Charter Senior Living of Newport News

Based on record review and staff interviewed, the facility failed to annually review the rights and responsibilities of residents with each resident, or his legal representative or responsible individual as stipulated in subsection H of this section and each staff person. Evidence: 1. The record for resident #6 contained an annual review of rights and responsibilities dated 12/12/2023. Resident #6?s date of admit was 12/20/2023. 2. The record for resident #5 did not contain an annual review of rights and responsibilities. Resident #5?s date of admit was 09/01/2020.

Based on observation and staff interviewed, the facility failed to ensure menus for meals and snacks for the current week was dated and posted in an area conspicuous to residents. Evidence: 1.The weekly menu was not posted on the safe secure unit. 2. The daily menu posted did not document the substitution of baked beans and apple streusel cake for the lunch meal observed. 3. Staff #3 acknowledged that there was no weekly menu posted on the safe secure unit and the substitutions were not documented.

Based on staff interviewed and documents reviewed, the facility failed to develop a written emergency preparedness and response plan that shall address documentation of initial and annual contact with the local emergency coordinator to determine (i) local disaster risks, (ii) communitywide plans to address different disasters and emergency situations, and (iii) assistance, if any, that the local emergency management office will provide to the facility in an emergency. Evidence: 1. Staff #1 could not provide annual documentation of emergency preparedness review with a local emergency coordinator.

Based on interview and document review, the facility failed to review the emergency preparedness plan annually or more often as needed, documenting the review by signing and dating the plan, and making necessary plan revisions. Evidence: 1. Staff #1 could not provide documentation of an annual review of the emergency preparedness and response plan.

Based on observation and staff interviewed, the facility failed to ensure the first aid kit included all required items. Evidence: 1. The first aid kit did not include adhesive tape. 2. Staff #2 acknowledged the first aid kit did not include the required item.

Based on document reviewed, resident and staff interviewed, the facility failed to ensure it reported to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident. Evidence: 1. On 5-12-25, resident # 5 stated receiving roommate?s 2:00 p.m. medications by mistake after the registered medication aide (RMA) brought both residents? afternoon medications to the room. 2. Resident #5?s clinical notes, dated 3-16-25 at 5:15 p.m. and 3-16-25 at 5:34 p.m. included notation of this medication mistake, noting, ?The resident accidently picked up the wrong medication and swallowed it during the mid-day med Pass?. (sic). Notification to the resident?s physician and poison control noted. The resident?s clinical notes dated 3-16-25 at 5:24 p.m. noted, ?physician requested spot checks and vitals to be taken?. Clinical notes dated 3-16-25 at 9:50 p.m. noted, ?Resident, complained of stomach discomfort and threw up dinner meal?. The resident?s physician was contacted, and the nurse instructed the staff to provide the resident with fluids. Clinical notes dated 3-17-25 at 12:05 p.m. noted, resident complained to staff, (Registered Medication Aide) of being up most of the night throwing up?. (sic) 3. A review of resident #5?s roommate?s medication list noted resident #6?s afternoon medication as: Carbidopa/Levodopa ER 50-200 tablet at 2:00 p.m. for Parkinson?s and Entacapone 200 mg tablet at 3:00 p.m. for pain. Resident #5 is not prescribed these medications. 4. Resident #5?s afternoon medication prescribed was Gabapentin 100 mg tablet. 5. Staff #1 acknowledged a medication error occurred and the regional licensing office was not notified of this incident.

Based on observation and staff interviewed, the facility failed to ensure it did not administer outdated medications and ensure that medications are refilled in a timely manner. Evidence: 1. On 5-12-25, during the medication pass with staff #3, resident #1 was administered medication that was outdated. The physician?s order dated 5-5-25 and April and May 2025 medication administration record ( MAR

Based on document reviewed and staff interviewed, the facility failed to ensure the physician or other prescribers orders, written and oral, for administration of all prescription and over-the-counter medications and dietary supplements shall identify the diagnosis, condition, or specific indications for administering each drug. Evidence: 1. On 5-12-25, resident #4?s physician?s order dated 5-5-25 did not include the diagnosis for Memantine tablet. 2. Resident #5?s physician?s order dated 11-22-24 did not include diagnoses for Magnesium Oxide tablet, Ozempic injection, Famotidine tablets and Melatonin tablets. 3. Staff #1 acknowledged the physician?s orders did not include the diagnosis or specific indications for administering each drug.

Based on observation, document reviewed, and staff interviewed, the facility failed to ensure medications shall be administered in accordance with the physician?s or other prescriber?s instructions. Evidence: 1. On 5-12-25, during medication pass observation with staff #3, resident #2?s Metamucil Orange Packer order dated 3-25-25 and May 2025 medication administration record ( MAR

Based on document reviewed and staff interviewed, the facility failed to ensure the Medication Administration Record ( MAR

Based on document reviewed and staff interviewed, the facility failed to ensure the order for PRN

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

Based on document reviewed and staff interviewed, the facility failed to ensure the licensee was in compliance with all regulations for licensed assisted living facilities and terms of the license issued by the department, with relevant federal, state, and local laws; with other relevant regulations; and with the facilities own policies and procedures. Evidence: 1. On 9-10-24, the inspectors observed medications in the dumpster located behind the facility?s dining room. Staff #2 and #3 retrieved three large black trash bags from the dumpster. The contents of the bags consisted of over two-hundred sixty-four (264) bubble packets, bottles and containers of medications for forty-seven (47) residents including from pills, creams, inhalers, ear drops, patches, eyedrops, cough syrups, antidiarrheal, ointment, etc. that had not been destroyed per the facility?s medication management policy. The date of the medications ranged from 2-28-24 to 8-15-24. (See Photos) 2. The facility?s ?Department Medication Management Policy No: MED-001, Medication Administration, Effective 9/2017-Revised 10/2021?, section ?Discontinued Medication? noted medication staff will: ??remove the discontinued medication from the medication storage cart/cabinet and store in the designated secure area for drugs awaiting return/destruction. Unless otherwise prohibited under applicable state laws, non-controlled medications supplied in sealed containers may be returned, if unopened, to the issuing pharmacy. Medication destruction will be conducted per applicable state law. Two medication staff members (at least 1 licensed nurse must be present) will destroy all controlled medications. The Health and Wellness Director and/or designee will be responsible for destroying non-narcotic medications?Medication destruction will be recorded in the resident?s record/file and on a destruction log sheet, as required by state law?. 3. Staff #1 acknowledged staff #2?s last day at the facility was 09-11-2024. Staff #3?s record included documentation of further personnel action.

Based on document reviewed and staff interviewed, the facility failed to ensure it had, kept current, a implemented a written plan for proper disposal of medication. Evidence: 1. On 9-10-24 during a complaint inspection regarding the improper disposal of medication, a request for a copy of the facility?s medication disposal policy was requested from staff #2 and #3. The facility?s, ?Department Medication Management Policy No: MED-014, Medication Drug Disposal? policy was provided to the inspectors. 2. On 9-25-24, staff #1 confirmed in an email that the medication disposal policy received was in fact the one (1) page document that was sent on 9-10-24.

Based on document reviewed and staff interviewed, the facility failed to ensure prior to being admitted or retained in a safe, secure environment, a resident must have a cognitive impairment due to a primary psychiatric diagnosis of dementia and be unable to recognize danger or protect his own safely and welfare. Evidence: 1. On 12-26-24, resident #6?s assessment of serious cognitive impairment dated 9-20-24 did not indicate that the resident has a serious cognitive impairment. Resident was place in safe, secure unit upon admission on 9-26-24. 2. Staff #3 acknowledged the aforementioned resident, prior to placement on the secure unit, did not have a diagnosis of serious cognitive impairment by an independent clinical psychologist or physician licensed to practice in the Commonwealth.

Based on record reviewed and staff interviewed, the facility failed to ensure staff orientation included the facility?s organizational structure. Evidence: 1. On 12-26-24, staff #9?s record did not have documentation of receiving the facility?s organizational structure. 2. Staff #4 acknowledged the staff?s record did not include documentation acknowledging receipt of the facility?s organization structure.

Based on record and staff interviewed, the facility failed to ensure the physical examination form included all required information. Evidence: 1. On 12-26-24, resident #6?s physical examination statement documented the resident was considered ambulatory. The resident was admitted to the facility?s safe, secure unit which is non-ambulatory. 2. Staff #3 acknowledged the aforementioned resident?s physical examination form did not include the correct classification.

Based on record reviewed and staff interviewed, the facility failed to ensure the resident?s personal and social information was kept current. Evidence: 1. On 12-23-24, resident #1?s DSS social data and mental health determination form noted the resident?s date of admit was 3-26-23. The facility?s face sheet noted resident?s physical move in date as 3-28-23. Staff #4 stated the resident?s physical move in date was 3-28-23. 2. Resident #3?s DSS social data noted resident?s physical admission date was 10-10-23. The facility?s face sheet and DSS mental health form noted physical move in date as 10-6-23. Staff #4 stated the resident?s physical move-in date was 10-6-23. 3. Staff #4 acknowledged the aforementioned residents? social data was not kept current.

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

Based on record reviewed and staff interviewed, the facility failed to ensure the resident?s rights and responsibilities was reviewed annual. Evidence: 1. On 12-26-24, staff #9?s record did not have documentation of annual acknowledgement of resident?s rights and responsibilities. Staff?s date of hire noted as 5-17-23. 2. Staff #3 and #4 acknowledged the aforementioned staff?s record did not have documentation of annual rights review.

Based on observation and staff interviewed, the facility failed to ensure the menus for meals and snacks for the current week was dated and posted in an area conspicuous to residents. Evidence: 1. On 12-23-24, the menu and snacks for the current week was not posted in the facility. 2. Staff #5 acknowledged the current menu and snacks was not posted.

Based on observation, resident and staff interviewed, the facility failed to ensure medications was stored in a manner consistent with current standards of practice. Evidence: 1. On 12-26-24, resident #1?s individualized service plan ( ISP

Based on document reviewed, staff interviewed and observation, the facility failed to ensure a resident?s medication was administered not earlier than one hour before and not later than one hour after the facility?s standard dosing schedule. Evidence: 1. On 12-26-24, during the medication pass observation with staff #8, the following 08:00 a.m. medications for resident #7 were administered at 09:37 a.m.: Biotin, Donepezil, Memantine, Omeprazole, Oyster shell calcium plus D, and Vitamin B-12. 2. Staff #3 stated the facility had extended dosing hours. 3. Review of the facility?s medication policy submitted during the initial application did not document extended dosing hours. 4. Staff #1 acknowledged the aforementioned resident?s medication was not administered within the dosing schedule time.

Based on record reviewed, staff interviewed and observation, the facility failed to ensure it posted the ?No Smoking-Oxygen in Use? sign in a room where oxygen was in use. Evidence: 1. On 12-26-24, resident #5?s record noted resident is prescribed oxygen at bedtime. The room did not have a ?No Smoking-Oxygen in Use? sign posted. 2. Staff #2 and #3 acknowledged the aforementioned resident?s room did not have the required ?No Smoking-Oxygen in Use? sign where oxygen is in use.

Based on staff interviewed and observation, the facility failed to ensure hazardous materials are in a locked area and not accessible to other residents. Evidence: 1. On 12-26-24, unsupervised work area with sanding saw, putty knife, an approximately 2 feet of a 2X4 piece of lumber and debris was observed first floor hallway near the bistro and receptionist area. 2. Staff #4 located the worker responsible for the unsupervised worked area.

Based on observation and staff interviewed, the facility failed to ensure the interior of the building was maintained in good repair. Evidence: 1. On 12-23-24, during a tour of the facility with staff #2, room #108?s wall was observed to have dark scuffed marks and paint tearing along the entrance walls and closet door to the room. 2. Staff #2 acknowledged the room?s wall was in need of repair.

Based on staff interviewed and observation, the facility failed to ensure glare was kept to a minimum in rooms used by residents. When necessary to reduce glare, coverings shall be used for windows and lights. Evidence: 1. On 12-23-24, the overhead light on the first floor near the nurse station, hall 1 and the overhead light near the bistro was observed not having coverings. 2. Staff #2 acknowledged the overhead lights were not covered to reduce glare.

Based on staff interviewed and documents reviewed, the facility failed to ensure fire and emergency evacuation drills frequency and participation was in accordance with the current edition of the Virginia Statewide Fire Prevention Code. The drills for each shift in a quarter shall not be conducted in the same month. Evidence: 1. On 12-26-24, fire drills date was noted as 12-4-24 (9a-4p); 12-6-24 (15:00); 12-12-24 (630a -245p/ 330p); 10-31-24 (16:00- 16:15); 9-27-24 (11:45-12:00 p); 8-13-24 (15:14-15:30) and 7-18-24 (8:08 a- 8:10 a) 2. The facility did not complete drills for each shift. Staff #1 acknowledged the drills were not completed for each shift in a quarter.

Based on documents reviewed and staff interviewed, the facility failed to ensure the record of the required fire and emergency evacuation drills included all required information. Evidence: 1. On 12-26-24, the fire drills conducted on 12-12-24, 12-6-24, 12-4-24, 11-20-24 did not include the method used for notification of the drill, the number of residents participating; any special conditions simulated, the time it took to complete the drill, weather conditions and if any problems were encountered. 2. The fire drills conducted on 10-31-24, 9-27-24; 8-13-24 and 7-18-24 did not include the method used for notification of the drill and any special conditions simulated. 3. Staff #1 acknowledged the fire and evacuation drills conducted did not include all required information.

Based on document reviewed and staff interviewed, the facility failed to ensure the resident emergency and practice exercise was conducted with all staff currently on duty on each shift. Evidence: 1. On 12-26-24, the resident emergency- elopement drill conducted on 11-20-24 at 2:20 p.m. and 12-12-24 training conducted on 630a/ 245p and 330p did not include documentation of all staff currently on duty on each shift.

Based on record reviewed and staff interviewed, the facility failed to ensure written acknowledgement of the receipt of the disclosure by the resident or the legal representative was retained in the resident?s record. Evidence: 1. On 8-15-24, resident #1?s record did not have written acknowledgement of receipt of the facility?s disclosure. The resident?s date of admit was noted as 8-5-24. 2. Staff #1 acknowledged the resident?s record did not have written acknowledgement of the facility?s disclosure.

Based on record reviewed and staff interviewed, the facility failed to ensure each 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 8-15-24, staff #9?s TB document in the record was dated 7-8-24. The staff?s date of hire was noted as 7-1-24. A discussion was conducted regarding staff?s status, was staff a transfer or a new hire. 2. Staff #1 and #2 acknowledged the staff?s TB was not within the required timeframe.

Based on observation and staff interviewed, the facility failed to ensure the posting for the name of the current on-site person in charge was current. Evidence: 1. On 8-15-24, the on-site staff person in charge posting was dated 8-13-24. 2. Staff #4 acknowledged the staff in charge posting was not current.

Based on record reviewed and staff interviewed, the facility failed to ensure the administrator provided written assurance to the resident that the facility had the appropriate license to meet the care needs of the resident at the time of admission. A signed copy by the resident or legal representative shall be kept in the resident?s record. Evidence: 1. On 8-15-24, resident #1?s record did not include a copy of the signed written assurance document. 2. Staff #1 acknowledged the resident?s record did not include a signed written assurance.

Based on record reviewed and staff interviewed, the facility failed to ensure the physical examination was within 30 days of a resident?s admission. Evidence: 1. On 8-15-24, resident #3?s physical examination date was noted as 11-23-2022. The resident?s date of admit noted as 9-28-24. 2. Staff #1 acknowledged the resident?s physical examination was not within 30 days of the date of admission.

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 interior and exterior of the building was maintained in good repair and kept clean and free of rubbish. Evidence: 1. On 8-15-24 during a tour, the roof on the rear of the building, the back dock, kitchen area entrance from rear is missing a portion of the fascia. The fascia on the front porch covering area is in need of repair. 2. The carpet in resident?s room #136 is in need of cleaning. The ceiling tile above the table near the juice bar in the dining area in the safe, secure unit contains a large brown circular spot. 3. Staff #1 and #7 acknowledged the interior and exterior areas of the facility is in need of repair.

Based on observation and staff interviewed, the facility failed to ensure the findings of the most recent inspection of the facility was posted. Evidence: 1. On 8-15-24, the most recent inspection for the facility was not posted. Staff #4 and the inspector search the front area for the document but was not successful in locating the facility last inspection. 2. Staff #1 and #4 acknowledged the most recent inspection for the facility was not posted.

Based on record reviewed and staff interviewed, the facility failed to ensure the criminal history record report was obtained on or prior to the 30th day of employment for each employee. Evidence: 1. On 8-15-24, staff #9?s criminal background check document in the record was dated 1-20-23. The sworn disclosure was dated 7-8-24. The staff?s date of hire noted as 7-1-24, during a discussion with staff #2, it was determined the staff was a new hire and not a transfer staff. 2. Staff acknowledged; the staff did not have a criminal background check within the required time requirement.

Based on record reviewed and staff interviewed, the facility failed to ensure that staff had training relevant to the population in care. Evidence: 1. On 5-7-24, staff #6 and #7?s training record did not have documentation of oxygen training. The facility currently has a resident who is prescribed oxygen via nasal cannula continuously. 2. Staff #2 acknowledged the staff?s record did not have documentation of oxygen training

Based on record reviewed and staff interviewed, the facility failed to ensure that the health information required by these standards was maintained at the facility and included in the staff record for each staff person. Evidence: 1. On 5-7-24, staff #1?s record did not have documentation of the results of a risk assessment documenting the absence of tuberculosis (TB) in a communicable form. Staff?s date of hire was noted as 4-16-24. 2. Staff #6?s record did not have documentation of a current TB assessment. Staff?s date of hire noted as 6-25-07. 3. Staff #1, #2 and #3 acknowledged the staff?s record did not have documentation of a current TB assessment.

Based on record reviewed and staff interviewed, the facility failed to ensure that staff maintained current certification in adult first aid. Evidence: 1. On 5-7-24, staff #7?s First aid and CPR certification was expired as of 3-14-24. Staff?s date of hire noted as 2-21-24. 2. Staff #2 and #3 acknowledged the staff?s first aid certification was not current.

Based on document reviewed and staff interviewed, the facility failed to ensure that the listing of all staff who have current certification in first aid or CPR was kept updated. Evidence: 1. On 5-7-24, the first aid/CPR posting for the facility did not include all nursing department staff who are first aid or CPR certified. 2. Staff #2 acknowledged the first aid/CPR posting did not include all required staff and not updated.

Based on documents reviewed and staff interviewed, the facility failed to ensure the written work schedule include the names and job classification of all staff working. Evidence: 1. On 5-6-24, the concierge/activity schedule did not include the staff?s full name nor job classification. 2. The housekeeping/maintenance schedule provided did not include the staff's full name and job classification. 3. Staff #1, #2 and #4 acknowledged the staff schedules provided did not include all required information.

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. Evidence: 1. On 5-6-24, resident #3?s record did not have documentation of an interview between the administrator and or facility designee. 2. Staff #2 and #3 acknowledged the resident?s record did not have a documented interview.

Based on record reviewed and staff interviewed, the facility failed to ensure that it did not admit or retain individual with any prohibited conditions or care needs without supporting documentation. Evidence: 1. On 5-6-24, resident #9?s May 2024 medication administration record ( MAR

Based on record reviewed and staff interviewed, the facility failed to ensure the resident personal and social information was kept updated. Evidence: 1. On 5-7-24, resident #4?s personal and social information document, the admission date and advance directive information section were blank. 2. Staff #2 and #3 acknowledged, the aforementioned resident?s social data was not updated.

Based on record reviewed and staff interviewed, the facility failed to ensure that upon admission, the assisted living facility shall provide an orientation for new and their legal representative. If needed, the orientation shall be modified as appropriate for residents with cognitive impairments. Acknowledgement shall be signed and dated, and such documentation shall be kept in the resident?s record. Evidence: 1. On 5-7-24, the orientation document in resident #6?s record was not signed and dated by the resident, who is assigned to the safe, secure unit neither the legal representative. The resident?s date of admit noted as 12-20-23. 2. Staff #2 acknowledged the orientation document was not signed and dated by the resident neither the resident?s legal representative.

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

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

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

Based on document reviewed and staff interviews, the facility failed to ensure that when any portion of the assisted living facility is subject to inspection by the Department of Health, the facility shall be in compliance with those regulations, as evidenced by a subsequent annual inspection from Virginia Department of Health. The report shall be retained at the facility for a period of at least two years. Evidence: 1. On 5-6-24, the health inspection provided was dated 3-17-23. The facility did not have documentation of contact with the health inspector prior to the health inspection expiring nor after the expiration. 2. Staff #1 acknowledged; the health inspection had expired. There was no written documentation of contact with the Health Department to obtain an inspection prior to its expiration date.

Based on observations and staff interviews, the facility failed to ensure that it readily accessible at least one pharmacy reference book, drug guide, or medication handbook for nurses that is no more than two years old as reference materials for staff who administer medication. Evidence: 1. On 5-6-24, staff #7 was asked where the facility?s drug book was kept. The book was located on the nurse?s station. The drug reference book was for year 2019. 2. On 5-7-24, staff #11 was asked where the facility?s drug book was kept. Staff obtain a book dated year 2019 from top of the medication cart. 3. Staff #7 and #11 acknowledged the drug reference book 2019 was more than two years old.

Based on observations and staff interviewed, the facility failed to ensure medical supply and equipment was appropriately labeled. Evidence: 1. On 5-6-24, the glucometer for resident #14, was not labeled. Staff #6 acknowledged the glucometer was not labeled. 2. On 5-7-24, the glucometer for resident #4 was not labeled. Staff #11 acknowledged the glucometer was not labeled.

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

Based on observation and staff interview the facility failed to ensure that medications ordered for PRN

Based on observation and staff interviewed, the facility failed to ensure that the interior of all buildings shall be maintained in good condition. Evidence: 1. On 5-7-24, the ceiling in the dining area near the window in the safe, secure room was observed to have a large brownish colored circle on the tile. The ceiling in the common area in the safe, secure unit was observed to have large and small areas of a brownish colored circles on the ceiling tiles. Staff #8 stated that the circles are from water leakage, but the source is unknown. 2. Staff #8 acknowledged that there were brownish colored circle areas on the ceiling tiles in areas of the safe, secure unit.

Based on documents reviewed and staff interviewed, the facility failed to ensure that all staff, residents, and volunteers review the facility?s emergency preparedness plan initially and semi-annually. The review shall be documented by signing and dating. Evidence: 1. On 5-6-24, the emergency preparedness plan for the facility is not being reviewed and signed and dated by all staff on all shifts. 2. Staff #2 and #4 acknowledged the facility?s emergency plan is not being reviewed with all staff on all shifts.

Based on observation and staff interviewed, the facility failed to ensure that the fire and emergency evacuation drawing posted in the facility included all required information. Evidence: 1. On 5-6-24, during a tour with staff #4, the fire and evacuation drawing observed on the first floor did not include the assembly areas, telephones and/or area of refuge. The postings on the second floor also did not include this information. 2. Staff #4 acknowledged the fire and emergency evacuation posting did not include all required information.

Based on observation and staff interviewed, the facility failed to ensure the emergency numbers are posted. Evidence: 1. On 5-7-24, the inspector inquired of staff #7 where the emergency numbers and/or Poison Control Center number was located. Staff search for the number at the first-floor nurses? station near the resident?s record room; but could not find the Poison Control Center telephone number. 2. Staff on the second-floor nurses? station- was asked where the emergency telephone numbers, poison control number was located. Staff #13 searched for the numbers but were not able to locate the emergency and Poison Control Center number. 3. Staff # 2 and #3 acknowledged the emergency numbers, Poison Control Center number is not available near the telephones in the facility.

Based on documented provided and staff information, the facility failed to ensure that at least every six months, all staff currently on duty on each shift shall participate in an exercise in which the procedures for resident emergencies in the facility are practiced. This information shall be maintained for at least two years. Evidence: 1. On 5-6-24, the review of the facility?s resident emergency/emergency preparedness plan was conducted. All staff in the facility is not documented as participating in the required review and/or practice for resident emergency. 2. Staff #2 and #4 acknowledged the resident emergency review and practice exercise was not completed and /reviewed by all staff in the facility.

Based on documents reviewed and staff interviewed, the facility failed to ensure that no employee shall be permitted to work in a position that involved direct contact with residents until a background check has been completed, unless the person works under the direct supervision of another employee for whom a background check has been completed in accordance with the requirements of the background check regulation (22VAC40-90) Evidence: 1. On 5-6-24, staff #10 provided the inspector with the sworn disclosure and background check documentation and list of all new staff since the last inspection. 2. Staff #10 ( CRC

interviewed, the facility failed to ensure prior to admitting a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia to a safe, secure environment, the licensee, administrator, or designee shall determine whether placement in the special care unit is appropriate. The determination and justification for the decision shall be in writing and shall be retained in the resident?s file. Evidence: 1. On 04-03-24, resident #3?s record did not include documentation of the licensee, administrator, designee?s justification for placement on the safe, secure unit. Resident admitted to the facility?s safe, secure unit was noted as 3-11-24. 2. Staff #1 and #2 acknowledged the resident?s assessment document for placement on the safe, secure unit by the licensee, administrator or designee was not documented and in the record.

Based on record reviewed and staff interviewed, the facility failed to ensure it did not admit or retain individuals with any of the prohibitive conditions or care needs without supporting documentation. Evidence: 1. On 4-3-24 resident #2?s record documented resident prescribed Seroquel, Belsomra and Melatonin psychotropic medications on 3-20-24. The psychotropic treatment document did not include the date and signature of the prescriber. 2. Staff #1 and #2 acknowledged the psychotropic treatment plan in resident #2?s record did not include the date and signature of the prescriber.

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