Avamere at South Hill

The facility failed to take appropriate action to protect a resident from elopement after signs of cognitive decline were noted, leading to an unsupervised fall and medical emergency.

Fire sprinkler PIV has a rusted/broken post (used to open/close).

Facility failed to maintain control of resident records, storing 69 boxes in an unsecured stairwell. Facility also failed to ensure 3 of 4 sampled staff completed facility orientation and 1 of 6 staff completed CPR and first aid training.

Facility failed to ensure completion of annual continuing education requirements for 1 of 4 sampled staff (Staff B) by their birthday.

Facility failed to ensure negotiated service agreements were signed by residents, representatives, or facility/case management for 6 residents.

Facility failed to obtain resident's prescribed medications in a correct and timely manner.

Facility failed to update negotiated service agreements (NSAs) following changes in mental health for 1 resident and skin conditions for 2 residents.

Facility failed to notify the prescribing provider when a resident refused their medication for 1 resident (Resident 8).

Facility failed to document daily blood pressures and follow provider medication parameters for 1 resident (Resident 9).

Facility failed to ensure systems promoted safe medication services; 2 of 9 residents did not receive medications as prescribed. Specific issues included missed doses of Trazodone, Rivaroxaban, and Metolazone, along with documentation errors.

The facility failed to maintain an effective communication system, resulting in delayed or no responses to resident call lights. Multiple instances were documented where residents, including one who had fallen, waited significant periods without staff response because the system was malfunctioning and paging the wrong rooms.

Initial inspection (08/16/2024) cited missing annual fire alarm testing, sensitivity testing, and monthly detector testing. Reports provided by 09/26/2024.

Initial inspection (08/16/2024) found no documentation for semi-annual hood cleaning. Provided by 09/26/2024.

Initial inspection (08/16/2024) found door penetrations, doors failing to latch, and wedged fire doors. Corrected by 09/26/2024.

Initial inspection (08/16/2024) found multiple unapproved extension cords and power strips in use. Removed/Corrected by 09/26/2024.

Initial inspection (08/16/2024) found no documentation for 4-year fire/smoke damper inspection. Completed/Provided by 09/26/2024.

Initial inspection (08/16/2024) found no backup generator inspection/service, load testing, or visual inspection documentation. Provided by 09/26/2024.

Initial inspection (08/16/2024) noted incomplete fire drill reports with missing information. Acknowledged by 09/26/2024.

Initial inspection (08/16/2024) found storage too close to fire sprinklers in marketing office, stairwell, and reception closet. Corrected by 09/26/2024.

Initial inspection (08/16/2024) cited numerous missing sprinkler system testing records/documentation. Reports provided by 09/26/2024.

Initial inspection (08/16/2024) found missing inspection documentation and penetrations in fire walls/ceilings. Completed by 09/26/2024.

Initial inspection (08/16/2024) found no documentation for annual 90-minute emergency light test. Scheduled to be completed.

Initial inspection (08/16/2024) cited missing maintenance documentation, annual service, and unsecured extinguishers. Corrected by 09/26/2024.

Facility failed to complete a national fingerprint background check for identified staff (Staff K and Staff E).

Facility failed to report allegations of a caregiver's neglect (incontinence care) to the department abuse/neglect hotline.

The licensee failed to complete a fingerprint background check for one staff member. This was an uncorrected deficiency from June 13, 2024.