/11/2025 regarding allegations in the area(s) of: Personnel and Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 81 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 4 Observations by licensing inspector: An observation of the safe secure unit was reviewed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the (allegation) of non-compliance with standard(s) or law. However, violation(s) not related to the (complaint) but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Based on the record review and staff interview the facility failed to ensure all staff who are mandated reporters under ? 63.2-1606 of the Code of Virginia shall report suspected abuse, neglect, or exploitation of residents in accordance with that section. Evidence: 1. Resident #1?s progress noted dated 08/29/25 documents the following: ?RMA was notified by hairstylist that resident came out from memory unit and one of the RCA was throwing hands with the resident and RCA was using cursing words to the resident.? 2. During an interview on 09/15/25 with staff #1 and staff #2, staff #1 and staff #2 confirmed being notified on 08/30/25 of an allegation of suspected physical abuse involving staff #4 physically assaulting resident #2 on 08/29/2025, however the staff did not report the incident to Adult Protective Services (APS). 2. During an interview on 09/15/25 with staff #3, staff #3 confirmed staff #1 notified staff #3 on 09/01/25 of an allegation of suspected abuse involving staff #4 physically assaulting resident #1 on the day of 08/29/25. Staff #3 confirmed staff #3 did not report the suspected abuse to APS. 3. During an interview on 09/15/25 with collateral contact #1, collateral contact #1 confirmed the facility staff did not report to APS the allegation of suspected abuse involving staff #1 physically assaulting resident #1.
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An announced renewal inspection took place on 04/03/2025 from 8:00 am to 5:30 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 83 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: Breakfast, Lunch and an activity were observed. A medication pass observation was completed for three residents. The following was reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, medication carts, fire inspection report, health inspection report, and a staffing schedule. The 1ater temperature was measured. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Based on the record review and staff interview the facility failed to ensure a record of the required fire and emergency evacuation drills shall be kept in the facility for two years. Such record shall include: the date and time of the drill. Evidence: 1. The facility?s record of the fire drills completed on the following dates did not include the time of the drill: 09/30/25, 10/09/25, 11/21/25, 12/24/25. 2. Staff #4 acknowledged the fire drill records did not include the times fire drills were completed on 09/30/25, 10/09/25, 11/21/25, and 12/24/25.
Based on the record review and staff interview the facility failed to ensure medications shall be administered in accordance with the physician?s or other prescriber?s instructions. Evidence: 1 The record for resident #3 contains the following physician orders dated 02/14/25: Clopidogrel 75mg, take 1 tablet by mouth everyday; Losartan 50mg, take 1 tablet by mouth everyday; Pantoprazole, take I tablet by mouth everyday; Levetiraceta, take 1 tablet by mouth twice a day; Montelukast, take 1 tablet by mouth every day; Rosuvastatin, take 1 tablet by mouth every day. 2. Resident?s # 3 March 2025 MAR
Based on the record review and staff interview the facility failed to implement a written plan for medication management to include methods to ensure that each resident?s prescription medications and any over-the counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages. Evidence: 1.The facility?s medication management plan provided during the onsite inspection includes the following: ?the RMA on duty contacts the dispensing pharmacy to obtain a refill at least seven (7) days prior to a medication running out unless the medication is on a cycle refill with the pharmacy.? 2. During the medication pass observation with staff #2. The following medications scheduled for 7:30 am were not on the cart for resident #3: Prednisone, Calcium Vitamin D3, and Loratadine. 3. Resident?s #1 April 2025 Medication Administration Records ( MAR
Based on the record review the facility failed to ensure the comprehensive individualized service plan ( ISP
Based on observation and staff interview the facility failed to develop and implement a procedure for posting the name of the current on-site person in charge in a place in the facility that is conspicuous to the residents and the public. Evidence: 1. Upon arrival at the facility on 04/03/25 at 8:00 am, the Licensing Inspector (LI) observed a posting of the Shift Supervisor listed as staff #7. Staff #7 was not on site at the facility upon the LI arrival. Staff #6 acknowledged staff #7 was not onsite at the facility upon the LI arrival.
Based on the record review the facility failed to ensure upon admission, the assisted living facility shall provide an orientation for new residents and their legal guardian including emergency response procedures, mealtimes, and use of the call system. Evidence: 1. The record for resident #1, admission date 02/27/25, did not contain documentation the facility provided an orientation to the resident and/ or their legal guardian upon admission. The orientation in the record was dated as completed on 03/27/25.
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 9/09/24 from 8:37 am to 1:37 pm and 9/26/24 from 10:07 am to 10:43 am. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 9/06/2024 regarding allegations in the area(s) of: Personnel and Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 77 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 4 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 5 Observations by licensing inspector: Review of the medication carts was completed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation?s area(s) of non-compliance with standard(s) or law were: Resident Care and Related Services A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Based on the record review and staff interview the facility failed to implement a written plan for medication management to include a plan for proper disposal of medication. Evidence: 1. The facility?s medication management plan dated 6/10/21 includes the following: ?all discontinued medications will be returned to the pharmacy or destroyed within 72 hours of discontinuance.? 2. The record for resident #1 contains a physician communication form, completed by staff #1 and dated 8/29/24 that includes the following: ?resident had coumadin orders changed on 8/21 to 2.5mg 1/2 tab 7 days a week. Previously, order was 2.5mg 1 ? pills 5 days a week and 1 pill on Sundays and Wednesdays. It seems a med error has been made due to previously ordered med card still being in cart and pills being popped.? 3. The record for resident contains the following physician orders: Physician order dated 8/12/24, ?Coumadin 2.5mg pills, ?1 ? pills (3.75mg) 5 days a week and 1 pill (2.5mg) on Sundays & Wednesdays, continue weekly INR.? Physician order dated 8/21/24, ?out of range INR (3.46); please take 2.5mg ? pills (1.25mg) 7 days a week. 3. Resident?s #1 Medication Administration record documents the resident?s coumadin medication for physician order dated 8/12/24 was discontinued on 8/21/24. 4. During an interview with staff #1, and staff #5 both staff confirmed, resident?s #1 coumadin medication (3.75mg) that discontinued on 8/21/24 was not removed from the facility?s medication cart until 8/29/24.
Based on the record review the facility failed to ensure medical procedures or treatment ordered by a physician or other prescribed shall be provided according to his instructions and documents. The documentation shall be maintained in the resident?s record. Evidence: 1. The record for resident #1 contains a physician order dated 4/24/24 ?check PT/INR weekly.? The resident?s record did not contain lab results and/or documentation of the resident?s INR levels being checked weekly during the following timeframes: 6/17/24 through 6/27/24, 6/27/24 through 7/08/24, 7/08/24 through 7/26/2024.
Based on the record review and staff interview the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident. Evidence: 1. The record for resident #1 contains a progress note dated 9/02/24 that states ?resident was in room closet stumped over. Resident pushed the emergency call bell. Resident was unresponsive when the paramedics showed up.? During an interview with staff #5, staff #5 reported staff #5 responded to resident?s#1 emergency call bell on 9/02/24 and observed the resident to be unresponsive. Staff #5 stated 911 was called and the paramedics transported the resident to the hospital emergency room. 2. Resident?s #1 hospital notes stated upon arrival to the emergency room, the resident ?is unresponsive with sonorous respirations and hypertensive.? Resident?s #1 hospital notes document the resident date of death as 9/02/24 to include a final diagnosis of ?intracranial hemorrhage.? 3.The facility did not notify the regional licensing office within 24 hours of the resident?s need for emergency services, transport to the emergency, and the resident?s death that occurred on 9/02/24. 4. The facility?s incident reports policy dated 5/12/22 includes the following to be major incidents that have negatively affected or that threaten the life, health, safety, or welfare of any resident that must be reported as required by the standard: ?the death of a resident when the death is unanticipated? ?incidents that require the assistance of an outside agency such as police, fire, rescue, or emergency community service board contact.? 5. Staff #8 confirmed, resident?s #1 need for emergency services outside of the facility and the resident?s death was not reported to the regional licensing office within 24 hours of the incident.
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced renewal inspection took place on 04/16/2024 at 08:38 am until 05:15 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 84 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 5 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: Additional Comments/Discussion: Breakfast and an activity were observed. A medication pass observation was completed for four residents. The following was reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, medication carts, fire inspection report, health inspection report, and a staffing schedule. Water temperature was measured, and the call bell system was monitored. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov.
Based on the onsite record review, it was determined that the facility did not ensure the Individualized Service Plan be signed and dated by the licensee, administrator, designee, and by the resident or his legal representative. Evidence: 1. Resident?s #6 ISP
Based on the onsite record review, it was determined that the facility did not ensure that the Comprehensive Individualized Service Plan shall be completed within 30 days after admission; and include a description of identified needs and date identified based upon the UAI
Based on the onsite record review, it was determined that the facility did not ensure the resident had within the 30 days preceding admission, a physical examination by an independent physician. The report of such examination shall be on file at the assisted living facility and shall contain the following: the date of the physical examination; results of a risk assessment documenting the absence of tuberculosis; a statement that the individual does not have any of the conditions or care needs prohibited by 22VAC40-73-310-H. Evidence: 1. The record for resident #3, admission date, 06/29/23, contains a physical examination that does not include the date of the physical examination. 2. The record for resident #6, admission date 6/29/23, contains a risk assessment for TB dated 5/25/23. 3. Resident?s #6 physical examination includes a response of ?yes, requires continuous licensed nursing care.?
Based on the onsite record review, it was determined that the facility did not ensure that upon admission, the assisted living facility provide an orientation for new residents and their legal representatives. Evidence: 1. The record for resident #1 did not contain an orientation for new residents to include emergency response procedures, mealtimes, and use of the call system.
Based on the onsite record review, it was determined that the facility did not ensure medications shall be administered in accordance with the physician's or other prescriber?s instructions. Evidence: 1. Resident?s #7 physician order dated 12/05/23, and the medication administration record for April 2024 includes the following: ?Vitamin B1 50 mg, take 1 tablet by mouth every day.? During the medication pass observation, staff # 4 administered a Vitamin B1 100mg tablet to resident #7, however this is not the prescribed dosage according to the resident?s physician order. 2. Resident?s #7 physician order dated 03/23/23, and the medication administration record for April 2024 includes the following: ?Vitamin D3 1000IU, take 1 tablet daily.? During the medication pass observation, staff # 4 administered a Vitamin D3 5000IU to resident #7, however this is not the prescribed dosage according to the resident?s physician order.
Based on the onsite record review, it was determined that the facility did not ensure that prior to admission, whether a potential resident is a registered sex offender and document in the resident's record that this was ascertained and the date the information was obtained. Evidence: 1.The record for resident #1 did not include a Sex Offender registry check prior to admission. 2. The record for resident #2 did not include a Sex Offender registry check prior to admission.
Based on the onsite record review, it was determined that the facility did not ensure the Fall Risk Rating was reviewed and updated after a fall. Evidence: 1. The progress notes in the record for resident #1 documented falls that occurred on 12/15/23, 12/16/23, 12/18/23, 1/1/24, 1/8/24, 1/20/24, 1/25/24. There was no evidence of fall risk rating being completed after experiencing a fall. 2. The progress notes in the record for resident #2 documented falls that occurred on 3/9/24 and 3/15/24. There was no evidence of fall risk rating being completed after experiencing a fall. 3. The progress notes in the record for resident #4 documented falls that occurred on 11/3/23, 11/5/23, 11/26/23, 12/3/23. There was no evidence of fall risk rating being completed after experiencing a fall. 4. The progress notes in the record for resident #5 documented falls that occurred on 11/8/23 and 12/31/23. There was no evidence of fall risk rating being completed after experiencing a fall. 5. The progress notes in the record for resident #6 documented falls that occurred on 11/2/23, 11/18/23. There was no evidence of fall risk rating being completed after experiencing a fall.
Based on the record review the facility failed to ensure individualized service plans ( ISP
Based on a review of documentation and interview, it was determined that the facility did not ensure that an annual inspection is conducted by the appropriate fire official to comply with the Virginia Statewide Fire Prevention Code (13VAC5-51). Evidence: 1. The most recent fire inspection completed at the facility was dated 3/10/23. 2. Staff #6 confirmed that the annual fire inspection had not been completed.
Based on observation, it was determined that the facility did not ensure that medications shall be stored in a manner consistent with current standards of practice and the storage area shall be locked and the individual responsible for medication administration shall keep the keys to the storage area on his person. Evidence: 1. During a tour of the facility, the Licensing Inspectors observed that the medication cart located on the second floor was unlocked and unstaffed. 2. Staff #6 acknowledged that the medication cart on the second floor was unlocked and unstaffed.
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced complaint inspection took place on 12/14/2023 from 10:21 am to 2:38 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 11/27/23 and 11/28/23 regarding allegations in the area(s) of: Resident Care and Related Services, Building and Grounds, and The Safe Secure Environment Number of residents present at the facility at the beginning of the inspection: 80 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 3 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: An observation and review of the safe secure unit, round logs, staffing schedule, and the medication cart was completed. Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegation?s area(s) of non-compliance with standard(s) or law were: Resident Care and Related Services A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Based on the record review the facility failed to ensure when hospice care is provided to a resident, the assisted living facility and the hospice organization shall communicate and establish an agreed upon coordinated plan of care for the resident. The services provided by each shall be included on the individualized service plan ( ISP
Based on the record review the facility failed to implement a written plan for medication management to include methods to prevent the use of outdated, damaged, or contaminated medications. Evidence: 1. During the medication cart observation with staff #1 the following expired medication was observed on the medication cart located in the safe, secure unit: Senna Plus tablets, expired 09/07/23 for resident #1.
Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced monitoring inspection took place on 09/21/2023 from 8:50 am to 11:45 am The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A Self report was received by VDSS Division of Licensing on 08/27/2023 regarding allegations in the areas of: Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 84 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. 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: 6 Observations by licensing inspector: An observation of the safe secure unit was completed. Additional Comments/Discussion: None The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Donesia Peoples, Licensing Inspector at 757-822-9957 or by email at donesia.peoples@dss.virginia.gov
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