Inspection Reports for
Varenna at Fountaingrove

The Administrator provided all requested documents during the inspection. No deficiencies were cited during this visit.

No deficiencies were cited during the inspection. The Licensing Program Analyst reviewed resident records and facility policies related to the incident.

The facility was found to be in compliance with no deficiencies cited during the inspection. Emergency disaster drills and staff training were reviewed and found to be up to date.

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.

No deficiencies were cited during this inspection. The Licensing Program Analyst reviewed resident files and began reviewing staff files and training, with plans to continue the inspection at a later date.

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 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 facility was found to be in compliance with no deficiencies cited during this visit. The inspection included review of fire safety, emergency preparedness, infection control, and facility conditions. Some documents were requested to be updated and submitted by 05/14/2025. The annual inspection will be continued at a later date.

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

The complaint was unsubstantiated. The allegation was that facility staff were not safeguarding residents' personal property and personal space. The investigation included record reviews, interviews, and a police report. No violations were found.

The investigation found no evidence to support the allegation that facility staff failed to safeguard residents' personal property and personal space. The missing bracelet reported by a resident was found by police within the resident's unit, and no violations were substantiated.

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.

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

The inspection found no deficiencies. Fire clearance was approved for multiple buildings, emergency and fire drills were conducted as required, and staff files showed required criminal record clearance and annual training.

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 facility was found to have no deficiencies cited during this visit. Emergency disaster supplies, infection control, medication storage, and fire safety measures were all observed to be in compliance. Some documents were requested to be updated and submitted by 6/23/2024.

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 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.

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, interviews, and documentation, the allegation was found to be unfounded, meaning it was false or without reasonable basis.

The investigation reviewed resident files, contracts, refund policies, 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 deficiencies cited.

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.

The facility was found to have adequate infection control measures, including PPE supply, screening procedures, and staff compliance with mask wearing. Fire extinguishers were properly serviced, and emergency supplies were sufficient. No deficiencies or citations were noted during the inspection.

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 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.

No citations were issued during the visit.

No citations were issued during this Case Management visit.

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 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 investigation found that the facility has COVID-19 policies and procedures in place, including sending staff home if symptomatic or exposed. Interviews with staff confirmed compliance with these protocols. The allegation was determined to be unfounded with no deficiencies cited.

The inspection found the facility well-prepared with adequate personal protective equipment and proper infection control screening procedures. Fire safety equipment was properly serviced and fire clearance approved. No deficiencies were cited during the inspection.

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 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 unfounded.

Based on interviews with staff, residents, and review of notices provided to residents, the allegation was found to be unfounded, meaning the allegation was false, did not happen, or was without 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.

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.

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 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.

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.

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.