Inspection Report
Renewal
Census: 66
Deficiencies: 6
Mar 24, 2025
Visit Reason
An unannounced mandated renewal inspection was conducted on March 24 and 25, 2025 to assess compliance with applicable standards and regulations for Mennowood Retirement Community.
Findings
The inspection identified multiple violations related to resident records, individualized service plans, medication management, and storage. The facility failed to keep resident personal and social data updated, ensure individualized service plans reflected assessed needs and were properly signed, and maintain proper medication orders, storage, and availability.
Deficiencies (6)
| Description |
|---|
| Facility failed to ensure the resident's personal and social data information was kept updated. |
| Resident's individualized service plan (ISP) did not include all assessed needs. |
| Resident's individualized service plan (ISP) was not signed and dated following update by resident or legal representative. |
| Facility failed to ensure no medication, dietary supplement, diet, medical procedure, or treatment was started, changed, or discontinued without a valid physician order. |
| Facility failed to ensure resident permitted to keep medication in room complied with storage regulations and self-administering policy. |
| Facility failed to ensure PRN medications were available, properly labeled, and properly stored. |
Report Facts
Residents present: 66
Resident records reviewed: 7
Staff records reviewed: 4
Resident interviews conducted: 3
Staff interviews conducted: 8
Inspection Report
Monitoring
Census: 69
Deficiencies: 2
Mar 11, 2024
Visit Reason
An unannounced on-site monitoring inspection was conducted to review compliance with applicable standards and laws at Mennowood Retirement Community.
Findings
The inspection found non-compliance with applicable standards, including failure to ensure blood glucose monitoring practices consistent with CDC recommendations and failure to have individualized service plans signed and dated by required parties.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure blood glucose monitoring practices were consistent with CDC recommendations; resident's glucometer was not labeled. |
| Facility failed to ensure individualized service plans were signed and dated by the licensee, administrator, or designee, and by the resident or legal representative. |
Report Facts
Inspection duration day 1: 8.67
Inspection duration day 2: 3.32
Deficiencies cited: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alyshia E Walker | Inspector | Current inspector conducting the inspection |
| Willie Barnes | Licensing Inspector | Contact person for questions regarding the inspection |
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 0
Mar 11, 2024
Visit Reason
An unannounced on-site complaint inspection was conducted on March 11 and 12, 2024, following a complaint received on March 1, 2024, regarding allegations in the areas of resident care and building and grounds.
Findings
The evidence gathered during the investigation did not support the allegation of non-compliance with standards or law. The inspection findings will be posted publicly and a copy is required to be posted on the facility premises.
Complaint Details
Complaint received by VDSS Division of Licensing on 2024-03-01 regarding allegations in resident care and building and grounds; investigation did not substantiate the complaint.
Report Facts
Residents present: 69
Resident records reviewed: 1
Staff records reviewed: 0
Resident interviews conducted: 2
Staff interviews conducted: 3
Inspection Report
Renewal
Census: 93
Deficiencies: 3
Mar 14, 2023
Visit Reason
An unannounced on-site renewal inspection was conducted to assess compliance with applicable standards and laws for facility licensing renewal.
Findings
The inspection found non-compliance with several standards including failure to have required psychotropic treatment plans, unsigned individualized service plans, and water temperatures outside the required range.
Deficiencies (3)
| Description |
|---|
| Facility failed to admit or retain individuals with required documentation for psychotropic medication treatment plans. |
| Individualized service plans were not signed and dated by the resident or legal representative for three of ten records reviewed. |
| Hot water at taps available to residents was not maintained within the required temperature range of 105 to 120 degrees Fahrenheit. |
Report Facts
Inspection days: 2
Residents with unsigned ISPs: 3
Water temperature readings: 121
Water temperature readings: 123
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alyshia E Walker | Inspector | Current inspector conducting the inspection |
| Willie Barnes | Licensing Inspector | Contact person for questions regarding the inspection |
| Staff #2 | Acknowledged missing psychotropic treatment plan and unsigned ISPs | |
| Staff #8 | Acknowledged water temperatures were outside required range | |
| Director of Nursing | Responsible for corrective actions and monitoring related to deficiencies | |
| Maintenance Director | Responsible for corrective actions and monitoring water temperature |
Inspection Report
Renewal
Census: 72
Deficiencies: 4
Jun 9, 2022
Visit Reason
The inspection was a renewal visit conducted on June 9 and June 16, 2022, to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection found multiple violations related to admission assessments, staff documentation, certification, and background checks. The facility was cited for non-compliance and given the opportunity to submit a plan of correction.
Deficiencies (4)
| 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 prior to admission. |
| Facility failed to maintain personal and social data on staff, including verification that staff received a copy of their current job description. |
| Facility failed to ensure each direct care staff member maintained current certification in first aid. |
| Facility failed to obtain a criminal history record report on or prior to the 30th day of employment for certain employees. |
Report Facts
Number of residents present: 72
Number of resident records reviewed: 9
Number of staff records reviewed: 5
Inspection Report
Renewal
Deficiencies: 0
Jun 15, 2021
Visit Reason
The inspection was conducted as a renewal inspection initiated and concluded on June 21, 2021, using alternate remote protocol due to a state of emergency health pandemic.
Findings
The inspector reviewed 3 resident and 3 staff records and additional documentation and determined no violations with applicable standards or law; no violations were issued.
Report Facts
Resident records reviewed: 3
Staff records reviewed: 3
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 26, 2020
Visit Reason
A complaint inspection was initiated due to allegations regarding resident accommodations and resident care and related services at Mennowood Retirement Community.
Findings
The investigation was conducted remotely due to a state of emergency health pandemic. The evidence gathered did not support the allegations of non-compliance with standards or law.
Complaint Details
A complaint was received regarding allegations in the areas of resident accommodations and related provisions and resident care and related services. The complaint was not substantiated.
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