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: July 15, 2025

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-80 COMPLAINT INVESTIGATION

Technical Assistance:

N/A

Comments:

Type of inspection: Complaint Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 7/15/2025 2:45 P.M ? 4:30 P.M. 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 6/26/2025 regarding allegations in the area(s) of: resident care Number of residents present at the facility at the beginning of the inspection: 68 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: 3 Observations by licensing inspector: Building and grounds, activities, and dining services. Additional Comments/Discussion: n/a An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support 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 Jeff Marnien, Licensing Inspector at (540) 571-0189 or by email at Jeffrey.marnien@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-450-D
Complaint related:	No
Description:	Based on record review and staff interview, the facility failed to ensure when hospice care is provided to residents, the assisted living facility and the licensed hospice organization shall communicate and establish an agreed upon coordinated plan of care for residents and services provided by each shall be included in the individualized service plan. Evidence: 1. During document review on 7/15/2025, the Licensing Inspector (LI) observed that the individualized service plan (ISP), dated 4/4/2025, for resident 1 did not include the hospice services, started 3/17/2025, that were being provided. 2. Staff 1 was interviewed on 7/15/2025 and confirmed that hospice services were not on the ISP staff used to reference care needs of resident 1.
Plan of Correction:	The Health and Wellness Director (HWD) or designee conducted an audit of the Individualized Service Plan (ISP) to ensure that all residents receiving hospice care have an established coordinated plan of care included in their ISP in compliance with state regulations. Any negative findings were promptly corrected. HWD or designee will conduct ISP 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 POC and the results of the audit with the Department Head. Additional improvement plans will be developed and implemented as necessary, including training to correct any deficient practices.