VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Charter Senior Living of Fredericksburg
20 Heartfields Lane
Fredericksburg, VA 22405
(540) 373-8800

Current Inspector: Sarah Pearson (540) 680-9469

Inspection Date: March 26, 2025 and March 27, 2025

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 3.2- (17) LICENSURE AND REGISTRATION PROCEDURES 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Technical Assistance:

N/A

Comments:

Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 3/26/2025 11:00 a.m. ? 5:20 p.m.; 3/27/2025 9:30 a.m. ? 6:00 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: 44 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: 3 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: Building and grounds, dining services, resident rooms, activities, resident council, and medication pass. Additional Comments/Discussion: N/A 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 Jeff Marnien, Licensing Inspector at (540) 571-0189 or by email at Jeffrey.marnien@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-50-A
Description:	Based on record review and staff interview, the facility failed to provide a disclosure statement with information that is accurate. Evidence: 1. During record review the LI observed the disclosure statement provided to resident 1 was incomplete. 2. On page 3 of the disclosure statement under section 5 General number, Position Types, and Qualifications of staff on each shift the number of direct care staff for the 7:00 a.m. ? 3:00 p.m. shift was blank. Also missing was information for the 3:00 p.m. ? 11:00 p.m. shift.
Plan of Correction:	The disclosure statement has been updated to reflect the position types, numbers and qualifications of staff on each shift. ED or designee will review periodically to make sure all elements of the disclosure are current in accordance with the regulations. The Executive Director will review the audit results and report findings to the Quality Assurance Committee at least quarterly.
Standard #:	22VAC40-73-640-A
Description:	Based on document review and staff interview, the facility failed to ensure the facilities medication management plan addressed methods to prevent outdated medications and the facilities standard dosing schedule. Evidence: 1. During the review of the facility's medication management plan (Policy No. Med-012, effective 11/2024), LI observed that the plan did not include procedures to prevent the use of outdated, damaged, or contaminated medications, nor did it address the facility's standard dosing schedule. 2. Staff 5 and Staff 6 confirmed, during interview with LI on 3/27/2025, those elements were missing from the facilities medication management plan.
Plan of Correction:	Medication management plan updated to include detailed procedures for preventing the use of outdated, damaged, or contaminated medications. HWD or designee will review the medication management plan periodically and make appropriate updates to ensure compliance with the regulations, The Executive Director will review the audit results and report findings to the Quality Assurance Committee at least quarterly.
Standard #:	22VAC40-73-640-D
Description:	Based on observation and staff interview, the facility failed to have readily accessible at least one pharmacy reference book, drug guide, or medication handbook for nurses that is no more than two years old as reference materials for staff who administer medications. Evidence: 1. During tour of the building on 3/26/2025 the LI requested staff 7, to provide the drug guide or medication handbook. 2. Staff 6 and staff 7 confirmed a drug guide or medication handbook could not be provided.
Plan of Correction:	The medication handbook that is no more than two years is readily accessible to the staff who administer medications. HWD or designee will review periodically to ensure the medication handbook that is no more than two years is readily accessible to the staff who administer medications. The Executive Director will review the audit results and report findings to the Quality Assurance Committee at least quarterly.
Standard #:	22VAC40-73-660-A
Description:	Based on observation and staff interview, the facility failed to ensure resident prescribed medications were stored in a medicine cabinet, container, or compartment when administered by the facility. Evidence: 1. During the medication pass at 10:00 a.m. on 3/27/2025 for resident 5, admitted 11/21/2023, Licensing Inspector (LI) observed Sarna Sensitive 1% lotion was not in the medication cart. 2. Staff 2, hired 10/25/2024, confirmed with LI the medication was not in the cart but was located in the resident?s bathroom.
Plan of Correction:	No negative outcome occurred to residents #5. The Health and Wellness Director (HWD) or designee did an audit of the medication cart to make sure all medications are properly stored in accordance with the state regulations. No other negative finding. HWD or designee will conduct medication audits monthly for the next 3 months. Issues Identified will be resolved and reported to the Executive Director (ED). The Executive Director will review the audit results and report findings to the Quality Assurance Committee at least quarterly.
Standard #:	22VAC40-73-680-C
Description:	Based on observation and staff interview, the facility failed to ensure medications were administered not earlier than one hour before and not later than one hour after the facility's standard dosing schedule. Evidence: 1. During the medication pass at 10:00 a.m. on 3/27/2025, LI observed that the acetaminophen 325 mg tablet, scheduled for 10:00 a.m. for resident 2, admitted 1/10/2028, admitted, was administered at 11:13 a.m. 2. Staff 2, hired 10/25/2024, confirmed with LI that the medication was administered more than one hour after the standard dosing schedule.
Plan of Correction:	No negative outcome to resident #2. The Health and Wellness Director (HWD) or designee provided education to the medication technicians and nurses on timely and safe medication administration on 3/28 and during their departmental meeting on 4/28 HWD or designee will conduct medication administration record audit weekly for the next three months The Executive Director will review the POC and the results of the audit with the Department Heads. Additional improvement plans will be developed and implemented as necessary, including training to correct any deficient practices.
Standard #:	22VAC40-73-680-K
Description:	Based on record review and staff interview, the facility failed to ensure when a medication is ordered for as needed (PRN) use and administered by registered medication aides that the physician order is a detailed order that includes directions as to what to do if symptoms persist. Evidence: 1. LI observed resident 2, admitted 1/10/2028, PRN orders did not include physician instructions what to do if symptoms persist. 2. Staff 7, hired 7/24/2024, confirmed during interview with LI on 3/27/2025, that all PRN orders for resident 2 did not include instructions what to do if symptoms persist.
Plan of Correction:	No negative outcome to resident #2. The Health and Wellness Director (HWD) or designee conducted an audit of the PRN medication orders. Negative findings were resolved. HWD or designee will ensure all PRN medication orders include instructions on what to do if symptoms persist. HWD or designee will audit at least 10% of resident files monthly for a period of six months to ensure compliance in accordance with the regulation. The Executive Director will review the audit results and report the findings to the Quality Assurance Committee at least quarterly.
Standard #:	22VAC40-73-680-M
Description:	Based on observation and staff interview, the facility failed to ensure medications ordered for PRN administration shall be available, properly labeled for the specific resident, and properly stored at the facility. Evidence: 1. During a medication cart audit in the memory care unit on 3/27/2025, the LI and staff 2 observed nitroglycerin .4 mg, prescribed 2/27/2024, was missing for resident 5, admitted 3/17/2025. 2. Staff 2 assisting with the cart audit confirmed the medication missing from the medication cart.
Plan of Correction:	No negative outcome occurred to residents #5. The Health and Wellness Director (HWD) or designee did an audit of the medication cart to make sure all medications are properly labeled and stored in accordance with state regulations. No other negative finding. HWD or designee will conduct medication audits monthly for the next 3 months. Issues Identified will be resolved and reported to the Executive Director (ED). The Executive Director will review the audit results and report findings to the Quality Assurance Committee at least quarterly.
Standard #:	22VAC40-73-690-F
Description:	Based on observation and staff interview, the facility failed to ensure the medication review by the licensed health care professional certified the requirements outlined in this subsection were met. Evidence: 1. During record review the LI observed the medication reviews, dated 4/22/2024 and 10/23/2024, did not include a certification the criteria in this subsection were met. 2. LI reviewed the document with staff 5 on 3/26/2025 who confirmed the certification was not provided.
Plan of Correction:	The certification is included in the current pharmacy medication review completed on 4/15/25. HWD or designee will ensure the pharmacy medication review includes the certification as required by the regulations when it is completed by the pharmacist. The Executive Director will review the audit results and report findings to the Quality Assurance Committee at least quarterly.
Standard #:	22VAC40-73-980-A
Description:	Based on observation and staff interview, the facility failed to ensure a complete first aid kit shall be on hand in each building at the facility, located in a designated place that is easily accessible to staff. Evidence: 1. During tour of the building on 3/26/2025 the LI requested staff 7 to provide the first aid kit. 2. A first aid kit taken from behind the concierge desk was provided for review. Missing from the first aid kit were triangular bandages. 3. Staff 7 confirmed triangular bandages were missing from the first aid kit.
Plan of Correction:	The first aid kit for the building has been updated to include triangular bandages and made easily accessible to the staff. HWD or designee will conduct a monthly audit and complete the check list to ensure all the items are available in the kit in accordance with the regulations. The Executive Director will review the audit results and report findings to the Quality Assurance Committee at least quarterly.
Standard #:	22VAC40-73-980-C
Description:	Based on observation and staff interview, the facility failed to ensure first aid kits shall be checked at least monthly to ensure that all items are present. Evidence: 1. During tour of the building on 3/26/2025 the LI reviewed the facilities first aid kit. 2. The LI did not observe a completed monthly check ensuring all items are present. 3. Staff 7 confirmed the monthly check was not completed for the first aid kit.
Plan of Correction:	HWD or designee completed the checklist to ensure all the items are available in accordance with the state regulations. HWD or designee will conduct a monthly audit and complete the check list monthly to ensure all the items are available in the kit in accordance with the regulations. The Executive Director will review the audit results and report findings to the Quality Assurance Committee at least quarterly.