Inspection Reports for
Regency at Augusta
43 Pinnacle Drive, FISHERSVILLE, VA, 22939
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
7.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
18% better than Virginia average
Virginia average: 9.1 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
72 residents
Based on a October 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Monitoring
Census: 72
Deficiencies: 1
Date: Oct 21, 2025
Visit Reason
The inspection was a monitoring visit triggered by a self-reported incident received on 2025-10-14 regarding allegations in the area of resident care and related services.
Findings
The inspection findings supported the self-report of non-compliance with standards or law, resulting in violations issued related to the facility's failure to assume general responsibility for the health, safety, and well-being of a resident who was found outside of memory care for approximately one minute.
Deficiencies (1)
The facility failed to assume general responsibility for the health, safety, and well-being of the resident who was found outside of memory care and unaccounted for approximately one minute.
Report Facts
Residents present: 72
Resident records reviewed: 1
Staff records reviewed: 0
Resident interviews conducted: 1
Staff interviews conducted: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela N Via | Licensing Inspector | Inspector conducting the inspection and named in the report |
| Executive Director | Named in plan of correction for actions including staff notification and education | |
| Maintenance Assistant | Installed locked box around exit button as part of plan of correction | |
| Staff 1 | Staff member who showed video footage and confirmed details of resident being outside memory care |
Inspection Report
Monitoring
Census: 74
Deficiencies: 0
Date: Sep 5, 2025
Visit Reason
The inspection was a monitoring visit triggered by a self-reported incident received by VDSS Division of Licensing on 2025-09-01 regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation did not support the self-report of non-compliance with standards or law. The licensing inspector reviewed resident records, incident reports, staff communication, and staff schedules and found no evidence of non-compliance.
Report Facts
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: 1
Inspection Report
Monitoring
Census: 71
Deficiencies: 0
Date: Aug 29, 2025
Visit Reason
The inspection was a monitoring visit following a self-reported incident received by VDSS Division of Licensing on 2025-08-15 regarding allegations in the area of Resident Care and Related Services.
Findings
The licensing inspector toured the facility, reviewed medication records, the medication management plan, and incident reports. The evidence gathered did not support the self-report of non-compliance with standards or law.
Report Facts
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: 1
Inspection Report
Monitoring
Census: 73
Deficiencies: 0
Date: Jul 2, 2025
Visit Reason
The inspection was conducted as a monitoring visit following a self-reported incident received by VDSS Division of Licensing regarding allegations in the area of Resident Care and Related Services.
Findings
The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law. The licensing inspector observed residents, reviewed video footage, incident reports, and staff communication, and conducted interviews without identifying any deficiencies.
Report Facts
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: 1
Inspection Report
Monitoring
Census: 70
Deficiencies: 2
Date: May 21, 2025
Visit Reason
The inspection was a monitoring visit triggered by a self-reported incident received by VDSS Division of Licensing on 2025-01-22 regarding allegations in the area of Protection of Adults and Reporting.
Findings
The investigation supported the self-report of non-compliance with standards and laws, resulting in violations issued related to failure to provide care as specified in individualized service plans and failure to ensure residents were free from physical abuse. Staff involved in abuse were suspended and terminated, and corrective education plans were implemented.
Deficiencies (2)
Facility failed to ensure that the care and services specified in the individualized service plan (ISP) are provided to each resident.
Facility failed to ensure residents were free from physical abuse.
Report Facts
Number of residents present: 70
Number of resident records reviewed: 1
Number of staff records reviewed: 3
Number of interviews conducted with staff: 1
Dates of staff hiring: Staff 3 hired 7/28/2025, Staff 4 hired 11/9/2020, Staff 5 hired 10/8/2024
Date of self-reported incident: Self-reported incident received on 2025-01-22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Gale | Licensing Inspector | Contact person for questions about the VDSS Licensing Programs |
| Angela N Via | Current Inspector | Inspector on-site during inspection |
Inspection Report
Monitoring
Census: 70
Deficiencies: 1
Date: May 21, 2025
Visit Reason
The inspection was a monitoring visit triggered by a self-reported incident received by VDSS Division of Licensing on 2025-02-15 regarding allegations in the area of Protection of Adults and Reporting.
Findings
The investigation supported the self-report of non-compliance with standards or law, resulting in violations issued related to physical abuse and forced isolation of a resident by staff. Staff involved were suspended and terminated, and re-education on abuse reporting was planned.
Deficiencies (1)
Facility failed to ensure residents were free from physical abuse and forced isolation.
Report Facts
Number of residents present: 70
Number of resident records reviewed: 1
Number of staff records reviewed: 1
Number of interviews conducted with staff: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff 2 | Named in physical abuse finding; suspended and terminated for abuse and neglect | |
| Staff 3 | Observed abuse incident involving resident | |
| Executive Director | Reported incident to Adult Protective Service and Regional Licensing Office; suspended and terminated Staff 2; re-educated team members |
Inspection Report
Monitoring
Census: 70
Deficiencies: 0
Date: May 20, 2025
Visit Reason
The inspection was a monitoring visit following a self-reported incident received by VDSS Division of Licensing on 2025-03-03 regarding allegations in the area of Resident Care and Related Services.
Findings
The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law. The licensing inspector observed memory care resident areas and reviewed incident reports without identifying deficiencies.
Report Facts
Number of resident records reviewed: 2
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 1
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 0
Date: May 20, 2025
Visit Reason
A complaint was received by VDSS Division of Licensing on 2025-05-12 regarding allegations in the areas of Resident Care and Related Services and safeguarding resident property.
Complaint Details
Complaint related to allegations in Resident Care and Related Services and safeguarding resident property; investigation did not substantiate the allegations.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law.
Report Facts
Number of residents present: 70
Number of staff records reviewed: 2
Number of interviews conducted with staff: 1
Number of resident records reviewed: 0
Number of interviews conducted with residents: 0
Inspection Report
Monitoring
Census: 70
Deficiencies: 0
Date: May 20, 2025
Visit Reason
The inspection was a monitoring visit following a self-reported incident received by VDSS Division of Licensing on 12/10/2024 regarding allegations in the area of Resident Care and Related Services.
Findings
The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law. The licensing inspector observed the facility, reviewed incident reports and staff training, and found no deficiencies.
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: 1
Inspection Report
Monitoring
Census: 71
Deficiencies: 9
Date: May 19, 2025
Visit Reason
The inspection was a monitoring visit conducted on May 19 and May 20, 2025, to review compliance with applicable regulations and standards at the assisted living facility.
Findings
The inspection identified multiple areas of non-compliance including insufficient scheduled activities, incomplete tuberculosis risk assessments for staff, failure to complete sex offender checks prior to admission, incomplete individualized service plans (ISP) reflecting residents' needs, medication management deficiencies, missing Do Not Resuscitate (DNR) orders on ISPs, failure to include inability to use signaling devices in ISPs, and inadequate fire drill frequency and participation.
Deficiencies (9)
Facility failed to ensure at least 21 hours of scheduled activities available to residents each week for no less than two hours each day.
Facility failed to ensure each staff person submitted tuberculosis risk assessment on or within seven days prior to first day of work.
Facility failed to ascertain prior to admission whether a potential resident was a registered sex offender.
Facility failed to ensure identified needs on the uniform assessment instrument (UAI) were included on the comprehensive individualized service plan (ISP).
Facility failed to implement a written plan for medication management.
Facility failed to administer medication in accordance with physician orders.
Facility failed to ensure Do Not Resuscitate (DNR) orders were included on the Individualized Service Plan (ISP).
Facility failed to ensure for each resident with inability to use signaling device, the inability was included in the resident's ISP.
Facility failed to ensure fire and emergency evacuation drill frequency and participation was in accordance with Virginia Statewide Fire Prevention Code.
Report Facts
Number of residents present: 71
Scheduled activity hours: 20.5
Scheduled activity hours: 19
Missed nutritional supplement doses: 105
Missed nutritional supplement dates: 35
Fire drills completed: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela N Via | Licensing Inspector | Current inspector conducting the monitoring inspection |
| Jessica Gale | Licensing Inspector | Contact person for questions about the VDSS Licensing Programs |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: May 24, 2024
Visit Reason
The inspection was conducted in response to a complaint received on 2024-05-06 regarding allegations related to resident care at the facility.
Complaint Details
The complaint was substantiated as the evidence gathered supported the allegations of non-compliance with standards and laws related to resident care and abuse reporting.
Findings
The investigation found multiple violations including failure to report a major incident within 24 hours, failure of mandated reporters to report suspected abuse, and failure to ensure the health, safety, and well-being of residents, specifically related to an incident involving Resident 1 who was reportedly handled roughly and did not receive lunch.
Deficiencies (3)
Facility failed to report to the regional licensing office within 24 hours any major incident that negatively affected or threatened the life, health, safety, or welfare of any resident.
Facility failed to ensure all staff who are mandated reporters reported suspected abuse, neglect, or exploitation of residents in accordance with Virginia Code 63.2-1606.
Facility failed to assume general responsibility for the health, safety, and well-being of the residents, including failure to provide lunch and prevent rough handling of Resident 1.
Report Facts
Number of resident records reviewed: 1
Number of staff records reviewed: 2
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Named in abuse and neglect findings and statements regarding Resident 1 | |
| Staff 2 | Named in abuse and neglect findings and statements regarding Resident 1 | |
| Staff 3 | Interviewed regarding incident reporting and abuse allegations | |
| Staff 4 | Named in abuse and neglect findings related to rough handling of Resident 1 | |
| Staff 5 | Manager / RMA | Reported suspected abuse and involved in investigation of Resident 1 |
| Executive Director | Executive Director/designee | Responsible for re-education and corrective action plans |
Inspection Report
Renewal
Census: 63
Deficiencies: 0
Date: Jan 29, 2024
Visit Reason
The inspection was a renewal inspection conducted to review the facility's compliance with regulatory standards.
Findings
The Licensing Inspector observed residents during activities and meals and reviewed resident council reports, dietician report, pharmacy review, fire drills, emergency drills, and healthcare oversight.
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 2
Date: Jan 29, 2024
Visit Reason
The inspection was conducted due to a complaint alleging insufficient staff for residents in care and the unit being dirty.
Complaint Details
The complaint was substantiated as valid. There was an allegation of insufficient staff and unclean conditions, both of which were confirmed during the inspection.
Findings
The complaint was found to be valid with violations identified related to insufficient staffing in the secured unit and unclean conditions with rubbish and used briefs in bedrooms and bathrooms.
Deficiencies (2)
Facility did not have sufficient staff numbers to be responsible for the care and supervision of residents in the safe, secure environment.
Building was not clean and free of rubbish; used briefs were found in bedrooms and bathrooms and floors were dirty.
Report Facts
Number of interviews conducted: 8
Residents moved from unit: 17
Residents remaining in unit overnight: 12
Residents returned to secured unit overnight: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela N Via | Licensing Inspector | Current inspector conducting the complaint inspection |
| Director of Health and Wellness | Named in plan of correction to ensure sufficient staffing |
Inspection Report
Monitoring
Census: 58
Deficiencies: 0
Date: Feb 3, 2023
Visit Reason
The inspection was a monitoring visit to review the physical plant including the building and grounds of the assisted living facility.
Findings
The inspection found no violations of applicable standards or laws. The inspector observed the secured unit and assisted living unit, noting that cleaning supply storage areas should remain locked and carts should not be left unattended.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 14, 2022
Visit Reason
The inspection was conducted in response to a complaint received on 2022-11-07 regarding allegations in the area of admission and discharge of residents.
Complaint Details
Complaint investigation related to allegations in admission and discharge; the complaint was not substantiated.
Findings
The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. No deficiencies were cited.
Report Facts
Resident records reviewed: 4
Staff records reviewed: 0
Staff interviews conducted: 5
Resident interviews conducted: 0
Inspection Report
Renewal
Census: 58
Deficiencies: 7
Date: Dec 6, 2022
Visit Reason
The inspection was a renewal inspection conducted over three days (December 6-8, 2022) to assess compliance with licensing requirements for the assisted living facility.
Findings
The inspection identified multiple violations including failure to complete required six-month or annual reviews for residents in the secured unit, incomplete dementia training for staff, lack of first aid certification for some staff, outdated posted certification lists, unsecured storage of cleaning supplies, incomplete emergency preparedness documentation for residents, and incomplete fire drill documentation.
Deficiencies (7)
Failed to ensure three of three residents' records included a six-month or annual review of appropriateness for placement in a secured unit.
Failed to ensure three of four staff records completed at least 10 hours of dementia training within the first four months of hire.
Failed to ensure three of ten staff records had documentation of completion of first aid certification within 60 days of hire.
Failed to ensure the posted list of staff with first aid and CPR certifications remained current.
Failed to ensure cleaning supplies were stored in a locked area.
Failed to ensure two of seven resident records had signed documentation of a six-month review of the emergency preparedness plan.
Failed to ensure all required information was documented on two of twelve fire drill forms reviewed.
Report Facts
Residents present: 58
Resident records reviewed: 14
Staff records reviewed: 11
Interviews with residents: 4
Interviews with staff: 6
Staff dementia training hours: 7.5
Staff dementia training hours: 6
Staff dementia training hours: 6.25
Staff first aid training not completed: 3
Fire drill forms missing data: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela N Via | Licensing Inspector | Current inspector conducting the inspection |
| Janice Knight | Licensing Inspector | Contact person for questions about the inspection findings |
| Staff 1 | Named in dementia training deficiency with 7.5 hours completed | |
| Staff 2 | Named in dementia training deficiency with 6.0 hours completed | |
| Staff 4 | Named in dementia training deficiency and cleaning supplies storage observation | |
| Staff 8 | Named in first aid training deficiency | |
| Staff 10 | Named in first aid training deficiency | |
| Staff 11 | Named in first aid training deficiency | |
| Staff 12 | Interviewed regarding incomplete fire drill forms | |
| Business Office Manager | BOM | Interviewed regarding first aid training and certification list deficiencies |
| Director of Health and Wellness | DHW | Responsible for auditing emergency preparedness reviews and secured unit placement audits |
| Director of Environmental Services | DES | Responsible for housekeeping training and fire drill form compliance |
| Executive Director | ED | Monitors corrective actions and training compliance |
| Director of Innovations Memory Care | DIMC | Monitors secured unit placement audits |
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 1
Date: Jul 28, 2022
Visit Reason
The inspection was conducted in response to a complaint received by VDSS Division of Licensing on 7/21/2022 regarding allegations in the area of resident care and related services.
Complaint Details
A complaint was received on 7/21/2022 regarding resident care. The evidence gathered supported some of the allegations. A violation notice was issued.
Findings
The investigation supported some, but not all, of the allegations; non-compliance was found in the area of resident care and related services. A violation notice was issued and the licensee was given the opportunity to submit a plan of correction.
Deficiencies (1)
The facility failed to ensure a medical procedure for one resident was completed as ordered, specifically a sacral x-ray was not requested as per physician's order.
Report Facts
Residents present: 62
Resident records reviewed: 1
Staff records reviewed: 0
Resident interviews conducted: 1
Staff interviews conducted: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela N Via | Licensing Inspector | Current inspector conducting the inspection |
| Janice Knight | Licensing Inspector | Contact person for questions regarding the inspection |
Inspection Report
Monitoring
Census: 64
Deficiencies: 4
Date: Jun 23, 2022
Visit Reason
The inspection was a monitoring visit triggered by a self-reported incident received on 2022-06-14 regarding allegations in the area of resident care and related services.
Complaint Details
The visit was not complaint-related but was triggered by a self-reported incident regarding resident care and related services.
Findings
The investigation supported the self-report of non-compliance with standards and laws, resulting in violations issued related to individualized service plans not being signed, failure to provide specified care and services, medication management plan implementation failures, and medication administration errors.
Deficiencies (4)
Facility failed to ensure one of three residents' individualized service plans (ISPs) were signed by the resident or legal representative.
Facility failed to ensure the care and services specified in the ISP were provided to one of three residents.
Facility failed to ensure implementation of the medication management plan.
Facility failed to ensure one medication for one of three residents was administered according to the physician's order.
Report Facts
Residents present: 64
Resident records reviewed: 3
Staff records reviewed: 4
Resident interviews: 4
Staff interviews: 6
Missing medication count: 30
Medication administration record reviews: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela N Via | Licensing Inspector | Current inspector conducting the monitoring inspection |
| Janice Knight | Licensing Inspector | Contact person for questions regarding the inspection |
| Staff 4 | Interviewed regarding unsigned ISP for resident 1 | |
| Staff 5 | Interviewed regarding resident 1's laundry and care | |
| Staff 6 | Interviewed regarding medication receipt and handling | |
| Executive Director | Responsible for implementation and monitoring of plans of correction | |
| Director of Health and Wellness | Responsible for implementation and monitoring of plans of correction |
Inspection Report
Monitoring
Deficiencies: 1
Date: Apr 12, 2022
Visit Reason
An unannounced focused monitoring inspection was conducted to review medication administration records and observe staff administering medications to ensure compliance with standards.
Findings
The facility was found noncompliant in medication administration documentation, specifically staff failing to initial electronic medication administration records for two of six EMARs reviewed. Staff interviews and documentation review confirmed the deficiencies.
Deficiencies (1)
Facility failed to ensure staff initialed the electronic medication administration records (EMARs) when medications were administered for two of the six EMARs reviewed.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela N Via | Inspector | Current inspector conducting the inspection |
| Staff 1 | Staff on duty to administer medications on 3/27/2022 who is no longer employed at the facility | |
| Executive Director | Executive Director | Interviewed regarding medication administration and staff |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Feb 18, 2022
Visit Reason
The licensing inspector conducted an unannounced complaint inspection in response to a complaint received on 2022-02-10 regarding allegations that a medication was not ordered in a timely manner and was not administered as ordered.
Complaint Details
Complaint was substantiated based on documentation and interviews confirming medication ordering and administration failures for one resident.
Findings
The investigation supported the complaint as valid, finding that the facility failed to ensure timely ordering and administration of medication for one of four residents, resulting in missed doses and undocumented medication omissions.
Deficiencies (3)
Facility failed to ensure one of four residents' medications were ordered in a timely manner to avoid missed doses.
Facility failed to ensure one of four residents received one medication as ordered.
Facility failed to ensure one of four February EMARs reviewed documented omissions.
Report Facts
Residents involved: 4
Missed doses: 2
Dates medication not administered: 2
Days notification prior to refill: 7
Date complaint received: Feb 10, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela N Via | Licensing Inspector | Conducted the complaint inspection and interviews |
| Unnamed Executive Director | Executive Director | Interviewed regarding medication administration failures |
| Unnamed Administrator | Administrator | Interviewed regarding EMAR omissions |
Inspection Report
Monitoring
Deficiencies: 0
Date: Jan 12, 2022
Visit Reason
A non-mandated monitoring inspection was initiated to review criminal record checks and sworn statements for all current staff hired since the last inspection.
Findings
The inspection determined no violations with applicable standards or law. No violations were cited.
Inspection Report
Renewal
Census: 54
Deficiencies: 8
Date: Nov 30, 2021
Visit Reason
An unannounced renewal inspection was conducted over three days from November 30 to December 2, 2021, to assess compliance with assisted living facility regulations.
Findings
The facility was generally clean and compliant with posted menus and medication administration; however, multiple deficiencies were found related to staff scheduling, individualized service plans, emergency documentation, medication management, oxygen orders, fire drills, and criminal record reports.
Deficiencies (8)
The staff schedule did not indicate the staff person in charge for each shift.
Individualized service plans (ISPs) failed to include all assessed needs for six of eight resident records reviewed.
Required information was not provided to emergency personnel during resident transport.
Medications were not readily available for three of four residents, including missing PRN medications in the medication cart.
One of eight resident records was incorrectly assessed as capable of self-administering medications.
Two of three oxygen orders lacked required information regarding the source of oxygen.
Fire drills were not conducted on each shift in a quarter as required.
One of 52 criminal record reports was not completed within the required timeframe for a rehired staff member.
Report Facts
Residents in care: 54
Resident records reviewed: 8
Discharge records reviewed: 1
Staff records reviewed: 5
Medication administration observations: 4
Criminal record reports required: 52
Inspection Report
Deficiencies: 0
Date: Jun 29, 2021
Visit Reason
A non-mandated self-report inspection was initiated to investigate allegations in the areas of resident care and related services based on a self-report received by the department.
Findings
The evidence gathered during the investigation did not support the self-report of non-compliance with standards or law.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 3, 2021
Visit Reason
A monitoring inspection was initiated due to a complaint received by the department regarding allegations in the areas of resident care and related services. The inspection was conducted remotely due to a state of emergency health pandemic.
Complaint Details
Complaint related: Yes. The complaint was substantiated as the evidence gathered supported the allegation of non-compliance with standards or law.
Findings
The investigation supported the allegation of non-compliance with standards or law, specifically that the facility failed to ensure one of three residents received the services specified in the individualized service plan (ISP). A violation was issued related to failure to document deviations from the ISP and failure to provide notice of deviation to the resident or legal representative.
Deficiencies (1)
Facility failed to ensure one of three residents received the services specified in the individualized service plan (ISP), including failure to document deviations and resident refusal of care.
Report Facts
Inspection dates: 3
Residents involved: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela N Via | Inspector | Current inspector conducting the investigation |
| Staff B | Interviewed regarding resident A's shower refusal | |
| Director of Health and Wellness | Named in plan of correction to ensure future resident ISPs reflect bathing schedules | |
| Memory Care Director | Named in plan of correction to ensure future resident ISPs reflect bathing schedules | |
| Executive Director | Named in plan of correction to ensure future resident ISPs reflect bathing schedules |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 21, 2021
Visit Reason
A complaint inspection was initiated due to a complaint received by the department regarding an allegation in the area of administration.
Complaint Details
A complaint was received regarding an allegation in the area of administration. The director of health and wellness was contacted and requested to submit information. The information gathered did not support the allegation.
Findings
The investigation did not support the allegation of non-compliance with standards or law.
Inspection Report
Renewal
Census: 20
Deficiencies: 2
Date: Dec 2, 2020
Visit Reason
A renewal inspection was initiated on December 2, 2020 and concluded on December 7, 2020 to assess compliance with licensing requirements at the assisted living facility.
Findings
The inspection found non-compliance with tuberculin skin assessments and medication management plan implementation. Violations were documented and a violation notice was issued to the facility.
Deficiencies (2)
The facility failed to ensure two of the three tuberculin skin assessments were completed prior to the first day of work, with missing results and incomplete forms.
The facility failed to implement the medication management policy by ensuring all information on the medication administration records (MARs) was transcribed accurately, including discrepancies in medication timing and diagnoses.
Report Facts
Inspection dates: 3
Current census: 20
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