Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 1
Sep 15, 2025
Visit Reason
An unannounced complaint inspection was conducted following a complaint received on 2025-09-11 regarding allegations related to Personnel and Resident Care and Related Services.
Findings
The investigation did not substantiate the complaint allegations of non-compliance; however, violations unrelated to the complaint were identified, specifically failure to report suspected abuse by mandated reporters as required by Virginia Code.
Complaint Details
Complaint was received on 2025-09-11 regarding allegations in Personnel and Resident Care. The evidence did not support the allegation of non-compliance with standards or law. The violation found was not related to the complaint but identified during the investigation.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure all mandated reporters reported suspected abuse, neglect, or exploitation of residents in accordance with 63.2-1606 of the Code of Virginia. |
Report Facts
Number of residents present: 81
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of staff interviews conducted: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donesia Peoples | Licensing Inspector | Inspector conducting the complaint investigation |
| Staff #4 | Staff member involved in physical assault allegations and no longer employed with the facility |
Inspection Report
Renewal
Census: 83
Deficiencies: 6
Apr 3, 2025
Visit Reason
An announced renewal inspection was conducted on April 3, 2025, to assess compliance with applicable standards and regulations for the assisted living facility.
Findings
The inspection identified multiple violations including failure to post the current person in charge conspicuously, incomplete resident orientation documentation, delays in completing individualized service plans, deficiencies in medication management and administration, and incomplete records of fire and emergency evacuation drills.
Deficiencies (6)
| Description |
|---|
| Facility failed to develop and implement a procedure for posting the name of the current on-site person in charge conspicuously. |
| Facility failed to provide orientation to new residents and their legal guardians upon admission including emergency procedures and call system use. |
| Comprehensive individualized service plans (ISP) were not completed within 30 days after admission and did not reflect all identified needs. |
| Facility failed to implement a written medication management plan ensuring timely refills to avoid missed dosages. |
| Medications were not administered according to physician orders; resident did not receive prescribed medications as documented. |
| Facility failed to keep complete records of required fire and emergency evacuation drills including date and time for two years. |
Report Facts
Number of residents present: 83
Number of resident records reviewed: 6
Number of staff records reviewed: 3
Number of resident interviews conducted: 2
Number of staff interviews conducted: 3
Missed medication dosages: 3
Missed medication administration days: 8
Fire drill dates missing times: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donesia Peoples | Licensing Inspector | Conducted the inspection and documented findings |
| Staff #2 | Acknowledged missed medication dosages and inability to explain documentation discrepancies | |
| Staff #4 | Acknowledged incorrect documentation of resident medication administration and fire drill record deficiencies |
Inspection Report
Complaint Investigation
Census: 77
Deficiencies: 3
Sep 9, 2024
Visit Reason
An unannounced complaint inspection was conducted on September 9 and September 26, 2024, following a complaint received on September 6, 2024, regarding allegations in the areas of Personnel and Resident Care and Related Services.
Findings
The investigation supported some but not all allegations of non-compliance related to Resident Care and Related Services. Violations were found including failure to report a major incident within 24 hours, failure to implement a proper medication management plan, and failure to ensure medical procedures were provided according to physician orders.
Complaint Details
Complaint investigation was triggered by allegations received on 2024-09-06 regarding Personnel and Resident Care. The investigation substantiated some allegations related to Resident Care and Related Services.
Deficiencies (3)
| Description |
|---|
| Facility failed to report to the regional licensing office within 24 hours any major incident that negatively affected or threatened the life, health, safety, or welfare of a resident. |
| Facility failed to implement a written plan for medication management including proper disposal of medication. |
| Facility failed to ensure medical procedures or treatment ordered by a physician were provided according to instructions and documentation. |
Report Facts
Residents present: 77
Resident records reviewed: 1
Staff records reviewed: 4
Staff interviews conducted: 5
Inspection dates: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donesia Peoples | Licensing Inspector | Current inspector conducting the complaint investigation |
| Staff #1 | Interviewed staff involved in medication management and record review | |
| Staff #5 | Interviewed staff who responded to emergency call and confirmed medication issues | |
| Staff #8 | Confirmed failure to report resident emergency and death within 24 hours | |
| Executive Director | Person responsible for corrective actions and notification | |
| Resident Care Director | Person responsible for medication cart audits and corrective actions |
Inspection Report
Renewal
Census: 84
Deficiencies: 10
Apr 16, 2024
Visit Reason
An unannounced renewal inspection was conducted to assess compliance with applicable standards and regulations for the facility's license renewal.
Findings
The inspection identified multiple violations related to resident physical examinations, fall risk assessments, sex offender registry checks, resident orientation, individualized service plans, medication storage and administration, and fire inspection compliance. Plans of correction were proposed for each deficiency.
Deficiencies (10)
| Description |
|---|
| Facility did not ensure residents had a physical examination by an independent physician within 30 days preceding admission, with required documentation missing or incomplete. |
| Facility did not ensure Fall Risk Ratings were reviewed and updated after residents experienced falls. |
| Facility did not ensure prior to admission that potential residents were checked against the Sex Offender registry and documented accordingly. |
| Facility did not provide orientation for new residents and their legal representatives upon admission. |
| Comprehensive Individualized Service Plans were not completed within 30 days after admission and did not include all required information. |
| Individualized Service Plans were not signed and dated by required parties including the resident or legal representative. |
| Individualized Service Plans were not reviewed and updated at least annually or as needed for significant changes in resident condition. |
| Medications were not stored securely; medication cart was found unlocked and unstaffed. |
| Medications were not administered according to physician orders; incorrect dosages were given during medication pass observation. |
| Facility did not ensure an annual fire inspection was conducted by the appropriate fire official as required. |
Report Facts
Number of residents present: 84
Number of resident records reviewed: 10
Number of staff records reviewed: 5
Number of resident interviews: 2
Number of staff interviews: 3
Dates of documented falls for resident #1: 7
Dates of documented falls for resident #2: 2
Dates of documented falls for resident #4: 4
Dates of documented falls for resident #5: 2
Dates of documented falls for resident #6: 2
Date of last fire inspection: 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donesia Peoples | Licensing Inspector | Conducted the inspection and is the contact for questions |
| Staff #6 | Acknowledged medication cart was unlocked and unstaffed; confirmed annual fire inspection had not been completed | |
| Staff #4 | Observed administering incorrect medication dosages during medication pass |
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 2
Dec 14, 2023
Visit Reason
An unannounced complaint inspection was conducted due to complaints received by VDSS Division of Licensing on 11/27/23 and 11/28/23 regarding allegations in Resident Care and Related Services, Building and Grounds, and The Safe Secure Environment.
Findings
The investigation supported some but not all allegations of non-compliance related to Resident Care and Related Services. Violations were found including failure to coordinate hospice care plans and failure to implement a written medication management plan to prevent use of expired medications.
Complaint Details
Complaint related: Yes. The complaint was substantiated in part regarding Resident Care and Related Services. The complaint involved failure to coordinate hospice care and medication management issues.
Deficiencies (2)
| Description |
|---|
| Failed to ensure coordinated hospice care plan including hospice services in the individualized service plan (ISP) for resident #2. |
| Failed to implement a written medication management plan to prevent use of outdated, damaged, or contaminated medications; expired medication found on medication cart for resident #1. |
Report Facts
Number of residents present: 80
Number of resident records reviewed: 3
Number of staff records reviewed: 3
Number of staff interviews conducted: 2
Expired medication date: Sep 7, 2023
Hospice aide order date range: Hospice aide order dated 05/02/23 to 07/30/23 for resident #2
Inspection Report
Monitoring
Census: 84
Deficiencies: 0
Sep 21, 2023
Visit Reason
An unannounced monitoring inspection was conducted following a self-report received regarding allegations in the area of Resident Care and Related Services.
Findings
The evidence gathered during the investigation did not support the allegation of non-compliance with standards or law. The licensing inspector completed a tour of the physical plant and observed the safe secure unit.
Report Facts
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: 6
Inspection Report
Complaint Investigation
Census: 79
Deficiencies: 0
Aug 24, 2023
Visit Reason
An unannounced complaint inspection was conducted due to allegations received on 08/21/2023 regarding personnel and resident care and related services.
Findings
The investigation did not support the allegation of non-compliance with standards or law. The inspection included a tour of the physical plant, medication pass observation, and review of medication carts.
Complaint Details
Complaint was received by VDSS Division of Licensing on 08/21/2023 regarding allegations in the areas of Personnel and Resident Care and Related Services. The evidence gathered did not support the allegation of non-compliance.
Report Facts
Number of residents present: 79
Number of staff records reviewed: 3
Number of interviews conducted with residents: 4
Number of interviews conducted with staff: 3
Inspection duration (minutes): 77
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donesia Peoples | Licensing Inspector | Named as the current inspector conducting the complaint investigation |
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 4
Jul 20, 2023
Visit Reason
An unannounced complaint inspection was conducted due to allegations received on 07/06/2023 and 07/11/2023 regarding Resident Care and Related Services and The Safe Secure Unit.
Findings
The investigation supported some but not all allegations of non-compliance related to Resident Care and Related Services. Several violations were identified including failure to complete Uniform Assessment Instrument prior to admission, failure to develop a preliminary plan of care within required timeframe, failure to implement a written medication management plan for controlled substances, and failure to administer medications according to physician orders.
Complaint Details
Complaint investigation was triggered by allegations received on 07/06/2023 and 07/11/2023. The evidence supported some but not all allegations related to Resident Care and Related Services. A violation notice was issued.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure the Uniform Assessment Instrument (UAI) was completed prior to admission for resident #2. |
| Facility failed to ensure a preliminary plan of care was developed on or within seven days prior to admission for resident #2. |
| Facility failed to implement a written plan for medication management to ensure accurate counts of controlled substances during staff changes. |
| Facility failed to ensure medications were administered in accordance with physician's instructions for resident #1. |
Report Facts
Residents present: 81
Resident records reviewed: 5
Staff records reviewed: 3
Resident interviews conducted: 2
Staff interviews conducted: 2
Controlled substance count missing signatures: 7
Medication administration errors: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donesia Peoples | Licensing Inspector | Conducted the inspection and is the contact for questions |
| Staff #4 | Acknowledged missing Uniform Assessment Instrument for resident #2 | |
| Staff #2 | Acknowledged missing preliminary plan of care or individualized service plan for resident #2 | |
| Resident Care Director | Named in plan of correction and oversight of medication management and care plans | |
| Executive Director | Named in plan of correction and oversight of care plans and medication administration | |
| Assistant Resident Care Director | Named in plan of correction related to medication administration |
Inspection Report
Monitoring
Census: 79
Deficiencies: 1
Jun 13, 2023
Visit Reason
An unannounced monitoring inspection was conducted to review compliance with regulations following a self-reported incident regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation supported the self-report of non-compliance with standards related to resident safety and well-being, resulting in violations being issued. The facility failed to assume general responsibility for the health, safety, and well-being of residents, particularly related to aggressive behaviors among residents.
Deficiencies (1)
| Description |
|---|
| The facility failed to assume general responsibility for the health, safety, and well-being of the residents, evidenced by multiple incidents of resident aggression and injury. |
Report Facts
Number of residents present: 79
Number of resident records reviewed: 3
Number of staff records reviewed: 2
Number of resident interviews: 1
Number of staff interviews: 1
Inspection Report
Renewal
Census: 75
Deficiencies: 16
Apr 18, 2023
Visit Reason
An announced renewal inspection was conducted on April 18 and 19, 2023 to assess compliance with applicable standards and regulations for the assisted living facility.
Findings
The inspection identified multiple areas of non-compliance including failure to conduct required resident reviews, incomplete staff training and certification documentation, medication management deficiencies including expired medications and inaccurate controlled substance counts, incomplete individualized service plans, and missing documentation such as discharge statements and DNR orders. Plans of correction were proposed for all deficiencies.
Deficiencies (16)
| Description |
|---|
| Failure to ensure six-month and annual reviews of residents' appropriateness for continued residence in the safe, secure unit. |
| Failure to ensure required staff training within the first seven working days of employment. |
| Failure to obtain required certification documentation for direct care staff. |
| Failure to complete annual TB risk assessments for residents. |
| Failure to provide dated discharge statements for discharged residents. |
| Failure to develop preliminary plans of care on or within 7 days prior to admission, and missing required signatures. |
| Failure to complete comprehensive individualized service plans within 30 days after admission including accurate documentation of resident needs. |
| Failure to include hospice care services in individualized service plans. |
| Failure to ensure individualized service plans are signed and dated by residents or legal guardians. |
| Failure to implement a written medication management plan to prevent use of outdated medications and ensure accurate controlled substance counts. |
| Failure to ensure medication storage areas are locked and medications are stored properly. |
| Failure to ensure medication administrators are licensed or registered as required. |
| Failure to document medical procedures or treatments ordered by physicians as instructed. |
| Failure to ensure over-the-counter medications remain in original labeled containers until administered. |
| Failure to include Do Not Resuscitate (DNR) orders in individualized service plans. |
| Failure to obtain criminal history record reports on or prior to the 30th day of employment for staff. |
Report Facts
Number of residents present: 75
Number of resident records reviewed: 10
Number of staff records reviewed: 6
Number of resident interviews: 4
Number of staff interviews: 6
Medication pass observations: 4
Expired medication dates: 3
Controlled substance count missing signatures: 18
Staff hire date: Nov 14, 2022
Staff hire date: Jul 11, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donesia Peoples | Licensing Inspector | Inspector conducting the renewal inspection |
| Staff #1 | Observed administering medications without required license or registration | |
| Staff #3 | Observed with expired medications on medication cart and improper medication storage | |
| Staff #4 | Staff lacking orientation documentation and certification | |
| Staff #7 | Acknowledged staff #4's certification was missing from record | |
| Staff #8 | Staff with delayed criminal history record report | |
| Staff #2 | Confirmed medication administration of expired medication | |
| Resident Care Director | Responsible for conducting audits and ensuring compliance with plans of correction | |
| Assistant Resident Care Director | Responsible for conducting audits and ensuring compliance with plans of correction | |
| Executive Director | Responsible for oversight and compliance with corrective actions | |
| Business Office Manager | Responsible for communication regarding staff certifications and criminal history reports | |
| Resident Care Coordinator | Involved in ISP training and compliance |
Inspection Report
Monitoring
Census: 73
Deficiencies: 3
Jan 19, 2023
Visit Reason
An unannounced monitoring inspection was conducted to review compliance with regulations, including a self-report received regarding allegations in Resident Care and Related Services.
Findings
The inspection found violations related to staff criminal history record reports, medication management including inaccurate controlled substance counts, expired medications, improper medication storage, and failure to maintain medications in pharmacy-issued containers with proper labeling.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure the criminal history record report was obtained on or prior to the 30th day of employment for each staff person. |
| Facility failed to implement a written plan for medication management including prevention of outdated medications, accurate controlled substance counts, adequate supervision of medication administration staff, and proper disposal of medications. |
| Facility failed to ensure medications remained in pharmacy issued containers with prescription labels until administered to residents. |
Report Facts
Number of residents present: 73
Number of resident records reviewed: 3
Number of staff records reviewed: 5
Number of staff interviews conducted: 4
Number of expired medications observed: 1
Number of unmarked pills observed: 5
Controlled substance count discrepancy: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donesia Peoples | Licensing Inspector | Conducted the inspection and is contact for questions |
| Staff #1 | Involved in medication count discrepancies and medication cart observations | |
| Staff #2 | Observed with medication storage issues and unable to provide disposal plan | |
| Staff #4 | Staff member with late criminal history record report and required to complete Medication Aide Refresher course |
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 1
Jan 19, 2023
Visit Reason
An unannounced complaint inspection was conducted to investigate allegations related to Resident Care and Related Services at Commonwealth Senior Living at Cedar Manor.
Findings
The investigation supported some, but not all, allegations of non-compliance in Resident Care and Related Services. A violation was found related to the facility's failure to ensure Individualized Service Plans (ISPs) included descriptions of identified needs based on the Uniform Assessment Instrument (UAI).
Complaint Details
The complaint investigation was substantiated in part, with evidence supporting some areas of non-compliance related to Resident Care and Related Services.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure the ISP included a description of identified needs based upon the UAI, specifically mechanical and human help needs for stairclimbing, transferring, dressing, toileting, walking, and wheeling were not documented in ISPs for residents reviewed. |
Report Facts
Number of residents present: 73
Number of resident records reviewed: 3
Number of staff records reviewed: 5
Number of staff interviews conducted: 4
Number of resident interviews conducted: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donesia Peoples | Licensing Inspector | Conducted the inspection and is the contact for questions |
| Resident Care Director | Named in plan of correction for evaluating and correcting care plans | |
| Executive Director | Named in plan of correction for evaluating and correcting care plans |
Inspection Report
Renewal
Deficiencies: 4
Apr 12, 2022
Visit Reason
An unannounced mandated renewal inspection was conducted on April 12 and 13, 2022, to assess compliance with applicable standards and laws for Commonwealth Senior Living at Cedar Manor.
Findings
The inspection identified multiple non-compliances including failure to provide timely written assurance of appropriate licensing at admission, failure to ascertain and document sex offender status prior to admission, lack of orientation for new residents, and failure to prevent use of expired medications.
Deficiencies (4)
| Description |
|---|
| Facility failed to provide written assurance of appropriate license to residents or legal representatives at time of admission. |
| Facility failed to ascertain and document sex offender status prior to admission. |
| Facility failed to provide orientation for new residents and their legal representatives including emergency procedures, mealtimes, and call system use. |
| Facility failed to prevent use of outdated, damaged, or contaminated medications as observed on medication cart. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Dec 21, 2021
Visit Reason
A complaint investigation was initiated due to allegations regarding staffing and supervision, resident care, and call bell systems at the facility.
Findings
The investigation found non-compliance with standards, specifically that the facility call bell system was not in good repair or fully operational, supported by observation and staff interview.
Complaint Details
A complaint investigation was initiated on 11/30/2021 and concluded on 1/25/2022. The evidence gathered supported the allegation of non-compliance with standards or law, and violations were issued.
Deficiencies (1)
| Description |
|---|
| Facility call bell system was not in good repair, condition or fully operational. |
Inspection Report
Renewal
Census: 39
Deficiencies: 7
Apr 27, 2021
Visit Reason
A renewal inspection was initiated on April 27, 2021 and concluded on May 4, 2021 to assess compliance with applicable standards and laws for Commonwealth Senior Living at Cedar Manor.
Findings
The inspection identified multiple violations including failure to document allergic reactions in admission physical exams, lack of fall analysis documentation, incomplete individualized service plans, untimely medication refills, missing diagnosis on medication orders, and failure to administer medications according to physician orders.
Deficiencies (7)
| Description |
|---|
| Facility failed to ensure resident admission physical examinations included descriptions of reactions to known allergies. |
| Facility failed to document an analysis of the circumstances of falls for residents meeting assisted living care criteria. |
| Individualized Service Plans did not include descriptions of residents' identified needs and had discrepancies in code status documentation. |
| Facility failed to ensure medications were refilled in a timely manner, resulting in missed doses. |
| Prescriber's orders did not include diagnosis or specific indications for administering medications. |
| Medications were not administered in accordance with physician's instructions, including failure to administer Clotrimazole and document insulin administration. |
| Treatments ordered by a physician were not provided according to instructions and documentation was missing. |
Report Facts
Inspection duration: 8
Resident census: 39
Missed medication doses: 15
Blood sugar readings: 426
Blood sugar readings: 486
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donesia Peoples | Inspector | Conducted the inspection |
| Staff #1 | Acknowledged multiple deficiencies related to documentation and medication administration | |
| Resident Care Director | Resident Care Director | Responsible for reviewing physical examination reports, fall analyses, medication administration, and ensuring compliance with physician orders |
| Executive Director | Executive Director | Responsible for reviewing physical examination reports, fall analyses, and medication management oversight |
| Assistant Resident Care Director | Assistant Resident Care Director | Responsible for ensuring medication administration and documentation compliance |
Inspection Report
Complaint Investigation
Deficiencies: 12
Mar 22, 2021
Visit Reason
A complaint investigation was initiated due to allegations regarding staffing and supervision, administration of medications, resident agreements, medication management plans, personal care services, general supervision of care, medication storage, and call systems.
Findings
The investigation found multiple violations including inaccurate staffing disclosure statements, incomplete resident agreements regarding medication policies, failure to document resident needs in Individualized Service Plans, delayed staff response to call bells, medication management deficiencies including missed and improperly administered medications, unlocked medication storage, and improper medication storage in resident rooms.
Complaint Details
The complaint investigation was substantiated with findings supporting allegations of non-compliance in staffing, medication administration, resident agreements, supervision, and call system responsiveness.
Deficiencies (12)
| Description |
|---|
| Facility did not keep its disclosure statement current regarding the general number of direct care staff on each shift. |
| Written agreements did not include documentation that residents were informed of the policy regarding administration of medications and dietary supplements. |
| Individualized Service Plans did not include descriptions of residents' identified needs such as side rails. |
| Facility failed to ensure prompt response by staff to resident call bells, with documented delays up to over an hour. |
| Facility failed to implement its medication management plan, resulting in missed medication administrations due to refills needed and drugs not available. |
| Facility discontinued medications without valid physician orders. |
| Medication storage cart was left unlocked and unattended. |
| Residents were permitted to keep medications in their rooms despite being incapable of self-administration as per assessments. |
| Medications were administered outside the facility's standard dosing schedule, with delays documented up to several hours. |
| Medications were administered not in accordance with physician's instructions, including administration of medications on incorrect days and missed doses. |
| Treatments ordered by a prescriber were not provided or documented as ordered, such as weekly resident weights. |
| Medication Administration Records did not include initials of direct care staff administering medications. |
Report Facts
Inspection dates: 5
Direct Care Staff count discrepancy: 8
Call bell response times: 67
Medication administration delays: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donesia Peoples | Inspector | Conducted the inspection and complaint investigation |
| Staff #1 | Provided documentation and acknowledged multiple deficiencies including staffing, medication administration, and resident agreements | |
| Staff #2 | Acknowledged call bell response time issues | |
| Staff #3 | Responsible for medication cart left unlocked | |
| Executive Director | Responsible for ensuring compliance with disclosure statements and monitoring call bell response times | |
| Resident Care Director | Responsible for medication management, ISP documentation, and monitoring compliance | |
| Assistant Resident Care Director | Responsible for medication management and ensuring physician orders are followed |
Inspection Report
Monitoring
Census: 46
Deficiencies: 4
Feb 3, 2021
Visit Reason
A monitoring inspection was initiated due to the state of emergency health pandemic declared by the Governor of Virginia, conducted remotely to review compliance with applicable standards and laws.
Findings
The inspection identified multiple non-compliances including failure to ensure staff completed required state-approved training for Uniform Assessment Instrument (UAI) and Individualized Service Plan (ISP), incomplete documentation of resident needs in ISPs, and missing staff initials on Medication Administration Records (MAR).
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure the Uniform Assessment Instrument (UAI) for private pay individuals was completed by a staff person who has successfully completed state-approved training on the UAI. |
| Facility failed to ensure the designee successfully completed the department approved Individualized Service Plan (ISP) training. |
| Facility failed to ensure the Individualized Service Plan (ISP) included a description of identified needs. |
| Facility failed to ensure the Medication Administration Record (MAR) included the initials of direct care staff administering the medication. |
Report Facts
Inspection dates: 3
Resident records reviewed: 3
Staff records reviewed: 3
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