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Public Google reviewers rate this highly and often mention compassionate and attentive care staff. Schedule a visit to confirm the fit.
based on 88 Google reviews
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Public Google reviewers rate Commonwealth Senior Llving at Churchland House highly. Reviewers highlight: compassionate and attentive care staff, strong and accessible leadership. Reviewer identity is not verified, and online reviews may not capture everything. Schedule a visit to assess the fit directly.
Families can expect a highly compassionate and professional care team, with many reviewers praising the leadership and the warm, family-like atmosphere. While the facility is generally noted for being clean and well-managed, there are critical reports regarding inconsistent hygiene care and maintenance issues that families should investigate.
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Key Review Excerpts
“The Resident Care Director came out, calmly reassured her, and gently guided her back to her room. The compassion in her voice and the way she treated that resident was genuinely moving.”
“I had concerns about my father's memory issues, but after speaking at length with the Executive Director, Luke Peterson, I felt much more confident about our decision.”
“My mom lived at Churchland House for over two years eventually transitioning into memory care. Our experience was excellent and the staff extremely kind and caring.”
Source: VA State Licensing Agency
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 01/21/2026 at 8:15 am to 4:10 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: 69 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:3 Number of interviews conducted with staff: 6 Observations by licensing inspector: Breakfast, lunch, and an activity were observed. The call signaling system was monitored. 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. 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 and staff interview the facility failed to ensure prior to a resident?s admission to a safe, secure environment, the resident shall have been assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare. Evidence: 1. Resident #1?s, (admitted to safe secure environment on 01/15/26) assessment for serious cognitive impairment dated 01/02/26 documents a response of ?No? for the question, Is the Individual named above unable to recognize danger or protect his/her own safety and welfare. 2. During an interview on 01/21/26 with staff #6, staff #6 confirmed resident #1?s assessment for serious cognitive impairment did not document the resident had an inability to recognize danger or protect her own safety prior to the resident?s admission to the safe secure environment on 01/15/26.
Based on observation and staff interview the facility failed to ensure all resident records shall be kept in a locked area. Evidence: 1. During a tour of the facility on 01/21/26 the Licensing Inspector (LI) observed resident records located in the lobby. The resident records were not in a locked area. 2. During an interview on 01/21/26 with staff #4, staff #4 observed the resident records and confirmed the resident records were not in a locked area.
Based on the observation of the water temperature, the facility failed to ensure hot water at taps available to residents shall be maintained within a range of 105?F to 120?F. Evidence: 1. The water temperature measured in resident #4?s restroom sink was measured to be 94?F. 2. Staff #5 confirmed the water temperature measured in resident #4?s restroom sink was measured to be 94?F.
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 08/14/25 from 9:15 am to 4:30 pm. 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 07/31/2025 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: 70 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: 2 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 5 Observations by licensing inspector: A review of the facility?s policy and procedures was completed. Residents were observed in the common areas. 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 allegations of non-compliance with standard(s) or law. However, violation(s) not related to the self-report 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 incident report review, resident record, and staff interviews, the facility failed to ensure care provision and service delivery shall be resident-centered to the maximum extent possible and include: Prompt response by staff to resident needs as reasonable to the circumstances. Evidence: 1. Resident #1?s incident report dated 07/31/25 documents the following incident: ? On 07/17/25 at 10:34 pm, ?while resident was being transferred from shower chair to wheelchair resident became weak unable to stand and was lowered to the floor by staff, who requested immediate assistance to transfer resident back to wheelchair and into bed. Resident did not complain of pain at this time.? ? On 07/22/25 at 10:30 am, ?x-ray was ordered per physician, resident sent to ER.? 2. The record for resident #1 contains the following: ? A progress note dated 07/18/25 stating the resident is complaining about her right leg and right hip hurting. An x-ray exam was completed on the resident. ? x-ray results sent to the facility on 7/18/25 at 22:47/10:47 pm documents ?Bones are osteoporotic. A right hip prosthesis is seen. A distal femoral nondisplaced oblique fracture is seen in the supracondylar region. Nondisplaced distal femoral supracondylar fracture.? 3. During an interview on 08/14/25 with staff #1, staff #1 confirmed resident #1?s x-ray results were sent to staff #1?s fax machine located in staff #1?s locked office however staff #1 was not working at the facility when the x-ray results were sent. Staff#1 did not read the results until 07/21/25 when staff #1 returned to the facility. Staff #1 confirmed the direct care staff was aware of resident #1?s completion of an x ray, but the direct care staff did not have access to the results. 4. Staff #1 confirmed resident #1?s physician order instructing the facility to send the resident to the emergency department (ED) was sent to the facility on 07/21/25 however staff #1 did not read the physician order until 07/22/25 and the resident was sent to the ED on 07/22/25 around 10:30 am. The resident did not receive treatment until the 4th day after the x ray results were completed. 5. The record for resident #1 contains hospital notes (page 5) dated 07/22/25 that document the following: ? ?right distal femur metaphysical comminuted closed fracture. Other fracture of right femur, initial encounter for closed fracture.? ? The patient was treated non operatively and was placed in a hinged knee brace locked in 30 degrees of flexion, The leg was wrapped in soft roll and an ace wrap to help protect the skin from the brace. The resident returned to the facility on 07/22/25.
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 08/14/25 from 9:15 am to 4:30 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 08/06/2025 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: 70 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 2 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: A review of the facility?s policy and procedures 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 allegations 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, medication administration 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 #1 contains the following: ? A physician note and hospital discharge summary signed and dated by the physician on 11/26/24 that includes instructions to take paroxetine 20 mg daily for major depressive disorder. ? a physician visit note dated 12/04/24 that includes instructions to take paroxetine 20mg, 1 tablet by mouth once a day ? a physician visit note dated 05/19/25 that includes instructions to take paroxetine 20mg, take 1 tablet by mouth every night at bedtime. 2. Resident #1?s November 2024, December 2024, January 2025, February 2025, March 2025, April 2025, May 2025, June 2025, and July 2025 Medication Administration Records ( MAR
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 01/14/2025 from 8:09 a.m. to 5:03 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: 74 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: A tour of the facility was conducted to include inside and outside building grounds. Breakfast, lunch, and activities 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. 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 observation 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 01/14/2025 at 8:09 am, the Licensing Inspector (LI) observed a posting of the Manager on Duty listed as staff #5 and the Shift Supervisor listed as staff #7. Staff #4 and staff #6 was not on site at the facility upon the LI arrival.
Based on the onsite record review the facility failed to ensure any person required to obtain a criminal history report shall be ineligible for employment if the report contains convictions of barrier crimes. Evidence: 1. Staff #4, date of hire 10/01/24, criminal record report contains two convictions for barrier crimes (18.2-57).
Based on the record review the facility failed to ensure a method of written communication shall be utilized as a means of keeping direct care staff on all shifts informed of significant happenings or problems experienced by resident, including complaints and incidents or injuries related to physical or mental conditions. The information shall be included in the records of the involved residents. Evidence: 1. The record for resident #1 contains the following progress notes: 11/09/24 ?resident did not return from hospital on 7-3 shift.? 11/09/24 ?resident is still in the hospital. Daughter called and said he would not be coming back today.? 11/10/24 ?resident returned home around 2:45 pm.? The resident?s record did not contain documentation of reason for the resident?s hospital visit to include problems experienced by resident, incidents, or injuries.
Based on the record review the facility failed to ensure the comprehensive individualized 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 10/22/24 from 9:14 am to 1:47 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 09/30/24 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: 70 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 2 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3 Observations by licensing inspector: A review of the facility?s policy and procedures 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 allegations 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 staff record review the facility failed to ensure direct care staff shall meet one of the requirements in this subsection. If the staff does not meet the requirement at the time of employment, he shall successfully meet one of the requirements in this subsection within two months of employment. Evidence: 1. The record for staff #1, hire date 5/07/24, did not contain documentation of staff #1 meeting one of the direct care staff qualifications. 2. The record for staff #1 contains a new hire form that documents staff #1?s job title as a personal care assistant (PCA). Staff #5 was unable to provide documentation staff #1 completed a personal care aide training program approved by the Virginia Department of Medical Assistance Services.
Based on the record review the facility failed to ensure the Uniform Assessment Instrument ( UAI
Based on the record review the facility failed to ensure for each resident with an inability to use the signaling device the following shall be met: the facility shall document the rounds that were made, which shall include the name of the resident, the date and time of the rounds, and the staff member who made the rounds. Evidence: 1. The record for resident #2 contains an 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 07/25/24 from 9:33 am to 12:45 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 07/01/2024 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: 65 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: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: A review of the facility?s policy and procedures was completed. 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 the facility failed to ensure the comprehensive individualized service plan ( ISP
Based on the record review the facility failed to ensure the Medication Administration Record ( MAR
Based on the record review the facility failed to implement a written plan for medication management to include: Methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes. Evidence: 1. The facility?s medication management plan includes the following: ?shift counts are performed at the end of each shift or when the person responsible for medication changes.? 2. The facility?s ?Narcotic Shift Count? form did not include staff signatures for both the off going and oncoming shifts for the following dates and shifts: 06/04/24, 3-11 Shift. 06/04/24, 11-7 shift. 06/07/24, 11-3 shift. 06/20/24, 3-11 shift. 06/22/24, 7-3 shift. 06/23/24, 7-3 shift. 07/14/24, 3-11 shift. 07/17/24, 7-3 shift.
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 02/08/24 from 8:05 a.m. to 6:21 p.m. 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: 69 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 4 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 6 Observations by licensing inspector: A tour of the facility was conducted to include inside and outside building grounds. Breakfast, lunch, and activities 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. 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 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 #1 contains a physician order dated 10/11/23 documenting the following instructions: ?Take blood pressure Q AM if systolic is less than 110 administer Midodrine 2.5mg.? Resident?s #1 record and the Jan. 2024 Medication administration record ( MAR
Based on the record review the facility failed to ensure at the time of discharge, the assisted living facility shall provide to the resident, and as appropriate, his legal guardian and designated contact person a dated statement signed by the licensee or administrator that contains the following statement: the actions taken by the facility to assist the resident in discharge and relocation process; the date of the actual discharge from the facility and the resident?s destination. Evidence: 1.Resident?s #7, discharge statement dated 09/20/23 did not include the following documentation: actions taken by the facility to assist the resident in discharge and relocation process and the resident?s destination.
Based on the record review the facility failed to ensure ISP
Based on the record review the facility failed to ensure an assisted living facility shall comply with the Virginia Statewide Fire Prevention Code (13VAC5-51) as determined by at least an annual inspection by the appropriate fire official. Evidence: 1. The facility?s record contains an annual fire inspection completed on 02/14/22. Staff # 6 acknowledged the facility?s record of the last fire inspection completed is dated 02/14/22 and the facility has no record of an annual fire inspection being completed for 2023.
Based on the record review the facility failed to ensure the comprehensive individualized care plan ( ISP
Based on the record review the facility failed to ensure the Uniform Assessment Instrument ( UAI
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 09/25/2023 from 9:16 am to 12:50 pm. 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 08/17/2023 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: 62 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: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 4 Observations by licensing inspector: A review of the staffing schedule, and daily shift communication log was completed. An observation of the safe secure environment 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 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
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