Coles' Retirement Home, INC.

Based on a review of facility documentation the facility failed to ensure that 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 in the facility for at least two years. Evidence: The facility was unable to provide any documentation of a practice exercise for a resident emergency. This was confirmed by staff.

Based on a review of facility documentation the facility failed to ensure that the fire and emergency evacuation drill frequency and participation shall be in accordance with the current edition of the Virginia Statewide Fire Prevention Code (13VAC5-51). Evidence: The facility failed to ensure monthly fire and emergency evacuation drills as fire drills were dated 6-15-25, 8-15-25, and 11-11-25. This was confirmed by staff.

Based on a review of the facility?s first aid kit the facility failed to ensure that a complete first aid kit shall be on hand in each building at the facility, located in a designated place that is easily accessible to staff but not to residents. Items with expiration dates must not have dates that have already passed. The kit shall include the following items: 1. Adhesive tape; 2. Antiseptic wipes or ointment; 3. Band-aids, in assorted sizes; 4. Blankets, either disposable or other; 5. Disposable single-use breathing barriers or shields for use with rescue breathing or CPR (e.g., CPR mask or other type); 6. Cold pack; 7. Disposable single-use waterproof gloves; 8. Gauze pads and roller gauze, in assorted sizes; 9. Hand cleaner (e.g., waterless hand sanitizer or antiseptic towelettes); 10. Plastic bags; 11. Scissors; 12. Small flashlight and extra batteries; 13. Thermometer; 14. Triangular bandages; 15. Tweezers; and 16. The first aid instructional manual. Evidence: The facility?s first aid kit did not contain antiseptic ointment or triangular bandages. This was confirmed by staff.

Based on a review of facility documentation the facility failed to ensure that it shall implement a semi-annual review on the emergency preparedness and response plan for all staff, residents, and volunteers, with emphasis placed on an individual's respective responsibilities. The review shall be documented by signing and dating. The orientation and review shall cover responsibilities for: 1. Alerting emergency personnel and sounding alarms; 2. Implementing evacuation, shelter in place, and relocation procedures; 3. Using, maintaining, and operating emergency equipment; 4. Accessing emergency medical information, equipment, and medications for residents; 5. Locating and shutting off utilities; and 6. Utilizing community support services. Evidence: The facility was unable to provide documentation of a semi-annual review on the emergency preparedness and response plan for all staff and residents. This was confirmed by staff.

Based on a review of resident records the facility failed to ensure that the rights and responsibilities of residents in assisted living facilities shall be reviewed annually with each resident or his legal representative or responsible individual and each staff person. Evidence of this review shall be the resident's, his legal representative's or responsible individual's, or staff person's written acknowledgment of having been so informed, which shall include the date of the review and shall be filed in the resident's or staff person's record. Evidence: -The record for Resident # 1 (admit date: 3-13-15) and Resident # 2 (admit date: 10-2-23) did not contain documentation of an annual review of resident rights. -The record for Staff # 1 (date of hire: 6-5-06) and Staff # 2 (date of hire: 5-30-17) did not contain documentation of an annual review of resident rights. This was confirmed by staff.

Based on a review of resident records the facility failed to ensure that the Uniform Assessment Instrument ( UAI

Based on a review of facility documentation the facility failed to ensure that an assisted living facility shall comply with the Virginia Statewide Fire Prevention Code (13VAC5-51) as determined by at least an annual inspection by the appropriate fire official. Reports of the inspections shall be retained at the facility for at least two years. Evidence: The facility?s fire inspection was dated 11-6-24. This was confirmed by staff.

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 ensure that for each resident assessed for assisted living care, except for those who self- administer all of their medications, a licensed health care professional, practicing within the scope of his profession, shall perform a review every six months of all the medications of the resident. Evidence: The facility was unable to provide documentation of a medication review. This was confirmed by staff.

Based on a review of resident resident records 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 be on file at the assisted living facility and shall contain the following: 1. The person's name, address, and telephone number; 2. The date of the physical examination; 3. Height, weight, and blood pressure; 4. Significant medical history; 5. General physical condition, including a systems review as is medically indicated; 6. Any diagnosis or significant problems; 7. Any known allergies and description of the person's reactions; 8. Any recommendations for care including medication, diet, and therapy; 9. Results of a risk assessment documenting the absence of tuberculosis 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; 10. A statement that the individual does not have any of the conditions or care needs prohibited by 22VAC40-73-310 H; 11. A statement that specifies whether the individual is considered to be ambulatory or nonambulatory as defined in this chapter; 12. A statement that specifies whether the individual is or is not capable of self- administering medication; and 13. The signature of the examining physician or his designee. Evidence: The record for Resident # 2 (admit date: 10-2-23) contained ?Progress Notes? from the resident?s physician from August 2023 and a ? PPD

Based on observation the facility failed to ensure that at least one direct care staff member shall be awake and on duty at all times in each building when at least one resident is present. Evidence: No direct care staff member was on duty in the building when residents were present on 4-23-25 when the licensing inspector was on site. This was confirmed by the facility?s administrator who was present during the inspection.

Based on a review of facility documentation the facility failed to ensure that 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. Evidence: The facility was unable to provide documentation of a practice exercise for a resident emergency by staff.

Based on a review of resident records the facility failed to ensure the resident's record shall contain the physician's or other prescriber's signed written order. Evidence: The facility failed to provide documentation of signed physician?s orders for Resident # 1 and Resident # 2 observed during med pass.

Based on a review of resident records the facility failed to ensure that the Uniform Assessment Instrument ( UAI

Based on observation during a tour of the facility the facility failed to ensure that common face/hand washing sinks shall have paper towels or an air dryer and liquid soap for hand washing. Evidence: The licensing inspector observed that there was no liquid hand soap in the bathroom in Room # 7 on 4-16-23.

Based on a review of facility documentation the facility failed to ensure that it shall develop and implement an orientation and semi-annual review on the emergency preparedness and response plan for all staff, residents, and volunteers, with emphasis placed on an individual's respective responsibilities. Evidence: The facility provided documentation of a semi-annual review of the emergency preparedness and response plan for residents but was unable to provide documentation of a semi-annual review of the emergency preparedness and response plan for all staff.

Based on a review of facility documentation the facility failed to ensure that when any portion of an assisted living facility is subject to inspection by the Virginia Department of Health, the facility shall be in compliance with those regulations, as evidenced by an initial and subsequent annual reports from the Virginia Department of Health. The report shall be retained at the facility for a period of at least two years. Evidence: During the inspection the facility provided a health inspection dated 12-5-23.

Based on a review of resident records the facility failed to ensure that within the 30 days preceding admission, a person shall have a physical examination by an independent physician. Evidence: -The record for Resident # 6 (admit date: 10-2-23) contained a Physician?sProgress Note dated 7-31-23 that did not address all required items for a physical examination report and the resident?s TB screening was dated 8-3-23.

Based on a review of the first aid kit the facility failed to ensure that the first aid kits shall be checked at least monthly to ensure that all items are present and items with expiration dates are not past their expiration date. Evidence: The facility?s first aid kit checklist review was last dated 11-10-23.

Based on a review of resident records the facility failed to ensure that the resident's record shall contain the physician's or other prescriber's signed written order or a dated notation of the physician's or other prescriber's oral order. Orders shall be organized chronologically in the resident's record. Evidence: The records of 3 of 3 residents observed during medication pass did not contain signed physician orders.

Based on observations during a tour of the facility, the facility failed to ensure that the interior and exterior of all buildings shall be maintained in good repair and kept clean and free of rubbish. Evidence: Areas of the wall in Room # 7 were cracked and puckered with chipped and peeling paint. Photographic evidence was taken.

Based on a review of resident records the facility failed to ensure that the Uniform Assessment Instrument ( UAI

Based on a tour of the facility the facility failed to ensure that all furnishings, fixtures, and equipment, including furniture, window coverings, sinks, toilets, bathtubs, and showers, shall be kept clean and in good repair and condition. Evidence: The shower grab bar in the upstairs bathroom was rusted. Photographic evidence was taken.

Based on a review of staff records the facility failed to ensure that each staff person submit 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 submit the results of a risk assessment annually. Evidence: The record for Staff # 2 (date of hire: 5-30-17) contained a TB screening last dated 3-18-17.

Based on a review of staff records, the facility failed to obtain a criminal history record report on or prior to the 30th day of employment for each employee. Evidence: The record for Staff # 2 (date of hire: 5-30-17) did not contain documentation of a criminal history record report. The administrator was unable to locate the documentation.

Based on observation the facility failed to ensure that menus for meals and snacks for the current week shall be dated and posted in an area conspicuous to residents. Evidence: The facility did not have the menu posted.

Based on a review of staff records, the facility failed to obtain a criminal history record report on or prior to the 30th day of employment for each employee. Evidence: The record for Staff #1 (date of hire: 5-29-17) did not contain documentation of a criminal history record report. Staff # 4 stated that facility had not obtained a criminal history report for Staff # 1.

Based on a review of resident records, the facility failed to ascertain, prior to admission, whether a potential resident was a registered sex offender and failed to document that this was ascertained and the date the information was obtained. Evidence: The record for Resident # 3 (admit date: 12-2-21) did not contain documentation of a sex offender registry search. Staff # 4 stated that the facility was waiting to receive the results of the sex offender search for Resident # 3 that the facility requested.

Based on a review of resident records, the facility failed to ensure that a risk assessment for tuberculosis was completed annually on each resident as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: -The record for Resident # 3 contained a TB screening last dated 10-1-2020. The record for Resident # 5 contained a TB screening last dated 3-8-17.

Based on a review of staff records the facility failed to ensure that each staff person submit 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 submit the results of a risk assessment annually. Evidence: -The record for Staff # 3 (date of hire: 10-7-21) did not contain an initial TB risk assessment. -The record for Staff # 1 (date of hire: 5-29-17) contained a TB screening last dated 3-18-17. -Staff # 4 stated that current TB screenings had not been obtained for Staff # 1 and Staff # 3, but would be scheduled.

Based on a review of staff records the facility failed to ensure that each staff record contained the required personal and social data. Evidence: -The record for Staff # 1 (date of hire: 5-29-17) did not contain the following personal and social data: verification that the staff person had received a copy of his/her current job description, name and number of person to contact in an emergency, an original criminal record report and a sworn disclosure statement. -The record for Staff # 3 did not contain the following personal and social data: name and telephone number of person to contact in an emergency.

Based on a review of staff records the facility failed to ensure that it documented the type of training, the entity that provided the training, number of hours of training, and dates of the training and shall be kept by the facility in a manner that allows for identification by individual staff person and is considered part of the staff member's record. Evidence: The record for Staff # 1 (date of hire: 5-29-17) did not contain documentation of any training hours. Staff # 4 stated that Staff # 1 had completed training hours, but the facility failed to document the training hours.

Based on a review of resident records, the facility failed to ensure that each resident had a physical examination within 30 days preceding admission and that the physical examination report contained the date. Evidence: -The physical examination report for Resident #2 (admit date: 3-9-17) was not dated to reflect that it was completed within 30 days preceding admission. -The physical examination report for Resident # 3 (admit date: 12-2-21) was dated 10-1-2020.

Based on a review of staff records the facility failed to ensure that the sworn statement or affirmation was completed for all applicants for employment. Evidence: -The record for Staff # 1 and Staff # 3 did not contain a sworn statement or affirmation. Staff # 4 stated that the facility had not requested sworn statement or affirmation forms for Staff # 1 and Staff # 3 upon employment.

Based on a review of staff records, the facility failed to ensure that staff orientation and initial training occurred within the first seven working days of employment. Evidence: The record for Staff # 1 (date of hire: 5-29-17) did not contain documentation of staff orientation and initial training. Staff # 4 stated that orientation and training had been completed for Staff # 1 but not documented.