Bickford of Virginia Beach

Based on a review of staff records, the facility failed to ensure that each staff person submits the results of a tuberculosis (TB) risk assessment on or within seven days prior to the first day of work at the facility and that each staff person submits the results of a risk assessment annually. Evidence: 1. The TB assessment presented for Staff # 3 during the on-site inspection was incomplete. None of the screening elements were checked. 2. Staff #1 and Staff #2 acknowledged that the TB screening form was incomplete. 3. Photographic evidence available

Based on a review of documentation and interviews, the facility did not ensure that each direct care staff member maintain current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. Evidence: When requested, Staff #1 was unable to provide documentation of Staff # 3 having current certification in First Aid.

Based on inspection of resident?s room and BFMs interviewed, the facility failed to ensure a resident?s room was free from foul, stale, and musty odors. Evidence: 1. On 8-13-25, following a complaint of resident in room 305 having an odor and resident not able to care for self and dog, the inspector and staff # 3 went to room 305. The room had a very strong odor of urine and dog food. Interviews with BFMs stated, the resident?s dog urinates on the resident?s bed and floor. Pads were placed on the floor for the dog, but the dog will not always use the pad. Staff #3, stated the administrator was aware of the situation with the dog and the resident?s family was also notified. The ISP

Based on observation and staff interviewed, the facility failed to ensure cleaning supplies and other hazardous materials were stored in a locked area. Evidence: 1. On 8-22-25, two (2) bottles of cleaning spray were observed in the hallway on a storage bin located near resident #2?s room- #307. 2. Staff #1 acknowledged the cleaning items should have been placed in a locked storage.

Based on record reviewed and staff interviewed, the facility failed to ensure the resident?s individualized service plan ( ISP

Based on observation and staff interviewed, the facility failed to ensure the name of the current on-site person in charge was posted. Evidence: 1. On 8-12-25, the name of the current on-site person in charge was not posted. The posted document was dated 8-3-25 to 8-9-25. Staff #3 acknowledged the staff in charge posting was not current.

Based on observation, document reviewed, and staff interviewed, the facility failed to ensure it disposed of medication as required. Evidence: 1. On 8-12-25, during a medication pass and cart audit with staff #5, a packet of Melatonin for resident #2 was on the medication cart. A check of the resident?s August 2025 medication administration record ( MAR

Based on observation and staff interviewed, the facility failed to ensure a health care oversight (HCO) report was provided to the licensing inspector. Evidence: 1. On 8-12-25 the ?What your inspector needs from you today? document was provided to the administrator. The Healthcare Oversight (HCO) document was not provided. 2. On 8-13-25, the healthcare oversight was again requested but not provided during the two days of on-site inspection. 3. The administrator completed the ?What your inspector needs from you today? document but did not complete the section for the HCO review information.

Based on document reviewed and staff interviewed, the facility failed to ensure the menu included all information. Evidence: 1. On 8-12-25 the facility menu for August 2025, Week 4, did not include a listing of snacks provided. 2. Staff #1 acknowledged the facility?s menu did not include snacks.

Based on record reviewed and staff interviewed, the facility failed to ensure the comprehensive individualized service plan ( ISP

Based on documented reviewed, and staff interviewed, the facility failed to ensure the activity calendar included all information: Evidence: 1. On 8-12-25, the posted activity calendar for the month of August 2025 did not include the length of time for the activity and it did not include the type of activity. 2. Staff #1 acknowledged the activity calendar did not include all information.

Based on observation and staff interviewed, the facility failed to ensure blood glucose monitoring practice was conducted. Evidence: 1. On 8-12-25 during the medication pass observation with staff #5 on the assisted living unit, the glucometer for resident #1?s glucometer was not labeled. Staff acknowledged the glucometer was not labeled. 2. On the safe, secure unit (SCU)- Mary B?s unit, medication pass observation was conducted with staff #6. Residents #3 and #7?s glucometer were not labeled. Staff #6 acknowledged the glucometers were not labeled. 3. The facility?s policies and procedures, PP ? 10750- Infection Control: Communicable Diseases- (VA). Revised: 11-2024: Blood Glucose Monitoring Procedures, page 3 of 3, #1 noted: ?Each piece of the individual?s equipment must me labeled with his or her name regardless of where the equipment is stored?. 4. Staff #1 acknowledged facility staff did not follow facility?s policy for labeling of glucose monitoring supplies and equipment.

Based on staff interviewed, the facility failed to ensure at lease once every six months, all staff currently on duty on each shift shall participate in an exercise in which the procedures for resident emergencies are practiced. Documentation of each exercise shall be maintained in the facility for at least two years. Evidence: 1. On 8-13-25, staff #1, did not provide documentation of all staff on each shift practicing resident emergency at least once every six months. 2. Staff #1 acknowledged not having documentation of resident emergency for all staff on each shift.

Based on record reviewed and staff interviewed, the facility failed to ensure individualized service plan ( ISP

Based on observation, record reviewed, and staff interviewed, the facility failed to ensure medications ordered for PRN

Based on observation and staff interviewed, the facility failed to ensure the availability of a 96-hour supply of emergency food and drinking water. At least 48 hours of the supply must be on site at any given time, of which the facility?s rotating stock may be used. Evidence: 1. On 8-12-25, a check of the facility?s emergency supplies was conducted with staff #4. There were 21 boxes of 6 (1-gallon) water jugs. All of the boxes had a date of 3-31-25. 2. Staff #4 acknowledged the water for the emergency supply was expired.

Based on record reviewed, documents reviewed, and staff interviewed, the facility failed to ensure the resident?s personal and social data document was kept updated. Evidence: 1. On 2-5-25, resident #1?s physical examination dated 11-25-24 noted resident allergic to Cephalexin. This allergy was also noted on the resident?s individualized service plan ( ISP

Based on record reviewed, document reviewed, and staff interviewed, the facility failed to ensure the resident?s individualized service plan ( ISP

Based on document reviewed and staff interviewed, the facility failed to ensure it did not admit or retain individuals with any prohibitive conditions per 63.2-1805 D Code of Virginia for assisted living facilities. Evidence: 1. On 2-5-25, resident #1?s physician?s orders (POS) dated 1-8-25 documented resident prescribed Quetiapine (Seroquel) psychotropic medication. The facility did not have a psychotropic treatment plan for this medication. 2. Staff #1 acknowledged the resident did not have a treatment plan for the prescribed psychotropic medication.

Based on document reviewed and staff interviewed, the facility failed to ensure the physician or other prescriber orders, both written and oral, for administration of all prescription and over-the-counter medications and dietary supplements included all required information. Evidence: 1. On 2-5-25, resident #1?s physician order sheet (POS) dated 1-8-25 did not identify the diagnosis, condition, or specific indications for administering the following medications: (a) Century Mature Multivitamin, (b) DHEA 15mg, (c) Estradiol 0.7% gel, (d) Levothyroxine, (e) Memantine, (f) Methyl-Guard capsules, (g) Quetiapine, (h) Rivastigmine Patch, (i) Vitamin D plus K 5000 international unit (IU) and (j) Zinc Gluconate. 2. Staff #1 acknowledged the resident?s POS did not include all required information, diagnosis or specific conditions for medications.

Based on document reviewed and staff interviewed, the facility failed to ensure within 30 days preceding admission, the physical examination contain the required information. Evidence: 1. On 2-5-25, resident #1?s physical examination for admission to the facility?s dated 11-25-24 noted the resident was ambulatory. The resident?s assessment of serious cognitive impairment dated 11-25-24 noted the resident was unable to recognize danger or protect his/her own safety and welfare. According to staff #1, the resident was admitted directly to the facility?s safe, secure unit upon admission to the facility. 2. The resident?s risk assessment documenting the absence of tuberculosis (TB) in a communicable form was dated 10-29-24. Staff #1 confirmed the resident?s admit date was 12-10-24. 3. Staff #1 acknowledged the facility?s physical examination was not correctly documented for a resident admitted to the safe, secure unit. The physical examination document noted the resident was ambulatory (physically and mentally capable of self-preservation). The TB risk assessment was more than 30 days.

Based on document reviewed and staff interviewed, the facility failed to ensure that staff was considerate and respectful of the rights, dignity, and sensitivities of a person who is aged, infirm, or disabled. Evidence: 1. On 2-5-25 and 4-9-25, the licensing inspector conducted an inspection regarding an emailed incident report from staff #1 on 1-3-25, informing the inspector that a resident in the safe, secure memory care unit was ?alleged to have been physically abuse by a staff (CC #1) on 1-1-25 at approximately 8:15 p.m. Resident #1 was at the nurse?s station with a lamp, phone, basket and other items in resident?s arm. CC#1 tried to get the items from the resident, but the resident refused/resistant items being taken. Two witnesses (staff #3 and CC #2) reported and provided written statements that CC#1, ?pushed resident down into a chair, squeezed resident?s hand, resident then hit CC#1. CC#1 then hit the resident?Resident #1 kicks CC#1 and CC#1 stomped on the resident?s right foot. Staff #3 and CC#2 goes to where the resident and CC#1 are on the memory care unit and intervenes in the situation. CC#1 then reaches around staff #3 and grab the back of resident #1?s neck. Staff #3 and CC#2 removes the resident from the situation and takes resident to resident?s bedroom. On the way to the bedroom CC#1, follows the resident and hit the resident on the buttocks.? 2. On 4-9-25, staff #1 acknowledged staff CC#1 was not considerate of a resident on the safe, secure memory care unit who is aged and infirmed and did not treat the resident with dignity and respect.

Based on observation, record reviewed, and staff interviewed, the facility failed to ensure medications ordered for PRN

Based on record review and staff interviewed, the facility failed to ensure each resident?s prescription medications and any over-the-counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages. Evidence: 1. On 9-16-24, during the record review with staff #1, resident #8?s physician?s order dated 8-2-24 noted resident prescribed Risperidone (Risperdal) twice a day, original date noted 7-3-24. This resident?s September 2024 medication administration record ( MAR

Based on observation, record reviewed, and staff interviewed, the facility failed to ensure PRN

Based on document reviewed and staff interviewed, the facility failed to ensure a staff person on or within seven days prior to the first day of work at the facility submitted the results of a risk assessment documenting the absence of tuberculosis (TB) in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: 1. On 9-13-24, during staff record reviews with staff #1, staff #6?s record did not have documentation of the absence of TB in a communicable form. The TB document from a local medical facility dated 8-10-23 documented the staff to ?return to have Tb skin test read between 48-72 hours?return for reading between Saturday 08/12/23 at 05:15 PM and NO LATER THAN 04:45 PM on 08/13/23?. Staff?s date of hire noted as 8-11-23. 2. Staff #1 and #6 acknowledged there was no documentation of the absence of TB within the required time prior to the first day of work.

Based on document reviewed and staff interviewed, the facility failed to ensure the medication administration record ( MAR

Based on documents reviewed and staff interviewed, the facility did not have documentation of the current semi-annual review on the facility?s emergency preparedness and response plan for all staff, residents, and volunteers. Evidence: 1. On 9-11-24, the facility?s documentation of the semi-annual review of its emergency preparedness and response plan for all staff, residents, and volunteers was dated 2-28-24. 2. Staff #1 acknowledged, the emergency preparedness and response plan were not conducted semi-annually as required.

Based on records reviewed and staff interviewed, the facility failed to ensure it did not admit or retain individuals with a prohibitive condition or care needs. Evidence: 1. On 9-11-24, during medication pass observation with staff #4, resident #4 was administered Escitalopram (Lexapro). The resident?s September 2024 medication administration record ( MAR

Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan ( ISP

Based on record review and staff interviewed, the facility failed to ensure the resident?s record include documentation of a fall risk assessment. Evidence: 1. On 9-11-24, during record review with staff #2, resident #2?s record did not have documentation of an annual fall risk assessment. A review of resident?s clinician notes dated 8-17-24 at 08:06 AM, the resident?s record noted a fall with skin tear to the left arm. The record did not have documentation of an assessment following a fall. 2. On 9-11-24, during record review with staff #2, resident #3?s record did not have documentation of an initial fall risk assessment. Resident #3 assessed at the assisted living level of care and the resident?s date of admit noted as 12-7-23. The staff presented an assessment that was dated 9-11-24. 3. On 9-16-24, during record review with staff #1, resident #7?s fall risk assessment provided was dated 3-25-24. The resident?s clinical notes documented falls on 4-13-24 at 05:05 AM?resident observed walking in the courtyard. All of a sudden resident was observed on the ground lying on back by the table and chairs?no injuries noted. Clinical notes documented on 4-11-24 at 09:00 AM, unwitnessed fall?resident found on floor in room next to sink on floor?resident complained of right shoulder and right hip pain and chest pain. The resident was sent out to ER. Clinical notes documented on 4-4-24 at 12:30 AM, resident was heard yelling for help by another resident; resident observed on the floor lying on left side behind the door?right side of resident?s head appeared to be swollen and sore when touched?resident sent out to the ER. The fall risk assessment provided was dated 3-25-24. There were no assessments for the falls noted in the record. 4. Staff acknowledged that the risk assessment for the residents were not completed as required.

Based on record reviewed and staff interviewed, the facility failed to ensure a resident individualized service plan ( ISP

Based on record reviewed and staff interviewed, the facility failed to ensure the rights and responsibilities of residents were reviewed with residents. Evidence: 1. On 9-11-24 during record review with staff #2 and on 9-16-24 with staff #1, resident #2?s record did not have documentation of an annual review of the rights and responsibilities of residents in an assisted living facility. The resident?s date of admit was noted as 12-23-22. 2. On 9-16-24 during record review with staff #1, resident #8?s record did not have documentation of an annual review of the rights and responsibilities of residents in an assisted living 3. Staff #1 acknowledged the resident?s record did not have documentation of the annual rights review.

Based on record reviewed and staff interviewed, the facility failed to ensure it obtained acknowledgement of having provided orientation to the resident or legal representative and kept a copy in the resident?s record. Evidence: 1. On 9-11-24, during record with staff #1 and #2, resident #1?s record did not have documentation of having received orientation to the facility as a new resident. 2. Staff #1 and #2 acknowledged the resident?s record did not have documentation of an orientation to the facility.

Based on document reviewed and staff interviewed, the facility failed to ensure at least once every six months, all staff currently on duty on each shift shall participate in an exercise in which the procedures for resident emergencies are practiced. Documentation of each exercise shall be maintained. Evidence: 1. On 9-11-24, a review of staff?s participation in an exercise in which the procedures for resident emergencies were conducted, dated 6-21-24 (missing person), did not include all staff on each shift. 2. Staff #1 acknowledged; the resident emergency practice conducted on 6-21-24 did not include all staff on each shift.

Based on record review and staff interviewed, the facility failed to ensure the personal and social data for a resident is in the resident?s record. Evidence: 1. On 9-11-24 during record review with staff #2 and on 9-16-24 during record review with staff #1, resident #3?s record did not have documentation of a completion of a personal and social data document with the required information. 2. Staff #2 acknowledged the resident?s personal and social data record was not in the resident?s record.

Based on document reviewed and staff interviewed, the facility failed to ensure the fire and emergency evacuation drills included all the required information . Evidence: 1. On 9-11-24, a review of the facility?s fire and emergency evacuation drills dated 6-1-24 and 7-18-24 did not include the weather conditions. 2. Staff #1 acknowledged the fire and emergency documents did not include all required information.

Based on document reviewed and staff interviewed, the facility failed to ensure the listing of all staff who have certification in first aid or cardiopulmonary resuscitation (CPR) was kept up to date. Evidence: 1. On 9-13-24, the inspector inquired of staff #5 where the First Aid/CPR listing was posted. Staff point to the wall across from the medication room near the nurse?s station on the assisted living unit of the building. Staff #7 came to the area at the same time and ask if the inspector needed help. The inspector pointed to the FA/CPR listing and showed both staff members, the listing which was updated by staff #7 on 9-10-24. The posted list included names of staff with dates that are were not current. Staff #8?s card expired 7-24-24, staff #9?s card expired 9-7-24 and staff #10?s card expired 3-7-24. 2. Staff # 5 and #7 acknowledged the First Aid/CPR listing was not kept up to date.

Based on document reviewed and staff interviewed, the facility failed to ensure the physician or other prescriber?s orders included all required information. Evidence: 1. On 9-16-24, resident #2?s physician?s orders and medication administration record ( MAR

Based on record reviewed and staff interviewed, the facility failed to ensure a documented interview between the administrator or a designee responsible for admission and retention decisions, the individual, and the legal representative, if any, was completed. Evidence: 1. On 9-11-24, record review with staff #1 and #2, resident #1 (date of admit 8-27-24) and #3 (date of admit 12-7-23) record did not have documentation of an interview. 2. Staff #1 and #2 acknowledged the residents record did not have documentation of an interview.

Based on document reviewed and staff interviewed, the facility failed to ensure that the physician or other prescriber orders, both written and oral, for administration of all prescription and over-the-counter medications and dietary supplements shall include the name of the resident, the date of the order, the name of the drug, route, dosage, strength, how often the medication is to be given, and identify the diagnosis, condition, or specific indications for administering each drug. Evidence: 1. On 7-23-24, resident #1?s physician?s order dated 4-8-24 did not include the diagnosis, condition, or specific indications for the following drug and/or supplement: (a) Combigan 0.2-0.5% eye solution and (b) Buspirone 10 mg tablet. Physician?s orders dated 7-9-24 did not include diagnosis for (a) Salonpas 4% patch, (b) Cephalexin 500mg capsule, (c) Diclofenac Sodium 1% topical gel and (d) Tramadol 50 mg tablet. 2. Staff acknowledged the resident?s physician?s orders did not have the diagnosis, condition, or specific indications for the drugs/supplement.

Based on documents reviewed and staff interviewed, the facility failed to document the analysis of the circumstances of a fall and the interventions that were initiated to prevent or reduce risk of subsequent falls. Evidence: 1. On 7-23-24, resident #1?s record reviewed with staff #2, noted fall assessments were dated 5-6-22, with a score of 12; and 6-18-24 with a score of 14. According to staff #2, the resident did not have any documented falls. 2. On 7-9-24, the email and incident report from staff #1 regarding resident #1?s bruising?s on body noted the resident?s ?most recent fall that the staff are aware of was on 7/6/24 @10:50 p.m. and again on that same 11-7 shift on 7/7/24 @ 6:00 a.m.?. Interview with staff #11 and resident?s clinical notes documented by the same staff noted, resident was in bedroom screaming and on the floor. Staff #11 stated during phone interview on 7-29-24, observing resident sitting ?Indian style? on the floor in the room. Staff stated not documenting the fall on 7-6-24 and stated reporting the situation to the supervisor, staff #2. 3. On 8-16-24, the facility?s fall policy was requested from staff #1. The ?FALLS? document was dated ?Revised 4-2014?. No updated policy provided. 4. Staff #11 acknowledged not documenting the two times resident was observed on the floor.

Based on record reviewed and staff interviewed, the facility failed to ensure that the resident?s individualized service plan ( ISP

Based on record reviewed and staff interviewed, the facility failed to ensure when a resident is admitted to a hospital for treatment or any condition, the facility shall obtain new orders for all medications and treatments prior to or at the time of the residents return to the facility. The facility shall ensure that the primary physician is aware of all medication orders and has documented any contact with the physician regarding new orders. Evidence: 1. On 7-23-24, resident #1?s discharge summary noted resident was admitted to a local hospital 6-21-24 to 6-27-24. The resident?s record did not have documentation of primary physician contact and made aware of all medication?s orders. The resident?s clinical notes documented primary physician and power of attorney notified on 6-21-24 when resident was transferred from the facility to the Emergency room, but no documentation of return to the facility and communication with physician. 2. Staff #2 stated the resident?s primary came to the facility on 7-2-24 and reviewed the resident's discharge summary, however there was no documentation in the resident?s record.

Based on record reviewed and staff interviewed, the facility failed to ensure that the medication administration record ( MAR

Based on record reviewed and staff interviewed, the facility failed to regularly observe each resident for changes in physical, mental, emotional, and social functioning. Evidence: 1. On 7-23-24 during a complaint inspection received regarding bruises to anterior chest, neck and forearms of resident #1, the inspector observed bruising to the resident neck area, no other area was checked to avoid resident becoming agitated. 2. The bruising was in the same area of the body reported in the complaint and in the photos received. The photos reviewed showed the areas of bruising to resident?s neck area, back area, right forearm and left wrist area. 3. Interview with C-1

Based on document reviewed and staff interviewed, the facility failed to ensure that each resident?s prescription medications and any over-the-counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages. Evidence: 1. On 7-23-24, resident #1?s May 2024 medication administration record ( MAR

Based on observation and staff interviewed, the facility failed to ensure the first aid kits contained all required items. Evidence: 1. On 9-25-23 during a check of the first aid kit for the nursing station with staff #2, the antiseptic ointment was dated 08/2021. The first aid kit for the vehicle used to transport resident, antiseptic ointment was dated 02/2023. 2. Staff #2 acknowledged the first aid kit for the nursing station and vehicle?s antiseptic ointment were expired.

Based on record reviewed and staff interviewed the facility failed to ensure the individualized service plan ( ISP

Based on observation and staff interviewed the facility failed to ensure the availability of a 96-hour supply or emergency food and drinking water. At least 48 hours of the supply must be on site at any given time, of which the facility?s rotating stock may be used. Evidence: 1. On 9-25-23 during a tour of the facility, when asked about the facility?s emergency supply, staff #5 stated the facility did not have any water and the food supply was what was currently in the facility. The facility was expecting a food order from its local supplier, but no water was part of the food order. 2. Staff #1 acknowledged the facility did not have at least 48 hours of emergency supply on site on 9-25-23.

Based on record reviewed and staff interviewed, the facility failed to ensure that it reported to the regional licensing office within 24 hours any major incident that has negatively affected the or that threatens the life, health, safety, or welfare of any resident. Evidence: 1. On 9-30-23, staff #1 submitted to the licensing office, two incident reports for resident #9. The incidents noted falls and transporting to a local hospital due to resident acknowledging pain. These incidents occurred 9-21-23 and 9-23-23. 2. On 10-2-23, the licensing office received an incident report for resident #10. The incident noted resident was hospitalized with a diagnosis of Acute Respiratory Failure with Hypoxia due to COPD and Exacerbation and UTI. This incident occurred on 9-23-23.

Based on record reviewed and staff interviewed, the facility failed to ensure that each direct care staff maintained current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. Evidence: 1. On 9-25-23, staff #6?s record did not include current first aid within sixty days of hire. The staff?s date of hire was noted as 3-24-23 and first day of work noted as 4-5-23.

Based on observation and staff interviewed, the facility failed to ensure hot water at taps available to residents shall be maintained within a range of 105 degrees Fahrenheit (F) to 120 degrees F. Evidence: 1. On 9-25-23 during a tour of the facility, the water temperature in room #112 tested at 122 degrees Fahrenheit.

Based on record review and staff interviewed, the facility failed to ensure when private duty personnel from licensed home care organizations provide direct care or companion services to residents in an assisted living facility, the facility shall provide orientation and training to the private duty personnel. Evidence: 1. On 9-25-23, a private duty personnel was observed accompanying resident #5 to the medication room. CS-1 record did not include documentation on the type and frequency of services to be delivered to the resident by the private duty personnel. The facility failed to ensure that the requirements regarding tuberculosis (TB) were met; CS-1?s TB was dated 4-1-22. The facility did not have documentation of orientation and training to CS-1 regarding the facilities policies and procedures related to the private duty personnel?s duties. 2. Staff #1 acknowledged the required training, orientation and documentation for CS-1, private duty personnel for resident #5 was not completed.

Based on record reviewed and staff interviewed, the facility failed to ensure that individualized service plan ( ISP

Based on observation, document reviewed, and staff interviewed, the facility failed to ensure medications ordered for PRN

Based on observation and staff interviewed, the facility failed to ensure the facility?s infection control policy was implemented during the medication pass observation. Evidence: 1. On 9-25-23 during the medication pass observation with staff #3, resident #5?s blood sugar was checked. The staff was observed removing the glucometer from the container and placing it on top of the medication cart. Next the staff placed the glucometer on counter behind the medication cart next to the oscillating fan that was in use. The glucometer was not sanitized prior to the finger stick be conducted.

Based on record reviewed and staff interviewed, the facility failed to ensure that six months after placement of the resident in the safe, secure environment and annually thereafter, the licensee, administrator, or designee shall perform a review of the appropriateness of each resident?s continued residence in the special care unit. Evidence: 1. On 9-25-23, resident #1?s record did not have documentation of continued appropriateness of place and continued residence. The resident?s dated of admit noted as 3-15-23.

Based on observation and staff interviewed, the facility failed to ensure when there are indications that ordinary materials or objects may be harmful to a resident, these materials or objects shall be inaccessible to the resident except under staff supervision. Evidence: 1. On 9-25-23 during a tour of the safe, secure unit with staff #10, a heavy steel iron was observed on unit in the ?Sewing is my therapy? activity section. 2. Staff #4 acknowledged the item was not appropriate for the residents on the unit.

Based on observation and staff interviewed, the facility failed to ensure that the signaling device permitted staff to determine the origin of the signaling or is audible and visible in a manner that permits staff to determine the origin of the signal. Evidence: 1. On 9-25-23 during a tour of the safe, secure unit with staff, the call bell in room #503 was pulled at 09:56 a.m. Staff members #4 and #6 were observed in the dining area of the unit. The inspector and staff #10 waited in the room and then came out of the room and waited for a staff to response to the call bell. Staff #10 stated the pager was observed on staff, however, neither staff #4 nor #6 responded to the call bell. At 10:06, the inspector inquired of staff if they heard the call bell. Staff #4 check the pager and stated not knowing the call bell had been alerted. Staff also stated that pagers do not always work, and the problem had been reported.

Based on record reviewed and staff interviewed, the facility failed to ensure either directly or indirectly, that the health care service needs of residents are met. Evidence: 1. On 9-25-23, resident #7?s record included a physician?s order dated 4-25-23 for occupational therapy, ?OT please eval and tx; cervical spinal stenosis, arthrosclerosis of c spine, paresthesia upper extremity, DJD c-spine? The record did not include documentation of therapy services. The individualized service plan did not include services beginning or ending.

Based on record review and staff interview, the facility failed to ensure the orientation training included all required information. Evidence: 1. On 9-25-23, the facility orientation document completed by staff #8 did not include purpose of the facility, daily routines, specific duties and responsibilities of the staff?s position and methods of alleviating common adjustments problems that may occur when a resident moves from one residential environment to another.

Based on record reviewed and staff interviewed, the facility failed to ensure when hospice care is provided to a resident, the assisted living facility and the licensed hospice organization shall communicate an established an agreed upon coordinated plan of care for the resident. The services provided by each shall be included on the individualized service plan ( ISP

Based on records reviewed and staff interviewed, the facility failed to ensure it did not admit retain individuals with a prohibitive conditions or care needs. Evidence: 1. On 9-25-23, resident #5?s record included an order dated 7-12-23 for Sertraline and Trazodone (start date 1-27-23). The record did not include a psychotropic treatment plan for these medications. 2. Resident #6?s physician order dated 7-7-23 for Haloperidol and Lorazepam (start date 6-9-23). Trazadone noted with a prescribed with a start date of 7-27-23. The record did not include a psychotropic treatment plan for these medications.

Based on observation, document reviewed, and staff interviewed, the facility failed to ensure the facility?s medication administration record ( MAR

Based on document reviewed and staff interviewed, the facility failed to ensure it complied with the Virginia Statewide Fire Prevention Code (13VAC5-51) as determined by at least an annual inspection by the appropriate fire official. Evidence: 1. On 9-25-23, the fire inspection provided to the inspector was dated 5-3-22. 2. Staff #1 acknowledged the 5-3-22 fire inspection was the latest fire inspection for the facility.