Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 4
Jul 2, 2025
Visit Reason
The inspection was conducted in response to a complaint received on 2025-06-09 regarding allegations in the areas of Resident Care and Related Services, Administration and Administrative Services, and Resident Accommodations and Related Provisions.
Findings
The investigation supported some, but not all, of the allegations. Several violations were identified related to infection control procedures, individualized service plans, medication management, and provision of linens. A violation notice was issued and the licensee was given the opportunity to submit a plan of correction.
Complaint Details
Complaint was substantiated in part; evidence supported non-compliance in Resident Care and Related Services, Administration and Administrative Services, and Resident Accommodations and Related Provisions.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure proper infection control procedures; medication cart audits revealed unlabeled glucometer instruments. |
| Facility failed to ensure individualized service plans included all assessed needs; medication administration by lay person not listed in ISP. |
| Facility failed to follow medication management plan to ensure timely filling and refilling of prescription and over-the-counter medications; several medications and supplies were unavailable during audits. |
| Facility failed to ensure residents had sufficient bed and bath linens in good repair; towels were not provided to residents. |
Report Facts
Residents present: 44
Resident records reviewed: 5
Staff interviews conducted: 4
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 1
Jul 2, 2025
Visit Reason
The inspection was conducted in response to a complaint received on 2025-06-24 regarding allegations related to building and grounds conditions at the facility.
Findings
The investigation found non-compliance with standards as the facility failed to ensure that temperatures in all resident-used areas did not exceed 80 degrees Fahrenheit. Specifically, the activity room temperature was measured at 81.0 degrees Fahrenheit while in use by residents.
Complaint Details
The complaint was substantiated as evidence supported the allegation of non-compliance with temperature standards in resident areas.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure that temperatures in all areas used by residents did not exceed 80 degrees Fahrenheit. |
Report Facts
Temperature: 81
Residents present: 44
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 0
May 6, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-04-24 regarding allegations in the areas of Administration and Administrative Services, Personnel, Staffing and Supervision, and Buildings and Ground.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The licensing inspector completed a tour of the physical plant and reviewed PPE supply and staff schedule.
Complaint Details
Complaint investigation related to allegations in Administration and Administrative Services, Personnel, Staffing and Supervision, and Buildings and Ground. The complaint was not substantiated.
Report Facts
Number of residents present: 44
Number of resident records reviewed: 0
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 4
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 2
Mar 24, 2025
Visit Reason
The inspection was conducted in response to two complaints received by VDSS Division of Licensing regarding allegations in the areas of Personnel, Staffing and Supervision, and Resident Care and Related Services.
Findings
The investigation supported some, but not all, of the allegations; non-compliance was found in Resident Care and Related Services. Violations related to medication management and documentation were identified.
Complaint Details
Two complaints were received on 03/14/2025 and 03/19/2025 regarding Personnel, Staffing and Supervision, and Resident Care and Related Services. The evidence supported some allegations related to Resident Care and Related Services.
Deficiencies (2)
| Description |
|---|
| Facility failed to implement their written plan for medication management to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes. |
| Facility failed to ensure that all medications administered to residents, including over-the-counter medications and dietary supplements, were documented on a medication administration record (MAR). |
Report Facts
Number of residents present: 40
Number of resident records reviewed: 3
Number of staff records reviewed: 3
Number of interviews conducted with residents: 3
Number of interviews conducted with staff: 3
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 8
Feb 24, 2025
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2025-02-07 regarding allegations related to Admission, Retention, and Discharge of Residents and Resident Care and Related Services.
Findings
The investigation supported the allegations of non-compliance with multiple standards including failure to complete fall risk ratings after falls, incomplete discharge statements, failure to provide refunds within 60 days of discharge, incomplete resident assessments and individualized service plans, failure to notify designated contacts of resident falls, and failure to administer medications according to physician instructions.
Complaint Details
The complaint was substantiated as evidence gathered supported the allegations of non-compliance in areas including resident care, discharge procedures, notification of falls, and medication administration.
Deficiencies (8)
| Description |
|---|
| Facility failed to ensure a fall risk rating is completed when the condition of the resident changes and after a fall. |
| Facility failed to ensure a discharge statement was completed and retained in the resident's record. |
| Facility failed to ensure within 60 days of discharge, each resident or their legal representative be given any refunds due. |
| Facility failed to complete a resident's UAI prior to admission and whenever there is a significant change in the resident's condition. |
| Facility failed to ensure the comprehensive individualized service plan be completed within 30 days after admission. |
| Facility failed to review and update individualized service plans as needed for a significant change of a resident's condition. |
| Facility failed to notify the next of kin, legal representative, designated contact person, or responsible social agency of any incident of a resident falling within 24 hours. |
| Facility failed to ensure medications be administered in accordance with the physician's or other prescriber's instructions. |
Report Facts
Residents present: 40
Resident records reviewed: 2
Staff interviews conducted: 3
Fall dates for Resident #1: 2
Fall dates for Resident #2: 4
Medication administration dates missed for Resident #1: 38
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Darunda Flint | Licensing Inspector | Current inspector conducting the inspection |
| M. Tess Pittman | Licensing Inspector | Contact person for questions regarding the inspection |
| Staff #3 | Confirmed Resident #1 had a credit due that was not refunded |
Inspection Report
Monitoring
Census: 42
Deficiencies: 5
Feb 7, 2025
Visit Reason
The inspection was a monitoring visit conducted to review compliance with personnel, resident care, and additional requirements for facilities caring for adults with serious cognitive impairments, following two self-reported incidents received by VDSS.
Findings
The investigation supported the self-report of non-compliance with multiple standards, resulting in violations issued related to staff training, window safety, supervision of residents, and annual review of resident rights. The licensee was given the opportunity to submit a plan of correction.
Deficiencies (5)
| 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 ensure protective devices on bedroom and bathroom windows to prevent residents from exiting through unsecured windows. |
| Facility failed to ensure all direct care staff attend at least 18 hours of training annually. |
| Facility failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs. |
| Facility failed to ensure the rights and responsibilities of residents are reviewed annually with each staff person. |
Report Facts
Residents present: 42
Resident records reviewed: 2
Staff records reviewed: 2
Resident interviews: 2
Staff interviews: 4
Inspection Report
Complaint Investigation
Census: 45
Deficiencies: 0
Nov 12, 2024
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2024-11-01 regarding allegations in the areas of Resident Care and Related Services and Building and Grounds.
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 to the VDSS website within 5 business days of receipt of the inspection summary.
Complaint Details
Complaint received on 2024-11-01 regarding Resident Care and Related Services and Building and Grounds; investigation did not substantiate allegations.
Report Facts
Number of residents present: 45
Number of resident records reviewed: 3
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 3
Inspection Report
Monitoring
Census: 45
Deficiencies: 1
Nov 12, 2024
Visit Reason
The inspection was a monitoring visit conducted on November 12, 2024, following two self-reported incidents received by VDSS regarding allegations in Resident Care and Additional Requirements for Facilities that Care for Adults with Serious Cognitive Impairments.
Findings
The investigation supported some but not all of the self-reports, identifying non-compliance with standards related to Additional Requirements for Facilities that Care for Adults with Serious Cognitive Impairments. A violation notice was issued regarding unsecured windows that allowed a resident to exit the safe environment.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure protective devices on bedroom and bathroom windows and windows in common areas to prevent residents from crawling through. |
Report Facts
Number of residents present: 45
Number of resident records reviewed: 2
Number of staff records reviewed: 0
Number of resident interviews conducted: 2
Number of staff interviews conducted: 4
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 0
Oct 22, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-09-26 regarding allegations in the areas of Resident Care and Related Services, Resident Accommodations and Related Provisions, and Buildings and Ground.
Findings
The investigation found no evidence to support the allegations of non-compliance with standards or law. The inspection summary will be posted publicly within 5 business days.
Complaint Details
A complaint was received by VDSS Division of Licensing on 09/26/2024 regarding allegations in Resident Care and Related Services, Resident Accommodations and Related Provisions, and Buildings and Ground. The evidence gathered did not support the allegations.
Report Facts
Number of residents present: 42
Number of resident records reviewed: 2
Number of staff records reviewed: 0
Number of interviews conducted with residents: 2
Number of interviews conducted with staff: 4
Inspection Report
Renewal
Census: 42
Deficiencies: 16
Oct 22, 2024
Visit Reason
The inspection was a renewal visit conducted to assess compliance with applicable standards and laws for continued licensing of the assisted living facility.
Findings
The inspection identified multiple violations related to resident care documentation, staff certifications, medication administration, fire safety compliance, and resident rights. The facility was found non-compliant in several areas and issued a violation notice with required plans of correction.
Deficiencies (16)
| Description |
|---|
| Failed to ensure appropriate determination and justification for placement in the special care unit for a resident with serious cognitive impairment. |
| Failed to ensure direct care staff maintain current certification in first aid. |
| Failed to provide written assurance of appropriate license to meet care needs at admission. |
| Failed to complete fall risk rating at required intervals and after condition changes. |
| Failed to ascertain and document sex offender status prior to admission. |
| Failed to obtain written agreement/acknowledgment of notification signed by resident or legal representative at admission. |
| Failed to provide orientation documentation for new residents and legal representatives. |
| Failed to develop preliminary plan of care on or within seven days prior to admission. |
| Failed to ensure comprehensive individualized service plans accurately reflect resident needs and services. |
| Failed to review and update individualized service plans as needed for significant changes in resident condition. |
| Failed to review resident rights and responsibilities annually with residents or their representatives. |
| Failed to conduct dietary oversight every six months for special diets by a dietitian or nutritionist. |
| Failed to administer medications according to physician orders; medication doses missed. |
| Failed to act on pharmacy medication review recommendations in a timely manner. |
| Failed to comply with Virginia Statewide Fire Prevention Code by not having annual fire inspection. |
| Failed to ensure fire and emergency evacuation drills were conducted with required frequency and documentation. |
Report Facts
Number of residents present: 42
Number of resident records reviewed: 4
Number of staff records reviewed: 4
Number of interviews with residents: 4
Number of interviews with staff: 4
Missed medication doses: 6
Date of last dietary oversight: Jul 23, 2023
Date of last fire inspection: Apr 19, 2023
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 5
Sep 18, 2024
Visit Reason
The inspection was conducted in response to two complaints received by the VDSS Division of Licensing on 09/17/2024 and 09/18/2024 regarding allegations in the areas of Staffing and Supervision, Resident Care and Related Services, Buildings and Ground, and Emergency Preparedness.
Findings
The investigation supported some, but not all, of the allegations. Areas of non-compliance were found in Resident Care and Related Services and Buildings and Ground. Several violations were cited including failure to complete comprehensive individualized service plans timely, inadequate personal care such as toenail trimming, failure to prepare and serve prescribed diets correctly, lack of proper 'No Smoking-Oxygen in Use' signage, and failure to maintain air conditioning at appropriate temperatures.
Complaint Details
Two complaints were received regarding Staffing and Supervision, Resident Care and Related Services, Buildings and Ground, and Emergency Preparedness. The evidence supported some allegations related to Resident Care and Buildings and Ground. A violation notice was issued.
Deficiencies (5)
| Description |
|---|
| Facility failed to ensure the comprehensive individualized service plan was completed within 30 days after admission. |
| Facility failed to ensure personal assistance and care were provided as necessary, including assistance with trimming fingernails and toenails. |
| Facility failed to ensure prescribed diets were prepared and served according to physician's orders. |
| Facility failed to post 'No Smoking-Oxygen in Use' signs and enforce smoking prohibition where oxygen is in use. |
| Facility failed to provide air conditioning system in all resident areas to maintain temperatures not exceeding 80°F. |
Report Facts
Number of residents present: 46
Number of resident records reviewed: 2
Number of staff interviews conducted: 4
Number of resident interviews conducted: 5
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 7
Aug 26, 2024
Visit Reason
The inspection was conducted in response to two complaints received by VDSS Division of Licensing on 07/30/2024 and 08/21/2024 regarding allegations in administration, staffing, resident care, buildings and grounds, and care for adults with serious cognitive impairments.
Findings
The investigation found some substantiated areas of non-compliance in administration, staffing, resident care, and care for adults with serious cognitive impairments. Violations included failure to secure outdoor areas, failure to report major incidents timely, inadequate communication among staff, incomplete individualized service plans, insufficient supervision of residents, and medication administration errors.
Complaint Details
The inspection was complaint-related based on two complaints alleging issues in administration, staffing, resident care, buildings and grounds, and care for adults with serious cognitive impairments. Some allegations were substantiated, including failure to secure outdoor areas, failure to report incidents, inadequate communication, and medication errors.
Deficiencies (7)
| Description |
|---|
| Facility failed to have a secured outdoor area or provide direct care staff supervision while residents with serious cognitive impairments were outside. |
| Facility failed to report to the regional licensing office within 24 hours of a major incident involving resident elopement. |
| Facility failed to ensure written communication was used to keep direct care staff informed of significant resident incidents. |
| Facility failed to ensure individualized service plans were signed and dated by the licensee or resident/legal representative. |
| Facility failed to provide supervision of resident schedules and care, including attention to wandering from the premises. |
| Facility failed to ensure medications were administered according to physician's instructions, with multiple missed doses documented. |
| Facility failed to ensure medication administration records included dosage administered for sliding scale insulin. |
Report Facts
Residents present: 47
Resident records reviewed: 4
Staff interviews conducted: 4
Resident interviews conducted: 2
Duration resident missing: 1
Missed medication doses: 15
Inspection Report
Monitoring
Census: 47
Deficiencies: 2
Jul 23, 2024
Visit Reason
The inspection was a monitoring visit to assess compliance with applicable standards and laws at the assisted living facility.
Findings
The inspection found non-compliance with standards related to maintenance and cleanliness of the facility, including issues with smoke detectors, fencing, debris, and furniture condition.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure the interior and exterior of the building were maintained in good repair and kept clean and free of rubbish, including a hanging smoke detector, missing fence post, fallen window screens, and debris from a fallen tree. |
| Facility failed to ensure all furnishings, including furniture, were kept clean and in good repair; two couches in the common area were ripped with exposed stuffing. |
Report Facts
Number of residents present: 47
Number of resident records reviewed: 3
Number of staff records reviewed: 1
Number of interviews conducted with residents: 3
Number of interviews conducted with staff: 2
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 6
May 6, 2024
Visit Reason
The inspection was conducted in response to three complaints received by VDSS Division of Licensing regarding staffing and supervision, resident care and related services, and buildings and grounds.
Findings
The investigation supported some, but not all, of the allegations. Areas of non-compliance were found in Resident Care and Related Services and Buildings and Grounds. A violation notice was issued with opportunities for the licensee to submit a plan of correction.
Complaint Details
Three complaints were received on 04/17/2024 and 04/24/2024 regarding staffing and supervision, resident care and related services, and buildings and grounds. The evidence supported some allegations related to resident care and buildings and grounds.
Deficiencies (6)
| Description |
|---|
| Facility failed to ensure services to prevent clinically avoidable complications, including worsening of an ulcer for Resident #4. |
| Facility failed to ensure prescribed diets were prepared and served according to physician's orders for Resident #4. |
| Facility failed to ensure medications were administered within the correct time frame according to the facility's standard dosing schedule for Residents #1 and #3. |
| Facility failed to ensure medical procedures or treatments ordered by a physician were provided and documented for Resident #2. |
| Facility failed to maintain the interior and exterior of all buildings in good repair and free of rubbish; bathroom ceiling tile missing and stained. |
| Facility failed to ensure a signaling device that terminates at a continuously staffed central location was present on the second and third floors. |
Report Facts
Number of residents present: 48
Number of resident records reviewed: 4
Number of staff records reviewed: 0
Number of resident interviews conducted: 4
Number of staff interviews conducted: 3
Medication administration omissions: 18
Dates Accu-Chek not documented: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| M. Tess Pittman | Licensing Inspector | Contact person for questions about the VDSS Licensing Programs |
| Darunda Flint | Licensing Inspector | Current inspector conducting the inspection |
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 4
Apr 10, 2024
Visit Reason
The inspection was conducted in response to two complaints received by VDSS Division of Licensing regarding allegations in the areas of Personnel, Resident Care and Related Services, and Additional requirements for Facilities that Care for Adults with Serious Cognitive Impairment.
Findings
The investigation supported some, but not all, of the allegations. Violations were found in areas including Personnel, Resident Care and Related Services, and Additional requirements for Facilities that Care for Adults with Serious Cognitive Impairment. Several violations related to administrator coverage and activity coordination were cited.
Complaint Details
Two complaints were received on 04/04/2024 and 04/09/2024 regarding allegations in Personnel, Resident Care and Related Services, and Additional requirements for Facilities that Care for Adults with Serious Cognitive Impairment. The evidence supported some of the allegations. A violation notice was issued.
Deficiencies (4)
| Description |
|---|
| The facility failed to ensure the designated, qualified staff person responsible for managing or coordinating the structured activities program is on site in the special care unit at least 20 hours a week. |
| The facility fails to have an administrator of record. |
| The facility failed to ensure if an administrator resigns or is discharged, to immediately employ a new administrator or appoint a qualified acting administrator so that no lapse in administrator coverage occurs, and failed to notify the department's regional licensing office in writing within 14 days of a change in administrator. |
| The facility failed to ensure the monthly activity calendar posted for both the assisted living and memory care unit included the type of the activity. |
Report Facts
Number of residents present: 52
Inspection duration: 7.92
Hours spent by Activities Coordinator: 10
Administrator coverage lapse start date: Mar 20, 2024
Notification timeframe: 14
Inspection Report
Renewal
Census: 52
Deficiencies: 26
Apr 10, 2024
Visit Reason
The inspection was a renewal inspection conducted on April 10 and April 11, 2024, to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection found multiple violations of regulatory standards including failure to ensure appropriate placement and review of residents in the special care unit, failure to report major incidents timely, inadequate staff training, incomplete resident assessments, medication management issues, and deficiencies in emergency preparedness and documentation.
Deficiencies (26)
| Description |
|---|
| Failed to ensure appropriate placement determination for residents with serious cognitive impairment in the special care unit. |
| Failed to perform six-month and annual reviews of residents' appropriateness for continued residence in the special care unit. |
| Failed to report major incidents to the regional licensing office within 24 hours. |
| Staff annual training did not include at least two hours on infection control and prevention. |
| Failed to ensure timely tuberculosis risk assessments for staff and household members. |
| Failed to complete written fall risk ratings for residents meeting assisted living criteria. |
| Failed to complete fall risk ratings annually, after condition changes, and after falls. |
| Failed to ascertain and document sex offender status prior to admission. |
| Failed to complete annual resident UAI assessments. |
| Comprehensive ISP did not include current identified needs or service descriptions. |
| Failed to retain a licensed health care professional with required experience for on-site oversight. |
| Failed to ensure annual review of resident rights and responsibilities documentation. |
| Failed to conduct dietary oversight every six months for special diets. |
| Failed to prevent use of outdated medications and properly dispose of expired medications. |
| Failed to have a current pharmacy reference book or medication handbook accessible to staff. |
| Medication carts were found unlocked and unattended during observations. |
| Medication aides were not supervised by a qualified individual. |
| Failed to ensure medication reviews every six months for residents assessed for assisted living care. |
| Failed to ensure valid written Do Not Resuscitate (DNR) orders were included in individualized service plans. |
| Hot water taps were not maintained within the required temperature range of 105°F to 120°F. |
| Signaling devices did not reliably indicate the origin of call signals to staff. |
| Failed to document fire and emergency evacuation drills for 2023 and 2024. |
| Failed to ensure monthly checks of first aid kits and expiration dates of items. |
| Failed to document staff participation in emergency procedure practice exercises at least every six months. |
| Failed to obtain criminal history record reports on or prior to the 30th day of employment for staff. |
| Failed to maintain original criminal history record reports in staff records. |
Report Facts
Number of residents present: 52
Number of resident records reviewed: 6
Number of staff records reviewed: 4
Number of interviews with residents: 4
Number of interviews with staff: 4
Number of residents reviewed in medication review: 4
Number of documented falls for Resident #1: 5
Dates of Resident #1 falls: Falls on 3/21/2024, 3/9/2024, 2/29/2024, 1/29/2024, and 1/13/2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Darunda Flint | Licensing Inspector | Current inspector conducting the inspection |
| M. Tess Pittman | Licensing Inspector | Contact person for questions about the inspection |
| Staff #1 | Mentioned in multiple findings including incident reporting, medication cart supervision, emergency drills, and call bell signaling | |
| Staff #2 | Mentioned in tuberculosis risk assessment deficiency | |
| Staff #5 | Mentioned in infection control training, tuberculosis risk assessment, and criminal history record report deficiencies | |
| Staff #6 | Mentioned in criminal history record report deficiency | |
| Staff #7 | Mentioned in criminal history record report deficiency | |
| Staff #8 | Mentioned in pharmacy reference materials deficiency |
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 8
Feb 21, 2024
Visit Reason
The inspection was conducted in response to eight complaints received by VDSS Division of Licensing regarding allegations in the areas of Administration and Administrative Services, Personnel, Resident Care and Related Services, and Buildings and Grounds.
Findings
The investigation supported some, but not all, of the allegations. Areas of non-compliance were found in Personnel, Resident Care and Related Services, and Buildings and Grounds. Multiple violations were identified including failure to employ a full-time administrator, unqualified direct care staff, improper snack labeling, unlocked medication carts, lack of supervision for medication aides, missed medication administration, poor building maintenance, and lack of signaling devices for residents.
Complaint Details
Eight complaints were received on various dates in February 2024 regarding Administration, Personnel, Resident Care, and Buildings and Grounds. The evidence supported some allegations, resulting in a violation notice and opportunity for plan of correction.
Deficiencies (8)
| Description |
|---|
| Facility failed to ensure an administrator serve on a full-time basis as the on-site agent of the licensee. |
| Facility failed to ensure direct care staff meet one of the requirements in this subsection; staff had an expired CNA license. |
| Facility failed to ensure snacks for the current week be dated and posted in an area conspicuous to residents. |
| Facility failed to ensure the medication cart be locked and the individual responsible for medication administration shall keep the keys on their person. |
| Facility failed to ensure medication aides are supervised by a qualified individual. |
| Facility failed to ensure medications be administered within the facility's standard dosing schedule; missed doses were documented. |
| Facility failed to ensure the interior of the building be maintained in good repair and kept clean and free of rubbish. |
| Facility failed to ensure all assisted living facilities have a signaling device easily accessible to the resident that alerts direct care staff. |
Report Facts
Number of complaints received: 8
Number of resident records reviewed: 1
Number of staff records reviewed: 3
Number of interviews with residents: 5
Number of interviews with staff: 5
Inspection Report
Monitoring
Census: 54
Deficiencies: 2
Jan 18, 2024
Visit Reason
The inspection was a monitoring visit conducted to review building and grounds as well as emergency preparedness following a self-reported incident regarding allegations in these areas.
Findings
The inspection found violations related to inadequate heating in resident apartments and common areas, with temperatures below the required 72°F, and the facility's failure to have a written emergency preparedness plan addressing loss of heat and other emergencies.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure heat was supplied from a central heating plant or electrical heating system maintaining at least 72°F in resident areas during waking hours. |
| Facility failed to develop a written emergency preparedness plan including analysis of potential hazards such as loss of utilities or emergencies disrupting normal operations. |
Report Facts
Number of residents present: 54
Number of apartments below 72°F: 15
Inspection duration: 2.33
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| M. Tess Pittman | Licensing Inspector | Contact person for questions regarding the inspection |
| Darunda Flint | Licensing Inspector | Current inspector on-site during the inspection |
| Staff #1 | Facility staff involved in the tour and emergency preparedness discussion |
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 5
Jan 18, 2024
Visit Reason
The inspection was conducted due to five complaints received by VDSS Division of Licensing regarding allegations in Administration and Administrative Services, Admission, Retention and Discharge of Residents, Resident Care and Related Services, Buildings and Grounds, and Emergency Preparedness.
Findings
The investigation supported some, but not all, of the allegations. Areas of non-compliance were found in Administration and Administrative Services, Buildings and Grounds, and Emergency Preparedness. A violation notice was issued with opportunities for the licensee to submit a plan of correction.
Complaint Details
Five complaints were received on 12/29/2023, 1/2/2024, 1/13/2024 (2), and 1/16/2024 regarding multiple areas. The evidence supported some of the allegations. A violation notice was issued.
Deficiencies (5)
| Description |
|---|
| Facility failed to report to the regional licensing office within 24 hours of a major incident involving a resident's unexpected death. |
| Facility failed to ensure a record was established for each staff person. |
| Facility failed to ensure menus for meals for the current week were dated and posted in an area conspicuous to residents. |
| Facility failed to ensure the interior of the building was maintained in good repair and kept clean and free of rubbish, including missing peephole, roof hole, and smoke detector issues. |
| Facility failed to develop and implement a semi-annual review on the emergency preparedness and response plan for all staff, residents, and volunteers. |
Report Facts
Number of residents present: 54
Number of resident records reviewed: 3
Number of staff records reviewed: 1
Number of interviews conducted with residents: 3
Number of interviews conducted with staff: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff #1 | Acknowledged failure to report major incident and could not provide documentation for emergency preparedness review. | |
| Staff #2 | Staff record was not available; hired 1/12/2024. |
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 9
Dec 14, 2023
Visit Reason
The inspection was conducted in response to three complaints received by VDSS Division of Licensing regarding allegations in the areas of Staffing and Supervision, Resident Care and Related Services, and Buildings and Grounds.
Findings
The investigation supported some but not all allegations, identifying non-compliance in Resident Care and Related Services and Buildings and Grounds. Multiple violations were cited including failures in individualized service plans, medication administration, oxygen use training, building maintenance, elevator inspection, and heating system adequacy.
Complaint Details
Three complaints were received on 12/05/2023, 12/06/2023, and 12/09/2023 regarding Staffing and Supervision, Resident Care and Related Services, and Buildings and Grounds. The investigation substantiated some allegations related to Resident Care and Related Services and Buildings and Grounds.
Deficiencies (9)
| Description |
|---|
| Facility failed to ensure resident’s comprehensive individualized service plan included a description of identified needs. |
| Facility failed to ensure the individualized service plan was signed and dated by the resident or their legal representative. |
| Facility failed to ensure individualized service plans were reviewed and updated at least once every 12 months and as needed for significant changes. |
| Facility failed to ensure medications were administered within one hour before or after the facility's standard dosing schedule. |
| Facility failed to post 'No Smoking-Oxygen in Use' signs and enforce smoking prohibition where oxygen is in use. |
| Facility failed to demonstrate that all direct care staff assisting residents using oxygen supplies had training or instruction in use and maintenance of resident-specific equipment. |
| Facility failed to ensure the interior of the building was maintained in good repair and kept clean and free of rubbish. |
| Facility failed to ensure elevators were kept in good running condition and inspected at least annually; elevator inspection certificate expired. |
| Facility failed to ensure heat was supplied adequately to maintain at least 72°F in resident areas during waking hours. |
Report Facts
Number of residents present: 54
Number of resident records reviewed: 3
Number of staff records reviewed: 0
Number of resident interviews: 3
Number of staff interviews: 1
Number of complaints received: 3
Elevator inspection certificate expiration date: Mar 31, 2022
Resident apartment temperature: 67
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| M. Tess Pittman | Licensing Inspector | Contact person for questions regarding the inspection |
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 6
Oct 26, 2023
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2023-10-18 regarding allegations in the areas of Background Checks, Personnel, Admission, Retention and Discharge of Residents, Resident Care and Related Services, Buildings and Grounds, and Additional Requirements for Facilities that Care for Adults with Serious Cognitive Impairment.
Findings
The investigation supported some, but not all, of the allegations. Areas of non-compliance were found in Personnel and Resident Care and Related Services. Multiple violations were cited including failure to maintain required records for private duty personnel, incomplete approval of UAIs, unsigned individualized service plans, medication administration documentation errors, incomplete medication administration records, and employment of a staff member with a misdemeanor barrier crime conviction.
Complaint Details
The complaint was substantiated in part; violations related to Personnel and Resident Care and Related Services were found. Some allegations were not supported.
Deficiencies (6)
| Description |
|---|
| Facility failed to provide or obtain required information in the record for private duty personnel. |
| Facility failed to ensure for private pay individuals, the administrator or designated representative approves and signs the completed UAI. |
| Facility failed to ensure individualized service plans were signed and dated by the resident or their legal representative. |
| Facility failed to ensure medications were administered within the facility's standard dosing schedule and properly documented. |
| Facility failed to ensure MARs included required items such as name, signature, initials of staff administering medications, and dates medications were prescribed. |
| Facility employed a staff member convicted of a misdemeanor barrier crime. |
Report Facts
Number of residents present: 49
Number of resident records reviewed: 6
Number of staff records reviewed: 2
Number of resident interviews conducted: 2
Number of staff interviews conducted: 3
Date of hire for staff with barrier crime: Aug 3, 2023
Date of criminal history report: Oct 11, 2023
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 6
Oct 2, 2023
Visit Reason
The inspection was conducted in response to six complaints received by VDSS Division of Licensing between 09/21/2023 and 09/27/2023 regarding allegations in areas including Background Checks, Personnel, Admission, Retention and Discharge of Residents, Buildings and Grounds, and Additional Requirements for Facilities that Care for Adults with Serious Cognitive Impairment.
Findings
The investigation supported some but not all allegations; non-compliance was found in Background Checks and Buildings and Grounds. Multiple violations were cited including improper record confidentiality, failure to ensure background checks before employment, failure to maintain building interior in good repair, and employment of a person with a felony barrier crime conviction.
Complaint Details
Six complaints were received regarding Background Checks, Personnel, Admission, Retention and Discharge of Residents, Buildings and Grounds, and Additional Requirements for Facilities that Care for Adults with Serious Cognitive Impairment. The evidence supported some allegations related to Background Checks and Buildings and Grounds.
Deficiencies (6)
| Description |
|---|
| Facility failed to ensure all staff records were treated confidentially; records were accessible to maintenance and housekeeping staff. |
| Facility failed to ensure no employee worked in direct contact with residents before background checks were received. |
| Facility failed to ensure all resident records were treated confidentially; records accessible to maintenance and housekeeping staff. |
| Facility failed to maintain the interior of the building in good repair and kept clean and free of rubbish, including stained and missing ceiling tiles, unsecured construction area with hazards, and unclean kitchenette equipment. |
| Facility failed to obtain criminal history record reports on or prior to the 30th day of employment for multiple staff members. |
| Facility employed a person convicted of a felony barrier crime. |
Report Facts
Number of residents present: 46
Number of resident records reviewed: 5
Number of staff records reviewed: 63
Number of interviews conducted with residents: 5
Number of interviews conducted with staff: 5
Number of complaints received: 6
Shifts worked without background check: 11
Shifts worked without background check: 5
Inspection Report
Monitoring
Census: 39
Deficiencies: 4
Aug 1, 2023
Visit Reason
The inspection was a monitoring visit conducted on August 1, 2023, following a self-reported incident received on June 19, 2023, regarding allegations in the areas of Admission, Retention and Discharge of Residents.
Findings
The investigation did not support the self-report of non-compliance; however, violations unrelated to the self-report were identified. These included failures to provide written assurance of appropriate licensing at admission, assist residents in discharge or transfer planning, and develop preliminary and comprehensive individualized service plans within required timeframes.
Deficiencies (4)
| Description |
|---|
| Facility failed to provide written assurance to a resident or legal representative documenting appropriate license at admission. |
| Facility failed to assist the resident and legal representative in the discharge or transfer process, including preparation for relocation. |
| Facility failed to ensure a preliminary plan of care was developed on or within seven days prior to admission. |
| Facility failed to ensure a comprehensive individualized service plan was completed within 30 days after admission. |
Report Facts
Number of residents present: 39
Number of resident records reviewed: 1
Number of resident interviews: 1
Number of staff interviews: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff #1 | Acknowledged inability to provide preliminary and comprehensive individualized service plans for Resident #1 |
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 2
Aug 1, 2023
Visit Reason
The inspection was conducted in response to a complaint received on 2023-06-30 regarding allegations related to buildings and grounds at the facility.
Findings
The investigation found violations related to the facility's failure to maintain the interior in good repair and cleanliness, including hazards such as a couch blocking a hallway, exposed and damaged ceiling tiles with leaks, and failure to maintain air conditioning temperatures within required limits.
Complaint Details
The complaint was substantiated as evidence supported the allegations of non-compliance with standards related to buildings and grounds.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure the interior of the building was maintained in good repair and kept clean and free of rubbish. |
| Facility failed to provide an air conditioning system for all areas used by residents, with temperatures exceeding 80°F in some areas. |
Report Facts
Number of residents present: 39
Number of resident interviews: 2
Number of staff interviews: 1
Temperature measurements: 84
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 13, 2023
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2023-03-09 regarding allegations in the areas of Resident Care and Related Services, Resident Accommodations and Related Provisions, and Building and Grounds.
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 and a copy is required to be posted on the facility premises.
Complaint Details
Complaint investigation related to allegations in Resident Care and Related Services, Resident Accommodations and Related Provisions, and Building and Grounds. The allegations were not substantiated.
Report Facts
Number of resident interviews: 2
Number of staff interviews: 1
Inspection Report
Renewal
Census: 38
Deficiencies: 19
Apr 11, 2023
Visit Reason
The inspection was a renewal inspection conducted on April 11 and April 13, 2023, 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 documentation, tuberculosis risk assessments, first aid certification, posting of on-site person in charge, annual resident assessments, individualized service plans, medication management, code status documentation, hot water temperature, fire safety inspection, and criminal history record checks. Plans of correction were proposed for each deficiency.
Deficiencies (19)
| Description |
|---|
| Failed to ensure residents are assessed by an independent clinical psychologist or physician for serious cognitive impairment prior to admission. |
| Failed to document type, entity, hours, and dates of staff training in a manner identifiable by individual staff. |
| Failed to ensure tuberculosis risk assessments were completed and dated for staff prior to first day of work. |
| Failed to ensure direct care staff maintain current certification in first aid. |
| Failed to post the name of the current on-site person in charge in a conspicuous place. |
| Failed to annually complete a tuberculosis risk assessment for each resident. |
| Failed to complete a resident's Uniform Assessment Instrument (UAI) at least annually. |
| Failed to develop a preliminary plan of care on or within seven days prior to admission. |
| Failed to ensure comprehensive individualized service plans include current identified needs and services based on UAI. |
| Failed to ensure individualized service plans are reviewed and updated at least once every 12 months. |
| Failed to ensure personnel are available to assist residents in reaching the dining room or when eating. |
| Failed to ensure menus for meals for the current week are dated and posted conspicuously. |
| Failed to implement medication management plan to prevent use of outdated medications and ensure proper disposal. |
| Failed to ensure over-the-counter medications remain in original container labeled with resident's name or pharmacy-issued container until administered. |
| Failed to ensure valid written Do Not Resuscitate (DNR) orders are issued by attending physician and included in individualized service plans. |
| Failed to maintain hot water temperature at taps available to residents within 105°F to 120°F. |
| Failed to comply with Virginia Statewide Fire Prevention Code as determined by annual inspection by appropriate fire official. |
| Failed to ensure criminal history record report is obtained on or prior to the 30th day of employment for each employee. |
| Failed to ensure temporary agency staff background checks are completed by Virginia State Police. |
Report Facts
Number of residents present: 38
Number of resident records reviewed: 8
Number of staff records reviewed: 4
Expired medication date: Nov 18, 2022
Last fire inspection date: Mar 24, 2022
Staff #6 hire date: Aug 23, 2022
Staff #6 criminal history report date: Nov 30, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff #1 | Designated on-site person in charge; confirmed Staff #2 lacks current first aid certification | |
| Staff #2 | Direct care staff lacking current first aid certification and incomplete TB risk assessment | |
| Staff #3 | Staff with incomplete training documentation | |
| Staff #4 | Staff with incomplete training documentation | |
| Staff #5 | Temporary agency staff with incomplete background checks | |
| Staff #6 | Staff with delayed criminal history record report |
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 17, 2023
Visit Reason
The inspection was conducted in response to a complaint received on 2023-02-16 regarding allegations related to Building and Grounds and Emergency Preparedness.
Findings
The investigation found no evidence to support the allegations of non-compliance with standards or law. The entrance door into the safe, secure environment was reviewed and no resident or staff records were examined.
Complaint Details
A complaint was received by VDSS Division of Licensing on 02/16/2023 regarding allegations in the areas of Building and Grounds and Emergency Preparedness. The evidence gathered did not support the allegations of non-compliance.
Report Facts
Number of interviews conducted: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Darunda Flint | Current Inspector | Inspector conducting the complaint investigation |
| M. Tess Pittman | Licensing Inspector | Contact person for questions regarding the inspection |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 19, 2023
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2023-01-11 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 of receipt.
Complaint Details
Complaint received on 2023-01-11 regarding Resident Care and Related Services; investigation did not substantiate the allegations.
Report Facts
Resident records reviewed: 4
Staff interviews conducted: 1
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 2
Dec 19, 2022
Visit Reason
The inspection was conducted in response to a complaint received on 2022-11-28 regarding allegations in the areas of Administration and Administrative Services, Resident Care and Related Services, Resident Accommodations and Related Provisions, and Emergency Preparedness.
Findings
The investigation supported some but not all allegations; non-compliance was found in Emergency Preparedness. Violations included failure to conduct a semi-annual review of the emergency preparedness and response plan and failure to maintain complete records of fire and emergency evacuation drills.
Complaint Details
The complaint was substantiated in part, specifically regarding Emergency Preparedness violations.
Deficiencies (2)
| Description |
|---|
| Facility failed to develop and implement a semi-annual review on the emergency preparedness and response plan for residents with emphasis on individual responsibilities. |
| Facility failed to ensure a record of required fire and emergency evacuation drills was kept with all required details. |
Report Facts
Number of residents present: 42
Number of staff records reviewed: 3
Number of staff interviews conducted: 2
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 0
Oct 12, 2022
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 2022-08-26 regarding allegations in the areas of Admission, Retention, and Discharge of Residents, Resident Care and Related Services, and Resident Accommodations and Related Provisions.
Findings
The investigation did not support the allegations of non-compliance with standards or law. The inspection included a tour of the physical plant focusing on a safe, secure environment, and an exit meeting was planned to review findings.
Complaint Details
A complaint was received on 2022-08-26 regarding allegations in the areas of Admission, Retention, and Discharge of Residents, Resident Care and Related Services, and Resident Accommodations and Related Provisions. The evidence gathered did not support the allegations of non-compliance.
Report Facts
Number of residents present: 36
Number of resident records reviewed: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Darunda Flint | Licensing Inspector | Current inspector conducting the inspection |
| M. Tess Pittman | Licensing Inspector | Contact person for questions regarding the inspection |
Inspection Report
Monitoring
Census: 36
Deficiencies: 0
Oct 12, 2022
Visit Reason
The inspection was a monitoring visit to review compliance with additional requirements for facilities that care for adults with serious cognitive impairments.
Findings
The inspection found no violations of applicable standards or laws. All exits within the memory care unit were reviewed and secured.
Report Facts
Number of residents present: 36
Inspection Report
Monitoring
Census: 43
Deficiencies: 0
Jul 14, 2022
Visit Reason
The inspection was a monitoring visit to review the physical plant, including the building and grounds, and to test the call bell system.
Findings
The inspection found no violations of applicable standards or laws. The call bell system was reviewed and tested without issues.
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 0
Jul 14, 2022
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 07/11/2022 regarding allegations in the areas of Administration and Administrative Services and Buildings and Grounds.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. The licensing inspector completed a tour of the physical plant including the building and grounds.
Complaint Details
Complaint related inspection with allegations in Administration and Administrative Services and Buildings and Grounds; allegations were not substantiated.
Report Facts
Number of residents present: 43
Inspection Report
Monitoring
Census: 43
Deficiencies: 4
Jul 14, 2022
Visit Reason
The inspection was a monitoring visit conducted on July 14, 2022, following three self-reported incidents received by VDSS Division of Licensing regarding allegations in staffing, admission, resident care, emergency preparedness, and care for adults with serious cognitive impairments.
Findings
The inspection found multiple violations related to the care and placement of residents with serious cognitive impairments, including delayed assessments, lack of written approvals for placement, missing documentation of appropriateness of placement, and failure to secure exit doors leading to unprotected areas. The facility was found non-compliant and violations were issued.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure residents were assessed by an independent clinical psychologist or physician prior to admission to a safe, secure environment. |
| Facility failed to obtain written approval for placement of residents with serious cognitive impairment in a safe, secure environment. |
| Facility failed to ensure licensee, administrator, or designee determined appropriateness of placement in the special care unit for residents with serious cognitive impairment. |
| Facility failed to ensure doors leading to unprotected areas were monitored or secured through devices conforming to building and fire codes. |
Report Facts
Residents present: 43
Resident records reviewed: 3
Self-reported incidents: 3
Inspection Report
Renewal
Census: 38
Deficiencies: 7
May 5, 2022
Visit Reason
The inspection was a renewal inspection conducted to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection identified multiple violations including failure to complete tuberculosis risk assessments, incomplete uniform assessment instruments, failure to ensure resident rights and dignity, inadequate staff availability during meals, maintenance issues, signaling device accessibility problems, and delays in obtaining criminal history record reports for employees. Plans of correction were submitted for all deficiencies with no adverse effects on residents noted.
Deficiencies (7)
| Description |
|---|
| Failed to complete a risk assessment for tuberculosis on each resident as required. |
| Failed to ensure the uniform assessment instrument was completed as required for private pay individuals. |
| Failed to ensure a resident's right to be treated with courtesy, respect, and dignity. |
| Failed to ensure personnel were available to assist residents in reaching the dining room or when eating. |
| Failed to maintain the interior and exterior of buildings in good repair and free of rubbish. |
| Failed to ensure a signaling device was easily accessible and staff responded timely to resident calls. |
| 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: 38
Number of resident records reviewed: 8
Number of staff records reviewed: 4
Number of staff with late criminal history reports: 4
Call bell system repair completion date: May 27, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| M. Tess Pittman | Licensing Inspector | Contact person for questions about the VDSS Licensing Programs |
Inspection Report
Monitoring
Census: 37
Deficiencies: 4
Apr 12, 2022
Visit Reason
An unannounced, focused monitoring inspection was conducted to review personnel, resident care, building and grounds, and additional requirements for adults with serious cognitive impairments.
Findings
The inspection found multiple violations related to medication management, including expired medications on medication carts, incomplete or inaccurate physician orders, medication administration timing errors, and missing required information on medication administration records (MARs). Corrective actions and audits were planned to address these issues.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure their written plan for medication management includes methods to prevent the use of outdated medications; expired medications were found on medication carts. |
| Facility failed to ensure physician or other prescriber orders include all required information such as resident name, date, drug details, and indications. |
| Facility failed to ensure medications were administered within one hour before or after the scheduled dosing time. |
| Facility failed to ensure the MAR included all required information, including diagnoses for medications. |
Report Facts
Residents in care: 37
Medication carts with expired medications: 3
Medication administration audit frequency: 3
Audit duration: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff #3 | Terminated for failure to ensure medications were administered within the facility's standard dosing schedule | |
| Darunda Flint | Licensing Inspector | Conducted the inspection |
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 24, 2022
Visit Reason
An unannounced complaint inspection was initiated due to allegations regarding resident care and related services, including additional requirements for facilities caring for adults with serious cognitive impairment.
Findings
Records were reviewed, staff interviews conducted, and a tour of the safe, secure environment was held. Any violations identified during the investigation are documented in the violation notice.
Complaint Details
The inspection was complaint-related, investigating allegations in resident care and services for adults with serious cognitive impairment.
Inspection Report
Complaint Investigation
Deficiencies: 2
Mar 24, 2022
Visit Reason
An unannounced complaint inspection was initiated due to allegations regarding resident care and related services in the facility's safe, secure environment.
Findings
The facility failed to ensure doors leading to unprotected areas were properly secured and monitored, and failed to document that residents received bathing at least twice a week as required. Staff interviews and record reviews confirmed these deficiencies.
Complaint Details
The inspection was complaint-related. The complaint involved allegations in the areas of resident care and related services. The complaint was substantiated by findings of unsecured doors and inadequate bathing documentation.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure doors leading to unprotected areas were monitored or secured through devices conforming to applicable building and fire codes. |
| Facility failed to ensure personal assistance and care were provided to each resident as necessary, specifically lacking documentation of bathing at least twice a week. |
Report Facts
Audit frequency: 5
Audit duration (weeks): 8
Residents scheduled for shower and skin check: 4
Audit frequency: 5
Audit duration (weeks): 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff #5 | Notified and rearmed the alarm on the door but unable to state why it was unarmed. | |
| Staff #1 | Acknowledged documentation did not indicate if bathing was completed and was unable to verify at the time of inspection. | |
| Staff #2 | Acknowledged documentation did not indicate if bathing was completed and was unable to verify at the time of inspection. | |
| Maintenance Director | Completed 100% audit of exit doors and will conduct ongoing audits. | |
| Administrator | Completed oversight of the exit door audit and will receive reports of issues. | |
| Assistant Resident Care Coordinator | Completed 100% audit of bathing schedules and will conduct ongoing audits. | |
| Resident Care Coordinator | Completed oversight of bathing audit and will receive reports of issues. |
Inspection Report
Complaint Investigation
Deficiencies: 6
Jan 31, 2022
Visit Reason
An unannounced complaint inspection was initiated due to allegations regarding administration, staffing, resident care, and building conditions. The inspection included on-site observations, interviews, and record reviews to investigate these complaints.
Findings
The investigation found multiple violations including inadequate direct care staffing in special care units, failure to report medication errors timely, insufficient qualified staff to administer medications, lack of valid physician orders for treatments, failure to document medication errors properly, and poor maintenance of building conditions such as flickering lights and unsecured ceiling tiles.
Complaint Details
The complaint investigation substantiated some allegations of non-compliance with standards and law related to staffing, medication administration, incident reporting, and building maintenance.
Deficiencies (6)
| Description |
|---|
| Facility failed to ensure at least two awake direct care staff on duty at all times in special care units except during night hours when 20 or fewer residents are present. |
| Facility failed to report a major incident affecting resident health to the regional licensing office within 24 hours. |
| Facility failed to have adequate staff with knowledge, skills, and sufficient numbers to provide required services. |
| 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 proper actions and documentation in the event of a medication error. |
| Facility failed to maintain interior and exterior of buildings in good repair and kept clean and free of rubbish. |
Report Facts
Shifts with two direct care staff in special care unit: 12
Dates without LPN or RMA scheduled: 3
Dates with insufficient CNA coverage: 8
Dates Ted Hose not placed on Resident #3: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Darunda Flint | Inspector | Named as current inspector conducting the complaint investigation. |
| Staff #1 | Provided staff schedules, acknowledged medication error non-reporting, and involved in findings related to staffing and medication errors. | |
| Staff #2 | Involved in medication error incident and related findings. | |
| Resident Care Coordinator | Scheduled/working during deficient staffing periods and responsible for audits and in-service training. | |
| Administrator | PCA | Scheduled/working during deficient staffing periods and responsible for audits and in-service training. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Jan 31, 2022
Visit Reason
An unannounced complaint inspection was initiated due to allegations regarding resident care and related services at the facility.
Findings
The facility failed to ensure that physician or other prescriber oral orders were reviewed and signed within 14 days, and failed to meet conditions permitting the use of PRN medications, including lack of detailed medication orders specifying symptoms, dosage, time frames, and directions.
Complaint Details
Complaint related: Yes. A complaint was received regarding allegations in resident care and related services. The complaint was investigated with on-site observations, record reviews, and staff interviews.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure physician's or other prescriber's oral orders were reviewed and signed within 14 days. |
| Facility failed to ensure conditions permitting the use of PRN medications were met, including detailed medication orders. |
Report Facts
Audit frequency: 3
Audit duration (weeks): 8
Medication dosage: 200
Medication dosage: 25
Date of medication order: Jan 8, 2022
Date of MAR medication administration: Jan 25, 2022
Inspection Report
Monitoring
Census: 35
Deficiencies: 23
Jan 31, 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 areas of non-compliance including failures in resident assessments, documentation, staff certifications, medication administration, record keeping, and facility policies. Violations were documented and discussed with the Administrator.
Deficiencies (23)
| Description |
|---|
| Facility failed to ensure residents were assessed by an independent clinical psychologist or physician for serious cognitive impairment prior to admission. |
| Facility failed to obtain written approval for placement of residents with serious cognitive impairment in a special care unit. |
| Facility failed to document determination and justification for placement in the special care unit by licensee or designee. |
| Facility failed to exercise general supervision and establish policies and procedures in conformance with applicable law. |
| Staff records lacked current tuberculosis risk assessments. |
| Direct care staff member lacked current certification in first aid. |
| Facility failed to post the name of the current on-site person in charge conspicuously. |
| Resident records lacked written assurance of facility license to meet care needs. |
| Facility failed to ensure physical examinations and tuberculosis risk assessments were current for residents. |
| Facility failed to complete fall risk ratings after falls and annually for residents. |
| Facility failed to ascertain and document sex offender status prior to admission. |
| Resident records lacked required personal and social information. |
| Facility failed to provide orientation for new residents and legal representatives. |
| Facility failed to complete Uniform Assessment Instrument (UAI) for residents prior to admission and annually. |
| Facility failed to develop preliminary and comprehensive individualized service plans for residents. |
| Facility failed to obtain written acknowledgment of receipt and review of resident rights and responsibilities. |
| Resident records and medication carts were not kept current, retained properly, or secured. |
| Facility failed to ensure physician orders for medications included all required information. |
| Medication storage areas and carts were unlocked and accessible. |
| Medications were not administered according to the facility's dosing schedule and orders. |
| Medication Administration Records (MAR) lacked required information including diagnoses, dosages, and parameters. |
| Signaling devices were not operational or accessible to residents to alert staff for assistance. |
| Facility failed to obtain criminal history record reports on or prior to the 30th day of employment for staff. |
Report Facts
Residents in care: 35
Staff records reviewed: 3
Resident records reviewed: 6
Medication administration observation: 35
Audit frequency: 3
Audit duration: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Darunda Flint | Licensing Inspector | Conducted the inspection |
| Staff #4 | Certified Nursing Assistant without current first aid certification | |
| Staff #9 | Observed administering medications during inspection | |
| Staff #2 | Acknowledged medication binders should be locked and issues with medication administration | |
| Staff #3 | Acknowledged medication carts were unlocked | |
| Staff #1 | Informed about medication administration issues | |
| Staff #8 | Acknowledged failure to obtain criminal history record reports timely | |
| Staff #7 | Did not have completed criminal history record report at time of inspection |
Inspection Report
Complaint Investigation
Deficiencies: 2
Jan 31, 2022
Visit Reason
An unannounced complaint inspection was initiated due to allegations regarding staffing, supervision, and resident care and related services at the facility.
Findings
The facility failed to implement established policies and procedures, including delayed emergency response after a resident fall and failure to conduct and document two-hour rounds for residents unable to use signaling devices.
Complaint Details
The complaint was substantiated with findings that the facility did not follow required policies for emergency response and resident monitoring. The complaint related to staffing, supervision, and resident care was investigated through observations, record reviews, and staff interviews.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure implementation of policies, procedures, and services, evidenced by delayed emergency response after Resident #1's fall on 12/23/2021. |
| Facility failed to ensure direct care staff made and documented rounds at least every two hours for residents unable to use signaling devices. |
Report Facts
Dates of inspection visits: On-site observations conducted on 01/31/2022 and 02/14/2022
Fall incident date: Resident #1 fell on 12/23/2021
Audit duration: 8
Rounds audit frequency: 3
Inspection Report
Routine
Census: 34
Deficiencies: 2
Nov 18, 2021
Visit Reason
The inspection was an initial routine inspection initiated on November 18, 2021, to assess compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection identified multiple violations including unsecured access to potentially harmful materials, safety hazards such as exposed wires and tripping hazards, and maintenance issues including damaged screens, carpet stains, and unoccupied units due to ongoing repairs.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure ordinary materials or objects that may be harmful to residents were inaccessible except under staff supervision, including unlocked doors to laundry and housekeeping closets containing cleaning products and exposed TV wires posing safety hazards. |
| Facility failed to maintain the interior and exterior of all buildings in good repair and kept clean and free of rubbish, including ripped screen porch door, debris and branches in courtyard, unleveled walkways posing tripping hazards, sharp fence corners, exposed wires by outdoor lighting, carpet stains, and ten units unfit for occupancy due to air conditioning repairs and exposed ceilings with hanging wires and standing water. |
Report Facts
Resident census: 34
Units unoccupied: 10
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