Babcock Manor, INC.

Based on observations of the facility physical plant, the facility failed to ensure that protective devices were on windows in common areas to prevent residents with serious cognitive impairments from opening windows wide enough to be able to crawl through. EVIDENCE: 1. The window to the right in the downstairs common area did not contain a protective device to prevent the window from opening wide enough for a resident to crawl through on the day of on-site inspection. The facility houses a mixed population of residents of which includes residents with a serious cognitive impairment.

Based on observations of the facility physical plant, the facility failed to ensure that interior areas were adequately lighted for the safety and comfort of residents and staff. EVIDENCE: 1. At approximately 9:38am on the day of on-site inspection the lighting in the bathroom upstairs by room 3 was noted to be inoperable.

Based on observations of the facility physical plant, the facility failed to ensure that doors leading to the outside had a system of security monitoring of residents with serious cognitive impairments. EVIDENCE: 1. The doors leading to the outside downstairs in the hallways beside rooms 1 and 6 were noted to have alarm devices that were inoperable at the time of inspection. The licensing inspector (LI) opened both doors several times and noted that the alarm did not sound.

Based on staff record review and staff interview, the facility failed to ensure that direct care staff received at least two hours of training in infection control and prevention annually. EVIDENCE: 1. The record for staff person 1, hired 11/20/1998, and staff person 2, hired 11/18/2019, did not contain documentation that these employees have received annual training in infection control and prevention. Staff person 5 confirmed in interview on day of inspection that infection control training has not been completed.

Based on staff record review and staff interview, the facility failed to retain records for all staff at the facility. EVIDENCE: 1. The LI requested to review the record for staff person 4 on the day of on-site inspection. In an interview with staff person 5 during the inspection, staff person 5 expressed that they were unable to locate staff person 4?s record for the LI to be able to review.

Based on staff record review, the facility failed to ensure that a screening for tuberculosis was completed on or within seven days prior to the first day of work. EVIDENCE: 1. The record for staff person 3, whose first day of work is documented as 04/28/2025, has documentation that a screening for tuberculosis was not completed until 06/02/2025.

Based on resident record review, the facility failed to ensure that a documented interview was completed prior to or on the day admission. EVIDENCE: 1. The record for resident 1, admitted on 03/04/2025 did not contain documentation of an interview with the resident prior to or at the time of the residents admission to the facility.

Based on resident record review, the facility failed to ensure that resident physical examinations contained a statement that the individual does not have any prohibited conditions or care needs. EVIDENCE: 1. The record for resident 3, admitted on 11/02/2023, has a physical examination dated 10/30/2023 that has documentation that the resident requires continuous licensed nursing care, which is a prohibited condition for admission to an Assisted Living Facility.

Based on resident record review, the facility failed to ensure that a fall risk rating was completed after a resident fell for resident who are assessed as assisted living level of care. EVIDENCE: 1. The record for resident 1 has documentation that the resident sustained a fall on 03/10/2025 and was sent to the local emergency room for evaluation. The record does not contain documentation that a fall risk rating was completed for this fall. The uniform assessment instrument ( UAI

Based on resident and staff record review, the facility failed to ensure that an annual review of resident rights was completed with staff and residents. EVIDENCE: 1. The record for resident 3 has documentation that the last review of resident rights was completed with this resident on 11/02/2023. 2. The records for staff person 1, hired 11/20/1998, and staff person 2, hired 11/18/2019, do not have documentation of a re4view of resident rights being completed annually for these employees.

Based on review of the facility oversite of special diets, the facility failed to ensure that the oversite of special diets was signed and dated by the dietician or nutritionist. EVIDENCE: 1. The oversite of special diets report provided to the licensing inspector for review on the day of on-site inspection did not contain documentation of the date that the oversite was completed or the signature of the dietician or nutritionist who completed the oversite.

Based on resident record review, the facility failed to ensure that residents assessed as assisting living level of care received a medication review every six months. EVIDENCE: 1. The record for resident 2, admitted to the facility on 07/11/2024, did not contain documentation that a medication review has been completed for this resident. The uniform assessment instrument ( UAI

Based on observation of the facility physical plant, the facility failed to post a ?No-Smoking Oxygen in Use? on all rooms where oxygen is being used. EVIDENCE: 1. At 9:48am o the day of on-site inspection, the licensing inspector (LI) observed resident 5 in his room (room 2) with oxygen in use via a oxygen concentrator and nasal cannula. The room did not contain a ?No-Smoking Oxygen in Use? posting.

Based on observations of the facility physical plant, the facility failed to ensure that cleaning supplies were stored in a locked area. EVIDENCE: 1. Room 6 located downstairs in the facility was noted to contain a container of Member Mark Disinfecting Wipes and a bottle of Clorox Multi Surface Cleaner with Bleach sitting out on a wheelchair in the room. The door to the room was open. In an interview with staff person 5 on the day of inspection, staff person 5 expressed that resident 6, who resides in this room, is currently in the hospital.

Based on review of facility documentation, the facility failed to ensure that a review of the facility emergency preparedness plan was completed semi-annually with all residents. EVIDENCE: 1. The facility documentation of review of their emergency preparedness plan with residents had documentation that the last date completed was in December 2023.

Based on staff record review and staff interviews, the facility failed to ensure that new staff received orientation and training within the first seven working days of employment. EVIDENCE: 1. The record for staff person 3 did not contain documentation of this employee receiving orientation and training to the facility. In an interview with staff person 4 conducted on the day of inspection, staff person 4 expressed that this employee has been employed for several months.

Based on staff record reviews, the facility failed to ensure that all personal and social data was maintained in staff records, EVIDENCE: 1. The record for staff person 3 did not include the date of hire for this employee or documentation/receipt of the employees job description.

Based on resident record review, the facility failed to ensure that Individualized service plans ( ISP

Based on staff record reviews, the facility failed to ensure that a sworn statement or affirmation was completed for all applicants for employment. EVIDENCE: 1. The record for staff person 3, who is currently employed at the facility, did not contain documentation of a sworn statement or affirmation.

Based on observations of the facility physical plant, the facility failed to ensure that a system of security monitoring was on all doors leading to the outside for monitoring of resident with serious cognitive impairments. EVIDENCE: 1. The 3 doors downstairs that lead to the outside were noted to have inoperable door alarms during the on-site inspection on 05/24/2024. The house houses a mixed population of residents such as resident 4, who has a diagnosis of dementia and is assessed with disorientation to some spheres some of the time with date and day being the spheres affected on the uniform assessment instrument completed on 12/17/2023.

Based on observations and staff interviews, the licensee failed to ensure that at all times the department's representative is afforded reasonable opportunity to inspect all of the facility's buildings, books, and records as specified in ? 63.2-1706 of the Code of Virginia. EVIDENCE: 1. During the on-site inspection conducted on 05/24/2024, staff person 1, the designated person in charge, did not have access to staff records, staff and resident review of the emergency preparedness plan and staff review and practice of resident emergencies. This documentation was not available for the LI to review during the on-site inspection.

Based on resident record review, the facility failed to ensure that a uniform assessment instrument ( UAI

Based on resident record review, the facility failed to ensure that Individualized service plans ( ISP

Based on resident record reviews, the facility failed to ensure that physician orders were maintained in resident records. EVIDENCE: 1. The record for resident 2 has documentation that the resident was admitted to Hospice services on 04/10/2024 and that Hospice is providing wound care services for a wound on the residents left ankle. In an interview with staff person 1 conducted on 05/24/2024, staff person 1 expressed that this is correct. The record for resident 2 does not have documentation of the physicians order for the treatment/wound care being provided to resident 2?s left ankle. 2. The record for resident 3 has documentation that the resicnet is receiving wound care services from Hospice from a wound on the residents coccyx and right heel. In an interview with staff person 1 conducted on 05/24/2024, staff person 1 expressed that this is correct. The record for resident 3 does not have documentation of the physicians order for the treatment/wound care being provided to resident 3?s coccyx and right heel.

Based on resident record review, the facility failed to ensure that residents assessed as assisted living level of care received a mediation review at least every 6 months. EVIDENCE: 1. The record for resident 2, assessed as assisted living level of care on their uniform assessment instrument dated 08/06/2023, has documentation that the last medication review was completed on 08/23/2023 for this resident. 2. The record for resident 3, assessed as assisted living level of care on their uniform assessment instrument dated 12/17/2023, has documentation that the last medication review was completed on 05/11/2023 for this resident.

Based on observations, resident record review and staff interviews, the facility failed to ensure that a physician's written order was obtained that specifies the condition, circumstances, and duration under which the restraint is to be used. EVIDENCE: 1. Resident 1 was observed by the LI at 8:09am on 05/24/2024 to be sitting in a Geri Chair with a tray that was secured over top. Documentation in Hospice notes dated 05/06/2024 has that ?During the day they sit her in a geri chair for her safety to prevent her from ambulating without assistance?. The record for resident 1 did not contain documentation of a physicians written order for the use of a Geri Chair with a secured tray that includes the condition, circumstances, and duration under which the restraint is to be used. In an interview with staff person 1 on 05/24/2024, staff person 1 confirmed they were not able to locate a physician order for the use of a Geri Chair in the record for resident 1.

Based on observations, resident record review and staff interviews, the facility failed to ensure that direct care staff kept a record of restraint usage, outcomes, checks, and any assistance required in subdivision 4 of this subsection and shall note any unusual occurrences or problems if any. EVIDENCE: 1. Resident 1 was observed by the LI at 8:09am on 05/24/2024 to be sitting in a Geri Chair with a tray that was secured over top. Documentation in Hospice notes dated 05/06/2024 has that ?During the day they sit her in a geri chair for her safety to prevent her from ambulating without assistance?. In an interview with staff person 1 on 05/24/2024, staff person 1 expressed that there was not documentation of a restraint record to include the usage, outcomes, checks or any assistance required for the Geri chair use for resident 1.

Based on observations of the facility physical plant, the facility failed to ensure that cleaning supplies and other hazardous materials were stored in a locked area. EVIDENCE: 1. The laundry room located downstairs in the facility was observed to be unlocked at 8:13am on 05/24/2024. A bottle of Scrubbing Bubbles Mega Shower Foamer, a can of Favor Furniture Polish, a can of Comet with Bleach Cleaner, a bottle of Great Value Glass Cleaner, a bottle of Great Valus All Purpose Cleaner with Bleach and a bottle of First Choice Lavender Cleaner were observed sitting out on a table in the laundry room.

Based on observations of facility documentation, the facility failed to ensure compliance with the Statewide Fire Prevention Code (13VAC5-51) by ensuring a inspection by the appropriate fire official at least annually. EVIDENCE: 1. Facility documentation made available for review during the on-site inspection show that the last fire inspection was completed at the facility on 06/13/2022.

Based on review of staff records, the facility failed to ensure that the direct care staff met the required training requirements EVIDENCE: 1. The record for staff person 5, hired on 04/10/2023, did not contain documentation that this employee has direct care certification/training. An interview was conducted with staff person 6 who expressed that this employee, who works the 3rd shift as a care aid, has not completed direct care staff training.

Based on review of staff records, the facility failed to ensure a screening for tuberculosis was completed on or within seven days prior to the first day of work for new employees. EVIDENCE: 1. The record for staff person 5, hired on 04/10/2023, has documentation that a screening for tuberculosis was not completed until 06/02/2023.

Based on resident record review and staff interview, an individualized service plan ( ISP

Based on resident record review, the facility failed to ensure that individualized service plans ( ISP

Based on a review of resident and staff records, the facility failed to ensure that am annual review of resident rights was completed with residents and staff. EVIDENCE: 1. The records for residents 2, 3, 5 and 6 and the records for staff 2 and 3 did not contain documentation that these individuals received an annual review of residents rights.

Based on resident record review and staff interview, the facility failed to ensure that when a diet is prescribed for a resident by his physician or other prescriber, that it is prepared and served according to the physician?s or other prescriber?s orders. EVIDENCE: 1. The record for resident 2 contains a signed order, dated 12/28/2022, for the resident to be on a fluid restriction of 64 ounces daily. Interview with staff 2 revealed that staff are not ensuring that the resident only receives 64 ounces of fluid daily. Interview with staff 3 revealed that she was not aware of the order for the resident to only receive 64 ounces of fluid daily. 2. The most recent dietitian oversight was dated 04/06/2023 and lists 13 residents with a special diet. A list of special diets was not observed in the kitchen on the day of inspection. Interview with staff person 3 expressed that everyone receives the same meals and was not aware of special diet orders for any resident.

Based on resident record review, the facility failed to ensure that medications are administered in accordance with the physician?s or other prescriber?s instructions. EVIDENCE: 1. The record for resident 2 contains a signed order, dated 12/28/2022, to hold the resident?s prescribed Carvedilol 3.125 MG when the resident?s systolic blood pressure is less than 110. The 05/21/2023 through 06/20/2023 medication administration record ( MAR

Based on resident record review and staff interview, the facility failed to ensure that medical procedures or treatments ordered by a physician or other prescriber were provided according to his instructions and documented and the documentation is to be maintained in the resident?s record. EVIDENCE: 1. The record for resident 2 contains a signed order, dated 12/28/2022, to hold the resident?s prescribed Carvedilol 3.125 MG when the resident?s systolic blood pressure is less than 110. Interview with staff 2 revealed that staff document the resident?s blood pressure on the back of the medication administration record ( MAR

Based on observations and resident record review, the facility failed to ensure that a restraint was only used in accordance with physician orders/instructions. EVIDENCE: 1. During a tour of the facility physical plant, both LI?s in the presence of staff person 1 observed resident 3 lying in bed with half rails up on both sides. The back of a recliner chair was placed at the side of the bed from the end of the half rail towards the foot of the bed and a wheelchair was placed at the side of the bed towards the end of the bed. Interview with staff person 1 expressed that this is done to keep resident 6 from trying to climb out of the bed. A review of the record for resident 6 noted that there is not a physician order for a restraint to keep resident 6 from climbing out of bed.

Based on observation during a tour of the physical plant, the facility failed to ensure that the interior of the building is maintained in good repair. EVIDENCE: 1. The baseboard heater across from room 2 was noted to be separating from the wall. 2. The floor in the hallway next to the dining room was noted to have several cracks/gaps between the floor boards. 3. The public restroom upstairs by the nursing office was noted to have an inoperable door knob on the day of inspection as the door would not stay closed. 4. The door frame around the door to room 10 was noted to be broken/cracked on the day of inspection.

Based on review of staff records, the facility failed to ensure that a completed criminal history report was received within the first 30 days of employment. EVIDENCE: 1. The record for staff person 5, hired on 04/10/2023 did not contain documentation of a completed criminal history report on the day of inspection.

Based on a review of resident records, the facility failed to ensure that the statement prepared and provided to the prospective resident and his legal representative, if any, that discloses information about the facility included all required components. EVIDENCE: 1. The record for resident 2, admitted on 04/29/2022 and resident 3, admitted on 11/15/2022 had a ?Assisted Living Facility Disclosure Statement? that did not include a statement of whether or not the facility has an on-site emergency electrical power source for the provision of electricity during an interruption of the normal electric power supply.

Based on a review of staff records, the facility failed to ensure all staff received annual training in methods of dealing with residents who have a history of aggressive behaviors or dangerously agitated states. EVIDENCE: 1. The record for staff person 2, hired on 01/15/2020 and staff person 3, hired in 4/1989 have documentation that the last training for aggressive behaviors was conducted in 2020.

Based on a review of resident records, the facility failed to ascertain prior to admission whether a potential resident was a registered sex offender. EVIDENCE: 1. The record for resident 2, admitted on 04/29/2022 has documentation that a sex offender screening was not admitted until 05/03/2022. 2. The record for resident 3, admitted on 11/15/2022 has a sex offender screening that does not have a date of completion.

Based on a review of resident records, the facility failed to ensure that all identified needs were reflected on resident individualized service plans ( ISP

Based on a review of staff records, the facility failed to ensure annual training on resident rights and responsibilities with all staff. EVIDENCE: 1. The records for staff persons 2 and 3 have documentation that the last training in resident rights and responsibilities was completed on 12/15/2020.

Based on a review of resident records, the facility failed to ensure that a current resident photo was available for identification purposes. EVIDENCE: 1. The record for resident 2, admitted on 04/29/2022 did not contain a current photo on the day of inspection.

Based on a review of resident records and interview with staff, the facility failed to ensure that special diets prescribed to residents were prepared and served according to physician instructions. EVIDENCE: 1. The record for resident 2 has documentation of a controlled carbohydrate diet. The record for resident 4 has documentation that the resident is on a regular soft food diet. 2. On the day of inspection it was observed that a special diet list was not available in the facility kitchen. Interview with staff person 1, who was preparing the lunch meal, expressed that there are currently no special diets and that all residents receive the same diet/food.

Based on observations of the facility physical plant, the facility failed to post a ?No Smoking-Oxygen in Use? sign at all rooms where oxygen is in use. EVIDENCE: 1. Room 9 upstairs was noted to have an oxygen concentrator sitting by the first bed in the room. The room did not have a ?No Smoking ?Oxygen in Use? sign posted.

Based on observations of the facility first aid kit, the facility failed to ensure that expiration dates have not passed on items inside the kit. EVIDENCE: 1. The facility first aid kit was noted to have a bottle of Betadine with an expiration date of 12/2020.