Inspection Reports for Great Falls Assisted Living

The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-07-10 regarding allegations in the area of Administration and Administrative Services.

The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. No deficiencies were cited.

Complaint related to allegations in Administration and Administrative Services; investigation found no substantiation of non-compliance.

The inspection was conducted in response to a complaint received by the VDSS Division of Licensing on July 8, 2025, regarding allegations in the area of Resident Care and Related Services.

The investigation found some areas of non-compliance related to Resident Care and Related Services, specifically medication administration timing violations. A violation notice was issued and the licensee was given the opportunity to submit a plan of correction.

The evidence gathered supported some, but not all, of the allegations related to Resident Care and Related Services. The complaint was substantiated in part.

The inspection was a monitoring visit to review compliance with applicable standards and laws at the assisted living facility.

The inspection found non-compliance with facility policies and procedures related to resident privacy during blood glucose monitoring and failure to secure cleaning supplies and hazardous materials in locked areas.

The inspection was a renewal unannounced mandated visit to review compliance with applicable standards and regulations for the assisted living facility.

The inspection found non-compliance with several standards including medication aide training, private duty personnel qualifications, and registration with the Department of State Police. Plans of correction were submitted to address these violations.

The inspection was a monitoring visit conducted following receipt of an incident report regarding allegations in the area of Resident Care and Related Services.

The licensing inspector completed a tour of the physical plant and found no violations of applicable standards or laws during the inspection.

An unannounced renewal inspection was conducted to assess compliance with applicable standards and laws for the assisted living facility.

The inspection found non-compliance with medication management and physician order review requirements, including failure to accurately transcribe medication orders to MARs within 24 hours and failure to ensure physician's oral orders were signed within 14 days.

Unannounced monitoring inspections were conducted on 2022-08-31 and 2023-01-12 in response to facility-reported incidents.

Resident and staff records were observed and interviews conducted. No violations were cited as a result of the inspections.

An unannounced focused inspection was conducted to follow-up on a violation that was cited on 2022-03-15.

Staff schedules and facility documentation were reviewed. No violations were cited and an exit meeting was held.

An unannounced renewal inspection was conducted to assess compliance with licensing standards, including review of meals, medication administration, activities, building and grounds, and records.

The inspection identified multiple violations related to staffing levels during night hours, staff certification in first aid, unsigned uniform assessment instrument forms, and unsigned individualized service plans. Plans of correction were required for each deficiency.

A non-mandated complaint inspection was initiated due to a complaint received regarding allegations in the areas of Administration and Administrative Services and Resident Care and Related Services.

The evidence gathered during the investigation did not support the allegation of non-compliance with standards or law.

Complaint was received and investigated; the allegations were not substantiated.

A non-mandated monitoring inspection was initiated due to a self-reported incident regarding allegations in the area of Resident Care and Related Services.

The investigation did not support the self-report of non-compliance with standards or law, but violations unrelated to the self-report were identified, including failure to document analysis and interventions after a resident fall.

A complaint inspection was initiated due to an allegation related to Resident Care and Related Services, triggered by a complaint received by the department.

The investigation found non-compliance with standards regarding the improper handling of resident information during hospital transport and failure to obtain new medication orders after hospital discharge. Violations were issued based on these findings.

The complaint investigation was substantiated with violations issued related to resident care and related services, specifically concerning resident information confidentiality and medication order management.

A renewal inspection was initiated on April 5, 2021, and concluded on April 13, 2021, to assess compliance with applicable standards and laws for Great Falls Assisted Living.

The inspection determined non-compliance with applicable standards related to background checks, specifically failure to obtain a criminal history record report within 30 days of hiring an employee.