Commonwealth Senior Living at Kilmarnock

Based on a review of documentation and interviews, it was determined that the facility did not ensure that the resident?s Individualized Service Plan ( ISP

Based on a review of documentation and interviews, it was determined that the facility did not ensure the supervision of resident?s schedule, care and activities including attention to specialized needs, such as prevention of falls on the premises. Evidence: 1. During interviews on 3/12/26 staff #1 and staff #2 said that on 2/21/26, resident #1 was found on the floor of his apartment at approximately 8:55 am by staff #4. Resident #1 did have some bruises on his right side from the fall and was transported to the hospital. 2. Resident #1?s pendant report had no entries from resident #1?s room on 02/20/2026-02/21/2026 between the hours of 6:00pm to 7:00am. 3. Staff #1 and staff #2 stated during interviews on 3/12/26 that a review of facility camera footage of resident #1?s apartment from the 7pm-7am shift of 02/20/2026-02/21/2026, determined that resident #1 had not been monitored since receiving his evening medication at 7:14pm on 02/20/2026. 4. Staff #1 and staff #2 stated during interviews that based on their internal investigation, that included staff schedule and the staff monitoring check logs on the 7pm-7am shift on dates 02/20/2026-02/21/2026, it was determined that staff #5, staff #6, and staff #7 were working and forged their signatures on the rounds log and had not checked on the resident for more than 12 hours.

Based on a review of the facility?s policy and interviews, it was determined that the facility did not ensure that compliance with all regulations for licensed assisted living facilities and terms of the license issued by the department; with relevant federal, state and local laws; with other relevant regulations; and with the facility?s own policies and procedures in reference to wound and skin care. Evidence: 1. The facility?s Wound and Skin Care RC-12.071-(CL08) policy states on page 2 #5 Respond appropriately to wound or skin integrity issues: a. Whenever a Caregiver observes an area of concern on a resident?s skin (e.g., redness, wound, rash, swelling, bump, discoloration, etc.) and/or if the resident expresses any skin discomfort, the Caregiver is to note it on the Daily Shift to Shift Communication Log and report it to the Resident Care Director b. The Resident Care Director or designee will notify the physician and family immediately. 2. During interviews conducted on 1/6/26, staff #1 and staff # 2 reported that resident #1 fell while at the facility on 12/12/25 at 6:15pm and EMS was called to the facility at 7:03pm, but resident #1 was not transported to the local hospital. During an interview on 1/6/26, staff #1 stated she called the physician for resident #1 on 12/13/26 at 1:16pm, which was not immediately as required by the facility?s policy. 3. The facility?s Wound and Skin Care RC-12.071-(CL08) policy #7 states that when a resident has a wound or skin integrity issue the Community nurse or designee will meet with the resident, complete the Skin Integrity Monitoring form and document in the resident?s electronic health record (EHR) 4. The record for resident #1 did not contain a Skin Integrity Monitoring Form. 5. During an interview on 1/6/26, staff #2 confirmed that the facility did not follow the facility?s policies for Wound and Skin Care for the fall of resident #1 on 12/12/25.

Based on a review of documentation and interviews, it was determined that the facility did not ensure 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. Based on a complaint received on 12/29/25 by the Licensing Regional Office and interviews conducted on 1/6/26 resident #1 fell at the facility on 12/12/25, at approximately 6:15pm. The fall resulted in skin tears on both hands of resident #1. EMS was called after the fall at 7:03pm and assessed resident #1. EMS determined that resident #1 did not need to go to the hospital as the injury had been treated appropriately. EMS was called back to the facility on 12/14/25 at approximately 1:18pm due to the wound on the left hand of resident #1 needing treatment because resident #1 was picking at the wound which resulted from the fall on 12/12/25. 2. During an interview on 1/6/26, staff # 2 confirmed that an incident report was not sent to VDSS Central Regional Licensing Office Inspector in reference to the incident involving resident #1 within 24 hours.

Based on a review of documentation and interviews, it was determined that the facility did not ensure to submit a written report of each incident specified in subsection A of this section to the regional licensing office within seven days from the date of the incident. Evidence 1. Based on interviews conducted on 1/6/26 resident #1 fell at the facility on 12/12/25, at approximately 6:15pm. The fall resulted in skin tears on both hands of resident #1. EMS was called after the fall at 7:03pm and assessed resident #1. EMS determined that resident #1 did not need to go to the hospital as the injury had been treated appropriately. EMS was called back to the facility on 12/14/25 at approximately 1:18pm due to the wound on the left hand of resident #1 needing treatment because resident #1 was picking at the wound which resulted from the fall on 12/12/25. 2. During an interview on 1/6/26, staff # 1 confirmed that a written report was not submitted to VDSS Central Regional Licensing Office in reference to the incident involving resident #1 within seven days from the date of the incident.

Based on the review of the documentation and interviews, it was determined that the facility did not ensure that the facility shall regularly observe each resident for changes in physical, and that the facility shall provide appropriate assistance when observation reveals unmet needs. Evidence: 1. During an interview on 1/6/26, staff #1 stated that on 12/14/25 she provided treatment to resident #1 for the wound that had resulted from a fall on 12/12/25. Staff #1 reported that resident #1 had been picking at the wound on her left hand. The treatment provided by staff #1 for resident #1 included using clear adhesive tape to close the skin tear and then wrapping in gauze. 2. During interviews on 1/6/26, staff #1 confirmed that on 12/14/25 she used adhesive medical tape on resident #1?s left hand to close the wound prior to EMS transport to Emergency Room because she did not have any sutures. (Picture #1)

Based on a review of resident records and interviews, it was determined that the facility did not ensure medical procedures or treatments ordered by a physician or other prescriber shall be provided according to his instructions and documented. The document shall be maintained in the resident?s record. Evidence: 1. Resident #1 was transported by EMS to the local hospital on 12/14/25 due to requiring care for the skin tears on both hands that resulted from a fall on 12/12/25 at the facility. 2. The record for resident #1?s file did not have documentation for the discharge summary/treatment from the Emergency Room visit on 12/14/2025 to address the wounds. 3. Staff #1 confirmed that the facility did not receive an Emergency Room discharge/treatment plan for resident #1 from the Emergency Room visit on 12/14/2025.

Based on the review of staff records, the facility did not ensure that the annual required staff tuberculosis risk assessment, documenting that staff is free of tuberculosis was not present in staff records. Evidence: 1) The record for staff #3 did not contain an annual tuberculosis risk assessment. The last tuberculosis risk assessment was dated 08/13/2024. 2) The record for staff #4 did not contain an annual tuberculosis risk assessment. The last tuberculosis risk assessment was dated 09/11/2024. 3) Staff #2 confirmed that the records for staff #3 and staff #4 did not have an annual tuberculosis risk assessment on file.

Based on a review of the resident records, the facility did not ensure that prior to or at admission, there shall be a written assurance to the resident that the facility has the appropriate license to meet the resident?s care needs at the time of admission. Copies of the written assurance shall be given to the legal representative/resident and a copy signed by the legal representative/resident shall be kept in the resident?s record. Evidence: 1) The records for resident #1 and resident #3 did not contain a copy of the signed written assurance. 2) Staff #2 confirmed that there was not a copy of the written assurance in the records of resident #1 and resident #3.

Based on review of resident records, the facility did not ensure that a resident, prior to admission, whether a potential resident, who will have a stay longer than 3 days, is a registered sex offender and documented in the resident record that this was ascertained and the date of the information obtained. Evidence: 1) The record for resident #3 did not contain a sex offender screening by Virginia State Police. 2) Staff #2 confirmed that there was not a sex offender screening by Virginia State Police in the record for resident #3.

Based on a review of the resident records, the facility did not ensure that prior to or at the time of admission that there be a written agreement or acknowledgement of notification dated and signed by the resident or applicant for admission or the appropriate legal representative and by the licensee or administrator. Evidence: 1) The record for resident #1 did not contain a copy of a written agreement. 2) Staff #2 confirmed that there was not a copy of a written agreement in the record of resident #1

Based on the review of resident records, the facility did not ensure that an annual Uniform Assessment Instrument ( UAI

Based on a review of resident records, the facility did not ensure that residents Individualized Service Plan ( ISP

Based on a review of the facility?s records, the facility did not comply with the Virginia Statewide Fire Prevention Code (13VAC5-51) as determined by at least an annual fire inspection by the appropriate fire official. Evidence: 1) The previous fire inspection dated for 09/03/2024. 2) Staff #2 confirmed that an annual fire inspection had not been completed since 09/03/2024.

Based on a staff interview, the facility did not ensure that the onsite emergency generator and its capacity to provide sufficient power for the operation of lighting, ventilation, temperature control, supplied oxygen and refrigeration. Evidence: 1) Staff #2 confirmed that the facility?s generator was not operational at the time of the onsite inspection.

Based on a review of facility?s records the facility did not ensure that fire and emergency evacuation drill frequency and participation shall be in accordance with the current edition of the Virginia Statewide Fire Prevention Code (13VAC5-51) The drills required for each shift in a quarter shall not be conducted in the same month. Evidence: 2) The last fire and emergency evacuation drill frequency was dated 7/22/2025. There were no fire and emergency evacuation drills were noted prior to 7/22/2025. 3) Staff #2 confirmed that the most recent fire and emergency evacuation drill frequency and participation was completed on 7/22/2025 and that there were no known quarterly drills completed prior to 7/22/2025.

Based on a review of the facility?s records, the facility did not ensure that a record of the required fire and emergency drills shall be kept at the facility for two years. Evidence: 1) The last date on record for fire and emergency drills was dated 7/22/2025. 2) Staff #2 confirmed that there were no prior fire and emergency drills that were completed in 2023 on record at the on-site inspection.

Based on a review of the facility?s records, the facility did not ensure that at least once every six months, all staff currently on duty on each shift shall participate in an exercise in which the procedures for resident emergencies are practiced. Documentation of each exercise shall be maintained in the facility for at least two years. Evidence: 1) There was no date on record for six-month practice plan for resident emergencies. 2) Staff #2 confirmed that there was no date on record and documented for six-month practice plan for resident emergencies

Based on a review of documentation and interviews, it was determined that the facility failed to ensure compliance with all regulations for licensed assisted living facilities and terms of the license issued by the department with relevant federal, state and local laws; with other relevant regulations; and with the facility?s own policies and procedures. Evidence: 1. The facility?s policy for Medical Emergencies on page 4 states that in case of a medical emergency that could result in death, serious medical impairment or disability to a resident, the local Emergency Medical Services (EMS) system shall be activated by calling 911 immediately and the staff follow the direction of the 911 dispatcher. Chest Pain a. Signs and symptoms of a medical emergency include but not limited to #vi. Shortness of Breath. 2. Based on interviews on 8/19/25 with staff #2, staff #3, and staff #7, all staff confirmed that on 8/10/25, staff # 1 first noticed that resident #1 had difficulty breathing at approximately 6:30am. Staff #2, staff #5, and staff #6 all entered the room of resident #1 and witnessed her having difficulty breathing on the morning of 8/10/25. No facility staff called 911 until approximately 9:04 am after resident #1 stopped breathing. 3. During an interview on 8/19/25 staff #3 confirmed that the facility did not follow their own policies and procedures for Medical Emergencies.

Based on a review of documentation and interviews, it was determined that the facility failed to ensure that each facility shall 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. Based on a report from the local law enforcement agency, on 8/10/25 resident #1 stopped breathing and EMS was contacted. Staff initiated CPR until EMS arrived. Resident # 1 was declared dead by EMS at 9:27am. 2. The facility did not make a report of this incident within 24 hours to the regional licensing office. The first report of this incident was received by the Licensing Inspector on 8/14/25 at 11:08am. 3. During an interview on 8/19/25, staff #3 confirmed that an incident report about the death of resident #1 was not made to the Regional Licensing Office with 24 hours of the incident.

Based on a review of documentation and interviews, it was determined the facility failed the general responsibility for the health, safety and well-being of the residents. Evidence: 1) A complaint was received from the local law enforcement agency on 8/14/25 reporting that resident #1 expired at the facility on 8/10/25. 2) During interviews with staff #2, staff #3, and staff #7 on 8/19/25, it was stated that staff # 1 entered the room of resident #1 and observed that resident #1 was having difficulty breathing at approximately 6:30am. Staff #1 notified staff #6 about resident #1 having difficulty breathing. Staff #6 notified staff #5 about resident #1 having difficulty breathing at 7:15am. Staff #5 notified staff #4 when resident #1 stopped breathing at 8:59 am. 3) Based on interviews with staff #3, resident #1 was still having difficulty breathing when staff #6 entered the room at 7:05am, when staff #5 entered at 7:15am, and when staff #2 and staff #6 entered the room at 8:35 am. When staff #2 and staff #5 entered the room at 8.59am, they noticed resident #1 was not breathing. Staff #5 then called staff #4 (Resident Care Director) and was instructed to call 911 and start CPR at 9:04 am since the resident was full code. 4) Based on interviews with staff #3 on 8/10/25, staff #3 stated that staff #5 called 911 at 9:04am and then staff #2 and staff #5 started CPR until EMS arrived at 9:22am. 5) Staff #2 said during an interview on 8/19/25 that resident #1 was declared deceased by EMS at 9:27am on 8/10/25. 6) During an interview on 8/19/25 staff #3 confirmed that staff failed to provide life saving measures to protect the health, safety and well-being of resident #1 until resident #1 stopped breathing at which point 911 was called.

Based on a review of the resident #1?s record and interviews, it was determined that the facility failed to regularly observe resident for changes in physical, mental, emotional and social functioning. Evidence: 1) In a review of the record for resident #1(date of admission 3/28/24, weight was 101 lbs.), resident #1?s weight was 109 lbs. on 1/16/25 and 105.6 lbs. on 2/5/25. There was no documented weight for March 2025 and for April 2025. Resident #1 had a documented weight of 85lbs on 5/2/2025. There was no documented weight noted in the record for June 2025. Resident #1 had a documented weight of 85 lbs. on 7/3/2025. At the time of her death, her weight was documented at 88 lbs. on 8/10/2025. 2) In the record for resident #1 there was no mention of the loss of weight and no physician?s order to address the weight loss. 3) The record for resident #1 noted that resident #1?s most recent examination by the facility physician occurred on 5/27/2025. In the visit notes from the examination on 5/27/25, the weight for resident #1 was not listed. There was no mention of the loss of weight by resident #1 in the visit notes. 4) There was a physician?s order for resident #1 to be referred for Hospice care on 7/17/25, but still no physician?s orders to address the loss of weight by resident #1.

Based on a review of documentation and interviews, it was determined the facility failed to implement interventions as soon as a nutritional problem is suspected. Evidence: 1) In a review of resident #1?s record, there was no documentation of any interventions implemented due to the weight loss of resident #1, or that the physician was contacted. 2) Resident #1 weighed 105 lbs. on 2/5/25. There was no documented weight noted for March 2025 and for April 2025. Resident #1 weighed 85 lbs. on 5/2/25. The weight for resident #1 dropped by 20 percent within three months. 3) Staff #3 was asked to provide documentation to demonstrate that interventions were put in place for the weight loss of resident #1 but was unable to provide any documentation to demonstrate any interventions were implemented.

Based on a review of resident records, it was determined that the facility did not ensure that the facility shall document that the order of priority specified in subsection A of this section was followed, and the documentation shall be retained in the resident?s file. Evidence: 1. The Order of Priority list contained in the record for resident #5 only had the physician?s signature, and no indication was documented as to why approval was not completed by the resident, a guardian or a relative. 2. Staff #5 reviewed the record for resident #5, and was unable to provide documentation during the onsite inspection that the Order of Priority was followed and documented.

Based on a review of resident records and interview, it was determined that the facility did not ensure that individualized service plans shall be reviewed and updated at least once every 12 months and as needed for a significant change of resident?s condition. Evidence: 1. The most recent Individualized Service Plan ( ISP

Based on a review of resident records and interview, it was determined that the facility did not ensure a valid indication of Do Not Resuscitate Order (DNR) for withholding cardiopulmonary for a resident in the event of cardiac or respiratory arrest in the resident?s Individualized Service Plan ( ISP

Based on a review of documentation and interview, it was determined that the facility did not ensure that an assisted living facility shall comply with the Virginia Statewide Fire Prevention Code (13VA5-51) as determined by at least an annual inspection by the appropriate fire official. Evidence: 1. There was no documentation available for viewing during the onsite inspection of a current fire inspection. 2. Staff #6 confirmed that contact has been made with the fire department in which the facility was informed that there is a staffing issue and inspection would be completed, however, a date was not as to when that would be.

Based on a review of emergency evacuation drill log and interview, it was determined that fire and emergency evacuation drill frequency and participation shall be in accordance with the current edition of the Virginia Statewide Fire Prevention Code (13VAC5-51). Evidence: 1. The last documented emergency evacuation drill was completed on 5/30/24. 2. Staff #4 confirmed that the facility?s last drill took place on 05/30/2024 and prior to this date, the last drill took place during May 2023.