Brookdale Danville Piedmont

Based on staff record review, the facility failed to ensure that each staff person submitted the results of a tuberculosis risk assessment on or within seven days prior to the first day of work at the facility. EVIDENCE: 1. The record for staff person 2, whose first day of work was 08/10/2025, has documentation that the screening for tuberculosis was not completed until 08/11/2025. 2. The record for staff person 3, whose first day of work was 11/04/2025, has documentation that the screening for tuberculosis was not completed until 11/06/2025.

Based on resident record review, the facility failed to ensure that resident physical examination were completed within 30 days preceding admission to the facility. EVIDENCE: 1. The record for resident 2, admitted to the facility on 04/18/2025, has documentation on the first page of the residents physical examination that the date the physical examination was completed was 11/12/2024.

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

Based on observations of the facility physical plant, the facility failed to ensure that the current week?s menu was post in an area conspicuous to residents. EVIDENCE: 1. At approximately 9:08am on 12/11/2025, the day of on-site inspection, the facility menu that was posted was for the previous week of 11/30/2025 through 12/06/2025.

Based on observations of the facility medication carts, the facility failed to implement their medication management plan (MMP) in regard to methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes. EVIDENCE: 1. The facility MMP has documentation on page 6 under Maintenance of Scheduled II-V Medications that medications will be counted by a licensed nurse/RMA from the off-going shift and from the oncoming shift at the beginning of each shift or whenever a change is made within the shift. Both staff?s signatures and the count of bingo cards and sheets will be documented on either the Schedule II count sheet provided by the communities preferred pharmacy and the communities controlled medication inventory sheet. 2. The facility Controlled Substance/ MAR

Based on observations of the facility first aid kit, the facility failed to ensure that items in the kit did not have expirations dates that had already passed. EVIDENCE: 1. At approximately 10:10am on the day of on-site inspection, the facility first aid kit contained a bottle of Mckesson Premium Hand Sanitizer with Aloe that had an expiration date of September 2025.

Based on staff record review, the facility failed to ensure that direct care staff received certification in first aid within 60 days of employment. EVIDENCE: 1. The record for staff person 2, hired on 07/15/2024, has documentation that the employee did not receive certification in first aid until 02/26/2025. In an interview with staff person 4 on the day of on-site inspection, staff person 4 expressed that no other certification in first aid was available for review for staff person 2.

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

Based on observations of the facility medication carts, the facility failed to implement their medication management plan (MMP). EVIDENCE: 1. The facility MMP has documentation on page 7 that medications that have expired or have been discontinued will be disposed of per policy. 2. The facility medication cart for the T-Bird Hall contained an opened Toujeo Solostar Insulin pen in a pharmacy labeled bag for resident 6 with pharmacy instructions to discard 56 days after opening or reconstituting. The bag has documentation that the insulin was opened on 02/07/2025, which would require discarding of this medication by 04/05/2025. 3. The facility medication cart for the T-Bird Hall contained an opened Lantus Insulin vial for resident 7. The vial did not contain a open/discard date to insure that the medication is disposed of 28 days after opening per manufacturer inspections.

Based on observations of the facility physical plant and resident record review, the facility failed to ensure that a resident may be permitted to keep his own medication in an out-of-sight place in his room only if the uniform assessment instrument ( UAI

Based on observations during the facility morning medication pass conducted on 04/14/2025, the facility failed to ensure that resident medications were administered not earlier than one hour before and not later than one hour after the facility's standard dosing schedule. EVIDENCE: 1. During the morning medication pass conducted on 04/14/2025, the LI observed that the 8am medications for residents 2 and 8 were not administered to these residents until after 9:28am on the day of on-site inspection.

Based on observations of the facility physical plant, the facility failed to ensure that cleaning supplies were stored in a locked area. EVIDENCE: 1. A container of Waxman Kleen Freak Disinfecting Wipes was observed out on a shelf in the Spa Room at 8:41am on the day of On-site inspection. The door to the Spa Room was observed to be unlocked.

Based on review of the facility fire and emergency evacuation drills, the facility failed to ensure that all required information was included on the drill log sheets. EVIDENCE: 1. The facility Logbook Documentation sheets for fire drills dated 01/24/2025, 02/28/2025 and 03/27/2025 does not contain required documentation for the method used for notification of the drill; any special conditions simulated; weather conditions; and problems encountered, if any.

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

Based on observations and staff interviews, the facility failed to ensure that a special diet ordered by a physician was prepared and served according to physician orders. EVIDENCE: 1. The record for resident 3 has a physician order dated 03/17/2023 and again on 11/10/2023 that the resident is to receive a texture modified diet. The special diet board in the kitchen also has documentation that resident 3 is on a texture modified diet. The licensing inspector (LI) observed resident 3?s breakfast meal sitting on a bedside table in front of the resident on the day of inspection. 2 slices (strips) of bacon were observed on the styrofoam container. An interview was conducted with staff 6 on the day of inspection in which staff 6 expressed that slices/strips of bacon is not considered a texture modified diet.

Based on resident record review and staff interviews, the facility failed to follow their medication management plan in regard to the ordering of medications. EVIDENCE: 1. The facility medication management plan has documentation that ?if a medication is not available at the scheduled time of administration the pharmacy will be notified, an entry will be made in the resident log notes in the medical file and the HWD/RCC or their designee will be notified. Charting ?medication not available? on the MAR

Based on observations of the facility morning medication pass, the facility failed to ensure that medications were administered not later than one hour after the facility standard dosing time. EVIDENCE: 1. The scheduled 8am medications for resident 3 were not administered until 9:18am on the day of inspection. 2. The scheduled 8am Gabapentin 300mg for resident 4 was not administered until 9:25am on the day of inspection. 3. The scheduled 8am medications for resident 1 were not administered until 9:44am on the day of inspection.

Based on record review, the facility failed to ensure that within the 30 days preceding admission, a person shall have a physical examination by an independent physician. The report of such examination shall contain all required components which include significant medical history, any diagnosis or significant problems, and a statement that specifies whether the individual is considered ambulatory or non-ambulatory. EVIDENCE: 1. The record for resident 9, admitted 01/31/2022, contained a ?Physician/Healthcare Provider Plan of Care? physical examination form which indicated that the physician visit occurred on 08/05/2021 but was signed by a physician on 02/08/2022. This form did not indicate if the individual has any significant medical history, if there are any diagnoses or significant problems, or if the individual is considered ambulatory or non-ambulatory.

Based on resident record review and staff interview, the facility failed to ensure the fall risk rating was updated for residents after a fall. EVIDENCE: 1. The record for resident 3 contained documentation by facility staff, dated 10/30/2022, that the resident fell on 10/29/2022 and was sent to the emergency room due to head injury; however, the most recent fall risk completed for the resident was dated 05/18/2022. Interview with staff 4 revealed that there is not an updated fall risk rating to reflect the fall from 10/29/2022. 2. Progress notes for resident 5, dated 11/04/2022, indicated that the resident had fallen on that date; however, the most current fall risk evaluation completed by the facility was dated 10/12/2022.

Based on resident record review, the facility failed to ensure prior to or at the time of admission, the required personal and social information for a resident was obtained. EVIDENCE: 1. The resident-personal social data document for resident 1 does not include document regarding the following: service in armed forces (if applicable), information on advance directives, DNR orders, or organ donations (if applicable), clergyman/place of worship (if applicable), next of kin (if known), and the address, phone number and cell phone number for the resident?s personal physician and person dentist. 2. The record for resident 3 contains a signed physician?s order, dated 11/08/2022, that the resident has an allergy to Sulfa Antibiotics and this allergy is also included on the resident?s November 2022 medication administration record; however, the resident-personal social data document for the resident indicates that the resident has no allergies.

Based on resident record review, the facility failed to ensure for private pay individuals, the uniform assessment instrument ( UAI

Based on resident record review and staff interview, the facility failed to ensure that all identified needs were addressed on individualized service plans ( ISP

Based on observation, the facility failed to ensure that the menus for meals and snacks for the current week shall be dated and posted in an area conspicuous to residents. EVIDENCE: 1. While completing a tour of the physical plant on the date of inspection, collateral 2 observed that the posted weekly menu was from the week of October 9, 2022 ? October 15, 2022, and the posted weekly snack menu was from July 3, 2022 ? July 30, 2022.

Based on medication cart audits, resident record review and staff interview, the facility failed to implement components of their medication management plan. EVIDENCE: 1. The facility?s medication management plan states the following: ?A medication cart audit occurs quarterly and is completed by the HWD/RCC or their designee. An audit requires removal and reorder of all expired medications. The HWD/RCC will review the forms after the audit has been completed.? and the plan indicates that for medication refill orders medication staff are responsible for monitoring the needs for refills and the pharmacy should be notified when a seven day supply is remaining. 2. The Mount Cross medication cart contained a container of Bisacodyl 10MG suppositories as needed for constipation for resident 12; however, the medication expired on 06/30/2022 and also contained a bottle of Prednisone 10MG tablets for resident 3; however, the prescription was filled on 10/19/2022 and only contained 10 tablets for the resident to take within 5 days with a start date of 10/19/2022. 3. The November 2022 medication administration record ( MAR

Based on resident record reviews, the facility failed to ensure that physician orders were maintained in resident records. EVIDENCE: 1. A physician order dated 08/11/2022 to change the diet for resident 8 from a puree diet to a regular diet was not located in the record for resident 8 on the day of inspection.

Based on observations of the facility medication carts, the facility failed to ensure that all medication remained in the pharmacy issued container with prescription label until administered to the resident. EVIDENCE: 1. A Lantus Solostar insulin pen was observed on the T-Bird cart without a pharmacy prescription label or resident name. 2. 1 green and 2 white pills were observed lying loose in the bottom of the second drawer of the T-Bird medication cart. 3. A yellow gel capsule was observed lying loose in the bottom of the second drawer of the Mount Cross medication cart.

Based on a medication cart audit, resident record review and staff interview, the facility failed to ensure medications ordered for as needed administration ( PRN

Based on observations of the building, the facility failed to post ?No Smoking-Oxygen in Use? signs in a room of the building where oxygen is in use. EVIDENCE: 1. At approximately 9:41AM, one licensing inspector (LI) observed resident 4 using oxygen in her room and multiple portable oxygen tanks. There was not a ?No Smoking-Oxygen in Use? sign posted at the room.

Based on observation, the facility failed to ensure that the interior of all buildings shall be maintained in good repair. EVIDENCE: 1. While completing a tour of the physical plant on the date of inspection, collateral 2 observed that the wall on the left side of the dining room, next to a table and chair, had a long scratch in which a layer of paint was removed. 2. In the conference room/therapy room on the left back side of the building, collateral 2 also observed that a portion of the ceiling was broken and a portion of the ceiling contained a dark stain around a vent.

Based on an audit of the facility medication carts, the facility failed to ensure that blood glucose monitoring practices that are consistent with CDC recommendations were followed. EVIDENCE: 1. The Mount Cross medication cart contained a glucometer bag labeled for resident 10 on the cart but the meter inside the bag was not labeled with the residents name. 2. The T-Bird medication cart contained glucometer bags labeled for residents 11 and 12 on the cart but the meters inside of the bags were not labeled with the residents name. 3. The T-Bird medication cart contained a glucometer bag labeled for resident 5 on the cart but the meter inside of the bag was labeled for resident 12.

Based on a review of staff records, the facility failed to ensure that the results of a risk assessment documenting the absence of tuberculosis was submitted for each staff person on or within seven days prior to the first day of work at the facility. EVIDENCE: 1. The record for staff person 3, hired 03/21/2022, contained a TB screening chest x-ray report with a completion date of 02/04/2021.

Based on a review of resident records, the facility failed to ensure that physical examinations were completed within 30 days preceding admission and contained all required information. EVIDENCE: 1. The record for resident 6, admitted on 02/08/2022, has documentation on the physical examination that the actual exam was conducted on 08/05/2021. The physical examination form was also incomplete as it did not contain information as to whether the resident was ambulatory or non-ambulatory.

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

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

Based on a review of facility documentation, the facility failed to follow their procedures for methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes. EVIDENCE: 1. The shift change sign sheet for counting controlled substances on the Mount Cross medication cart did not have staff signatures for the count at 3pm on 04/06/2022 and 11pm on 04/06/2022. 2. The shift change sign sheet for counting controlled substances on the T-Bird medication cart did not have staff signatures for the count at 11pm on 04/02/2022 and 11pm on 04/16/2022.

Based on observations of the facility physical plant, the facility failed to ensure ?No Smoking-Oxygen in Use? signs were posted in any room where oxygen is in use. EVIDENCE: 1. Room 13, which belonged to resident 2, contained eight containers of oxygen; however, a ?No Smoking-Oxygen in Use? sign was not posted in the room on the day of inspection.

Based on observations of the facility physical plant, the facility failed to maintain the interior on good repair. EVIDENCE: 1. The second set of columns inside from the front door of the facility were noted to have cracked drywall around the columns at the ceiling.

Based on a review of facility documentation and interviews with staff, the facility failed to ensure that resident rights were provided to residents. EVIDENCE: 1. A facility incident report dated 7/19/2021 has documentation that on 7/8/2021 staff person 2 was made aware of concerns in regards to resident 1. The concerns list that staff person 1 had been using her cell phone to voice record their interactions with resident 1 while in the residents room. It also has documentation that staff person 1 had made statements to resident 1 that she was going to get resident 1 kicked out of the facility. The incident report documents that during the investigation, staff person 1, who was suspended from employment pending the investigation, admitted to using a cell phone to voice record resident 1 as well as admitted to making comments about getting the resident 1 kicked out of the facility, of which both actions go against resident rights to be free from abuse or neglect.