Inspection Reports for Varenna at Fountaingrove

The inspection was a continued annual inspection conducted on 05/13/2025 as part of the facility's annual regulatory oversight.

The facility was found to be in compliance with no deficiencies cited during the inspection. The facility maintains required plans including Infection Control and Emergency Disaster Plans, and staff training and clearances were verified.

The inspection was a continued annual inspection conducted to evaluate compliance with licensing requirements for a continuing care retirement community.

No deficiencies were cited during this inspection. The facility was found to have complete resident files, required infection control and emergency disaster plans, and fire clearance approved for 322 residents. The Licensing Program Analyst will return to complete review of staff training and emergency drills.

The inspection was a required unannounced 1-year annual inspection conducted to evaluate compliance with licensing requirements for the continuing care retirement community.

The facility was found to be in compliance with no deficiencies cited during the inspection. Emergency preparedness, fire safety, infection control, and other regulatory requirements were reviewed and found satisfactory. Some documents were requested to be updated and submitted by 05/14/2025.

The inspection was a case management visit conducted to obtain information on a resident incident reported by the facility.

The Licensing Program Analyst reviewed resident records, facility policies, and interviewed staff regarding the incident. No deficiencies were cited during the inspection.

The inspection visit was conducted in response to a complaint alleging that facility staff were not safeguarding residents' personal property and personal space.

The investigation found no evidence to substantiate the allegations. Resident R1's reported missing bracelet was recovered by the police, and no violations were found regarding personal property or personal space safeguarding. No deficiencies were cited.

The complaint alleged that facility staff were not safeguarding residents' personal property and personal space. The investigation was unsubstantiated, meaning there was insufficient evidence to prove the alleged violations occurred.

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Licensing Program Analysts conducted an annual inspection on 07/31/2024 to evaluate compliance with regulatory requirements and facility operations.

The inspection found no deficiencies. Fire clearance was approved for multiple buildings, emergency drills were conducted as required, and resident and staff files were complete with required clearances and training.

The inspection was a Required - 1 Year unannounced annual inspection conducted to evaluate compliance with licensing regulations for the continuing care retirement community.

The inspection found the facility to be in compliance with no deficiencies cited. Emergency disaster supplies, infection control, medication storage, and safety measures such as evacuation chairs were all observed to meet requirements. Some documents were requested to be updated and submitted by 6/23/2024.

The inspection was a Required - 1 Year unannounced visit conducted to evaluate compliance with licensing regulations for the continuing care retirement community facility.

The facility was generally compliant with emergency preparedness, staff training, and resident record requirements. However, a deficiency was cited for improper food storage practices in the kitchen, where pizza toppings, pizza sauce, and salad bar items were uncovered and exposed, posing a contamination risk.

The inspection was an unannounced complaint investigation visit conducted due to an allegation that the facility was not providing due refunds in a timely manner.

The investigation reviewed resident files, contracts, refund documentation, and conducted interviews. It was found that refunds, including entrance fees and monthly fees, were provided timely and in accordance with contracts. The allegation was determined to be unfounded with no violations or deficiencies cited.

The complaint alleged that the facility was not providing due refunds in a timely manner. After review of records and interviews, the allegation was found to be unfounded, meaning it was false or without reasonable basis.

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The inspection was a Case Management - Annual Continuation visit focused on infection control procedures, staff records, hiring documents, vaccination information, and staff training at the facility.

The inspection found safety hazards including tools and rug scraps left in hallways during carpet installation in the South building, and unlocked housekeeping carts with accessible toxins/cleaners posing immediate health and safety risks to residents. Plans of correction were required to address these issues.

The inspection was a Required - 1 Year unannounced visit focused on infection control procedures and practices at the facility.

No deficiencies or citations were found during the inspection. The facility demonstrated compliance with infection control practices, had sufficient supplies including PPE and emergency food and water, and fire safety equipment was properly serviced.

An unannounced complaint investigation was conducted following allegations that facility staff treated a resident inappropriately, including speaking rudely and loudly, pushing a resident's walker causing near loss of balance, and improper reassessment of the resident's care needs.

The investigation found insufficient evidence to substantiate the allegations of inappropriate staff behavior and improper reassessment. The allegations were determined to be unsubstantiated after review of resident records, interviews with staff and related parties, and examination of reassessment documentation and care plans. No deficiencies or citations were issued.

The complaint was unsubstantiated. Allegations included staff speaking rudely and loudly to a resident, pushing the resident's walker causing near loss of balance, and failure to properly reassess the resident's care needs. Conflicting information was obtained during the investigation, and there was no preponderance of evidence to prove the violations occurred.

The visit was a Case Management visit conducted to interview a resident and review records.

No citations were issued during the visit.

The inspection was conducted as a complaint investigation regarding an allegation that the facility was not following COVID-19 safety protocols by requiring staff to work while symptomatic.

The investigation found that the facility has COVID-19 policies and procedures in place, including sending staff home if symptomatic or exposed. Staff interviews confirmed no instances of staff being required to work while symptomatic. The allegation was determined to be unfounded.

The complaint alleged that the facility required staff to work while symptomatic with COVID-19. The allegation was found to be unfounded based on interviews, record reviews, and observations.

The inspection was an unannounced 1 Year annual inspection focused on the Infection Control procedures and practices of the facility.

The facility was found to have adequate infection control measures including PPE supply, screening procedures, and staff compliance with mask wearing. Fire safety equipment was properly serviced and no deficiencies were cited during the inspection.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 05/24/2021 regarding the provider including factors not allowed by statutes for increasing monthly care fees and not charging for optional services listed in the contract.

Based on interviews with staff and residents and review of required notices, the allegation was found to be unfounded, meaning the allegation was false, did not happen, or lacked reasonable basis. No deficiencies were noted at this time.

The complaint alleged that the provider included factors not allowed by statutes for increasing monthly care fees and was not charging for optional services listed in the contract. The investigation found no violation of statutes and the allegation was determined to be unfounded.

The inspection was an unannounced complaint investigation conducted due to a complaint received on 10/19/2020 regarding alleged confidentiality breaches and improper reassessment of a resident.

The investigation substantiated that resident personal information was not kept confidential when a letter was delivered folded and unsealed, exposing confidential information. The allegation that the resident was not properly reassessed was unsubstantiated due to insufficient evidence.

The complaint was substantiated regarding the breach of confidentiality of resident personal information. The allegation that the resident was not properly reassessed was unsubstantiated due to insufficient evidence. Appeal rights were given.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2021-01-05 regarding providers including factors not allowed by statutes for increasing the monthly care fee.

The Department reviewed multiple documents including the resident complaint, Certificate of Authority, financial presentations, and audited financial statements, and interviewed key personnel and complaining parties. It was determined that the legal fees, settlements, and fines were not included in the calculation of the monthly care fee increase and were not passed through to residents. Therefore, the complaint was found to be unfounded.

Complaint was regarding providers including factors not allowed by statutes for increasing the monthly care fee. The complaint was investigated and found to be unfounded because the questioned costs were not considered in the monthly care fee calculations.

The inspection was an unannounced complaint investigation visit conducted due to complaints alleging that the resident council was not receiving timely responses from the Licensee and that the facility’s emergency plan/notification system did not meet regulations.

The investigation found that the facility complied with all relevant stipulation and waiver requirements regarding emergency plans, resident notifications, and resident council responses. The allegations were determined to be unfounded, with no deficiencies cited during the visit.

The complaint alleged that the resident council was not receiving timely responses from the Licensee and that the facility’s emergency plan/notification system did not meet regulations. After review of documents, interviews, and observations, the allegations were found to be unfounded.