Inspection Reports for
Chantilly Lace Manor

The facility was generally well maintained with appropriate physical plant conditions and resident accommodations. However, deficiencies were cited related to emergency preparedness, medication record accuracy, staff health screenings, and staff certifications.

The visit was triggered by a complaint investigation (56-AS-20251008092142). Staff stated they did not have access to resident files requested by Licensing Program Analysts.

A Type B deficiency was cited for failure to provide access to resident records, including admission agreements, physician's reports, and resident registry, which poses a potential health, safety, and personal rights risk to persons in care.

The visit was triggered by complaint investigation number 56-AS-20251008092142. Staff stated they did not have access to resident files requested by licensing analysts. A deficiency was cited accordingly.

The facility was cited for a Type B deficiency due to staff not having access to resident files containing admission agreements, physician's reports, and resident registry during the visit, posing a potential health, safety, and personal rights risk to persons in care.

Several deficiencies cited on 02/12/2025 remained uncorrected, including failure to provide a statement of understanding of regulation, missing signed admission agreement for resident #1, storage of supplies in a resident's private bathroom closet, and presence of surveillance cameras in all residents' bedrooms. Civil penalties of $3600 were assessed for failure to correct deficiencies by the due date.

The inspection found multiple deficiencies including failure to maintain medication administration logs, incomplete physical health records for staff, improper storage of facility supplies in a resident's closet, missing signatures on resident admission agreements, and presence of cameras in resident bedrooms, all posing potential health, safety, or personal rights risks.

The facility was found to be operating within its approved capacity and in generally safe and clean conditions. However, multiple deficiencies were cited related to incomplete Infection Control Plan, storage of expired and altered label medications, failure to maintain PRN medication logs, and an incomplete Emergency Disaster Plan.

The complaint investigation was initiated based on allegations that facility staff did not seek timely medical attention for a resident and did not dispense medications as prescribed. The first allegation was unsubstantiated; the second was substantiated.

The allegation regarding failure to seek timely medical attention was unsubstantiated as evidence showed the resident was taken to the hospital the same day. The allegation regarding medication dispensing was substantiated, with three residents' medications not listed on the centralized record and two medications appearing to have been administered, posing a potential health and safety risk.

The complaint investigation was based on allegations of uncleared staff working at the facility, inadequate staff training, and incomplete staff records. The first two allegations were found unsubstantiated, while the third was substantiated due to missing CPR training and TB test documentation for employees.

The investigation found the allegations regarding uncleared staff and inadequate training to be unsubstantiated, but substantiated that the facility staff records were incomplete, specifically lacking proof of CPR training and tuberculosis tests for employees.