Deficiencies per Year
16
12
8
4
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 1
Oct 6, 2025
Visit Reason
The inspection was conducted in response to a complaint received on 2025-07-23 regarding allegations related to the Criminal History Record Report.
Findings
The investigation found some non-compliance with the Criminal History Record Report requirements, specifically the facility failed to obtain a criminal history record report on or prior to the 30th day of employment for certain staff members.
Complaint Details
A complaint was received by VDSS Division of Licensing on 2025-07-23 regarding allegations in the area of The Criminal History Record Report. The evidence gathered supported some, but not all, of the allegations. A violation notice was issued.
Deficiencies (1)
| Description |
|---|
| Facility failed to obtain a criminal history record report on or prior to the 30th day of employment for each employee. |
Report Facts
Number of residents present: 42
Number of resident records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 1
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 6, 2025
Visit Reason
The inspection was conducted in response to complaints received by VDSS Division of Licensing on 2025-07-27 and 2025-08-10 regarding allegations in the area of Resident Care and Related Services.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. No deficiencies were cited.
Complaint Details
Complaint investigation related to allegations in Resident Care and Related Services; the allegations were not substantiated.
Report Facts
Number of resident records reviewed: 0
Number of interviews conducted with residents: 2
Number of interviews conducted with staff: 1
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 5
Jul 3, 2025
Visit Reason
The inspection was conducted in response to a complaint received on 2025-06-23 regarding allegations in the areas of Resident Care and Related Services and Building and Grounds.
Findings
The investigation found some substantiated areas of non-compliance related to resident care and building maintenance, including undocumented menu substitutions, unclean and poorly maintained building interiors and grounds, and inadequate waste collection provisions.
Complaint Details
The complaint was received by VDSS Division of Licensing on 2025-06-23 regarding allegations in Resident Care and Related Services and Building and Grounds. The evidence gathered supported some, but not all, of the allegations.
Deficiencies (5)
| Description |
|---|
| Facility failed to ensure menus and snacks for the current week were dated and posted in an area conspicuous to residents; substitutions were not documented. |
| Facility failed to maintain the interior and exterior of all buildings in good repair and kept clean and free of rubbish, including dog feces on carpet and debris in resident courtyard. |
| Facility failed to have adequate provisions for the collection of garbage and waste material; bulk trash was observed in rear of facility. |
| Facility failed to ensure all furnishings, fixtures, and equipment were kept clean and in good repair; multiple chairs were not in good repair. |
| Facility failed to ensure grounds were properly maintained, including mowing grass and trimming bushes. |
Report Facts
Number of residents present: 46
Number of resident interviews: 3
Number of staff interviews: 3
Inspection Report
Renewal
Census: 44
Deficiencies: 12
May 7, 2025
Visit Reason
The inspection was a renewal visit conducted to assess compliance with applicable standards and regulations for the assisted living facility.
Findings
The inspection identified multiple violations including failure to ensure required staff training, lack of evidence of liability insurance, missing resident acknowledgments, incomplete fall risk assessments, expired medications, building maintenance issues, incomplete emergency practice documentation, and deficiencies in criminal history record checks for staff.
Deficiencies (12)
| Description |
|---|
| Facility failed to ensure direct care staff attend at least 10 hours of training in cognitive impairment within four months of employment. |
| Facility failed to provide evidence of liability insurance coverage according to licensed capacity tier. |
| Facility failed to retain written acknowledgment of receipt of disclosure by residents or legal representatives. |
| Facility failed to ensure a fall risk rating is completed after a fall. |
| Facility failed to ensure a written agreement/acknowledgment of notification dated and signed by resident or legal representative at or prior to admission. |
| Facility failed to provide orientation for new residents including emergency procedures, mealtimes, and call system use. |
| Facility failed to implement written plan for medication management including prevention of outdated medications; expired medications were observed. |
| Facility failed to maintain interior and exterior of buildings in good repair and free of rubbish; debris and missing flooring observed. |
| Facility failed to document staff participation in practice exercises for resident emergencies at least once every six months. |
| Facility failed to ensure criminal history record report obtained on or prior to 30th day of employment for staff. |
| Facility employed staff with a felony barrier crime conviction. |
| Facility failed to maintain original criminal history record report in staff file. |
Report Facts
Number of residents present: 44
Number of resident records reviewed: 4
Number of staff records reviewed: 3
Number of resident interviews conducted: 4
Number of staff interviews conducted: 4
Number of expired medication types observed: 3
Dates of falls for Resident #3: Falls occurred on 2025-02-26 and 2025-04-16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff #1 | Unable to provide evidence of liability insurance; confirmed lack of criminal history report for Staff #7; confirmed last emergency practice exercise documentation | |
| Staff #3 | Did not have required cognitive impairment training within four months of hire | |
| Staff #5 | Staff record did not include original criminal history record report | |
| Staff #6 | Convicted of felony barrier crime; employment terminated on 2025-05-07 | |
| Staff #7 | No completed criminal history record report as of inspection date |
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 2
Feb 18, 2025
Visit Reason
The inspection was conducted in response to three complaints received by VDSS Division of Licensing regarding allegations in the areas of Admission, Retention, and Discharge of Residents and Buildings and Grounds.
Findings
The investigation supported some, but not all, of the allegations; non-compliance was found in the area of Buildings and Grounds. Violations included failure to maintain the interior and exterior of buildings in good repair and cleanliness, and failure to keep the facility free of infestations of insects and vermin.
Complaint Details
Three complaints were received on 02/05/2025 (2) and 02/06/2025 regarding allegations related to Admission, Retention, and Discharge of Residents and Buildings and Grounds. The evidence supported some of the allegations related to Buildings and Grounds.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure the interior and exterior of all buildings were maintained in good repair and kept clean and free of rubbish. |
| Facility failed to keep free of infestations of insects and vermin; specifically, 5 rooms were identified as having live bed bugs. |
Report Facts
Number of residents present: 50
Number of resident records reviewed: 3
Number of staff interviews conducted: 3
Number of rooms with bed bugs: 5
Inspection Report
Monitoring
Census: 50
Deficiencies: 1
Feb 18, 2025
Visit Reason
The inspection was a monitoring visit conducted following a self-reported incident received by VDSS Division of Licensing regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation supported the self-report of non-compliance with standards or law, resulting in violations issued. Specifically, the facility failed to ensure physical restraints were not used for purposes of discipline or convenience, leading to the termination of a staff member.
Deficiencies (1)
| Description |
|---|
| The facility failed to ensure physical restraints shall not be used for purposes of discipline or convenience. |
Report Facts
Number of residents present: 50
Number of resident records reviewed: 1
Number of staff records reviewed: 4
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 2
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 3
Dec 10, 2024
Visit Reason
The inspection was conducted in response to two complaints received by VDSS Division of Licensing regarding allegations related to buildings and grounds at the facility.
Findings
The investigation supported the allegations of non-compliance, resulting in violations issued related to administrator coverage lapse, infestation of insects and vermin, and expired elevator inspection certification.
Complaint Details
Two complaints were received on 10/29/2024 and 11/06/2024 regarding buildings and grounds. The evidence gathered supported the allegations of non-compliance.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure immediate employment of a new administrator or appointment of a qualified acting administrator after resignation or discharge, resulting in a lapse from 11/15/2024 to 12/08/2024. |
| Facility failed to keep free of infestations of insects and vermin; 7 rooms identified with live bed bugs on 11/20/2024. |
| Facility failed to ensure elevators were kept in good running condition and inspected at least annually; elevator inspection certification expired on 05/25/2024. |
Report Facts
Number of residents present: 52
Number of resident records reviewed: 1
Number of staff interviews conducted: 2
Number of rooms with live bed bugs: 7
Administrator coverage lapse days: 23
Inspection Report
Monitoring
Census: 55
Deficiencies: 3
Sep 12, 2024
Visit Reason
The inspection was a monitoring visit focused on a self-reported incident received on 2024-09-02 regarding allegations related to additional requirements for facilities that care for adults with serious cognitive impairments.
Findings
The investigation supported the self-report of non-compliance with multiple standards, including failure to ensure doors leading to unprotected areas were properly secured, inadequate supervision of residents including wandering, and failure to document staff participation in emergency practice exercises. Violations were issued accordingly.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure doors that lead to unprotected areas were monitored or secured through devices conforming to applicable building and fire codes. |
| Facility failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs such as wandering from the premises. |
| Facility failed to document staff participation in practice exercises for resident emergencies at least once every six months. |
Report Facts
Number of residents present: 55
Distance resident eloped: 0.4
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 0
Sep 12, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 09/12/2024 regarding allegations in the area of Resident Care and Related Services.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The inspection findings will be posted publicly within 5 business days.
Complaint Details
Complaint related to Resident Care and Related Services; the allegations were not substantiated.
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: 3
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 0
Aug 22, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2024-08-20 regarding allegations in the area of Resident Care and Related Services.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The inspection findings will be posted publicly.
Complaint Details
Complaint received on 2024-08-20 regarding Resident Care and Related Services; investigation did not substantiate the allegations.
Report Facts
Number of residents present: 55
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
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 1
Aug 12, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-08-09 regarding allegations related to additional requirements for facilities that care for adults with serious cognitive impairments.
Findings
The investigation supported the allegation that the facility failed to ensure the designated staff person responsible for managing or coordinating the structured activities program was on site in the special care unit at least 20 hours a week. Violations were issued based on this non-compliance.
Complaint Details
The complaint was substantiated based on interviews with floor staff and Staff #2, who verified that Staff #2 was not on site in the special care unit at least 20 hours a week.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure the designated staff person responsible for managing or coordinating the structured activities program was on site in the special care unit at least 20 hours a week. |
Report Facts
Number of residents present: 57
Inspection duration: 10
Number of staff interviews: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| M. Tess Pittman | Licensing Inspector | Contact person for questions about the inspection |
| Darunda Flint | Licensing Inspector | Current inspector conducting the inspection |
Inspection Report
Renewal
Census: 49
Deficiencies: 15
Apr 23, 2024
Visit Reason
The inspection was conducted as a renewal inspection to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection identified multiple violations related to resident assessments, staff training and certification, medication administration, documentation, dietary oversight, emergency preparedness, and criminal history record reports. Plans of correction were proposed for each deficiency to ensure future compliance.
Deficiencies (15)
| Description |
|---|
| Facility failed to ensure residents admitted to a secure environment were assessed by an independent clinical psychologist or physician for serious cognitive impairment. |
| Facility failed to document determination of appropriateness for placement in the special care unit for residents with serious cognitive impairment. |
| Facility failed to retain written acknowledgment of receipt of disclosure by resident or legal representative. |
| Facility failed to obtain required certification documentation for direct care staff. |
| Facility failed to ensure direct care staff completed required annual training hours. |
| Facility failed to ensure tuberculosis risk assessments were completed within required timeframes for staff. |
| Facility failed to ensure direct care staff maintained current first aid certification. |
| Facility failed to ensure physical examination by an independent physician within 30 days preceding admission. |
| Facility failed to ensure written agreement/acknowledgment of notification was signed by resident or legal representative at admission. |
| Facility failed to conduct dietary oversight every six months by a dietitian or nutritionist. |
| Facility failed to ensure medications were administered within one hour before or after scheduled times and failed to document medication administration accurately. |
| Facility failed to ensure medication reviews were performed every six months by a licensed health care professional. |
| Facility failed to ensure monthly checks of first aid kits were documented. |
| Facility failed to document staff participation in practice exercises for resident emergencies at least every six months. |
| Facility failed to obtain criminal history record reports on or prior to the 30th day of employment for certain staff. |
Report Facts
Number of residents present: 49
Number of resident records reviewed: 5
Number of staff records reviewed: 4
Number of resident interviews: 4
Number of staff interviews: 4
Number of medications not administered: 6
Number of medication doses missed: 3
Number of medication doses missed: 3
Number of medication doses missed: 4
Number of medication doses missed: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff #1 | Unable to provide documentation of 2023 annual training and medication review within last 12 months | |
| Staff #2 | Medication observation on 4/23/2024; medications not available for Resident #3 | |
| Staff #5 | Direct care staff | Missing certification documentation, missing annual training, missing first aid certification |
| Staff #6 | Criminal history record report obtained late | |
| Staff #7 | Criminal history record report obtained late | |
| Staff #8 | Criminal history record report initially missing but later obtained and cleared |
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 0
Jan 25, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2024-01-19 regarding allegations in the area of Admission, Retention, and Discharge of residents.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The inspection findings will be posted publicly.
Complaint Details
Complaint related to Admission, Retention, and Discharge of residents; allegations were not substantiated.
Report Facts
Resident records reviewed: 3
Staff records reviewed: 0
Resident interviews conducted: 0
Staff interviews conducted: 1
Inspection Report
Monitoring
Census: 49
Deficiencies: 6
Nov 21, 2023
Visit Reason
The inspection was a monitoring visit focused on a self-reported incident received by VDSS Division of Licensing regarding allegations in Resident Care and Related Services.
Findings
The investigation supported the self-report of non-compliance with multiple violations issued related to staff orientation, training, documentation, medication administration, and controlled substances management.
Deficiencies (6)
| Description |
|---|
| Facility failed to ensure orientation and training required within the first seven working days of employment. |
| Facility failed to maintain personal and social data on staff including verification of receipt of current job description. |
| Facility failed to ensure staff submit results of tuberculosis risk assessment prior to contact with residents. |
| Facility failed to ensure direct care staff maintain current certification in first aid. |
| Facility failed to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes. |
| Facility failed to ensure medications were administered within one hour before or after the facility's standard dosing schedule and failed to document administration of multiple medications for Resident #1. |
Report Facts
Residents present: 49
Staff records reviewed: 1
Resident records reviewed: 1
Staff interviews conducted: 1
Hydrocodone tablets unaccounted: 40
Days of medication not documented: 22
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 6
Jul 20, 2023
Visit Reason
The inspection was conducted in response to three complaints received by VDSS Division of Licensing regarding allegations in resident care, accommodations, buildings and grounds, emergency preparedness, and additional requirements for adults with serious cognitive impairments.
Findings
The investigation supported some but not all allegations, identifying non-compliance in resident care and buildings and grounds. Multiple violations were cited including failure to complete annual resident assessments, inadequate personal care assistance, unlocked medication cart, medication administration timing errors, poor building maintenance, and inadequate air conditioning.
Complaint Details
Three complaints were received on 07/10/2023 (2) and 07/21/2023 (1) regarding resident care, accommodations, buildings and grounds, emergency preparedness, and care for adults with serious cognitive impairments. The evidence supported some allegations leading to a violation notice.
Deficiencies (6)
| Description |
|---|
| Facility failed to complete a resident's UAI at least annually. |
| Facility failed to ensure personal assistance and care were provided to meet resident needs. |
| Medication cart on Cedar Point unit was unlocked and unattended. |
| Medications were not administered within the facility's standard dosing schedule. |
| Interior of the building was not maintained in good repair and was not kept clean and free of rubbish. |
| Facility failed to provide air conditioning in all resident areas; dining room temperature exceeded 80°F. |
Report Facts
Number of residents present: 53
Number of resident records reviewed: 5
Dates of inspection: 2
Medication administration missed dates: 2
Inspection Report
Monitoring
Census: 53
Deficiencies: 1
Jul 20, 2023
Visit Reason
The inspection was a monitoring visit conducted to review compliance with regulations related to admission, retention, and discharge of residents, as well as resident care and related services. The visit included investigation of a self-reported incident received on 07/11/2023.
Findings
The investigation did not support the self-report of non-compliance; however, a violation was identified related to failure to retain physician's notes and progress reports in the resident's record. The facility was cited for this deficiency and given the opportunity to submit a plan of correction.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure any physician's notes and progress reports in the possession of the facility were retained in the resident's record. |
Report Facts
Number of residents present: 53
Number of resident records reviewed: 1
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 6
Jun 15, 2023
Visit Reason
The inspection was conducted in response to three complaints received by VDSS Division of Licensing regarding allegations in staffing and supervision, admission, retention and discharge of residents, resident care and related services, resident accommodations, and buildings and grounds.
Findings
The investigation supported some, but not all, of the allegations. Non-compliance was found in resident care and related services and buildings and grounds. Multiple violations were cited including failure to provide written meal service agreements, medication administration errors, missing signatures on medication administration records, lack of valid DNR orders, poor building maintenance, and inadequate call bell response systems.
Complaint Details
Three complaints were received on 06/01/2023 and 06/05/2023 regarding staffing and supervision, admission, retention and discharge of residents, resident care and related services, resident accommodations, and buildings and grounds. The evidence supported some of the allegations, specifically in resident care and buildings and grounds.
Deficiencies (6)
| Description |
|---|
| Facility failed to ensure residents have a written agreement for meal service options between dining area and room. |
| Medications were not administered according to the facility's standard dosing schedule for multiple residents. |
| Medication Administration Records (MARs) lacked name, signature, and initials of all staff administering medications. |
| Facility failed to ensure a valid written Do Not Resuscitate (DNR) order was included in the individualized service plan. |
| Interior of the building was not maintained in good repair and was not kept clean and free of rubbish; vent in dining room had grey substance and a fan was a trip hazard. |
| Facility failed to ensure a signaling device that terminates at a continuously staffed central location and permits staff to determine the origin of the signal. |
Report Facts
Number of residents present: 50
Number of resident records reviewed: 7
Medication administration omissions: 10
Call bell response delay: 10
Number of complaints received: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Darunda Flint | Licensing Inspector | Inspector conducting the complaint investigation |
| M. Tess Pittman | Licensing Inspector | Contact person for questions about VDSS Licensing Programs |
Inspection Report
Monitoring
Deficiencies: 1
May 23, 2023
Visit Reason
The inspection was a monitoring visit conducted on May 23, 2023, following a self-reported incident received on May 4, 2023, regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation supported the self-report of non-compliance related to medication administration timing. Violations were issued for failure to ensure medications were administered within the facility's standard dosing schedule. The facility submitted a plan of correction addressing the issues.
Deficiencies (1)
| Description |
|---|
| 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, except for drugs ordered for specific times. |
Report Facts
Number of resident records reviewed: 1
Number of staff interviews conducted: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| M. Tess Pittman | Licensing Inspector | Contact person for questions regarding the inspection |
Inspection Report
Renewal
Census: 48
Deficiencies: 12
Apr 24, 2023
Visit Reason
The inspection was conducted as a renewal inspection of the assisted living facility to assess compliance with applicable standards and regulations.
Findings
The inspection identified multiple violations related to staff records, training, certification, resident care plans, medication management, and documentation. The facility was found non-compliant with several regulatory standards and was required to submit plans of correction.
Deficiencies (12)
| Description |
|---|
| Failed to ensure criminal history record reports were obtained within 30 days of employment for staff. |
| Failed to ensure orientation and training occurred within the first seven working days of employment for staff. |
| Failed to document type, provider, hours, and dates of staff training in personnel records. |
| Failed to maintain personal and social data, including job description and emergency contact, in staff records. |
| Failed to ensure direct care staff maintained current certification in first aid. |
| Failed to ensure physical examination by an independent physician within 30 days preceding admission. |
| Failed to complete comprehensive Individual Service Plan (ISP) within 30 days after admission and address identified resident needs. |
| Failed to implement written plan for medication management, including prevention of outdated medications and proper disposal. |
| Failed to ensure medications were administered within one hour before or after scheduled times. |
| Failed to include diagnosis, condition, or specific indications for administering medications on Medication Administration Records (MAR). |
| Failed to act on pharmacy medication review recommendations in a timely manner. |
| Failed to ensure sworn statement or affirmation was completed for all applicants for employment. |
Report Facts
Number of residents present: 48
Number of resident records reviewed: 8
Number of staff records reviewed: 4
Number of expired medications observed: 13
Number of residents with late medication administration: 9
Inspection Report
Renewal
Census: 30
Deficiencies: 8
Apr 28, 2022
Visit Reason
An unannounced renewal inspection was initiated by two Licensing Inspectors on April 28, 2022 and concluded on April 29, 2022 to assess compliance with applicable standards and laws.
Findings
The inspection identified multiple violations related to resident assessments, documentation, medication management, discharge procedures, individualized service plans, and facility maintenance. Corrective plans were established for each deficiency.
Deficiencies (8)
| Description |
|---|
| Facility failed to ensure residents admitted to a safe, secure environment were assessed by an independent clinical psychologist or physician for serious cognitive impairment. |
| Facility failed to document determination and justification for placement in the special care unit for residents with serious cognitive impairment. |
| Facility failed to maintain personal and social data on staff including verification of receipt of current job descriptions. |
| Facility failed to complete a fall risk rating by the time the comprehensive Individualized Service Plan (ISP) was completed for residents meeting assisted living care criteria. |
| Facility failed to provide a dated discharge statement signed by licensee or administrator for discharged residents. |
| Facility failed to ensure the ISP included descriptions of residents' identified needs based on the Uniform Assessment Instrument (UAI). |
| Facility failed to prevent use of outdated medications; expired medications were found in medication carts. |
| Facility failed to maintain the interior of the building in good repair and kept clean and free of rubbish; issues included dirty vents, ripped porch screening, peeling wallpaper, dirty refrigerators, debris and ladder in stairwells. |
Report Facts
Residents in care: 30
Staff records reviewed: 4
Resident records reviewed: 8
Expired medications observed: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Darunda Flint | Licensing Inspector | Current inspector conducting the inspection |
| Director of Resident Care | Named in relation to auditing resident records and medication administration | |
| Administrator | Named in relation to addressing deficiencies and corrective actions | |
| Business Office Coordinator | Named in relation to auditing staff personnel files and discharge statements | |
| Maintenance Coordinator | Named in relation to cleaning and maintenance corrective actions | |
| LPN Supervisor | Named in relation to auditing UAI and ISP accuracy |
Inspection Report
Deficiencies: 0
Mar 24, 2022
Visit Reason
A non-mandated self-report inspection was conducted following a self-reported incident related to Part VI Resident Care and Related Services.
Findings
The investigation did not find evidence to support non-compliance with standards or law.
Inspection Report
Deficiencies: 1
Mar 24, 2022
Visit Reason
A non-mandated self-report inspection was conducted following a self-reported incident regarding compliance with additional requirements for facilities caring for adults with serious cognitive impairments.
Findings
The investigation supported the self-report of non-compliance with standards related to monitoring and securing doors leading to unprotected areas. Violations were issued due to failure to properly monitor and secure a resident's secure care bracelet, which was found on the resident's walker rather than on the resident, allowing the resident to exit the safe, secure environment.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure doors leading to unprotected areas were monitored or secured through devices conforming to applicable building and fire codes, including failure to properly monitor and secure a resident's secure care bracelet. |
Report Facts
Inspection duration: 80
Date of incident: Mar 17, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Darunda Flint | Inspector | Current inspector conducting the inspection |
| Staff #1 | Acknowledged inconsistency in monitoring the secure care bracelet of Resident #1 | |
| Director of Resident Care | Director of Resident Care | Completed in-service on wonder guard placement and monitoring; responsible for monitoring compliance |
Inspection Report
Monitoring
Census: 25
Deficiencies: 12
Feb 10, 2022
Visit Reason
An unannounced monitoring inspection was conducted to review compliance with applicable standards and laws, including follow-up on violations from a prior inspection.
Findings
The inspection identified multiple violations related to facility supervision, staff certifications, resident documentation, medication administration, building maintenance, and employee criminal history record reports. Plans of correction were provided for each deficiency.
Deficiencies (12)
| Description |
|---|
| Facility failed to exercise general supervision and establish policies and procedures in conformance with applicable law; resident records lacked current Disclosure Statement, Resident Agreements, and related documents. |
| Direct care staff member lacked current first aid certification. |
| Facility failed to ensure physical examinations within 30 days preceding admission and annual tuberculosis risk assessments for residents. |
| Facility failed to complete fall risk ratings at least annually and after falls for certain residents. |
| Facility failed to ascertain and document sex offender screening prior to admission for some residents. |
| Resident personal and social information was incomplete for some residents. |
| Facility failed to complete Uniform Assessment Instrument (UAI) for residents prior to admission, annually, and after significant changes. |
| Facility failed to develop preliminary plan of care prior to or within seven days of admission and failed to complete comprehensive individualized service plans timely. |
| Facility failed to obtain written acknowledgment of receipt and review of residents' rights and responsibilities from residents or their representatives. |
| Medications were not administered according to the facility's standard dosing schedule; documentation and medication availability issues were noted. |
| Facility failed to maintain the interior of the building in good repair and clean condition; specific maintenance issues were observed. |
| Facility failed to obtain criminal history record reports on or prior to the 30th day of employment for an employee. |
Report Facts
Residents in care: 25
Medication doses missed: 15
Dates of resident falls: Falls documented on 12-27-2021 and 02-05-2022 for residents #1 and #3
New ownership date: New ownership attained responsibility on 12-01-2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff #1 | Acknowledged lack of first aid certification for Staff #4, discrepancy in Resident #5 medication administration, and failure to obtain criminal history record report timely | |
| Staff #4 | Certified Nursing Assistant | Did not have current first aid certification |
Inspection Report
Original Licensing
Census: 28
Deficiencies: 4
Nov 18, 2021
Visit Reason
An initial inspection was initiated to assess compliance with applicable standards and laws for licensing of the assisted living facility.
Findings
The inspection identified multiple violations including failure to post the current on-site person in charge, failure to post dated menus conspicuously, lack of a current diet manual available to food preparation personnel, and maintenance issues with building repairs and cleanliness.
Deficiencies (4)
| Description |
|---|
| Facility failed to develop and implement a procedure for posting the name of the current on-site person in charge in a conspicuous place. |
| Facility failed to ensure menus for meals and snacks for the current week are dated and posted in an area conspicuous to residents. |
| Facility failed to ensure a copy of a diet manual containing acceptable practices and standards for nutrition is kept current and readily available to personnel responsible for food preparation. |
| Facility failed to maintain the interior and exterior of all buildings in good repair and kept clean and free of rubbish, including vegetation over gutters and unoccupied units in disrepair. |
Report Facts
Census: 28
Units unoccupied due to disrepair: 4
Loading inspection reports...
